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Parcel 034-1085-20-000 09/15/2006 04:27 PM
PAGE 1 OF 1
Alt. Parcel 28.29.15.559B 034 - TOWN OF SPRINGFIELD
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 - GENSEN, JACK L & BONNIE S
JACK L & BONNIE S GENSEN
727 294TH ST
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 727 294TH ST
SC 2198 GLENWOOD CITY
SP 1700 WITC '
SP 7059 SPRINGFIELD SAN DIST #1 y
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 28 T29N R1 5W LOTS 5 & 6 BILK 12 VIL Block/Condo Bldg:
HERSEY
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-29N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/17/2003 706158 2113/178 WD
883/538
422/588
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/26/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 1,800 95,350 97,150 NO
Totals for 2006:
General Property 0.000 1,800 95,350 97,150
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 1,800 95,350 97,150
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 034-1085-30-025 09/15/2006 05:20 PM
PAGE 1 OF 1
Alt. Parcel 28.29.15.559CD 034 - TOWN OF SPRINGFIELD
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 - FAYERWEATHER, DEAN R & SHANNON RODGERS
DEAN R & SHANNON RODGERS FAYERWEATHER
727 294TH ST
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2198 GLENWOOD CITY
SP 1700 WITC
SP 7059 SPRINGFIELD SAN DIST #1
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 28 T29N R15W LOTS 7 & 8 BLK 12 VIL Block/Condo Bldg:
HERSEY ALSO PT OF ABANDONED UNION ST
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-29N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/15/2003 743686 2435/581 MISC
04/10/2002 675873 1869/503 WD
07/23/1997 883/538
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/03/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 2,000 0 2,000 NO
Totals for 2006:
General Property 0.000 2,000 0 2,000
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 2,000 0 2,000
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
r M,
• is
C"
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REPORT OF INSPECTf~N INDIVIDUAL SEWAGE SYSTEM
Sanitan.y Permit
State Septic
NAME township S$. CAoix County:
t. Location Section
SEPTIC TANK
Size gattons. Numbers o6 Compartments { j
Diztance From: Wett r St. 12% or greater 4tope 6t
8ui t. Wettands
.~ding ~ _ ~
Highwater 6t.
DISPOSAL SYSTEM
.
Diatance From: Wett 6t. 12% or greaten Atope 5t.
r
Buitding St, Wet.iands Ft.
Nighwater az.
FIELD DIMENSIONS:
Width o5 trench 6t. Depth o6 .tack below tite in.
Length o6 each tine 6t. Depth o6 tock oven tite in.
Numb en o6 tines Depth o j tiZe b et ow grade in.
Totat Length o6 tines 6t. Stope o6 .trench in pen 100 6t.
DiAtance between Zines fit. Depth to ibedrock 6t.
Totat absorbtion area 6t2 Depth to groundwateA 6t.
.'Requited area 6t2 Type of Coven: Papers oa Straw
PIT DIMENSIONS:
Number o6 pits Grave. around pigs yes no
Outside diameters 6t. Depth betow inlet St.
2
Totat absorbtion anea 6t z
A
Area required 6t2 rn
INSPECTED BY TITLE
APPROVED DATE t 19
REJECTED DATE 197
w
67 State and County State Permit #
PLB
w Permit Application County Pe ; #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
I T U
B. LOCATION: ° '/4 W Section , T!~ N, R / F-tmt W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township-_?e,,_
C. TYPE OF OCCUPANCY: *Commercial ' *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY L~C« Total gallons No. of tanks Prefab concrete` Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-PlaceOther (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement _~Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length AAA th Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter / Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester, NAME c' 17> r Il~ ~F' C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature M 6 c Phone
Plumber's Address V +2cc• ✓~2~ L~/~ r
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
gin,. W.
F
t ~ ~f
ZIP Car), IU N A >,t1' t
Chu rLln
f
3
LIJ AJ 12 41~
Do Not Write in Spac el~vv FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application C Fees Paid; : State C C' Co . C C Date 7
Permit Issued! ate) Z~_ Issuing Agent Name ' C C_.
