Loading...
HomeMy WebLinkAbout038-1012-50-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 128656 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Jon A. & Gloria Erickson TOWN OF STAR PRAIRIE 038-1012-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 03.31.18.33E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent t Air I take ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System ` Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing _ i i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over FBed/ Over Depth of Seeded/Sodded xx Mulched Bed/Trenh Center rench Edges Topsoil Yes [ ] No L] Yes ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2395 CARDINAL DR 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes No 3 ~ Use other side for additional mformat Kn 1 l J J SBD-6710 (R.3/97) Date Insepctor' Signat Cert. No. e'l 7 SA~1ai~ - ~S3 County Sanitary Permit Application 4 ST. CROIX COUNTY WISCONSIN Ol in accord with Chapart 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT ~v " L U 1 rersonal information you provide maybe used for secondary purposes ST. CROiX COUNTY GOVERNMENT CEN i ER ,Privacy Law. S. .E.04(1}(r)j 11Gi Carmichael Road 3~' 00CROIX C UNTY Hudson, WI 54016- 10 Y CMMUNITY D (715)386-4680 -ax 015;386-4586 Attach complete pie aDer not less than it 1,'2 x 11 inches in size. County Sanitary Permit Al ° - afipn r • w . 2Z I r 5 -3 I. Application Information - Please Print all Information Location: Prope~ty Owner Name y~ I 11/6 1 i4 NCG i/4, stet ~5 c~ t/ F-- l & k j- C, / N, R E (or Vd 'rope-ty Owner's Mailing Address L h' i i1 r ? of Number 314^k Number 6 A ~i/ . -n_ q -5 l C~' dl 1 C.11 'iJ'l c/1tCC ~L 1 v City, State Zip Code Phone Numer Subdivision Name or~CSlvl Number 11 Type of Building: (check one) r'N amity ❑ Village i own of or 2 Family Dwelling - No. of Bedrooms: - Putiiic'Commemc al c;descnbe use): _ _ /2Ct State owned Nearest Road . _ ,y ~j 11. Type of Permit: (Check only one box on line A. Check. box on line B it applicable) C'am` c Parcel Tax Number (s) 1.1 & Repair 2. El Reconnection 3.JNon-piumbing 4. J Rejuvenation Sanitation B) Permit Number Date Issued State Sanitary Permit was previously issued % l J N. Type of POWT System: (Check all that apply) Non-pressurized in-ground ❑ Mound ? 24 in. suitable soil Mound s 24 in. suitable soil a Mound A=G Sand Filter 10 Constructed Wetland rJ Peat Filter L Drip Line Pressurized In-around Holding Tank O Single Pass n ❑ Other AA-grade Aerobic Treatment Unit 0 Recircuiating V. Dispersal7reatment Area Information: t. Design Flow (gpd) 2. Dispersal Area 3. Dispersai Area 4. Soil Application Rate 5 Percolation Rafe c. Sysier- Elevation 7. Final Grade Required Proposed (GaisJdayisc.tt.) (Min./inch) Elevation X150 S6Y 5-76, , 76 ~p 6-z-, VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted class Tanks Tanks D ~ D Can . .