HomeMy WebLinkAbout020-1153-90-000
4
n N O -0 n
O y c d O r
7 N o N
CD D C
CD O N f
I
N) CD
cr)
c0 J N M m N O CO
Z C
N N ro m O :3
C CNp W C
`I A Q in N (n 7 Qp J
07
O (CO 00 (D
n N * J O C
O O
J A O 3 O O
j N (D O
v N N 0 ~y
Df c N N
Tr` (D tl W t
N
N
v O t O O m F
_ D
(ro N O (~h~~I
O Cl A (D O N ro O C
y
c is
o"
o•
A o
° a c (n cn cn o 0
NN
O Q' Cl) (p N N O N
< (D = < N
ro d N
D ~ m
CD
f1 3 ~ r
z ~ C
D co o
n 7 •~y
o'
VroN
ro cc
0 N -
(D ro
` a
w (o
ci 3
Z 9 A Z N
? U 00
r fl p Z O
3
N
0
N
O ZZ< W
W O
N G
I 3 z
R-
a 7J
o U) co
3 m
z
(D
A
co
O(D D
N
a _
O. ,n
co
' ~ cJ C
ro z O.
O O
c 3 cD
7 (D
ro ~
N a
m
cm y
(D N
N
Q Q
a
CL
I N N~
N _ N
Q X
N O
v
(D O
(D
J Q p
(D
cn n
A N
I O ~ V
(D 7Q
O
oO a
O CD
O Q.
D.I.L.H.R.
Leroy Jansky Q.W.S.
Nib. t-A, WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES 13 E. Spruce Street
Division of Health Chippewa Fails, W l 54729
Section of Plumbing & Fire Protection Systems (715) 7213-8786
ON-SITE WASTE DISPOSAL INSPECTION REPORT
Name of Premises
Street City County
Master Plumber Address
Owner Address
❑ County Permits ❑ Appropriate State Permits
Type of Building: ❑ Public ❑ Single Family or Duplex
CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM
❑ Building Sewer ❑ Conventional Soil Absorption System
❑ Septic Tank ❑ Conventional System-in-fill
❑ Holding Tank ❑ Alternate Mound System
❑ Seepage Bed ❑ Holding Tank
❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System
BRIEF, FACTUAL COMMENTS AND SKETCH:
s -
} a e
E #
E
t _
a
# a # g.. B # mm v
€
I
e
E
E ;
3
#
E E
r E-
E E 3 q.
3 F qq
b ~ E E
3 E
r
€ i 1 ; I
, t
3
3 i
3
3 #
E i ~ 3 E
..,.....3E m ~ . r ~ ¢
a e.
f l
f
t 3 s
a r 3
x E E
E
i
c I z ~
a
> E
E
a
a-
1
s
i e
€
F
I
3 £
4 f f _ 3 _
es.~. ....e». . ?.tee »,e _ ~..._._,_,.._3 ~ , i_... , - .
~ L £
€ i v t
e 3? 3 j a i ( ~ f
jj
#
a
a m -
e.,__.. _ m__._- - - .......,e _ T 4-...
i e €
~ .m
x € E
3 E
3 e
3 3 e
E
i
#
< i E
; a W
E
E ' 7
}
3
a
.T j
~ s j ~ ~ € ' § ......E
❑SEE ATTACHED
DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary)
DATE OF INSPECTION
Signature of Inspecto
-inspector Yellow - Local Inspector Pink - Plumber or Responsible Parr
o v' O 3 m o t~
5 "0 3 r* h.
CD F 2. -0
7
v ~
a) CD 'A (0*)
0 U) P C",
m m to rn C. CL N)
m on p a
N N C O O= CND CP O (\_'1
CD `
CD w
`Y
A A N 7 1 o co
1
o
C) CC) CD co m CD h
3 3 m CD !a.
7 y O
~ W CD CD
m co ~ h a ~
v N
3
(D ° A ~ o O
z
CD co co 00 (D N 0 c
_ g 6 •
N
c v Z
a
"o _0 0 (yq
z COC CO OCC
O G G G
- ~ - T
Q c N fA (D °
,:c: C o <
m
C/)
N
= 3
N (D
7 7
tl rT
Z
° co z
S = CD O_
~ = CL
n _ O
v D
O CD
7 (D 7 O
Cn
.Z1 N
(D
C
C N
CD
w CD d
n 3 = i N
z CD O D O A Z 0
!n C ;o r•'
= A Z 3
N D_ 6)
0
CZ N W
co - G
CL " z
0 3 ?
O X Cl)
3 m ~
y Z
(D
C.0
C_
N N o -
CD C
Q (n
Z) T
= w c
C Z C- O a
O
= 3 m
O N
CD
N C,
m 5 r
= CD
CD ID
CD N A
d Q 'C
C
C1
N N `•C
X
CD C? O
-I Q O
CD A
CP O" A
A O
= A C+a
O 00
Efl O r A
O N }a}
O CL V
COMMERCIAL TESTING LABORATORY, INC.
