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HomeMy WebLinkAbout014-1061-50-000 _ n cn p 3 m n m c d CO) c o 0 p ~ \ 1 3 o rv r r.~ o Cl) m m o 00 o co C • n N 3 0 N N CL a j o ~ 3 Wo ~cn o N a 3 N O p A i"'! • _,i Con , CD m n = W A O O O o T! 7 N d O O k m co D m a f) `D W N a V A O co co o o Cl) = CD h -4 -4 ~I z co N O N O C ~1 A ' C !V m 0 N • 11 N y o w v Ul ("D cn ^ 1 i U) W N `p O C 0 a N T--,, zco z c a:3 N R 9 D (D O o' Cl) m !r • v ~r Q ' CD co c co m w CL z m 1 cn O p Z_ CD n A Z O m a ~ O(n ~ N co 'U mCO CD ~ z c 3 A c - cn N C O A o o D / !n O a ID `-...a 3 = C G " 0 1.0 N C a) CD u m 3. o W o m 2: N 0 S O-n CD (D 7c b o _U) n N ft a3 a a N C ~ CL v 3 c., (D O O A O b w = dC O O cfl O A O ~ yb O O ti Parcel 014-1061-50-000 12/19/2005 03:15 PM PAGE 1 OF 1 Alt. Parcel 29.31.15.4606 014 - TOWN OF FOREST 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 - LIVING WORD CHAPEL INC LIVING WORD CHAPEL INC 2746 HWY 64 EMERALD WI 54013 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE SEC 29 T31N R1 5W 4A SE1/4 SW 1/4 LOT 1 Block/Condo Bldg: CSM VOL 5/1208 CHURCH Tract(s): (Sec-Twn-Rng 401/4 1601/4) i 29-31 N-1 5W it Notes: Parcel History: Date Doc # Vol/Page Type i Bill Fair Market Value: Assessed with: 2005 SUMMARY 0 Valuations: Last Changed: 06/02/1987 Description Class Acres Land Improve Total State Reason OTHER X4 4.000 0 0 0 NO Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 : 37'9711, CERTIRED SURVEY MAP a 01 S.E. '/V- ^ SW'/L+ SEC. 23 731 N-R.1EW. N TOWN OF FOREST ST. CRIOX COUNTY, WISCONSIN, g N 85~ - SS 1/ -ae w 3 06. 76 ib FILED 900 SEP151982 % 00 0 0 JAAAW Of ooMML o ~o 1 b°w' w'«a' 4 WI afo. oo sq. Fr. f zl OR ~ ~ I 'q C)3 E'S QI 7 ` a f- ~l m m QI I ~ I Q I O r~ 06 Cn Z - `.cl OED ! 3'' O APPROVED Lo ~4 i ;SEP '31982 ST: cRoix COUNTY COMPZE"IS1StYI! PARKS PLANNING AND .,ZONING COMMITTEE O A 9 00 00 N W°_ 0 °o S.W. COR. 3&33' _80L7 E>` 00 RIw- _ RAW 5 87°-30-c~3 E n Lu _ S I/ 4- 75 COR. 0 S.TH. 6 V- 7.51 LLI r6 ~o LEGEND a: tin f- 0= I `/4" IRON pIPI= SET Lit U LLI a0 Ln Q®0a~® G 0WT /./3 L8.1 L_ I N. FT. ,y 'sue -TO B No. O38a, D. o' !oo' x'00_ BOOTH (RICHARD S-1413 EAR LAKE, WIS. F SC Al.~ i Ip0" °y► r e 40 ~ V004,000 cutlvt'~'4 Volume 5 Page 1208 'SHEET / O F03 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX A969 BUREAU OF PLUMBING MADISON, WI 53707 ❑CONVENTIONAL ❑ALTERNATIVE Sta(e Plan LD. Nu mber ed) ❑ Holding Tank El In-Ground Pressure ❑ Mound (lf aui~g ~ NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION D TE. r - I it k- O 2i BENCH MAR KJPer manenl reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. T LEV.. CST REF. PT. ELEV. N,`i of PI.,,A-. MP/MPRSW No. County S-I.,y Perm[ Number. SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED' DYES LINO DYES LINO BEDDING VE. NT DIA.. VENT MATL f(;H WATER NUMBER OF ROAD. JPROPS WELL BUILDING VENT TO FRESH LAHM _ FEET FROM y- LINE ~Q IAIR Iv~ET YES LINO l• f~ i-1YES LINO NEAREST _ Q I L!( DOSING CHAMBER: MANUFACT UR FH JBEDDING LIOUI[ I CnPAC I TY PUMP MODEL JPUMP; SIPHONMANUFACTUHEIi WARNING LABEL LOCKING COVER PROVIDED: PROVIDED'. DYES LINO EYES LINO DYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF 1'I+: )PFRTY bVF LL BUILDIN(, VENT TO FR ESH (DIFFERENCE BETWEEN FEET FROM vE AIR INLET PUMP ON AND OFF) OYES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing "j I1 - )In>.