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Parcel 036-1044-80-000 06/30/2006 12:09 PM
PAGE 1 OF 1
Alt. Parcel 19.31.17.281B 036 - TOWN OF STANTON
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
DENNIS A & JANICE JOHNSON O - JOHNSON, DENNIS A & JANICE
1448 210TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1441 210TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 19 T31N R17W 1A PT NE NW COM 445'W Block/Condo Bldg:
OF NE COR,TH S 272', W 160' B 272'E
160' TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
19-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 423/410
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/05/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.750 10,000 117,800 127,800 NO
COMMERCIAL G2 0.250 8,000 42,000 50,000 NO
Totals for 2006:
General Property 1.000 18,000 159,800 177,800
Woodland 0.000 0 0
Totals for 2005:
General Property 1.000 18,000 159,800 177,800
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
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Parcel 036-1044-80-100 11/28/2012 01 56 PM
PAGE 1 OF 1
Alt. Parcel 19.31.17.281 B-10 036 - TOWN OF STANTON
Current ;Xj ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
08/15/2006 00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
DENNIS A & JANICE JOHNSON O - JOHNSON, DENNIS A & JANICE
1448 210TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 1441 210TH AVE
SC 3962 SCH DIST NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 3.080 Plat: 5247-CSM 21-5247 036-2006
SEC 19 T31 IN RI 7W PT NE NW CSM 21-5247 Block/Condo Bldg: LOT 01
LOT 1
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
19-31N-17W NE NW
Notes: Parcel History:
Date Doc # Vol/Page Type
04/18/2012 954653 EZ-U
03/08/2007 846105 OC
07/25/2006 830483 CSM
05/24/1966 284485 423/410 WD
2012 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/28/2011
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.080 35,400 119,400 154,800 NO
Totals for 2012:
General Property 3.080 35,400 119,400 154,800
Woodland 0.000 0 0
Totals for 2011:
General Property 3.080 35,400 119,400 154,800
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
• AS BUILT SANITARY SYSTEM REPORT
-NER TOWNSHIP iz , ~ SEC. R W
0. ADDRESS 3 ST. CROIX COUNTY, WISCONSIN.
_ i3DIVISION LOT LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
--------_T - ~i a ~r
r
i
1
I
17
-'TIC TANK(S) MFGR.~ ; CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
-'NCHES NO. ofwidth length area
no. of lines width length area y;
depth to top of pipe
:1REGATE, :?.K RATE AREA REQUIRED( - AREA AS BUILT' Y f 6 1 ,
>claimer: The inspection of this system by St. Croix County does not imply complete
=liance with
p State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
.tem operation. However, if failure is noted the County will make every effort to
ermine cause of failure.
,ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
"INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER , 1.
RRPOP,T OF IJTSPECTIO'I--INDIVIDUAL SE07AGE DISPOSAI, SYSTEii
Sanitary Permit
r State Septic
T&WNSHIP ~~cz
• St. Croix County
Sr.T'TIC TA77I f .
SAZe gallons. `umber of Compartment
Distance Front: Tell ft, 12% or greater slope ft.
Building ft. Wetlands f.
11ighwater ft.
DISPOSAL SYSTE:1 Tile Field or Seepage Pit(s)
Distance From: Well ft. 12%.or greater slope' ft
Building; ft. Wetlands ~ f:.
FIELD Flighwater ft.
Total length of lines -ft. Number of lines Length of
each line eft. Distance between lines ft. Width of the
trench -ft. Total absorption area sq, ft. Depth
of rock, below tile in. DP-pth of rock over tile in. Cover
over . rock,, Depth of the below grade _in, Slope of
trench in per 100 ft, Depth to Bedrock ft. Depth to
ground water ft.
PITS
Number of pits Outside diameter ft. Depth below inlet
ft. Gravel around pit: `yes no. Total absorption area
sq. ft.
.Square feet of seepage trench bottom area required
Cquare feet of seepage nit area required '
Inspected by: Title:
Approved Date 197 ,
Rejected Date 197.
State and County State Permit #
PLB67 Permit Application County Permit
,T
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required _ State Plan I.D. # _
A. OWNER OF PROPERTY Mailing Address:
1-5 ~4; 0 If, P3
B. LOCATION: Z(4 % Vii, Section j~/7 , T- ~::Tt N, R (or) W Lot# -City
Subdivision Name, nearest road, lake or landmark Blk# Village
- Township _'5:;6*,!~6
C. TYPE OF OCCUPANCY: -Commercial -Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher V YES NO Food Waste Grinder YES 'IQ0 # of Bathrooms
Automatic Washer L- YES NO Other (specify)
E. SEPTIC TANK CAPACITY e-ro Totalgall,o,nn C; No. of tanks _
*Holding tank capacity 9~I~Nons~ No. of tanks
New Installation Ai' i eplacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) _Total Absorb Area sq. ft.