514 Main s.reet, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
CROIX COUNTY R J,O 'f SATE: 6/07;
1 THOUSE nATF RF.CEWEPt 6/06
;,I:S0Nt WI 540:1,
4. THOMAS C, NELSON
23. Zvi<<
i ?t Judy Ha Lvers
JATION' 853 Bradley 11r 4iur[ar
,-,-LECTOR'* J. Thomp
i 1f.'CE OF SAMPLE: Ut i x i
LIFORM*4 0 /100
4TERFRETATION't Racteriol09iC6kL.
3 PPm
,)hove 14 PPm exceeds tht•
i7rm BaLteria/100
,;1.3?-•?~it1""l3'aEAt fTIQ•'~.
LLHNi :it-ti rani
OFA DEPEND, T
2` (9®
O A
o Means "LESS THAN" iie sec l as :,a Leve i.
J 4T
PROFESSIONAL LABORATORY SERVICES SINCE 1952
4
ST. CROIX COUNTY ZONING OFFICE
t. Croix County Courthouse
77r-Tr r e e
Hudson, 1.11 54016
Telephone - (715)3£36-4680
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form--
is essential so that the_prc~~~e_r_ty can be
-
located. - -
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning office, and mail,
a-!---- .1 4+-h form
7 - to the above acidros Test -;-g ''ill b v "lone a.
soon as possible after fee and form are received. V
WATER TESTING----------------------------FEE: $ 25.00
(For nitrates and coliform bacteria)
WATER TESTING FEE: $175.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system is properly functioning at Elie
of
inspection) i`
Property owner's name ~J-3 L ry ch i
Property owner's address a C&C
Legal Description AIL 1/4 of the 5c 1/4 ot~ Section
Town of Lot dumber r' Subdivision Name_ _
FIRE NUMBER LOCK BOX NUMBER TL-7 Color of house E 2e~,~~ Realty sign by house? so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBL A I,IAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the .rater for several hours before the
test can be conducted.
WINTER TESTING: Many times .rater lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangement, with this,
office to ensure time when entry may be gained.
Firm or individual requesting services: C~zc.y~--
Telephone Number
REPORT TO BE SENT TO: O
fate Closing a-
Signature l c - -
l1_Z.1___.
n~
AS BUILT SANITARY SYSTEM REPORT
~``sSEC N-R W
OWNER ~,~-P~ S TOWNSHIP -
ADDRESS " ST. CROIX COUNTY, WISCONSIN.
LOT LOT SIZE
SUBDIVISION
`2 7) PLAN VIEW
Distances and dimensions to meet requirements of H63
W-EVERYTHING WITHIN 100 FEET OF SYSTEM
r
i
a
I di a e oath Arrow I
SC LE ;
BENCHMARK: (Permanent reference Point) Describe:`
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: ~k Tr Liquid Capacity: l--
Number of rings on cover Tank manhole cover elevation: "'t,'
Tank Inlet Elevation Tank Outlet Elevation: -/1" o-
PUMP CHAMBER Number of gallons
Manufacturer: -r-;- gallons; total capacity oT-
iJunber of.gal . pump set or a cyc c- head ;
distribution lines gallon: size pump ran name of pump
gallon per minute horsepower
and model number '
Type of warning evice -
Number of gallons_
HOLDING TANK: Manufacturer -
Elevation of manhole cover
Type of warning device-, Number o pits eet iameter
SEEPAGE PIT SIZE:
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit elevation feet.
R {ile depth`
`r wi th S
SEEPAGE BED SIZE: number of lines le:ggth' t r<--_ lengC~l
SEEPAGE TRENCH: width REA AS BUILT
REA REQUIRED
PERCOLATION RATE
LNSPECTOR
R
PLUMBER 09--,0
- LICENSE NUMBER-
REPORT Of- INSPECTI INOIVIVUAI_ til_UTAGL SyS-HM
S ave -i tan t( I'(>'1 I 7/
Sta(,' Scpt(c
',A. iI Tow vtAIf 4 p St. Cnn (x Cnuvi ItI
sec tiovtp;ULut SubdiviA-<_o 1-4
i'I IC fANK
~ r c ga_efovtA Nurnben oh carnpani tmevttA
!)(ti ti(lwc (nom: weee f _ Bu-~_~deviq 120 /,seo pe
H~ ghwa to it
I'IIMI'1N(; CHAM6(R
~y~ Mode f Numbr ~i
S~ rc ga('tanA Pump Mrzv z uc-~'unen '
((O I-DING TANK
Size gatfovtA N nb o~j Ca a tmevit
1' u m p e n //A A ,m S^il A1te rn
!)~Atavrc e (tom; weef Buti~'/C,,(-ng -~12$ 54'ope.
