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' AS BUILT SANITARY SYSTEM REPORT
Cr,~~ (.TOWNSHIP -/vrr,ti^j - SEC.TN-RAW
OWNER
ADDRESS'' ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
S OW-EVEMT]HING WITHIN _10 FEET OF SYSTEM
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I di a e No th A ro
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BENCHMARK: (Permanent reference Point) Describe
Elevation of vertical reference point: ) Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover : { Tank manhole cover elevation:"
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER t
Manufacturer: Number of gallons
Number of gal. pump set or a cycle_ gallons; total capacity o
distribution lines gallon: size ot pump, (11.-. 1, ,g-f (C head;
gallon per minute horsepower ~ /a brand name of pump
and model number , 1, -/c ;
Type of warning device
HOLDING TANK: Ma acturer_ Number of gallons
Elevation manhole c(',ver
Type o arni -device
SEEPAGE PIT SI - Number o pits eet diameter
feet li d d'ept~- seepage pit in et pipe-elevation
bott of seepage pit (1-evasion feet.
SEEPAGE BED SIZE: number cif lines width- - -31 tile depth/
SEEPAGE TRENCH: width length
PERCOLATION RATE_ AREA REQUIRED AREA AS BUILT c<J
INSPECTOR
DATED PLUMBER ON JOB'S~
LICENSE NUMBER ~ _ ~.r~
DEPAR?TMENT OF INDUSTRY, INSPECTION REPORT FOR ' SAFETY & BUILDINGS
-LABOR & HUMAN RELATIONS ALTERNATIVE PRIVATE / DIVISION
P.d.'30x 7969 SEWAGE SYSTEMS • Z, BUREAU OF PLUMBING
MADIS,ON, WI 53707 ❑ Mound ❑ Pressure Distribution f
NAME OF PERMIT HOLDER. AUDHESS OF PERMIT HOLDER. INSPECTION DATIE PLAN ID NUMBER
BENCII MARK IP-n-,,w raf...... p~in11 DE SCRIBE. IFDII II III N I FROM PLAN IILF.PI. LI.LV CST HII PI. LI. kV
SEPTIC TANK:
G
MANUF C7URER: LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET LLLV A OF
PROPERTY I.INI WE LL. 181-fliDINg
OARS PROW
DOSING CHAMBER:
MANUFACTURER. LIQUID CAPACITY: PUMP MODEL: PUMP MANUFACTURER: WARNING LABEL LOCKING COVER
_ PROVIDED: PROVIDED:
OS Al I ~-D 6v EYES ENO DYES ENO
GALLON PER CYCLE PU MP AND CONTROLS OPERAT IONAL NUMBER OF WELL BUILDING VENT TO FRESH
AIR INLET
DIFFERENCE BETWEEN FEFTPI~(~M 1,110per"ry
uNE:
PUMP ON AND OFF El YES ❑ NO ` NEAREST-----t.
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
El YES [11 NO meets the criteria for medium sand. ELEVATIONS MEASURED.
DISTRIBUTION SYSTEM:
WIDTH. LENGTH: NO. OF SPACING CENTER LENGTH: DI AM ET EH. MAT F.HIAL AND MARKING
BEDITR~ENet~... TRENCHES: TO CENTER: ~ ~{OI±
WMENSIONS 11AIa N
MANIFOLD: PUMP: MANIFOLD PIPE MATERIAL AND MARKING NO. DISTR. DISTH. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
DIA.: PIPES. DIA.:
ELEyA'TtQN
f: 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: SODDED. SEEDED: MULCHED:
CENTER: EDGES-.
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS:
r
SIGNATU @ T Ll t h - F
DILHR-SBD-6227 (R. 05/81)
l
DEPARTMENT OF INDUSTRY,
INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 ! BUREAU OF PLUMBING
MADISON, WI 53707
❑ CON V E NT I ONA ❑ ALTERNATIVE state Plan LD. Number
(II assigned)
❑ Holding Tank
In-Ground Pressure ❑ Mound
IN
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. IT ELEV.
f~ y
Name of Plumber. JMPIMPRSW N,) County. Sanitary Permit Number.
