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,Parcel 042-1066-30-000 01/16/2007 04:38 PM
PAGE 1 OF 1
Alt. Parcel 24.29.18.368B 042 - TOWN OF WARREN
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 - GREENFIELD, DONALD E & BERNADINE B
DONALD E & BERNADINE B GREENFIELD
1472 HWY 12
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1472 HWY 12 E
SC 2422 ST CROIX CENTRAL
SP 1700 WITC Se In L
Legal Description: Acres: 1.742 Plat: N/A-NOT AVAILABLE
SEC 24 T29N R18W 1.742 A NW NE LOT 1 CSM Block/Condo Bldg:
VOL 4/1127
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 866/363
07/23/1997 652/153
2006 SUMMARY Bill Fair Market Value: Assessed with:
149539 82,000
Valuations: Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 1.740 34,600 25,200 59,800 NO
Totals for 2006:
General Property 1.740 34,600 25,200 59,800
Woodland 0.000 0 0
Totals for 2005:
General Property 1.740 34,600 25,200 59,800
Woodland 0.000 0 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
Parcel 042-1034-95-000 01/16/2007 04:48,PM
PAGE 1 OF 1
Alt. Parcel 13.29.18.207B 042 - TOWN OF WARREN
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
O - GREENFIELD, DONALD E & BERNADINE B
DONALD E & BERNADINE B GREENFIELD
1472 HWY 12
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1472 HWY 12 E
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 13 T29N R18W E 280 FT OF S 484 1/2 Block/Condo Bldg:
FT OF SW SE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 866/363
07/23/1997 553/285
2006 SUMMARY Bill Fair Market Value: Assessed with:
149230 170,800
Valuations: Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 42,500 82,100 124,600 NO
Totals for 2006:
General Property 3.000 42,500 82,100 124,600
Woodland 0.000 0 0
Totals for 2005:
General Property 3.000 42,500 82,100 124,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 103
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP e, SEC N-R/ jW
ADDRESS/ ~~,r ,~,r Itv ST. CROIX COUNTY, WISCONSIN.
1
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet. requirements of H63
SHOW-EVERYTHING WITHIN 100 FEET OF SYSTEM
Act
LXA
-A - - -
I di atiF o-~,th~ Arrow
SCALE: I I
:
IENCIIMARK: (Permanent- reference Point) Describe:
Elevation of vertical. reference point:----- -Slope at site: _
SEP'T'IC TANK: Manufacturer:--r/ Liquid Capacity
Number of rings on cover - c= _Tan~ manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CI? 1MBER
Manufacturer.: _ Number of gallons
Number of gal. pump sego- a cycle _ gallons; total capacity
distribution lines___ _gallon: size of pump- head-,
gallon per minute horsepower brand name of pump
and model number ;
Type of warning c(e_vice_
IIOL,DING TANK: Manufacturer _ Number of gallons______
Elevation of manhole cover
1'y~> of warning device _
- - - -
SEEPAGE PIT SIZE: -NdM e r. OT p is _ met ometcr
feet Liquid depth - seepage pit inlet pipe-elevation----- - _
bottom of seepage pit e evati_on feet.
SE'1, I'AGI? BED SIZE: number of lines width leoVth tit-e depth- -
51;hPAGE L'RENCH: width- length
PERCOLATION RITE ARFA REQUIRED ______-AREA AS BUILT _ 3,/-
INSPI C'FOR
- - - -
DATI:D - - - S PLUMBER ON JOR
- - - -
LIC1.N51? NLfMhI?k
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit= ~.7
f / State Septic _S
PdAME~ oeG 4. - oea TOWNSHIP ~"-Aosev St. Croix County LOCATION A06 SectiondyLot # Subdivision
SEPTIC TANK
r
Size gallons Number of compartments
I)istance from: Well Building 12% slope
Highwater
11LIMPING CHAMBER
Size gallons Pump Manufacturer Model Number_
HOLDING TANK
Size gallons Number of Compartments
Pumper Alarm System _
Distance from: Well Building 12% slope
Highwater
ABSORPTION SITE
Bed Trench
Distance from: Well Building 12% slope
Highwater
ABSORPTION SITE DIMENSIONS
Width of trench ft Required area ft.
