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O 7 C:) W CD O O 7 W (D (D 7 3 N N (D CD n (Cp (D 6 O O W (D CL a 0 o (D (D ryc y CD O n C) i(D i 1 Wisconsin Department of Health and Social Services Plb. #67 Division of Health 01 PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTEMS A. OWNER OF PROPERTY TYPE OR USE BLACK INK Name AddressStreet, City, Zip Code) County B. OCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED Cheok One: ' CITY VILLAGE LEGAL DESCRIPTION:J/Y TOWNSHIP i i C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO / i I 1 ADDITION D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT MATERIALS: Prefab Concrete P~ured in Place Steel Other NU13ER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check One: One or Two Family Residence Commercial Industrial Other ` Specify Number of Persons to be Accommodated F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT Tile Size NO.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pitt Inside diameter Liquid Depth P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Mast To Fall 1st Wetted overnight in Minutes Last Period Lest Peri Period One Inch Example P- 0 36" To Soil 10" C1 2611 25 es or no 30 1 2 1 2 1/2 60 ILL- RECORD DATA FROM MINIMUM OF 3 TEST HOLES i Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B 0 R I N G S- Minimm 36" Below Pro osed Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches xample - 0 7211 7219 Blaok To Soil 121'• Clay 1811• Sand 1/8"; Gravel 2411 I RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDE I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3)2 Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. NAME TITLE Type or print) REGISTRATION NO. or MASTER PLUMBER LICENSE No. ADDRESS DATE SIGNATUF; MASTER PLUMBER MAKING APPLICATION lip Signatures License Numbers MP RSW (To be Completed by Issuing Agent) Date of Application Fee Paid # Permit Issued (date) Permit Number Agent (name) For: Town, Village, City, County, eta. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See Corres.T PER RECEIVED VALID. NO. PERMIT NO. Yes or No) REVIEWED BY APPROVED DATE (Initials) Yes or _ COMMENTS: REPCRT OF INSj- CTICN---INDIVUAL STEMAGE-DISPOSAL SYST'21 PRIPtiRY TRIIJM NT consists of Septic Tank° Cther (Describe) SEPTIC TANK: Distance from: Well ft., Lot Line ft. Building ft. High watermark ft. 12% or great-r slope ft. Wetland ft. Cistern ft. No. compartments. Liquid canacity,±-/e, al. EFFLU INT DISKS: L SY`'T'M consists of _Tile field. Seepage pit (s). Seepage Pit or Tle Field: Distance from: Well ft. Building ft. Lot Line ft. Cistern ft. High Watermark of water course ft. Slope 1? or greater ft. Wetland ft. Total length of the lines L- ft. Number of lin,~s~-. Length of each line- )ft. Distance between lines~ft. Width of trench in. Total effective absorption area of trench bottor ;-;Sr. ft. Depth of filter material below the in. Depth of filter material over the in. Cover over filter material Depth of tile below finished grade in. Slope of trench bottom in. per 100 ft. Depth of bedrock ft. Depth to ground vrater ft_ Number of Pits Outside diameter ft. Depth below inlet ft. Lining material Gravel around pit,: Yes. No. Total sbsorption area so. ft. Square feet of seepage trench bottom area required Square feet of seepage pit area required Inspected by; 4 Title: i i1 A proved Date ,19/z v` ejected , Date ,19 County, Town of Owner V Sanitary Per 't No. Pronerty Addr=ess Septic Tank Permit No. Subdivision Wisconsin Department of Health and Social Services Plb. #67 10/69 Division of Health PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTEMS A. OWNER OF PROPERTY TYPE OR USE BLACK INK Name Address (Street, City, Zip Code) f 7 CC,/C f Ill County B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED Check One: CITY VILLAGE LEGAL DESC RIPTIONs Sr L TOWNSHIP