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(D N m Q 7 (O 'O 3 CD (v D Q 7 O w. p D D 3 cn ( 3 m p O D ? p O co cD n s m w 3 3 0 ° v o n o n m p Q O O cL O D p ~ O A o lD C a . -UMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 C,2: FAX - 715 - 962 - 4030 G ,.CROIX CTY GOV.CTR REPORT BATE; 1124/Q. 01 CARMICHAEL ROAD ,N, WI pa Z-,, 2 --107 c_6 !moo 2, iiLLECTORt M. Jens, i ns ATE COLLECTED** 1-19-94 'ME COLLECTEW 2:00pm OF SAMPLEt Kitchen faucet % 6 ANALYZED:1-21-44 ^!L mi= ANALYZED'# 11.00am ✓~O /y - a 1 F `'v--- C CALL. C. oE.6NDEGEN~Fry t. o° A wi Approved Lab Na, a J A b, 7 PROFESSIONAL LABORATORY SERVICES SINCE 1952 03/24/94, 12:52 $715 962 4030 COMM. TEST LAB 444 COUNTY CLERK 1j001 COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST* CROIX CWNTY ZONIW, OFFICE ST. CROIx CTY GOV. CTR ^ Zr'aRT ?~G, : 65427141 PAGE 1 1105 CAR~fICHA11 ROAD REPORT LATE: 1l24/~4 DATE RCEIVE ► 1121194 HUMM, WI 54016 ATTN: THOMAS C. NEZbaq OWNER: Thomas Ha[onen LOCATION: 1321 HWY 65► New R i chino W COLLECTOR; M4, Jenkins DATE COULECTEDIf 1-19--94 Tim COLLECTED: 2;0gpo SOURCE OF SAMPLE: Kitchen faucet DATE ANALYZED%-21-94 TIME ANALYZFD;11: d0am COLIFORM#MF'CC: 0 1104 41[ INTERKETATZON; Bacteriological[Y SAFE NITRATE-N: 8 PAm Above 10 PPz exceeds the recomaEended Fublic Drinking Water Standard. Co[iform Bacteria/100 ml Nitrate-Nitrogen, mg/L i' LAB TECMICIAN: Pam Dane 4 ~~.MnE0ar4yT 4 WI Approved Lab Ho, 19 d"~► < deans "LESS THAN" Detectab[e Levei Approved by: ig PROFESSIONAL LABORATORY SERVICFS slNr.r 1Q49 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ppxnpnru■ ST. CROIX COUNTY GOVERNMENT CENTER • ' 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 January 21, 1994 Nanci Johnson Century 21 706 19th Street S. Hudson, WI 54016 Dear Ms. Johnson: On January 19, 1994, an inspection of the septic system on the Thomas Halonen property, 1321 Hwy.65, New Richmond, Wisconsin, was conducted. A water sample was also collected, and forwarded to the laboratory for testing. When the results are received, you will be notified. At the time of the inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based on 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 inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact this office. Sincerely, Mary Jenkins Assistant Zoning Administrator ST. CROIX WISCUNSi ZONING OFFill -14 HUD rr'1 RE~it . . PT r~'_CA ' t-sl- (s ar re:ri t j-~I'!J~?r1c ~C' fee wtt.)1 ..i';;• i a side water zinc s are Uften turned of czuring w r:~er ^n making accoss to the hon-,e necFssar.•,'. Pleas, m,ako arra!- t his cif-fic.e t ri t1Y'e. a ~1.T t when, r try !tn mot:; s S 1.r.. ~.i . r 4~. - $35a 04r y 'wi. i ti. i_ ~ • 'F _i f,. :i _ ~ -:2~1 iKo & ` _ LCf SDr%1 lv i s~fc~ 7 - L~C) 1c0 -3V4~ 75 s<, }P ~j?u~' east:. ~P,V1 Gl(({~/ ~l ck P!!~)x Cow}, d'~1r5 SE' 1, F, P T Vy-- t l system l ns ~3 , ? e: i S waar_~ discharge to gro un<3 '?3 a.oW 3k z oul rFlativ. - vertity that the 4r-., I T L E f E ry 3"~1 oc e _tY Iz,S'LTSON El' ~~~ti' c,1tt1 v t 17u'C.Y ldjiJ~I ,~.ari _ t.2 h INSPECIiORS SXETCH OF SYSTEM LOCATION R SY571e "1 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 2- L.'