HomeMy WebLinkAbout036-1094-20-000
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Parcel 036-1094-20-000 06/30/2006 09:51 AM
PAGE 1 OF 1
Alt. Parcel 36.31.17.566B 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): 0 = Current Owner, C = Current Co-Owner
GARY B & DIANE L GORKA O - GORKA, GARY B & DIANE L
LAUREL SUPPER CLUB C LAUREL SUPPER CLUB
890 LINCOLN AVE
AMERY WI 54001
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1905 HWY 64
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 36 T31N R1 7W 2A BEG NW COR NW NW SEC Block/Condo Bldg:
36 TH S 16 RDS E 20 RDS N 16 RDS W 20
RDS TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
36-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/21/1998 594216 1389/005 WD
12/21/1998 594215 1389/001 TI
07/23/1997 837/406
07/23/1997 728/225
more...
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/06/2003
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 2.000 25,000 172,400 197,400 NO
Totals for 2006:
General Property 2.000 25,000 172,400 197,400
Woodland 0.000 0 0
Totals for 2005:
General Property 2.000 25,000 172,400 197,400
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 SANll'AR ' SYSTEM REPORT ±
R y
OWNER TOWNSHIP
ADDRESS ~ - a ST. CROIX COUNTY j WISCONSIN.
' - --'x------- LOT SIZE
SUBDIVISION L{ - - - - - - LO 'T
PLAN VIEW
Di:,cances and dimenniu"n t_u uu i i cquIt umcni n o1_ HVS
--IoW LVLVYTH I Nt; WITHIN IOU l KLT OF SY:;'I`I'-Il
I
~Y lC L- ?
' i .-,7 t. iL" 5l 1. ~ / <.<.~/ " ✓ J. F L> -`f .ei.;1
i
a Ix- r
/
i
ILA
t I 1
44,
S. I Y,
It (I1 ,ntt~ 04))JI A r!1w
BENCIIMAIZK: (Permanent reference Point) Describe : 9:~:~.
Elevation of vertical reference point: Scope at site: _
SEPTIC TANK: Manufac t Q-'e-r Liquid Capacity : _j"01)
Number of rings on .cover Tank manhole cover elevata_oti:
Tank Inlet. Elevation: Tank Outlet _Elevation:
PUMP CHAMBER
Manufacturer: - ~i --e - Number of gallons
Namber of gat. pump set for cycl- _-.--gallons; totes c pacLty Of
distribution lines I;alIOU: size of pump____ _ _ tread;
gallon per mi.nutr horsepower brand name of pump
and model number
Type of warning devace~~/ c ;
HOLDING TANK: Manufacturer Number of I;allons _ -
Elevation of rrranhole cover
Type of warning device
SEEPACE PIT SIZE: Nutuber of pits feet diameter
]eet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet-
SL:t;I'At_;E BED SIZE: number oI I hies wid( li Leogrh_____ file depth_-_
SEEPAGE TRENCH width lengLh
PERCOLATION RATE --AREA REQUIRED,, - AREA AS BUIL'1
LNSPEC I.'OR
3
DA 1'1'.1) PLUMBER ON-7,101
LICENSE NUMBER
• DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969' •00 BUREAU OF PLUMBING
MADISON, WI 53707
❑CONVENTIONAL ❑ALTERNATIVE State Plan LD. Number
, ` 111 ass~9ned)
pi~i~~)°,~,i~A~ yTiyJ`,.... ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Q/ O-I3'36
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DATE
BENCH MARK (Permanent refe nde pomt) DESCRIBE IF DIFFEHENT FROM PLAN. REF. PT. ELEV.. CST REF PT. ELEV.
LA:
N a~nl Plu finer C I J _ 4~ ~..L ♦ ~l i. L~~II..
f =P/ Me RSW No Cou ni y. Sanitary Permit Number.