C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY C C Gallons NEW INSTALLATION REPLACEMENT ADDITION i MATERIALS: Prefab Concrete Poured in place .2..._ Steel other ! NUMBER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check One: One or Two Family Residence commercial -4- Industrial Other Specify Number of Persons to be Accommodated_ Number of Bedrooms X- F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside diameter Liquid Depth P E R C O L A T I O N T E S T 11 Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Overnl ht in Minutes Last Period Lest Period Period One Inch Example P- 0 36" To Soil 10" Cl 26" 25 es or no 30 1/2-- 1/2_ 1/2 60 y o /a RECORD DATA FROM MINIMUM OF 3 TEST HALES i ompute size of absorption area in accord with H 62.20 Wis. Administrative Code. I S O I L B 0 R I N G S- Minimum 36" Below Pro osed Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches j xample - 0 7211 7211 Black To Soil 12"• Cla 18"• Sand 18". Gravel 24" ! r RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDE E I, the undersigned, hereby certify that the percolation tests reported on t is form were made by me or under by supervision in accord with the procedures and method specified Chapter H 62.20 (3), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my /knowledge and belief. NAME l! ti1~7 ~1 1 ?12 ice TITLE (Type or Print) ` REGISTRATION NO. or MASTER PLUMBER LICENSE No. ADDRESS r A 2 !_L~~L'. - LaL .r e ? DATE - 71 SIGNATURE ~?,,~-r1L MAS'PER PLIJP 113:-,R MAKING APPLICATION Signatures License Number: MPf MP RSW (To be Completed by Issuing Agent) Date of Application Fee Paid $ Permit Issued (date) Permit Number Agent (name) For: Town, Village, City, County, etc. (Specify) Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See Corres,T FEE RECEIVED VALID. NO. PERMIT NO. (Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) COMMENTS: r SEPTIC TANK PERMIT N0. ~ Plb. X43. R E P O R T O N S O I L P E R C O L A T I O N T E S T A N D S O I L B 0 R I N G S TO DIVISION OF HEALTH - PLUMBING SECTION P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code NAME PROPERTY ADDRESS LOCATION (Check One) City Village Town County City or Township WATER SUPPLY FROMs Public Utility Cooperative Private Well SEWAGE DISPOSAL INSTALLED BY: Address Date SEPTIC TANK SIZE Material Percolation & Soil Borings Test Date EFFLUENT DISP.: Tile Size No. Lin. Ft. Trench Width _ Depth of Tile Seepage Bed: Length Width Depth of Tile Seepage Pits Outside Diameter Liquid Depth TYPE OF OCCUPANCY: RESIDENCE: Number of Bedrooms OTHER: (specify) Number of Persons FOOD WASTE GRINDER: Yes No Dishwashers Yes No Automatic Clothes Washers Yes No ~r P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted overnight in Minutes Last Period Last Period Period One Inch Example P- 0 3611 To Soil 1011, Clay 261, 25 es or no 30 1A 1/2 _I L2 60 RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B 0 R I N G S- Minimum 36"'Below Pro osed Abso tion System Test Total Depth Depth to Ground Water De th to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thloknaas in Inches Example B- 0 7219 72" Bla To Soil 12" Clay 1810 Sand 18„ Gravel 2411 RECORD DATA FROM MINIMUM OF 3 TEST HOLES I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super- vision in aooord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. NAME TITLE Type or Print) REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ADDRESS DATE SIGNATURE •3sa3 u013eloojad 043 6ui,anp Jane-.j6 943 anoge aq JaleM 10 sayoul x1s uey3 avow Jleys aseo ou ul •ale.i uolleloojad 043 a3elnoleo of pasn aq lle4s doap lanai aa3eM JeU14 941 •pasn aq p[no4s JenJa3ul 3sa3 aa3ao4s a sa3nulw ual uey3 ssal ul Aeme sdaas Janea6 943 anoge aa3eM jo sayoul xis 043 aJ94M saseo ul •J0neJ6 043 anoge sayoul xis nano Sou lulod a o3 Ajessaoau uayM 0104 943 6u!ll!30a 1jno4 auo jo po ped a jol sJena93ul a3nulw