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2, state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS `j
r'•
LOCATION: ~E'/4 '/4, Section 2T N, RCS E.W, Township or eeipa4i#y i
Lot No a' ' 1 Block No. V~,//g-ze- r- . ~ .a County
t b ision a e
Owner's Name:
Mailing Address: i
i ,
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGSj1~ J`~= y -PERCOL TION TESTS
x=
SOIt- MAP SHEET SOLI- TYPE 4L~-~-a ca_
PERCOLATION TESTS
TEST DEPTH? HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS ICHARACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL I BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P
I `
_ o t, e- Hod
IP-
C-z
P-
SOIL BORING TESTS
r
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
i NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B _
7 Cc C? 7 , S 6`' IL
r. B 7 -2 , , - U~ Igo TL t9 41- 3l 4c .
IB
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square fee of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. H-014 !Jti ~ 'ST C P- A; ~ r" 1 Indicate scale
or distances. Give horizontal and vertical reference points. ndicate slope.
'.L
-IN
I _ I N
1 -
I
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test. holes are correct
to the best of my knowledge and belief.
Name (print) _.C Al tA' f E Certification No.
?
Address J- /y oja A( d / C- CGS ! N .5,__1
Name of installer if known }L-
CST Signature
hCOPY A - LOCAL AUTHORITY
e ~
'7
October 29, 1979 N -7
Red Cedar Plumbing Heating
1120 N. Broadway
Menomonie, WI 54751
Plan Identification No. 79-04900
Gentlemen:
Re: Molding tank - 2,600 gallons
Hersey Baptist Church
NE 1/4, SW 1/4, Section 28, T29N, R15W
Town of Springfield, St. Croix County, Wisconsin
Examination of plumbing plans and specifications for the above-mentioned
project has been completed.
In accord with Chapter 145, Wisconsin Statutes, and Chapter H 62, Wisconsin
Administrative Code, the plumbing plans and specifications are approved
contingent upon compliance with the following stipulations.
1. Our review of the holding tank plan has not been evaluated for
structural stability, only for compliance to design requirements of
Chapter H 62 of the Wisconsin Administrative Code.
2. The holding tank shall be maintained and the contents disposed of as
required under Section H 62.20 (7), Wisconsin Administrative Code.
3. The architect, professional engineer, registered designer, owner or
plumbing contractor shall keep at the construction site one set of plans
bearing the stamp of approval of the department.
4. In the event Installation of the plumbing Improvements or system has
not commenced within two years from this date, this approval shall become
void and new application shall be made for approval of tnese plans before
work may commence.
r
Red Cedar Plumbing s Heating
rage 2
October 29, 1979
In granting this approval, the Division of Health doer not hold itself
liable for any defects in plans or specifications, plan omissions,
-xamination oversight, construction or any damage that may result in
ur after installation and reserves the right to order changes or additions
should conditions arise making this necessary.
This approval is based on Chapter H 62, Wisconsin Administrative Code,
requirements. It shall be necessary to obtain and fulfill the permit
requirements of the city, village, township or county in which this
installation is to be constructed. Failure to obtain local permits will
automatically void this acceptance.
Approved/Issued By The Department
of Health and Social Services
Division of Health
Jar~ies A. Sarq~nt, Chief
Section of Plumbing and
Fire Protection Systems
JAS:KS:bah
Enclosures
cc: Mr. Dennis Sorenson, 014S - District 5 - La Crosse
Mr. Harold C. Barber, Zoning Administrator, St. Croix County
t `
y- ST. CR0I X COUNTY
T
T f
WI S C 0 N S I N
Z O N I N G O F F I C E 7 9 6- 2 2 3 9
A: iu-
Post 0666.ice Box 227
t i_! = Hammond, WI 54015
O W N E R
P U M P E R
A G R E E M E N T
PLEASE BE ADVISED, That until you atce again noti6 ied, I w.itt
canzxac with SE % J f't'il7` lx,1'4, 0
w(.J CLIZ i ..>i. i., iulr~I.;e't 'l±U%i. l.~le j.Jl4~ v t'. u 8 %i.Zf1;C; VA.-n S.L'Z WU.Jtie. 'a in 1.ItL
danitahy system to be .located on the pxopexty and 6utuxe home site
l
L,,Z' C~-
Zoca ed in S Cxaix County, Wisconsin, Township oJ
being in the N: - % a6 .the o6 Sec. T. N.-R. W.