~t.E> , Vil- Responsibility Statement L the undersigned, assume responsibility ="or repairireconnenction%rejuvenatiorvinstaiiation o" non-piumbing for the POWTS shown on the attached plans. A license is not required for tenalift repair or the installation of non-piumbing sanitation system.. Plumber's Name (print; Plumber's Signature (no stamps, MP APRS No. Business Phone Number dlcc.K-Jl4E u), czl n tin , u~kt itZ7710 -715- - 7`f - 3.1,;2 Plumber's Address (Street, City State. Lip Code) Vill. County Use Only Disapproval Sanitary Pe mil Fee Date Issued ssuo5 Agant aignatt,~fe tN sta. `~ps) , n/ , I Aparoved - Owner 3iv~nit,.al Averse ? D,etermanaiton IX. Conditions of Approval/Reasons for Disapproval (J l Nld SC tT0 Ci a u z w o W SQL a! U o a s u 5~v ~lj Z~ IZ, 4 IS- ~3 V :Z w I ~ J R~bCN~~- 4 a W 6 , PLI% 17 LZ k~- ° oay- ~ V v O-z - i S v~,~ RECEIVED MAY 3 YGi ST. CROIX COUNTY COMMUNITY DEVELOpME NT f I.L.H.R. 83.08(2) PROJECT INDEX SHEET = Owner: A) CA-1.O.J 2q~-,3G~ Address V 'p-4.2. -i3o* III C-iPDivAL 'DRi UC lJQcJ l2i ~I^ti1o~17 4~(S. . Sh/ Site Location: NE /y pw j She. 3 T 31N, K I,~, 4J Of ST'4~ Q y r s-+ GLoix e•000 ry Project Description: IL x ,51 . Co.o J tti //o~ t L Sf/S 1E~1 (iN MotfLEo k I) . ~~icfCSo,JS y r,4 SoiL - SE£ IIS M~ty I~a IS Fgi~~~G S S~ EM 'f1,t_ 5t,ftA IStfE~- s~ IE FOQ R~pc ~ce.K~~ r- y ~tl~ ~IL`S ow! NQl ~D g's I;Rf41, ? fJ~t~CY 5 ` J 4A9E,,l E..u t ftfk t~rt~ t i S ~}T?^ LGac2 SCJiLS Irk R&poSED RfPL-hGE ~l=v1 /`~~cCfi 7}iQE • ~U(Th 13 to p CO ot 3+ia jA L s y STeM LG,+S S -71:,) . Av iN~ ~pU V(3 ~i2 SSu~c 51/ 7 i 5 7f"J ~G-3 AV~Uk v&e- TAkLy i=STi~Ifs1-tD• wAS-EE f10'-J ( F6 (Z F-I-O.k e- i 5 30D 41, "eje 5%24-0 SySf ~r Fort 3 3, D~oo-'q'; 5 P D' Page 1. PLOT PLAN VIEWS Page 2. CROSS SECTION & SYSTEM PLAN VIEWS w Page 3, PIPE LATERAL LAYOUT Page 4. DOSING CHAMBER CROSS SECTION Page 5. PUMP PERFROMANCE SPECS PLUMBER: DATE: SITE EVALUATER/ DESIGNER .4 - SIGNATURE HOMESITE SEPTIC PLUMBING CO. 656 O'NEIL RD.. HUDSON, WIS. 51016 ROBERT ULBRIGHT tj WIS. MASTER PLUMBER UC, N0.3307 M.P.R,S. j~ + MINN. iNSTALLFR i Gc91GNER LIC. No. 00663 a ~ a g ~ .M ~ ~ ` rt _ ~ i _ „ w. F_ i . _ ~e ~5a . R . - . ~O j r w ~ b r r` ~ ~.c~-o 5 Naa1 ~ ' t.t t~ i 211 f t LIN _ V4 i i yak ~ .p ~ i t~ A {ul o ~ h L O a J R y o D ?tom 0 y 7p O I i7 , m y It) c a ti CEDffi~ Li9~f'C I lrt r f~,. I' , 4 / t / 1 ~ ~ r °T ~ 7~ i`ft I ~ ii 1 ~i r a , ~ J ~ ~ r. (c", e I I I J J y y D-li~ tit ' y 1 Ldl i ~ ~ I I, ~ ~ - 1, qqp 1 ~ rt M IN. s •anr.t(j luutpieD sr umoux peo.t aql jo aucj lsu3 aql pug i .j)jgdo dd aql jo auil ylnoS aql of uoilulai ui uorlgaol slt 2upaogs pjagu it tp aql slon.tlsuoa iugj CIiluo io uosiod aql Xq do u.-Auip duet il!nq sv. uu aq ll!m antLL z 'dtq!ssod se A. UHd0-dd acll jo ease alml sr asn o; se os moltu ll!m suoneln2al apoD ;)AQVJlslulwpd utsuoasir41 aql sg A,L1 I3dOXd aql uo lsaAk puu glnoS jEJ su palan.t;suoa aq jpm piayuie.ip at{y •T :suoiltpuoa 5ut,Aollo} aql qlc,-, ~U. lign[`j paxlutu pug ola.iaq pagagllg dgw aql gl!m a:)uep.toaau uc sauti uoiloauuoa pug Iagwuga dcund `plaguiutp aql lan.tlsuoa of (,U-dgdO-dd) l9Z9VV 'oN luawnaoQ su 9£l Auj uo sp.toaa-d jo 9£8 awnlo,k ui a3gj0 spaa(I jo ialsi$a)l Xluno:) Yroa-) -IS aql ui pap.ioaa.t paap aql ui paq!iasap taalgd lugl jo iaujoa lsannglnoS aql ui puul 3o gair luaiagjns d X. 3'lClU3H3S of 5 ' , CROSS 5 EcTlv/,- - l-GV°LWD PQESSORE $ eD Sc Alt ; l 9R•t0E ~i v; s NCO orF J i. ,IDr~ E ci ST,^~~ J OE - - 1 310 COJfR 3~0/ Cr1A Hybl ~ppRovE0 ~ RECrrtTE 59 uppl.,e bvtofS ion _ _ sysrvl ~I~vtno~ r 7 • = A66RE6l1t /,T whSNL - 1 o f= l y " LET ~ ren I S 9 2. 