~I I I R MATE HIAL 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: WIDTR LENGTH NO OF J DISTH PIPE SPAC.I n, ;()VER INSIDE DIA -PITS LIQUID BED/TRENCH /f 0 TRENCHES nl PIT DEPTH DIMENSIONS I 11; 171 i II.L OF PTH I)IS I"I PIPF DISTH PIPF DISTR. PIPE MATERIAL NO H NUMBER OF E ERTV WELL BUILDING VENT N TO FH ESH I I IIF .L13c)VE OVER [ k V INl If ELEV END / PIP LI NE AIR ILET FEET FR z NEAREST-->~ MOUND SYSTEM: II~F l/~ 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 Y ES LI meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER iE Y,I OHF PERMANENT MARKERS OBSEHVATION WELLS _ DYES LINO DYES LINO UEPTH OVER THFN(:R BED DEPTH OVEH TRENCH BFI) DEPTH OF TOPSOIL ~SO nnFU SEEDED MULCHED CF NI FH EDGES DYES LINO DYES LINO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: ll)TH LEN(, IH NO. OF LATERAL SPACING GRAVE L DEPTH BF LOW PIPF FILL DEPTH ABOVE COVFH BED/TRENCH TRENCHES DIMENSIONS '.SAN (FOLD P M UMP ANIFOLD DISTR_ PIPE MANIFOLD MATERIAL NO DISTR DISTR PIPE DISTRIBUTION PIPE MA I I HIAI & M,'O KIN(, I I EV. ELEV. DIA ELEV. PIPES DIA.: ELEVATION AND DISTRIBUTION 1~~ MATION 'OIE_SIZE HOLESPACI NG DHILLLD(1 OHH[ CT LY COVER MATERIAL VERFICAL LIFT CORRESPONDS TO APPROVED PLANS DYES NO _ DYES LINO PERMANENT MARKERS: COMMENTS: ossERVnrIONWELLS - NUMBER OF PROPERTY wELL BUILDING FEET FROM LINE DYES _]NO DYES LINO NEAREST y a,/ v Sketch System on Retain in county file for audit. Reverse Side. A uRE - TITLE DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION 3 SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AIVD PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% 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. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: ViAl ` 6J011Z cll t^F A ~o e L - =.✓c= . ~ A L c~ 'S' Property Location: City, Village or Township: County: 56 t/aSL✓ %S iTN/R /S ID (or) W ~ e 5 f ~f'. CRoi x Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: 5 7,L~ (If assigned) TYPE OF BUILDING h` Number of ® Public* ❑ Variance* ❑ Other (specify)* 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 ~Q © A-)e- >41 x HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: ~L S C~4JC~e'7~ e EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ® New ❑ Replacement ❑ Experimental X 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 inst tion of the private sewage system shown on the attached plans. Name of Plumber: Si nature: MP/MPRSW No.: Phone Number: , ✓ P_ ~,F- - j ib, f IM p f-T 4f_L?9 (7is)6,17d- ~&7 Plu r Address: Name resigner: 4~ Fqkcl cw/ 1LJ, S LJe_Jee-~-I JILd 4-- COUNTY/DEPARTMENT USE ONLY Sig ature of Issuing Agent- Fee: Date: ❑ APPROVED Sanitary Permit Number: tA~~ ( L'~~~ ❑ DISAPPROVED i~ 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 (R.07/81) • - fo loo .r: a C All, ; TTY, ~ ~ ~ , ~ A 4 M c--N IS, e A ,f c p x' -A lm W ~r fA a ^ 'f fir,,; N lb ac v p n III ~ q ~ y ~ - # tI~ r~1t11~~ ~ . ..,.v..._ . -vin D.I.L.H.R. Plb. t-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Leroy Jansky O.W.S. Division of Health 13 E. Spruce Street Section of Plumbing & Fire Protection Systems Chippewa Falls, Wl 54729 ON-SITE WASTE DISPOSAL INSPECTION REPOJV 5) 723-8786 Name of Premises Street City County Master Plumber Address Owner Address 1<7771 n ❑ County Permits ❑ Appropriate State Permits ~J Q' Type of Building: ❑ Public ❑ Single Family or ~ lex 21 r~ G CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM ❑ Building Sewer ❑ Conventional Soil Absorption System 0 ❑ Septic Tank ❑ Conventional System-in-fill ❑ Holding Tank ❑ Alternate Mound System r ❑ Seepage Bed ❑ Holding Tank ❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System BRIEF, FACTUAL COMMENTS AND SKETCH: 3rn E E _a. A _ _ 4 E E t 1 E_ E F E a: ' _ _x... . - _ 3 t t { - e 4- 4- a E 71 E E i ' s c _ E c E w 3 e ~ mm i i 4-1- 1 < . } k T 3 3 . { . X. , .e e. , e ` s t e , f r s E ~ a ' e i t e yy i r E c s E E I ` f s: } x ; i E _ 3 a 3 t t e ' ' e v r s e s ~ i p p t ~ i.. e e F 1 E £ ~ r e f i 3 z E , t 3 i k = e . < R R t t a E ~ r 3 r < < a f t { ~ 3 s ~ E f ~ c ; i i a ' d E w__ ❑SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party ' Department of Industry, Labor & Human Relations Division of Safety & Bldgs. State o ► 1 isconsin Bureau of Plumbing Platting & Fire Protection P ,O. Box 7969 Madison WI. 5370/ fcl- 1108266 3815 IN AL L CORRESPONDENCE REFER TO PLAN IDENTIFICATION NO. NAME OF PROJECT TYP OF AP OVA v_yc JRy STREET AND NO. Y V ~ CITY OR TOWN 1COUN1rY STATE ZIP nT' CL, C) X OWN R + i - L l -4, riel D 'K-O C: It PAL, a F S ~i 1Z t T,4,4L Md I S l 1 N 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. Sincerely, James Sargent-Bureau Direc r / PLANS REVIEWED BY: - DATE cc: DP -OWS Owner DI LHR Plumber H & R (2) County , Mfp. Rep. Buc. of Health Fac. & Services DILHR SBO 6099 (N. 06/80) Rec- & Env. Services Plb. 60 3/70 PROJECT DETAIL DATA SHEET NAME OF BUSINESS LOCATION me'RALS street or highway city or township - county - LEGAL DESCRIPTION SIF Y/ q OWNER ry Mailing address ARCHITECT OR ENGINEER Address ZIP PLUMBER Eveoze-+ f Rotclt _ Address _/Y)Ai,v_ _Sf_ M P `f q 9 i4.C. q~ w ins e-J r Z I P -f Yo o Z 1. Check appropriate building usage(s) and fill in ).he information requested opposite each usage listed: Existing building _ New building Addition If addition to existing building attach detailed memo for each. ( ) Drive in restaurant Car spaces Restaurant Seating capacity (10 sq. ft./person) ( ) Dining hall Per meal served Toilet waste Yes No ( ) Motel ( ) Hotel ( ) Cottages Number of units: 2 persons/unit 4 persons/unit _ TOTAL NUMBER OF UNITS Churches Number of persons Kitchen Yes No_ ( ) Bar or cocktail lounge Seating capacity dcoy!q. ft./person) ( ) Nursing or rest home Number of beds ( ) Mobile home park Number of units - dependent (camper trailer) - nondependent (mobile home) ( ) Retail store Number of employees Number of customers ~10 sq. ft./person) ( ) Service station Number of cars served (daily) _ ( ) School Number of classrooms Meals s_erved Yes No Showers provided Yes _ No ( ) Factory or office building Number of persons (total -a] I shi fts-T_ ( ) Apartments Number of bedrooms -f ( ) Other Specify 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes _ No X Dishwasher Yes, _ No X Automatic clothes washer Yes No Automatic potato peeler Yes Other . (Specify) 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned i Q) O Percolation test results - ATTACH PERCOLATION TE3'T AND SOIL BORINGS REPORT SHEET COMPLETE OTHER SIDE r' Seepage trench bottom area planned width Iinear feet depth / Seepage bed area planned p p w i d t h 7 1 inear feet lp O depth _30 _ - Seepage pit planned outside diameter depth below inlet depth _ See approved plan for specificatigns and details. $ignatura'Ctf person comploti,qg „fR,rm: STATE DIVISION OF HEALTH, PLUMBING SECTION Z C eI'r,,~y, P. 