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HomeMy WebLinkAbout020-1048-50-000 n (n O 9 -0 n d ~1 o Er I r° R, oc CD ° M fu 3 ~S o n v N ai O N CO r O ON CD 3 O N O 00 -4 0- (n (0 Lo 0 3 co O ~ W s CD ^ Nm v 3 .4 \ 1 0) , ca b O 3 3 N O O y^ N I ~ Cl) ~ D a n D O) 3 O G V w 41 i h :iz D { co co n O r- cn N co co ~ in G D 3 Q ~ co co "NA OCC OCC CC O 0) O -D G C G O IE3 o D T v a - o x "M 7 c°n c°o cn co m I 3 °N' 0 N O. C) N z zoozo o D O 4 o' m cD • N CD N N N c CD N W m' a a 3 5 z CD -I fn a A Z o m G7 0 z co co N O g co CL z 3 p z m m y z Z:t (D A o ~ I ' coo C7 0 ~ N D N O_ 4 - W (D p_ d v d N N O_ N a D p L z 2 m Q - CD CNcD~3 5 CO N -0 CD _ N O O' O =r CD U,ry CD O N N O W CD O Nt N C~ O N d n.. N b • d ~ 0~ ~v 0 N CD O N a ~ N p N ~ Z (D O7 CD (D b 3 2 G N n o I Q= o ~ a 0 b w 0 S D q ONo A e» O e °o i Parcel 020-1048-50-000 12/19/2005 03:22 PM PAGE 1 OF 1 Alt. Parcel 20.29.19.186C 020 - TOWN OF HUDSON 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 RICHARD L WALDSCHMIDT O - WALDSCHMIDT, RICHARD L 476 CTY RD A HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.349 Plat: N/A-NOT AVAILABLE SEC 20 T29N R19W NW NE LOT 1 C.S.M. V IV Block/Condo Bldg: P1000 ORD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 CS4/100 07/23/1997 623/393 2005 SUMMARY Bill Fair Market Value: Assessed with: 91756 390,900 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 2.349 116,900 281,800 398,700 NO 05 Totals for 2005: General Property 2.349 116,900 281,800 398,700 Woodland 0.000 0 0 Totals for 2004: General Property 2.349 51,100 185,300 236,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ' Parcel 020-1048-50-000 02/02/2005 04:19 PM PAGE 1 OF 1 Alt. Parcel 20.29.19.186C 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner RICHARD L WALDSCHMIDT ` WALDSCHMIDT, RICHARD L 476 CTY RD A HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 SCH D OF HUDSON / 7~ SP 1700 WIT C ~~ago hd Legal Description: Acres: 2.349 Plat: N/A-NOT AVAILABLE SEC 20 T29N R19W NW NE LOT 1 C.S.M. V IV Block/Condo Bldg: P1000 ORD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 CS4/100 07/23/1997 623/393 2004 SUMMARY Bill M Fair Market Value: Assessed with: 47982 305,600 Valuations: Last Changed: 11/11/2004 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 2.349 51,100 185,300 236,400 YES Totals for 2004: General Property 2.349 51,100 185,300 236,400 Woodland 0.000 0 0 Totals for 2003: General Property 2.349 20,300 157,300 177,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1048-50-000 01/24/2005 08:10 AM PAGE 7 OF 1 Alt. Parcel 20.29.19.186C 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner " WALDSCHMIDT, RICHARD L RICHARD L WALDSCHMIDT 76 ~vT-a' R A, ~0 2ivt1 . QH U DSON WI 54016 eo / Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC n Legal Description: Acres: 2.349 Plat: N/A-NOT AVAILABLE 1 M. V IV Block/Condo Bldg: SEC 20 T29N R19W W NA P1000 ORD ` Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: C rQ \ a Lo Parcel History: V C(Q / Date Doc # Vol/Page Type 07/23/1997 CS4/1 tT 1 r y 3~~ D U ID 0 7/23/1997 623/3930 2004 SUMMARY Bill Fair Market Value: Assessed with: 47982 305,600 Valuations: _ Last Changed: 11/11/2004 Descriptio Class Acres Land Improve Total State Reason COMMERCIAL G2 2.349 51,100 185,300 236,400 YES Totals for 2004: General Property 2.349 51,100 185,300 236,400 Woodland 0.000 0 0 Totals for 2003: General Property 2.349 20,300 157,300 177,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f ~ ' REPORT OF INSPECTION - INDIVIDUAL SCWAGL SYSTEM 1 4 San-i_;(:a~:t! Penm_i,t %.70C.0_ Sate. Sept `C-- 79P NAME _ ow c_p St. CAoix County Location- ~~S ttonQQ Lot # _ Subdl:v~.6tion SEPTIC TANK Size _ga~T'an6 NumbeA a6 eampaA,tmen-t/5Di6tance Ahom: Weft 0 BuiTding_ 126 6Tope Highwa.te.A PUMPING CHAMBER Size _gat.eans _ Pump Manu6a~etuAeA ModeY- NumbeA HOLDING TANK Si ze, gaTlon.,5 NumbeA oA CompaAtme.nt6 Pampe.n AEaAm Sy6tem vi6 tance Anom: Wet Buitd.tng 120 .Cope HighwatvL ABSORPTION SITE Bed Tn.enc6i Di6 tanee AAam: Weed ~ Buitding 1'26 5~ope H~ghwa;teA ABSORPTION SITE DIMENSIONS Width o4 VAench ~ ~ - At Req u,tAed aAea_ _A .t: Length oA each 6"ne 5 AT Depth aA 4ock below alcTetin NumbeA oA e-i.ne6 Depth oA Aoe.k oveA tiee ~ i,n Ta al- een._q h oA Une,5 At Depth aA tite below gAade- - _r n Di6 ance. be..twe-en- ine.6 At Se ope oA tAe.nch 2 .Ln, peA 100 At To.tctt a.0.5oAp.t4'.on ane_a-- At Type, oA CoveA: Pa.peA an 6010R) PIT DIMENSIONS Numb en o o pits GAavek. aAou.n r,),4 th ye.3 no 0 ut,5ide. d,l.amet eA At Depth below Lneet AT Total abAoAption aAea_ At Acea Ae.quinwd At ~ INSPECTED BY TITLE_ APPROVED DATE 19h REJECTED DATE 19f REASON FOR REJECTION x REPORT ON INSPECTION OF SANITARY PERMIT # (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection ~J t / J Time of Inspection me, maress, icen NO. OT ns ing Plumber 3-2~ 3 INST LATIO CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System BEN ermanent reference Point) Describe: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO ; 8 HOLDING TANK: Manufacturer o gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? ❑ YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.05/80 Signature of Inspector: Department of Industry, Labor & Human Relations Division of Safety & Bldgs. State of Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison W1. 53707 l~ Tel. 608-266-3815 n ~ co APR 27 981 i ZONING OFF ` ~NALL CORRESPONDENCE REFER TO PLAN 1_ o IDENTIFICATION NO. NAME OF PROJECT TYPE OF APPROVAL STREET AND NO. CITY OR TOWN NTY ATE ZIP OWNER Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto- matically void this acceptance. Sincerely, James Sargent-Bureau Director IPLANS REVIEWED BY: DATE: cc: DPS-OWS Owner DI LHR Local PI Plumber H & R (2) County Mfg. Rep. Bur. of Health Fac. & Services DILHP, SBD-6099 (N. 06/80) Rec. & Env. Services PIb,100a 12!78 Detach And Return Upper State of Wisconsin DIVISON OF Of This Form With SECTION N HEALTH OF PLUMBING l AND FIRE PROTECTION SYSTEMS Any Return Correspondence MAIL ADDRESS: P.O. BOX 309 MADISON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: 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. II. 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 ❑ 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 flew 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. PIb 100a 12/78 OR •MO Detach And Return Upper State o Wisconsin DIVISON OF HEALTH Portion Of This Form With n SECTION OF PLUMBING C AND FIRE PROTECTION SYSTEMc Any Return Correspondence MAIL ADDRESS: P.O. BOX 309 MADISON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: PLAN ID. # DETACH HERE 401 PROJECT NAME PLAN ID. # ° This is to acknowledge receipt of your plans and specifications for the above-indicated project. AFe ZONING Preliminary review indicates the plan review fee required is $ ; OFFICE ❑ 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. II. 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 certifiedsoil 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. Plb 100a 122/78 peta,ch And Return Upper ti State o Wisconsin DIVISON OF Portion Of This Form With SECTION N HEALTH OF PLUMBING AND FIRE PROTECTION SYSTEMS Any Return Correspondence+ MAIL ADDRESS: P.O. BOX 309 MADISON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: 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 $ /9/ ApR UFQ ❑ Plan accepted for review. Fee received is $ ION/ Fee is being returned because of ❑ Overpayment ❑ Underpayment. F/(F 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. II. 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 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. . El 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). i Depth and type of fill. ❑ Copy of onsite report by county or dis'r;ct p: urnhjng t,:.mervisor. Length of time fill has been in Place. -LH 115 Rev. 9178 REPORT ON SOIL BORINGS AND PERCOLATION TESTS ' WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES 6 t P.O. BOX 309, MADISON, WISCONSIN 53701 ' LOCATION: 6d'/4, ' /v g /4, Sectionc2_0_,TzyN,Rd5 (or6.2T"ownship or Municipality Lot No. , Block No. J's~1ru fj ~i^oo~c'i-/-Y County s Yfl~Qi =c X15 :Z_ v Su d vi io am 7-rl Owner's/Buyers Name: " co . 