Length of each line / ft Depth of rock below tile in.
Number of lines Depth of rock over tile_in.
Total length of lines ft Depth of tile below grade- in.
Distance between lines ft Slope of trench -in. per 100 ft.
Total absortption area ft Type of Cover: _
PIT DIMENSIONS
Number of pits Gravel around pits yes____ no
Outside diameter ft Depth below inlet _ ft
Total absorption area ft
Area required ft ?
r„
f.
LNSPECTE,D BY TITLE
APPROVED DATE " ? - 198_
r'
REJECTED DATE 198
REASON FOR REJECTION
State and County State Permit #
PLB 67 ~f. Permit Application County Permi #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED Q
Date Approval Received from State if Required State Plan I.D. # 11-64
A. OWNER OF PROPERTY Mailing Address:
,,oOe 0'7 K~e e:
B. LOCATION: 1 tt✓'/4 AIL Section T~.I'/ N, R (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# % 2 Village
Township Gf c'/ F eL
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY ZP ' 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 or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENNTSPOSAL SYSTEM: Percolation Rate Total Absorb Area ` sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: 3 36" No. of Lineal Ft. " Width ~ Depth rTile depth (top)2-~jNo. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land - 5 :%fi Distance from critical slope
WATER SUPPLY: Private 9 Joint ❑ Community ❑ Municipal ❑ _
Owners name as listed on H 115 if other than present owner:
1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME -4'j c 4 cr s--cl 141 ae yz C.S.T. # f /yam? and other information
obtained from (owner/builder).
y S Y
Plumber's Signature 'a ti' MP/MPRSW# S Phone - z 2
Plumber's Address ~ , V /1lccL' ~ u l3 c l am,
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application / -y" s/ Fees Paid: State ° County ,q Da
Permit Issued/Rejected (date) Issuing Agent Name IL, -L%
Inspection Yes, ~_No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2, state (pink copy) 4, plumber (canary copy)
Revised Date 7/1 /78
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTFTY, DIVISION
LABOR
HUMAN NDLATIONS PERCOLATION TESTS (115) P.O. BOX 7969
I q MADISON, WI 53707
O TOWNS H~MUNICIPALITY: LOT NI SU V NAME:
LOCATIQ~/~~j SECTION: ~ N/R I (or) W
CUIYNgTYY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE OB ONS A
k DESCRIPTION: D ONS: OLA ION TESTS:
❑Residence NO.BEDRMS.: ~AL New ❑Replace° -
RATING: S= Site suitable for system U= Site unsuitable for system
,
CNTIO❑NAL: IMOUND: IN-GR❑OUs au SSURE: SYSTEM IaULHO~LDI G~NK. RECO MENDEeD- S(AA Y iE=aM:(optio al) Al?
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V.
f If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Y Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
13-2- 7~
9- 4 4Z
B-3
,I
B- /_7
B-_5 7 Z, 3~
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- 3 3= /
P- D 3 02 ' E
P- 3
P-
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 A6 it e4 5:14 Z~ ,-t-
T0.0 ye law
.'eel 34 '05 3
_ a -71
T,_
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♦ 74A
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1, 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: CERTIFICATION NUMBER: PHONE NUMBER optional):
L-z
CST SI ATUR
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
D I L H R-S B D-6395 (N. 03/81)
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Plb 100a 12/78
Detach And Return Upper State of Wisconsin
DIVISON OF Of This Form With SECTION N HEALTH
OF PLUMBING
AND FIRE PROTECTION SYSTEMS
Any Return Correspondence MAIL ADDRESS: P.O. BOX 309
MADISON, WISCONSIN 53701
608-266-3815
DATE:
PROJECT:
NE4, S.
of War-
PLAN ID. #
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 plan review fee required is $
❑ Plan accepted for review. Fee received is $ -
Fee is being returned because of ❑ Overpayment ❑ Underpayment.
Providing one of the two catagories above is checked, remit correct fee in one payment. ~ ~
tal-
No fee has been remitted. Plans submitted with no fees will be held in abeyance. -
❑
Plans being returned. a
Additional information required. SEE BELOW.
1. Plan Submission
❑ Additional information shall be submitted in triplicate unless specifically noted.
