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HomeMy WebLinkAbout028-1037-50-000 n to O K v n d v1 c y c o :3^ v CD fD0 ~ D m CD C O D D CD ? 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A m CD ~n cn (D D) N 3 m - 3 m °w N C ° L N z D D o z D a O m v O ~ O y a C Cp Cp N ~y,~~ • CD (D O (D 7 C w CD NA O p m CD =3 O. p Z CD CD a c c) Q A z v a. CD ~ N -I N ao v co v rJ 00 CD a 3 o z :E x O - O 3 3 N N (D N a a N _ N D CD D CD Q- 3 a 3 CL a s o m c D m c m o a oz a N CD I i ~ I N O CD i CD A CD w D I ~'r O N c v N I a o O ' a A M w 0 CD CD 4 0 N O fA 69 0 0 T ti 0 CD (D O a 0 a ti Parcel 028-1037-60-000 07/27/2006 03:15 PM PAGE 1 OF 1 Alt. Parcel 27.28.17.228C 028 - TOWN OF RUSH RIVER 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 - VANG, WANG ZAO WANG ZAO VANG 1877 18TH AVE HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1877 18TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 17.006 Plat: N/A-NOT AVAILABLE SEC 27 T28N R17W PT SE NE BEING LOT 1 Block/Condo Bldg: CSM 2/302 1.5AC & INC COM E 1/4 COR;TH S 89'W 740.09FT TO POB; TH CONT S 89'W Tract(s): (Sec-Twn-Rng 40 1/4 160 114) 571.69FT;TH N 00'W 1294.34FT;TH N 89'E 27-28N-17W SE NE 573.74 FT; TH S 00' E 1292.67FT TO POB 17.006AC Notes: Parcel History: Date Doc # Vol/Page Type 11/09/2004 779515 2692/624 WD 04/02/2002 675119 1865/112 QC 03/31/1999 600384 1415/055 WD 02/18/1999 598055 1404/447 AFF more... 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 08/30/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.500 25,000 176,300 201,300 NO AGRICULTURAL G4 15.506 2,800 0 2,800 NO Totals for 2006: General Property 17.006 27,800 176,300 204,100 Woodland 0.000 0 0 Totals for 2005: General Property 17.006 27,800 176,300 204,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch PRGRM Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 n °ma~ a J` ST. CROIX COUNTY CERTIFIED SURVEY MAP I, Arthur L. Wegerer, registered land surveyor, hereby certif-," That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of John Nlonicken, owner of said land, I have surveyed, divided, and mapped said parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed; and that this land is located in the SE14 of the NEB, of Section 27, T 28 N, R 17 W, Town of Rush River, St.Croix County, G'Jisconsin, to-wit: Commencing at the East 14 corner of Section 27; thence North along the Section line 1289.201 to the Centerline of an existing Town Road; thence S 89°44120" W 1072.441 along said Centerline to the point of beginning; thence S 000151401' E 311.141; thence S 89°44120" W 210.001; thence N 0001514011 W 311.141 to the Centerline of an exssting Town Road; thence N 89°44120" E 210.001 along said Centerline to the point of beginning. The above described parcel contains 1.500 acres of land subject to Town Road Right-Of-Way over the Northerly 33' thereof. Dated this 7th. day of September, 1976. ntgvu i cti Arthur L. Wd rer Wis. R.L.S. No. S-963 r` , J 0 r n✓ , Dittloff Engineering eG,.: ~j" River Falls, VII. 51,022 . ARTHUR L. e cR . . . a: •WEG-? • TOWN ROAD 5-9~3 N 89°44'20" E 210.00 S 89°44'20" k ELLS`.NORTIt Wis. 1900 00 1072.44' -to 0 M N 89° 44'20" E Co °o SUR~E~ 210.00' = O N Ir o~ O co z N EAST 1/4 CORNER 4 SECTION 27-28-17 APPROVAL OF THIS Mll'IOR SIJ8 N M JJ _ DOES NOT MEAN AP. : V,~L FOR PTIC SYSTEM. R,.F~ R TU H ~2.