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HomeMy WebLinkAbout040-1205-10-000 0(n o K v 0 b u o 3 c m m n ~ ~ zv 2 2 v o O' N N r CO N O) ~ .O O O O O CD CO 1 A .2 Q. O_ N F N O O O _ ^I® rn a W W U p 0 0 1} N ~ N I (D ~ , O CO O 6 6 (D O J O O O O O N r 7 O Cn V N m to N 7 fA cn O r C VO (D 0 N 3 w _ CD 3 N U 3 ~ ~ C N 1 3 N N O O 'O O _ W A j cn ~ n c N n p N c lot zz ° T "t 000 0 T. a i cn (n cn o a O O v c m (D v N CD z z m z C 0o D Q (D (D N O N ti N /yam 1, C-"45 N iL N CD co cp Z CD U: 00 A n A~ Z O a) fl G In: i~ Cn - 03 -V M N fD fD _ CO z 0 3 A A o - z 3 m N z (D A W CL N ' O , O r,_ CC n N O G 3 X o CD ff1 ~_5 -7 7 N O 1- U maU' a (D Oz OD 7 G 7 N ` X W c Lri D 7 N Or Q A CL (n 0 0 -0 0- 0 3 N a ~ O 7 N O 07 O N = n . O 7 CD ~u C~ _O CD Q ~ O o b (D 7q J ,~n O 4- o I 00 (D v Parcel 030-1053-95-100 03/08/2005 04:55 PM PAGE 1 OF 1 Alt. Parcel 23.30.19.198B-10 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner - LOW, JOHN R JOHN R LOW RAILSBACK RANDY RAILSBACK RANDY 3406 SE 18TH PL CAPE CORAL FL 33904 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 1452 RIDGE RUN SC 3962 NEW RICHMOND SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 6.003 Plat: 1628-CSM 17-4450 030/03 SEC 23 T30N R19W PRT GL 3 F PT LOTS 1 Block/Condo Bldg: LOT 06 & 2 CSM 5/1346 NKA CSM 17-4450 LOT (6.003AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 06/12/2003 725621 2274/032 AGREE 01/31/2003 707745 17/4450 CSM 07/23/1997 786/96 2004 SUMMARY Bill Fair Market Value: Assessed with: 5177 341,500 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.000 255,800 80,200 336,000 NO Totals for 2004: General Property 6.000 255,800 80,200 336,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount 040-OTHER ASSM'T SPECIAL ASSESSMENT 284.43 Special Assessments Special Charges Delinquent Charges Total 284.43 0.00 0.00 ST. CROIX COUNTY WISCONSIN PLANNING & ZONING OFFICE I I NIP" ■ M ■ _ runt ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 FAX (715) 386-4686 August 9, 2005 Sam & Jessie Nye 570 Omaha Road Hudson, WI 54016 RE: Remodelingibedroom addition, Town of Troy, St. Croix County Parcel # 040-1205-10-000 - Computer #16.28.19.955 Dear Mr. & Mrs. Nye: You have requested the Zoning Office review your remodeling/addition project for compliance with the state sanitary code (COMM 83). When remodeling or adding onto a dwelling, you are required to examine whether or not the planned modifications involve an increase in design wastewater flows to the Private On- site Wastewater Treatment System (POWTS). I have reviewed your remodeling plans for the above residence. The project involves finishing two additional bedrooms in the lower level of the structure. The septic system was designed and installed based on wastewater flow for three (3) bedrooms with a maximum occupancy of six (6) persons. This project will increase the total number of bedrooms to five (5). Technically the POWTS will be undersized for the number of finished bedrooms within the residence; however, current occupancy does not exceed the design wastewater flow for the POWTS. An Occupancy Affidavit is required to disclose the disparity between number of bedrooms and septic system sizing to any future owner(s) of the residence. This affidavit has been submitted to the St. Croix County Register of