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Home My WebLink About002-1031-20-000 C g State of Wisconsin ` Department of Industry, Labor and Human Relations SAFETY & BUILDINGS DIVISION •~IJI ~~SL s~*,`3~f:i71F~i,.Vi1 r1V~ 1`.~`-~ T't, s aural soil. I'-. inch(;s cf suitable natural sci I. L!: yet-a +0r; s'.atem,?, ot-s sf 4•r-litt.eii in "j '-"rj "i? ts~' li f' cder:-d. T ,is approval is p .,~p'i7 ti.i I:• riaY;!.+tui', i..~'i ~ .i~.. ..4a 7 } DILHR-SBD-6423 (N. 04/81) Department of Industry, Labor and Human Relations weseonsln Division of Safety & Buildings ~ DILHR Bureau of Plumbing P.O. Box 7969 pEPRRT TEnT OF - InOUSTRV, LROOR 6 HUMRn RELRTIOns Madison, WI 53707 Tel. (608) 266-3815 • ; f , ` ~ I,U~ t- Yt k7 R ru'C } (NC.. IN ALL CORRESPONDENCE REFER TO PLAN F es, /SLAIN IDENTIFICATION NO. r\~ t- >.nrt r~1, 4y1 . rte. -7 NAME OF PROJECT JAJJ< PRIVATE SEWAGE ONLY - ❑IGENERAL PLUMBING PLANS Fee Received: LOCATION Priority Plan Review Only /V VV, /Ve CITY OR TOWN COUNTY Examination of plumbing plans and specifications for this project has been completed. In accord with Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon compliance with the stipulations shown on the plans. Please review your code for the requirements of each code section noted. The licensed plumber responsible for this installation shall keep at the construction site one set of plans bearing the deoartment's stamp of approval. The installer shall also notify the appr° inspections are to be made. In the event installation has not begun within two years from inns ud. approval will be void and new plan approval shall be obtained before wo:r, begin. In granting this approval, the Division of Safety and Buildings does not hole; itself liable for any defects in plans or specifications, plan omissions or examination oversight, and reserves the right to order changes or additions if necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit requirements of the city, village, township or county in which this installation is to be made. Failure to obtain local permits will automatically void this approval. Sincerely,// James SargE t--;' Bureau Dire or PLANS -REVIEWED BY: DATE: i cc: DPS - OWS Owner H & R & Rec. San. Section Local PI Plumber Bur. of Health Fac. & Services County Other DILHR SBD-6099 (R. 05/82) n cn O K m n C:~ r~ O c m o ~+1 0" 3 (D H 3 3 v µ d N FBI 0 Q N ? 7. co CO O lA\ ' N N C p O) ' C N zt Q W N N d= O O j N 'Y Co O O~ < ? v O ~ O1 N N O rr. f/I C A ~ 61 O W ~ Q) cn •C D o N p n C O CD W N) C: 0 C, CD N) 0 N W ( ~ 0 CD- A O CL CD co w Uf co ro N O C 1 o = o m .A ~ a cn cn cn ~ ° N v v v v ff Cil Od. - ~ CD to l1 A z N a z z O D D o 0 C: J d 7 V 1 p W N Z m t -i N N p Z O z n A Z O u FID o J W CL M z A L) O Z i> fr1 ^j m F % A tk Cl) rte.. r:i i f. D CL a o' - ~ c z a p co N m rl A b n Oi N ti N O ~ O A ti O N Oq O 0 (D ° i ti 8 PM Parcel 002-1031-20-000 12/21/2005 12:1 PAGE 1 OF 1 OF 1 Alt. Parcel 15.29.16.217 002 - TOWN OF BALDWIN 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 O - MENTINK, DAVID A & JOAN M DAVID A & JOAN M MENTINK 2453 CTY RD E WOODVILLE WI 54028 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2453 CTY RD E SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 15 T29N R16W NW NE TOWN BALDWIN Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-29N-16W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1193/335 QC 07/23/1997 1193/334 WD 2005 SUMMARY Bill M Fair Market Value: Assessed with: 86838 Use Value Assessment