~40 m GQ`~ P -7 N S' O 10 11 00 ^ X X FENCE N 0 o I.. X24" IRON PIPE WEIGHING ED W 1.13 LBS. / LINEAL FOOT 0 WS 1976 ~ APPROVED O 16"W D66de c In Z w,,~~n w ST. CROfX COUNTY O COMPREHENSIVE PARKS P! a`!NING S V 0 AND ZONING COMM, f i tr ° NORTH SEP -15 oa °0601, S 89°44'20" W 210.00 SCALE IN FEET t 100 75 50 0 100 Vol,,une 2 Page 302 _ "5 /q,1 UV -1 I R/IV Itt t.l I ~ lrl . l t 'I ] /UN1 y{t1 <.~~;~;y ALTERNATIVE PRIVATE ~AtI I Hair SEWAr3E SYSTEMS r~lvl'.ir r I Mound I~ Pressure Dtstrtbtttton/H/ A~~ ill ':S nl I'1 r..... 111111 _ V + M I INtiI'11 IIII Ir II ?I 2 'A..n.. ~J ~ 3 ~Il it rrl Nl IIIIrM I'/AN ~ ~ I' I I V- .t I'TIC TANK: TI If 11111x1 AVAr 11! I IANI NI I I /~I•~V IIANM r)I/111 1 I I v VI1111'1If 1 V I INI WI I I K)S1NG CHAMBER: In NU AI 11,11111 ~1 ll ll lllrl AI'Ar IIV - --1 .11111{ 1'I IMI' Mf tl rl 1 PUMP MANI 1 A/' 1 ~ WAIININ(. I All11 I rrl M INf I ,AI 1 ON (F H (Y(_i F l /7 ~t Hf"ll If n vlVl 1 )IF (F 1f Nt;F Hf IWI- EN uMI nNI~r nP n+ul X111"IIAill)NAt YES I I N(~ I I vl I'L/MP ON AND OF F I Om 6-R/+0y~-~ RHP TV ~YE' NIN FEEFf~VTP Wfll -I, YES I I NO ROM Nf ~ iI No i I 4 AM t 111 cease until SORPTION SYSTEM: Check the soil moisture at hall the depth of pluwlnq the soil is dry enough to continue.) cavation. (If soil can be rvlle Mound site plo of ex d Into d will', consUufhlll wed t - - per lendicular to sloIm Check the texture of the till material-fur and Iurlows thrown upslope. mound systerns to make certain that it PROVIDE A DIAGRAM I_J YES [ J NO meets the enterla for medium sand. OF SYSTEM. SHOW ELEVATIONS MEASURED- ASTRIBUTION SYSTEM: Willi, JIP ETN Nr)!)VYPAf,INr, ["FNiN( 4 TH CFNiFH M --AT(UMP MANIFpI p HIA PIPE ! 1 ANI) MA{IH INI. N11 HI 0 HIS III PI 2t C7 IPF Hln AMAIlf)HLE SPAT tN1. (1H11 1 111 f:HRRF('TI l ,r. 11FPTN01 I,HAVI l - ✓ / o IIVf 4 IPIPFS -{-1 YES NO VFR i1CA1 LIr, (~f)f1f11s NF Ti AVi~lil iV}-~-~ UIL COVER: PI nnls U - _ 1A YES I NO f _ ~ _ - 111111 NI - L~)",P'Tll f1VER FS HF.P 111 HF I()PS(111 _ SHHI)f If SFF frf H I ) YES I I NO I ] YES I.) NO I I YES I NU - E N TS : 511 HH SHI)ti7?1 (H oh/H1) 7 / 1 1 1 I r r~ 11 I I 1' l~ REPORT OF INSPECTION - 7NDIVIUUAL SEWAGE SYSTEM Sanitary Permit z Slate Sep t_ is/FJ-y NAME -`COWNSHIP_ St . Cro i x Coul)t y WCATIONvIZ-7 Section /Lot # Subdivision SEPTIC 'T'ANK Sf- ze gallons Number of co11lpartill ents 1)istit nct f roIII: WeI I- Bull -ding 12% slope If Ighw<iter PUMP I N(; CIIAMBE'R Size gallons Pump Manufacturer Model Number IIO1,D LNG TANK Size gallons Number- of Compartment:; Pumper A1.arm System !)Lstaii ce from: Well-- Building- 127, slope IligIIwater ABS0RPT 10N S I-TE, Bed Trench 1)f.stance from: Well Building sl -ope IIIghwater ABSORPT ION SITE, DIMENSIONS Width of trench ft Required area lt. Length of each line ft Depth of rock below the in Number of lines Depth of rock over ti_le i I I I'otal LeI)gtI I of lines ft Depth of tile be.tow grade in. 1)istance. between lines ft Slope of trench in. per 100 It total absortptfl.on area ft 't'ype of Coves: PFT DIMENSIONS Number of pits Gravel around pits yet no Outside diameter ft Depth below inlet ft . 