--r and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST: Cleo/'X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 110 M'4 5 S Er 2 g,/ o N Eti GOVT. LOT 5W 1145W 1/4,S 2Cv T.30 N,R f~ E {or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 137-1 tt LO . Ca 5 IP,4A7- OF ? ~4 c.c S . CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [2POWN NEAREST ROAD tJ E W R CAMO OP 4v/. ( ) i C.k ^ O.a p N-W Y. Ce 5 [ J New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building j J Replacement [ ] Public or commercial describe_ Code derived daily flow G= gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material .5C 57 - 54 jr/ hGo 44,1,~l Flood plain elevation, if applicable V. ~ It c o ss S = Suitable for system 7NV IO U L ~MMO N D IN1a"9 El -GR U ESSURE AT-GRADE T- ~ _ / SSYYSTEW IN FILL HOLDING TANK, U = Unsuitable fors stem ❑ B LA-S ❑ U El S '01 6 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou1~ry Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends ~Y/ Ground 6 22-3g !o VR 313 51 56,e Av,~2 C S 2f . 5 elev. ft. f- 75Y2 y/CQ S , A-4, s Depth limiting factor it N Olt' - A ~ t 'Zd us /P,Q U .4!9 ° > Remarks: Boring # \ 1 . Ground elev. ' ft. Depth to Gmiti~; .-ctor Remark,: CST Name:-Please Print R0 SE-P-T-- U L R fC~ T-- Phone: -7,5-_ 3 g6 Address: (Q S S O ',1.1 Q I 'L PD ~f C) A-3 V So Cc9 1 . $ y0/ Co 124 C S Tn 1-41f>_) Signature: Date: CST Number: SUHx 2y - f-ROST 19°-f~ P/?4 EZ- ~ SE•t-~'ov~-/ s~t-Tv~P~t-T7D-~, Th1°S test stt8 APPROVED ?.'La ,t v .4for a conventional SePtIC SY'Sterr /Y. 6: 4~ 13e-elgo -C Ole T- ~=-o/~ 7'~''`7 , 7b 4- ~j 4 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y Roots Bed Trend Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Mow Ground elev. ft. Depth to limiting factor T--T Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: JI ~+rsr~aG `fa vSF ' ate o w~ II k ~ r,a =30 i 7- k D,t°MNfitw vE~r 41 ► T ' ,v S 3z i -7o Of fi- ULA3r C a?, y~ >t/3ov~ y,P~1v~~ k /00,0" i This. test site AppFIOVEOB 56. f for a cc) ~;tlonal septic s YsteM. j ~ ~eTTO~-1 y Ut^~ (sys,tM~ 2.?' CERTIFIED SURVEY MAP Located in part of the SW34 of the SW a and in part of the SE-4- of the SW34, all in Section 26, T30N, R18W, Town of Richmond, St. Croix County, Wisconsin. nPpROVED N W} Corner of OWNER Section 26 Masonry Nail Found Marvin L. Utecht MA)'. Z'( K: 1321 Hwy. 1165" New Richmond, WI 54017 ST. CR01X CpUNTI' C) ,oxnprohvnsive plwning s zoning and Parks COMMitt•80 O L n UNP_ATTEV LANLni` lfnot rQcordod Note Existing Shed to be removed. Within 30 day9 of oval date 85' 50 North line of the 5~ of the SWi (569040'15"E, 2Gi2.22'~T-' o 90 15 E 7371 val •shati bs 33.00 SB9 sHEO 701.71' 9 4 15"E 1~ Ln N00°04'15"E QD I 0 loo' 181.76' ° 33 HOUSE DARN CSI 2) Q N49055145"W - l l I I -JI 12.00' Ln nl I( LOT 2 ni 1111 -I =1 rM M 9.00 Acres Inc. R/W i F~J~ ~i Ln I O 392,045 .S.q. Ft. <i J w 1 I= 100' 8.50 Acres Exc. R/W CD _JI C-1 of 370,213 Sq. Ft. Oo L 65 45 0 On O vJ -~I 0) o r` -45.001 689.71' x N89040115"W 734.71 o M 1 TT I~ AN P V~ V~ ~ 1 I z v v LrV~ 777'x" U L In li. iV I' m C ~ ~ 1. 1'•,1,\~: •11:x• C' OC) I c a ~ O O CD SCALE IN FEET y U) 0 100 200 400 1 ) a~ U) S39037'32"E 1946.32' a~ u) N-SW Corner of N39037'32"W 2606.57' w Section 26 South line of the SW~ z H Masonry Nail Found 1 N U E-+ Vol 9 Ps6c 2466 ~ SI-IFFY 2 OF 2 SHEETS; i Cgniu, A A; Premier Group 70619th Street South Hudson, Wisconsin 54016 (715) 386-8207 (612) 436-8433 Adar 1321 Hwy. 65 0 . Ci New Richmond Fire # Dist 08 9 Acre Farmette Twsp Cty St. Croix Ext Alum. Yr Blt 999 Ht FA Oil Style 2 Story Lot Size SMFL TFF Tax Yr 19-92- !f This large two story has had many new updates 9 acre 927 1575 Sapprox.1400 1 including new roof, windows, reinsulated