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES ❑NO DYES ❑NO
OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
BEDDING . VENT DIA.. VENT MAT L.. HIGH WATER TN U ET FMBERROM
ALARM. - - LINE LAIR INLET.
DYES ❑NO DYES ONO AREST
DOSING CHAMBER:
MANUFACTURER BEDDING. JLIQUID CAPACITY PUMP MODEL. PU MP~SIPH N MANUFACTURER WARNING LABEL LOCKING COVER
S o 1 PROVIDED PROVIDED
DYES ONO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLET
PUMP ON AND OFF) YES ❑NO (NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at tl e epth of plowing t7( T H - [11AMIT111 MATERIAL AND MARKING,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. JLENGTH NO. OF DISTR. PIPE SPACING COVER JINSIDE DIA UPITS LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS
GRA 'F L>FI'TII I II _L DEPTH DISTR PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PH OP ERTV WELL. BUILDING'. VENT TO FRESH
EF LOW,'li'CS AROVECOVEH ELEV INLET ELEV.END PIPES FEET FROM IuNE AIR INLET
.
NEAREST----op-1
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D meets the criteria for medium sand. TIONS MEASURED.
YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
I 1 _ DYES ❑NO DYES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH. BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
ICENTER EDGES
DYES ❑NO DYES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER
BED/TRENCH TREK HES
DIMENSIONS ( t
MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO DISTR. fSTR P IPE DISTRIBUTION PIPE MATERIAL & MARKING
FI ELEVDIA E PIPES A.:
ELEVATION AND C (7 'v '
DISTRIBUTION
INFORMATION HOILSIZE HOLE SPACING DRILLED CORRECTLY COVE ERIAL VERTICAL CORRESPONDS TO APPROVED
PLANS
' YES ❑NO J ~1 YES ❑NO
COMMENTS: PERMANENT MARKERS'. OBSERVATION WELLS: NUMBER OF P o ERrv WELL: BUILDING.
I J r FEET FROM LINE'S t r - l
YES ❑NO YES ❑NO NEAREST-
-
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Sketch System on I l ain in county file for audit. C~2
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Reverse Side. - I , `
U SI G NFyILft f.. TITLE
F _
DILHR SBD 6710 (R.01/82)
DEPARTMENT.OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PCB 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.
Property Owner: Mailing Address:
Property Location: ity, Village ownship: ^ County:
rL'/oj~~IJ'/aS ' /T30 NCR/ y W ~ - i '
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
T (if 121,8)'
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
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 UC't~ f
HOLDING TANK CAPACITY /
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: (`fier"
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit
AZT Alternative (specify)_y~ _ i-.RR.~C1~E~c-yet ❑ Seepage Trench
.C..
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint -0 Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Namelumber: Signature: MP/MPRSW No.: Phone Number:
'H-i _f
Plumber's Address: Name of Desig r:
15) 44.x'/ 6 L, 4 i 1 ;
COUNTY/ DEPARTMENT USE ONLY
ignatu of Issuing A nt:/ Fee: Date: APPROVED Sanitary Permit Number:
DISAPPROVED
e son for Disapproval: yy
;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-
4taliation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DiL HR-SBD-6398 (N.03/81)
RI PORT OT INSPECTION INDIVIDUAL S(WA(ll SySIIM
S r , t S r o?