1 't'otal absorption area ft Area required ft I N S P H (:T E1) RY T I'T'LE: APPROVED DATE I 2i REJEC'T'ED DA'lb: I c)ti REASON FOR REJECTI.ON IIIJ I L.'I' -',A J I TAKY SYSTEM RKPOK'1' `I'OWNS11. Ll' W j K'I' CRt)CX COUNTY WISCONKIN W1 0' t' LOT S 1_ "L I; t' I .AN VIEW IIQ l i im 11- I'll I- I. n n"'t_`I. rcqui i emu n! s of H6) .,kIOW EVL;I{YTH I NG W.L` H l_N 100 FRET OF SYSTEM I , 1 4- , I _ i I dt at or; the Arrow I I CAI.f... I''I.IJI;11H1 RK, (PvrluaneUL rutere"CV I'UKI Describe; Fl (1 v,tt tMt „L WrLIC a l reterel" e PO " ALope al- 61 w ';FIN I L: TANIK Manu.laul i.tre,r . I-.,.L.quid Oapau lt.y ;rover w ; evat. i un Ni uul,cr u l C`.1_lijytt c)n cover [ttaClItC?1 t 'l'ank l.rrle L h:l.eval L.can: Tank 0 LAL EleveaL;r_on 1'IIMI' t-;IIAM(~1:13 I°1a" L tac L;urer : Number of g al Lons I~uulp aet ~`or cyc:~ e gallons, total c'<apac i I y o ~iurker of gal.. _ ti1.Ge o uur a I i t i i lout L"n Li"vH ra.I l~,tr I k h I 1,111 WC nl l nul e, hor6e power unc1 ti~uu~ I I,i_utip flll,t c I numh'., r . /1,,' (d w.arn1_11p, dt'vi<'c~/,~,, v f~ HlC TANK MilIMI W ILICe'r Numbai ui ga1.lulr:, I'v:lI i-can ~aI manho e cover 1 o t w~l t o i- K device I'll' Number of Its ~ I I_tquid debt fi.-- e~ v a l_ i_ t:a nsee page pit. inlet pipe-eie;vat ion IwI tutu u( s r p E e )r i t feet. -..th elr tile depth l IiL.L) SIZE: number of l inns w ~tlt ' i\(:] 'i'Itl-':NCH wtcll.lt 1UTAgL1.1 1 t 1,I.~~ T I ON KATE --AREA RL:QI TAEED _A ATtEf~ AS }31JILT , 1 INSPECTOR PLUMBER ON J B - ~ - 1011.1~ LICENSE NUMBER DEPARTMENT OF APPLICATION 3 JWDUSTRY, FOR SANITARY SAFETY & B 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'/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. The owners copy or a legible reproduction of the soil test report must be included. j Property Owner: Mailin dress: M,L LAS l' ~L4 L% S Property Location: Cvty-Aq4i~r Township: County: 5La '%,A/L_%S 7iT-;;,3 N/R I I f(or) W lqt 's /-j K)) V;C- /z- 5-)L" Lot Number: Bik No.: Subdivision Name: Neare Road, Lake or Landmark: State Plan I.D. Number: J - (If ass" ed) g` TYPE OF BUILDING / Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. T AL NUMBER PRE A POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHEF GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specif.. SEPTIC TANK CAPACITY G Owe X X HOLDING TANK CAPACITY X LIFT PUMP TANK/SIPHON CHAMBER _211 ClAje_ X MANUFACTURER: "S G1n1G1z~~e S I Rod oc t- EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) 5:;J QC' _I ,)d /~weS 5 Qe E] Seepage Trench 76) Water Supply: Owner's Name as Listed on Soil Test Report (if other than present owner): R1 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: S natui • MP/MPRSW No.: Phone Number: ✓(,~E f f c L.~/f ~ r -Eck p <Fl(71,fl 6yq- 33 7 Plumbe ' ddress: Name of _Designer: J COUNTY/DEPARTMENT USE ONLY Sign ure oling A ent1 Fee: Date: APPROVED Sanitary Permit Number: ' DISAPPROVED "Reason for Disapproval: I 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. LDISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber LHR-SBD-6398 (N.03/81) 1 D ► , C-N W cam: ~ IV IA 41- a y F^ I-A 63 t) i Z ,g.. ash CID c f ~ k' cn rya - 10- 1 0 r~ z r.. f C~ 03 9 r c W ~ ♦ ° v p Ar 6" wt ~t n r Cl\ ~ { ! (4 1 g c~ fS ? r t - t is ~ o LAi 7,1 ( ti• -44 a 1$ 4 lbH I~ (I L or' y~ IL C w D v I ~ LIG 41, ~ ~r Wda OSb£ '*ZH 09 `SIIOA St t . sa~aydS „q/s `09MIS'S HOOtdS `HOSdS sp!IoS xeW sdwnd ;uanIM peaH y$!H OSIHMS PUe HOOtdS 4109dS :f4pede3-peOH 31nNIW k0d