5D • = e(euATio~ of in,ufR flea*rno.,) of To of 1 LAZe~nl S 92. Cc O CAr~ V It of ►,U C~c-u~=~'~ I~ss~ ~E BED A St. i ~ f I~t o 0 v 3'~~ ~7 ~Lfwn// - - l s7 W C, 16 ~o O BED of: U AZtiEO ~`l~ ---kit" 3/H' A5yRe6nT a C C1 ~ G l~ 'TI O r a i 40, O -7,D y i 70 z ~ o m Lh „ n G j1y~ -t ~ n N a q 1 m o Ln (n ' o i v I ~ D T ~ nl Y 7 lJ ~ A fi rn O I o c~ i G y w lr ` °o n C cou P L n ` t e .y j I i tv D . i 4 1 y s- PAGE _ OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS i VENT CAP H"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 25' FROM POOR, 12"MW. w~tvMN~a(rQW1 WINDOW OR FRESH / ~ AIR INTAKE ,jppe ~-&-o4T/ON GRADE. Z Ie"MIN. CONDUIT XN 930 \ \ INLET PROVIDE I AIRT141{T. 014 I III 1L APPROVED JOINT/ A v r I III APPROVED .IOIMTS W/C.T. PIPE / 00,k1 q D I III W/C.I. PIPE EXTENDIMG 3' Nl I II ALARM EXTEUDIN6 3' ONTO SOLID SOIL a~ I I I ONTO SOLID SOIL B ~~`aSI^11p~1 44 c at' CLEV. FT. OFF I (I' I l COMCKETE BLOCK mlvA f io q, FUSEK EXIT PLKP\iTiED C)NLY IF TANK 1, ~Jr:CTURar' HAS !Ct! J{PPROVAL 2., 0 SEPTIC f / SPEC.IFICATIMis DOSE TANKS' MA►IUFACTLlK~E..K:t~o"~e11 ~~~Cl(~~4 IJUMBERPOF DO ES, PER DAU TANK SIZE: dam{ IV GALLONS DOSE VOLUMD,'S) / ALARM MANUFACTURER: rIGtf e,-- ' INCLUDING BACKfLOW_GALppLOyN~ MODEL NUMBER: V` CAPACITIES: A ~ IAICHC$ORR36 GICLLQ ONS SWITCH TYPE: meR GJ dU F"'i -r 8= Z INCKES OR /361 CsAILONS PUMP MANUFACTURER: G= ~~5S INCHES OR GALLONS MODEL NUMBER: / !12 P' D=~St_INCHESOlt GALO 5 Pj&(-,I 3Ac& MERCuiry F/c~ITS MOTE: PUMP AND ALARM ARE TO DE SWITCH TYPE: MINIMUM DISCHARGE RATE ~o GpM INSTALLED ON SEPARATE CIRCUITS J VERTICAL DIFFEREMCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE..//,-7 FEET 7Ajk SPECS + MIyyNIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . 2.5 FEET EA (1 Of- y~ P IVI. + FEET OF FORCE MAIN X ' 23 FYo►t.FRICTION FACTOR. ' 09 FEET t-40AJS 2 - TOTAL ~Als. TOTAL DYNAMIC HEAD 3 FEET. 7 INTERNAL DIMENSIONS OF AD : LE H ;WIDTH / / ;LIQUID DEPTH A SIGNED: LICEIJSE 1JUMBER: DATE: I HEADI 34 f110 - - 2 CAPACITY 32 1,05 30 1100 195 - CURVE 28 99 26 EFFLUENT 24 MODEL and 75 MODEL 169 DEWATERING = 22 79 165 20 -,S Q , I l., 16 50 MODEL - 163 MODEL \•'c,+,r,C.!LcL. ~L''I/,'V4~G,GG tI 166 } 12 40 SS - to MODEL MODEL 20 - - 13T, 139 - 165 SEWAGE and r2 5 DEWATERING 6 - - - + - MODEL MODEIy 161 4 r• f 10 - MODEL 2 a 5 53. 55 57.5 . - - - i 9 0 GALLONS 10 20 30 4050 go, 0 60I 90 11 1110 f 24 TS LITERS 0 30 /S0 240 320 400 j 22 FLOW PER MINUTE i TO 20 - 1 50- MODEL- I 1 j---'---T-^-_-~ _ 285 W SS r-----+---- J _~r--_._~ = 1a Q 14 _ _ f /tom MODEL - T-- i y 12 40_ t O - MODEL \ - ,J T" F 10 '35 36 0 MODEL' \ 30 294 \ 1.. ° 3 MODEL L 1 , 6 21). 