Deeds office and will be recorded against the deed. The original system was installed in November 1979 by Paul Cudd and was inspected by zoning staff at the time of installation. The system was found to be code compliant at that time. Inspection report, as-built, and sanitary permit documents are on file with the zoning department. The last servicing of the tank was on 11/7/04 and the system inspected by Kim O'Connell on 8/8/05 to verify that it appears to be functioning properly. To prolong the POWTS lifespan, the septic tank should be pumped at least once every three years or when the tank becomes 1/3 full of sludge and scum. In addition, water conservation measures should be implemented, for example repair/replacement of leaking plumbing fixtures, reducing shower time, running the dishwasher only when full, avoid using a garbage disposal, using a wash machine with a suds-saver feature, etc. The long-term function of your POWTS is dependent upon proper maintenance of the system. If this POWTS should fail at any time in the future, the system will be need to be inspected by a licensed plumber or POWTS maintainer to determine if it requires replacement according to state code requirements in effect at that time. The proposed remodeling and room addition project must comply with all applicable building codes. Please contact the Building Inspector for the town of Somerset to obtain a building permit. Should you have any questions, please contact this office. Sine ely, Pamela Quinn Zoning Specialist Cc: Brian Wert, Building Inspector file ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: A/z 1/4, ~ 1/a, Section l , Town_,,'~N, Range W, Town of , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service [ - - Did flow back occur from absorption system? Yes No-Z- (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: /6r' Construction: Prefab Concrete Steel Other Manufacturer (if known): l Age of Tank (if known): 19 Z-12 79 1 - (Licensed Plumber Signature) (Print Dame) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) , 411A }ra,idz ' REPORT t"fir a k txbiyy AS BUILT SANITARY SYS abV Sl ' W SLO P r Td~ rl, TOWNSHIP n~} . CROIX COUNT ISCO SIN " LOT LOT SIZE t ,a k r Q~~ ~ tPLAN VIEW f IJ62 20 o 1Q~AS to meet requirements o "in'lf~'' rise r~r toy'wi, ¢aa• , .t , "~IN 100FEET OF SYSTEM R INC WT ~ y Y r ~ Y } t P 8f r~~~1 Potj Y~ f^~S~ s ~'r AR _ S 7 i(t 1 tS y f~e~ 4~1 ~ . ""A i yY pl cP i e r r1~, ~~4 r C 1 r 2' ~y.kr~ rS s S~ ad v~xd?~ ~t a ~t } r *1 .r Y2 faI.~r' Fp41+X,,, t?~ 7'' S t •{F.W !.(W y« r al iy } x}~ta rd is}-t' e i r S xL S {1 rr d0 M'4t ~ Y 7 isr~l' l 'T a i i ~,t~,! s F TV, tirYthl 1°~ 7 i F`S y, r ~~f i i+1,° i ~S. t II 4 1 S 'd U rSS 8 7'~`tY .Rf tY ai fn L , r+rr ~n k- ti s NA 1'r L + , ~ y`kpr~gvi Fly ; r i CG~NCRET STEEL DRY k ~tJ s ° Depth cover ,tV Cjtll eTlgt r'3 ea it a x 1 wi t . ten to area s to t of e :2 149V22 r 7 ~,AV' REQUIRED AREAS BUILT tie q z ~l3 R ~.r~peci ref this system bar St r Cro ','County does not imply L< , r^ t"O dministrati.ve CQdes. There are other areas ct at this point of Construction. St. Croix . if failure is f©x system operation. However, 47, rc ~ ,Cp #xy wil malts every effort to determine Cause of failure. NOT, BE DISPOSED THROUGH ZS.: SYS 33'0 't y tU ~ )Y~ ,F~.