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Home My WebLink About020-1149-70-000 0 en O K m 0 t 7 t_ O y F C O `+1 7 n 3 K A 0 C r (D d fD 3 - 0 v v w O N c W pro ~C • :1 C) CD iv 1 r-0 CD 3 m N CL (D (n a a a m N y O w(D 3 W W Cn mi co ~ O ^ N CL SU N N m p -1 CSV `S C --0 O O V O CD CCDD n 61 cn O 3 a = CD 7 m cn p 0 ID O cn v v} C D C a n m fl N W a w W ci c 3 (00 0) N x (D m ° ~ n rt G U) W CD co m Ul W m CD 00 N N o C C7 c o . Q o G a v -0 M 10 0 C (D G z O O O (D i-i W o N rt N• v O _v o rt o v CD m P N CD CD 7 Z a ~ I N (D CL - N Z O z CD ~ z co z O 00 m" D (D 0 O a Oo CAD N • W m m Oll CC) C CD (D Fl- Z Cn (O N a A C) O 7 W w ca -0 mN)W t CD z V x ' A A G °o a 3 m Cl) !p z CD A O ~ w F D 0- a o - 0) C o m m I ~ A. ,A A n O I N O O a A O b N (D ~ bG A ~ O O L ti Parcel 020-1149-70-000 02/23/2006 10:04 AM PAGE 1 OF 1 Alt. Parcel 33.29.19.805 020 - 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 - ROBB, CARMEN L CARMEN L ROBB 595 PARTRIDGE CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ` 595 PARTRIDGE CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.030 Plat: 0215-COUNTRYSIDE VILLAGE SEC 33 T29N R19W COUNTRYSIDE VILLAGE LOT Block/Condo Bldg: LOT 19 19 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 33-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1075/576 QC 07/23/1997 880/440 07/23/1997 734/492 07/23/1997 713/107 2005 SUMMARY Bill Fair Market Value: Assessed with: 92673 207,000 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.030 75,100 136,000 211,100 NO 05 Totals for 2005: General Property 2.030 75,100 136,000 211,100 Woodland 0.000 0 0 Totals for 2004: General Property 2.030 30,200 107,700 137,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 113 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 t COWNIERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax,-Wisconsin 54730 715-962-3121 800 - 962 - 5227 O I I tr!. ST. CROIX COUNTY REPORT DATEf 8/17? 811h/ COURTHOUSE BATE RECEIVED'* WDSON, WI 54016 ATTW THOMAS C. NELSON v~ S:~/A - / > c-2 0 /q. -0111 61CATION: 595 Fat tr idae r: l h -4udTm l~I~ ILLECTORI M. Jenki.> JURCE OF SAMPLE: Outss4 5 Ff I O` 9A Means "LESS THAN" Detectable Level Approved by.' PROFESSIONAL LABORATORY SERVICES SINCE 1952 16e~ ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street Hudson, WI 54016 t- Telephone - (715)386-4680 The St.ry Croix County Zoning Office nstitutionshe service and water inspections to Lending private individuals. r~~oietion of this form is essen}iA~ so that the nrooerty ~An be lmatad• Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING---- -FEE: $ 25.00 (For nitrates and coliform bacteria) WATER TESTING FEE: $175.00 (For VOC'S) FEE: $25.00 SEPTIC SYSTEM INSPECTION--- (Determines if system is properly functioning at t me of inspection) ,V j. Property owner's name Property owner's address T N_R Legal Description 1/4 of the 1/4 of Section' , Town of Lot Number -",,Subdivision Name >c'!y~t~ FIRE NUXBER,_ LOCK BOX urtxR]0 Color of house Realty sign by house? J!, If so, list firm: PLSASB INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, SHEET. WITH LOCATION SHOWN, AND A COPY OF THE LISTING Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the % test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone Number RSPORT_ TO.BE SENT TO: Closing date Signature e' o E.y Y r ST. CROIX COUNTY WISCONSIN y y'T}f ZONING OFFICE ~ a Mks. ST. CROIX COUNTY COURTHOUSE 71 . 911 FOURTH STREET • HUDSON, W154016 (715) 386-4680 Aug. 16, 1990 Darlene Sorenson First Federal of LaCross 201 S 2nd St. Hudson, WI 54016 Dear Ms. Sorenson: An inspection of the septic system of the John Emmeck property located at 595 Partridge Circle was inspected on Aug. 15, 1990. At the same time I also obtained a water sample for testing. The results of that test will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspections. This not not in any way warrant or guarantee the continued proper functioning or operations of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system is totally dependent upon proper maintenance of the system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Mary Jenkins Assistant Zoning Administrator cj AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP l> 1~_n.. J -SEC ..