Loading...
HomeMy WebLinkAbout032-2018-50-000 °o r 0) 3 d CD n A~ 714, \ m 13 it (L1 Cn = N Z 'C'D A O Cl) n y O N cn O O CD 0 O N CD m z Q CD N (o a) CD 0 j ►n7 a ry M CD o. (D w r- C-n ' /\T 0 c CD n CD O m p A7 3 0 CD LY p 0) 'a o N _ co U) N . , C a W O O Q N4 CD w < CL _ CD o r a CD Co CO r icy N N N= ~~'Y, !mil z OCC OCC Occ A O -D -D G G G N z \a \ O 0 o 3 vim, ~ D aQ \ C? u 1 N I~ T 0 0 0 a in 3 L11. M CD CL FF Vl c N 5 fV D t°D° o N O v N Z -1 U) Z CD I c CAD CD Z ~ A Z CD r, o U) 0 A Z y l`J m a o' ry Cl) --i Ul W m w r.. a z p v z M m co CD i;: f o n Q. 3 Q C V O T N O v m m y S p a U) a " A Cl) 1 " I N O ft O U i` o ~A D °o k-j F), ON Q 0 a ti `D NN '69 O c o as C:> CD a~ Parcel 032-2018-50-000 11/16/2006 10:02 AM PAGE 1 OF 1 Alt. Parcel 5.30.19.537E 032 - TOWN OF SOMERSET 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 - DEWALL, ROBERT A & NANCY D ROBERT A & NANCY D DEWALL 575 170TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 493 CTY RD V V SC 5432 SOMERSET V _ SP 1700 WITC Legal Description: Acres: 5.650 Plat: N/A-NOT AVAILABLE SEC 5 T30N R19W PT OF SE NE 5.65A LOT 2 Block/Condo Bldg: CSM VOL 4/1200 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 05-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 655/250 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/24/2003 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 5.650 86,400 24,000 110,400 NO Totals for 2006: General Property 5.650 86,400 24,000 110,400 Woodland 0.000 0 0 Totals for 2005: General Property 5.650 86,400 24,000 110,400 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 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP w- ADDRESS _ ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 YESYTHING WITHIN 100 FEET OF SYSTEM F-99 2 I di er e No th Arrow Sc BENCHMARK: (Permanen reference Point) Describe : t'A-/,".) sr Elevation of vertical reference oint: f '~~U r P S 1 op e at site: #,SEPTIC TANK.-' Manufacturer: >S './Liquid Capacity:. J Number of rings on cover an manhole cover elevatio .Tank Inlet Elevation: Tank Outlet Elevation~~"'i~' PUMP CHAMBER y~ ~f Manufacturer: Number of gallons Number of gal. pump set or a cycle _ gallons; total-capacity of--- distribution lines gallon: size o pump_ head" gallon per minute horsepower and model number bran3-name of pump Type of warning e-ice ' HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover - Type of warning device SEEPAGE PIT SIZE _ Number o pits meet diameter feet liquid depth seepage pit in eft pipe-elevation bottom of seepage pit elevert on feet. SEEPAGE BED SIZE: number of lines w-fc t z_ 3E _lertgth_&LLtile depth SEEPAGE TRENCH: width length PERCOLATION RATE A~U INSPECTOR DATED PLUMBER LICENSE NUMBER - - / 3 ;2- DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 4 ONVENTIONAL ❑ALTERNATIVE State Plan 1,13, Number C (if assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME O z_z-ER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. B NCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV. T I Name o Plumber. r. IMP/MPRSW No. C'- "y Samtary ermi Nu 4 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER r PROVIDED PROVIDED I ❑YES LINO ❑YES LINO BEDDING. VENT DIA.. VENT MATL. HIQH WATER NUMBER OF ROAD. PROPERTY WELL: - BUILDING. (VENT TO FRESH ALARM LINES i AIR INLET. FEET FROM ❑YES LINO LIYES LINO NEAREST DOSING CHAMBER: MANUFACTUH ER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED'. ❑YES LINO ❑YES LINO ❑YES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PiiOPERTV WELL BUILDING, JVINTTOIRESH (DIFFERENCE BETWEEN FEET FROM "E AIR INLET PUMP ON AND OFF) ❑YES LINO NEAREST 110 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing - :I .r,,r 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 DISTR. PIPE SPACING COVER INSIDE DIA Sk PfTS_ LIQUID BED/TRENCH TRENCHES MATERIAL LIT DEPTH. NUMBER OF PHOPERTV WELL . BUILDING. VENT TO FRESH DIMENSIONS ~GHT [ CPTII FILL DEPTH UjISTR'jNI'IL . PF DISTR PIPE DISTR. PIPE MATERIAL . f!71NEARU~ BF LOta f If I5 ABOVE ,OVER ELEV ET 111-111E ND V , LINE AIR INLETFEET M -s MOUND SYSTEM: Mound site plowed perpendicular to slope Check thee~ 