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AS BUILT SANITARY SYSTEM REPORT'
OWNER TOWNSHIP J'i7N-lilyW
ADDRESS Zl,, ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION
PLAN VIEW
Distances and dimensions to meet requirements of- HO6 as
hL_E_VERYTHING WITHIN 100 Fl?I-:'T OF SYSTEM
.
IT,
r`
IT
A
I di a e orrh Arr,,w I
SCAT.
f'p `~~i Cv~ is y
BENCHMARK: (Permanent reference Point) Deser- ihe: of dot
Elevation of-vertical reference point: Slope at si t c, : le':,
SEPTIC TANK: Manufacturer: Li-quid Capm, it y : /C~q e-
Number of rings on cover Tank ma r o hI e cover e 1 evat ion: Tank Inlet Elevation: 't'ank Out let I,:1uv;.ii ion:
PUMP CHAMBER
Manufacturer: Number of gaItons
Number of gal. PUMP set for a cycle };allorls , tut <i1 c.lI>:wi t y o
distribution lines_ gallon: s le of` pump_
gallon per minute horsepower brand namt ut bump
and model number
Type of warning J_eV_ce
HOLDING TANK: Manufacturer Number of gaIlour
Elevation of manhole gover
`I'y e of warning device _
SEEPA E PIT SIZE: _ Numier or 1)1-t s[(ee t di aloe i
feet liquid dept seepage pit inYeL pipe-etevaiion
bottom of seepage-pit t elevation feet
SEEPAGE BED SIZE: number of lines width le ,~,t_Ii ? t i I c clupt h
-
SEEPAGE TRENCH: widthT length
PERCOLATION RATES REA REQUIRED AR' /
Sill"C
DATED - - PLUMBi%ll ON J011
LICENSE NUMBFk `fp_~, -:5 r
r DEPARTMENT OF INDUSTRY, ) 'r INSPECTION REPORT FOR SAFETY & BUILDINFS
LAB",)R~& HViMAN RELATIONS r 7 PRIVATE SEWAGE SYSTEMS DIVIS,.;N
P . 50X 7,369 BUREAU OF PLUMBIN
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure O Mound
O~ O INSPECTION DATE:
NA ,;;;;)L DER: AD~ESS OF PERMIT HOLDER
4/1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. j REF. PT. ELEV.: CST REF. PT. ELE V.
oS s s a 7
Name of Plurnher: P/MPRSW Nn.. Co my Sanitary Permit Number
s "y o ao -
SEPTIC TANK/HOLDING NK:
C, 7,4
MANUFACTURER. LIQUID CAPACITY. TANK INLET LEV_ TANK OUTLET ELEV. WARNING LABEL LOCKING COVER,-
P OWDED: PROVIDED/
YES ENO yE~ ENO
BEDDING: VENT DIA. VENT MAT L.. HWATE NUMBER OF ROAU PROPERTY WELL. BUILDING. JVENT TO FRESH
M I LINE AIR JNLET:
FEET FROM r
YES EY S N4` NEAREST - C ~G
DOSING CHAMBER:
MANUFACTURER BEDDING JLIQUID CAPACI TV PUMP MODEL ~UMP,SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
EYES ENO EYES ENO DYES ENO
GALLONS PER CYCLE: PU AND ONTRgcS ERATI NAL NuPeRrv WELL BUILDING I VENT To FRESH
(DIFFERENCE BETWEEN f ! FEET FROM LINE AIR INLET
PUMP ON AND OFF) Y-1yLes NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil mois ure at e cjepth of plo Ing In I I, [1,M,!~ TER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire, nstruc Ner n shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDIH LENGTH NO. OF TSTR PIPE SPACING CoVFH INSIDE DIA. ITS LIQUID
BED/TRENCH TRENCHES / MAJ~HIAC PIT j DEPTH'.
