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Parcel 042-1000-40-000 07/31/2006 11:52 AM
PAGE 1 OF 1
Alt. Parcel 01.29.18.04 042 - TOWN OF WARREN
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
VERNON M NELSON O - NELSON, VERNON M
1156 150TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1156 150TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 1 T28N R18W SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
01-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 36.000 4,800 0 4,800 NO
UNDEVELOPED, G5 1.000 100 0 100 NO
OTHER G7 3.000 18,000 96,100 114,100 NO
Totals for 2006:
General Property 40.000 22,900 96,100 119,000
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 22,900 96,100 119,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 118
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
3 ?A"4
wisconsin Department of Industry,
PLB-1 INSPECTION REPORT Labor & Human Relations
Safety & Buildings Division
Bureau of Plumbing
Name o remises Date an T.>3-No:
street-- 1- y- County Sanitary Permi t
Mater` m er i rm ~ ame dr ss
Journeyman Plumber Address
Owner Address
~i
r
yy
l~
A yyt~
....,a.smm..._ ...-...ten
U
A 7 CEIVE
iscusse wi igna ure
( )See Attached.
DILHR-SBD-6192 (R.10/82) Signature o-T-Fi-sf-- 77 um ),,n up. n- i e waste pec7a is,
Inspector Local Inspector Plumber or Responsible Party -Owner
Parcel 042-1000-40-000 05/12/2006 03:39 PM
PAGE 1 OF 1
Alt. Parcel 01.29.18.04 042 - TOWN OF WARREN
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
VERNON M NELSON O - NELSON, VERNON M
1156 150TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1156 150TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 1 T28N R18W SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
01-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 36.000 4,800 0 4,800 NO
UNDEVELOPED G5 1.000 100 0 100 NO
OTHER G7 3.000 18,000 96,100 114,100 NO
Totals for 2006:
General Property 40.000 22,900 96,100 119,000
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 22,900 96,100 119,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 118
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & H+.JMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON, WI 53707
❑CONVENTIONALALTERNATIVE State Plan 1. D. Number
gn
El Holding Tank IX In-Ground Pressure 1:1 Mound (l f 18" 30ed)39 84
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSPECTION DATE:
VetLnon M. Nees ova RR# 1 , New Richmond, W1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SE!-4 NE%, Section 1, T29N-R18W, Tows of WvL ten
Narne of Plumber: MP/MPRSW No. Coumy Samtary Permit Number:
Evenett Botdt 4489 St. Cnoix 43649
SEPTIC TANK/HOLDING TANK:
MANUFACTURER'. LIQUID CAPACITY. TANK INLET ELE V.. TANK OIfT LET ELEV. WAR
. NING LABEL LOCKI G C V
'E D
• ~ /~A < P PR V S PR
U0 ~T ` OV ED'
YES ❑ N O Y N O
BEDDING: VENT DI VENT MATL. HIGH WATER NO NEA NUMBE A- 0. f ROAD'. ruE~l WEL LBUILD NGIVE TO FRESH
ALARM FEET FROM / NAIR INLET:
DYES ONO DYES OREST /
DOSING CHAMBER:
NU CTUR BEDDING. FT PUMP MODEL. PUMP' SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
g PROVIDED: PROVIDED:
DYES NO W' '"a YES ONO EE ONO
GALLONS PER CYCLEP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR I ET
PUMP ON AND OFF) DYES ONO L NEAREST ~ 4, 0 7"'/' 74
SOIL ABSORPTION SYSTEM. Check e soil moisture at the depth of plowing ENCrH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until L FORCE
the soil is dry enough to continue.) AIN,
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH No of Dcov R JINSIDE DIA Plrs uQwD
TRENCHESM L: PIT DEPTHDIMENSIONS
GRAVELDEPTH FILL DEPTH DISTRPIPF DISTR. PIPE DISTRE IAL. NOD TR PROPERTY WELLBUESH
BELOW PIPES ABOVE COVER ELEVNLET ELEV. END PIPES LINENEAREST--r
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D YES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE JPERMANENT MARKERS JOBSERVATION WELLS
DYES NO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH - LENGTH. NO. of LATERA SP CING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHE.g:
DIMENSIONS ~
MANIFOLD PUMP MANIFOLD DISTR. PPE MANIFOLD MATERIAL NO. IR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV ELEV CIA ELEV PIPF DIA/ ,P•
ELEVATION AND 91.7a S-7.0-5 9 f J t" ,,,1 C
/
DISTRIBUTION r
INFORMATION HO LE~ HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
YES ONO ~J DYES O
COMMENTS: PERMANENT MARKER . OBSERVATION WELLS: f NUMBER OF PR OPERTV WELL. BUILDING:
AY LINE ~J J / J6
FEET FROM
n ~ ES L] NO YES ❑ NO NEAREST ° !4`
C'5 1 2-.01
2
-4 o
Sketch System on V
Retain in county file for audit.
