340 WISCONSIN ADMINISTRATIVE CODE 11,HR 83 Appendix · 2020. 8. 19. · 340 wisconsin administrative code 11,hr 83 appendix appendix chapter ilhr 83 wis. adm. code forms used by the

340 WISCONSIN ADMINISTRATIVE CODE11,HR 83 Appendix

APPENDIX

CHAPTER ILHR 83

WIS. ADM. CODE

FORMS USED BY THE DEPARTMENT

IN ADMINISTRATION OF THIS

ADMINISTRATIVE CODE

INSTRUCTIONS AND EXAMPLE OF

SIZING PRESSURE DISTRIBUTION SYSTEMS

Register, February, 1985, Nn. 350

INDUSTRY, LABOR AND HUMAN RELATIONS 341IMIR 83 Appendix

OEPARTItYE pF REPORT ON SOIL BORINGS AND SAFETY [r<a"" IS 01 11 11OHSTfl Y, OI L' 351 O'd

PERCOLATION TESTS (115) o;$°I5; 09HUVA11 RIEOLAI IONS .,,,°,{X63631118 Chepter 145.645)

LIX 4T10','/

SECTiO'1 1pi•r<II P!'u • .L Pa LITV OF r :0

I

S ?I,'t S nL 'f/i H/R E i^.IW

C OII•ITY r}1Efl'S EIlYER31I LE' r.'4 LI •19piTL SS....

--...., ^... .....,

VSE

._.... _-

0A1 E5065ERVAT10ti5xrA0E_ _

' _ R1].EFlRt4 0}e '^1 FnllAE nF v C IOY_

P90£IL£9ESf RIPII^`. E CLATIn41fsT,[

RATIW S-51—LdY1a1— V A S is pa_,eSY Ea lvsls-,

PIT i•1 {,RIXFAl RiE11tiHE Ti}3f En l'iF p^--.G i.t EL V'-r"E•E£[)S 'SEAL: •. --

l q uq s qu q s qo q s qu ^ q s q s q U

r f -

.k• Ha}Ok 511e1. •î • e' F..^ 3 ' E_.T ^ -

PROFILE DESCRIPTIONS

E`0 —4s........

TFIH I:J EL EYAIIO'r p £PTH TO GP U`..11TERI-HES E'HAn 4CTER ìC SAIL Jlllk"i}<{^.; r ;£55 C^1i J^1^SF YlllliE. .l^^(1 UEPSIa

!u.teER _p=DER VEp 1-a«IGHEST Tp 5E0RnC .:IF nÊERV[p Ê[.sEERY r{-. eP[^•

B-

B-

a

a9aK.3ral f1we Ei•16iTE5 -t

IJ.1,sETi._.p EPTHI tiLET.

WAIERiYHOLE5P1[R 5'YrE LS P.G._-_

1£41 TIC'£IHTESZV al 1r V

p4p PAIFA

tSl F}51!n LEVEL I'.^HES fl.11£!".HSF.KEEnI n PER 1'.L ri_

_sEPioRt

P

PLOT PL0. .1-<.-s.^+[ : • a.' :• s.l a x 1' . ^. _. . ..r r • .:c I..-..r

of- ,•a .E. <, e:.a.o, .«.,.:. <Ê.- ., ,.,r,{ .<a _, ,,,r l,t{„3s-.,,, ,I, r.Î,:....,.,,^r^ 1.:-.a •.Ir:^r•.., ^..1 {-.,. ::

1x+.l lty-. r - .

SYSTEM ELEVATION

t

!.[ «l ...fr•s^M. ezrebr <ert.l, t l'ass'eso.l[eitt r<V=+IF,r.-IS,,,;.-.n,.er,3is.b•r^..,e.rc+.l ntr,rr:,n:..I.......r-.r..l..r..r:...r...•.ti......-A^^-.H nrreea5<,a-a[«atx«eaa:a.:w.o-va-at«<Ixar^,or e^<uvL a•. cn<.a•L I, r>. e..t:,^.,^...,t,,. ,..II. ^-

liatr E Jp....•T .--. ,. .___.__._EES}•, L}FIF 11 e: .I

A ppPf 55_ _ _.-..

LEUi E ^ - 1. ... .F .:. ^!l

msrRISETI pv: n-, , r.r r, ....r. .1.-.4 .. r.= n.: ^, ••

Register, February, 1985, No, 350

342 WISCONSIN ADMINISTRATIVE CODEJUIR 83 Appendix

°^ APPLICATION FOR SAN ITARY PERMIT r

fPLB671 n s.,a n :urrrr=

-At1azhT 'rte P'= • -.^„3.. g ins Ii 63 G511 . s A . I,r C. .. ^. r>. •., ...*i >îf .11 .i.-Sae - Ts tl. lO r rl[,uci •J sf, • ,In zq u PLEAS EPHINT

_c g 6nFRTY LOCK Tro`+

1I4 114.5 , T , N, Fl E fos l l°J ir.:,•, cc

LOT r.VVEER BLOCK r.U1'8E R S`JE Ptt r^tt+': `:c4'f ^.F-'t`Sr Rlr>ti r <r ,t,ta Sr.,iF :.,.r rr tie.\'kF•'

TYPE OF SUILUIP:C OR USE SEfl1 Cb

I a. 2 F— I, 71 t-, of 18 •,.T,<

THIS PEH I dIT IS FOfl A

dl 5 I m F, H -.. r.l R

R I _nt S^ I ALSOfPI ,. K S,- H-, P- AH r al S lst.m H^^ P 1

IF TH1515 A CONVEddTlO'dAL SYSTERI CO:?PIETE THIS BLOCK

. Ssap>e EFS .. S. Pe , 5-. rPl H. .T..-

•-T• .:

-$YStemin Fdl_

l, G^^•^•t A...,,

3.Fnr50nch AF+c,_.E-t- 1, O.. F.`.. P,•^•J _ ...r_.,-_ A n IF S'rctxm Tr.JIH, I,8 --ii A-^ 11,C+-i 3'^^r A,F A,S If:•;.:.r!,^,

Y...r T -C-%-

I. P. 5.Ned • d r. r-^nr,

,r. rIF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK. . ^.I 1.. (I ..,..I P.,.,.,

Yee<T C <,

L at e P,. 5 C.-.:

t C

- ^ ^ —.-

:

FERCOL 1}O'<RAIf ESORPT ì'. KR EA KR»f«1+1'. aHE^,L ., ^_. uEOUifiEP Sr,.. F..,, nee,. z,BErr s,...^ ATFR $LiF LY

P.,, 1,^ P

L-IEZ Urif:rs^g f,-11 {ixrit,^z'a res(•^ni l"1{t,>, i . a.:,,.ltr,-I^.rzi.<a.,^^+t,sr.+rr s.^„ri..ît:rn"fl^,^î

COUNTY/ DEPARTMENT USE ONLY$ }',,..: a r,. t.,: ' .3 A,-•. osx^w..aQ

-;. G •rte I-: r^st

or^RSSPSJ33 iR SET• OtsTRipVllO4ft; _rsG,-rrO--C•.+r Tn. 6:e„.,ts-i ,p;.:^r^-,,.

Register, February, 1885, No. 350

SANITARY PERMITTRANSFER/RENEWAL

(PLB 67-T)

wm

'xJC

iu`G

OW0

COUNTY

`: ® I L H R UN IFORM PERMi7 R

zdc

r

J^..1

zdxiC

z

g'a H-I

YDv î

y50

to

W

PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:

NAME: SIGNATURE'. NAME, PHONE NUMBER:

ADDRESS: PHONE NUMBER: ADDRESS:

I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previousiy been approved for this

property.

PLUMBER'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGEDk',

PLUMBER'S ADDRESS: PREVIOLSP4UMBER'S ADDRESS:

MP/MPRSW NUMBER: PHONE NUMBER:

1 1

MPIMPRSW NUMBER: PHONE NUMBER:

t Y

DISTRIBUTION: Ong, ral - CountyCOPY -3 V—i. of Pl—tbinqCopy - Owner

SIGNATURE OF ISSUING AGENT: DATE APPROVED:

- -D t L H R -S B D-6399 (R. 5182)

Copy - Plumber

C4Ip.NN-

C'"

zr^c

z

z

rooa

ro

cD

SANITARYOUNTYk

m PERMITOWNER

CHAPTCR 145.135 WISCONSIN STAY11TI!l

PLUMBER

LIC. #... ... . .........

TOWN OF

LOCATED

17 11 1.17 111. 111 Z17l'.l.- 11 1-1:11Z11^1

SEC-T--N;R,-[-:

AND/OR LOT-- BLOCK

SUBDIVISION

PLB 68-T

COUNTY

z

TRANSFER /RENEWALOWNER

PLUMBER LIC.