DIMENSIONS j f
(,Hi'i r,rl li FILLDEPTH UISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO ISTRJ NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BE Ln 4P Pf ~ ABOVE COVER EI_EV INLET ELE END. PIPES ' LINE / t A I tLEy:
FEET FROM
NEAREST--s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture /mace ill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound s fe s to r I that it ON REVERSE SIDE. SHOW ELEVA-
meets cr eria fosa TIONS MEASURED.
YES NO SOIL COVER. TE XT UHE ERMANENT..AR'ARKERS OBSERVATION WELLS
EYES ENO EYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH;BED DEPTH OFT PSoIL 'SO DDE SEEDED MULCHED.
CENIEH EDGES -
YES ENO EYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: _
W'IDTH' LENGTH. NO OF. LATE AL SPACIN : ;RA EL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOL D TR PIPE r MANI OLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA EV. PIPES'. DIA.'.
ELEVATION AND ( `I
DISTRIBUTION HOLE SIZE HOLE SPACING. DRILLE CO ECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
JNFORMATION PLANS
DYES ENO OYES ENO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPE RTV WELL: BUILDING:
V FEET FROM LINE.
DYES ENO DYES ENO NEAREST-~r
°t
/4, rn
1 0
Sketch System on Retain Th~1`10 unty file for audit.
Reverse Side.
SIGNATURE. TITLE /
DILHR SBD 6710 (R. 01/82)
DEPAfl i ME'NT OF APPLICATION SAFETY & BUILDINGS
IND:JSTRY,, = FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PL13 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 ;pa a or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license num~er shown. The owners copy or a le~ible reproduction of the soil test report must be
included. ,
Property Owner: Mailing Addres :
Cotme.P.Um Entetcptr E6u, Inc. 105 DeaAbotcn Street, Beta t, W1 53511
Property Location: Cx'~j kIXMXXTownship: Hrrd~Sdn County: St. Ch0iX
SE t/4 Sol t/4S 27 /T 29N N/R 19 )e<R*j W
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
3 C.S.M. 1-94 and U.S. 12 (Ifassignec~200805
TYPE OF BUILDING o
Number of
❑ Public* ❑ Variance* 1E Other (specify)* i Bedrooms:
Q 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
HOLDING TANK CAPACITY
i
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inchPROPOSED (Square feet): ❑ New ❑ Replacement ❑ Experimental Z Seepage Bed ❑ Seepage Pit
r/ ❑ Alternative (specify) ❑ Seepage Trench i
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
❑ Private ❑ Joint ❑ Public United Mining, Inc.
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: MP/MPRSW No.: Phone Number:
Plumber's Address: r Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Z
$igna uu a of Issu;ig gent• Fee: Ct~ Date: APPROVED San Permit Number:
J
_ ~.%f C.~ ~ - ;7 .9~ ❑ DISAPPROVED
Reason for Disapproval: E
C
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 sn-
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)
'EH t 1,15 f
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701 80-1262
REPORT ON SOIL BORINGS AND PERCOLATION TESTS Sheet 1 of 2
LOCATION: SE % SW's, Section 27 , T?%, R 19 ) W, Township or Municipality Hudson
Lot No. 3 Block No. Certified ~Suu~rve~yo MNapr~1 county St. Croix
Owner's Name: United Mining Inc. % Have ~ incV 1S
Mailing Address: Pine City, Mn.
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other Comercial
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 11/16/81 2/15/82 PERCOLATION TESTS None
16 8 2PIA Borrow Pit
SOIL MAP SHEET 66 SOI L TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- 5 132 None > 132 48, Bl sil; 36, layered Ih s w/layers of si;
48, light Bn s.
B- 5A 132 None 7 132 24, Bl sl; 42, Bn s; 66 light Bn s w/pockets
of silt.
B- 5B 120 None -,;1120 42, Bl sil; 18, light Bn s w/layers of si; 60,
light Bn fs layered.
PLAN VIEW (Locate percolation tests, oil bore holes and suitable soil areas.)