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 COVER. TEXTURE - PERMANENT MARKERS. OBSERVATION WELLS ❑YES LINO ❑YES LINO DFPTH OVER TRENCH. BED DEPTH OVER TRDNCH;BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CFN I FH EDGES' ❑YES LINO ❑YES LINO ❑YES NO PRESSURIZED DISTRIBUTION SYSTEM: _ WIDTH LENGTH NO. OF LATER I SPACING. GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVEH BED/TRENCH TRENCHES (f DIMENSIONS ? i MANIFOLD PUMP MANIFOLD DIST IPE MANIFOLD M .71ERIAL NO. DISTR. ID:STRPIPE DISTRIBUTION PIPE MATERIAL & MARKING ELF VELEVDIAELEV. PIPES DA.. ELEVATION AND DISTRIBUTION INFORMATION MOLE SIZE HOLE SPACING DRILLED CORRECTL COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS _ ❑YES NO ❑YES LINO COMMENTS: 4. PERMANENT MARKERS. ;OBSERVATION; WELLS: NUMBEROF PROPERTY WELL. BUILDING. FEET FROM LINE ❑YES ❑Nor ❑YES LINO NEAREST J-~r C7 II Sketch System on Retain in county file for audit. Reverse Side. SIGNATU$E:-~- TITLE. DILHR SBD 6710 (R. 01/82) 'r DEPARTMENT OF APPLICATION 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: C +y.or Townshi Count _,/4S _ iT ; Ni R or) W Lot Nu ber: Blk No:: ]Subdivision Nam Nearest Road, Lake or Landmark: State Plan I.D. Number: II (If assigned) TYP OF BUILDIN Number of Public* ❑ Variance* ❑ Other (specify) Bedrooms: ❑ 1 or 2 Family *State A pproval 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 LIFT PUMP TANK/SIPHON CHAMB R MANUFACTURER: A . e, n ti:t, EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit 1,2, 3 C`~; ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: r-~ Sig re: MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY ~Signat a of Issuin A ent: Fee: Date: APPROVED Sanitary Permit Number: ~ . ~/f1 n~ Gi e 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) ryl 0-1 i ~y r A 1, w ' i f j i t , I i ? nIT o- O C'191 i I n ~ • 3 3 t ~ - ~ G t ~i A 1Y ~i'S.~ilfM~~~'vl~~l z - ' r ~ , :tom (,v : ~-4 ~ ~ , } All i C r d5 5 S Q L~ 1 O toJ' 6" c~S fir, A ~ &AQ n ~r f ~a cast r~ P Pc P rYux~ - ~ so~ PC Vo- N 3 v a ~ ~11 ell lie c - r ~ ~+s~.~~ Rork 7 4 4 DEPAC F7ENT ter rte) j' v ~'•~'r..,.,. """~'~'(-~:.:'~--c~~~-, ~ ~p.~~ ~ ~ 1982 P1 b. - 60~ 1/7R PROJECT DETAIL DATA SHEET NAME OF BUSINESS Io h ~ e GL - ~Ir -T k LEGAL DESCRIPTION S,f`v - /iJ FYU SpC 5 T3a --I9, s c OWNER MAILING ADDRESS Jl} l S C Z I P S-y has AK44T c, u i R ADDRESS PLUMBER $R--Bf J 16?if R ZIP TELEPHONE NUMBER 71S; - 4~ S/3 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H-6.2176. (13, 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 ( ) 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 station (X) Employees ( total of all shifts) . . Number of employees ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 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? •~o.c ' _ ~n s ( ) 24-Hour service ~82° ~ " i re Total number of customers /!O ( ) Schools . . . . . . . . . . . . . . Number of classrooms _FT Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . . . . . . . Number of cars served daily ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . . (Specify) . . . . . . . COMPLETE OTHER SIDE 2. Indicate whether the following facilities are present. -Floor drain yes no A\ Number of drains Food waste grinder yes no Y Dishwasher yes no Automatic clothes washer yes no Y, Number of clothes washers f~ 3. Septic tank capacity 30 C~oj Holding tank capacity Septic or holding tank manufacturer we rS C Q ykk 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches dePth' I number of trenches SEEPAGE BEDS: total square feet c '*67,D d width 30 length of bed depth 'Y 8 11 SEEPAGE PITS: total square feet outside diameter r depth below inlet total depth from top to bottom of pit i Signature of Pers omPletin9 form: FOR DEPARTMENTAL USE ONLY a Address Zip Telephone Number Date ~ r vY { i Lys 7 T 40 Department of Industry, Labor & Human Relations State of ~~j Division of Safety & Bldgs. State Ot Wisconsin lumbing Platting & Fire Protection P.O. Box7969 g Madison WI. 53707 Tel. 608-266-3815 OD RRESPONDENCE EFER TO PLAN IDENTIFICATION 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 DILHR Local PI Plumber H & R (2) County Mfg. Rep. Bur. of Health Fac. & Services DILHR SBD-6099 (N. 06/80) Rec. & Env. Services SBD 6678 (9/91) (Plb 100a) Detach And Return STATE OF WISCONSIN DILHR Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 Any Return Correspondence P.O. BOX 7969 MADISON, WI 53707 608-266-3815 DATE:' f PROJECT: :a r PLAN ID. #Z 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 required fee is $ Fee Received is $ ❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming. ❑ Plan accepted for review. ❑ Plans being returned. ❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW. held in abeyance. 