0. Box 309, Madison, Wisconsin 53701 fa rr ! r BOLOOT A. T App ro,,,ed OLWw•' ° Date: Address: . L7AL.;W 1 N. O , W, 0 e THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE Date: INSTALLATION FROM CITY, VILLAGE, TOWNSHIP OR COUNTY PERMIT REQUIREMENTS AND SHALL BE VOID IF REVISED WITHOUT THE WRITTEN APPROVAL OF THE DIVISION OF HEALTH. i DEPARTMENTAL USE ONLY CID ~J API I F7 1) i;w , o~~ (ACS -t (3 CID- + I , y,c of n~ ~ F° A 00 W w w i , Two ' w ( o 44 O*T 9 P4L 0 fit lea ~ m z ~ r- - rte a ''•~~~~•~+~r aaaaaa,,i C~ 2 fi ob Z 00 4P. )b ri ray f , ~ r ~ A p 02 to r o ,7 3 Q10 AL 11 ILA ti. - r O w Ne je • 0 /LIIrwd Act Pet- o Oro lRe-s+ Tsp. Sf. COQa I►c. Lai CRoxs Se G*/oI) 4 it OpA~,J r,C-LC( 1v ! ~vMB` cojiuoaaf'"d 0 /C~H? k J ;i~ , c yl~ %i Lim YA MP cr n~pF ~ ASS ONDENG~ j / - ~ ► Al°le-iQ -V Q d rv, , cove A o Q ~j M A R s/4' o qo .p `'0.'{ ` p ,'SV h•s - t. Cyr- •l~1.. r:.J~ t^ ' ► M (11/ 45 1 4.0 47 60 0, 5' 'r-n11,14 ?6, so 0PVC EVERS -WIN, T / L~ wls. Z l/ m p 1 min • < Z1 .n k a 3 D s? Z" ~ o v o- g p D 8 > ~ : ~1> i ~ ( , ft vo p Q. E ~ n • O N ~ r 1^ l f ~ i Q G. ~ ~ - S Ip ik ~ i ~ - O 6 $y' ~ • ~ , i I iw p -0 i C • «o ; i ~ t I U - i i LY 4A ' t der qQ C r f } 1 f 84, sozyoG ~~iI Ija.~ C1- ,y c , ~ o ~ ~ I 1 fv _ " o • C Z _ I- _ ~ c ~ n ~ JO LAJ / -b a r ON 'L e'oIVTOF REPORT ON SOIL BORINGS AND `;Al f TY & 13UI ISION 'VUUST USTRY, DIVVIS ABOR REANDLATIONS PERCOLATION TESTS (115) MADISON, WBOX 76 IiJMA I 53909 (H63.09(1) & Chapter 145.04'.1) 0CAT1 N. SEC> ION - _ - TO NSHIPiMUNIr IPAI IIY LOI-N l~ HIK NO tifiltlVISION NANIE. SE '/5 / ,~9 /T31 N/R/S'(r,rl Wo A-0 es 7~s AUNT~ O W NE R' S 7B U YE R'S NA E: MAILING ADDRESS— - - I' - s ~.Vc:JoQc( e 904 Pe L a _-L 11- Ej 1 e k a i d )SE j rJ14 MIN/S DATES OBSERVATIONS MADE - - BE MS.: COM R IA DE§CRIPTION: ~ - - _[ROFIF I_E D~$7`fTll T IONS JResidence ( New Replace l r7 - IATING: S- Site suitable for system U° Site unsuitable for system - - OsTI❑UONAL]1M®QUND s ❑u INGMIS EIU SYSTE(MINIILLHOLDIcNGri'JK RFCOMMf-NDEDSY;;~~M:(opunii.J) f Percolation Tests are NOT required =DESIGNRATE: If an pot nrnn of the tested area is in the - - ,nder s.F163.09151(b), indicate: LFlood plain , indicate FloodPlain elevati(n: PROFILE DESCRIPTIONS BORING TOTAL D PT T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH ILA40ER DEPTH IN, ELEVATION _QBSERYED H G ST TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B- 05 > + (z',~- Vfir~•CaLoa M:~.ed ~.:,f5/~wd ~-fR B 7. 99, > ,c 6L-5,L 411 SL, (o„ (I AL -~6 L PERCOLATION TESTS T DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVELINCHES RATE MINUTES vUMBER INCHL-S AFTERSWELLIN INTERVAL-MIN. PERIOD I PER15D2 P Rlo(5PER INC H _ ~.7;W Al - F' OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas Indic4ke scale or tL tanceYAkescribe what are the hori - ntal and vertical elevation reference points and show their location on the plot plan. Show the surface elev<`ttioa',~~; H:,la rings and the direction and percent and slope. ?qo ')YSTE,M ELEVATION 96, 7S'~ for ~IICU Ppe a ' Bole,:, 1-~o k i P.21. Pf C, es- m - 400 o a, No. r _W j35 3 - lDd,a° ' 5 w to R A c! e. po A 14 J i¢ C L. Q .c 9 S nKNe 4 Acr<fOw y~ 4°f. old ~c g(- 99.E PA Ak}IK R,v-e- -wA q _ - ptke mf>J a F ii~ s' F~, PSLd~ of a5"" F0? -r-►t t.. Gue, LL Mtn? , r P b the undersigned, hereby certify that the soil tests reported on this form w,,te made by me in a curd with the procedures and ,neu,tnf.'ln-,-ifltsd r W, rosin i(ninistrative Code, and that the data recorded and the location of the tests are correct to the bee t of my knowledge and belief AME (print): r" ~f FSTS WERE C OMf I E I Fl) ON r JDRESS - - CEHTIFICA710N NUM".I i, PHI), If NIIMISI R of T ATHRL ~f ISTRIBUTION Original and ont, ropy to Local Ai, iho,ity, Pr opeity Owner roil Scut 1, lei i. HR-SBD 639', IH U2%t3 Ir /42' r r I h Fr►rn.