Indicate on the plan the locationahd - 1,tre feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
1
t I
+
( f
05
[ 0 I
{
LEGE
f
o R P+ PE FOXJND
I
_ v
C31 SOL PIT LOCATION f !
I
4 5- - - - ? -
l
I BORING N UMB R E j ! LbT
t
t i
_'BOUNDARY OF SUITA E
.RIIN x1-0-0* t N
-
- -4 - --I--
OT OM EL VATIO 1 -94 5 -
I 1 l
/ fiA _
w ALTUI2NlTE - AR ?~5'l00
BOTTOM' ELEVATION 89 0 i
o .
g f 1 ~ f
f
{ ` r f { / i ` f I 11_94
I
N p1'E pp +
i
} TOE s> I
I
I, 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 location of test holes are correct
to the best of my knowledge and belief. SHEET 1 of 2
Name (print) Walter J. Gregory Certification No. 55-588
dress 123 E. Elm Street, River Falls, Wi. 54022
d
of installer if known
All,
...n., ~ CST Sig~fati;~ ~
`KCAL AUT..
.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INJ'135TF~Y,, DIVISION
LA-30R AND P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115 MADISON, WI 53707
Sheet 2 of 2 80-1262
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BILK. NO.: SUBDIVISION NAME:
SE 1/4 3V1/ 27 /T 29 N/1119 f W Hudson 3 Certified Survey Map
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
St. Croix United Mining, Inc. Pine City, Minn.
USE DATES OBSERVATIONS MADE
7EDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: ER LA ON TESTS:
❑Residence x ®New ❑Replace 11/1 6 81 2/15/82
- 2 / 1-(Q7 2
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
RIS ❑U EIS [:]U [:]S ❑U ❑S ❑U ❑S ❑ll
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: A 10 90.5/89.0 Floodplain, indicate Floodplain elevation: NO
PROFILE DESCRIPTIONS ~ IA::-/"712
BORING 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.)
B 5C 132 N 95.6
None 132 36, BI sil; 18, Bn very fine ls; 36, light Bn s,
la ered• 42li ht Bn s.
6,B1 sil 12,Bn l; 0 Bn s; 36,Bn s w irre~ular
B- 5D 168 98.7 None 7168 pockets o~ fine Is; 6jayer of si; 26, n s& fight
B-5E 150 96.0 None 7 150 48,B1 sil; 121Bn sn & silt layered; 36,light Bn s &
B-6 132 99.1 None > 132 301B1 sil; 48, Bn s & gr; 18,s & si, irregular layers,
18,light Rn s_
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P-
P- NONE
P-
P-
r
P_
PLAN 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.
SYSTEM ELEVATION 90.5-0/89.0-A
TABLE OF ELEVATIONS (7 f ! `
BORING GROUND ELEVATION
NLIBER
LOT 3
B-5 93.2 r... ~o w r
B-5A 99.7
B-5B 94.3
i... _ -
oooo,
1
LEGEND
C~ ORIGINAL AREA ` 10
I
i?
' ~n 1 E
ALTERNATE AREA
C,
RErFIVF
i, the undersigned, hereby certify that the soil to ported Y~~Fjjjor weade by me in accord with the procedures methods specified in the'Wisconsin
Admimistrative Code, and that the data recorded an ttae location }#~t{{{~~ tests are tsarr ct to the best of my knowledge and belief. r
OFFICE f, SHEET 2 0 2
NAME (print): ` TESTS WERE COMPLETED ON:
Walter J. Gregory SV I G ; 11/16/81 2/15/82 2 / 16 / 8 2
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
123 E. Elm Street, River Falls, Wi. 54022 55-588 (715)425-7631
a
2;Z_ N
Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
13/81)
Parcel 020-1075-80-000 011112008 0838
PAGE 1 OF 1
Alt. Parcel 27.29.19.305C 020 - TOWN OF HUDSON
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 - CORNELLIER ENTERPRISES
CORNELLIER ENTERPRISES
105 DEARBORN ST
BELOIT WI 54511
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 631 COMMERCE DR
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 2.030 Plat: N/A-NOT AVAILABLE
SEC 27 T29N R19W SE SW LOT 3 OF CSM Block/Condo Bldg:
V4/1151
Tract(s): (Sec-Twn-Rng 40 114 160 1 /41
27-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 654/277
2007 SUMMARY Bill Fair Market Value: Assessed with:
202799 238,800
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 2.030 161,100 57,900 219,000 NO
Totals for 2007.