TOWN OF LOCATED-

SEC-T-NR-E-

AND/OR LOT- BLOCK

---- SUBDIVISION

CRAPT[R 1bb,135 WISCONSIN STATUTES

GoP,zO

z

pay

YOz

C4I;.CP

346 WISCONSIN ADMINISTRATIVE CODEILFIR 83 Appendix

D tachlsstr tP.n twtl

eac And Return UpperSTATE OF WI5CON5l1j OILHRD1V1S1ON OF SAFETY & R1111MIGS

Portion Of This Form With`

BUREAU OF PLUMBING

Any Return Correspondence1 20S E WASHINGfO!i AVE. 661178

Y.O. Box M9MADISOU. Yr 153707

4 s1:u, s>>sDATE_

PRpJEt:T

FLAN rD ,.

of tncr, ,. t saa

PROJECT NAME .,.,_._. PLA!11D_v .............. _

Thls is to ackrt*wWge rt celpt of your plant and speoifiwtions for the above indicattd projam

Pre'.m^nary renew kndzares tea rayarri fae isS ..._Fee Hese-e:,j rt5

uME.p errant-Yeau L S tLtsa :t. a IK. qs--I a.t. ,. ;rt - Ref jfsL _ gq Pianar<.,ptedfprrt-•Rw, i_J Pa'.t tla l reswrsd.q No fax hall e -I'M _Rd b . :tledw•Ih no fe,t n-116, it A61 t:enar in'nm,t -+:n regv+ad. SE OELOW.

he'd in abafa-

1. N't y pm;siônA.d3:Yror.at i^!«mat:w'sh>'f bz saMn'.1ttd '^ du>» ca g e w

- ksi-speranca':y rates.[7 PI., nol6." 1. wi or pFrnsans.0 AI infumst:en su ..

M dsa'S to i', ai, da:ad a W ua:ad

a t,-PW;na j `tn `li H63Cat2)0l%v._inAdm.',;strati.e Cndr_ 0Mf-iar:t is L

11. Prnsunaa Dstnb,ton $}Stamd l !.LCâln Gror. AliFSSU•alO APR"shoo Irn rrse of an anerratire system r^ ai t, f on^.er

aM rotariri. tl wp/iU C—tv aM^te reP,,ed It r<,prl- 7 D> ;y, w!c^',I.-,^t

for Prasswire d'slr.butpn_ 13 So t bg&Mrcn,at.o•tZIA data.

[] Goss srctiat of seiSem, I^Y.pe la:eral Iaye^t_f] Plan rxw of system- I ^7P:ai p r an-q Vo. l.,at'w of 11,c,tm Stam Form br County . tt reprrl

UI. PrPEata 5,na7x U'sprul Sya!Emsq Gro.xef shpr .; zh 2' ro^twxs an E+,}re sea of sn 3 a!mP

lmr system eatend:ry 75' an a•1 sdex[7 Elarat^_ of pFrmanxni reference pone Iband k J,q Lerafoys of area nr Yab!x Irn repiavrrc-n y pro.+la

»'J Al.d[] M, lot siax std It lateral d.slan fro-

tenage csPOtaf system to a: Sn9s, £61 L—, waif. ..starmm'ry poo:t, watFr serrce pprg Etc_

q CCr4V^[t.On detail Pf Hpf%C. Fq?dn9 d RII N , kAfi le Cara Sruc[edw [ani: msmu Eacisner if pc-casl.

L Coratrictwn dala^f and uostaactwn of so,f afn^'ytimsystem_

L7 sal borir.9 an4 Perwlatlon test — ITS tnnp'Etad I-7 rartif--,M wit tnt" H Cove),

Ca pate d,ta rrralire to a.pttas r,, of tr 13.2tnPxs oI PLO W "M_f_

--'. Deed rastr.crvn re.r, .ad 11 crcf ICo^d.^. .m ds:r„at..,^ t 1 ac*r I

W. IKtlj nq Tlkl. ^ P,a1^'.e of }r..3 ng tank shen.rq sent, man`.a !x v' a^.i

-uf ,acf^rer ,£ p<-east. Co+p'<te Corr11-1 <n dxtm is .1pte r.,ns pace.

„ I. H>!drvj teA a^rer2 t s-Tai bf mn rNr aol Frial u--! us

_p;rnr.=^^t bn-szr erernsnit.Reston tar n7 fo'd-n1 ta-t. Scl lot 11 s._.n.- 1ft— , It rc011-P:at 0.1 sh1x 13 xatan of f.>'a -q tv-k n th talarar d.11ass I^ a-r n, td Wig, n ware• :< a I>P-1. ,r

I^t r..es sn r-.nlpoots, a:l neattar s:r a.cx roairEtc Pre.'dxtz-cY.TVkx-.tê',^.atm^re:ne:xe po.^1.

V. Ldt Ps pGrtv, at cs s For total lift P,mp d:sMSry, head a-^5 ga'4rs—1,xd ce 0,_S. .. kn^t h &depth of fctce ma n.Data I & rrad:l of ;.—P of aufcn^sat.< s•pMxt .'vl+! ^3

e,p,pa:' yat, Brand and a.a ,a K rate GPMLGass s<ct.ae of t£t p P —A sh ,,y W ,(o MbF1w,nD}-

VI, Sa E=ast In F,H U01 m br Va prwr to plan mg—)7 Ton1 a,,, £r--red 1 1 '1 1 to W" 2m heyond Asia of t=Coen

bxt«e Lda tr ope f>ag nl.[] Davh and t" nt f uj_

Coq7ofeobte report 6y o¢ if«dstrfct self.


INDUSTRY, LABOR AND HUMAN RELATIONS 347ILHR 83 Appendix

ce IA ^peL.^ Wixc.^sln keputmxntof Industry,Libor &Human Relations

Sa GetV & eu^!d^n^s Pie:san. eurew of ppxn6:n^

PAIVATE SEWAGE SYSTEM INVESTMATION REPORT

N— of P-

Q a b.I,Soe Tester Ak-e _

sn-, Penn ts Plan I D_No. Type pi

P:raon, Present al &'

Typo el 8u^ ld j; LL: Pub - ;L nSiny'2 Family [[IhaP'e%

B HIE F. FACTUAL COMI ENTS AND SKETCH

DISCUSSED AI Tff PLUM BER CST SIGNATURE

PATE OF INSPECTIONS .;âtê N 1 •.xectar

_ Lrca ts>[cto. G^tx•c+P.esca'S.^4 Garsuiexn eBO6 s]N 5811

Register, February, 1985, N0.350

348 WISCONSIN ADMINISTRATIVE CODEiLHR 83 Appendix

DEPARTVFkr OF IM1D95TRV, INSPECTION REPORT FOR sarE l+sEÎeulM1esLA OORdHWANRELATIO55 PRIVATE SEWAGE SYSTEMS IYISô,.P 0, e0%T}E3 6vfl Edl]9F Fotval,GMADISON, W1 53]0]

. CO]1VE NTI4'EAL ALTERNATIVE

H,'d nT Tz-.k In G—d Pressure Ll— T J

CI-

SEPTICTANCWOLOIN: TANK-

:- a' lul-

_.YES F.O I,I^ „. f _YES n ^hEAgE 1^ _ j_ I __

DOSING CHALV.

GALLPYS GET; CYCIF ^--- - "' NUVBER OF^ ^r•_s !i I +EI S _•,U

tDIF FEREM1{E BE TWffE FEET FROM I

'L VPON 0.h00FFl 1 LS 0 _,_NEARESTSOIL ABSPRPPPN SYSTE C ev. .. - 1 FORCE --ve.la.e•.o. Ili n^[e M d•,aw <.-^ .Ir, r e.n. r![rs ap9.a d-y er-.-i x^ c 1 NAIk

WNYFHT ONAL SYSTEM_ _ _ __ _ —

BEO7IRENCFE .. FIT ^. -_ -OJUENSIONS

=^^ I fEfT FAON —L NEAREST^^

V.pUH O -STTN.

Rrcu'a s e tt p'cf:Ed pErpend CU L T• }p s lr^: , c—, "1 to atule rd 11, f A }w ^ PROVJOLADJAGAAhIOFSYSTENSa •d luT—1 Thron-n v ps'4p3'. ..vf ss tt. ms h> m^tr c.rltn mn .E ON REVERSE SIDE. SHU.VELEVAmu

-. _ ^..+IS iF.a c•1•ri31n^•-.-J Vm s^ •i+l TIONS MEASURED.. YES ti0

FAESSUR12E0 DISTRIBUTION SYSTEU

BEDfTREHCHOJVERSIONS 1

E LEVATIO•NMPur016TRI _TN]N 1111 _.-^— --ENFORWTEON I ^ ' ^'

aSwY€5_ . 1.O YES

.

CONVENTS: ^^ ~• +"^ -- NV EER OF '-' 'EET Ffl ON }}

E.O_ _ -ES — F:9 ,HEAR

EST

,—iJ+,

S a ted, 5rs'e•n r+^ ^ RElt non Ea^nty }.1z lm d•^dl


INDUSTRY, LABOR AND HUMAN RELATIONS 349iLHR 83 Appendix

State of Wisconsin 1 Deparlmenl of Industry Labor and Human Helatlons

$4FEFY b BvitO^^v050^vi 6104

6ri,^ a^ Pr^.MyP O B±. )263

Plan Identification 1o.

