HomeMy WebLinkAbout002-1034-10-000
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,EPARTMENT, OF INDUSTRY, INSPECTION REPORT FOR _ y SAFETY & BULIDINGS
LABOR &ifUMAN RELATIONS ALTERNATIVE PRIVATE DIVISION
P.O. BOX 7969 SEWA.15E SYSTEMS ,rQ ` BUREAU OF PLUMBING
MADISOIy, Wt 53707 ❑ Mound ;K Pressure Distribution
;XvI4~ OPERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: PLAN ID NUMBER:
5~_ Ad hJ i / C~ cc>i1S' ' ' I - 1 ~1
BENCH MARK (Permanent reference point) DESCRIBE IF IFFERE T FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SEPTIC TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.:'.'r PROPERTY LINE: WELL: BUILDING:
1, ;--1
Il~al f .~.r
5
DOSING CHAMBER:
MANUFACTURER: LIQUID CAPACITY: PUMP MODEL: PUMP MANUFACTURER: WARNING LABEL JLOCKING COVER
PROVIDED: PROVIDED.
C _ YES ❑ NO 5<YES ❑ NO
GALLON PER CYCLE PUMP AND CONTROLS OPERATIONAL- NUA+$eR 00 PROPERTY WELL: BUILDING: VENT TO FRESH
DIFFERENCE BETWEEN FEETR OM LINE: • _ AIR INLET
PUMP ON AND OFF YES ❑ NO NEAREST--.*'
SOIL ABSORPTION SYSTEM: Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire, construction
shall cease until the soil is dry enough to continue.)
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM
and furrows thrown upslope: mound systems to make certain that it OF SYSTEM. SHOW
F-1 YES NO meets the criteria for medium sand. ELEVATIONS MEASURED.
❑
DISTRIBUTION SYSTEM:
. WIDTH: _ LENGTH: NO.OF SPACING CENTER LENGTH: DIAMETER: MATERIAL AND MARKING:
TRENCHES: TO CENTER:
MANIFOLD: PUMP: MANIFOLD PIPE MATERIAL AND MARKING. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
r~ry4 j DIA.: PIPES: / DIA.:
SAT HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: DEPTH OF GRAVEL OVER PIPES: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
YES ❑ NO a YES El NO
SOIL COVER:
TEXTURE:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OFTOPSOIL SODDED. SEEDED: MULCHED.
CENTER EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS:
J
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Parcel 002-1034-10-000 07/26/2006 11:14 AM
PAGE 1 OF 1
Alt. Parcel 16.29.16.232A 002 - TOWN OF BALDWIN
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
ERNEST H & DELLA M LATHE O - LATHE, ERNEST H & DELLA M
2379 CTY RD E
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2379 CTY RD E
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE
SEC 16 T29N R16W IN NE NE W 445 FT OF N Block/Condo Bldg:
978.87 FT OF NE NE TOWN BALDWIN
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1041/265 WD
07/23/1997 838/04
07/23/1997 689/553
07/23/1997 584/216 J1' u
.r n9
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/28/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 11,400 132,100 143,500 NO
AGRICULTURAL G4 6.000 600 0 600 NO
Totals for 2006:
General Property 10.000 12,000 132,100 144,100
Woodland 0.000 0 0
Totals for 2005:
General Property 10.000 12,000 132,100 144,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 510
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
OE,PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/~: LOT NO.: BLK. NO.: SUBDIVISION NAME:
/IV / 1 /T'/R~I01P(or)W
COUNTY: OWNER'S BUYER'S NAME: MAILING DDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE R TONS: ER LA ON TESTS:
XResidence ❑ New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: JIN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑S ❑u ❑S DU fps ❑U ❑s ❑u ❑s ❑U
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. 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 ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/ rt r r i t r/ Z ~ rr ;r r r
h rf r r i t/
B- 7 9'1 /oc 3 .3L ✓
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIODS PERINCH
P J %`7 o If
P- fyo .4 C, 1,
P-
P_
P_
PLAN P-
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 /
-~'ocr o" -
40/
y5/ ; 3N 9~~ b"
o
4 "4
Wi
q 5
8-2, 304'
te-
-
~4s
+ - _
l I} eA
~ ~ U.Ld SeA~r ~ '
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 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):
C S URE: j)
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
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% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Add
0o Al /4 0
Property Location: City, Village or Township: County:
A/Q/a/VE%S & / T c~?N/ R e) (or) W 9 '1 "1 :v 5 f'
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY pC?a p NC'_ X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER goo 0 7C X
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New & Replacement ❑ Ex~jerimental ❑ Seepage Bed ❑ Seepage Pit
j ❑ Alternative (specify) -Ziy C Ro y Kz ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
K Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for instal lion of the private sewage system shown on the attached plans.
Nam.!.9f Plumber: ISiRda-ture:1W MP/MPRSW No.: Phone Number:
e- e (f, 7L 96 L jo 7L4- (7 1 3IS 7 ?
Plu Address: Name of signer:
7 LC
~ n z ' ve, t--
a t~ d ~ f, "i tom, s s'
COUNTY/DEPARTMENT USE ONLY
Sig t e of Issuin A ent Fee: Date: APPROVED Sanitary Permit Number:
?a - ❑ DISAPPROVED
ea on for Disapproval:
Alternate course(s) of Action Available:
I
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
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State of Wisconsin \ Department of Industry, Labor and Human Relations
Please Reply to:
SAFETY & BUILDINGS DIVISION
r- -1 Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Plan Identification Number
Re:
PRIVATE SEWAGE SYSTEM ONLY-
~ tt
The Bureau of Plumbing has reviewed plans, site survey information and installation details fort construction an native private
sewage system to be installed at the above-mentioned location. The plans and specifications were pre 'red b.~
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!iyYZ.l..~/
DI LHR-SBD-61 59 (R. 7/81) mes Sargent, B erector
Plb 100A 12/79
Detach And Return Upper State of Wisconsin
• DIVISON OF HEALTH
Portion Of This Form With SECTION OF PLUMBING
j AND FIRE PROTECTION SYSTEMS
Any Return Correspondence MAIL ADDRESS: P.O. BOX 309
J MADISON, WISCONSIN 53701
608-266-3815
DATE: PROJECT:
y U1a, Sec
n' f rnI
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 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.
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.
III. 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
El 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
iL-1 Calculations for total lift pump discharge, head and gallons pumped per cycle.
J Size, length & depth of force main.
J Detail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM.
(s) or siphon(s).
_ Cross section of lift pump tank. showing pump
V S io n 11%F~11 must be placed ;rior to pian SLIbm:Solon)
atal area filled (fill to extend 20' beyond edge of tench before side slope begin).
J Depth and type of fill.
Copy of onsite report by county or disl_s? t plumbing supervisor.
-:me, "i his r cei: ill t.lace.
PIb 100- 12/7$
State o Wisconsin
Detach And Return Upper
DIVISON OF HEALTH
Portion Of This Form With SECTION OF PLUMBING
J AND FIRE PROTECTION SYSTEMS
Any Return Correspondence MAIL ADDRESS: P.O. BOX 309
MADISON, WISCONSIN 53701
608-266-3815
DATE: PROJECT:
,NE,16,29,.
m of Bald
a.u
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 $
ti
❑ Plan accepted for review. Fee received is
Fee is being returned because of ❑ Overpayment ❑ Underpayment.' 0~~
.
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 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.
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.
111. 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). 4
❑ 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 supervisor.
i-ength of ~.rne fill has been in place.