u93 3e lanai ja3eM ul doap 043 aunseaw 3ulod aouaaajaa paxlj a woaj pue JaneJ6 043 JOAO sayoul xls ue43 avow Sou 3ulod e 03 0104 943 03 a93eM ppe ssal ao sa3nulw ua3 ul Aeme sdaas (q) £ uol3oaS ul palApads se Janej6 943 JOAO aa3eM jo s943u! Z1 40 6ullll3 PUOOas 943 If (o) •3sa3 uollelooaad 943 a3eln3leo o3 pasn aq lle4s poliad a3nulw ua3 3sel 043 ul s.inooo 3ey3 lanai aa3eM ul doap 943 *jn04 auo COI un.a 3sa3 a43 pue sa3nulw ual se uaie3 aq lle4s s3uawainseaw uaaM3aq lenaa3u1 aw13 943 pol.iad 6u!llams llos 043 jade sa3nulw of uey3 ssal ul ~(eme sdaas aa3eM jo sayoul xis 3salJ 043 u94M (q) •93e.a uopeloojad 043 a3elnoleo o3 pasn aq lle4s lenaa3ul a3nulw Of lsel ay3 ul s.inooo 3ey3 lanai aa3eM ul doap ayj •doap lanai .aa3eM painseaw lse[ 043 10 sllwll ay3 o3 3daoxa spolaad luawai nseew £ 3sel 943 6uijnp apew aq lou lle4s Jana[ jaleM ay3 jo luawlsnfpy •40ul ue jo 91/1 ue43 avow ~taen lou op s6u►peaa anlssaoons oml 41 sanoy anon uey3 ssal ul paleulwua3 aq Aew 3sa3 943 'Aldwe ~ljeau sawooaq aloy ay3 uayM Janea6 243 anoge sayoul xis aano lou luiod a of ra3eM 431m sal04 043 6ulllldau 1sjn04 anoj jo poliad a aoj sa3nulw of 10 slenJa3u1 le lulod aouaaaja.i paxi j a wojj pa.inseaw aq l le4s Jana[ ,aa3eM ul dorp 943 pue lanea6 ay3 anoge sayoul xis uey3 aaow jou jo 43dap a o3 pa3snjpe aq Heys Jana[ aa3eM ayj •panowaa aq lfegs 0104 043 03ul p946nols se4 4014m llos Auy (e) :3uawaanseaw alej uoj3elooaad •molaq (o) h uol3oaS ul Pall!oads se Ala3elpawwl paeow d ueo 3sa3 943 ssal ao sa3nulw ual ul Aeme sdaas aa3eM 3o sayoul Z1 40 6ullll3 puooas 043 if •a.inpoooid ay3 leadaa ssal ao sa3nulw ua3 ui Aeme sdaas aa3eM sl43 11 •lanea6 243 JOAO aa3eM 40 s943ul Zl .inod Alinjajeo Aelo ou jo alllil 6uiule3uoo silos Apues ul (q) `molaq (q) pue (e) h suolloaS ul pailloads se poooo.id lfe4s 3sa3 uoj3elooaad a43 pol.iad 6ulllaMs 943 .aa3le Alaleipawwi *jeaA ay3 jo suoseas 3s933am 043 6u u np lsixe film 3ey3 suol3lPu00 043 yoeoadde film If 3e43 os sanoy Of ue43 avow ao sanoy 91 uey3 ssal lou Yams o3 pamolle aq lfe4s llos a41 •panowaa aq lou Heys sanoy .inol aajAe 9104 043 ul 6ululew9a jaleM •sanoy .ino4 3se9[ 3e jo polaad a jol Janea6 043 nano sayoul Z1 30 43dep e o3 aa3eM 431m palll3 sl aloy 3sa3 a43 os 'uo4dls oi3ewolne ue se 4ons ualeM jo a lon.a9sa,a sn[d.ins a 6uiAiddns Aq ao Ajessaoau 11 6u! l l ljaa ' Janeu6 943 aano sayoul Zl 40 43dap wnwlulw a of jalem Jeep galm pally Allnjaaeo aq lleys alo4 ayj e :llos jo 6uillams pue uollejn3eS •sa104 943 ul Janea6 jo pues asjeoo jo sayoul oml 0oeld pue salo4 943 3o wolloq 943 woaj leijalew asool 043 an0wab •llos lei nleu 043 asodxa o3 luawn.ilsul palulod dje4s a 431M salo4 a43 jo wolloq pue sapls ay3 u946noN :0104 jo uollejedaad (Z) (•sea.ae palll3 Almou ul sisal jo uollejapisuoo [eloads jol 431eaH 10 uo!sl^10 ay3 loeluoo) •piaij 96eule.ip ao lld a6edoas pasodoad 943 do 43dap ay3 of pue jo e9je 943 ul 'aalawelp ul sayoul Z1 03 h 's0104 le-alla9n DOJ43 lseaJ le ajoq .ao 610 salo4 jo adAl (1) ajnpaooJd lsaj uoi3eloo.aad Plb 60 NAME OF BUSINESS LOCATION street or highway city or township county LEGAL DESCRIPTION OWNER Mailing address ZIP ARCHITECT OR ENGINEER Address ZIP PLUMBER Address IP 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed: Existing building New building Addition If addition to existing building attach detailed memo for each. ( ) Drive in restaurant , Car spaces ( ) Restaurant . . . . , Seating capacity 10 sq. ft./person) { ) Dining hall . . . . . . . . Per meal served Toilet waste Yes No ( ) Motel ( ) Hotel ( ) Cottages . . Number of units: 2 persons/unit 4 persons unit TOTAL NUMBER OF UNITS ( ) Churches . . , , . , , Number of persons Kitchen Yes No ( ) Bar or cocktail lounge . . . . Seating capacity (10 sq. ft./person) ( ) Nursing or rest home . . . Number of beds Mobile home park . . . . Number of units - dependent (camper trailer) - nondependent (mobile home) ( ) Retail store . . . Number of employees Number of customers (10 sq. ft./person) ( ) Service station . . . . . . . Number of oars served daily) ( ) School . Number of classrooms Meals served Yes No Showers provided Yea No ( ) Factory or office building Number of persons (total all shift- ( ) Residence . . . . . . . . . Number of bedrooms ( ) Apartments . . . . . . . . . . Number of bedrooms ( ) Other . . . . . . . . . . . . . Specify 2. Indicate whether or not the following facilities are oonneotedt Food waste grinder . . . . . Yes No Dishwasher . . . . . . . . . Yes No Automatic clothes washer Yes No 3. Fill in the appropriate information for the following as indicateds Septic tank capacity planned TOTAL Septic tank capacity required Percolation test results - ATTACH PERCOLATION TEST REPORT SHEET Seepage trench bottom area planned width linear feet depth Seepage bed area planned width linear feet depth Seepage pit planned outside diameter depth below inlet depth Seepage trench bottom area required width linear feet depth Seepage bed area required width linear feet depth Seepage pit required outside diameter depth below inlet Signature of person completing forms STATE DIVISION OF HEALTH, PLUMBING SECTION P. 0. Box 309, Madison, Wisconsin 53701 Addresst Approved: ZIP Dates Dates THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE INSTALLATION FROM CITY, VILLAGE, TOWN- SHIP OR COUNTY REGULATIONS OR PERMI'P (OVER) REQUIREMENTS. INFORMATION REQUIRED FOR SUBMISSION OF PLANS 1. Legal description of property on which septic tank and effluent disposal system is to be installed. 2. Percolation test data from a minimum of three test holes. Tests are to be conducted in the area and to the depth of the proposed effluent absorption system. Where ground water and/or bedrock conditions exist, the vertical depth from grade level to same shall be indicated. 3. A detailed plan of the proposed installation specifying the location of the building served, size and design of septic tank, effluent absorption system with location and numerical identification of percolation test holes. 4. Indicate on plan lateral distances between septic tank effluent disposal system and building, well and lot lines. 5. Include complete data on expected use of the building. See Section H 62.20. LAK0P STREAM _ P A G E 50 T _CNCH~ R L4~1' J 751 P A G BED ' S 25' ~~D 25 cqL W E L L -T- Tit, J l._ l_ 50 6' - _j B L D G 6 . 000 2r 31 p+► _ GAL. 1 lo C1 P 3 ~ GA 0 50r 25' i 50 ' is WELL SE E P G E I T~ i ~ P P i LO T L I N E 0•t- P ■ Peroolation test hole SAMPLE PLAN DEPICTING SEEPAGE TRENCH, SEEPAGE BED AND SEEPAGE PIT b # 60 PROJECT DETAIL DATA SHEET ~S N. 1E OF BUSINESS Oy✓~'r w C _r31 /y AC, r w LEGAL DESCRIPTION itI ~J~y ~~/7 yy S~' ~2 6 ~cN,e,^s~T s7'- C r~Tx OWNER np_~ ~f 1-5 r4KCI? MAILING ADDRESS 29 Z) t4il-1- s i IoE :Z!,_,4jj S S` a / l_ ~ 4^, rnF,<Edo Ve yn, h.~ I P ARCHITECT, ENGINEER, C)IL v1h P-0~,, ADDRESS Q 3 mew r or~ PLUMBER OR DESIGNER (v i ~c ZIP 5 YoL~ TELEPHONE NUMB ER(~7i 7 ve 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 ( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbas i n . . . . . . . . . . . . . Number ( ) 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 7 ( ) 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 _Z_ ( ) 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 Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . . . . . . . Number of cars served daily ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . . (Specify) . . . . . . COMPLETE OTHER SIDE 2. Indicate whether the following facilities are present. Floor drain yes no Number of drains Food waste grinder yes no Dishwasher yes no Automatic clothes washer yes _ no Number of clothes washers L,,,)I 3. Septic tank capacity 000 9~Ls Holding tank capacity Septic or holding tank manufacturer Uj1ssrg, 