~33 T~f N-R NW ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of R63 W- LVLRYTHING WITHIN 100 FEET OF SYS' E14 t I di a r or, the A row SCAL. c BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: ba,2 6-4 - _ Number of rings on cover : Tan manhole cover elevation:- - Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cyc e gallons; tota capacity o~ distribution lines gallon: size o pump- --head; gallon per minute horsepower bran name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover _ Type of warning device - SEEPAGE PIT SIZE: mum er o piCs feet iametor feet liquid dept seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines -width /d'; length-'53 the depth _ SEEPAGE TRENCH: width _ length PERCOLATION RATE jAEA REQUIRED AREA BU LT INSPECTOR DATED _ PLUMBER ON JOB LICENSE NUMBER DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISOTS, WI 53707 4 CONVENTIONAL ❑ALTERNATIVE IS,,,, PI,, I,D, N,mber. Holding Tank El In-Ground Pressure El Mound (if assigned) NAM OF PERMIT HOLDER: ADDRESS OF ERMIT OLDER: INSPECTION DA E BE H MARK (Permanent ref .ncs pant) DESCRIBE IF DIFFERENT FR M PLAN: REF. PT. E V.: CST REF. PL ELE V. (7, W S~ S 3 / r LICE` vim) y'y~ yq, 60 INIS&i, p{ Plumber. ^ MP/MPRSW No.. County Sanitary Pemy~it fNumber: SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAAPACITY. LjNKNLEI TANK OUTLET PROVIDEDPROVIDEDPA P h) _4:V !If YES ENO DYES ❑NO r W AT L.. NUMBFEET FROM ROAD PR OPERTV ELL. BUILDING. VENT TO FRESH BEDDING jVrNT CIA VENT M IGH WATER (N(Y/a/ I ALARM - ( LINE /-/0 66 e AIR INLET'. I YES ❑NO DYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER JBEDDING. LIQUID CAPAPPIMP PUMP MODEL. PUM 1PHIIN MANUFACTURER WARNING LABEL LOCKING COVER ' PROVIDED: PROVIDED. DYES ❑NO DYES ❑NO DYES ❑NO SH GALLONS PER CYCLE: CONTROLS OPERATIONAL NUMBER OF RGPERTV wILL BuILDNG IAIRINLET (DIFFERENCE BETWEEN FEET FROM NE AIR -j► PUMP ON AND OFF) YES ❑NO _ NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing F N:,T n M.1E TER MATE RIAI AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF IDISTR PIPE SPACINI, COVER INSIDE DIA st PITS LIQUID BED/TRENCH TRENCHES MATERIAL PIT DEPTH-. DIMENSIONS CHAVE 1 DFPTII FILL FPTH DISTR PIPE DISTR. PIPE DISTR. IPE MATERIAL O. R NUMBER OF PROPERTY WELL BUILDING- VENT TO FRESH IsEIr tiIIPw ABOVecovlP ELFV„INLy ELEV IND PIP FEET FROM ~LINE AIRwLET. rG7. USA / . NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL COVER. TEXTURE PERMANENT MARKERS. OBSERVATION WELLS DYES ❑NO DYES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED =OPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES ❑NO DYES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: -IDTH LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING EI EV. ELEV. DIA. ELEV. PIPES. DIA.'. ELEVATION AND DISTRIBUTION ROLL SIZE HOLE SPACING. DRILLED CORRECT LV COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED 1N FORMATION PLANS DYES ❑NO DYES ❑NO COMMENTS: PERMANENT MARKERS. JOBSERVATION WELLS. NUMBER OF PROPEERTY WELL: BUILDING: FEET FROM LIN: D YES ❑ NO 0 YES ❑ NO _ NEAREST- Sketch System on etain in county file for audit. Reverse Side. G T RE. TITL DILHR SBD 6710 (R. 01/82) TRANSFER FORM [A. L V 6 7~ T SANITARY PERMIT State Permit Sanitary Permit # County nitary Permit Transfer Date Original Permit Issuance Date Property Location: '/4 '/a, Section , T N, R E (or) W Lot # City Subdivision Name, Nearest Road, Lake or Landmark BLK # Village Township TYPE of Occupancy:. Commercial Industrial Other (Specify) Single Family nuplex No. of Bedrooms Variance C. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab Concrete Poured-in-place Steel Fiberglass Other(Specify) New Installation Replacement LIFT PUMP TANK/SIPHON CHAMBER Total gallons Prefab Concrete Poured-in-place -Other (Specify) D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: No.Lineal Ft. Width Depth Tile Depth(top) No. Trenches Seepage Bed: Length Width Depth Tile Depth(top) No. of Lines Seepage Pit: Inside aiameter Liquid Depth No. Seepage Pits Percent slope of land Distance from critical slope E. WATER SUPPLY: ❑ Private ❑Joint ❑ Community ❑ Municipal Present Sanitary Permit Holder Phone No. Sanitary Permit Transferred To: Phone No. Name Name Address Address Zip Zip I, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with section H 62.20., Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH-115 prepared by the Certified Soil Tester and/or any additional soil tests that may have been required. Plumber's Signature MP/MPRSW # Phone Plumber's Address Information obtained from (owner or agent) PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh- bor's ro Pert v. If well has of been drille I ) Signature of Issuing Agent 1. County (Yellow copy) 3. Owner (Pink copy) DIVISION OF HEALTH 2. State (White copy) 4" Plumber (Green copy) P.O. BOX 309, MADISON WI 5370". EH 115 • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES Sheet 1 of 4 DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 Job No. 76-665 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: SE %,SE--%, Section _Z,, , TAN, R 19 E (or) W, Township or Municipality Hudson T Lot No. NBlock No. County Sub isio Name n G Owner's Name: Francis H, Ogden. 54022 Mailing Address: _ 123 E. Elm Street, River Falls, WI TYPE OF OCCUPANCY: Residence x No. of Bedrooms 3 Other C EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 7/22_28190 PERCOLATION TESTS SOIL MAP SHEET 66 SOI L TYPE Burkhardt - Sattre C=I ex PERCOLATION TESTS AT ELEV-':90W 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 /o x E%3 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) R-1 A9 ff 47 Z Al-OA1,57 -5p B 4- 790 7 S' <5i PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. 1LSe 94S Sa Ft. Indicate scale t3(i or distances. Give horizontal and vertical reference points. Indicate slope. t i ~ k I t { i _ ~ t 4~ p_`-. w 1 - ~'y. N I 77 _ { I I i I j I 14> I I I t I II I I 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. Name (print) Tames T Swgncrm Certification No. SS-21 S2 Address 123 F Flm St- Rjjrer Fallc wT 54092 Name of installer if known CST Signature EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH Sheet 2 Of 4 P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS Job No. 76-665 LOCATION: SE SE 1/4, Section 33 , TaN, R 19XXo'r) W, Township or Municipality Ridson Tnt,nshiF Lot No. 19-_, Block No. County SA Croix ubdivislon ame Owner's Name: Francis H Ogden Mailing Address: 123E Elm Street, River Falls} WI 54022 TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 7/22-28/80 PERCOLATION TESTS 7/73/90 SOIL MAP SHEET _ 66 SOIL TYPE -Burkhardt SattrP f mm~lg PERCOLATION TESTS AT ELEV. _ "CJ TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- SINCE HOLE HOLE AFTER INTERVAL INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 BER MIN/IN 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 7~ 110A45- ; " Tr /S"5/, -.5-0 "..5- B- PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of ahsorption area needed for building type and occupancy. Use 945 Sn Ft Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. 4 ~ f I I I f i , - - { _ I N i 44 I q i i 1 i ~ ~ I ~ 1 I I 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. Name (print) James T. SiATangnn Certification No. 55-215 - Address 123 E- Elm St_-RJ)Mr- FalAs, W! 54022 Name of installer if known __-1N~-_ - CST Signature _ a t i , f 1 Ill AN V I I_W ',l E I I,II Located in the SE1/4 of the SE1/4 of Section 33, .fi T29N, R19W, Hudson 7) 1.01' Township, Lot 19 , ly Countryside Village, St. Croix County. N IC 1 UNPLATTF.R) LAND'; LOCAV I ON 51CI,- w COUNTRYSIDE VILLAGE O O 4-4 o 0 O oo cat t~ _ 1 LQI IQ ZS r--4 I~ 001 , . o (n o o H ~ CIO In Original. - Suitable Area ~►og v~ 1000 Sa.Ft.