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED
_ ❑YES ❑NO ❑YES ❑NO
BEDDING . VENT DIA.. VENT MATE HI( ;H WATER ~FE UMBER OF GOAD'. PR OPERTV WELL BUILDING VENT TO FRESH
ALARM ETFROM uNE AIR INLET
❑YES ❑NO I ❑YES ❑NO EAREST
DOSING CHAMBER:
MANUFACTURER BEDDING I IQllll) CnPACI rV PUMP MODEL PUMP/SIPHON -MANUFACTURER
WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
GG ❑YES ❑NO ❑YES ❑YO ❑YES ❑NO
GALLONS PER CYCLE: PuMPANDCONrgoLSOPERATIONAL NUMBER OF PanPeRTY wELL LDING vENrroFRESH
(DIFFERENCE BETWEEN I FEET FROM ~ ~1A AIR INLET
PUMP ON AND OFF) YES ❑NO NEAREST-).
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing f TER MATERnf AND . nRKwc;
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:
BED/TRENCH IEN<;TH NQ OF Dlsriz PIPESPncINC a)vEl+ - Nslur Dln -airs LIQUID
TRENCHES
DIMENSIONS MAiEHIAI PIT DEPTH
It F! I)!F'i I 1111 UE PTH FIST Ii PIPE DISTR PIPE DISTR-PIPE MATERIAL. NO DISTH NUMB
U ER OF PROPERTY WELL BUILDING VENT TO FRESH
Il ..V I'll' nHOVF. (:OVER EIf V. INIlf ELEVEN PIPES LINE. AIR LET
.
1- FEET FROM A
NEAREST--s_
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-
❑YES NO meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER rEriuRE PERMnNENTMARKERS otssERVnnoNwELLs
_ ❑YES ❑NO ❑YES ❑NO
DEFPiHRfIV FR TRENCH HE D DEPT ti OVER THE NCH BE l) f)E PTH OF TOPSC)Il S()f)U
C N FIJ SEEDED JMULCHED
TE FDCiES
r❑YES ❑NO ❑YES ❑_NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH "IDIH J. ENCTII NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL UFPTH ABOVE COVER
/4C TRENCHES 61' (04
DIMENSIONS I I " J 0 - V7:IF PUMP MACH ro Ll) DISTR. PIPE MANIFOLD MATERIAL NO DISTR DISTR PIPE I)ISi HIBUIION PIPE"nTh. ftlAl & RinRKIN(:
ELEVATION AND EI E ELEV Dln ELEV J PIPES i DIA I Z
DISTRIBUTION • a b
INFORMATION ~H(.l SII HOLE SPACING URILLI D COHHF_,I LV COVER MA - FIAL VEHTICAL LJF I Lon RESPONDS To APPHOVEU
PLANS
YES ❑NO `
rXCI
❑YES ❑NO
COMMENTS PERMANENT MARKERS OBSERVATION WELLS ~FN U BER CF PROPERTY WELL EEFROM a"EYES ❑NO YENO EAREST-
~ (n1 nn q 1 b--
~-C.l.a,~,~
Sketch System On Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE -
DILHR SBD 6710 (R. 01/82)
DEPAR FMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
DIVISION
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING
P.O. BOX 7969.
MADISON, WI 53707 State Plan I D.Nunnin-
❑ CONVENTIONAL El ALTERNATIVE (If a-gned)
K
❑ Holding Tank In-Ground Pressure D Mound INSPECTION DATE. J
NAME /OF PERMIT HOLDER . ADDRESS OF PERMIT HOLDER. J V
REF. PT. ELEV.. CST REF. PT. ELEV..
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
}dk/MPRSW No.. 1o..Iy Sanitary Pe-, N.-
45,61 5 Name of PIUN~
OVER PROVDED
SEPTIC TANK/HOLDING TANK: I
MANUFACTURER. LIQUID CAP ACITV. TANK INLET ELE V.. TANK OUTLET ELEV. PROVIID DLABEL LO C KKINNG G C
EYES ENO EYES ENO
NUMBER OF ROAD: PR OPERTV WELL BUILDING VENT TO FRESH
BEDDING. VENT DIA.. VENT MAIL. HIGH WATER LINE. AIR INLET
ALARM FEET FROM
DYES ENO EYES ENO NEAREST
DOSING CHAMBER: PUMP,'SIPH ON MANUFACTURER WARNING LABEL pROVIIDED COVER
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL . PROVIDED.