1 C c7 Mailing Address: S TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS 3'i>11-41 SOIL MAP SHEET__ .51 ' NAME OF SOIL MAP UNIT SZ 1-3 -g;aC- -S`l74 PERCOLATION TESTS T EST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE JM_ INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER/ 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- 1 s rt See Dr.t yw ~ .L A-lo 3 (p P__3 rt U0 -3 P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES f/ B- T; /6cr/►' B- .2 c~ Z L ~t c, r n s. r ` l+ f+ [ 'r 2 L7 B- 3 6•r Mau e- 7 cr rr n &2 L. drr Me B- i( MW e-- s " Me . s B `e -P- _-7. Jr a~•l R u e r S PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the Ian the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ' 0019 " Indicate scale or distances. 1 -2- Give horizontal and vertical reference points. Indicate slope. Ski R~ re A~ ea Fes'' f>'1~`t E , s ~ lxs- 4114.4 P~tG- .hau.. 13z F~.= ©v.S'' ~rt`.vo,-r\.S} eat t✓/lasP4, 7ur~ F l33 r,C.= /C &I I' / prmPvsQd O ~ O f. R7 Y ~ . Is BK: lar s~" 1 t, ~r + o e t~ ow~a• /on' As-fA y~ 3 ,C7 )Sores t )-.at ~(.;a CcrNir L L ~ ~ S'trQ~E+2 3 ~u " At//~avL ~ d~ -t 4t- C~l I, the undersigend, 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. Name (print) Z.~t h'5 ft C'.r ev Certification No. Address -Z !l@. a fy®/~p .Name of installer if known Copy A -Local Authority CST Signature r' ILA O E c l w ~ c CP N ,G Tfn - s . ~ ill ~ -r- ~ ~ a• i -I V\ n Ct, y 1 - - _i_: } G _ i i ,.J h ,G7vrc~,,2 Department of Industry, Labor & Human Relations Division of Safety & Bldgs. State o Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison WI. 53707 Tel. 608-266-3815 IN ALL CORRESPONDENCE 77 vH REFER TO PLAN IDENTIFICATION NO. J I Q V Crv~ S f , 4 NAME OF PROJECT TYPE OF APPROVAL STREET AND NO. N ' ° N C144 "gig- Vic- 14 CIT OR TOWN / ICCftJ'NTY STATE ZIP OWNER Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval shall become void and new application shall be made for approval of these plans before work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto- matically void this acceptance. Sincerely, James Sargent-Bureau Dire CI-Q-11 PLANS REVIEWED BY: _ DATE: / 11 1 _7 /I cc: DP Owner DILHR Lori Plumber H & R (2) _ount Mfg. Rep. Bur. of Health Fac. & Services DI LH R SBD-6099 (N. 06/80) Rec. & Env. Services r Plb-100a 12/78 Detach Anti Return Upper State of Wisconsin STATL OF WI SCGNS.IN U ILHR Portion Of This Form With u i v i SI ON uF SAFEYY 1'. 6U ILiD I N GS EsUkLAU OF PLUMBING Any Return Correspondence ,?.Q1 ~L. W ASMING7UN AVE* RM 17€ P u BUx 7969 tMAO I S JN s *1 53 70 7 DATE: Ll' PROJECT: C~C?c~04``it 1 X \/O-u~ I--- 7-ecp ry Irv N y~i S . y lZ>t q V .,77> C) V C) X_ PLANID.# DETACH HERE PROJECT NAME ` r - PLAN ID. # ~ C)C? This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the plan review fee required is $ "r ~ f L( ❑ 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 ❑ Profile of holding tank. L_l 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. l_, 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) l Total area filled (fill to extend 20' beyond edge of trench before side slope begin). ❑ Depth and type of fill. 1 Copy of onsite report by county or district plumbing supervisor. 3_I '_:1"") of ti;. 4lIl !',as ~f #"i :;n rrl,?