282 I I i~ 4 10 - I - . _~Dfllf~4'1 MODEL r 2 5 r 267, 299 7 I I 3280 Old Millen; Lane GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 160 190 P.O. BOIL 16347 + Louisville, Kentucky 40216 LITERS 0 9o ISO 240 320 400 460 $60 640 720 (502) 778-2731 FLOW PER MINUTE i `97" Cast Iron Series CAPACITY NERD UNITS/MIN • Automatic or Non ALll061.01C. Feat Maters Gal. Llrs. 5 152 57 216 - • M.P. 1 Ph., 115V or 230V. 10 105 51 193 `J - • Non-Clogging vortex impeller design. 15 457 43 163 • Passes solids (sphere). 20 610 21 104 1 • 1~," NPI d~SChdrge LUCK VUIrb' 24.5 • Float operated submersible (Noma 6) meth- ~}/Lr alllcal switch. ASS 976erwa listed i sc-2225 • Automatic reel thel mai overload protection. YW. • Stainless steel screws, quard. handle and arm and seal assembly. Man - • Watertight neoprene' Li' ring Oetween motor and pump huusmg. C ass~a1A stanaa4s U' ppro~~i N97, non-automarrc. araneole pacwaynJ wnh a P,ggybacN mercury Moat rwJU i IIII i ~,..„o ~I . . ~ t.~: t~ r`~~~ ~a .~r _ . } F t i I i II I d S I EASEMENT AGREEMENT This agreement made this76H day of 1989, by and between Keith E. Maxwell and Nancy Maxwell, husband and wife (hereinafter MAXWELLS), and Jon A. Erickson and Gloria Erickson, husband and wife (hereinafter ERICKSONS). MAXWELLS are the owners of certain property described in the deed recorded in the St. Croix County Register of Deeds office in Volume 836 of Records on Page 136 as Document No. 446251. ERICKSONS are the owners of certain property described in the deed recorded in the St. Croix County Register of Deeds office in Volume 537 of Records on Page 313 as Document No. 333057. MAXWELLS have agreed to grant an easement to ERICKSONS across a portion of the MAXWELLS' property and this agreement is made to evidence the grant of that easement all on the terms and conditions set forth herein. Therefore, in consideration of the mutual covenants contained herein, the parties agree as follows: 1. MAXWELLS grant to ERICKSONS an easement to install and maintain a residential septic system on and under the property described in Schedule "A" attached hereto, which easement is subject to the conditions set forth in Paragraph 3 of this agreement. 2. In connection with said easement and sanitary residential septic svstem i ERICKSONS agree as follows: A. To pay for the installation of the septic svstem according to present required standards of the State of Wisconsin. B. To maintain the septic system in good working order at their expense so as to cause the least interference with the remainder of the MAXWELLS' property. C. After the installation of the septic system to bring the property to the same approximate grade and sod or seed the same to bring it to a lawn condition. 3. This easement shall extend for a period of 99 years commencing with the date of this easement agreement and shall run with the land owned by ERICKSONS during that rN S50 F:.. period. The parties agree, however, that the easement will terminate under either of the following conditions: A. As such time as the ERICKSONS' property is served by a public sewer system and ERICKSONS are afforded a reasonable opportunity to connect to such system. B. At such time as a subsequent purchaser of the MAXWELLS' property would be unable to finance