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches depth number of trenches SEEPAGE BEDS: total square feet S Z 7 Z width S y length of bed 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 Zip S-y0/7 Telephone Number (7iS, Z V6 -S Date 2 -^~~s'✓ Chief 1 and f ire c' y S Y'1 r"~ v C) n N O n (O O g 0 y f O f c 0 r, (D (D ~j (D Gi • (D N I(~ O W (n (O (n W W `(n W O N }r"~l o n 'O Z O. 0 o W I Q n~ N 0 ' O r N (O v C N Q7 O W Q7 O (D 16 W O W v Z W j N 0 0' I 7 O O i (D 0 O N 0 (D (D CO : O O (O 07 _ W O W 0 1=- N co 3 N CoW O O Z C N0 CI c y O O O o IO O N fl. d O O D a O O O o - C) 0 ID 0) N G~ C ? 0 U1 CD 00 ^.il C3) C/) 20 N O O 0 N i W 0 0 0 0 0 0 0 ~:-,2 N N o f~/7 N tin o D g° jo. N 0 (Nii a O Ln oN p\ is m y O d v ~ 4aai ~ (o = ~ 3 m = ~ trl 2) (D :tt ~z co K IQ. Z QJ Z O Z -I OZ Q O D CL G D Z5 7 lp to m m M , m -1 N N ti M (D W (D 0 l/ [1 n n r 0 ' '®f c (D CD Q a w m E E Z CD 0 Z (yD P j0 :r ~O vi 00 ~ ~ n lo z 0- O_ A 0 5' Z N W v W-0 m; M N (D N (D \ z o 0 a O O r. Z 3 3 m `Co (D (D W N O 0 _ N (D O 7 (D Q 3 0 O O OD.. O ~ < W W S O L co ID -0 O T 73 -P~ -O 7 0 Co ) O T N O O C- CD N W c N W ( C W T. =3 cn T. z O 7 O Z d N O N `G O_ -p v F O_ O O Q 0 (D - O N. N O N (D W :n N O CD j yr CD- O (D 00 7 N U v o m a a~ 10 O A p A D 0 0 (D X 7 N (D j c ~ V v T' O. W -0 (D W y Q0 7 ~N OO N_ 0 (D -0 N O' O_ D O W 0) C) 0 W W ..O O-. ?0 300 W 6 O to CO 0 O (D N m D W W N moo n) ?(Q 3 Q c .0 mC, ti o N O O Q O V W (D ~ W N O ~ S pp O 4 ~ CD CD yq O~ n Efl 0 fA lo O O t O O 0 O ~O 0 i O O v Wisconsin De artihent of Health and Socie.l Services PI.b,`G7 Division of Health PE-TMIT APL'LILATION FRIV ^.i : L'+C i; S1'JCf SEWAGE SYS Tx:"iS A. Ch(LTFR OF PC<OPEh1Y TYPE OR ? F~ BL'-(,K INK Add:-ess (St eet~ City, Zip, Cot:nty B. LCCA'TION OF' PM-':" R1: . 2 C1. ! WIM, LN CON.SU7,Ui I-"), AL iEr%ZD OR E`T E'D~D C're o' On , CITY VILe... 4 Lam:=AL, DF.SCA.IPiION: TO'rr2d5HIr ~ ~ ~ ~ ~ C. IS LOCAL PERi4I1 REQUIR-1 9 FOR THIS WOLF;? A _ YES NO D. SEPTIC TAN. CAPA.CI7Y i _ Gallon ~ ITU4 INSTALUTION REPLAC P ADi)! :IG"t: MATERIAL: Prefab Co,:crcte r Poured in Place Steel Other NL,'i3ER OF TAMK3 TO BY I2 ,j ^Lf 10: E. TYPE OF OCCUPANCY Check One: Ohie or Tvio Family Residence Cosanercial _ Indi-istrial Other~~~'~~~~. (Spec_Ify) Number of Personfc to be Accor;f;odated F. APtILIANCrS, ETCap„ Food Waste GrinderM YF.S NO Auto:f:~s.tic Clothes Washer ~ V YES ~ NO Dishwasher YES k NO Autorfatie Pot~tc Peelcr YES NO Other (Specify) G. EFFLUFN-P DISPOSAL SYST `I NEW ! EXTENSION ADDITION REPLAC :NT Tile Size No.Lin.Feet Trench Width Death Number of Lines Seep --c Beds Len-,th Width- Depth Tile Size No. Lines 1_,' - Se€,page Pits Inside diameter ~ Liquid Depth- - P E R C O L A T I O N T E S T Test' De?th Char c'uer of S i.1 Hour;;~~ Watet• Test Tice ^Dro in Water Level Inches NinUt: S Number Incheo I~ Thickness in Inches Since Hole a in Hole Interval Seco-id to I Next to Last To Fall 1st Wetted Overni,ht in Minutes I_ t Period ! Last Perioc Period 'ne Inch O 36" To Soil 10„_'Olnr 26" ~25~~__ yes or no 30 112 112 60 I 7-T- ~,7 ,1.. RECORD DATA FR:-'i MI`r1!`UN OF 3 TEST HOLi:S 'or ipute size of absorption area in azoord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 36" Below prop osed Absorption System Boring Total Depth Depth to Ground Water Depth to Bedrock umber ~Inchas Observed Esticated Observed Esti.ated Character of Soil with Thic'.cnass in Inches Example 1 - 0 72" 72" Blaok Top Soil 1211y,Clay 18"; Sand 18"; Gravel 24" RECORD DATA FRCM MINI:;UM OF 3 BORE HOLES COMPLETE. OMER SIDE I, the undersigned, hereby certify that the p:nnoolation tests reported on this form wena r~.de by r,+a or under by supp;v, ision in acoord with th6 preced iron zzzd wathod sp,;.,ifisd in Chsptor :i 52.20 ( 3), Wisoonsin Aclminisbratira Cod:;, and tl_:,t the data r•acorded and ic~ation of teat 11olt; ar. corl'eot to the