Valuations: Last Changed: 06/28/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 37.000 3,600 0 3,600 NO UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 2.000 4,000 146,300 150,300 NO i Totals for 2005: General Property 40.000 7,700 146,300 154,0000 Woodland 0.000 0 Totals for 2004: General Property 40.000 7,700 146,300 154,0000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 510 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges 00 Delinquent Charges 00 Total 45.00 w DETARTMENT Of INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS P.O. 13O 7669 AN RELATIONS P PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX MADISON, , WI WI 53707 BUREAU OF PLUMBING ❑CONVENTIONAL ❑ALTERNATIVE Stata Plan l.D. Number: III asfigned) ❑ Holding Tank ❑ In-Ground Pressure ( Mound NAME OF PERMIT HOLDER: ADORfi$S OF PERMIT HOLDER: INSPECTION DATE: Cj BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. Name of Plumber: 7(PESW No.: County: Sanitary Permit Number: LA 7 ! ' SEPTIC TANK/HOLDING TANK: - , _ MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK UTLET ELEV.: 1W7YES ARNING LABEL LOCVKINGC V IDED: PROV~ED ~i(~.7 ~G S3 ONO ❑~S ONO BEDDING: VEIL IA. VENT MATJ.: HIGAHR ^AlTER r NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH FEET FROM LIM AIR INLET OYES L ❑Y NO NEAREST Jf%'1/ DOSING CHAMBER: ! MANUFACTURER BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP-P/$IPHON rANUFACTURER. - WARNING LABEL LOCKING COVER PRO IDED: PROVIDED: •y, EYES ONO I' t 9 t/a X: r. YES NO GALLONS PER CYCLE: PUMP AND CONTROL OPERATIONAL: UMBER OF PROPERTY WELL BUILDING JVENTTOFRESH (DIFFERENCE YES ONO BETWEEN LINE AIR INLET PUMP ON AND OFF) , YES ONO FEET FNEARESROM T SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE th LENGTH IIIIAME TEH MATERIAL AND MARKING excavation. (If soil can rolled into a were tGOrtsLru jctl~on shall ~earsle~ ntil the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO OF DISTR. PIPf SPACING COVE 3 INSIDE DIA -PITS LIQUID TRENCHES MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTH PIPE DISTR. PIPE ISTR. PIP MATERIAL NO. DISTR. NUMBER OF R E TY WELL: BUILDING. V NT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLET ELEV. END. PIPES FEET FROM LINE: AIR INLET. NEAREST 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- O YES NO meets the criteria for medium sand. TIONS MEASURED. O SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONOIYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL- SODDED. SEEDED 1"U LCHED CENTER. EDGES r OYES Y NO YES ONO YES NO PRESSURIZED DISTRIBUTION SYSTEM: WO. -OF LATERAL SPACING GHAVEI_ DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH WIDTH LENGTH TRENCHES : DIMENSIONS MAN}FAD U PUMP MANIFgLO DISTR. PIPE MANIf°O LD MATERIAL NO UISTH 111:STRIP DISTH16UilON PIPE MANKIND ELEVATION AND L ELDtg.i elev PIPES DA: DISTRIBUTION f ~'>1 ^ C INFORMATION HOLE SIIF LI ID ItILLEU CnHHEC I I Y COVFR MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED - PLANS YES ON0 OYES ONO COMMEN TS: AON WELLS: NUMBER OF PROPERTY WELL: BUILDING ES I - I NO YES L7 NO NEARESTOM LINE 90-96P 3,6, 7I.37~ System on Side. T~ ) R 1 In count r'audit. G' SIG, NA TURF ITITLI 6710 (R. 01/82) j '7 R/ AS BUILT SANITARY SYSTEM REP OLJfJL:R} ~G~~/i' TOWNSHIP y~'yCS N-RlZW ADDRESSf~@ ST. CROIX COUN ISCO i° SUBDIVISION LOT LOT SIZE J// - PLAN VIEW Distances and dimensions to meet requirements of H63 zoO--f. _ yFJJYTHING WITHIN 100 FEET OF SYSTEM ~Sf o- t~orlSl' -717 - i~ o U P /~P 11 p C CJ I di a e oath Arrow 1 I S CAL ~ - - f - ~ ' BENCHMARK: (Permanent reference Point) Describe : 6, ode 7t N"W' n F s'h ed Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: -zoo ~c Number of rings on cover ~.1:2 --Tank manhole cover elevation:_/DUr / Tank Inlet Elevation. 