NO DYES ENO DYES ENO
S OF PROPERTY WELL BUIDING.Iv ENT TO FRESH
EYE E
GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL NUMBER LINE AIR INLET
FEET FROM
(DIFFERENCE BETWEEN ENO EST
PUMP ON AND OFF) EYES ~E NEEARAR DIAMETER MATERIAL AND MARKING
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN W'
the soil is dry enough to continue.)
IDE Dln ttP1LIQUID
CONVENTIONAL SYSTEM: T
WIDTH LENGTH OIST IPE SPACING COV I BED/TRENCH TRE MATERIAL DEPTH
DIMENSIONS Gf JCL 1FI1 - Ti FRESH
F DEPTH DIST R PIPE DISTR IPE/ NDISTR NUMBER OF 1 LIRNOPE. ER T Y W L BU j AIR INLET.
'H ILL . CIS MATERIAL -
I
BEIOwPIPE S AB OVeCOVER ELEV INLET ELEV. NO PIPES FEET FRM
NEAREST'
MOUND SYSTEM:
d site plowed perpendicular to slope Check the to Jtu o,~ the fill aterial for PROVIDE A DIAGRAM OF SYSTEM
SHOW ELEVA
thrown upslope: mound Sys m t make c rtain that it ON REVERSE ONS MEASURED.
[:an:dfurrows
meets the it i for mediu sand.
pERMANENT MARKERS OBSERVATION WELLS
EYES NO
IL COVER TEXTURE A
DYES NO EYES ENO
SEEDED MULCHED
DEPTH OVER TRENCH BED DEPTH OVER TRENCH ;BED DE TH OF TOP IL S DDED
CENTER EDGES EYES ENO
EYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER
V41 D T H LENGTH. NO OF LATERAL_S ACING. GRAVEL DEPTH BELOW PIPE.
BED/TRENCH Z_ TRENCHES
DIMENSIONS Cc
MA IFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NOEDIS DD IISAT~~n DISTRIBUTIONE MATERIAL & MARKING
LEV ELEV CIA ELEV.
ELEVATiONANDs~~ /D
DISTRIBUTION W-10-1 ERIAL VERTICAL LIFT CORRESPQN DS TO APPROVED
HALE SIZE HOLE SPACING DRILLED CORRECTLY PLANS
INFORMATION r I YES YES ENO
YES ENO PROPERTV WELL BUILDING:
JV FIE PROPERTY
PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF J
T FRM LINE
YES ENO NEAREST
YES ENO
Retain in county file for audit.
Sketch System on
Reverse Side. - - TITLE'.
SIGNATURE.
DILHR SBD 6710 (R. 01/82)
` DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR-AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) 1* 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:
(A Y r^ u 'V e R, S 1 e,
?'fib
Property Location: City, Village r T nshi
County:
/4 rn R Or) W C Lot Number: BlName: Neare t oad, Lake or LandmarkState Plan LD. Number:
s (lf ig ed
TYPE OF BUILDING
Public* ❑ Variance* ❑ Other (specify)* Number of
Bedrooms:
1 or 2 Family *State Approval Required. V A-
TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Replacement Experimental ❑ Seepage Bed ❑ Seepage Pit
8'z ri o1 Alternative (specify) f _ ❑ Seepage Trench
Water Supply: F0Owner's Name as Listed on Soil Test Report (If other than present owner):
A Private ❑ Joint ❑ Public
F e undersigned, hereby assume responsibility for installation a private sewage system shown on the attached plans.