General Property 2.030 161,100 57,900 219,000
Woodland 0.000 0 0
Totals for 2006:
General Property 2.030 161,100 57,900 219,0000
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Sfl M XIC?JJ-1N -SS 'C: MAW 989~9885l L 9L06S M NOSO y 'Ol O~J 73bH~/WZ y 51, L14 xioS(ol,v/esODOZ&
t131N3~ 1N3WNN3r10~ ,cLN/JO~ XIOb'~ :L$' ` `
S~Zoal OVA
<<qdmfAl X-LIP-1 l0/CaAJI1S
ZOOpS I~Y1 `LUAXp[hg '11J 71cL1umS Ot S `h~ua~[[a~H ~an_~hI I :aa
I cu/8 V
Is111,133ds 'Ouluoz
u_ingNal?[g xa[d
`x [alaau l
aa1-~Io _1110 Iah,7uoa 01 aalJ [aaI aSrald `SLtXaau0a _10 SUOIJSaI huh anLq no C 3I
n-lhpunoq puh[Iann aL[I aIO.Ij }pi,,q as QL h aah[d 7
I-1oda1 11017hau11ap puh[Ia~~ hjo Idoa P JltugnS -f
SG9b-98£-S~l
:szu,3p Jvjyzugns pa.1znba_z aryl of uoyrppn uj ~arf~t 7l
LL9b 2 SIL
:SILIaCI1LU0a ~~ord~eag
JhiuLn aLUOS alt, -Iac[ laAa;~oL~ `Ia,C aphid uaag Iou sm[ [1'u?algns [przuo3 Xjj. 'NSJ
IMauO -)AOCIP, )tlj paA~ai gal aa7uuuuo~ A~alAa~ [hauigaa L a1[I `LOO- `c- I -iagLUaaaQ aQ tiG9t-98£-su
furu¢rlrl
JMSULid 'S _1haQ uoraecwojujpu, /
0891-98£-SIL
C -1 jJd'j ,)ffL zzM o f ! r Fjjsrunupy> apoO
l47 '»S 'p[t:.lauzA - deLV :0A.1"S pa~~~~_►aJ Ica UT) IMIJI- 10111 Si~ZOQ"[ :ml
[ Ot IM `p[elauu l
pho~ ~IU11O;J 0,-C-
>~la[J LIAvoZ plhlaLUtj
Lrasuud glh8
D ! OZ 2 J D1 I N V d
INnOD ),Ic;l, u- ®
~ i- ~
/ '
~ ~~~~J
~
OGDEN ENGINEERING COMPANY
CIVIL ENGINEERING AND LAND SURVEYING
123 EAST ELM STREET
RIVER FALLS, WISCONSIN 54022
OFFICE PHONE (718) 428-7631 FRANCIS H. OGDEN, P.E.
JOB NO.
v ~~~{Cf~' e
y +r
198Z
',ice
pp-
Department of Industry, Labor & Human Relations
_ of ~~T z Division of Safety & Bldgs.
State o Wisconsin o~ fa Bureau of Plumbing Platting & Fire Protection
v P.O. Box7969
cc Madison WI. 53707
~~Ctj V Tel. 608-266-3815
w
IN ALL CORRESPONDENCE
REFER TO PLAN
I DENTI FICA TION NO.
NAME OF PROJECT
TYPE OF APPROVAL
STREET AND NO.
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.
Sincerely,
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) Rcc. & Env. Services
t Department of Industry, Labor & Human Relations
Division of Safety & Bldgs.