94,7 --Tank Outlet Elevation: PUMP CHAMBER anufacturer:~~~ Number of gallons-- Azo _ _ r-1 iiii aer of gal . pump set or a cycle gallons; totaT-capacity o~ it Ls tribution lines -52 _gallon: size of um .27 head; ~,atlon per minute horsepower_ brand name of pump and model number ~n 'T'ype of warning device_ HOLDING TANK: Manufacturer 1fz4 Number of gallons Elevation of manhole cover Type of warning device-,VA SEEPAGE PIT SIZE: _-Number pits eeameter feet. liquid depth Seep-. e pit inlet pipe-elevation bottom of seepage pit elevation-., feet. SI ',PAGE BED SIZE: number of lines - width__~le-%thz/7 tile depth'2z/ SEEPAGE TRENCH: width _~~RE length _jf/~ ' PERCOLATION RATE- ,z CO AA REQUIRED ,-AREA AS BUILT _ -3 7$ 1 37.5` INSPECTOR DATED-- f PLUMBER ON JOBS-/1 LICENSE NUMBER---- T/P__11-~Ts PLB 67 State and County State Permit # Permit Application County Permit # for Private Domestic Sewage Systems County Sr GRe ix *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A, OWNER OF PROPERTY Mailing JAddress: `019,/14 C,. r B. LOCATION: /a '/a, Section IS, TAI N, R_J(~ I (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township g1"rl ,j~ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks 0~ HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement X Lift Pump Tank or Siphon Chamber X Total gallons Prefab concrete X Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement X Alternate (Specify) /1jc, a /.9 S/ Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length Width Depth Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 1~:q f~l Distance from critical slope - WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, t NAME ✓e- f / v~C, i' C.S.T. # 0 and other information obtained from K (owner/builder). / Plumber's Signature MP/MPRSW# / 904 4 Id 9 Phone #7/ 5-68~ ~z; 73' Plumber's Address w [:cat PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. r. € .a _ I 3 4 I m. mot- ee e . _ . E I m L t a ,.a...d . m ;-e e . ° _am.. a ,a . s. a.,w w . E . n. a. .-s,=»....» e. ..P ..e. I P.. 7 ~ t i e j i tam e, m n .fie. e+». a mm a a ) r s . I i Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application - Fees Paid: State County, Date Permit Issue444eeete4 (date) ~C^ Issuing Agent Name a. C - C2', X10 - Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /78 J, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I;VQU,STRY, DIVISION LABOR.AND ' PERCOLATION TESTS (115) MADISP.O. BOX ON WI 53709 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) L CA ON:N~ SECTION: TOWNSHIP/MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: ate. - "17 /(//1 NA _ AllIl ~4 /5 /129N/11/4 (or COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: USE _ DATES OBSERVA`nONIONS MADE FI DE IS: P OLATION TESTS: ~S~Er NO.BEDRMS.: COMM CI'A/L DESCRIPTION: W Replace ~~JResidence ❑New ULIReplace It /Yl! f _l sc- RATING: S= Site suitable for system U= Site unsuitable for system _ CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FlL.LHOLDING TANK: RECOMMENDED SYSTEM (optional) S ®u ®s ❑u1❑s [kU ❑s ®u ❑s Chu 00"I)r/ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: IV-] I /"'o -e 1/1-3 Ff'✓ -~70 1 / S PROFILE DESCRIPTIONS BORIN15 TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) A0 l- a f s 9 la 10 1 G B- on e s /3'' I //l /Y "C/, C/ T B-3 'c/ 37 "G/ 9/v'' ' 0 C/. 