HomeMy WebLinkAbout042-1066-80-000
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AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP ~ SL'(. r N-R W
OWNER 14 i-;d' -Ho11c"'1-
ADDRESS ST. CROIX COUNTY, WISCONSIN .
SUBDIVISION 54 LOT Z>K LOT SILI
PLAN VIEW
Distances and dimensions to meet requirements of H63
Y.I;MTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) 'Describe: c?' %r01a 5-471* 1n 7,'
i n Z= e
~~'rt Elevation of vertical reference point: Qv.O' Slope at site:-570
SEPTIC TANK: Manufacturer: edee y _ Liquid Capacity: oU00
Number of rings on cover : oNC Tank itiantiole cover elevation _ _ _
an Inlet Elevation: Tank Outlet Elevation.
PUMP CHAMBER
Manufacturer: N fiber of gallons
Number of al . wn set or a c c'le gallons total ca ac i t y !3 P P y --0- b p Y
di8tribution lines gallon. size pump- Iiciid,
gallon per minute horsepower brand name of pump
and model number
Type of warning evfie-
HOLDING TANK: Manufacturer- Number- of ballons
Elevation of manhole cover~ _
Ty je of warning device/
SEEPAGE PIT SIZE: i~~ Number of pit s~_ __--lest diaai~t er
feet liquid d~pt'f-i~ i~ seepage It inlet pipe -elevation
bottom of seepage pf-t elevation//~_ feet.
Sr Lt AGE BED SIZE. number of lines W~ic~tlz left th 5~ti Le ate th 3
SEEPAGE TRENCH: width/ length-
PERCOLATION RATE ~i A-EU~I~ED AREA AS BUILT _
INSPECTOR
DATED PLUMBER ON JABr,~ r/~rs»
LICENSE NUMBER e1 P gs-VIS
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
t-ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
i2CONVENTIONAL ❑ALTERNATIVE sUleMenIo,"",be,:
111 nuyndl "
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
;Randy Bollum Hudson, W1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN Bernard Lewis Sub REF. PT. ELEV.: CST REF. PT. ELEV.
INW NW, Section 24, T29N-R18W, Warren Township, Lot 1
Name of PIUMbel'. IMPA01100*00.. County Sanitary Permit Number:
Everett Boldt 4489 St. Croix 34816
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY, TANK INLET ELEV.. TAN UT ET EL§ WARNING LABEL IL ING A
J P V ED: P IDE
Z' L (JZ `Z `c J L YES ❑NO Y ❑NO
BEDDING, IV ENT DIA.: IV ENT MATL. NI H W NUMBER F ROAD: PROPERTY WELL. 9UILDING: IV ENT _TO FR PH
ALA RM. P AIR ET
CI FE ET FR
OM /
DYES ONO ❑YES ❑NO NEAREST & 17q
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER.
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AN N R L OPERATIONAL NUMBER OF PROPERTY 1111-1- BUILDING V N O R
(DIFFERENCE BETWEEN FEET FROM LINE JA IR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST __j
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAME TER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO OF DISTR. PIPE SPACING COVER JINSIU1 DIA SPITS LIQUID
BED/TRENCH t THENCHES MATERIAU PIT
DIMENSIONS 5
FUE 7PIPEJ H FILL DEPTH UISTH I F DISTRPIPE JDISTR. IP MA IAL NODISTR NUMBER OF R Y WELLBUILDINGV NTT FRESH
VE OVER ELEV INLEL ELEV. N~j PIPES LIN _75_( AIR 7 FEET NEARESTM ~MOUND SYSTEM:
Mound site plowed perpendicular to slope he k the texture of the fill material or PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: o d systems to make certain at it ON REVERSE SIDE. SHOW ELEVA-
❑ the criteria for medium sand TIONS MEASURED.
/f me s
YES ❑NO
SOIL COVER TEXTURE P MANENT MA S OUSE HVAT ION WELLS
❑YESH ❑NO ❑YES ❑NO
uC PTH OVER TRENCH/B71-OG EPTH OVER TR N ! ED, DE TH OF TOPSOIL SODOC sfiko MULCHED
CENTER ES
~ S ❑N ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTE
WIDTH LENG JNOOFI/ LATERAL SPACING AVEL DEPTH BELOW PIPF FILL DEPTH AB VE COVER
BED/TRENCH TRENCS
DIMENSIONS
MANIFOLD UM MANIF Ln DISTR PIPE MANIrOLO MA EHIAL NO UI TH DISTR. I UISTHIUU I ION PIPE MATERIAL B MARKING
ELFV ELEV OIA ELEV. PIPES CIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE IIOLf SPACING DRILL U OIIHECILY COVER MATE HIA VERTICAL LIF T CORRESPONDS TO APPROVEU
PLANS
Y LINO ❑YES ❑NO
COMMENTS: DEHMAN N A TION WELLS NUMBER OF PROPERTY WELL BUILDING
FEET FROM LINE
/I I a DYES LINO OBSERVA 1JYES N _ [NEAREST
0"
L
Sketch System on tai 'in county file for audit.