(Ott mo xe J utt y d a cxtib ed as 6 o.tt owes : )
Dated this day o6 19~.
(OWNER )
11 A-10
State a Wisconsin) ~.3
County o6 St. Cxo.ix)
r1
Penzannatf-yappeane,d b,ane is -3~-i day o4 19 .
above named rTl1>~Z P". /~h
a me nvwno be the the who execute the Joxegoi.ng z ztxume.nt and achnowtedged the same.
ataxy u c, St. Cxv.cx County, W
My Comm. (.f. ° r .t) (E x pit ens) Z
hexe.inbe4oxe xe6entc.ed to as Pumpers,
join in the above agreement to the extent that I have a con:txact with
Owner as above stated./'. l
y1. (PUMPER)
AGREE TAEr+'i
day of by
This agreement, made'a'nd ntzred on this el(
and between the Township of ' F ddress
V EEREA S: In application has been made for a sanitation system on the
following described property: ;T e c. ~2 o b.5 7, )-It t sc y
"7904 00
VEEREAS: Septic tank drainage does not meet the minimum standards of tine
ordinance of St. Croix County and state codes.
VvF:.E;REAS: The owner agrees to install a holding tank for septic tank purposes
purpo8es.
NCB-, TE~EREFORE: For and in consideration of the issuance by the Town-
ship of &C t- 4 a of a permit for the above premises, the parties
do hereby agree a id bind themselves as follows:
1. Owner agrees that they will conform to all the rules and regulations
pertaining to a holding tank system. They agree that anytime said
township deems it necessary to pump out said tank, the owners shall
have same pumped out in 24 hours, or township will have said wcw ~
doneand charged to owners and place same on their tax bill as a
special charge.
2. The Township reserves the right to assess a bond if they desire to
cover any possible pumping charge in the sum of $,d a • a o•
IT IS UNDErtiSTOOD that this agreement shall be binding on the owners,
their heirs and assigns.
IN VITNESS VIFIERLOF, the parties have hereunto set their hands and seals
the day and year first above written.
Township of ,C• •
by
Developer ~co`"`~
or owner
STATE OF V,,J1CONSIri)
<,~P ?
COUNTY CF ST, CRCN) S S: 1979
E
Subscribed and sworn to before me this day of 15 jt . to
Notary I ublic, St. Cr C ~r1i n r
43476S .w. 803 PA411
Document No. This space reserved for recording data
HOLDING TANK AGREEMENT
Agreement Date C
- - This agreement is made between the - REGISTERS OFFICE
County or Local Governmental Unit I Holding Tank(s) Owner(s) ST. CROIX CO., WI
lick Tc`C, 'fzsh IP I f. Recd for Record
~1
(Called Municipality below) ln
I ` hl~, '_1 r t 'b 46,19b8
We acknowledge that application is being made for the installation of (a) holding
tank(s) on the following property, (Provide legal land description:) Gi 10:00 A M
a eAll ~
A,;
t V of Deeds
~ F-
r:S4;~ Black 12 Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145,LStats.