93'sc/ B- `f /t/me ~ BIS rrti p f ~ .,~t~ B-~ 9q'zl age I~ 111.5 9i' "s// ""C .3s ; 'Sc l B- - r r PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEV -IN HES RATE MINUTES NUMBER 44ASME6 AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RIOD PERIOD PER INCH P- / 44 -I&C'n 'd 119 P-3 A& n e, P- P- P- 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 / a 9 o u n y 7,R<. E 0 ~9• MeV Cal •Sc~~ol~~~Tk--~ Exlsfi ~r~~ ~ NouS o. C /!a rv .2ac f r-- CU B.vA A ' ASS ~"KI ' Cxkr~d p N.c 3 .,~,~e,e sN~~ctlc rt I~ 33' Exist 100, A-7 jt O~R A4 e 0 4, dl2 ti~'r2 NO 4~ heel Q p 514e~ 9y. - - 39/ 8 P-2 1? 9,. 7 ° I NEB RB' y0' I, the undersigned, hereby certify that the soil tests reported on this for. 4&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: rADDRESS: CERTIFICATION PHONE NUMBER (optional): C URE: / DISTRIBUTION: Or ininal and one copy to Local Authority, Property Owner and Soil Teste. DILHR-SBD-6395 (R. 02/82) OVER T i C ~(n• ~.~m I Y, )1J 3 Q-4 7j~ co IC4 a a; a ui ~1 C> t j ~ - O M 7` fi L-1 Pf) ca - c-A i CD I „i,awe„~.-,,.,.,-.__.T-.~~--_-~...- _ - 24 20 w '0 - LL 16 z SV °a 12 40 W 8 O ~ 4 M__ i 0 16 32 48 64 80 96 112 SOLIDS U.S. GALLONS PER MINUTE Head-Capacity: SV40 and SVK50 Submersible Residential Sump Pumps Max. Solids SV40, 11/2" & SVK50, 2" Spheres; 4 Pole, 60 Hz. HANDLING 32 tj 5: SUBMERSIBLE 28 Z 24 Sp~ SEWAGE W 16 & EFFLUENT 0128 I PUMPS 4 i 0 20 40 60 80 100 120 140 160 U.S. GALLONS PER MINUTE Head-Capacity: SP40A and SP50A Submersible Sump Pumps Max. Solids SP40A,11/4" & SP50A,11/2" Spheres; 115 Volts, 60 Hz., 1750 RPM 40 3s COS ~M0eaAaaAf 28 pp y`. ? 24 K75 r~ EVERETT A. 20 . ~ i2 16 SK6 WIN. • ~ 8 - r r r r t 1 I t 1 40 60 80 100 120 140 160 U.S. GALLONS PER MINUTE Head-Capacity: SK60, SK75 and SK100 Submersible Sewage Pumps Max. Solids 2" Sphere, 1750 RPM IS `N HYDR-O- MRTIC UU'T 1 8 1'1-1 PUMPS A Division of Wylain, Inc. - Post Office Box 327, 419/289 3042 Claremont 8 Baney Roads, Ashland, Ohio 44805 Fi-82 In Canada: Wyla/n Canada Ltd. Ltd*., 120 fast Dr., Brampton, Ontario L87 1C2 -7J # (7) L7> W - - - c C' (a I i y I I ~j 'U ~ ~ I I rj` -c ,CDC O <C - D I rD a c~ C, 0 tb Fay . ; (D C< i I IC) fo u, cs tT CP fi ~ ~ Ua I ~ T o • 'I` c I -n FTI 1- D-4 < f W N ~v M !I I~~s > mm I aa 2 r i v(? w--~ „ a b t, . 7C N 11 67 U 4' I ~r CA ^ -TI 00 c ~ I i < f rr• t/1 I / (A O "ECEIVED r r- "GT 7 8 198 h ~ ~ t' I e i r,; I 4 T7 DAL it 3 _ es { a Arl-'1 _ ~ 14 C~ 1 P n> o` 3 76 N 1~ P H i ,A • CA C ~ kb f~ YIN I~ 1x`r ice, fi f\ Y -s_„~~ N o i •r°°° ~1 ` r , .,0 p 1 81982 ~ TIC c,~ r~°o~A P~ a 1 rtl 7)3 X, I I I-D 7jj 11t 0 ,1114 III ~ j i i G • ' 0: a ;Tw ~ ~ ~ 333 IH c e 5-C -ir' 0 C T 1 8 1981: + d7 , c x x x ck) ,L q _ lei- -P i n_ to °o G Q I A-1 . ,a E y o b G ~ .wry ~ ~ Z u~. ~'d _ i ` Gov to D I ' JOB o. I' _artias~• C~ a' it ~ ^ ( 14,111 lilts," OCT 18 1982 + soui ca Cz~ Z n v, -AL " oo, 1 A Z a x l0 3 . :6 TM (4 'o it LZ' D zC r4 76 Liu T 1 A fit N ns -5 °"n ZIt . 61- % SBD6678 (9/81) (Plb 100a) STATE OF WISCONSIN DILHR 16 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 MADISON, WI 53707 608-266-3815 1rm ; O~ ; DATE: r, y PROJECT: ~'J,NE, 15,2t>' C 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. (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. 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. 