Re:

Plans andspecifications have been received and assigned the above planIdentification nura6 er. Prelininaxy review of these plans indicate theplans have aot been sealed or stooped in accord with Se" ion H 62.25 (2)(a)or H 63.09 (2)(e), Riscnnsin Adn[nis trative Cade.

these sections specifically Indicate that all plans shall be sealed orstooped in accord with Chapter A-E 1, Wie—nsin Adniaistrative Code, Aaster plunber o

uo

Waster 11luaber restricted sever ray design and sabalt

plans and specifications for those syst—a he is to.ins tall. Pesch sheetof plans and specifications the raster pl—ber or as ster plusber restricted

r thansubai[s shalt be signed, dated and include his license nber. ilhere

rare one sheet is hound together into one volune, only the title sheetneed be signed, dated and include the license number.

Rather than return the plans at this tine, please have the party preparingthe plans sign the affidavit below and return to this office.

AFFIDAVIT

I, the undersigned, hereby certify that the plans and specifications sobxittedand assigned the above project nuaber were prepared by or under uy directionand control.

PL4`1E TITLE

(Type rior Pnt) ^rn'

RLUISTRA7101 \VXSER OR MASTER PLUMBER LLCEXSE x0.

SIGNATURE DATE

DILHR SBD-6212 (R.09/81)


350 WISCONSIN ADMINISTRATIVE CODEILIIR 83 Appendix

Plb. — 601/78

PROJECT DETAIL DATA SHEET

NAME OF BUSINESS

LEGAL DESCRIPTION

OWNER

MA1LINGADDRESS

Zip

ARCHITECT, ENGINEER,PLUMBER OR DESIGNER

ADDRESS

Zip

TELEPHONE NUMBER

1. Check appropriate building usage(s) and fill in the infbrmation requested oppositeeach usage listed. Please consult Section H 62.20.

Existing building Newbuilding Addition

{ } Apartments and condominiums ......... Number of bedrooms( } Assembly hall .................................... Seating capacity( ) Bar., .................................................. Seating Capacity _ # of meals served { ) Bowling alley ..................................... Number of lanes ( ) With Ba_r( ) Campground and camping resorts ..... Number of severed sites

.......................................................... Number of unsewered sites

.......................................................... Total number of sites-( ) Camps ............................................... ( } Day use only Number of persons

.......................................................... ( ) Day and night Number of persons{ ) Catchbasin ........................................ Number{ ) Church ............... .1111.......................... ( ) No kitchen Number of persons

.......... .. .................... 111................... ( ) With kitchen Number of persons( ) Dance hall ......................................11. Number of persons( ) Dining hall ........................................ Number of meals served daily( ) Dog kennels ....................................... Number of of enclasures{ ) Drive-in restaurant ............................ Inside seating capacity{ } Dump station .................................... Number of dump stations

.......................................................... Car-wrvicL Number of car spaces( } Employes (total of all shifts) ............. Number of employes( ) 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

.....11.1 ..... .............. 111,1......................... Number of office personnel

... . ....................................... ...........1— Number of of patients( ) Mobile home parks; ........................... Number of sites( } Nursing homes ................................... Number of beds{ } Parks ................................................. Number of persons

( ) Toilets ( ) Showers{ ) Restaurant ........................................ Seating capacity

.......................................................... ( ) Dishwasher and/or disposal?( ) 24-Hour service

( }Retail stare ........................................ Total number of customers


INDUSTRY, LABOR AND HUMAN RELATIONS 351II.IIR 83 Appendix

( ) Schools .............................................. Number of classrooms { ) Meals ( )Showers

{ ) Self service laundry ........................... Total number of machines( } Service station ................................... Number of cars served daily

OTHER.....(Specify) ........................

COMPLETE OTHER SIDE

2. Indicate whether the following facilities are present.

Floor drain yes no Number of drainsFlood waste grinder yes noDishwasher ' yes no _Automatic clothes washer yes no Number of clothes

washers3. Septic tank capacity

Holding tank capacitySeptic or holding tank manufacturer

4. SEEPAGE TRENCHES; Total square feet width of trencheslength of trenches depthnumber of trenches

SEEPAGE BEDS: total square feet width~depthlength of bed

SEEPAGE PITS: total square feetoutside diameterdepth below inlettotal depth from topto bottom of pit:

Signature of person completing form: FOR DEPARTMENTAL USE ONLY

Address

Zip

Telephone Number

Date

Register, February; 1995, No. 360

352 . WISCONSIN ADMINISTRATIVE CODEILItH 83 Appendix

VV-SITE INVESTICAHON FOR

CONVENTIONAL SYSTEM IN FILL

0 v' Y Nildi'AGs ate `f^ C) FePl.—e.t s7l L)Pwlo 0 Fesidentialtea

T, 11-1

T. IDT,

L F-bl-

Co.Pl'te ltr

E-1h P.-k EL—till ^ ll $ F1rA3hc7 Grale Fl—ti-

-PE

- - - - - - - - - - b

A-,

Cr —F—

B

C

t

11111-16 1 Atl.l tLiv

— — — — — — — — — — — — — — — —

1—v

E —Z

T— 1 I f t'.

z


INDUSTRY, LABOR AND HUMAN REILATIONS 3531LIIR 83 Appendix

GROUND WATER MONITORING;

REQUEST FOR ADDITIONAL INFORMATION

PLEASE PROVIDE OR CLARIFY THE FOLLOWING:

Cl Legal description of property

D Owner's name and mailing address

F1 Depth and/or location of monitoring wells

F-1 Monthly rainfall

q Daily rainfall data for Alarch, April and May

C1 Observations and reporting of data is incomplete

El Plot plan required showing location of all monitoring wells

0 Surface elevation of all monitoring wells

Cl Information regarding artificial drainage

Cl EH-115: Report on Soil Borings and Percolation Tests

q Data report form not signed by Certified Soil Tester

q Data not submitted on PLB. 119 form

C1 Data not submitted in duplicate—one additional copy required

C] Verificaton of data and procedures from county


354 WISCONSIN ADMINISTRATIVE CODEII.IIR 83 Appendix

uepactrent of Industry, GROUNDWATER safety 5 Buildings Uivisicntabor and u "

T

' n kelatfons NONITORMG 1, gnx 7969eurrau of I q u=ing Nndtson, Wl scnnstn 53707

REPORTlq [

co "h—te: "h— Ir1<ths

1

_

.

fm , i 'Whoa.'[,'cat fan: Vie. Bl nok Sn W::l , TV ["oH kl'RF(lrE r0 WAI F: RIh'tt:\I'1 4S /T N/R e(orlw 1 HtifkVATIOti I:1. WELL I Wt,l-I. WI:1,1Toxrytsh 1p Hunlcapallty: PAT r.

County: rei s^Nane:

Hailing Address: ^ -` ^"" ^ l

—I—__ --E._-

PROPOSED I&DI5'TDtAl.SUHnIVISION ^ LOT

8ainfa 11 Data Obtained From: I __

J4D5THLY DATA.. — _.__^

Sep[ Oct 1av nee Jan Feb Total (AS'S 'j^ - +

Parch April Hay Total (Seed 7.fi"1 j

wfa= rasr raf.r.n a,u as a <.ta as c.r wrâ, ,. <fT^ wr. +.. _-H.oa.ft< t.en rar<ran m, wr.t, ^îi w t. eee .xz< ti<...

-ItrIF[cvi trAisA:Ea.ri ab< ,u< t<r ,ravrrt q ar.[as.- Ir «. <sa< b ,te<. a.e ay ,_<ear,r<,e<. a .fe a^:taa. aas=. ru reP a:.[Ue. n,a<.. t.af<1<t<.a-

^^1.--

^w b< r«msesa raa .acauux< ,r ac< e<s<.xr ,tun. col er_:f3 'w .:rulru[ a. f^ r.f<r^te:<. rattral=a .aun<I r[ ar.a^,g

Jfe<a1q rLU ute. r< allaats.r gb 1. N[e s. atl rcz<S.-- —

— ---

`-

-

1^ (Atlra6 a 56T63i51411/ <, Sa^6b53 [[f a Arc —wtea s,`31+l.f caY, fir ,:1]f.fcry tt<a a^.i eaafvte; trYaL as LIg1 a< -^..aer c, l<a a:aal[ng. 5.ÀSY cc:i<a al a,e Lre:.Ea-.ter ika[acrlri fop:.[ [o rte k,reaa at YtcaSfee,Y.O. s-e r4i 3. Nsal,:-a, a'i Y3l^t aa4 rcSaft [ re7 ro ate Itt<1 ..tacrl ay.

^.^___^

IhntVI DUAL LOI PIA_V-provide a diagran shoving accuratenronitoring wells. aDIV1SI0N-Attach a scaled nap

locations and surface elevations ttf allshoving well locations and relative

elev(1 ijln. = 100 eR fe_r red ) .

{]]{

ati

L

ons,

I I _ I

i

, the unders [gned, hereby certify that the data xecarded andI tion tests reported on this form are correct to the best of my knowledge

and belief,hate: T

â1LHR Saa-5412(N.05181)



Plan Identification No.

Gentlemen:

We have received a (PLB. 119) Groundwater Monitoring Report formfrom CST for the propertylocated in the

Please answer or verify the following and return to this office. Monitoringdata will be reviewed upon receipt of this information.