1. Plan Submission ❑ Complete data relative to anticipated use of bldg. ❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed. less specifically noted. ❑ Deed restriction required (1 copy). ❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy) ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2)(a) Wisconsin Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks Profile of holding an , showing vent, marh,,le alarm and manufacturer if precast. Complete construction details if II. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed. ❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of and notarized. (1 copy) government (sample enclosed). ❑ County onsite required 0 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement for pressurize distribution. ❑ Soil boring & percolation from county (1 copy). test data. ❑ Plot plan showing location of holding tank with lateral dist- ❑ Cross section of system. ❑ Pipe lateral layout. ❑ Plan view of system. ❑ Plot plan. ances to any building, wells, water service piping, water course, lot lines, swimming pools, all weather service road, ❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. III. Private Sewage Disposal Systems V. Litt Pump ❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons tion system extending 25' on all sides. pumped per cycle. ❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main. ❑ Location of area suitable for replacement system - provide Detail & model of pump or automatic siphons including soil data. size, pump curves, drawdown and average flow rate GPM. ❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or sewage disposal system to buildings, lot lines, well, water siphon(s). course, swimming pools, water service piping, Etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission) ❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench system. before side slope begin). ❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill. tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff. ' Department of Industry, Labor & Human Relations c Division of Safety & Bldgs. State of I Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison WI. 53707 Tel. 608-266-3815 INALL CORRESPONDENCE REFER TO PLAN IDENTIFICATION NO. NAME OF PROJECT 6 TYPE OF APPROVAL ~r ~ STREET AND NO. I~ CITY OR TOWN CO T F STATE ZIP 4 OWNER I 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, Cf/!/itA~ 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) Rec. & Env. Services SBD6678 (9/811 (Plb 100a)•~ STATE OF WISCONSIN DILHR Detach'And Return Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 Any Return Correspondence P.O. BOX 7969 MADISON, WI 53707 608-266-3815 DATE: / PROJECT:, 1J - ~E r PLAN ID. # r" 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 required fee is $ Fee Received is $ ❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming. ❑ Plan accepted for review. ❑ Plans being returned. ❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW. held in abeyance. 1. Plan Submission ❑ Complete data relative to anticipated use of bldg. ❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed. less specifically noted. ❑ Deed restriction required (1 copy). ❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy) ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2) (a) Wisconsin Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks ❑ Profile of holding tank showing vent, manhole alarm and manufacturer if precast. Complete construction details if ll. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed. ❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of and notarized. (1 copy) government (sample enclosed). El County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement for pressurize distribution.. ❑ Soil boring & percolation from county (1 copy). test data. ❑ Plot plan showing location of holding tank with lateral dist- ❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water ❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road, ❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. III. Private Sewage Disposal Systems V. Lift Pump ❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons tion system extending 25' on all sides. pumped per cycle. ❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main. ❑ Location of area suitable for replacement system - provide soil data. ❑ Detail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM. ❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or sewage disposal system to buildings, lot lines, well, water siphon(s). course, swimming pools, water service piping, Etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission) ❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench system. before side slope begin). ❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill. tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff. v DUS DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,' ' C DIVISION LABOR AN P.O. BOX 76 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 3707 LOCATION: SECTION: p OWNS IP/ LOT NO.:BLK. NO.: SUBDIVISION NAME: rf-%Li y- G 1/4 _5 /ILL N/R/Y$'(or)W c?C.~-i,4- r" AA- COUNTY: O ER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE ❑Reside NO. BEDRMS.ECOMPERCIALDESCRIPTI?N ~tNew R TONS: ER OLA ION TESTS: Id p 1\LC Y 1 1^c~c ❑ Re lace - Z S ' J - # - 1 6 ly RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ®S ❑U 2S ❑U ~S ❑U ❑S ®U ^'~.,vZV,t If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ROFILE DESCRIPTIONS 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.) L _ s C1 13- 4 7 C B PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- __3 P_ 2 - f 2 t i P- 3 S i - P- 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.C3 SYSTEM ELEVATION 8 c'' r J ` w e_ , rid Zi e 1, the undersigned, hereby certify that the so it 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): _t TESTS WERE COMPLETED ON: i ADDRF,S CERTIFICATION NUMBER: PHONE NUMBER optional): CS )GNATURE:f° DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DI LHR-SBD-6395 (N. 03/81) I DEPARTMENT OF TY & BUILDINGS INDUSTRY; REPORT ON SOIL BORINGS AND DIVISION 7LABOR AND PERCOLATION TESTS (115) y P HUMAN RDLATIONS ADI WI 53707 LOCATION: - SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BL : SUBDI`VI ION. ME:'~~ 4 k /LION/R''/ '1t (or) W COUNTY: t~ O ER'S BUYER' NAME: M ~LIZNG ADDRESS: " USE DATES OBS R S M NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DEWH ONS` ION TESTS: ❑Residence New ❑Replace / _ - RATING: S= Site suitable for system U= Site unsuitable for system G < 1 < _ NS1 ENTONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK; RECOMMEN E6! SYSTENt~6nal) _J u ❑ s ou❑ s ❑u . a s ❑ ❑ s ❑u 9f EL V. If Percolation Tests are NOT required DESIGN RATE: SYSTEM If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevatio 1 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SO WITH THICKNESS, COLD TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B~~- 13- B- C - PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH (Y-f7, SLY r P P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe wft~t ire the hori- points and show their location on the plot plan. Show the surface elevation at all borings ~ ~Q'cf~r~Ciyon and percent zontal and vertical elevation reference , of land slop. / a , - SYSTEM ELEVATION , _ t cl. ~t _ f` x ~ r:fir '11 \ 4 L % M 3 • I, 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 Wiscur.n Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME Kint); TESTS WERE COMPLETED ON: ADDR - - CERTIFICATION NUMBER: PHONE NUMBER optional): Cp T : ' i CST S NATURE• r DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. 'LHR-SBD-6395 (N. 03/81)