{ ~ ~ INSPECTOR z it ,I pew , i {S ?'S'ET? t PLUMBER' ON JO LICENS r z_ REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itahy Peam.it • State Septic / NAME rownahip JS.~. Cno.ix County Location 2)L Section _ SEPTIC TANK Size O _gatton.a. Number ob Compattmentz / j D.c.atance Fnom: Wett SV it. 12% on greaten 4tope 6t Bu.i.td.ing it. Wettandb ~ . H.ighwaten it. , DISPOSAL SYSTEM D.iatance Fnom: Wett -f- .12% on greaten ztope St. Bu.itd.ing 9 it. Wettands Ft. • H.ighwaten it. FIELD DIMENSIONS: Width oS' tn.enchit. Depth o6 tock below t.ite /P- in. Length os each tine it. Depth o6 noch oven t.ite .in. Number. o6 tin e,6 ~ Depth o6 t.ite below grade S D .in. 7otat .length o6 tinez it. Stope o6 .trench `7- in pen 100 it. 3 Di.6tance between tine.6__IL_.Jt. Depth to bedrock Totat abz onbtion area ~ . ~_jt2 Depth to gnoundwaten Requited area ~t2 Type os Coven: \1 Papers o Straw PIT DIMENSIONS: Numb en of p.it6 Gnavet an.ound pits ye.a no Outdide diame Depth below inlet ~ . _ZL . 2 Totat abzonbt.ion area it z A Area ~equined it2 3Z INSPECTED BY TITLE APPROVED ,DATE 1975F . _ REJECTED DATE 197 01 E i l '°14 5 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: NLr %4, Section "T T 7-8 N,R 19 F=W) W, Township or-R e+AeFftY `TR-O Lot No. Block No. 6__1`0 V *--2 S--rg--rio Nv County ~-r. C2p 1"o , Subdivision ame Owner's/Buyers Name: VCaN o 1S D y5ek_ Mailing Address:, 31 Z. ST• \141 54"O `Zz TYPE OF OCCUPANCY: Residence '?r% No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW _ REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS IO-C.- let PERCOLATION TESTS kA SOIL MAP SHEET $ Z NAME OF SOIL MAP UNIT ~ufz►c►~ly(LDT rr5lYt?c~-~) ~X CZ PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- LA"tlo" T TS No-r 6D Vvc-C Sot M j>S tIj01 W-C'L-_ SANA P- S ► L t i 0 v-n o - • ~c S vu Ars d-43 rQk r2--tR uS 00= Lr P- NCO, >L ~L" 'PI s• P- D 06L s"t>+-t 'r rr v t- s I p l c A-6 1,24 o f POZ.!W' 1111W7 P- ;1E M- ZO 2 L to L l O r. 2 p F 1Q " wl 'Ce 3 ►s P- ►z ~o+c' ~u21iLl.} 2 S~t~-s AT r7 m 11~,&OW A+•)o sa-r~c Sol 4T O~pT~►S aG gyp" To (00 V SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- l 'rl Z a r 4F Z 1$ 131 L Ts 10" !S, 8" • 34" r. dd . s B- 2 74 1-~ oI) a > 7 it B L -Ys Zo " s ~ ( 6`' Ur B- 3 '7Z ~arJ~" '72 17- a L -rs b Q." Gw • 4 u r,aa, . S 13- ¢ -7-5 00,ar ? `73 is Q ~ L. T ie " L + c. 33" n ca B- S 7-3 NorJc > '73 17- BI L. Ts ► IZ" Cyr - w.ad. 5 B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. N s t CL Ass 1 SO t L '2N-TLC V.MQ h Attm = 3 Zo s c IS Fr L PEAR BCD r c, a tFx. NS*>~ i 619wo!~p .__el-k-lerv • 47r0. e. 1 ~ X13 • ~ _ __~'I~P Ai~!_.~, , , .~a , X750 ~T2 z V 0.0 4 1. -5 , 100 j 0- r R `J I C! _.i 4 1 i (1 I N t µb W-P'7?u ? t ° t A~g ~o... ~M rs Fa?' o~a._. kai , methods I, the underslgend, hereby certify that the soil tests reported on this form were made by me in a rd wit c ress ~vd specified in the Wisconsin Administrative Code, and that the data recorded and location of test o are , ect-to tKe best "d my knowledge and belief. y IOr~r„ -T Name (print) ~A WI/ly S Certification 6. s 2 Address ( N ` Z >v P v ~2 ~iAn.ti-5 w S Name of installer if known Pnui-• -I-,- • C vpn 50'..