SNO11YO •s,n Oql OZl OOt_ 09 09 Ob _ 0z 7 Hosds - SdAnd )b HootdS m 09 iN3niJJ3 Das! ~Olm OV3H HOIH ozl obl WdH OSLt ` zH 09 `slloA 9tt !sajaydS „q/t 'GUS I --/c `££dS sp!IOS 'xeW ` sdwnd dwnS alq!sjawgnS SZdS pUe ££dS :4!oede0-peat' 31nNIW H3d SN011YJ 'S'n 09 09 Ob OE Oz Ol 0 b -1 r zL m 9l Z UFA= at ;R S ~ bz SdAnd 'ZH 09 `910d y !ajagdS ,v/c sP!IoS 'XeW dAns sdwnd dwnS alq!sjawgnS SEAS pue SZAS 44pede0-peat' 31nNIW Had SNOIIVD 'S'n 917 Oil se of sz oz sl of s o 3191SH3Aons b O 9 r z m SZ~S c 9l z T E~^S oz m m bz 9z saymne z9-H ~ ~ ~ m n tJ a t%H State of Wisconsin ` Department ndustr L"_' or and Human Relations Please Reply to: any-t:) F & BUILDINGS DIVISION re k bf Plumbing I Ox 7969 Madron, 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 Count er Enclosures ~ mes Sargent, B erector DI LHR-SBD-6159 (R. 7/81) DEPARTN3ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS ALTERNATIVE PRIVATE DIVISION P.Q. BOx}7969 SEWAGE SYSTEMS BUREAU OF PLUMBING MADISON, wI 53707. ❑ Mound ❑ Pressure Distribution NAME OF PERMIT HOLDER: AU DRESS OF PERMIT HOLDEN. INSPFCT"ION DATI`- PLAN ID NUMBER I -0 0,349 BENCHMARK IPni rnunnnl ro(xrnn~.n puinll UE.SCHIH& IF U14H IO NT FHOM PLAN HLf I`I LIJ V CS( HI 1 PI. ELEV. SEPTIC TANK: _ _ MANUFACTURER: LIOUID CAPACITY: TANK INLET ELEV.. TANK OUITEI LLE V. 1111 1(.ri Q PIiUPI'H (Y LINL. WF LL. RUILDIN(i F 0T FROM - - N A19EST «....s~, DOSING CHAMBER: MANUFACTURER: LIQUID CAPACITY: PUMP MODEL: PUMP MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO GALLON PER CYCLE PUMP AND CONTROLS OPERATIONAL. I ~}I $E PROPERTY WELL BUILDING qER INN LE FRESH DIFFERENCE BETWEEN FEET FI 6M LINE: PUMP ON AND OFF ❑ YES ❑ NO NEARE5?I`--- -r► 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 El NO meets the criteria for medium sand. ELEVATIONS MEASURED. DISTRIBUTION SYSTEM: WI DTH. LENGTH. NO.OF SPACING CENTER ~y - LGNGTH: DIAMETFR. MATERIAL AND MARKING. 8ED1TREN0I+ TRENCHES TO CENTER rQIT r DIMENSIGINS AtEI.IN MANIFOLD. PUMP: MANIFOLD PIPE MATERIAL AND MARKING NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. DIA.: PIPES: DIA.. ;ELEVATiss# HOLE SIZE: HOLE SPACING. DRILLED CORRECTLY DEPTH OF GRAVEL OVER PIPES: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑ YES El NO ❑ YES ❑ NO SOIL COVER: TEXTURE. MU LCHED. SEE OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. isOD DED. DED:YES L1 NO CENTER: EDGES: ❑ YES El NO ❑YES El NO ❑ COMMENTS: - - SIGNATURE: I I I I E DI LHR-SBD-6227 (R. 05/81) Plb 100a 12/78 State And Returrv Upper of Wisconsin DIVISON OF HEALTH Portion Of This Form With SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS Any Return Correspondence MAIL ADDRESS: P.O. BOX 309 MADISON, WISCONSIN 53701 yGn 608-266-3815 DATE: R'. CT: Cn ~ ~'t 4E4, Sec '7 T1 --I of P"J8 b 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. I It. 