exterior, L C D Approx Rm Size 1 # Baths WT Sch New RichmQ~ updated bath. Potential master bedroom with bath LR OMB BB on second floor. DR M ti`1 C 12.10x14 Dwshr ( Disp. H20-test on file_ Kit M v C 16.2x13.3 [ ) Re(ig ( ) R&O ( )Yes ( )No O ) $ Some finishing still needed but quite a nice FR M C 12.7x12 WS R ( ) 0 Avg Ht Mg 2 not fin. C. Wtr C. Swr. Avg Util S propert; witl a 16 stall barn and shed. BR 2 B 11x10 ( Well Septic Poss Date BR 2 12x10 Frplcs C. Air Bsmt part unf in. BR 2 12x9.6 ()Gar GDO [ ) Deck Patio N-462R DEN 1 12x9.6 Rec Rm Ldr UFFI Y N UKN Legal/Disclosure Loc. in part of the SW 1/4 f the 9W---174- & in part of the SE 1/4 of the SW 1/4 all in Sec. 26, PRICE:$79,000 T 30N, R 18W, in Town of Richmond. S/B/C 2.2 Lister Nanci Johnson Ph -8525 Brkr Century 21 Premier Group #230 Ph 386-8207 DIRECTIONS: 4 miles South of New Richmond on Hwy. 65. /t, I0 T- 'l i C I r I Information is considered accurate but we accept no liability for error. Listing may be changed or withdrawn without notice. 1001 .027yc 0P►007UNIT Each Office Is Independently Owned And Operated REALTOR' County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN • ..Av In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Y- Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road mtV~l~ Hudson, WI 54016-7710 (715)386-4680 Fax (715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application 1. Application Information - Please Print all Information Location: Property Owner Name / ) 5 1/4 5(,!~/4, Sec (J~ - ~Q L 7-0 / v kl`jtJ T Q N, R (or)G) Property Owner's Mailing Address Q (~JAJ Lot Number Block Number 13 21 #tA4 tv ~S Z Subdivision Name or CSM Number City, State ~ Zip Code Phone Number /N.,e~ s of 7 71-'5-- ayG - ~s~ 8 X II Type of Building: (check one) Deity Q Village Town of X 1 or 2 Family i l 13 Public/Commo ❑ State owned ' "U Neajestoad„ 11. Type of Permit: SSU~ ~V eox on line B if applicable) ; y Parcel Tax Number(s) zin if Y 73 ❑ Rejuvenation _ 7021A A) 1Repair PL J / lumbing 4 - Do Co on of? 6 B) Permit Number Date Issued ❑ State Sa IV. Type of POWT System: (Check all that apply) A Non-pressurized In-ground Q Mound Q Sand Filter ❑ Constructed Wetland ❑ Pressurized In-ground ❑ Holding Tank Q Single Pass ❑ Drip Line Q At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation 30D - • VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New T Exi tin Gallons Tanks Concrete structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenationfinstallation of non-plumbing for the POWTS shown on the attached plans. A license is not required for teralift repair or the installatio of non-plumbing sanitation system. Plumbers Name (print) lumbers g ere ( P PRS No. Business Phone Number o3s 7is"- a6 g 9 Plumber's Address (Stye@t, City, Stat VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuin Agent Signature (No stamps) Approved Owner Given Initial Adverse Determination "~A-1' IX. Conditions of Approval/Reasons for Disapproval(:~ &JL D r' x Z t 7Sax.