+S Copy A -Local Authority CST Signatur 7 State and County State Permit # -PLB l Permit Application County Pe t for Private Domestic Sewage Systems Count *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 51,11 N B. LOCATION: _'/n Section , T,~-WN, R~ E (or) W Lot# City Subdi sion Name, earest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family ~Duplex No. of Bedrooms _ No. of Persons D. SEPTIC TANK CAPACITY 1~2n/% Total gallons No. of tanks HOLDING TANK CAPACITY 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 refa concrete Poured-in-Place her (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New I--- Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (to) No. of Trenches Seepage Bed: L~ Length _s'U::f Width.,/,-52_Depth Tile depth (top) No. of Lines - Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land `~7/2 Distance from critical slope WATER SUPPLY: Private it ❑ 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 Certifie ZSoil Tester, NAME C.S.T. # ~~~and other information obtained from wner/builder). Plumber's Sig ature /MPRS # al---iZo Phone OK- 7 Plumber's Address dc~ 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. r , t nK F r t I 3 I , . m~ 4 f i i aN , t i ` j Jo Not Write in Space el FOR COUNTY AND STATE DEPARTMEN USE ONLY )ate of Application Fees Pad: State S, ~ 0 oun Q ~ Date C' Permit Issued7ie (d Ae) / Issuing Agent Nam nspection YeNo State Valid# Date Recd I, county (wcopy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /78 i r i r ~s ell, i~ j. REPORT TEM AS BUILT SANITARY SYS b TOWNSHIP SEC. T R/9 W .~..~.•~.f E- CROIX COUNT WISCONSIN P.O. S , ST. ICA SUBDIVISION 'LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SNOW EVERYTHING WITHIN 100FEET OF SYSTEM 4 114: J . Ism p /pp y t- m SL .'CIC TANK( ~s S). alp MFGR. ,ia+c~ ,.2-h.~ CONCRETE ST DRY-WE-1 l Depth N o rings on cover DRY"W a, `DRENCHES No of width engt a ea BAD no. of lines wi t r ten t area ept to t of e AG~'REGATE If I AREA AS BUILT ~r11 PERK RATE A QUI A A F~DISCLAIMER: The inspection of this system by St, Cros.County does not imply complete compliance with State Administrative Codes. There are other areas that it :is not possible to inspect at this point of construction. St. Croix County assumes no 'liability for system operation. However, if failure is `noted the County. will make every effort to determine.cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH IS SYS M. INSPECTOR DATED PLUMBER ON JO LICENS z REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM Sanitary Penm.i-t, State Septic_ NAME rownah.ip S$. Croix County Location ! Section SEPTIC TANK S.i.ze Cl 0 ga.t.Eonb. Number o6 Compan.tmen.tz / Distance Fnom: Wett SD S~. 12% on greaten scope S•t Bu.Ltd.ing 'r it. Wettandb ~ • Highwaten it. DISPOSAL SYSTEM D.Latance Fnom: Wett '57) it. 12% on gneateA ztope Buitd.ing 9 ~ t. W ettand.s Ft. • H.i.ghwaten b•t. FIELD DIMENSIONS: Width o6' trench it. Depth o6 rock below tite !;Z--in. V Length o5 each tine ~ G it. Depth o6 noch oven tite gin. Numbers o6 tines Depth o~ .tiZe betow grade SO in. v Total. Qength ob tinez it. Stope o6 .trench in pen l00 ~ . 3 D.i.6tance between Zinez--L-it. Depth to bedrock it. ~J Totat abbonbtion anew jt2 Depth to gnoundwaten ~ . Requited area ~t2 Type o6 Covet: f Papers o~c Straw PIT DIMENSIONS: Numbers o6 pit5 r GAavet around pitz yed no Ou~ide diame XX Depth below .in.Eet / . 