e o Plumbe : Signa MP/MPRSW No.: Phone Number:
( )
ber' s dress:
Name of Designer:
COUNTY/DEPARTMENT USE ONLY
FReasn ature of Issuing Agent: Fee: ` J Date: ❑
is n ^ _
_(''I ❑ DISAPPROVED
ofor 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)
State of Wisconsin ` Department of Industry, Labor and Human Relations
DATE:
SAFETY & BUILDINGS DIVISION
iureau of Plumbing
201 E. Washington Avenue
P.O. Box 7969
TO: Madison, Wisconsin 53707
< Plan Identification No. S
Re:_
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The Bureau of Plumbing has received a request to review some minor changes to
the above-mentioned plans. Those changes have been approved as
indicated below. The approved changes will become an addendum to the plans
previously approved and recorded on the plans on file. All other portions of
the installation shall conform to the original approval.
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Sincerely,
Plan Appr vals
Section of Private Sewage and Platting
cc: OWS
County
DILHR-SBD-6423 (N. 04/81)
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WORKSHEET - PRESSURE DISTRIBUTION NETWORK DESIGN
PROBLEM sc)
Design a pressure distribution network for a teem-home. The site
characterisitics are:
Depth of groundwater or bedrock in.
Landslope %
Percolation rate S,3min./in.
Distance from dose chamber to distribution system 01 0 ft.
Elevation difference between pump and distribution system=- ft.
Step 1. ESTI AT WASTEWATER LOAD
3 7 c3 ~ Czs ~y~°
Step 2. SIZE THE-ABSORPTION AREA X 3 - 1.50
I+ o
A) Area required 5 Q y6d~
- - -
B) Select length /0 0
C) Width is
D) I will- use a ' manifold.
Step 3. SIZE DISTRIBUTION PIPES
A) Hole size I will use is yq in.
B) Hole spacing I will use is in.
C) Lateral length is y9•~ ~ft.
D) Lateral size _ in.
Step 4. DISTRIBUTION PIPE DISCHARGE RATE
Step 5. SIZE MANIFOLD
71
A) Manifold length 7 ft.
F .
B) Number of distribution pipes = l"
C) Manifold diameter -j
in.
1 1
Step 6. SIZE THE FORCE MAIN ♦A) System discharge rate r /Y'
B) Force main diameter
C) Friction loss will be ft./100 ft.
Step 7. TOTAL DYNAMIC HEAD
A) Vertical lift 7 ft.
B) Friction loss , ft. p
C) TDH = p, ft.
t
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Step B. SELECT A PUMP
Step 9. DOSE CHAMBER SIZE
1
Step 10. DOSE VOLUME r
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Step 6. SIZE THE FORCE MAIN
(I
A) System discharge rate
B) Force main diameter
C) Friction loss will be ft. POD ft.
Step 7. TOTAL DYNA14I C HEAD
A) Vertical lift 7 ft.
B) Friction loss ft. a ~Df°0 ~x bd~Z
4
C) TDH = L ft.
Step B. SELECT A PUMP
Step 9. DOSE CHAMBER SIZE ,
Step 10. DOSE VOLUME
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WORKSHEET - PRESSURE DISTRIBUTION NETWORK DESIGN
PROBLEM S 57E,i►~o( I~
Design a pressure distribution network for a
characterisitics are: The site
Depth of groundwater or bedrock
in.
Landslope %
Percolation rate
i
x.31 min./in.
Distance from dose chamber to distribution system
Rn ft. j
Elevation difference between pump and distribution system- ft.
Step 1. ESTIMATE WASTEWATER LOAD
370 g3A2
Step 2. SIZE THE ABSORPTION AREA
1
A) Area required
B) Select length /00 '
Cx C) Width is
78 j`a
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D) I wi1T use a redl manifold.
Step 3. SIZE DISTRIBUTION PIPES
A) Hole size I will use is in.
B Hole spacing I will use is
in.
f-~
C) Lateral length is ft.
D) Lateral size 1
i n .
Step 4. DISTRIBUTION PIPE DISCHARGE RATE
c®hdit
11 two
Step 5. SIZE MANIFOLD r► ~R*~,LA~
A) Manifold length ft.
