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?TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BULIDINGS
R & 'lUMAN RELATIONS ALTERNATIVE PRIVATE Q J DIVISION
F. L,. Bow :969_ . SEW V E SYSTEMS BUREAU OF PLUMBING
MADISON, WI 53707 ❑ Mound Pressure Distribution
Ale
N ME OF PERM R. ADD~SS OF PERfIQ~T HOLDER:
INSPECTION DATE. PLAN ID NUMBER: Vj'~ k SWq S /W / 6S~S
B H K IPermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
SEPTIC TANK:
MANUFACT LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.:PROPERTY LINE: WELL BUILDING.
ILI IM
,4? I
DOSING CHAMBER:
E PUMP MA P`ACTUH ER: WARNING LABEL ING COVER
MANUFACTURER: LIQUID CAPACITY: PUMP M)er
ED DED
YES ❑ NO LOCYES ❑ NO
•a L' G'c;
GALLON PER CYCLE PUMP AND CONTROLS OPERATIONAL: UrMoeR Ow : PROPERTY WELL: BUILDING: IVAERNT1 TO FRESH
DIFFERENCE BETWEEN FEET ERt3fVk LINE:
PUMP ON AND OFF ❑ YES ❑ NO
1, 1 NEAei7
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
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
DISTRIBUTION SYSTEM:
;u WIDTH: LENGTH: NO.OF SPACING CENTER LENGTH: DIAMETER: MATERIAL AND MARKING:
O/T ~1Fz TRENCHES: TO CENTER: R{~,v~^,
€}If3llEddS►D+~. MAEN
MANIFOLD: PUMP: MANIFOLD PIPE MATERIAL AND MARK.IN.3. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
r - DIA.: .f - PIPES: CIA..
47 HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: DEPTH OF GRAVEL OVER PIPES: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
❑ YES ❑ NO ❑ YES ❑ NO
SOIL COVER:
TEXTURE:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. 7DDI-11, ISEFUED. MULCHED.
CENTER EDGES,
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS: '
c
Y~
SIGNATURE: ~J~~ TITLE:
DILHR-SBD-6227 (R. 05/81)
L
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit e Q
State Septic
AME 1,11V az A TOWNSHIP St. Croix County
OCA ON Section Lot # Subdivision
EPTIC TANK
Size gallons Number of compartments
istance from: Well Building 12% slope
Highwater
UMPING CHAMBER
Size gallons Pump Manufacturer -Model Number
OLDING TANK
Size gallons Number of Compartments
Pumper Alarm System
)istance from: Well Building 12% slope
Highwater
'ABSORPTION SITE
Bed Trench
!istance from: Well Building 12% slope
Highwater
,BSORPTION SITE DIMENSIONS
Width of trench ft Required area _ft.
Length of each line ft Depth of rock below tile_________ in.
Number of lines Depth of rock over tile___ __v-in.
Total length of lines ft Depth of tile below grade ~_in.
Distance between lines ft Slope of trench _in. per 100 ft.
Total absortption area ft Type of Cover:
11IT DIMENSIONS
Number of pits Gravel around pits_yes____no
Outside diameter ft Depth below inlet _ ft
Total absorption area _ _ ft
Area required ft
INSPECTED BY TITLE__ _
APPROVED DATE 198_
REJECTED DATE 198_
ZEASON FOR REJECTION
' DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PL13 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: 7 7 Address:
de krj X~41*~adw 4.&
Property Location: City, Villa or Townsh p: County:
'/oS / T < NCR (or) W_
Lot Number: Blk o.: ubdivision Name: Nearest Road, Lake or Landmark: State ~an I.D. Number:
(lf TYPE OF BUILDING CJ a
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
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: 06,4,1
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New 54 Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
.2 Alternative (specify)~7y t?,p~„Nn I~'~sc~.PF ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
54 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: MP/MPRSW No.: Phone Number:
'140 4
r ( )
Plum r s Address: ' Nam of Designer:
COUNTY/ DEPARTMENT USE ONLY
Si a re of Issuing )gent: Fee: Dr: Sanitary Permit Number:
APPROVED
d ❑ DISAPPROVED
R son 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 (N.03/81)
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LINDSAY BR OS. CO. ,
GOULDS SUMPTHING SEWAGE PUMPS
Model 3882
Performance Rating
Gallons per minute
Model 3881
Performance Rating WP1012 WPH1012
WPO511 WP1032 WPH1032
Gallons per minute Series No. ► WP0512 WP0712 WP1034 WPH1034
HP ► th ~Vi 1 1
WP0511S
Series No. ► WP0512S RPM ► 1750 3450
5 150 170 180 190
HP ► %
RPM 0, 1725 can 10 126 154 168 170
V 15 94 125 152 150
°a 5 144 i m 20 56 90 121 128
uq
= c 10 110 E 3 25 17 49 81 107
U O
E3. 15 75 i ° 30 14 40 86
e~ Do
20 40 m LL 35 10 64
O .
LL 25 6 40 43
0 45 24
F 26 0
Flood and pollution control 50 4
Liquid transfer
11/2 " Solids handling capability. Sewage and waste removal 2 " Solids handling capability.
211 NPT Discharge connection. -De-Watering 211 NPT Discharge connection.
Sump draining 3 " Optional.
Submersible effluent and sewage pumps - Model WP.
Lindsay
Product
Number Model RPM Horse ower Volt Phase Order No. W t.