Highwaten
nt,.~ORPTION SITE
lied T~tevich
rfVl('(' ~j1[(iYll~ IV P~'~ rlrI ._;,1~.i
fll ghwa tc ~t
l•'I'I ION SITE DIMENSIONS
(U(Ifl~ o f tncvtcft ht Regni ncd area I
r) t it It u
o cfb c (nw t4f4
l(tiI(li oA each 4~vic - t D
A
Nurnb(-n oA i',i_ne.A Depth o6 noef, oven tiYc ' (vi
7~~tae ecvtgxh. o6 f4' neA At Depth o{ t4.f.e beeow <lnade
D<Atav(ce betweevt fi.vieA At Mope oA tn.evici ivi. pe~~ 100 A(
luto(' abAonp.ti ovt ane.a :f/ (It T9t:pe a( c' Coven: a P e)I oI? A tnj(4W E~-
~ -
II PIMFNSIONti
V(tmI)o o f p<tA GA avt f ano(AY1 p-~ to I/cA
~uftirdc I arnclen {t~ Dcpth hveow (,vtl'et (f
I err(' A) (((p.t,iovi anea ~ ---~-t
_of
U;I'1 CfI D 6V l1 _ _ _ rr~' TIM
OATL S r'~ 19 j
h
I !IcIIP OAEI 19
'I 1~;i~N I Or RI 11 CfION
PLB 6 7 State and County State Permit #
ar .4fermit Application County Perm #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
James Halverson RR 2, Hudson, Wi
B. LOCATION: NW % SW Section 2j, T 2` N, R19 E (or) W) Lot# City Hudson, wi
Subdivision Name, Fox Talley nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial "Other (specify) *Variance
Single family x Duplex No. of Bedrooms j No. of Persons 2
D. SEPTIC TANK CAPACITY 1000 Total gallons No. of tanks 1
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify)
New Installation X Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate n Total Absorb Area sq. ft.
New X Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: x Length -52' Width 12' Depth 2" Tile depth (top) 36n No. of Lines 2
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 6%. Distance from critical slope none
WATER SUPPLY: Private ® Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner: James Halverson
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 sy
by the Certified Soil Tester,
NAME Stephen L. Aaby C.S.T. # 140
obtained from Builder (owner/builder).
Plumber's Signature, r lr~ MP/MPRSW# ME 5161L Phone # 696 - ?407
Plumber's Address Box 25 Woodville. Wi 4026
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.
PLUSE RIFER' TO ATTACH:) DRAAWI dGS i
E
E
_ a .n s . . .
E
9
t
E t ~
. . ~n.._..... ~,...p a ~ . _e , ....w, M.e . ~ .m a . e
r
La
.......e-,s., a - e w . ..e ..r m. ..e ~ r,..._... ~.em ..m ,w p _ _ - ~ j
3
.
Q .y.ea_..., e .E:e s ..~,a_ s e a. . < e ee... a m... a ....._.d .e ~ . _ . ~
E
,
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT U ONLY
Date of Application _ Fees Paid: Stater, &Q-0 County Date -
Permit Issued/RrtucTed-(date) Issuing Agent Name zfz
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
EN 1 ,1 5 WISCONSIN DEPARTMr T OF HEALTH AND SOCIAL SERVICES ll 8 ' 9~
DIVISION OF HEALT , BUREAU OF ENVIRONMENTAL HEALT n
P.O. BOX 309 JRfcEllVf
MADISON, WISCONSIN 53701 UN 9 1381 r
REPORT ON SOIL BORINGS AND PERCOLATION TESTS IONjNG
LOCATION: N~" '/4, Sid ?3_ T29 N, R 19 E (or)(W,)Township or Municipality East Hu s Wiftirc
'/4, Section
Lot No. 19 Block No. Fox Valley County St. C
Tames Halverson Subdivision Name )
Owner's Name:
Mailing Address: RA 2. Hudson" Wi 54016
TYPE OF OCCUPANCY: Residence x No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW- X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS June 3a 1961 PERCOLATION TESTS Tune 3, 1961
SOIL MAP SHEET 56 SOIL TYPE ttOE HITCH&
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
40 T.S. 12" Sandy Loam
P- 1 52 30" Sand 6" Gravel 2 No 10 5" 5" 5" 2
P- 2 52 36" Sand 16" Gravel 2 No 10 5" 5" 5" 2
8" Top Soil, 24" Sandy Loam
P- j j0" 20" Gravel 2 No 10, 5" 5" 5" 2
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B_ 1 96 None 40 T.S. 12" Sandy Loam 30" Sand 50" Gravel
2 Sty Nona 36" Sand 48" uraval
B 3 78 None 18" Sandy Loam 1811 Sand 4211 Grave
4 72 None 8" Top Soal 24" Sandy Loam 40" Gravel
B- 5 72 None 8" Top Soil 24" Sandy Loam 40" Gravel
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. 615 sa. ft. Indicate scale
or distances. Give horizontal and vertical reference poi ts. Indicat ope.
Ilk
111 v r;
. r r
i
N
E ! a i
xRQ xIl
171u K{ 2 i_ z L
i i I I I 7 F _ i t~ l
__.j_
s
~Z s _ ) z; .fin ik ► 7
y
I, the undersigned, hereby c ify at 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) Stephon L. Aaby Certification No. 1406
Address Box 254, Woodtrille, Wi
Name of installer if known
CST Signature.
f,.
41
h
t:.
- r
~a
n
• r
I
V ~ (
c,
V ~
J
v
I
3 ,
i -
i
i
i
v~
s
w 41 !
v J I
s
u - t-' +
~ n 1