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. Detach And 1Return Upper Portion Of This Form STATE OF WISCONSIN DILHR With DIVISION OF SAFETY & BUILDINGS Any Return Correspondence BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 P,O. BOX 7969 DATE: MADISON, WI 53707 608-266-3815 PROJECT: 8 1P 28~ h ' or;1CF PLAN ID. # _ J I _ DETACH HERE PROJECT NAME 1 _ This is to acknowledge receipt of your plans and specification PLAN ID. # Preliminary review indicates the required fee is $ S for the above indicated project. ❑ Underpayment - Please submit the additional fee. Fee Received is $ ❑ Plan accepted for review. ❑ Overpayment - Refund forthcoming. ❑ No fee has been remitted. Plans submitted with no fees will be ❑ Plans being returned. held in abeyance. ❑ Additional information required. SEE BELOW. I. Plan Submission ❑ Additional information shall be submitted in duplicate un- ❑ Complete data relative to anticipated use of bldg. less specifically noted. 2 copies of PLB 60 enclosed. ❑ El Plans not clear, legible or permanent. ❑ Deed restriction required (1 copy), ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2)(a) Wisconsin ❑ Condominium declaration. (1 copy) Administrative Code, ❑ Affidavit enclosed. IV. Holding Tanks 11. Pressurize Distribution Systems (Mound or In Ground Pressure) ❑ Profile of holding tank showing vent, manhole alarm and 1:1 Application for use of an alternative system signed by owner manufacturer if precast. Complete construction details if and notarized. (1 copy) site constructed. ❑ Holding tank agreement signed b ❑ County onsite required (1 copy), ❑ Design calculations for pressurize distribution. government (sample enclosed), Y owner and local unit of test data. El soil boring & percolation ❑ Reason for installing holdin from count 9 tank. Soil test or statement Cross section of system. ❑pipe lateral layout. Y (1 copy), ❑ ❑ Plan view system. ❑plot plan, ❑ Plot plan showing location of holding tank with lateral dist- ❑ Verification of Exception Status Form b ances to any building, wells, water service by County. (1 copy) course, lot lines, swimming piping water Etc. Provide benchmark with elevatiolnvrefe ence pol nt road, III. Private Sewage Disposal Systems ❑ Ground slope with 2' contours in entire area of soil absorp- tion system extending V. Lift Pump ❑ Elevation of perman nt efe enlce sides. po point (benchmark). ❑ Calculations for total lift pump discharge, head and gallons ❑ Location of area suitable for replacement system - Pumped per cycle. soil data. provide ❑ Size, length & depth of force main. ❑ Plot plan showing lot size and all lateral distances from 0 Detail & model of pump or automatic siphons including sewage disposal system to buildings, lot lines size' pump curves, drawdown and average flow rate GPM. course, swimmin , well, water 1:1 Cross section of lift pump tank showin 9 pools, water service piping Etc, siphon (s). g pump(s) or ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. ❑ Construction detail and cross-section of VI. Systems In Fill (Fill must be placed prior to plan submission) system. soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench ❑ Soil boring and percolation test on 115 completed by cer- before side slope begin). tified soil tester (1 Copy) ❑ Depth and type of fill. ❑ Copy of onsite report by county or district staff. a ST. CROIX COUNTY WISC0NSI N ZONING OFFICE 796-2239 HAMMOND, WI 54015 Division of Safety and Buildings Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Dave ilentink property located at the 11W of the '1: , Section 