New` Addition Replacement -Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length -..-Width T7 1 Depth Tile Depth No. of Lines 7
Seepage Pit: Inside diameter Liquid Depth Tile Size -
Distance from critical slope
Percent slope of land e7-)
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 ff-/ C.S.T. # 7 1 and other information
obtained from S ~?°SB ti' (owner46w46ed.
Plumber's Signature s MP/MPRSW# 10,5 Phone #014
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Ilk /J~ 4-71W
I 1
Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application Fees Pa'd: State l0 , Co my 7 f " Date Y ?
Permit Issue (date) _Issuing Agent Name- 4 c : ►,,t ,r
Inspection Yes- No Valid# Date Rec'd
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 6/1 /76
EH .115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
7-5
LOCATION r_'/4,A-1L Section]-/ , T~~N, R~~~ (or) W, Township or Mt"4 Fpal+ty
Lot No. , Block No. County
Subdivision Name
Owner's Name: D v 5 y i
Mailing Address: 'e -t~
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET _ SOIL TYPE L
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P_
C/
P-1-3 3~, r It 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-
I 7Z i (:7 7 B 7Z
i
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. iI-' Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
Y I
t I
_ F~v } - I
I f r__}I
Ilk'
I I _
_
I i tt I I 1 I i i
1 .»-a T i i {
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- t - -
11 I i t
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.
- e' / Certification No.
Name (print)
Address ~V,3, d,
Name of installer if known
CST Signature -
AS BUILT SANITARY SYSTEM REPOW1,
OWNER n Y~ ~S TOWNSHIP `13l~ lW
-T
ADDRESS 1t.A~11 ST. CROIX COUN'T'Y , W I C 0N:; 1 ~J
~l / 1 LOT LOT S I Z I,"
SUBDIVISION
PLAN VIEW
i
Distances and dimensions to meet requirements of I163
cz ~A W--EVERYTHING WITHIN 100 FE1,:T OF SYSTEM
0
~ ~ 'ate
d1 a e 140tt-h, Arrow
BENCHMARK: (Permanent reference Point.) Describe: tic' d A05
• C
Elevation of-vertical reference point:___j~E f _Slopc' rtt sift':__ _
SEPTIC TANK: Manufacturer: ntfvi; 1,icluld C211),1C i t y : I do v,
Number of rings on cover --Tank 111allho le cover e l eva l ton :
Tank Inlet Elevation: Tank Out lei I:leva( ion 4
PUMP CHAMBER
Manufacturer: P Aps _ Number oL gar l Ions
Dumber of gal. uet or a - cy-c 1 E I Tons ; t cat gal ~ <+I>~>~ i t Y or
distribution lines_ gal-lon:-- size _01, pump I~e~rd;
brain<I n<uu~' ~~I I>ruup
gallon per minute horsepower
and model number
Type of warning device
HOLDING TANK: Manufacturer Nuuil>er ut ~alloiis
Elevation of manhole Qover___
Type warning device
SEEPA~r PIT SIZE: „ Number or L)iLs feet diamc.I er
feet liquid depth seepage pit inlet pipe-elevaiiun
bottom of seepage pi- t e~vaLion-_ _ __fec t
SEEPAGE BED SIZE: number of lines width Le''1gt_It 3_; t t I dept h_')
SEEPAGE TRENCH : width len ; Lh
PERCOLATION RATE L, Ih~,,~ REA REQUIRED , ARrA AS I30Tl
INSPL:CTO
DATED ,c~- - PLUMBER ON Jffl ~
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOIR &.HIJIMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O BOX 7069 BUREAU OF PLUMBING
MAtISON,''kVI 53707
XCONVENTIONAL ❑ALTERNATIVE state Plan l).o. Number.