beat of my r 1 c~1F:d and buliof. / c.Fr-1 RFGISTRATIU:3 u . - ' or MASER PZ,_.D'ER ADDRiZS UATF SIG: A,Jt_, rrosl _ > r: r. r: U E rJL, a: 0.7 sib",-naturua MP PS7d E~ (To be Coiipletu by I.r.iu tr;:;r ) E Da,t'l of Fee Paid Pormit Z ssuod (date) Perait Niu bsr Agent (nera©) For. Torn, Villaeo, City, County, etc. (Specify) Notes The application{ oannot be oonsido:-ed for filing until, all of the above questiora are atisaered and tho fee paid. Agoras will, foi- and application, the fee of $10,00 end Copy (b) of the Per_nit (yeller copy) to the Division of Health. Chccks and money ordcrs should be r..de payable to the Division of Hearth. Do not write in space belcrs - FOR DZPAFi?,1,'ENT USE ONLY DA93] R EIV~1D~ L ACCEPTED BY -e6 RETURNED TRETURNED (Initials) (Date) TSaoirros,~ FEE Rr.Cas.UnT, VALID. NO. PXRC-UT NO. Yes or No REVIZ141TJ BY APPROVED DATE (Initials) (Yes or No) COMtENTS: p d c 0 O ~+1 v N m 1 3 rr sv OOy- 0 Al O c p CD (D cn p O W • (n z w C cn N O [ 1 :r 3 (0 CD (D m 00 rn° m z y rn m m j o N n N d (D 0 z ~ N ON f07 j m B E N r ~O1 3 W O O N O 7 VI W O O N m O O '.7 lr to z D co a o CD cfl O cn a ~ W ~ 3 Q 3 C) ° _p a m o = o o c co co 3 o r N m to o c v c _0 ~r 0 0 0 I o 0 0 0 - c vi w ai o o D o. N c v v v oN, o O N N O m v z N O O D co o m O a = CD V) N CD CD 1~ c m C. W ~3 a n 3 S CD -1 C/) o o A z m m a A z o o• W m w rn CD CD z 0 3 A o z m m A n m ~ y O 01 r D 3 mom ~ a m o m o a C N .n. n O L C m N OD 0 T N :3 O N ~ N N m O~ O O,C O G CD ooDFm N 'a CL 0 M a~ m CD - :E x C ~ m A C v N 3 CC) p N O O' O' O O O CD O O N ti O 0 yC cc 3 I co O H I a O A CD V 0 Op ! b ti Parcel 032-1072-20-000 12/19/2005 04:05 PM PAGE 1 OF 2 Alt. Parcel 26.31.19.351 B 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 NELS A & MARLYS ULSAKER O - ULSAKER, NELS A & MARLYS PO BOX 185 COTTAGE GROVE MN 55016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 22.270 Plat: N/A-NOT AVAILABLE SEC 26 T31 N RI 9W NE NE LOT 1 CSM VOL Block/Condo Bldg: 2/547 ALSO A PARCEL DESC AS THAT PT OF LOT 2 CSM 8/2250 LYING W OF FOLLOWING Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) DESC LN COM NE COR SEC 26; TH S 01 DEG W 26-31N-19W 645.04' ALG E LN NE NE TO NE COR LOT 2; TH CONT S 01 DEG W 675.29'; TH N 89 DEG more... Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1147/390 WD 07/23/1997 1015/572 WD 07/23/1997 834/93 2005 SUMMARY Bill M Fair Market Value: Assessed with: 77228 571,100 Valuations: Last Changed: 07/24/2003 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 22.270 252,600 207,000 459,600 NO Totals for 2005: General Property 22.270 252,600 207,000 459,600 Woodland 0.000 0 0 Totals for 2004: General Property 22.270 252,600 207,000 459,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 REPORT Of INSPECTION - INDIVIDUAL StWAGE SYSTEM 6, 2~ F~ &6C 0 Savl,L-tats y Penm,Lt--~~-_ sat z sep.ti c Q~- NAME - Townl5hip S Ctcotix County Lucaiavt- A/ F, AV Secio2Lot # Subdtvt6 i-on SEPTIC TANK S C, ze--,3--~ ~L)- _ga-teon6 Numb eit o4 eo mpaiz tmen t6 D(',~ avi ce (n_om: WeU ° 9 ~ 120 6f.ope. Htghwaten PUMPING CHAMBER S~ ze r gae~ovt~ Purn Mavru a~c.tunett , ~ _ p f 4 y~~ M i, d e f N u rn b e ti_ l HOLDING TANK S~ze_ -gaE'fov:b Nu mbcit o(I CompaitIm(yvrt5 Pumpetr___ Aea.izm Syt6tem 0 <-5tavlee Atom: Gle2~_ - g------- k o p e Htighwatetr A-6SORPTION SITE ~j 8 e d Ln- e. vi e It. D~.6tavrce ~tcorrr: LVe.P~ G f3ut2.dting12o AQ.ape 11 gIt wa-ten ADSORPTION SITC DIMENSIONS Width oo tn.evich. Ot Re.qu.