B) Number of distribution pipes =
C) Manifold diameter
in.
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Step 6. SIZE THE FORCE MAIN
A) System discharge rate 2
B) Force main diameter
C) Friction loss will be ft./100 ft.
Step 7. TOTAL DYNAMIC HEAD
A) Vertical lift ft.
B) Friction loss ft.
S~srE~ ~ S
C) TDH = ft.
Step B. SELECT A PUMP _
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Step 9. DOSE- CHAMBER SIZE
Step 10. DOSE VOLUME
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PROJECT DETAIL DATA SHEET
NAME OF BUSINESS
LEGAL DESCRIPTION ,~(r7 3~^T /7_ / ,P o ~T.¢alr~.✓
OWNER S ~u MAILING ADDRESS
~
Ni L~ intlmantn ZIP
ARCHITECT, ENGINEER, ADDRESS
PLUMBER OR DESIGNER
X i n J / i > z , w , l J t Z I P i::54-617
TELEPHONE NUMBER ~~35
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building .Y New building Addition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . . . . . . . . . Seating capacity
Bar . . . . . . . . . . . . . . . . Seating capacity 3 7 # 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 _To_
( ) Dining hall . . . . . . . . . . . . Number of meals served daily t
( ) Dog kennels . . . . . . . . . . . . Number of enclosures r...r
( ) Drive-in restaurant . . . . . . . . Inside seating capacity
Car-service Number of car spaces
( ) Dump station . . . . . . . . . . . . Number of dump stations
~Q Employees ( total of all shifts) . . Number of employees 11
( ) 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 _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
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State of Wisconsin D terse ustry, Labor and Human Relations
RE~EIVL~
SAFETY & BUILDINGS DIVISION
I oc-f
yr; y 9.81 _OffR ryE;?St W8Sh1 ,qtQ~! t zJ
_,'-ure ~ s~sai~ax:r
section 01
5-Loraqe 01
ranted to ertait use o ~,pproval is for tiie v a r i & i,~_ ~.Loo resign and size o cyst f=.
"iance is St:E:ject. tL> tidy' following Gf#tl(~ Lii:,<'
it any locally cancprre(i authorities nerving
53 of n one; s pev-, is to ins ai Sae.3uo is pVCIO,;
to, fulfill all pa'' r!iti L :')f fl)e ci l.'
C shall he )eressa.ry
ts . toiinsbip ~r t,~C►r:.,~. F° ;lur O is
village,
?sf .:vent: tt3f t this va 3anc-e cr a t.F'S N, i- i
-,vel Gr any C?uer operational or 3"iai i't"g`,,:r _.1~occu:r, the
-)ILHR-SBD-6423 (N. 04/61)
State of Wisconsin ` Department of Industry, Labor and Human Relations j
SAFETY & BUILDINGS DIVISION
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''awiind-- i n oversi !t,y c(,ostruc:tion er ai:,y'
t lt,aiatt n and resf~rvea the rigA to order cf. .r
_i the event construction >,as not c .enceit with }.t -I I
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D! I. HR-SBD-6423 (N. 04/81)
State of Wisconsin ` Department of Industry, Labor and Human Relations
Please Reply to:
SAFETY & BUILDINGS DIVISION
F Bureau of Plumbing
I P.O. Box 7969
Madison, WI 53707
Plan Identification Number
Re:
PRIVATE SEWAGE SYSTEM ONLY-
The Bureau of Plumbing has reviewed plans, site survey information and installation details for the construction of an alternative private
sewage system to be installed at the above-mentioned location. The plans and specifications were prepared by
and received for
approval on
The soil and site evaluation was conducted by
The site meets the soil and site requirements specified in chapter H 63, Wisconsin Administrative Code, for the use of
The proposed system is for a
Wastes from the building will discharge to a -gallon capacity septic tank which will discharge to a -gallon capacity
pump chamber from which a pump having a capacity of gallons per minute against a total dynamic head of feet will
discharge through a -inch diameter pipe to the soil absorption system.