Ilf ass~g ned
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER INSPECTION DATE
Deg&is Jt
BENCH MARK (Permanent reference pomt DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
N.me of Plumber. JMPIMPRSW Nt.. County. Sanitary Permit Number_
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV TANK OUTLET ELEV. 156, NLVIDEDPOVIDEDI J ) 7 47 YES ONO DYES NO
BEDDING: VENT DIA. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY JWELL. BTO FRESH
G ALARM FEET FROM _ LINE AI R~INLET
YES ONO I DYES ONO NEAREST O > l
DOSING CHAMBER: _
MANUFACTURER BEDDING. LIQUID CAP AC I TV - MP MO PUMPSIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
DYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: UMP NDCON HUL oPE HATIONAL NUMBER OF oPERTV T BUILDING I
ILIIJE AIR IrE FRESH
(DIFFERENCE BETWEEN FEET FROM AR NLET
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil FRIStUre at the depth of plowing I nrrl, ~:nr,'FTER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
b'VIUTH. LENGTH NO. OF IDISTR PIPE SPACING COVLH INSIDE DIA SPITS LIQUID
BED/TRENCH TRENCHES / MATERIAj PIT DEPTH.
DIMENSIONS M~ j Ep S,
GRAVE] FI'T~I FILL DEPTH DISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BC I')JI IPfS ABOVE OVER ELEV INLET ELE VEND PIPES ALINE. / AIRnINLET
-1
NEARESTO---s > T/
2 U rCST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check.tht~ text re of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: / 1,
mound systI s to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the cri ria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER TEXTURE t, P / , ERMANENT MARKERS OBSERVATION WELLS
t
DYES ONO DYES NO
DEPTH OVER TRENCH RED DEPTH OVER TR_ CH: BED 4 DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
DYES ONO DYES DNO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTH LENGTH NO.OF LATERAL SP CING. JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES f
DIMENSIONS
MANIFOLD PUMP MANIFq D DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA1 ELEV. PIPES DIA.:
ELEVATION AND .
DISTRIBUTION i
INFORMATION HILL SIZE HOLE SP,yCING DRILLED CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY J WELL: BUILDING:
FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST--~►
,
_T
Sketch System on Retain in county file for audit.
Reverse Side.
TITLE
SIGNATURE
DILHR SBD 6710 IR.01/821
DEPARTMENT OF '~~~~PPLICATION SAFETY & BUILDINGS
INDUSTRY, L~o NITARY DIVISION
LABOR'AND PE IT P.O. BOX 7969
All, PLE 7) MADISON, WI 53707
HUMAN RELATIONS
Attach plans for the system on pa1!0- s in e. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must pr a separating distances and physical characteristics as specified in chapter
01
H-63, Wis. Adm. Code, must be shown. An e must be signed, sealed and dated by the design er. If designed by a Master
Plumber, the date, signature and license number The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner:
Mailing Addr
`s , ~ r • ~ y, ti • } ti , l~ ,i.%..i 1 ~~u~....~tr1`~ ~ ~ ~ ~ .i ..JL.~..
Property Location: = City, Village or Township: County: }
'/4 '/aS iT N/R E (or) W 5_77-,1 )-itoi,~
Lot Number: Blk No.: Subdivision Name:. Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assignees
A N A ~
L-j
TYPE OF BUILDING ..11
Number of
Public* ❑ Variance* ❑ Other (specify)*Bedrooms:
Q 1 or 2 Family State Approval Required. \n
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 CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inchPROPOSED (Square feet): ~ New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
N Private ❑ Joint ❑ Public A, A
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
N e o Plumber :j, Signat re BIWMPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
t S jT
COUNTY/DEPARTMENT USE ONLY
Sign re of Issuing A nt: Fee: Date: T itary Permit Number:
APPRO ED - 7 ❑ D SAPPROVED
Reason 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 Plumhing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
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
INALL CORRESPONDENCE
f t~jc t. ev 5 ~ i/V1 Q,~•t T Q~v v ~i,Z j REFER TO PLAN
c) IDENTIFICA TION NO.
f! . ~J ! V Q 4c1 i GLI PKC14 ~ Y4 J i
574ot 7 ~ ~<p n
NAME OF PROJECT
TYPE OF APPROVAL r'LrjCIVrrs °•r~
STREET AND NO.
L ' WOf /CF i-
CITY OR TOWN COUNTY STAT ZIP
OWN R
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,
for
James Sargent-Bureau Di "Ile
PLANS REVIEWED BY: DATE:
cc: DPSfl S~ > Owner DI LHR
Plumber H & R (2)
!'.nunry - Mfg. Rep. Bur. of Health Fac. & Services
DI LHR SBD-6099 IN. 06/80) Rec. & Env. Services
SBD 6678 (9/81) (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
DATE: Z / 1 PROJECT: 608-266-3815
1
i
~ eOJ N I t"4 r7
y4/ *T-3 i t4j ~ 1 "7 ~
ANID.# 96 (_Z
DETACH HERE Y~
PROJECT NAME_f I' t ~ PLAN ID. # '4 Z
This is to acknowledge receipt of your plans and specifications for the above-indicated project. f
Preliminary review indicates the required fee is $ 15- Fee Received is $ ,S7- r f
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. E:] 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
►I. 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 (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 ❑ 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 0 Copy). ❑ Copy of onsite report by county or district staff.