the purchase of the property using a real estate mortgage on the MAXWELLS' property as security solely because of the location of the ERICKSONS' septic system on the MAXWELLS' property. Any subsequent purchaser would be required r`! Ti= ~~",S, ~R`S OF (LF to give 60 nays notice to ERICKSONS of the fact that he or she is ST. CROIX CO., WI unable to obtain such mortgage. ERICKSONS would then have the Recd for Record SEP 0 5 1989 right during that 60 day period to assist the purchaser of the at 8:0~i0 AM MAXWELLS' property to help him or her secure a mortgage. If a an~~ mortgage cannot be secured and the matter could be resolved by Register of Deed: ERICKSONS purchase of the easement property, then ERICKSONS shall have the right to purchase the easement property for its fair market value as determined by an appraisal. If the condition cannot be removed by ERICKSONS purchasing the easement property then the easement will expire one year after the end of the 60 day notice. 4. This agreement shall be governed by, construed and enforced according to the laws of the State of Wisconsin. 5. This agreement shall constitute the entire agreement between the parties. Any modification of the agreement or additional obligation assumed by either party in connection with this agreement shall be binding only if evidenced by a writing signed by both of the parties. 6. This agreement shall bind the parties hereto, their successors and assigns and rights given to either party and the terms and conditions of this agreement shall bind and inure to the subsequent owners of the MAXWELL and ERICKSON properties. 7. This agreement is an amendment to the Easement Agreement recorded in the St. Croix County Register of Deeds Office in Volume 848 of Records on Page 508 as 2 ~JUrk~F~i7J Document No. 450570 and intends to amend only the legal description of the easement but in all other respects confirms the original agreement. IN WITNESS WHEREOF the parties agree and have set their hand seals on this agreement the day and year first above written. 112 1T Keith E. Maxyle'll Incy Maxwell (I in A. Erickson ria Erickson t STATE OF WISCONSIN ) S CtZ01 K cot,.. ~ > SS. ti nally carne before me this r1day of t -7L49939, the above named lth:t- well Na y/Maxw 1, to me known to be the persons who executed the re "n 'ru e a d Cg e d the same. " ?`otarq.•Public '4".4 Si, er-Lo i V~ County State of Wisconsin My Commission Expires: 3 STATE OF NNISCONSIN ) ss. ST. CROIX COUNTY } Personally came before me this day of 0 1989, the above named Jon A. Erickson and Gloria Erickson, to me known to/be the person who executed the foregoing instrument and acknowledged the same. Ste hanie A. Desino STEPHANIE A. DESINO Notary Public, St. Croix County Notary Public-State of Wisconsin State of Wisconsin My Commission Expires January 10, 1993 I 4 BAKKE, NORMAN & SCHUMACHER, S.C. 1200 Heritage Drive P. O. Box 50 NEW RICHMOND, WI 54017 George E. Norman Facsimile - (715) 246-3802 Gary L Bakke Telephone - (715) 246-3800 Thomas R. Schumacher Carol Nolan Skinner September 8, 1989 Mr. Henry Nechville