15, T2911-:161.1 Baldwin Township in St. Croix County, revealed suita- ble soils at a depth of 16 inches, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to c(_),tLacL LhIS office. Ygur!5- truly, Thomas C. Nelson Assistant Zoning Administrator TCN:wjo 6/17/80 WISCONSIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING, PLATTING & FIRE PROTECTION POST OFFICE BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St , Croix Location NW 1/4 _ iqE 1/4 S L5 T 29 Town or Municipality _ Baldwin - Street Address RottLe 1 Woodville Lot No. Block Subdivision Landowner's Name: T-) AY e YYI 4' ; ~)-i' The application for this site is to serve a: ❑ new construction use. Q replacement system use. If this is a NEW CONSTRUCTION USE, the alternative private sewage system is to be included as: ❑ part of the 3%/5% limitation. This is number of the applications made through this office. D one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. 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. rid lot that meets the site criteria for a conventional private sewage system. If thisaa REPLACEMENT SYSTEM USE, the mound is replacing: LX 1 a failing conventional soil absorption system. ❑ a holding tank that was installed and in use prior to February 1, l(WO, U a privy that was installed and in use prior to February 1, 1980. I cer•tity that the above information is true and accurate to tf-l best of my knowl dge. Name 1lwu~:-__~ t _ iv~i S7 nature 11 Lrt' A,,iSISL21111.oI11l~ 1dL11111:;( i'dt of Date 1)( I ill~l [ 1 > 19 ~"I i LHk-sn- 6158 (N.7/80) VetiUon lot Modilu•lion of jr, WISCONSIN DEPARTMENT OF OFFICE USE ONLY Adeninistralive kule INDUSTRY, LABOR AND HUMAN RELATIONS Petltlon No. PRIVATE SEWAGE. DIVISION OF SAFETY & BUILDINGS E-No. P.O. BOX 7969, MADISON, WI S3707 ID-No. Name or Owner 7N.'m or Use Agent, Architect or Engineering Fir M Idaat Plumber Company Street4 Noreet No. Streel_ Ao No. Slate ru ZID tt City Cnunty city State ati Zip Phone Plan Numbers (1f Known) Phone fly- x'3'7 Type of Petition Set. Backs (Soil Absorption Experimental and I ee ❑ and Septic Systems) ❑ Loading Rates ❑ Site Evaluations LEGAL DESCRIPTION L-iJ VI~I,__Y._= %n, Section L~5_ ` ~ N, R E (or To ip_ -./c~.'..~ Subdivision Narnt County i WIS ONSIN ADMINISTRATIVE RULE BEING PETIT 1 N E D 1. Rule of the Wisconsin Administrative code cannot be entirely satisfied due to the following reasons: Ind 1 In he, -,I c"rnplying cxdctly with the rule, the lollowing allernalive is propox•d as .l rTlcdnti of providing an equivalent llel;ree of selely .u health i,J_~-~.~.. titriil,i,t Itt,~ .u"umcniti (1 nr %lie evalwtlioos, include 1-orm I 1 i--"keport on Soil Boring and Percolation Pests'') P DETAILED PLAN OR DRAWING COUNTY PERSONNEL AUTHORIZATION Rule s 1 cF. ' bcin~ petitioned On-sue inspection cundujtud (data) t c.: _M- , indicate the information recorded on this request torm is accurate and correct to the best of my knowledge and belief. VERIFICATION BY OWNER--PETITION 15 VALID ONLY IF NOTARIZED FOR INFORMATION CONTACT THE DEPARTMENT AT (608) 266-3815 being duly sworn, says he is pe(moner herein, thus he has read the foregoing Petition and that the time is true, as he verily believes. SubsLrtbcd and sworn to mu tltts ddy of ly County, Wisconsin, Signature of owner, ~uiary u u My cumrnomun - _ OFFICE USE ONLY__ DEPARTMENT ACTION I I I- LVAWATIONS SE I -HA( K 01- t t'f. KIMI N1 Al _ Ua[e Kecetved mount Paid _ K,Gceipt No Dalc Received ~Ikacctpt No~ i 'Uepdrtn~~;~ . „r ~+.A r 0K