i
2. Indicate whether the following facilities are present.
Floor drain yes no K Number of drains
Food waste grinder yes no >1
Dishwasher yes no
Automatic clothes washer yes no Number of clothes washers
3. Septic tank capacity Q oPC j
Holding tank capacity
Septic or holding tank manufacturer
4. SEEPAGE TRENCHES: total square feet width of trenches
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet c11,:D ' r width Es7--
length of bed ? S 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
i ~
Address r
Zip
Telephone Number
Date - -
PLUMBING
. ~Qa~aaas~cz~ -
~RPrt ~ti`:
DEPA f'0F NI~USIRY, L t's: r,i; t';U,,MAN RELATIONS
N OF i.^FETUND ';;ILUING'
SEE CO Pi PONDENCE
J
P1 b: 60
•/~g PROJECT DETAIL DATA SHEET 82-00262
NAME OF BUSINESS
LEGAL DESCRIPTION }
OWNER MAILING ADDRESS
/~_1_1_2_) ~01 ~_jh P~5 ~01
A-RCHI-TEC.T ENGINEER, cy ADDRESS
PLUMBER OR-DESIGNER
Z I P
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 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 RECEIVE,)
( ) Dog kennels Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity F t~1 1982
Car-service Number of car spaces
( } Dump station . . . . . . . . . . . . Number of dump stations PLU IeING BUREAU
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 TT 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
CL
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82-00262
b.
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r ~ ~ ga~ ig' i +
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f~ = ~0
✓ i i ~US x s 4r..
A-1
~i rA
RECEIVED
FEB 4 1982
PLUMBING BUREAU
F
C C a PLUMBING
Ifonl-tiona4
DEPA TMEOf Ilf. UST(1Y LAB' P. PIF TIONS
Div4S CN OF SAFLTY ND
4~_.E 9 Ft NDENCE
Department of Industry, Labor & Human Relations
Division of Safety & Bldgs.
State OI 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
81 9
TYPE OF APPROVAL
STREET AND NO. FF8 CF~~E~
r~
$ 198
CITY OR TOWN COUNTY STATE ZIP!, I~N~Nb' 2
0PA14
OWNER;
Gentlemen: ((u
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,
a~tiQ~
i
James Sargent-Bureau Director
PLANS REVIEWED BY: DATE:
cc: DPS-OWS Owner DI LHR
Local Fi Plumber H & R (2)
County Mtg. Rep. Bur. of Health Fac. & Services
DI LH R SBD-6099 (N. 06/80) Rec. & Env. Services
I~
f
SBD 6678 19/81) (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:
144
. C
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 an . showing vent, manh,)le alarm and
manufacturer if precast. Complete construction details if
11. 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. 0 copy) government (sample enclosed).
❑ 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. antes 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 ❑ 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. Svstems 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). F=1 Copy of onsite report by county or district staff.
R
INDUSTM OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
P.O. BOX 7969
LABOR AND ° PERCOLATION TESTS 115
HUMAN.RELATIONS MADISON, WI 53707
LOC ICI '/I))~j S ~ T~10~ 7~ / ,ter) W1 TOWNtP~ ~U_N CI,PALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
T3NRI~ 1
COUNTY:, OOWNER'S /BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSE V TIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFIL ONS: ER LA ION TESTS:
❑Residence New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: JMOUND: I1, QND-PRESS E: YSTEM-IN- ILLHOLDING T NK: RECOMMENDED SYSTEM: (optional)
~s❑u ❑s~ s❑ ❑s u .❑s
If Percolation Tests are NO-7 re uired ESIGN ATE: SYS
4 If any portion of the lot is in the
under s.H63.09(5)1b1, indicate: '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.)
B-'~
B Q_ Ic if
5, kw
B`' _
54
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_ ~L
P- -3
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. P
SYSTEM ELEVATION
3
X Lod a-~~u '
510 -
;p
G a
TN
I .
AS
1, the undersign 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 (pri TESTS WERE COMPLETED ON:
ADDRESS: ~a CERTIFICATION NUMBER: PHONE NUMBER optional):
CST SICjNAT y
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
I
DI LHR-SBD-6395 (N. 03/81)
kWh,