{rt NIV Y~ ~ a V y 1~ M 1 - \ I L J NO :4 ~1 - I ` III I I .Z ~ i aj Plb. # 60 1/78, PROJECT DETAIL DATA SHEET ( NAME OF BUSINESS t/1 Ile , eru F' fti / 1. LEGAL DESCRIPTION N LJ yy ~ /q Sec v i ay n1 t% l4 Lj OWNER 1 16 1t-All-I- MAILING ADDRESS t~ase f ~c~,su , ~~:~~►>7 Z I P ARCHITECT, ENGINEER, I c> ADDRESS 3/y Irc~ St T~/~taC'So%i PLUMBER OR DESIGNER Ili, ~S ZIP Sf<U/~ TELEPHONE NUMBER 3 Y Co - Y 4 6 y 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 1981 ( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons, ( ) Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . . Number t) ( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons ( ) With kitchen Number of persons ( ) Dance hall . . . . . . . . . . . . . Number of persons ( ) Dining hall . . . . . . . . . . . . Number of meals served daily ( ) Dog kennels . . . . . . . . . . . . Number of enclosures ( ) Drive-in restaurant . . . . . . . . Inside seating capacity Car-service Number of car spaces ( ) Dump station . . . . . . . . . . . . Number of dump stations ( ) 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 _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) . . . . . . . (.Jx. dcrc~rr~e b~n~~.r ~'rn~~/ee5 COMPLETE OTHER SIDE 2. Indicate whether the following facilities arp present. Floor drain yes X no Number of drains-_ j Food waste grinder yes no _x Dishwasher yes no x Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity Holding tank capacity Septic or holding tank manufacturer -eI t.5 &~n C,, ele cJS 4. SEEPAGE TRENCHES: total square feet _ width of trenches length of trenches depth number of trenches SEEPAGE BEDS: total square feet width length of bed y' 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 Address -31,0 cr&,1 1, /ics Zip .JrS~DI~ Telephone Number .?j Date a IDW EH 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES" a • , J <C P.O. BOX 309, MADISON, WISCONSIN 53701 , d LOCATION•lV~'/41~✓~'/,, Section:~,T.2LN,RZ4V (or W, ownship or Municipality Lot No. , Block No. j? S County S I c°~ _ u d' in ame sio + Owner's/Buyers Name: d"4 r Gtf' 114 -5 Mailing Address: _S~ Sct i t f e, f ~~ru u cLtc C!: s G Uf TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL -Z< EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM (OTHER DATES OBSERVATIONS MADE: SOIL BORINGS Z-9 O,p PERCOLATION TESTS SOIL MAP SHEET c~ NAME OF SOIL MAP UNIT PERCOLATION TESTS t~~~ cx TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 S VC- Y SVC_ ~ ~rF f~ I v o • A10 -3 P- P_ P_ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST .L IF OBSERVED IN INCHES B- /0 40 51, 7 B- 2- ffy7t. /~.L{J~C G'-` 7 ~s s! S~ " Ji/^, B- Wki C 12 B- If, 40Ae C- - In" 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 a 3 Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. r 14 k) a y - 15 j 4 let ctip 66 N l hw# - 31 TV C' Pry -v &l "Al wn o f ~ 4'.j C_ -P-4 ai ~ 66~s , ,e r ,C. ` N1 l~'r uo~ /.L?,4r/` I - /0v % the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods ,ified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my ledge and belief. t4ar Addint)~'~~ Certification No. -S - Nam !alter if known Copy CST Signature cal Authority 4 '~~P ao~ 1 Pt State and County State Permit # B 6 7 1 Permit Application County Perm-st for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED h Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: f~ Y4 it Section j T N, R E (or) ~W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Townships C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete N, Poured-in-Place Steel Fiberglass Other (specify) New Installation i Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate', ! Total Absorb Area sq. ft. New \ Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. -Width _Depth Tile depthjtop) No. of Trenches i Seepage Bed: Length ` Width Depth Tile depth (tope No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land- ti - - Distance from critical slope WATER SUPPLY: Private R1 Joint ❑ Community ❑ Municipal El Owners name as listed on EH 115 if other than present owner: I, 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 C.S.T. # - and other information obtained from (owner/builder). Plumber's Signature _ MP/MPRSW# Phone # - 1 Plumber's Address /i :z ~ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. E i 3 a ~.A . i 3 E j ! E P, i E 1 i Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Q Date of Application ;1 Fees Paid: State `s , Co n Date ' C-;2 ~'a Permit Issued/Rejee+ed (date) 42-;2 LIE Issuing Agent Name Inspection Yes No State Valid# Date Recd 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 7/1 /78