❑ Plans not clear, legible or permanent.
❑ All information submitted shall be signed, sealed or stamped in accord with Section H 62.25(2)(a) Wisconsin Administrative Code.
❑ Affidavit enclosed.
ll. Alternate sewage Disposal Systems (Mound Systems)
❑ PLB 108 (Application for use of an alternate system).
❑ County onsite required (1 copy). ❑ Design calculations for pressurized distribution
❑ Cross section of mound. ❑ Pipe lateral layout. ❑ Plan view of alternate.
I ll. Private Sewage Disposal Systems
❑ Ground slope with 2' contours in entire area of soil absorption system extending 25' on all sides.
❑ Elevation of permanent reference point (benchmark).
❑ Location of area suitable for replacement system - provide soil test data.
❑ Plot plan showing lot size and all lateral distances from sewage disposal system or holding tank to bldgs, lot lines, well, watercourse, etc.
❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast.
❑ Construction detail and cross-section of soil absorption system.
❑ Soil boring and percolation test on EH 115 completed by certifiedsoil tester (1 copy).
❑ Complete data relative to anticipated use of bldg. ❑ 3 copies of PLB 60 enclosed.
❑ Deed restriction required (1 copy).
IV. Holding Tanks
❑ Profile of holding tank.
❑ Holding tank agreement signed by owner and local unit of government (sample enclosed).
❑ Reason for installing holding tank soil test or statement from county (1 copy).
V. Lift Pump
❑ Calculations for total lift pump discharge, head and gallons pumped per cycle.
❑ Size, length & depth of force main.
❑ Detail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM.
❑ Cross section of lift pump tank showing pump(s) or siphon(s).
VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Total area filled (fill to extend 20' beyond edge of trench before side slope begin).
❑ Depth and type of fill.
❑ Copy of onsite report by county or district plumbing supervisGr.
Length of time fill has been in place.
Pl b~ # 60
1/78
PROJECT DETAIL DATA SHEET
NAME OF BUSINESS per? C51 re e_ n f-, e
LEGAL DESCRIPTION
.
OWNERo n e MAILING ADDRESS
ZIP
ARCHITECT, ENGINEER, LT lh S ADDRESS
PLUMBER OR DESIGNER
VV ZIP % U
TELEPHONE NUMBER f'/ 1~ ____~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 L- ' Addition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . . . . . . . . . Seatinq 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
( ) Day and night Number of persons
( ) Catchbasi.n . . . . . . . . . . . . . Number
( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons
( ) With kitchen Number of persons
( ) Dance hall . . . . . . . . . . . Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals served daily
( ) Dog kennels . . . . . . . . . . . . Number of enclosures _
( ) Drive-in restaurant . . . . . . . . Inside seating capacity _
Car-service Number of car spaces _
( ) Dump station . . . . . . . . . . . . Number of dump stations
(X) 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?
( ) 24-Hour service
( ) Retail store . . . . . . . . . . Total number of customers
( ) Schools . . . . . . . . . . . . . Number of classrooms Meals ( ) Showers
( ) Self service laundry . . . . . . . . Total number of machines
( ) Service station . . . . . . . . . . Number of cars served daily
( ) Swimming pool bathhouse . . . . . . Number of persons
OTHER (Specify) . - A", Y-LL--/Il,
61
COMPLETE OTHER SIDE
2., Indicate whether the following facilities are present.
Floor drain yes no X Number of drains
Food waste grinder yes no X
Dishwasher yes no y
Automatic clothes washer yes no Number of clothes washers
3. Septic tank capacity
Holding tank capacity
Septic or holding tank manufacturer
4. SEEPAGE TRENCHES: total square feet width of trenches J
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet width
length of bed depth
SEEPAGE PITS: total square feet outside diameter
depth below inlet
total depth from top to bottom of pit
Signature of person completing form: FOR DEPARTMENTAL USE ONLY
Address Zip S,/G'/7
Telephone Number 7/ - 2 y4 y S y
Date ~1~--1
I '
Op
VV , ~ k sal l ~ ~
S .