<.ned attea Levigth of each fivte. -fit Depth o() 'cock bet-ow n [l N u mb e. tz o (j Depth o o n o c- k o v e_ h :tti f. e. ~ t t TotaK te.vtgth o~j fine.3_ ~ 6t Depth of tite below gnade Zvi ViAtaviee between stope 0(, ttcevteh-_ in- pelt 100 Eotaf ab6o>tpt on ccn.e.ct rtg2 ~,t Type- o( Coven: Pap.en on ~,.tttaw DIMENSIONS Numbsl: o f Y Git.aveP. aitound p-tt6 ye6 nr, 0ut6.tde. diameteit {t Depth bekow 'vie(et (-t Totae. ab6oitp.ti0vt ane.a ~:t i Att. e- a n e_ q ui ite f t INSPECTED BY _ ~ TI TLC r APP"ROVED - DATE 19 8 i REJECTED - VA T t 19 8 R1=ASON FOf: RE Jt CTION Wisconsin Department of Industry, Labor & Human Relations PLB_1 INSPECTION REPORT Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protecction- ae an D. To. ame o rem,ses ~r oun y Sanitary Permit ,y Street dress Master Plumer ,rm ame ress Journeyman um er ress Owner - - - - - - d. ,gna ure ,scusse w, ( )See Attached. up. n_ i e Waste pec,a ,s re o ,s DILHR-SBD-6192(N.09/80) Sign atu um ,ng Green-Owner White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party ST. CROI X COUNTY WI SC O N S I N Ab i 5ip J4 t 1 +j y ZONING OFFICE 796-2239 HAMMOND, WI 54015 August 7, 1981 Nels Ulsaker 8421 Hillside Trail Cottage Grove, MN 55016 Dear Sir: This letter is notice that your violation, which was dated June 11, 1981, for a malfunctioning sewer system, has been corrected. There are other- violations on your trailer court which must be corrected and approved by the State of Wisconsin. If you have any questions regarding this matter, please feel free to contact me. Your truly, Harold C. Barber sl State of Wisconsin ` DEPARTMENT OF HEALTH AND SOCIAL SERVICES r DIVISION OF HEALTH DISTRICT 4 OFFICE 1298 Lombardi Avenue June 23, 1981 Green Bay, WI 54304 rr Telephone (414) 497-3219 - 414-497-3349 1 Mr. Nets Ulsaker 8421 H i l l s i de Trail Cottage Grove, MN 55016 Re: Country View Court Route 1, Sommerset, Wisconsin St. Croix County Dear Mr. Ulsaker: On June 18, 1981 the State Division of Health, in cooperation with Mr. Leroy Jansky, On-site Waste Specialist with the State Department of Industry, Labor, and Human Relations and Mr. Tom Nelson, Assistant Zoning Administrator for St. Croix County, a survey was completed at the above licensed facility. A copy of the report was left with you at the time of the completion of the inspection and it was fully discussed with assurances given that compliance with the deficiencies would begin immediately. The deficiencies consisted of the new construction of seven new pads which have Woodford hydrants installed below grade as well as a cement slab lacking around the water service line. In addition, the pump chamber should be extended to an above ground location and sealing of the sides with roofing cement should be completed. A vent cap should be installed on this pipe. An additional violation was the lack of an office at this location. Correspondence received on this date revealed that a Mr. and Mrs. Gilkerson on Lot 30 would act in your behalf as the resource person at this facility. This will satisfy the requirements of an office within the mobile home park. The survey was based on Chapter H 77, Mobile Home Parks, Wisconsin Administrative Code, and any additional questions which may arise from either this survey or other items pertaining to mobile home park operation can be referred to this office at any time. Very truly yours, Harold J. Daul, R.S. Environmental Health Specialist HJD:td cc: L.U arcTd C. Barber, St. Croix Co. Zoning Administrator, Box 227, County Office Building, 1030 Davis, Hammond, WI 54015 Leroy Jansky, On-site Waste Specialist, Chippewa Falls Division of Health, Dist. 6, Eau Claire Bureau of Environmental Health, Madison EH 1 04 Rev- 9/78 H014E PARK SURVEY Date of Survey Number of Sites Licensed ING DIVISION OF HEALTH pLgtT /-8 + Provided i . RECREATIONAL AND ENV.)