Reverse Side.
SITLE " sy.?.
DILHR SBD 6710 (R. 01/82) °
w,sconsin APPLICATION FOR SANITARY PERMIT ~~jj
1 L H R (PLB 67 f h~+~0 i COUNTY
oevaaTmenTOF )
InOUSTRY,LRBOR UNIFO;SANITARY PERMIT #
HIJTFn RElF7TlOns %u
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPS TY OWNER MAILI G ADDRESS
e~ h/v !j M /V L 5 0 x✓ 'd', J l C_ t•i 0 n?
PROPERTY LOCATION .
'7 0t*6-
' N, R v+ F
SE 1/4NE1/4, S / T
A'0(or)W TOWN OF: e- AJ
LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUM ER
I /IV /V /q 0,41 -7-R, Cl d N
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
XNew System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound X1in-Ground Pressure
Total # of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity 00 0AJ (f:- X
Lift Pump/Siphon Chamber 00 0 N e
Manufacturer: ; ` ' le
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
A '5 0
7 0 X Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for al tion of the priva e sewage system shown on the attached plans.
Name of Plumber (Print): MP/MPRSW No.: Phone Number:
Plu ddress: Name Designer:
R c~ c,~o r~7 f~, c vC J ~ e U }
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: ee: Date: ❑ Disapproved
/ ❑ Owner Given Initial
yApproved Adverse Determi ion
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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1-4 PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
,y
W i
- --VENT CAP
M"C. I. VENT PIPE
WEATHER PROOF APPROVED LUCKING
JUNC.TIOAI BOX MANHOLE COVER
25' FRGM DGGR,
r~ WINDOW OR F-RVSH t2 MIU.
f AIR INTAKE
GRADE -
y" MIN.
~ _ 18" MIIJ.
CONDUIT _ _
PROVIDE I
Ilk] LET /try AIRTIGHT SEAL I I
I
JAPI'Runt) JOINT A APPROVED 101AlTS
W/ c. -I. PIPE. I I I W/C.T. PIPE
EXTENDING, 3' * I II ALARM EXTENDING 3'
ONTO LOLID ;rift. _ Y I I ONTO SOLID SOIL
ON
C
PUMP--~_
OFF
o t` 1983
A /S E.Cc✓. COAICRETE BLOCK
RISER EXIT PERMUTED OIJL9 IF TANK MAUUFACTURE.R HAS SUCH APPROVAL
SPECIFICATIOUS
SEPTIC AND
I TANKS MAMUFACTURER: IC COMC&!14& NUMBER OF DOSES: ~ -PER DAB
TANK ,IZE : .4 00 G~.LOIJS DOSE VOLUME.: 90 . GALLONS
ALARM MAWUFACTURE.R: ~ ,ggng3 4-C& CAPACITIES: A= ~ ~j1AlCHES OR GALLONS
MODEL ►JUMBER: .20,04-/ B= t'1, 0 INCHES OR CALLOUS
SWITCH TYPE: p C= q INCHES OR p 7D GALLOAIS
PLIMP MAMUFACT UREK: / Vs6RO ✓nA7I Qc D= 4NICHES OR a2AF GALLOQS
MODFL NUMBER: 3 NOTE: PUMP AND ALARM ARE TO BE
f04 SWITCH TYPE: INSTALLED ON SEPARATE CIRCUITS i
7 ,I
PUMP DISCHARGE RATE GPM 5
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PINE.. J~O FEET
t '
+ MIMIMUM NETWORK SUPPL9 PRESSURE , FEET
+ f '/O FEET OF FORCE MAIN X ~F~ooFT.FRICTION FACTOR.. FEET
TOTAL DytJAMIC HEAD FEET
D12."m INTERNAL DIMEAIS':O~IS OF TAIJ 1 0 ;I1 LIQUID DEPTH
91GNED: L_ICEMSE HUMBER: /NIP l ~G7 / DATE:
Oj~
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18 1983
`„ter
2
All,
-its
CI-a
00, -414
1 •Yj ~y Q~ ~r, U~"M7i' I i t
~ ~V I s
y ~ n
HYOR=On RTIC H-82
' PUMPS
28
24
W SV33
W 20
LL
16-
V2'_ = 12
J
8
Q
H
4
SUBMERSIBLE 0 5 10 15 20 25 30 35 40 45
U.S. GALLONS PER MINUTE
SUMP Head-Capacity: SV25 and SV33 Submersible Sump Pumps
Max. Solids 3/4" Sphere; 4 Pole, 60 Hz.