V A hi t ~ ?-077ZoeTowvi A h -c p_ (D4?eA5E7 -St. C nl o i x C r 1 t i p
,r<< t I nn ~ Se_c Lon Lo,t Sub(14 v-i_A,i.ovi
,I PTIC TANK
S<re gaXkovtb Numbers o6 eornpantmen.tA
I~~titanee n0 M: WeEE_ - BuL~dLng 12o Agape
H~ ghwaten
PUMPING CHAMBER
S<ze gafkonA Pump MavnuAactuAeA Mode-Y N umber
IfOI.DING TANK
Si ze gaYLon A NumbcA oh Compa~ttmevn (5
PumpPh A.Q.anm SyAtem
0i6tance 6.n0 m: we.f~ 6 u4.f d4vtg 12~ AVove -
_ H -.q
ABSORPTION SITE
Bed T~i eneh
D~Atance 6n_om: WeEY_ 8u4 di vng r2o nknpe
H,Lghwa,te a
ABSORPTION SITE DIMENSIONS
Width oA tneneh ~t Req(I d anea ~I
Iength o6 each Pline At Depth oA nack below take in
Number oA T c.neb Depth o A noek oven tLke - <<i
lolae Eength 0A Ei.ne.6 t Depth of tike be 'ow gnade
Distance between P<YIeA At S f o p v oA th(' neh i -vt. peh 100 I
p.t con C-4 ?l oa (t Type oA Coveli: Papers ah A thaw
1-
I' I -L DIMENSIONS
Numbers oA p~.t6 GnaveY a7ouvnd pitA--- yeA nn
OutA.ide d.c-ametoL At Depth beEow Take-t - fiI
TotaY abAOnp.t.Lon area- --{~t
Anea n.equ~.ned - - -{~t
INSPCCTED By TITLE
APPROVED DATE 19 8
1:I_ it ('TI D DATE 19 n
RtASON FOR REJECTION
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ST. CROI X COUNTY
WI SC O N S I N
Y"J i3 V
r` ran, ZONING OFFICE 796-2239
HAMMOND, WI 54015 ~~QJ1
December 8, 1981
Division of Safety and Buildings
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation foi- the Howard Potter
residence located in the NEB„ ofthe NW-4 of Sec-
tion 4, T30N-R19W, Somerset Township, St. Croix
County revealed that soils are suitable for a
conventional system. However, due to space
limitations an inground pressure system will
have to be used.
Should you have any questions, please feel fr, ee..p
to contact this office.
Yours truly,._
Thomas C. Nelson e PR~M~~~ pF ~Nv v ~t3~~G~
T C N: s 1 SEE G®~
Enclosure
.
,y STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township/Municipality:
'41 NW 14 S T 30 N/R 19 9ky&*FW
Street Address: Subdivision: County:
R.R. St. Croix
Landowners Name: Mailing Address
'Howard Potter R.R- qnmPr,-,Pf-, WT 5409S
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
of ~L
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS. COUNTY OF This day of 'PC~ 19/ .
,E Kira
Ncf f Public, St e of Wisconsin
i
My Commission Expires:
DII,HR-SBD-6413 (N. 05/81)
" e ^~1
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS 1JJ
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING, PLATTING & FIRE PROTECTION
POST OFFICE BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix _
Location NE , 1/4 NW 1/4 S ! y T -io R 1 9 X~ W
Town orx jp i Somerset Tow„s,ip_ Street Address R R
Lot No. Block Subdivision Somerset, WI 54025
Landowner's Name: Howard Potter
The application for this site is to serve a: 7
f~❑ new construction use. $ O
Fx~ replacement system use.
If this is a NEW CONSTRUCTION USE, the alternative private sewage system is to be
included as:
❑ part of the 3%/5% limitation. This is number of the applications
made through this office.
❑ one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
❑ an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by
the department.
a lot that meets the site criteria for a conventional private sewage system.
If this a REPLACEMENT SYSTEM USE, the mound is replacing:
a failing conventional soil absorption system.