>ZONMENTAL SERVICES SECTION Complete Survey Partial Survey N of Parr c Follow Up ~e~ at on of Park City, V(Ila a or Twp. Name of Owner ~r 4,1ou y Ftr~i ing dress City, Village a e ZIP Code Phone Number Ayd N~ Titl Add s of Person Interviewed v c17 , Sta a License I.D. No. or Local Licensor L.Q-, !TOTE: The violations in operating procedure, facilities or h such period of time as may be specified, P Ysicai arrangement indicated below must be corrected by I H 77.03 - REGISTRATION H - IIOBiLE IIOH PARK PLAN _ 2 enera Area ra Wage 3 (2)(a) Sites Defined 7 (2) (a) Sites, Unit occupancy I ~ ~-II J `I ^ _ (2) (b) Basic Unit Locations, 6 (3) (a) Street Widths ( 3) (b) Driveway Surfacing Ci (4) Parking (5) Recreation Area T n 11 77.05 R SUPPLY 11 --52- AG D 1 SPOSAL it 2 Pu ) c +]J( 7 Sewerage PLL A-C TT (3)(a) Private Sewage System(s) / (3)(b) Plans Approved e-, (3)(c) Systems, Area Available H 77.07 PLUMBING 15 genera . on ormance T~- (2) Water Connections 11.03 - SOLID IJASTES l ` 17 drT"Tage, -on a Hers, Disposal l C(>'/ T9(2) Cleanliness 19 (3) Restriction j`~~ ~1 - (4) Rubbish Q II 77.09 - MANAGEMENT (2) Duties - Owner 22 (2)(a) Register Available 1 T3- (2)(b) Sanitary !Maintenance K/'7*- l7 24 (2) (c) Cooperates - Health Officials - (2) (d) Regulations Posted (3) Duties - n 26 Sanitary p Vk-,l (3)(a) Site - Sanitary Maintenance T7- - (3)(b) Compliance With Rules n ~j o? l ~ c--x-c (r~~•~.y.x„.~,,~ tit.-~c_.ti,t,f C~ ' Q '7 -12e- w Signature o Owner or Owner / s Representative Signature o Parson Conducting Survey Wisconsin Department of Industry, PL3-1 INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o remises Date an No. Street City County Sanitary Permit Master Plumber Firm Name dress Journeyman Plumber Address Owner Address Discussed with Signature ( )See Attached. DILHR-SBD-6192(N.09/80) Signature o is Plumbing up. on-Site Waste Specialist White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner Fib. r-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health Section of Plumbing & Fire Protection Systems 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: € w € r j S 3 { € $ ' t ~ I e , r s f ° t T- 4- ~ SS jy , , i a , € , € r f t t , L a a E ; , , _4---- , 3 3 € , # a _ a , 3 E j i , , r [ f q a 3 ❑SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector %/hite - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party ~PIb:?-A. WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health Section of Plumbing & Fire Protection Systems 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: t i E 9 3 e ~ I H { s i "L J-1 E z ~ m_K ......fit --.-.G'.. ~ 1_ ~ € ~ 7 F 3 i w~ 3 3. € F_. 3 3 [ t E 3 q € 3 ' € E E 3 n i s 3 E i f 3 f E E E a 1 „ _ a 3 t 3 € 3. 'r I, mm f ...g.».-. a_.,- _ . , e E a 3 e q 4_1 s E 3 E n~ E € I ~ 3 { F E 7 e ~ e i ~ { ~ 3 F c 3 € E x E 3 ? a i e -2- 4 e g E 3 } e e _ _ _ e . . . . x 3 e e r e . . e e Y e _ _ { j 3 ® .,.,..q _ . 1 ..,,......,E ' € 3 E e = a ~ e E e E W i ly E ~ ~ 2 f t E F ( ~ € t = t E € E 3 I i F w, _ _ A j r . E F f j E € r F f ❑SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector "!bite - Inspector Yellow - Local insoectnr Pink Pl .pmher or Responsible Party Wisconsin Department of Industry, PLB-1 INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o remises Date an o. Street City County Sanitary Permit Master Plumber Firm Name dress Journeyman Plumber Address Owner Address i 1 - - - - - - - - - - - - - iscusse wi 719 nature ( )See Attached. DILHR-SBD-6192(N.09/80) Signature o is um ing up. On-Site Waste Specialist White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner Plb. 1-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health Section of Plumbing & Fire Protection Systems 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: c 4" J4 a E ~ ~ t f I ~ ~ a A a~g fi t t - f. E E i . 1 € t } . g 1... f 1 { - $ S € f 3 a 3 3 E _ s j Y t E { l t f_.4 w _ r i $r d S i } t_ { t i r E { _ t) t* 3 , mod y F 3 F g i x m r` . . i a , . . ~ ° ~ _ . . _ E i E _ ° . e. } . E s { . e € 3 3 € r E ' e e x y r ~ 3 3 ~ # 3 3 E E 3 z - 3 ° 1 E f w _ 3 P r 3 E E s ~ ¥ ~ 3 t 3 i E E ~ E El SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector White - Inspector Yellow - Local Inspector Pink - Plumber or €tesponsiNe Party