2 Totat ab4onbt.ion area it Area x,equined it2 rn INSPECTED BY TITLE APPROVED DATE 197 j' . REJECTED DATE 197. E H X1,1 ' Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: 1`34 '/4,1`1i= ''/4, Section T ZN,R~ TIZCJ Y ) W, Township or-A~ftietlx►F+ty Lot No. I Block No. \-4, qtr- 5Ti--ri O N-m County ubdivision Name Owner's/Buyers Name: ~Cs N N iS V ek- Mailing Address: -7t4' 54-c -z z 1 TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET 2- NAME OF SOIL MAP UNIT A50tt.tc 4A(LD-r CSAT'rc«~ 13.9 CZ PERCOLATION TESTS TEST HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES NUM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL RAT': BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 M11 ~P- FJZCc L~?toN TESTS Nc~T Co 9~~Z i i IL}~S tk)D1c_ A-re- SAW0 P- ► L r.~ P iTI o ti . t tc S VU ~n ftitR - P -13 Y uS oi'= `mac ~r P Yv i L P % kc 'P i s P- TL la)4 20 A2 `T.ti-C T rr.~ c , ~ J F 1)`~ P- E2 C Pe :1Z f- IZ 'Ccy 20 4et t~►v 1p h`` F^I P- T~kaiz- c~-tL_,, A- r__ t!d`~ c~ 6v A+.>oa-rr SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- t `7 Z. % a N'E. -7 Z 1 ~ 131 t- 75 i o" 51 l ' 8" G , ' U, w. ad - 5 B- z ~►ors~ 7 ZI B L Tii 'Zo SJ 6-, <7 ZI" B- "7Z > arJ~ `77- 17- g I- "rs 15 s,l IZ"Gw • 4o" w•ad. s B- 4 "7 3 oo a c 7 `7 3 1f~ L` rl l rn.L A- S B- s 73 N0t~6 -73 IZa BI L rs B_ PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. n-C- J~ S ~ G L A S 4 1 So t t` fzA-CK w V-CQ v ~aR = a k Zo S (es IS 1& Z pe& -BCD 1 nG l tai ~vsr,4 l ;r D i c A-rr-s 1"v-i+c c T, -r LP c e irr+ o aR C~rZoc?&-~' r~ o_eV . kkl pt 3 ~..3 ~GG.L~,fRt?5t.,~ n L(Z "r 3• *4- \ i c a N w__ • t ~4------•- r" 00 a z `~~_cii• O 46- M_ y _..rw ~ ~.riF ~~C.L►MM~I.3D iUSrAtrLp'f!~~~+ Q s p~ MiN AAVM T►U t Tc MAV- SeS-r uSt 0(r- 540a S V ISSot 1. \ pA4 tap C~ r4 t,,.L, iCD..4 I, the undersigend, hereby certify that the soil tests reported on this form were made by me in aq*ord witliifhe pf oplures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test oles aretcprre~ciNto 'the best of my knowledge and belief. L' ~r 401 1 v irs Name (print) ~qN L 1~~~.1(L~iA`t? Certification 6. ~5,Z7 N N \v e PAcu_" S c7 2, Address ~ Name of installer if known Pt1 v~- 1t • C J+~ t' `~o'~' S _ Copy A - Local Authority CST Signatur .0000, State and County State Permit # PLB 67 Permit Application County Pe f mit # z for Private Domestic Sewage Systems County ' yl- *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: : ~ % A/ Section T N, RLT% E (or) W Lot# City Subdivision- Name, nearest road, lake or landmark Blk# Village - Township t 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 Total gallons No. of tanks Prefab concrete- L Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons /Prefab concrete Poured-in-Place Other (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 Width. r ' Depth ? ' Tile depth (top) No. of Lines , Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land- r Distance from critical slope WATER SUPPLY: Private,K] 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.S.T. and other information obtained from (.owner/builder). Plumber's Sig ature ( e ' Phone r Plumber's F.ddress 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. , k . _ f _ f , F , E I z , c . 3~ Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application r~ Fees Paid: State County / l Date j Permit Issued/R ed (de'te) Issuing Agent Name 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