r
/ V
EPAR`TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
rNDIJSTRY, DIVISION
ARCH AND PERCOLATION TESTS (115) MADISP-0. BOX 7969
ON WI 53707
it1MAN RELATIONS
'ATION --SECTION: p TO WiNSHIP/MUNICIPALITY: LOT 4 .:BLK. NO.: SUBDIVISION NAME:
1/ f;.1/ f /1 N/R j 0(or)W t., /
l1NTY OWN 'S /BUYER'S NAME: MAILING A DRESS:
1
t DATES OBSERVATIONS MADE
No. 8~1 l~aFiC 6EZ`Ttl~fiTaN~:tZ 6LATrbRTS
ltesidence_ [-:.New ❑Replace L--
AT ING: S- Site suitable for system U- Site unsuitable for system
INv~NMNAL: MOUND: iN4ROUND-PR 9V BEM IN FIL LHOLDING TANK RECOMMENDED SYSTEM:loptional)
s pub S au as 111 EIS c~uT[as
SYSTEM ILEI
1 f ercolatlon Tests are NOT required DESIGN RATE: oi tion of the lot is in the
lei s.H63 09(5)lb), indicate: [Floodplain, indicate Floodplam elevation:
PROFILE DESCRIPTIONS
)RING TOTAL H TO R AT R -ICHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
ST UMBER DEPTH IN. ELEVATION S RVED ES r. H E TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I ~
r' , ~ r r
li -
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
JUMBER INCHES AFTERSWE LING INTERVAL-MIN. PER INCH
> - -
r
AN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
ntal 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
land slop.
)-YSTEM ELEVATION r g f, .
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the undersigned, hereby eertlfy~ et the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
drnimistrative Goda, and that the data rvaoFdad and the lo=ion of the tests are correct to the best of my knowledge and belief.
'we
~
;AME print : TESTS WERE COMPLETED ON:
ADDRESS : ? CERTIFICATION NUMBER: PHONE NUMBER optional):
¢ ! CST SIGNATURE:
-ISTRIIK)TION: Original-Local Authority, 2nd pega-dureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
t I i R -SB D 46395 IN. 03/8 1)
} 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
i
/NALL CORRESPONDENCE
REFER TO PLAN
IDENTIFICATION NO.
G
NAME OF PROJECT
PE F APPROVAL
j 1
_1Z ~t
2C_ yet • •e'
STREET ArD No.
CITY OR TOWN CO NT STATE ZIP
OWNER
v
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.
cc: DP-3 Owner DI LHR
Lo s:11 PI Plumber H & R (2)
unty Mfg- Rep. Bur. of Health Fac. & Services
DI LH R SBD-6099 (N• 06/80) Rec- & Env. Services
Plh. # 60
1/78
PROJECT DETAIL DATA SHEET u "
NAME OF BUSINESS e"
roc ns
LEGAL DESCRIPTION A/"
OWN ERp i1 IGrK i7 f~ /c~ - MAILING ADDRESS 1~f~-LC Z4L_~1_~
ZIP
ARCHITECT, ENGINEER, / ADDRESS
PLUMBER OR DESIGNER
VV t, ZIP `/Z) / j
TELEPHONE NUMBER
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 L 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
( ) Day and night Number of persons _
( ) Catchbasin . . . . . . . . . . . . . Number
( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons
( ) With kitchen Number of persons
( ) Dance hall . . . . . Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals served daily
( ) Dog kennels . . . . . . . . . . . . Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity _
Car-service Number of car spaces
( ) Dump station . . . . . Number of dump stations
(~j Employees ( total of all shifts) Number of employees 1
( ) 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, mediC_sta
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . . . Number of sites
( ) Nursing homes . . . . . . . . . . . . Number of beds
( ) Parks . . . . . . . . . . . Number of persons 'Toil'ets ( }°-Showers
( ) Restaurant . . . . . . . . . . . . . Seating capacity
( ) Dishwasher and/or disposal?
( ) 24-Hour service
( ) Retail store . . . . . . . . . . . . Total number of customers
( ) Schools . . . . . . . . . . . . . . Number of classrooms Meals ( ) Showers
( ) Self service laundry . . . . . . . . Total number of machines
( ) Service station . . . . . . . . . . Number of cars served daily
( ) Swimming pool bathhouse . . . . . . Number of persons
OTHER . . . (Specify) . . . . . . .