Mr. Bob Ulbricht 967 Highway 65 655 O'Neil Rd. Roberts, WI 54023 Hudson, WI 54016 Re: Jon E. icksor, - Property Matter Dear Mr. Nechville and Mr. Ulbricht: I am enclosing to each of you a copy of the revised easement agreement in the above matter which now has been recorded for your records. Very truly yours, BAKKE, NORMAN & SCHUMACHER, S.C. Stephanie Desino Legal Assistant Enclosure i i i I I DAL SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~ -Z- STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8'% x 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. - ( PROPERTY OWNER PROPERTY LOCATION %4 S T N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned CI VILLAGE ' UWN OF ❑ Public El 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 0 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash ` I 5 ❑ Hotel/Motel 9 El Office/Factory 13 El Other: Specify , IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. O Replacement 3. ❑ Replacement of 411 Reconnection of 5.E1 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # . Date Issued V. TYPE OF SYSTEM: (Check only one) j Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill i VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2, ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE' REQUIRED (sq. ft.) PROPOSED (sq ft) (Gals/dayr'sq. ft.) (Min./inch) ELEVATION Feet Feet CAPACITY VII. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App- Tanks- Tanks strttcted Septic Tank or Hold!n Tank Lift Pump Tank/Siphon Chamber D L1 i Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print), Plumbers Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Approved ❑ Owner Given Initial I Adverse Determfnatlon X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: I i w i I - - - - SBD-6398 (formerly Plb-67) (R. 11,88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS 1 1,jyL" MADISON, WI 53707 (ILHR 63.09(1) & Chapter 145) LOCATION: 1 ~ SE Ti TOWNSHIPiRRl7MtCMA-G1TY: OT NO.:BLK. SUBDIVISION NAME: ME 3 /T s/ N/ R L~ E ( ) W sr-'M P~~i•°iE - COUNTY: OWNER'S BItY1ER'S-NAMfr- MA.LIN ADDRESS (Ilem( Toll") FOP/clfT0 nJ Cfl/'Di fJfl L Cv S . USE DATES OBSERVATIONS MADE NO.B DRMS.: 0MM RAL DES RI TION: FISFILE DESCR T N PERCOLATION TESTS: Residence 7-- - - ❑New (,,Replace Sc s 3 S,ycvs fS 4114EPy /1111 RATING: S= Site suitable for system U= Site unsuitable for system ONVEN NAL: MOUND: M-GROLIDS O URE: YSTEM-IN-FILLO LDING TANK: RECOMMENDED SYSTEM: (optional) ❑S ®U ❑S ©U ❑ DU ❑S ®U OS ❑U No✓df0G•T oe /k4oU,0 wry If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodpla in, indicate Floodplain I PROFILE DESCRIPTIONS /0 'DELj-*L T+ BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER EPTH IN. ELEVATION OBSERVED LST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.I B y Z r /0% 7,? r't)3 E n 133 yl • G y- a,, . ~ l -4 ill 'C' F2_ ' ~ - oQ . I-o mPAc7 0 ' 5 ( 4;11 ro7.9jeA Sf f: N co-• fCree wrJtt 144 sr SstA// v1 r o , S' -03 evr-E O1C jy B• S/ NO'1-ILED (.33 0(rdJE- flit-. oP *0. is S, 9~9 .2 S4 (~,)l , .G7' iy DEN1Efo ,OgI77FD Si/ B.2- /a 2, S T /2 TO .S' ?ve. oPS•t.