1. Were you notified by the CST of the intent to monitor groundwaterlevels at the above-mentioned site?

2. Were the wells propery installed?

3. Provide all observations you made during the time the site wasmonitored.

4. Did the soil tester monitor the site according to chapter ILHR 83,Wis. Adm. Code?

5. List any comments or pertinent information.

Signature of Person Completing Form


356 WISCONSIN ADMINISTRXrIVE CODE1 1,HR 83 Appendix

STATE Of RISCOSSIX-DEPARTMENT Or INDUSIRY. LABOR 5 HUMAN REIATI4^SaMSION OF SAFETY S RC11 DINGS - BUREAU OF PLCSBItiG

P.O. g0)(7969 -

MADISON, $I, 53707

APPLICATION FOR TIIF USE OF AN ALTEMATIV€ SYSTEM

laca[io n: Township/Municipality:

Street kddress: s:bd ivis [on: ^^ cuun [t-:

Landoeners Na... .'Iailieg address: ^~

T(Ye), the undersigned, hereby Hake application for an alternative system ont h a above-deaerlbed premises. I recognize that the above premises are notsuited for a conventional private sewage system. If approval is granted, Ia rem to have the syet en Installed In conforaence with the Bureau's approvalof plans and specifloations,

I further understand that an alternative system Is more complex in nature thena convent tonal private sewage system And as auch will require detailedinspeotion during construction and monitoring after the system 1 5 put intouse. I egree'to permit both county offielals charged with administering countysanitary ordinanoea and Bureau employes or other authoriaad persona to haveaccess to the above described premises at any reasonable tire for the purposeof Inspeotion the construction of or monitoring of the system. I further agreeto either personally or by may agent oontaot the proper county official toarrange the time and date to tegin construction of the system. .

I understand that this application does not permit me (the applicant) or nyagent (the Contractor) to tegin Installation. If the system 1 3 approved, theBureau will send the applicant a letter of approval which authorizesconstruction of the Alternative system after all necessary permits have beenobtained.

I agree to give notice to any subsequent buyer that an application for analternative system has been made and if Installed, that the promises are servedby an alternative system and further agree to give the buyer a copy of thisapplication.

The Bureau accepts this application subject to thia understanding and subjectto all the conditions and obligations set out in this application.

Signature of Applicant bate

STATE OF VISCUSSIN Subscribed and scorn to before ne

.55.

COUIiTY OF This day of 19-

Socary Public, State of Wisconsin

DILNR-580-6513 (h. OS/g1} My Cocaiaston Empires:


INDUSTRY, LABOR AND HUMAN RELATIONS 357ILIIR 83 Appendix

OILRR SBa-6696(Plb. H9)

APPLICATION FOR DEYELAP)MT OF FIND PLAINDEPARTMENT OF INDUSIRY, LABOR 6 KrKAN RE[ArIONS

Lfhea the inetslla tlon of o acv, replacement or expanded private sewage disposalgetsn io propossd for n flood plain area, this form must be oonpleted addsubaittad to tha 47ep3rt. nt of Industry, tabor A H—Relations along with plansand ether necessary

OW4ER'S NAHE DATE

ADDRESS OF 5Vtt0ISG OR WAT104 OF PROPERTY

LEGAL DESCRIPTION

TOWNSHIP COUNTY

Is this system new T replacement _ expanded

Is areas

In iaglonal floodway? yea _ no _ not determined

In regional fringe flood area? yes no _ not determined

Coetiguoue to ground higher than any of the abovet yea _ no

What to the aatsblished regional flood elevation?

Are flood plain raps published and available or determined by the Department ofNatural Resources?

Has or will permission be granted for the following;

Fill required for buildidgl pea no

Building permit? yes - no

Sewage disposal •yatee (sanitary permit)? yea _ no

Action taken locally by

Comments regarding development (zoning administrator, board of appeal*, etc.):

Favorable Unfavorable

Special Recommendations.

Signaturest

County Representative

Department of Natural Resources

Department of Industry, Labor S Hanan

RZegister, February, 1985, No. 360

358 WISCONSIN ADMINISTRATIVE CODE11,1111 83 Appendix

NOTE: This document is to be recorded in the Tract Index at the officeof the Register of Deeds in the county indicated below.

HOLDING TANK AGREEMENT

This Agreement is made and entered into this day of19—, by and between the

hereinafter called andhereinafter called the "Owner".

We hereby acknowledge that application has been made for a building permit on thefollowing described property, to wit:

or that continued use of the existing premises requires that a holding tank be installed on theproperty for the purpose of proper containment of sewage. We also acknowledge that saidproperty cannot now be served by a municipal sewer or septic tank-soil absorption system,

THEREFORE, as an inducement to the County of to issue a sanitarypermit for the above described premises, we hereby agree and bind ourselves as follows:

1. Owner agrees to conform to all applicable requirements of the Plumbing Code relating toholding tanks. Any time the Town or Municipality of through itsPlumbing Inspector or Health Officer, deems it necessary to pump out the subject holdingtank, the Owner shall have same pumped out in twenty-four (24) hours, or

will have said work done and charge same back to Owner and placesame on the tax bill as a special charge. The Owner further agrees that the Town orMunicipality of may enter upon the property described above at anyreasonable time, to inspect, or pump and haul wastes from the subject holding tank.

2. Owner agrees to pay all charges and costs incurred by the Town or Municipality offor inspection, pumping, hauling or otherwise servicing and

maintaining the subject holding tank in such a manner as to prevent or abate any nuisance orhealth hazard caused by such holding lank, shall notify theOwner of any such cost which shall be paid by Owner within thirty (30) days from the date ofnotice and in the event that the Owner does not pay said cost within thirty (30) days, Ownerhereby specifically agrees that all of said costs and charges maybeplaced on the tax roll as aspecial assessment for the abatement of nuisance, and said tax shall be collected as providedby Wisconsin Statute.

3. Owner agrees to have a quarterly pumping report submitted to the local government andthe county which will state the Owner's name, location of the property on which the holdingtank is located, the pumper's name, the dates, volumes pumped and the disposal site. Anannual pumping report or the fourth quarter report including a summary of the pumpinghistory of the previous year shall be submitted to the Department of Industry, Labor andHuman Relations by the governmental unit responsible, per section 146.01 (16); WisconsinStatutes.

4. We guarantee that the holding tank contents will be disposed of at a site meeting therequirements of chapter NR 113, Wisconsin Administrative Code.

5. This agreement will remain in effect only until the santiary permit issuing agent inCounty certifies that the subject property is served by either a public sewer or

a septic tank-soil absorption system that complies with ch. ILHR 83, Wis. Adm. Code. Inaddition, this Agreement may be cancelled by executing and recording said certification withreference to this Agreement, in the Tract Index indicated above.

(OVER)

DII.HltSBD-6123 (8.4/82)


INDUSTRY, LABOR AND HUMAN RELATIONS 359TEAR 83 Appendix

Page 2

S. This agreement shall be binding upon the indicated governmentaNnit and the Owner orheirs and assignees and shall run with the deed.

WITNESS our hands and seals this day of

SIGNATURE OFTOWN OR MUNICIPAL OFFICIAL (Include Title):

SIGNATURE OF OWNER(S);

Personally came before me this day of 19—____, theabove named to me known to be the personswho executed the foregoing instrument and acknowledged the same.

THIS INSTRUMENT NOTARY PUBLICDRAFTED BY:

;lily commission expires:


360 WISCONSIN ADMINISTRATIVE CODEII.HR 83 Appendix

SANITARY PERMIT SUBMITTAL FORM

COUNTY

DATE

TOTAL AMOUNT

TOTAL PERMITS

PERMITS BY NUMBER AND DATE ISSUED:

This form must accompany each group of Sanitary Permitsupon submission for State Funding.