Al.
COMPLETE OTHER SIDE
2. Indicate'whether the following facilities are present.
Floor drain yes no X Number of drains
Food waste grinder yes no >c
Dishwasher yes no
Automatic clothes washer yes no Number of clothes washers
3. Septic tank capacity
Holding tank capacity
Septic or holding tank manufacturer
f
4. SEEPAGE TRENCHES: total square feet ~;o width of trenches J
length of trenches depth E
number of trenches /
SEEPAGE BEDS: total square feet width
length of bed depth
SEEPAGE PITS: total square feet outside diameter
depth below inlet
total depth from top to bottom of pit
Signature of /person completing form: FOR DEPARTMENTAL USE ONLY
.Address
'
Zip
Telephone Number Z/ - 2 2G
Date
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I PAIITMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDIN(;
MUS.TR'Y eJ DIVISION
ABQR AND PERCOLATION TESTS (115) UMAN RELATIONS MADISP.O. BOX 7969
ON WI 53707
- - - -
- LOT-146` ]130k. NO.: SUBDIVISION NAME:
I~:ATION: SEC I N W TOWNSLA -IP71V-1-UN ICIPA LI TY:
1/4,11-1/4 /T " ' IR (or) N
I~NTY OWN 'SIBUYER'S NAME: MAILING ADDRESS:
0a 5: 17 ~ 2 5- /1
;L DATES OBSERVATIONS MADE
_ .
NO. BEDR C k _ l R TPT ION: ITffCSFTL-6ESCfiIP1`T~NS: ER COLATION TESTS:
Hesidence 1 New r]Replace
r L.
A TING: S= Site suitable for system U- Site unsuitable for system
JNVf NTIONAI OUND: IN•GROUNaPRESSURE: SYSTEM-IN FII I_ if LDINr; I-AIVr ECOMMENIA- 11 SY: l FM* (opt onal)
sEluIMosou -osou E]sEIrsuu[H
Ii1s,H63Alests 15)Ib) are NdOTatreequlred DESIGN RATE:j9WMSM FlEV. Floodplai liondicateeFl cos in the th lot c
dplain elevation:
T PROFILE DESCRIPTIONS
/RING TOTAL DLPIH R AT R-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
uJMB}+ER DEPTH IN. ELEVATION j1 QSSKRVED EST. HIG TO BEDROCK IF OBSERVED (SEE ABBHV ON BACK.)
13-
13-
13-
i
1
PERCOLATION / f
TESTS
TEST DEPTH WATER IN HOLE TEST TIME WATER LEVEL-IN H S RATE MINUTES
JUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD .1 P 1002 PER INCH
V'
F
r.AN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
,mal 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
t land slop.
iYSTEM ELEVATION • F%~ t
T
4"+ 11 ~j
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I~. ~..1 t 73fit; ,1,
. ~ 1
r~
X30
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the undersigned, hereby certify hat the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
edmimistrative Code, and that the date recorded and the location of the tests are correct to the best of my knowledge and belief.
. .e/M
NAM print : 1 r. h f r TESTS WERE COMPLETED ON
ADDRESS: ? CERTIFIQATION NUMBER' PHONF N11-- uptional)
f! t!
le~°1 CST SIGNATURE:
tiSTRIRUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
HP 5131)8395IN.03/81)
I r , ent of Industry, Labor & Human Relations
4U, Division of Safety & Bldgs.
State of Wisconsin Bureau lumbing Platting & Fire Protection
RECEIVE P.O. Box7969
u
-4 Madison WI. 53707
dE~ Tel. 608-266-3815
ZONING r`-
~ OFFICE
INALL CORRESPONDENCE
REFER TO PLAN
IDENTIFICATION NO.
NAME OF PROJECT
TYPE OF APPROVAL
STREET AND NO.
CITY OR TOWN UNTY 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,
GT~
James Sargent-Bureau Director
P' ANS REVIEWED BY: DATE:
°S-OWS Owner DI LHR
al PI Plumber H & R (2)
ty Mfg. Rep. Bur. of Health Fac. & Servic
'099 (N. 06/80) Rec. & Env. Services