\\~~4.0 Qa_ SCALE : 1" = 50' L1:CEND o; s9 l I o B-1. • BORE HOLE. I - w P~1 PERC. TEST. _n s • ELEVATION REFERENCE POINT. 0CP. 1• LOT CORNERS. LQI 18 VE RIF I CAI;, N ORT lI Rl: F1;1t1;NCT ELEV.=940.44 (P.K. NAXL I 10" OAK WIT1 LQI 20 YELLOW RIBBON) L0I 21 PARTRIDGE CIRCLE .lames T. Swanson Cert. i215? Ogden Eingineering Co. R2=80' 123 E. Elm Street: River Falls, Wisconsin 54022 ,Job No. 76-66 r Shoot 4 of 4 TABLE OF LOCATIONS AND ELEVATIONS # of Boring or Perc. Existing Ground Elevations Location* B-1 940.9 1991E 431N B-2 937.8 2191E 261N B-3 939.1 2231E 551N B-4 941.8 192'E 561N B-5 940.8 1851f 351N B-6 938.4 2671E 261N B-7 940.4 2981E 261N B-8 938.3 2801E 71N P-1 940.5 2051E 581N P-2 939.6 1981E 381N P-3 938.5 2241E 361N *Locations were measured East along the South line of Lot 19 and North at right angles from the South line of Lot 19. Measurements are taken from the Southwest corner of Lot 19. Bottom of original bed at 935.3. Bottom of alternate bed at 935.4. Ja es T. Swanson Cert. #2152 Ogden Engineering Co. 123 E. Elm Street River Falls, Wisconsin 54022 Job No. 76-665 `Sficct , o F I . I'I AN VII W 'k"I I~ II Located in the SE1/4 of the SF.1/4 of Section 33, _ T29N, R19W, Hudson IJ19 Township, Lot 19 , Countryside Village, St. Croix County. LOCATION SKE Mi UNPLATTED LANDS a• COUNTRYSIDE VILLAGE 00 O p 4-4 o 0 ro~ ro 0 ~ Q) ~ ro r LQI 19 ~y co 0 00 • 12 0 1 ~ M N r-1 Original. Suitable Area q~ ~~og = 1000 Sq.Ft-."'\ I Ile SCALE: So, Ida END a • BORE BOLL. P-1 w PERC. TEST. ;C CP • ELEVATION REFERENCE. POINT. 0 LOT CORNERS. o~ ci LQI 18 VI CAL NORTH RL FERENCl ELEV.=946.44 (P.K. NAIL I 10" OAK WITI LOI 24 YELLOW `sue RIBBON) LQI 21 PARTRIDGE CIRCLE James T. Swanson Cert.'Z152 Ogden Engineering Co. 123 E. Elm Street R=80' River Falls, Wisconsin 54022 Joh No. ;6-6G r ' Sheet 4 of 4 t TABLE OF LOCATIONS AND ELEVATIONS # of Boring or Perc. Existing Ground Elevations Location* B-1 940.9 1991E 431N B-2 937.8 2191E 261N B-3 939.1. 2231E 551N B-4 941.8 1921E 561N B-5 940.8 1851E E, 351N B-6 938.4 2671E 261N B-7 940.4 2981E 261N 2801E 71N B-8 938.3 P-1 940.5 2051E $ 581N P-2 939.6 1981E $ 381N P-3 938.5 2241E & 361N *Locations were measured East along the South line of Lot 19 and North at right angles from the South line of Lot 19. Measurements are taken from the Southwest corner of Lot 19. Bottom of original bed at 935.3. Bottom of alternate bed at 935.4. James T. Swanson Cert. #2152 Ogden Engineering Co. 123 E. Elm Street River Falls, Wisconsin 54022 Job No. 76-665 (DEPARTMENT OF APPLICATION s SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Property Location: City, Village o ownship: County: { S4 '/4S4. %S_43 /T ' q N/R !9 "&r H CJ cl Sa;✓ s' II .10 Lot Number: Blk No.: Subdivision 7N►ame: { Nearest Road, Lake or Landmark: State Ian D. Number: coU.V, 4~G~~' TX V L14-0 (If assigned) TYPE OF BUILDING Tr Number of Public* ❑ Variance* ❑ Other (specify)* If es 1de-V Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify' SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ltd New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit GALA SS O- t ❑ Alternative (specify) T ❑ Seepage Trench WaVer pply: Owner's Name as Listed on Soil Test Report (If other than present owner): riv ate ❑ Joint ❑ Public JA V IV G A x1(?s c /I iC _ i e /V O !r' O 5 V /-VAI, I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: ature: MP MPRSW No.. Phone Number: ScA t? Al lGf+Nd, )9156 Plumber's Address: Na a of Designer- 6 e-41oA4otv ie, UltS COUNTY/DEPARTMENT USE ONLY a ire of Issuin A en ~ Date: Sanitary Permit Number: APPROVED rte/ L° ❑ DISAPPROVED eason 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)