State of Wisconsin Bureau of Plumbing Platting & Fire Protection
P.O. Box7969
Madison WI. 53707
Tel. 608-266-3815
IN ALL CORRESPONDENCE
REFER TO PLAN
Cwt -:-2 ~~z~ 4 . IDENTIFICATION NO.
NAME OF PROJECT
_ y C
TYPE OF APPROVAL
STREET AND NO.
CITY OR TOWN C ~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 co m
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, /
Qm
James Sargent-Bureau Director
DATE:
PLANS REVIEWED BY: ' T ` Z
Owner DI LHR 6
rc: D OWS . Plumber H & R (2)
Lo Bur. of Health Fac. & Services
ounty , > Mfg. Rep.
Rec. & Env. Services
D I L D-6099(N.06/80)
Plb..# 60
PROJECT DETAIL DATA SHEET
NAME OF BUSINESS C-0 <('4 l /t E~ es I"711e.0 se+
LEGAL DESCRIPTION 7- C 7
OWNER 11;,e ey MAILING ADDRESS 1Q O'zie.~ 5' T
AFtic'i'T ZIP
ARCHITECT, ENGINEER, -Coals ADDRESS 12 4'2 ox-or s/
PLUMBER OR DESIGNER 8e
/o ~ ~ Gl~I ZIP S'3 5'//
TELEPHONE NUMBER 6OS' 34(_2 - 7,,,--7<1
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building New building Addition
( ) Apartments and condominiums . . Number of bedrooms
( ) Assembly hall . . . . . . . . . Seating capacity
( ) Bar . . . . . . . . . . . . . Seating capacity # of meals served
( ) Bowling alley . . . . . Number of lanes ( ) With bar
( ) Campground and camping resorts . Number of sewered sites
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons
( ) in ( ) Day and night Number of persons
Catchbas
( ) Number
Church .
( ) No kitchen Number of persons
( ) Dance hall ( ) With kitchen Number of persons
. Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals serv_e_U daily
( ) Dog kennels . . . . . . . . . . . . Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity
Car-service Number of car spaces
( ) Dump station . . . . . . . . . . Number of dump stations
( ) Employees ( total of all shifts) Number of employees
( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit
Number of units with 4 persons per unit
( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . Number of sites
( ) Nursing homes . . . . . . . . . . . Number of beds
( ) Parks . . . . . . . . . . . . . Number of persons ( ) Toilets
( ) Showers
Restaurant . . . . . . . . . . . . ( )
. Seating capacity
( ) Dishwasher and or disposal?
( ) Retail store ( ) 24-Hour service
( ) Schools , • . . Total number of customers _
Number of classrooms Meals ( ) Showers
( ) Self service laundry . . . . . Total number of machines
( ) Service station . . . . . . . . Number of cars served daily
( ) imming pool bathhouse . . . . . . Number of persons
( OTHER . . . (Specify) . . . . . . . t,UA~~ ~v<<s.=
COMPLETE OTHER SIDE
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2. Indicate whether the following facilities are present.
Floor drain yes ✓ no Number of drains
Food waste grinder yes no T
Dishwasher yes no
Automatic clothes washer yes no Number'of clothes washers
3. Septic tank capacity /Oocl
Holding tank capacity 4
Septic or holding tank manufacturer _ D I- MA
t.
4. SEEPAGE TRENCHES: total square feet width-of trenches
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length of trenches depth
number of trenches.
SEEPAGE BEDS: total square feet 4' / 6 width
length of bed Z 6 depth 2 "
SEEPAGE PITS: total square feet outside diameter
depth be,l.ow. inlet
total depth from top to bottom of pit
Signature of person completing form: ,FOR DEPARTMENTAL USsE *ONLY n'.
Address
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FRACTIONAL IY f~C LE f~ _fQ~~ MATERIAL
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CNN'D DATI ANGULAR 4 DATE DRAWING NO.
TRACED APP' + • A PP' D
11`TELEDVNE POST 18AE•iSE-18X24