❑ a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
I certify that the above information is true and accurate to the best of my knowledge.
r
Name Thomas C. Nelson SiynatUYli. -
Title _Ass; an _,Z_onng Administrator Date December 8, 1981
DILHR-sBD- 6158 (P.7/80)
.V
SAFETY & BUILDINGS
DEPARTMENT OF REPOR 1 ON SOIL BORINGS AND
INDUSTRY, DIVISION
HUMAN RE AND LATIONS PERCOLATION TESTS (115) MADISON, WI 53707
E--CT ION: TOWNSHIPhMFifVF6iiZA,L Y: rOT O. BLK NO.: SUBDIVISION NAME:
LOCATION;
113o N/R,~7j (or) wl
'/4 A
OUNTY: NER' BUYER'S NAME: MAILING XDDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDR CO R i PROFILE DES : CO~
a, Residence ~Newr .Replete 1 M a'} 1 . . ~;,7~r
i RATING: S= Site suitable for system U- Site unsuitable for system
ON ~~++NTI~AFL: MOnUND: IN-TIN• - t'LL~ iOLDf~+GyTAN(K: RECOMMENDED SYSTEM: (optional)
J V U S U ~S U I J Y❑ J t 3J Y c~ trl
SYSTE
If Percolation Tests are NOT required DESIGq RATE:
If any portion of the lot is in the '
j under s.H63.09(5) N. indicate: Floodplain, indicate Floodplain elevation:
1 PROFILE DESCRIPTIONS * y,`
BORING TOTAL DER H T GR UND ATEF14NCHES HA AALT~R OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERV D
TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
EST. HIGHEST
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y _
s Z ! e ! U S ? aG..,f `a.J IN 1 !!r w, Ca' +'3 a A+..
B-
B- VTO o 801, 51,
B.
B-
t PERCOLATIION TESTS
DEPTH WATER IN HOLE TEST TIME WATEM V S RATE MINE
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. lOD 1 P R1 PER INCH
P- Ile, V-i Vxyl
i
P- ZP-
i P
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• ~1~ji~,,,'C ~if / fr .':g r .+:^~,'r ~ / ! d/ / • c._ S~ fl l.c'. y'' ° s G~fn'.`/°dS' • l~"r
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State of Wisconsin ` Department of Industry, Labor and Human Relations
Please Reply to:
SAFETY & BUILDINGS DIVISION
-1 Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Plan Identification Number
8 I 9
Re:
PRIVATE SEWAGE SYSTEM ONLY- t C
7981
,1 off/(~ n~~,
The Bureau of Plumbing has reviewed plans, site survey information and installation details for the cons i ternative 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 & -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:
Other
County /-irector
Enclosures
DILHR-SBD-6159 (R. 7/81) mes Sargent, B
SBD667849/81) (Plb 100a)
STATE OF WISCONSIN DILHR
Detach And Return Upper DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Correspondence P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE:
PROJECT:
V T7 l' v
1 C, 1t~
PLAN ID. # n
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 required fee is $ Fee Received is $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
Il. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy)
government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations
❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data.
❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan.
course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
III. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides. pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide
soil data. ❑ Detail & model of pump or automatic siphons including
size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester 0 Copy). ❑ Copy of onsite report by county or district staff.
DEPARTMEN=T OF REPORT ON SOIL BORINGS AN sAf.ETY & BUILDINGS
INDUST>,RY, DIVISION
LABOR AND PERCOLATION TESTS (115) DI BOX 7969
HUMAN RELATIONS ` / - ~ MADI N N, WI 53707
3707
LOCATION: SECTION: TOWNSHIP/MbWWAR4_U_TY; LOT NO.: NO.: S IVISION MAME:
'V4t{'/4 _ 1t3rN1R (or)W~?fY>E'-v's el~
COUNTY: W ER' BUYER'S NAME: MAILING ADDRESS:
(-O/x Wtbnet j-Z.) -12 Qf n t 'y, 15 e 7 2_"S~/
USE DATES OBSE) TIONS MAD
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R D R ON TESTS:
Residence ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
ICOD STI~~ . M~ XX~ IN-GGROUND P RE: SYSTEM-IN-FILL HOLDING TANK: RECO~ ENDED SYSTE t• ptlonal t~ 1,•'
S DU DS U SS NU % 1
If Percolation Tests are NOT re wired DESIGN RATE: SYSTEM EL V.