P UMPS 28-
24
20
Z
G 16
ZL"'
12
J
8
I F..
4
0 10 20 30 40 50 60
U.S. GALLONS PER MINUTE
Head-Capacity: SP33 and SP25 Submersible Sump Pumps
Max. Solids SP33, 3/4" & SP25,1/4" Spheres; 115Volts, 60 Hz.,1750 RPM...
a
140
120
s~.
HIGH HEAD 2100
0 80
EFFLUENT a 60 SP100H
C 40
20 tts7pjD,.,
PUMPS
0 2.0 40 60 - - 80 100 120 140
U.S. GALLONS PER MINUTE
Head-Capacity: SP50H, SP100H and SKH150 High Head Effluent Pumps
Max. Solids SP50H, SP100H & SKH150, 3/4" Spheres;
115 Volts, 60 Hz., 3450 RPM
s
t4 0
i H f rA _ _ aQ
~ - -lam
7
r- 76
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" page 1
WORKSHEET - FRESSURE DISTRIBU'T'ION NETWORK DESIGN
PROBLEM
Design a pressure distribution network for c--'~ bedroom home. The site
characteristics are:
L
Depth of groundwater or bedrock 3 in.
Landslope ✓CA %
Percolation rate min./in.
Distance from dose chamber to distribuyion system q0 ft.
Elevation difference between pump and distribution system S ft.
Step 1. Estimate Wastewater load
Step 2. Size of absorbtion Area
A) Area required
B) Select length tij C
C) Width is ;
D) I will use a manifold
Step 3. Size Distribution Pipes
i
A) Hole size I will use is in.
B) Hole spacing I will use is u in.
C) Lateral length is 0 ft.
D) lateral size is in.
Step 4. Distribution Pipe Discharge Rate 7
Step 5. Size Manifold
A) Manifold Length ft.
B) Number of distribution pipes ,
C) Manifold diameter t~~ in.
~ t
• page 2
Step 6) Size of force Main
A) System dihcharge rate
B) Force main diameter
C) Friction loss will be ft./100 ft.
Step 7. Total dynamic head
A) Vertical lift ft.
B) Friction loss ft.
C) TDH = ft.
Step 8. Select a Pump
Step 9. Dose Chamber size
Step 10. Dose Volume.
Z)' cT , ,'rte v' ,
e.4
a
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SBD 6678 (9/81) (Plb 100a)
Detach And Return Upper STATE OF WISCONSIN DILHR
DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Corresponden 6 '7 8 P.O. BOX 7969
MADISON, WI 53707
608-266-3815
n ~ y
DATE: PROJECT:
two ;
I~ fir) amen
t
PLAN ID. #
DETACH HERE -
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. 0 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
11. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy)
government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data.
❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
111. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides. pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including
soil data.
size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.
State of Wisconsin ` Department of Industry, Labor and Human Relations
SAFETY & BUILDINGS DIVISION
Ztll f ast dash i n,,~ T V,
joy; 9ry P.O. Box 796
t"lute r,
..'e'ar °~r. t#t J .
eaiternative System
)E NE, 1, 29,1 8+4
own of Warren, t. Croix
-f
fl c' s1;9ject Petition tor , ic.aticjn ?iii
r,~~?T"L~VE'i
lie ruIt., z6 r'L' F4.' c`31ki bfrs is
for a replacement system.
vrAriance requested was to install amp -
tlom Without suitable soil for a
r <3}qust t, 1976.
All of teat data and statements s,~:)c.