PLEASE USE ADDITIONAL SHEETS IF NECESSARY.

i3 tI.HR^-SBfI-b45) (N. 1180)



WfsconsFn De â allmant or ,®1^1 W

T

L p

DIVISIOSN Or AFEBT 1, BUILDINGS

lYfflll INl((^î`' IYi'linH

IP 11

', 111 pF p201 E. {Ii:GTON AVE, RM 178

lAdustq, Labw and Human R41oI s REQUESTREQUEST P.O. BO%7959MAOISO

WASP

PLEASE MAIL ALL R EOUESTS TO:53707

ar 17

FORM IND.: TITLE OF MATERIALS REOUE9TEp: ORDEREDY OU TITY

ORDERED SENT'SENT

PLO-68 SANITARY PERMIT

PLO 68t SANITARY PE RM( IT TRANSFER

SBD . 6358 PERMtITAPP. FOR PRIVATE DOVESTtC SEWAGE SYSTEMS IPLB67)

580-6393 TRANSFER FORMFOR SANITARYPERMMT(PIS 6)F1

SBD-6095 REPORT ON INSPECTION OF SA141TARY PERMIT

SRD-6153 SANITARYPERMITSUBMITTAL

SOD -6395 REPORT ON SOIL BORINGS AND PERCOLATION TESTS 1115 1 r

SOD -6421 GROUNDWATER M!WVTOFtPJG REPORT IPLB I19)

SOD 6369 R PT. ON SOIL BORINGS AND PERC_TESTS- SU BDTVISION(ED 441

SOD - 6413 APPLICATfON FOR AN ALTER NATI VE SYST EM {PLR-I DRI

S80 - 6 158 VERIF1CA1ION FOR THE USE DFANALTERNATIVESYSTEM

STATE USE ONLY-AsSIGNMENTOF SANITARY PERMIT NUYSERS5 oflii

Floc

THE FOLLOWING PERMITNUMBERSARE ASSIGNED TOTHEVOU 74 TY IDENTIFIEDABOVE

IPLI10) PERMITNO, _..,. -._—THROUGH&INI7LUDING—.,,_.__ —.._-_PERMITS

(PLB68Tf PERMIT NO._..._ ,. THROUGH&INCLUDING ___ ._.. ..__ _ _._PERAI17SCL4_[,o—_

w x..;

OF SANITARY PERMITS RECEIVED 00 1000


362 WISCONSIN ADMINISTRATIVE CODEILHR 83 Appendix

WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND 9"N RELATIONSDIVISION OF SAFETY & BUILDINGS, 8U g EAU OF FLwa1NS -

P.O. BOX 7454, MADISON, WISCONS14 53707

Verification of Exception Status For an Alternative Private Sewage SystemIn the County of

Location )/4, 1/4, Sec. , T N, R E (or) W l

Tohn or Municipality Street Address

Lot No. , Block , Subdivisicn

Landowner's Na.e:

The application for this site is for:

new constroction use,

replacerent system use.

If this is NEW CONSTRUCTION USE, the alternative private sewage system is:

to have one of the first five app rovals guaranteed for this year. This isnvz+er of those applications. (Use one of the first fivequota nurYers—f—ssu eJ —to you.)

lone of the applications needing a quota rusher, The quota ou^her assigned tothis application is

[ ?for one additional ho*e Site on a faro to he occupied by a parent, child,grandchild, sibling, niece, nephew, or first cousin.

for an Individual lot for which a sanitary permit was issued but was laterruled unsuitable due to new or changed soil criteria established by thedepartment.

ffor an application on file prior to February 1, 1980.

^,. for a lot that milts the criteria for a conventional private sewage system.

If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system isreplacing:

Î a failing conventional soil absorption system.

La hotding tank that was installed and in use prior to February 1, 1980.

q a privy that was installed and in use prior to Tehruary I, 1980.

If this is a REPLACEMENT SYSTEM USE and the lot reets the criteria for aconventional private sewage system, check here.[ _I

I certify that the above infomation is true and accurate to ttwa best of myk nowledge.

Nara

SignatureCounty UFficial

Title

Date

DKKR-560-6158 (R 12182)


1 -I

t4

..V...ii

CCx!Q

zd

zr^

^ y

aC)n z

C ân4'

Wer7

m

m

00vP,

x0w0

PRIVY INSTALLATION AGREEMENTNOTE: This document is to be recorded in the Tract Index ai the office of the Register of Aeeds in the county indicated below.

COPY TO BE ATTACHED TO PLS. 67 WHEN APPLYING FOR A SANITARY PERMIT

PROPERTY OWNER: MAILING ADDRESS:

LOCATION:

1 '/a S T N/R E (oo W

CITY, VILLAGE ON TOWNSHIP; COUNTY;

I (we) acknowledge the following privy installation conditions:

I. No plumbing will he installed on the premises, Plumbing means any piping, fixtures, ckuipment, devices or appurtenances in connection with water supplies,water distribution and drainage systems, including hot water storage tanks, water softeners and water healers connected with such water and drainage systems.

2. 7'hc privy will not he erected within 50 Peet of any well, s tream or lake, 25 feet ofa door or window of any building, 10 feet of the line of any s treet or publicthoroughfare and 5 feet 0f a property line. Set hark% not mentioned shall not be less than those shown in seniors H63.10( I ), (Wis. Administrative Code),

3. The privy will not he installed on soils that do not have at least 3 feet of soil below the bottom of the proposed excavation that is free oi perindir.attlr:Itiooor bedrock. Where these conditions cannot he met a vault constructed in accordance with section 1`163,18(6), Wisconsin Administrative 0 +de will he usod.

SIGN ATURI: AND TITLE:

4. The soil condition has been verified by an appropriate county official orcertified aril tester as signed here.

5. The privy will he installed: (hark one} q over a +oil pit q over a vault.

6. This agreement shall he binding on the owner(s) or heirs and assignees.

C^01 atom

STATE OF WISCONSfN

Personally carne before me this day of the above named

, to me known to be the persons who executed the fl oing instrument and acknowledged the same,

THIS INST RLMENT DRA FTED tlY: NOTARY ¢L1C: 1MYCOMMISSION SXPIR

D73ÎF^:^T^6432 (R.3/82;

364 WISCONSIN ADMINISTRATIVE CODE11,1111t 83 Appendix

OPTIONAL WORKSHEET

L `000 Mullw

A l ,.C,:-- 3 RRVIVIDE AUTAILED11ST OE 511r1G OS[ PLATS.

C

p:ffirlrze FIT--sw—w

B,jI

. , , ^: LAI mTl— h 5— t & Q

E,d TL—h D.,,, l F) I.T-I.. N111 JG l -

11up r.J T T 0,,,l 1.1) z IL

T-I Ullli ILL9-

I,'" % A. III

F,

Baal A^::Oaul A

11. 1151ria•i TT

TV

ILW.

Ad—C e—MOVII)FAIDEIAILLUL5I0F 5 I 2 I 1GG.PLAN5

Rk— K • jx,j

1:_-L" 0-

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If I% ck.11. P.L 11—T 1111, IT10 1.... s..

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Al, LU L"I "I5}1116 u1 PL T,

nl'% —tl 1 .1 T 11. 0

Leêre r ierzth= Ir.

IV, 51'5 TIE IT N J ILL— ^l A4111— lrc-r5„x Kn 111

V. SEPTIC FA% A

1.

I.

S. ,1 11 —IT U— --- F

VL U 1\1, TALK

7.

V II. IIf 113,111. tAlk

—SHOW ALL INFORMATION ON PLANS—

Register, February, 1986, No, 359

INDUSTRY, LABOR AND HUMAN RELATIONS 365ILHS 83 Appendix

®I^r7^"'k

STATE OF WtS AFET MIL

PRIVATE SEWAGE SYSTEMS iluill YOFPlpi SEND BUILOI^pS

V

PLAN APPROVAL APPLICATION201

ewissg ria .,m sa"Tsoeass^ts

I NSTRVCTiON S: A.,- 4,1E in d' 1 app!.rz b'e data aM 5"t-it this form with pl ans. Harts as ill not be re.:enai until all Ierr are 1eca;11 d.Ti talk 1 p41 of N:s form de I,L^s re : ,sd Nan inlormi['oa. P^wrdi+L} codas can be purM-d from the D rtmant dl AITti.%t,Z-,U tena nt We,. 262 Sauth Th-1- Ale ., M1latliwn, W.i[ens n 53103 . 7 a%pbs [508125&3355.

7. APPLICATION FOR:L' Cor.ans^pna153ste Publ;c Buddn;111 D P1rrct -.35r5lc-m 130 q Na!eey Tant leit7 ftepla.=eranl Press •,rired System fib] C7 8ryxcdn^nt A!our!d i4ay D Pzliibrl For ]leadifia[i6n (6};; 3{rw Presnsred S,ste.m f36i l7 Stsla^^s.n Fdl {11 L"] Otber Allarnatirest5y

FrinL"1 Syslnnin Flood ge111C7 G=dnates M1fonit-iNj)1

3. FEE OOMPUTATEONS flrsdud4 e.iatii fenlal 4. FEE SUBMITTED FOR OFFICE WENAKk ALL "IiCK3 FAYAGLE TO 01i3a. 750. 1,5004aub 5cpl-e task -30,00 4a.

,W)3h. 1,50]- 2.5009a:!on septic lank;

50t

-4000 4b.J<.

septe la-.k -55.60 4e3,1. 4,wI-8.0w 91'1. t.1,11" Talk -70.00 4d.3e. 8.001 . 17,0001n septic [x^k -85,[17 4e.3f, 1 12.00()9!'.L, aeplie tank -Itk300 41.

3a. 500- 1,000vTE do chambas -30.00 43.3h. t.001 - 7.OJ09allpndase ch"L> ' -3500 41c - -3,. 2,OOl- 4.0009a ! l-dose chamber -50.00 4i. -3t. 4.001- 5,000gallendasechamlZ, -6500 4j3t 8,001-12 OOO ga ppn dose chamfer -8000 4k.3t. Uses IZWO9d'-dose cha.mter -95.00 41,

3, 500-5,0009allan ho!drg tank -3000 4m3n. 5,001 -101 gxlson ho'd-n9 ml, -40.03 4,

30_ 0. dr 10.0009e. ia^k -50.00 4o.