~rcJq w~ / c PAP, L e;) It '.t 4'e" 6--Q, li;lu ~D Cpk~._L~ Nor te-Kt5 Flu 35 7 ~3ai r~~ ~s N~ y 6PrRN tur u""u y3o3y ~r ~X l3' I t-F LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF RICHMOND COMPUTER NUMBER 026-1076-95-100 Parcel Number 26.30.18.402A OWNER NAME: First SCOTT E Last HAWKINS PROPERTY ADDRESS: se /2 PD --Street Name-- Type SD Apartment 1321 HWY 65 SECTION 26 TOWN 30N RANGE 18W '/4160 '/440 Line Description Line Description TOTAL ACREAGE 9.000 PLAT LOT BLK 01 SEC 26 T30N R1 8W PT SW SW 15 02 BEING LOT 2 OF CSM 9/2486 16 03 9 ACRES 17 04 18 05 19 VV_b 61~4ko 06 20 07 21 266 z~ 08 22 09 23 10 24 11 25 12 26 13 27 14 28 ,wt PL ~ i F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exi 1179 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 2 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel Soil Service Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Cron include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. 026-1076-95-100 Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s 15.04 (1) (m)). Property Owner Property Location Stenske, Peter Govt. Lot SW 1/4 SW 19 S 26 T 30 N R 18 W Property Owner's Mailing Address - 0 o ? (13 Lot # Block # Subd. Name or CSM# 1321 HWY 65 na na 8 Acers City State Zip Code Phone Number City Village e Town Nearest Road New Richmond WI 54017 715-246-6052 Richmond HWY 65 New Construction Use: ~ Residential I Number of bedrooms 2 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material outwash S . Flood plain elevation, if applicable na General comments and recommendations: Boring to meet code for system repair, system 3§ inches below grade ❑ Boring # Boring W; Pit Ground Surface elev. na ft. Depth to limiting factor 96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 *Eff#1 `Eff#2 1 0-19 10yr3/3 none sit 2msbk mfr gw 1f .5 .8 2 19-40 10yr4/4 none scl 2msbk mfr cs 1vf .4 .6 3 40-96 7.5yr4/6 none ms osg ml na na .7 1.2 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD5<-30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: f CST Number David J. Steel 248956 Address Steel Soil Service 711// Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 ( 10/8/2002 715-246-5085 s ' Page 3 of 3 STEEL'S SOIL SERVICE ~David J. Steel 1564 Cty Rd GG CST-POWTSM Peter Stenske New Richmond, W1 54017 Lic. # 248956 SW1/4,SW1/4,S 26,T30,R18W (715) 246-6200 Town of Richmond, St. Croix Co. (715) 246-5085 8 Acers Sl ~G r h a~o~Se =l 0 /D - F-OZ- AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP A"wa-o d SEC.( T3oN-R)9W ADDRESS 38 y0 j l i7 ~1, ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 ow, WITHIN 100 FEET OF SYSTEM I\V { I ; I w_yJ6 -Y7 _ I di a e NO th A ro _ , CAL Se !~'~chmy _y -f DEPARTMENT OF INDUSTRY SAFETY & BUILDINGS INSPECTION REPORT FOR LABOR &,HUMAN RELAT NS P VATE SEWAGE SYSTEMS q DIVISION P.O. BOX 7969yD Imo/ 77 BUREAU OF PLUMBING MADISON, WI 53707 ` l ❑ CONV NTIONAL ❑ ALTERNATIVE sate Plan D Number (if assigned) ~ UnF/ El Holding Tank ❑ In-Ground Pressure [:1 Mound NAME O PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. N) a /I ' ra i BENCH MAR (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV r Na,nL f Plumber: MP/MPRSW No.. Coumy. Sanitary Permit Number: ~3 C7 1 SEPTIC TAN OLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED-. ❑YES ❑NO ❑YES ❑NO BEDDING. VENT CIA VENT MATIL HIGH WATER NUMBER OF ROAD PROPERTY WELL BUILDING. (VENT TO FRESH ALARM. LINE AIR INLET. FEET FROM ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONT ROLS OPERATIONAL. NUMBER OF PR.;IPERTY WELL UI BLDING (DIFFERENCE BETWEEN FEET FROM r,E ~AIRINLET PUMP ON AND OFF) ❑YES ❑NO 7NEAREST--~► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing TER MATERIAL 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 DIR PIPE SPACING COVER INSIDE DIA #PITS LIQUID BEd/TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS GHA', F1 1) FPTH FILL DEPTH JUISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL NO. DISTR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BC LCJW I'll" 5 ABOVE COVER EL EV INLET ELEV. END PIPES. 