4 If any portion of the lot is in the e
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 41
PROFILE DESCRIPTIONS
L_ 2<4 C
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I )~G
B- Z. )car ~/l~ 's 7~►"i.~ ~i " _ -S.
41' 1
B- Al r C'"
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES 1
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ 1 fc " Y) 0, e) V,./-- Y fa
P- Vz_
P_ 3 J4 g 'Z `7
y'
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.
SYSTEM ELEVATION
+0Wn Y d.
-
t~ f
t - 2_- 106
loo _ 2'~'
P
'10 A~
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
, -)y\
ADDRESS: CERTIFICATION PHONE NUMBER
NUMBER. optional):
~rac~
~ - - 1226-
CST SIsJ
oftft-itV, 2nd page-Burezu of Plumbing, 3rd page-Prcperty Owner, 4th page-Soil Tester.
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township/Municipality:
S T 30 N/R ~W
Street Address: Subdivision: County:
R R St. Croix
Landowners Name: Mailing Address:
r r
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted. I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF This day of 19~
Notary Public, State of Wisconsin
My Commission Expires:
DTI,IIR-SBD-6413 (N. 05/81)
ST. CROI X COUNTY
'?r WI SC0 N S I N
ZONING OFFICE 796-2239
HAMMOND, WI 54015
December 8, 1981
I
Division of Safety and Buildings
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the Howard Potter
residence located in the NE'4 ofthe NW'--4 of Sec-
tion 4, T30N-R19W, Somerset Township, St. Croix
County revealed that soils are suitable for a
conventional system. However, due to space
limitations an inground pressure system will
have to be used.
Should you have any questions, please feel free
to contact this office.
Yours truly,
1110 1" 1101, e
Thomas C. Nelson
TCN:sl
Enclosure
a
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING, PLATTING & FIRE PROTECTION
POST OFFICE BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of st. Cro X
Location 1/4 NW___ 1/4 S 4 T N, R W
Town o►Rx2Y'Rnkki*j1k- ' S- mex luu n h i~, - Street Address
Lot No. , Block Subdivision Somerset, WI 54025
Landowner's Name: Howard Potter
The application for this site is to serve a:
❑ new construction use.
R replacement system use.
If this is a NEW CONSTRUCTION USE, the alternative private sewage system is to be
included as:
❑ part of the 3%/5% limitation. This is number of the applications
made through this office.
U -one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
❑ an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by
the department.
(_Ja lot that meets the site criteria for a conventional private sewage system.
If this a REPLACEMENT SYSTEM USE, the mound is replacing:
a failing conventional soil absorption system.
❑ a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
I (ertify that the above information is true and accurate to the best of my knowledge.
N,mE' Thomas C. Nelson ~
Siqnetu
Adminl_ ,traL<~r Date I) ~rcinl)8 19H1
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Parcel 032-2013-95-000 07/26/2006 11:57 AM
PAGE 1 OF 1
Alt. Parcel 4.30.19.522B 032 - TOWN OF SOMERSET
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 - POTTER, HOWARD D & JANICE
HOWARD D & JANICE POTTER
593 180TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 593 180TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 1.920 Plat: N/A-NOT AVAILABLE
SEC 4 T30N R19W 1.92A IN NE NW COM SE Block/Condo Bldg:
COR, TH N 1,315' TO INT HWYS 35 & 64 SW
25' TO CL TN RD, N 28 DEG W 77.65', NW Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
289.91' ALG CL TH N 80 DEG W 312.9' ALG 04-30N-19W
CL N 76 DEG W 91' ALG CL TO POB; TH S 2
DEG W 240.2'S 87 DEG W 284.9'N 5 DEG E
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.920 30,700 49,700 80,400 NO
Totals for 2006:
General Property 1.920 30,700 49,700 80,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.920 30,700 49,700 80,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 216
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00