~ R rsr' Rest 3-le / E Ilc~ /t „1 1 f , S its& r r J e►,d U'..IIS "tA CltUts~o~ All S,at's w, II h xve .;i <,•/,..r ArCw !,►~,s/ie./ tl. .S7t~ 1. J-,1t,1C- Clic, r- Ll', M►e r..l IAJ /0 X .3 _ Lit j rIfA 4, c.d.,.- f fell CI b r., c e- ~ 1 y 1 j kiOLDT f Aaby WAS ~ IC's ~ i X11 lei Department of Industry, Labor & Human Relations V Division of Safety & Bldgs. State of Wisconsin T~ Bureau of Plumbing Platting & Fire Protection P.O. Box7969 t~ ~ Madison W1. 53707 ti c r Tel. 608-266-3815 4:L__ LJJ (P INALL CORRESPONDENCE REFER TO PLAN aP ,..f 3 IDENTIFICATION NO. NAME OF PROJECT TYPE OF APPROVAL STREET AND NO. CITY OR TOWN NTY 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. f`k 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. Sincerely, ~litt4~ 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 DILHR SBD-6099 (N. 06/80) Rec. & Env. Services 11 SBD 6678 (9/81) 0b 100a) ~O 1 ~O n j STATE OF WISCONSIN DILHR Detach And Return Upper R `v IVISION OF SAFETY & BUILDINGS UREAU OF PLUMBING Portion Of This Form With 1 E. WASHINGTON AVE. RM 178 Any Return Correslondence Co .O. BOX 7969 ADISON, WI 53707 608-266-3815 DATE: PROJ Cam. ~ P1 AN in g 7 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 Pr,:file of holding an. , showing vent, marl-ale 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. III. 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). n Copy of onsite report by county or district staff. I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABGR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 LOCATION:S SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: //a .2.9 /T 31 N/R I1(or) W res ~ COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: St olx C,'~rn~ p Cl& IR I USE , DATES O SERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: R TONS: 1PERCOLATION TESTS: ❑ Residence ' KNew ❑ Replace ~d'J/_ C9~ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM-(optional) S❑u S❑u . XS EA aS~u oS~u If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL I If any portion of the lot is in the under s.H63.09(5)(b), indicate: I` Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DE IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r, B / q9 r if 0--1011 e~lhy B 9 y 8-51 ~irQ ~6' S _ it 99 fC-L B 5' 9F9 61--SL- 4,( SC . 9 rr Q PERCOLATION TESTS ttJ 1O TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERS ELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ r/ 0 o P- vZ @ 0 rc ~i P- P_ PLAN P- VIEW: 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 slop. NO r SYSTEM ELEVATION C/(O ° ~ / &=6pttl Li yi9cr~s 3a'o'9 v$5~ 155 4e~- /v'----~. # i E ;5,--Ipp134 Church 4 1 vOO.Or T0~ Of O Slob `I F\ o 0 r a-F o\ Nis C-1 29 Kreca B2 - 99,2' - D rn;.V . F A s- 6L-, X33 - qq 0' i We L L 111. -j 5~a Fie, i, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: ADDRESS: CERTIFI ION NUMBER: PHONE NUMBER optional): ST SIGN UR DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DI LHR-SB D-6395 (N. 03/81)