Reverse Side.
slG[ulrT f TITLE
DILHR SBD 6710 (R. 01/82)
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LA13OR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property wner: JJ Mailing Address: ~~ys
R ^J Q y I cJ Q m /q u C_{ S U w , (.V [ S
Property Location: Ciliert or Township: County:
/VLJ%/VLA-)'/4S Al /T-4,~ N/R I V(or) tj-),f '?02C.~ cif C q6
Lot Number: IBIk,No.: Subdivisi n Name: Nearest Road, Lakeor Landmark: State Plan I.D. Number:
e°/y (If assigned) TYPE OF BUILDINGiEE~~ T J~- - J
Number of
❑ Public* ❑ Variance* ❑ Other (specify) t-_~Ajz1. Ali. ag1V Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify-)-
SEPTIC TANK CAPACITY /000 0 A.1 e- K
HOLDING TANK CAPACITY 1114
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: e, e, S 9nJ c- r2 e- f G
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ;5 Seepage Bed ❑ Seepage Pit
/ ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
9 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for in Ilation of the private sewage system shown on the attached plans.
Name of Plumber: ignatu MP/MPRSW No.: Phone Number:
,5v e- P__ e- ff oo 44Y ' (7/6 ) &Y'/-3S7
Pl"r's Address: 1 Name of Designer:
ra w , L.~J r S ~ ✓ e re e- ~ ~ L d f
COUNTY/DEPARTMENT USE ONLY
anitary Permit Number: 43
Signature of Issuing Agent: Fee: Date: APPROVED T_3_31t?14
4~ 0, 1 DISAPPROVED Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
I~
S
1'o rw - S T C 100
0 w.n e r o f P r o p e r t y~/,~(~C/car'
Location of Property ~4_ lYiO k, Section T 2 N R_Z,~W
Township
Mailing Address
Subdivision Name
Lot Number C~1
Previous Owner of Property.
/
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? X Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other Uegal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. ~2_ ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
IANATURE OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
L)
DATE SIGNED DATE SIGNED
ST CROIX COUNTY CERTIFIED SURVEY MAP LOCATED IN PART
OF THE NW 1/4 OF THE NW 1/4 OF SECTION 24, T 29 N, R IS W, TOWN OF
WARREN, ST. CROIX COUNTY, WISCONSIN
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_U/✓PLATTED LANDS OWNED 6Y PL 4- 7r 4~. _9 OD
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY; C DIVISION
LABOR AN P.O. BOX 76
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LA /WON! Sp^~- /~~9H/R/ 6(or) TOWN SHIPAA(: LOTNO.:BLK.NO.:SUBDIVISIONNAME:
COUNTY: /Y OWSNE BUYER'S N- ,mil/) MAILIN ADDRESS:
~f. Cleo, AN d oLL v f--, N w, s
USE WW-eic - rttV R 0`'w l S DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER AL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ? D4New ❑Replace ? yi -13
RATING: S= Site suitable for system U_= Site unsuitable for system
ONVEN IONAL: IMOUND: IN-GROUND-PRESSURE: S ST M-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑u a s Flu a s ❑u EIS ❑u EIS ❑u
If Percolation Tests are NOT required jDESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 1 IL Floodplain, indicate Floodplain elevation:
PlAF (E, O P c_ z Sa r C 's PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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B- a ,2 > /
B- 3 9 r r t r n i t tr
B- Al Q rt ~t I ~11 11 ~n r' ti
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B- ~5 pt
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B PERCOLATION TESTS
EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P- / O D 14 ;Z , i a ,5
i
P- a o M4 Ziy
P. O o
P-
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PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 9- `fir
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1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON.
C1/ e o L ,I f / C7 / 3 - ? __F___
ADDRESS: CERTIFICATION N MBER: PHONE Nl1MBR(optlonal):
Z, IF
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