As an inducement to the County of _S~ f 1"~ i X to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
wnef ames) (Print) I Owner(s) Signature(s)
L &k(C t I Subscribed and sworn to before me on this date:
~ 6 Zop
C", - 4 _-r Z_ -
Municipal Official Name (Print) I Municipal Official Signature Notary Public
My commisslon expires c1
7-A'0116-S lie65 i
Municipal Offici 1 Title (Print) )
n d ;r
SBD-6123 (Ft. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
434'76 6 M. 80310AU f 12
HOLDING TANK SERVICING CONTRACT REGISTER'S OFFICE
ST. CROIX CO., WI
'ontractDate Recd for Record
This contract is made between the r tb 4 6 •lybJ
Holding Tank Owner(s) Name(s) and i Pumper's Name at 10:00 A M
~_~Reglsw of Oeeds
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
/
Block 12 . ~
1. The owner agrees to file a copy of this contract with the vocal governmental unit he einafter caiied the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
C 1 LJI
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The'sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s)
E'y Subscribed and sworn to before me on this date:
I ~
r-7
Pumper's Name (Print) Pumper's Signature Notary ublic
My commissi n exp'res:
A
Pumper's Registration Number
4 Q
t 7^ t
SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
HOLDING TANK SERVICING CONTRACT
contract Dale
This contract is made between the
- - - - - - - - - - - - -P - - - - - - - - - - - - - - - - - - - - -
Holding Tank Owner(s) Name(s) and Pum er's Name
C) eL.,cc L~ C k~_, -
_S ec,2(
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
VC/
1 . The owner agrees to file a copy of this contract with the local governmental unit hereinafter tailed the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
i
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The'sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s)
_ .ei y. 134pf ~s Cti h~ CUIJ
~._...a_.. Subscribed and sworn to before me on this date:
fir? 1q 1 PP,4-u
Pumper's Name (Print) Pumper's Signature Notary ublic
/ My commissi n exp'res:
Pumper's Registration Number J
A/ 7`2 _3
SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
PI b. = 60 -
1/7S
PROJECT DETAIL DATA SHEET
NAtiIE OF BUSINESS
LEGAL DESCRIPTION )V "7'~'7
OWNER MAILING ADDRESS
ZIP "SON ARCHITECT, ENGINEER, ADDRESS c) tjrc, d tv14
LUMBE 'OR DESIGNER
ZIPL
TELEPHONE NUMBER 7iS .2,:~5, 11
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20. 79 ® 49 0
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 . . . Numher of sewered sites
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . . ( ) Day use only Number of persons
( ) Catchbasin ( ) Day and night Number of persons
. . . . Number
Church . . . . . . . (~i) No kitchen Number of persons ZOO
( ) Dance hall ( ) With kitchen Number of persons
Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals served daily
( ) Dog kernels . . . . . . . . . . . . Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity
Car-service Number of car spaces
( ) Dump station . . . . . . . . Number of dump stations
( ) Employees ( total of all shifts) Number of employees
( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit
Number of units with 4 persons per unit
( ) Medical and dental office bldas. Number of doctors, nurses, medical staff
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . Number of sites
( ) Nursing homes . . . . . . . . . Number of beds
( ) Parks . . • . . . • .
Number of persons Toilers Showers
Restaurant
• Seating capacity
( ) Dishwasher and/or disposal?
24-Hour service 9
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Retail store
• Total number of customers
( Schools . .
Number of classrooms __FT Meals ~ ),_~S,4owers
( ) Self service laundry Total number of machines
S
( ) ervice 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 3 Number of drains
Food waste grinder yes no 1K
Dishwasher yes no Automatic clothes clothes washer yes no Number of clothes washers
3. Septic tank capacity
.c±E ~ c
Holding tank capacity e
Septic or holding tank manufactu r
4. SEEPAGE TRENCHES: total square feet - width of trenches
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet width
length of bed depth
SEEPAGE PITS: total square feet outside diameter
depth below inlet
total depth from top to bottom of pit _
ign ure of p, son completing form: FOR DEPARTMENTAL USE ONLY
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Telephone Number 93 c 7-3 91
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the Seaton
Date and reported upo ' b ems, Bureau
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EXAMINED Protect►on
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plumbin9 1 Health, ocial $erices.
of Environm cf Health and S
Deportment SARGEI 41 1 Chief Protcaon
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1120 N. Broadway MENOMONIE, WISCONSIN 54751 Phone: 715-235-7341
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