It is of utmost importance that the system be installed in complete accord with the plans and installation details and the conditions of
approval contained in this letter. The licensed plumber responsible for the installation shall notify the county inspector when the installation
of the system will commence so that the county inspector shall be able to inspect this installation. The installer shall not deviate from this
approval and shall follow the directions or orders issued by the appropriate local or state authorities.
In accord with ch. 145, Statutes, and ch. H 63, Wis. Adm. Code, the plans and specifications are approved contingent upon compliance 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 one set of plans bearing the stamp of approval of this department at
the construction site. If the installation of this system has not commenced within two years from the date of this letter, 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 oversight,
construction or any damage that may result in or after installation and reserves the right to order changes or additions should conditions
arise making this necessary. This approval is based on ch. H 63, Wis. Adm. Code, requirements. It shall be necessary to obtain and fulfill the
permit requirements of the county in which this installation is to be constructed. Failure to obtain county permits will automatically void
this acceptance.
cc: OWS
By:
County
Other
Enclosures c e%iYyl.G~/
mes Sargent, B erector
DI LHR-SBD-6159 (R. 7/81
Plra 190a 12/78 r ~T
- State of Wisconsin
Detach.And Return Upper DIVISON OF HEALTH
Portion Of This Form With SECTION OF PLUMBING
AND FIRE PROTECTION SYSTEMS
Any Return Correspondence Aa MAIL ADDRESS: P.O. BOX 309
MADISON, WISCONSIN 53701
608-266-3815
DATE: PROJECT:
t
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.
❑ No fee has been remitted. Plans submitted with no fees will be held in abeyance.
❑ Plans being returned.
❑ Additional information required. SEE BELOW.
1. Plan Submission
❑ Additional information shall be submitted in triplicate unless specifically note
❑ Plans not clear, legible or permanent.
❑ All information submitted shall be signed, sealed or stamped in accord with Section H 62.211'(2) (a) %'vi eons n horn', !isriatrve i One.
❑ Affidavit enclosed.
11. 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 11. 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 certified soil 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 6y 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.
J Cross section of lift pump tank showing pump(s) or siphon(s).
i. Sy_tems 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).
1 Depth and type of fill.
Copy of onsitn report by county or distri•',t plumbing supervisor.
~-_-.'_enarh of t r,„c fill hds been in place.
MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
.7n ,AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.:SUBDIVISION NAME:
/T- N/R;=. H (or) W
/4, '/4
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R F TONS: ER LA ION TESTS:
DResidence ❑New El Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVEccNTION'AIIL: IMOUND: IN-GROUNDS-PRESSURE: SYSTEcM-I -FILLHOLDIIN~G TANK: RECOMMENDED SYSTEM: (optional) F]U
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:
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.)
S.4 "4
Y, t
i_
B- ZONING
MU" 4
OFFICE
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES ATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH j
P_ I
P-
P
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
ui land slop.
SYSTEM ELEVATION 0Z_,-' I. ;4.
-
/7i~_kCnRfiS
IV
s
I
C -,23 S', 3
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):
24
CST SIGNATURE:
6,,-10,N: Original-Local Authority, 2nd page Bureau of Plumbing, 3rd page Property Owner, 4th page Soil Tester.
'N. 03/81)
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State of WISCUSICI Depar Industry Labor and Human Relations
SAFETY & E GS Di , c"
DATE: iii
Bureau of Plumb ir>
V, 201 E. Washington Avenue
P .O. 7969
Plan Identification No.
Re: r
00
r
The Bureau of Plumbing has received a request to review some minor changes to
the above-mentioned plans. Those changes have been approved died as
indicated below. The approved changes will become an addendum to the plans
previously approved and recorded on the plans on file. All other portions of
-ne installation shall conform to the original approval.
i e
1 L r c' -71a S
1
Si/ncerely,
4 ~
P
Plan Appr vals
Section of Private Se~wago rand! Platting
cc: OWS
County
7It 14.,'35°D 6423 (ti. 04-81)