{.+.:.nstdereel. !t}gs approval #r,roval is spect1 Ic ..'.t i,,:ai= .'a'U;i,IjzLL. PeLi3. '06 ivku C-
u-red fur any additional r } ifications,
Section of Private S w:. je`. ~tc< i; l r E t i tip;
aruy Jansky, Un-Siti, ~,tri(.. i-
art ld C. 33arber, Zmt, ir< }3Fr °1~Lr r,. _ # ix
DILHRSBD-6423 (N.04/81)
Department of Industry, Labor & Human Relations
of Division of Safety & Bldgs.
State Ot Wisconsin Bureau of Plumbing Platting & Fire Protection
,7 P.O. Box7969
E\... 8 Madison WI. 53707
Tel. 608-266-3815
r 6
rF INALL CORRESPONDENCE
REFER TO PLAN
T. IDENTIFICATION NO.
NAME OF PROJECT
TYPE OF APPROVAL
STREET AND NO. qc-
CITY OR TOWN . \
COUNTY STATE ZIP
OWNER
Gentlemen:
Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145,
Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com-
pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted.
The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of
plans bearing the stamp of approval of the department.
In-the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval
shall become void and new application shall be made for approval of these.plans before work-may commence.
In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan
omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary.
This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require-
ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto-
matically void this acceptance.
For Private Sewage Systems Only:
Sincerely, This approval is valid for two
years or it will be valid until
the expiration date of the initial
sanitary permit.
James Sargent-Bureau Director
PLANS REVIEWED BY: DATE:
cc: DPS-OWS Owner DI LHR
Local PI Plumber H & R (2)
County Mfg. Rep. Bur. of Health Fac. & Services
DI L H R SBD-6099 (N. 06/80) Rec. & Env. Services
100a) STATE OF WISCONSIN DILHR
S8p6678 (gid Return Upper DIVISION OF SAFETY & BUILDINGS
Deta~ Of This Form With BUREAU OF PLUMBING
POD ro E" 201 E. WASHINGTON AVE. RM 178
Return Correspondence P.O. BOX 7969
MADISON, WI 53707
40 608-266-3815
DATE: _ jON, PROJECT:
! ..,j
~ OFF~44P
iz t !WarrefPLAN ID. #
DETACH HERE
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
F,
Preliminary review indicates the required fee is $ Fee Received is $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2) (a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
11. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy) government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data. ❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form` by County. (1 copy) Etc. Provide benchmark with elevation reference point.
11. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides. pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including
soil data. size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. V1. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.
SBD 6678 (9/81) (Plb 100a)
STATE OF WISCONSIN DILHR
Detach And Return Upper DIVISION OF SAFETY & BUILDINGS
Portion, Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Correspondence P.O. BOX 7969
7 MADISON, WI 53707
608-266-3815
DATE: '&e PROJECT:
to sFQ'~,
gee y~yc ~9~
PLAN ID. #
DETACH HERE
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ r-; r-' Fee Received is $
Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
11. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy) government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data. ❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan.
course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
I11. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides.
pumped per cycle.
❑ Elevation of permanent reference point (benchmark).
❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including
soil data. size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water
siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53701
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location SE 1/4, NE 1/4, Sec. 1 T 29 N, R 18 KX4" W
Town ~irXX~1Xi}QiScXi~D~t1y Warren Street Address
Lot No. Block Subdivision
Landowner's Name: Vernon M. Nelson
The application for this site is for:
FXJ new construction use.
❑ replacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
Hto have one of the first five approvals guaranteed for this year. This -is
number - - of those applications. (Use one of the first five
quota num ersissueTto you.)
]one of the applications needing a quota number. The quota number assigned to
this application is - -
N for one additional homesite on a farm to he occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
I 1for an application on file prior to February 1, 1980.
L_1 for a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USL, the alternative private sewage system is
replacing:
Da failing conventional soil ah%orption system.
LJa holding tank that was installed and in use prior to February 1, 1980.
L la privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the lot meets the criteria for a
conventional private sewage system, check here. 1-1
I certify that the above information is true and accurate to the best of ny
knowledge.
Narr16rhomas C. Nelson Signature
(County Official
Title Assistant Zoning Administrator Date August 4, 1983
DILHR-SBD-6158 (R 12182)
SBD 6678 (9/81) (Plb 100a)~ STATE OF WISCONSIN DILHR
Detach And Return Upper DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Correspondenc P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE:;? PROJECT:
a0,c~~f*' N E, 1, 29, 1
t:
Marren
PLAN ID. #
DETACH HERE
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $
Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated l se of I&
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. 0 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
ll. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy) government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement:
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data. ❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
I II. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides. pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including
soil data. size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.