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) D Total area filled (fill to extend 20' beyond edge of trench before side slope begin). ❑ Depth and type of fill. f J Copy of onsite report by county or district plumbing supervisor. vencT.h of time fill has been in place. im, Wisconsin Department of Industry, PLB-1 ' INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o "remises Date Plan I.D. NO. Street city oun y Sanitary Permit Master Plumber Firm Name dress Journeyman Plumber Address Owner Address - - iscusse with Inature ( )See Attached. DTLHR-SBD-6192(N.09/80) Signature o is Plumbing up. On-Site Waste pecia is White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner r.. Plb. t-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health 'r y y Section of Plumbing & Fire Protection Systems 13 F. Spruce Street U`x'-~ =,:va Falls, ✓'✓I 54729 ON-SITE WASTE DISPOSAL INSPECTION REPdFtt Name of Premises Street City County Master Plumber Address Owner 6 ~ Address ❑ County Permits N~ ❑ 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: I 3y f f ;w s x x Y x € 3 ~ a- _ - kA ETC . E " " E 8 y }@ ! I f j~ ~yy R 1,5 _ ~ ~ wEM m x x s ~ _ , . 3 t.-..., s..- a- , . , , 77 z f x € x E x. _ p F ~ _ r 3 a x { A e e x t I f s _ _ ( ! i " g E a t x , _ a = x a i t x € € , x x E € F -;-r i i I t I € ~ ' t € x" 41 x x a E E E ~ w € i t ❑SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party r ~DEPARTME NT OF EC & DINGS INDUSTRY, REPORT ON SOIL BORINGS AND r~/ISION 76 LABOR'AND c r _ HUMAN RELATIONS PERCOLATION TEST (115) OOy~j,N 53707 LOCATION: SECTION: TOWN HIP/MUNICIP LITY: LOT NO.:BLK. NO.: IVIS10N NAME:% v BUYER'S NAME: MAILIN DDRESS: COUNTY~:::j OWNER'S e- a r t'- 'A rz A L cI L,,-7) .J c r S 4_7 USE DATES OBSERVATIONS MADE 15-ROF117 TONS: IFER A ION TESTS NO. BEDRMS.: COMMERCIAL DESCRIPTION: ®Residence ❑New Meplace : RATING: S= Site suitable for system U= Site unsuitable for system -PREII COaSTI❑V. IM0sOUND:ou l S u IN-GNR~OtJNDS ❑URE:SY❑STEM-IN❑-FILLHO❑LDING~:RECOMMENDED SYSTEM: (optional) EL If Percolation Tests are NOT required DESIGN RATE:SYSTEM 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.) B- 5'6 /0 . , " -115 C/ A154 01 il t( it K 17-3 - 72- B-3 Ci / •r7Lr, rr NFL > j~ c c e 7~ l~ p B- 'q 72- W' B- B- r r PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INC ES AFTER SWELLING INTERVAL-MIN. PERIOD t PERT D 2 PERIOD 3 PER INCH P- / © O 3 s P-4 11/4 LV-6 ow 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. SYSTEM ELEVATION 27, "7L 4 1/-, CJ PLC- ' A*1 - j O d I® 5~,,r~ o S' mar=e 8 r 3 CfF, 4z s 84 [.SAS fe L~ L t N C_ T•c ~k r - - - - (~'3f✓~0 1 } v/'3o 1631e-' Z7 P -A/', iooc 4 - - - - + , I k" r5,p eA a". Cel" - ScF " r4- T1< QO ~`4 OLd S~eP~ 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: _ f 't om C /'r - / - y/ ADDRESS: l) CERTIFICATION NUMBER: PHONE NUMBER optional): -3 7Y C SIG TUBE: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) PIb rUUa 1200 f Wisconsin e =ti State or '13etach And Return Upper DIVISON OF HEALTH Portion Of I 1 This C Form With SECTION OF PLUMBING Oki AND FIRE PROTECTION SYSTEMS Any Return Correspondence MAIL ADDRESS: P.O. BOX 309 MADISON, WISCONSIN 53701 608-266-3815 DATE: PROJECT: Sec. 27 r. 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 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. l_1 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 _J 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, „.imp(s) or siphon(s). V1, t~' :ir.E^i~E5 In F;ii (Fill must be placed prior to pian submission) 1 Total area filled (fill to extend 20' bey);d edge of trench before side slope begin). Depth and type of fill. Copy of onsite report by county or district plumbing supervisor. -i Levyth~ of tir-ne fill has been in place. i