~i~ gzusc ek aofS 2 SA'rY/ey srwDy c Ey o.t-, diS'ri.J 7- B_ / CW - "Of.!; rAT tAA._4f D _-2 S B 3 5.0 /vs'.c~ 3• o' I. 33 23'.F,09-Bo Oir-sc 5/ -Fr l! 1,o l . OPT" I~ r w fir o z .6, 54VP,V e?lfy 10411 tv/ 14,10y A37. .4 . ele B- MO t S PERCOLATION TESTS - To 731 ro vDU rT~ ~ 7- TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEV L-IN HES RATE MINUTES NUMMER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER INCH P. P_ P- 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. zonal 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. This test site NOT APPROVED SYSTEM ELEVATION for a conventional septic system. See expianatioh. • O>J S;-/ idt. Cp T 2 o J .v Cr - ~9 D ~~,v~'S 7~~f T~~, 'T^D-'A t3 N -u- I S o t~ 14,4 CGGd~j~~%~Oal Fr~iPf G~ ou s: Tf- :T7. E RSot,E'L L-E_Pay 3 ~5 KY) F~ U T ~w ~tT U~ S~DE- No~~ Fop '1140000 AP'PPou_4L, ; -r~trs Sr'r W001-D l,vvo/vim 14 Ur1i?~~1NCE ~PEV~EtJ love I 5E4ShA4f1_ S47Wk>t 7'1;10( 11 t,1 (-2)C01 PAc_Ti6A-) -f T010 2 1/' (3) Ph'rSE•ucF- e Z- Ft// .y~rT iii ~~ll STPATi 5 (YJ 15:xctSS'0E_ S/0 (S) Mo0.v~ w001-v KEEP -to 3E- C0,0 S71P0 c7 ElD P~4p_rijl1y ov,-..4il d~.4? ffj//,AG- s y sr~•-~ 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 : HOMESTTE SEPTIC FLUMBINU - TESTS W ~ E COMPLETED INS e7 655 C'NEIL RD.. A IDSON, Ili 51016 M,( 1/ i ~ Grp ADDRESS: UEERKsHT / `MS.MASTER PLUMBER LIC.NO.3307M.P.R.S- CERTIFICATION NUMBER: PHO E/NUM (ofjtionall: N0.1X1663 2 yp L .3? N T/ S CST SIGNATURE - DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD.6395 (R. 101831 - OVER - 1- ~ - yt ~ F w o 9 Q Y~ °4` t oc ~ 3 CT -V ~ v W W w y N h h N I k A M h~ p u _ Ckl ` `"IQ Q Q~ N ` M V 00 a_ ~ WI y • pq a; r N C X11 or ` I O 0 ni l \ 1&Z I ~ z AL roT~'~!d'~ in w cr. ~ ui ¢ a Oz z N z J J SANITARY PERMIT APPLICATION Z04 LHR In accord with ILHR 83.05, Wis. Adm. Code (COUNTY ^ - STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 81/2 x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/4 Y4, S T , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR GSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE ,i- OF _ RCEL TAX NUMBER(S) LJ Public E-1 1 or 2 Fam. Dwelling-# of bedrooms PA III. BUILDING USE: (if building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hail 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13E] Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 1 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: I 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 1 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq ft) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. Con- T xistin Gallons Tanks Manufacturer's Name oncre stuctte rusted Steel glass Plastic App INFORMATION New anks Tanks Semitic Tank or Holding Tank _ Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW NoBusiness Phone Number Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) i El Approved ❑ Owner Given Initial Surcharge Fee) i i Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: l i i I I 1 SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To. Safety & Buildings Division, Owner, Plumber