7p . GrWrdnaler kl rilori 3Par LOt -32,00 4p.IcV,er than I lop," tubd:ji " S'AT.J

3Q. Priority Wan It, Ir.: f+sa ! k 1:1 3hl 4Q.&A- it[al of pans in parsont,,

ap!ao.nl me al. N'Th doub'21. .3r, Pebt,on for Ws 11`_tO.

Setback -70.00 4r.&tx eraûawn -50.00

Total F.

b1LlaR5 g 0614d 1K, 02331 NOTE: Feaf sub}ecllo chvye on Jury 1, anrKAy. -OVER


366 WISCONSIN ADMINISTRATIVE CODE1LHR 83 Appendix

Thd fo`4r. _y + rprmar^+ ix req_'.m far C •. a, rerrn. A+ v 4. fla; a pr each oa?e of shr p 'a-.x mJat b1 ayN, s°a:N a' dtlyd LY rF r deser.

6_ VOVS[9461H-00.OUNG PRESSURE Oi51111BUTION EYSTE:IV.S

SS-tipû._?? fw UU Of e+A':rrra'ê 5lttln 1piWR$4Dir1131 s'y-dd by On-tr e-+d wSariaad.

Sb-CP-,aY^.

k. Ye.^lrata-+torn s:yad by ee^^xy t[IILNR59P6150 F.

Sd. 115 GW'JCmV.

Er. Pal p'a+ s`.v.-.'a b[ sar .,1 a'J fe!rral d a ..... ter. w ...tce 9caa perrx-e+t uèr nta po-rn Diec-eê-d 4etert o1 tbPe e< [rea lycl tarp -.n r+wsl M 3cr,del prard fr+!^'+ ers.>.^ i fw Myo+M prau.n, sbw a-ea far rap'dce+xrvt if

fw rrw co+str^ct^c+. "o CO l E51.

51. P.a}rzn of st[re+a w'E Cbt2na !q+PPls I'd perira-rnr aa!e+el _'W. TTAI)cm E51.

fv 5tsrern cress seca:o-+ 1-0 CWl ESI.

E". Pi4 1a'tral IrrC^r TTAV COPIEW

5^. DVa! r yci ^J.R det IIJ a1 sp:¢ sa-4 ^! stern+s:^^<tad, o• msnx a acatrG if p: tlat.:tII!tp ITa}p tOilESi

`q. Oes ,y Cr'aFbe! mesa aKlc,va !T ee-aerueTm akta's .1 s tara"sv.<Srd cmtI [WI ES I.

5 1 , Prr.+G n! . n+oG.CLdo m3.<enw.e. aararerat"^.<kaad ra tclar"e:dr,:+',T:a'a dasa+o\._a EEYad cop ESI

Sr if ast 5!e,a uI, re I,. IC-.e+t e-al yna'esMa.,-t sax enfaaI fro +a x h -t In— sn ro[req_ r M.

6_ CO"ENTIONAL PntYATE SEWAGE SY3TEtll9

63 Eaâ^xr4Y Cf m:a l111

11 1 51 1,1 M. n 111 r39a's larrap'-II-1 sra'eâ,A rr.. ea:sxrêt ion_

6b Prs.2ct pltlJ Da!a S<eI prnitl.y aN sarq.^frmat4o tTAU CP MSI.

A-N Uratn, of aer ¢ fa'.i, s.t atJ»-Cren lasren rN-xa-eH wia. i •'d[aè y` .. tl'u1'srat to a,y M.'d.ngs - r. L —"

. us, IJI I,ra s. ere lrr W- VII m,:s[ x:w sèn r'<bcato+al Puma+.er[ a4.êetil-ataM •tracal.e[tre.+ce _'a WtnhrJri j . lm L+GU:aqn.M scPtw th Z faar ta•Jaws r e true... t +Sr+9 s9 75 tre[4+r'a sEis C f iw.l,al aN rayxe r+: ":xnp (TWO COPIES'.

69. P.a+rrw of to3 absxCra, rr,'.rn aàn.n3 a3 d,—a^,sa-s. Per le+;tba, 1pax-y, etc. IT1YG C WIEsl

G. Gov sttto+ at»J eEV..Mâ+ frs•r-,+hen na trrte,r e'entm, ail AS:e, coâr ma:a..at, tlrcab s. r.<. (TWO COPIESL

61. Co'slrxa4+detai Cf uC!<s>-a .1 ste ce ..e..crni. er rra-,+'mt.rer if yre a aM'rta:ed ITNO Coif E51.

63 Ekra1'e1!ra Pt+"r ra•t aw'UTaartO'a,.ta^ta+a. po ,a. pa".s's per cych, snr¢N l;fr, Frs[a^FS - etc ITAo COTIESI.

T. ROLOIHG TANKS

la.RC:CCCer Ca soxtisl ISx51 bT at_Af.tl Ces'W,ll of a'f¢P,xr stn. d:ry i^1ta+-ed.

To A:.eeT. e dia:+ -s be:rrtn vn-<r aN laal v.,1 GI y,•e. n+.ear, rcra• iaN a-..1 recv:ixd .+re'xre,c! [o t`r loll. TF;J syea,vnS+r aat L+cL+daer.a.rr•a WC+t a ne wvlVh CS^P.y reC^ _

Ic. PRr t; a+ s"ony r 'yea'<i^ el Tc:i.y la-.a n1 1a I!!xra' d, • hxxs la el [.rti.vA, ee:I, ware • servra y4.ry- va:ar [w rue lot l;ry etc. Prrr:draw4ax a' x-+i sRrtea t rr +e.r ca p>: Ja_ l,cl^.3x a • : neea>x ss.r.ce roxi w-S h:n st+ a eet el ahr urvae otrc [MV Coms)

Td Fb'tl'Tq II-k poer'< t`rn'-+g+a-J, i-s J..Ye, at3+.-r a+E r..ati xrêr rf peraY'¢a:etl. PAT4teta [a-snv<[b:v data°i rt stico+JWCItd. ITHO[011E51.

Tr. hp;<er Daryl Rata 9•xr var y.y rl se.y .!yr.}! G^ IMq C W IE57- Tr.c n rre ra:++t31w resLErY.Y L-,a!a r+at':c+a w`rn [na rur.+txr of brd.rc* irs ^^dreted C+t he tiara

8. EYSTErr3 IN FILL

8a_ Srr!e^r ., f.l m,a1 .-r ate e, a+rte ...eat=;a:aa Sam IOILHRsB0fi195Y, rs wa: l a: a'1 at aaa êPrll:a neTf Lettd a, ilrto-d 6.

9 GROUtidA'ATER NON ITURING

?e. ttS p CSxe py IMOCp^lESl

4a. G • prA+a:e• Mo+.tw+y Rapor l iUILRg 599Ei111 InAO COPT E$1

4. Vn,i¢rcn of tlata a^ procM.rn r,a+r <o:rry ITY1G COiiE57.

N. 4+n4ârc-+ tiara.

10. 1ETITION 10 11 M00111[41104

IOr Pr:.a:e Sena;e Pri[aa l c. a.W 1¢+FO+m IDILIIR 3EDE5331.


C l ^! L H R u1SCCNS1N kRIVATE 5EksSE 5r51EHL.I COUNTY UNIT® SEcm% b . W NSIN STATUTES

CALEN.:..1 YEAR 1432

I" 5 1 5rLN INSTALLATIONS 6 EASFECTi6 4

YES NOI, No Cf SyStE+S Installed in

YES NO Follea9n3 Cetep.n es:

A. Cw—tioaelas M) 1. Gravity r)-',e

2.Ingro.ra Fress,re

TES AlB. Alternlle S)sten

I. M), ra

' 2. Ir.groand Press,re

3. Omer

C. ws161a3 Tarts

0. Prides

E. Repalrw/Altered

F. 2e0 ateaent 7a'm

2. W.. of 5)sta.s Irsyxfed

a, vas ENery Systea InspKtedFrio to 8K01111

3. No. of coostNctlM Inspections

a. xe+

b, R,plm—,.t

NE4 No c. Repafred/Altered

.4. No. of Faillrg Syste,' Ins; ec[fons

5. Other Inspections)Specify In S,.x::ryl

6. Total No. of Irs;ectioos

IV. EVOpCV•EAT ACTIONSYES W

I, Canstuticr,

"-

"faire' 'o Orders

a. No. of Field U,rectl vas

TES M D. N). 9f Dlrextires C-pltad With

C. No, of Orders IsSUed(After Dile tile)

d. No. of Ord1lS C" Had With

e. Na. of Orders Taten to tarpC—se lICA

f, %o, of Orcers Enforces

2. Failing Syst. Inspections

a. N). of Fa)11n3 System mSp.