1 LINE. FEET FROM AIR INLET. NEAREST--Wi 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. ❑YES ❑NO SOIL .`OVER. TEXTURE PERMANENT MARKERS. OBSERVATION WELLS 1 ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER THENCH, BE11 DEPTH OF TOPSOIL SODDED SEEDED. MULCHED CFNTFR EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/'TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL NO DISTR. DISTR. PIPE DISTHIBUTION PIPE MATERIAL & MARKING ELEV. ELEV. DIA. ELEV. PIPES DIA.. ELEVATION AND DISTRIBUTION 11011 SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: IBUILDING FEEET FROM LINE. ❑YES ❑NO ❑YES ❑NO NEAREST = _ k< LY Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE J TITLE. / „y' DILHR SBD 6710 (R. 01/82) I 0 vi0 3-0 n tv o _ 1 (DD ? m v h' i 2) (D k 3 (D ID \ 1 3 - as _ t c 0= N Z A CD (33 N 0 O w N O W ? 3 O3 C g Ow > (o T 0.0 O Q m Z a (D N A 3 p O A C CD SD CD 2) 5T -U 3 N Q Co J C, C1 7 CAD (D (D N O m 0 A C (D o D" Z: 3 O 7 N O K y N_ C C C (n < D a 2 m CD m a U) W ~ 0 0) cc, c n IV 3 n ~ 0 z L co 0 r, cn CD co 00 r S Q k 7 1 N N N 3 3 0 iff z O O O p C, o y U o 3 N N N o D O O O (D 0) cu Dl CD v o d N N tT _ o =V~ >CD co z o p 0 O n CD , N !1 CD N !!V~ CD a) O N \ C OIQ CD CD T~ n T_ n 3 z CD 0. z CD c is C~\ n A Z LL W CO O a z 3 I ~ A 3 co N CD A n N CS Q -a cr -0 W 1 p C• -0 D '.I. C S7 r- -a' CD On O Cp d n CL0 CD CD dND) N 7 7~ CD F S oo a o 3 0' W (D CD n O n o CD C N O om T CO N C N to a) C C O -p CD Q CD N CD N N Z ?CD No CD (a ° m ~o o ° n o o m o ~ m CD So m n-o g m rn Q) -0 j N C DL CCDD CD N K 0 7 CD a, n ao y N~ C fD - Z N C m N O O a0 ..Jn00 7 3 O o- 3 m x o a o•~m ~m j m = (0. CD 3 a) 0') N' N O O N c A N S (D 7 (p d ID A = w m a=t° 0 3 m s O O CL N O N N 3 ui (O 00_ " CD N CD 3 CCD D n 0 cDD n.. 7 7 0 N w a) o n j CD 3 3 o O 3 > > o n 0 n C-y m o m ~ o p N C ~ CSC 1 O ti b O *L O ray. O C1. y DEPARTMEIV-rOF APPLICATION SAFETY & BUILDINGS I'NDU6TRY, 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 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. The owners copy or a legible reproduction of the soil test report must be included. c --.14- - G05,37) Property Q4LQ er: Mailing Address: r f~%r ~ ran ~ ~S'~'~~ , / ~ ~ ,✓_'`~"i~iG Property Location: City, Village o Township: l C unty: 'V5iU %S &/T30 N/ R ~ {or) W Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedroom ~1Q 1 or 2 Family *State Approval Required. 7 OTAL NUMBER P FAB POURED-IST EL FIBERGLASS NEW REPLACE- OTHER ALLONS OF TANKS C CRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY A ill LIFT PUMP TANK/SIPHON CHAMBER MA, MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Min tes inch): PROPO EDAquarefeet): El New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit r__,1►°i ❑ Alternative (specify) ❑ Seepage Trench Water Supply: / Owner's Name as Listed on Soil Test Report (If other than present owner): rivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Na f Plumber: Signature: MP/MPRSW No.: Phone Number: Name of Designer: Plumb 's Ad ess: 4& AJ 4? &fll jJU COUNTY/DEPARTMENT USE ONLY Signs re of Is u'ng ent: Fee: Date: APPROVED Sanitary Permit Number: /f e. , ✓ " l ' s ❑ DISAPPROVED cX" 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 (N.03/81) . _ ~i /'1 s~~~ i i ~o ~ l ~©u~~