662372 WP 1750 /z
662143 3881 /2 230 1 512S 60
648949 z 115 1 W P0511 108
651125 '/2 208/230 1 WP0512 108 1
493244 WP 1750 3/4 208/230 1 WP0712 110 1..31
656887 (3882) 1 208/230 1 WP1012 114
503533 1 208/230 3 WP1032 112
503541 1 460 3 WP1 4 12`
503525 WPH 3450 1 208/230 1 WPH1012 114
(3882)
GOULDS Model 3870 Submersible Effluent Pumps
SPECIFICATIONS Order No. HP Volts Phase RPM Solids Max. Wt
Amps
Order No. HP Volts Phase RPM Solids AmMax. ps Wt' WPH1012E 1 230 1 3450 '1'4" 11.0 70
WP0311 E 1 /3 115 1 1750 9.4 56 WPH 1032E 1 208/230 3 3450 3/4" 7 70
WPH1034E 1 460 3 3450 V4" 3.5 70
WP03 (1h HP) TDH GPM WPH10 (1 HP TDH GPM
Lindsay
5 100 10 147 Product Model
Number Number Description
Total 10 85 Total 20 124
Dynamic 593540 W P0311 E 1h HP 115V
Head 15 62 Dynamic 30 98 550604 WPH1012E 1 HP 230V
Feet to Head
Water 20 36 Feet to 40 71 *Contact Pump Dept. for 3 Phase Units
Water
25 3 50 45 Availability.
60 18
WORKSHEET - PRESSURE DISTRIBUTION NETWORK DESIGN
PROBLEM
Design a pressure distribution network fora bedroom home. The site
characterisitics are:
Depth of groundwater or bedrock
in.
Landslope %
Percolation rated min./in.
Distance from dose chamber to distribution system Z ft.
Elevation difference between pump and distribution system ft.
Step 1. ESTIMATE WASTEWATER LOAD ndit1® al~~
Roy
AND HUMA
\ tNDU RY, to
DEP ARTh4ENY _
Step 2. SIZE THE ABSORPTION AREA Spp DENCE• _
SEE C
A) Area required
B) Select length
C) Width is D) I will- use a manifold. v
Step 3. SIZE DISTRIBUTION PIPES r 31
A) Hole size I will use is in. 11tt r„~,n
R) Hole spacing I will use is in.
C) Lateral length is ft.
D) Lateral size in, ; y
1
Step 4. DISTRIBUTION PIPE DISCHARGE RATE
Step 5. SIZE MANIFOLD
A) Manifold length ft.
B) Number of distribution pipes =
C) Manifold diameter - in.
a
Step 6. SIZE THE FORCE MAIN
A) System discharge rate L
B) Force main diameter
C) Friction loss will be ft. POO ft.
Step 7. TOTAL DYNAMIC HEAD
A) Vertical lift ft.
R B) Friction loss ft. C) TDH ft.
T
"dTIIlEl~ QF Sti?, r~•r; HUMAN RELATIONS
Step 8. ~ SELECT A PUMP PZP_F
Step 9. DOSE CHAMBER SIZE
- =c,r r' - ~ - ~ 1yn~ _ c,~ iii. •
Step 10. DOSE VOLUME
,sr=-
i b ~OcJ -
State of Wisconsin \ Department of Industry, Labor and Human Relations
Please Reply to:
SAFETY & BUILDINGS DIVISION
F Bureau of Plumbing
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
mes Sargent, B erector
DI LHR-SBD-6159 (R. 7/81)
I
Fib 100a'12/7:8
Detach And Return Upper State of Wisconsin
DIVISON OF HEALTH
Portion Of This Form With SECTION OF PLUMBING
G AND FIRE PROTECTION SYSTEMS
Any Return Correspondence MAIL ADDRESS: P.O. BOX 309
MADISON, WISCONSIN 53701
608-266-3815
DATE:
PROJECT:
3< C
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.
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 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 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.
❑ Length of time fill has been in place.
NDU8TM _NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTfiY, ' DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 3707
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
CO NTY: OWNER'S BUYER'S NAME: AILING ADDRESS:
r I
USE DATES OBSERVATIONS MADE
NO. BEDRMS.:
ce COMMERCIAL DESCRIPTION: New R ONS: PERCOLATION TESTS:
Residen ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system ) „
SSURI:SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
7EN NTIONAL: MOUND: IN-GROUND-PRE
S❑u ❑S 0u OS Du OS [:]U OS❑u
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. I 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.)
4 B
/)I wT,LN L C r3-~c.t'~ :tea 7
B L; 4(-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERT D PER INCH
P- , L
5'?
P_ A4C
P_ I
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. 91 C's'
SYSTEM ELEVATION l0
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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,(VERE COMPLETED ON:
I
ADDRESS: CERTIF CATIO NUMBER: PHONE NUMBER optional):
CST SIGNATURE'
S~(BUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
~HR-SBD-6395 (N. 03/81)
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Parcel 012-1038-60-000 07/26/2006 09:58 AM
PAGE 1 OF 1
Alt. Parcel M 16.30.17.247 012 - TOWN OF ERIN PRAIRIE
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 - GEURKINK, JEFF
JEFF GEURKINK
1722 CTY RD G
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1722 CTY RD G
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 16 T30N R1 7W SW SW 40AC Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1248/402 QC
07/23/1997 859/162
07/23/1997 847/293
07/23/1997 635/249
2006 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/31/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 49,000 20,000 69,000 NO
AGRICULTURAL G4 34.000 6,500 0 6,500 NO 00
UNDEVELOPED G5 2.000 200 0 200 NO
Totals for 2006:
General Property 40.000 55,700 20,000 75,700
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 55,500 20,000 75,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 316
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00