b. No, or Failing Syst bas ReplacedWE0 Orders

c. Na. of Orden far Repina dt

6. No of Sys[as .Not REPlecedAfter Orders

- e. Na, of Orders TnNen ca WCerpCN,.Sel

f. Orders Enforced oy OAICorRco,'"el

REP"CE- -AEW RENT

—of

YES NO

INDUSTRY; LABOR AND HUMAN RELATIONS 367ILHR 83 Appendix

STAY OF WISCONSINDILHR • RIV]SION Or SAFETY d 6UILOIN856.r+.CA:1 cA P"PS]NGP,0- FIX 7569MA715Oe, WISCONSIN 53707

1. W71 N0.1A:{ d F{RSC%NEL

I. [aa[y Ordl-Ne AdePtedl

2. Omfwce - Ldrq lies H 631

3. Cne ,es to and mince SinceAp9ro.al7

4. Cmaty Participtte5 1n ireWtscwsi n ryat

a • No• of Orders Issued

b. ND. df a—tS Applie3 Fpr

C. Na, of Grants Approved

d. ho. of Sy11as5 Installed

e. Na, of N,alntensxe ReportsRey tred

f. N). of Nsinten ,v:e R"rttF€led

g. ACV, Orders or Erfa rfemenLActives Agsinst An-Filers

h. Total Dollar Yalue of Grants

5, Total AK •oer of Staff

6. K), of Certified I"Peclars

7. N). of Certified Soil Testers

a. CST Co. Emplo),el

b. Na+, and Reg. No. of CST(S)

C. CST w Coa[reoV

Wl a and Reg. No. Of C51(i)

d. Cpnlract Availaale f6 Rerievt

ill TERMS

1. Na. of Sanitary P4mlts IsSUeden, 1, 1982 tnro gN M. 31, IS&

2. 63, of Porn Ets A2•• C". t,,Moz

3. No, of Pemits $fate Facilities

4. No. of Pe-its Rep lacenan[ (SAS)

S. RD. of remits ReplaceneA[(Tani Only)

6. No. of Permits for Repair

7. No. of PeM is Transferred

O. No, Of Pemit Rere-ols

9. N3. of Pe-

its Slot ittcd totie Depart—t.

10. No, or Pemits Rescimed

11. No. of Permit A;.plfcatlasReacted on Rerlea

DIM-560-6451(2.5/82)


368 WISCONSIN ADMINISTRATIVE CODEILlllt 83 Appendix

y. CO'ATf AWN1StRArION VI. RAYSiM FIELD AEMW

1. 6ailding Pemits Regvll" oy 1- Aa-:t Re riee in I- Field 5 Sy Ste'S InS[t111-

the Cu' nty7 YES NO Urxre Pery Sts Rele iSS,. O, rlrq (al-111 Year lvk.A[[arh Symary.

Z. Lamf USe trZoo log Pernit Iss.ed YES h+3ay t" Ca.nty7 a. Z of Ra r p3v Aeele.s In St ellca

as Snr.n t^ Plans _

d. ho.of rc-'s Refiring&,l Iding Pernits of 2. aerie. a R—M1? Ssl*le of Altl—Ltve

e, h). of Villages Aet7,iring

Systems IPStalled (1,rir.77 tre la{Efv^3 r fear-RI '-Iy Select 101 nr 5 5 ) stens, w, it fie"r

Sal Idin Pemits ofis

6rea ter, or A11 of t e Alternates if-" Less than 5 were tnstsllad.

C. ho. of Cities Rerylring

Oaf3di rq P¢nvTts of e. T of R—^ — Alternates InSLallel^'— as 5,-, oo Plans

3. Canty Filfng 5y 5t BV:VII. Oh-SITE TASTE SPTCIQIST OSE

ONLY

a. Ko. of Soil rest ReportsFuca Yrith Caonty I. Ka. of OrCe rs101recti ses ]ss: ed

O1 W^ Tn,S Ct"ty0. 1. Ores the CC, my Aa vied

All 5011 Test Rerart57 YE5 h9 2. No. of Sail Orsites by ffi5 This Co.

2. No dF {315} Soli AeerLS 3. hs. of Falling Sys LBO Inspn[icns

Ver if i ei in tre Field by CM Tnis tasty

C. 115 - Soli Tests ACCevvt e,i Are C0.WIetvJ 4. So. of CgnSlrici Tan fnsRealcfs of

Provenly: vy . 9 - f - P - sa C11S Tnis Cf,'nty

d. Does ttt C—ty Reviee All S. N], of Self—S Gy L.S Tnis Cc,o Ly

PlarS fu I_S 2 Fam, C.cllings7 YES h'16. Na. of Persons Atrendiro Sestoars

e. Dori I" fo^'ty Hera avEffective faiirq Systea FCr: Vill. Dt0q USE GhtY

1 1 I15's Befue Permit 3svia-1 YES h0 1- N^. of Solitary Pe- its Recelrei

2. Plans Cefcre Ccnstn.ctian7 YES lA 2. No. of Sanitary Pemits Sent to Co.

3. Plsts After Construction? YES No Fr4 110. Ta h^.

F. PLB 67's ACCePted a re Co spleled TOTAL = __._prpT'cr lyi: vg - 9 - f - p - Yp -

5. RKeip[s Total D.illars T

4. Ro, of vrittea Aotices of —^Sanitary Permit Rejection 6. Ala [a ClIty Oast"Med T

S. Ra3get 7. RauMsin Fu IJ Fc—s to Co Lr T_.

a. ReYCh a I— sanitary P—Itiss7ance

0. R—e Fran State Aids

c. Pews— from lospR tiro fees

d. Co.nty Pro-; rag Self S,PPCrlarqu Tat F—Rd!

Z GPA i PRO

TO TAL a-DGEr

e. Fee for C—ly S nitary Permit

1. Fee If difrerent forAlternate Systms

2. Fee if different fcrIbldirq Tats

J. Fee if different farAeplacetneet Taus

A. Fee for Inspection

S. Fee for YISComsio T,w

6. Fee for T a sree

1. fee for Plan Eaan

a. Fee far Privy

9. fee for Reraaat

10. Fee for Revision



Department of industry, Labor and Hu z-an RelationsDivision of. Safety & Buildings

Bureau of PkuebingP.O. Box 7969

Madison, RI 53707Tel. (698) 266-3375

IN ALL CORRESPONDENCEREFER TO PLAN

IDENTIFICATION NO.

NAME OF PROJECT

[]PRIVATE SEWAGE UN -q GENERAL PLUMBING PLANS Fee Received:

.Priority Plan Teyiew n y .

CITY OR rOWN N

Exaalnation of plusbing plans and specifications for this project has beencompleted. In accord with Chapter 145, Wisconsin Statutes and the WisconsinAWnistrative Code, the pluming plans and specifications are approvedcontingent upon coxpliance with the stipulations shown on the plans. Pleasereview your code for the requircrents of each code section noted.

The licensed plumber responsible for this installation shall keep at theconstruction site one set of plans bearing the departrent's st&V of approval.The installer shall also notify the appropriate inspector of xnen requiredinspections a re to be made.

In the event installation has not begun within two years from this date,approval will be void and rew plan approval Shall be obtained befo re work naybegin.

In granting this app roval, tnL Division of Safety and Buildings does not holditself liable for any defects in plans or specifications, plan o,issions orexamination oversight, and reserves the rfght to order changes or additions ifnecessary.

Tnis approval is based on Wisconsin Administrative Code require r2nts. Itshall be necessary to obtain and fulfill the pernit requirements of the city,village, township or county in which this installation Is to be raae. Failuretô

f

obtain local pomits will automatically void this approval.

Sincerely.

lôres Sarg t

Bu reau Dire or

Da

cc: CPS - OWS Owner M i, R & Ree. San. SectionLocal PI Pltw-l>er Bur. of Health Fac, 6 ServicesCounty Other

D1LNR 590-6099 (R. 05182)


370 WISCONSIN ADMINISTRATIVE CODE'ILHR 83 Appendix

rrrnsrna rw s[aei+Kai of an%1SCONSIN DEPARTMENT OF oEErfE USE OPiIreiâ=:ah ane R.:•e INDUS TRY, LABOR AND HUMAN RELATIONS

PRIVATE SEWAGEDIVISION OF SAFLTY 6 BUILDINGS -P.O. BOX 7959, MADISON, W 153707 I[h+o.

t'aceof oreer 9rni=[oe.cr.eea er V. is.ASCtYec.n7-1.11

t¢, Ca^-lr sr

rb^-a Plan\.r-^rrr llr%cc-.c) _rs

TIP, of Pe ti tion 5e[ B.ks ISa] Absarpticm EspzriRxntJa

Fee $ q and SeptK Systems] q Lot,fin9 Rates Site E.a!vavonc

LEGAL DESCRIPTION

Y.,_„_ %, SecBon , T N, R E (a) W, To+mship

Subdn;s?m N— C—ty

I. Rute of the Nysrors=n AdminBtrati, e colt rannu [ tz entirely sa .1W.6 die to the lldkaing rras,rr

2. In I"ofc—plyinge,actly p ith V7 rule, the fc4o'aing alSrrnllive is prnt—d as a me—Ap O,Eng an rWi,'a!ent drtirce,dfafe[y ar heal[h:

3. Sup"llgarV.en[s^Frnfilre.ilUatlpnf,irRlvdrFOrm115—"Repcnlu5alBwingandPe<ruatlonTestc "j

I



DETAILED PLAN OR DRAH'ING

COUNTY PERSONNEL AUTHORIZATION Ru!i Eeing petitiorsd

Ursiu [nspectSon eaMuted {date)

I, ,indicate V1 ineoematron wtt del on thisrewo form is accurate and Curets

to the best of my tno,.Wp and belief.

- VERI FICATION BYORNER—PETITION IS VALID ONLY I F NOTARIZED.FORtNfORMATION CONTACT TIIE DEPARTMENT AT (60) 266 3815

be;ng scaly'—, says he is petiti— herein, thus Fie has realthe faegn'ng"61;oo a d that the same is true, as FesenTy Mi—S.

Subscribe& and sworn to nu this day of 19—,

County, Nixonnn. Signature of o-.,rR"

.t-

My commifs!an eapers

OFFtCEU EOl1LYDEPARTMENT ACTION

SITE EVALUATIONS SET-BACK OR E%PERI MENTALDate Receised Amount Paid Rea<iptfio. Date Re0,ed I Paid eceiptNa

OeOU[nsent Aaron D2PUtment A4UOn

ADMMSTRATOR Due _BU RLAU Ilk flE SGNEE Data



As the sanitary permit issuing agent in the county stated below, I herebycertify that the following described property is now served by either a publicsewer or a septic tank — soil absorption system that complies with ch.ILHR 83, Wis. Adm. Code,

NOTE: This document is to be recorded in the Tract index at the officeof the Register of Deeds in the county indicated below, f

CANCELLATION OF A HOLDING TANK AGREEMENT

As the sanitary permit issuing agent in the county stated below, I hereby

certify that the following described property is now served by either a

public sewer or a septic tank — soil absorption system that complies with

ch. It 63, Wis. Adm. Code.

In addition, I understand that execution and recording of this document

cancels a holding tank agreement between the

and that was recorded on the _ day

of 19^ in Yolume page as

document number

Witness my hand and seal this day of

, 19—

County of

by (include title)

STATE OF WISCONSIN

Personally came before me this day of , 19^

the above named

to me known to be the person who executed the foregoing instrument and

acknowledged the same.

THIS INSTRUMENT NOTARY PUBLICDRAFTED BY:

MY COPJ41SSION EXPIRES:

Itegister, February, 1985, No. 350


DESIGN OF PRESSURE DISTRIBUTION NETWORKSFOR SOIL ABSORPTION FIELDS

To obtain uniform application of wastewater effluent over the entireinfiltrative surface of a soil absorption field, pressure distribution sys-tems are required. Section H 63.14 specifies the design criteria for pres-sure distribution systems. They are designed by balancing the headlossessuch that the volume of water passing out each hole in the network willbe equal. This is achieved by allowing 75 to 85 percent of the totalheadless in the network to be lost when the water passes through the holewhile only 10 to 15 percent of the total headless occurs in delivering thewater to each hole..

Since the design can become quite tedious, a simplified method hasbeen developed by the use of the tables and nomographs in s. 63.14.With this method, only a straight edge and pencil is needed to completethe design. To demonstrate the use of the tables and nomographs, thisexample is given.

Example:..

Design a pressure system for a soil absorption system consisting of 5trenches, each 3 feet wide by 40 feet long. The trenches are to be spaced 9feet on center.

Step 1: Select the desired distribution pipe length from the dimensionsof the required soil absorption area. Two layouts would be suit-able for this system. The distribution pipes in each trench maybe fed by a manifold along one end of the trenches or by a centralmanifold. In the first design, 5 distribution pipes are used, each40 feet long. In the second design, there are 8 distribution pipes,each 20 feet long. The first design will be used in this example.

Stop 2: Select all distribution pipe diameter compatiblewith the chosen hole diameter and hole spacing from Table 5.

Holes in %-in diameter spaced every 2.5 feet will be used in thisexample, though other combinations would be just as suitable.From Table 5, either a 1 %-in or 1 %-in distribution pipe is re-quired for a 40 foot distribution , pipe. Select the larger 1 !64ndiameter distribution pipe.

Step 3: Determine the total discharge rate of each distribution . pipe andthe number of. holes required by using the nomograph in Table 6.

Place a straight edge on the nomograph in Table 6 aligning the40 foot mark on the Distribution Pipe Length scale with the 2.5ft mark on the Hole Spacing scale. Where the straight edgecrosses the Number of Holes scale, read off the number of holesper distribution pipe; 16 in this example. To obtain the distribu-tion pipe discharge rate, realign the straight edge to join the 16mark.on the Number of Holes scale with the Y4-in mark on theHole Diameter scale. Where the straight edge crosses the Distri-bution Pipe Discharge scale, the discharge rate is given. In thisexample, it is nearly 20 gpm as shown. .

Step 4: Select the appropriate manifold size based on the number, lengthand discharge rate of the distribution pipes from Table 7. Forcentral manifold designs use the lower column headings and left



row headings. I<or end manifold designs, use the lower columnheadings and the right row headings. (If necessary, repeat stepsI through 4 until an acceptable network is laid out.)

The manifold length is that length of pipe required to connect all thedistribution pipes downstream from the manifold inlet. In this example,the inlet to the manifold is to be at one end. There are to be 5 distributionpipes spaced 9 feet apart requiring a manifold 36 feet long. Since an endmanifold design is to be used, the flow per distribution pipe of 20 gpin(from step 3) is read on the right side of Table 7, the number of 6 read onthe bottom under the manifold length at 35 feet. In this design, a 3-inmanifold is sufficient (See Table 7.) (If the inlet had been in the center ofthe manifold, the manifold length would have been 18 feet serving 2 dis-tribution pipes. In that case, the manifold could be 2-in diameter.)

Step 5: Determine the minimum dose volume required based on the to-taI pipe volume from the nomograph in Table 11,

On the nomograph in Table 11, the straight edge is placed on 1%_in mark on the Distribution Pipe Diameter scale (from step 2),and the 40 mark on the Distribution Pipe Length scale. The vol-UM of the distribution pipe isyead off the Pipe Volume scale. Inthis example, it is approximately 3.7 gal. Next, turn the straightedge maintaining the point on the Pipe Volume scale and align itwith 5 on the Number of Distribution Pipes scale. The minimumdose volume read off the Dose Volume scale is approximately 200gal. However, the final dose volume selected may be larger thanthis minimum depending on the desired number of doses per day.(See s.,ILHR 83.14 (6), Wis. Adm. Code).

Step 6:. Determine the minimum pump or siphon discharge rate from thenomograph in Table 8.

Using the nomograph 'in Table 8, the dosage rate is read from theDosing Rate scale by aligning the straight edge with 20 gpm onthe Distribution PiPe Discharge Rate scale (stop 3) with 5 on theNumber of Distribution Pipes scale. : The . minimum rate is 100gpm,

Step 7: Select the proper pump or siphon from the head-discharge char-acteristics described by the manufacturers.

The total dynamidhead of the network.must first be computed.For a ' punip system, this is equal to the elevation differences be-tween the pump and the distribution pipe inverts, the frictionloss in the pipe .which delivers the liquid from the pump to thedistribution system at the required. rate,.and 3 feet of head tocompensate for tosses in the distribution system. The pump ableto pump the minimum discharge rate at the total dynamic headcomputed is selected.

Siphon selection is based on the manufacturer's stated averagedischarge rate.' This rate is for free discharge,. Therefore, tomaintain this rate, the siphon discharge pipe invert must be ele-vated above the distribution pipe inverts a distance equal to theestimated distribution system. These losses included the frictionloss in the delivery pipe from the siphon to the network at theminimum discharge rate determined in step 7 plus 3 feet of head



to compensate for Iosses within the distribution system, Wherethe delivery pipe is more than 50 feet long, its diameter should beone size larger than the siphon discharge diameter to facilitateair venting.

Assume the dosing tank is located 25 feet from the distributionsystem inlet, and the difference in elevation between the pumpand the inverts of the distribution pipes is 5 feet. At a rate of 100gpm the headless in 100 feet of a 3-in plastic delivery pipe can beread from Table 9. Therefore, for 25 feet the headloss is 2.09 feetx 25 feet/100 f t = 0.52 ft. The total dynamic head of the systemis 5 feet of elevation head plus 0.5 feet of friction head in thedelivery pipe plus 3 feet•of account for losses in the distributionsystem. Therefore, a pump should be selected which is able topump at least 100 gpm against 8.5 feet of head.

If a siphon were used, its discharge invert would be elevated 0.5feet plus 3 feet or a minimum of 3.5 feet above the distributionpipe inverts.

In summary, the final design consists of five 40 foot distribution pipes,each 1%-in. in diameter connected with a 3-in end manifold with the inletfrom the dosing chamber at one end of the manifold. The inverts of thedistribution pipes are perforated with %-in holes spaced every 2.5 feet.The first hole should be located one half of the hole spacing or 1,25 feetfrom the manifold. If the last hole is equal to or greater than half the holespacing from the end of the distribution pipe, put another hole in thebottom of the cap or next to it.


Documents

340 WISCONSIN ADMINISTRATIVE CODE 11,HR 83 Appendix · 2020. 8. 19. · 340 wisconsin administrative code 11,hr 83 appendix appendix chapter ilhr 83 wis. adm. code forms used by the