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030-1050-10-000
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O 3 IV O N ^D fD 2 r = CD x y y CD rnm y Z d ni D O (n G f7 O � CD ' 0 O Q O 0 O b w CD CD m A A o O o O o O .. o �y O O' °O a 0 0 O- I, ti 9 7 - Wisconsiry Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 479350 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m) Permit Holder's Name: City Village X Township Parcel Tax No: Colbeth, Richard & Marie St. Joseph, Town of 030 - 1050 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /dr15 8 1x1'1 1 G j 22.30.19.193C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r Ue Benchmark 16-6 �Nt �-.. /d �. -11 / Aaratinn Bldg. Sewer F;1: Holding St/Ht Inlet ( c TANK SETBACK INFORMATION SVHt Outlet 7 . L 1 c W — 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic � 4-1 F ( T 7 7-7 I g ,' + p" � e g f 3 7 Z1 1 Z Header /Man. '1 cr'7, a Aeration wh. T Dist. Pipe 14 r 7 W Zllp C15 Holding Bot. System PUMP /SIPHON INFORMATION Final Grade 7 Z TZ -7 1 Manufacturer Demand St Cover, ` 1 S Q(p rd 0 . bG Model Number a.-- .7 el TDH I T Friction Loss System Head TDH Ft Tz� 9y. Forcem in Length Dia. ist. to Well SOIL ABSO TION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 4114 "7 � ^. G ` _�� \ SETBACK SYSTEM TO // P/L BLDG , WELL LAKE /STREAM LEACHING Manufacturer:A r INFORMATION Type Of System: I CHAMBER OR 1 Gdr��1✓ -r �A A j C ` �� /V UNIT Model Number: �T DISTRIBUTION SYSTEM JCS J / Header /Manifold Distribution x Hole Size x Hole Spacing Ve to Air Intake Pipe(s) ` \ LA eoe( Length 1 Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Z) ✓`� Bed/Trench Edges ` Topsoil �. � Yes D No Yes No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 660 Valley View Trail - Somerset, WI 54025 (SW 1/4 SE 1/4 22 T30N R19W NA Lot 2 Parcel No: 22.30.19.193C 1.) Alt BM Description= �� k 4' . � ( x ��e �_ G z 66d CAJ'� 2.) Bldg sewer length = G , L.. 1 b �L - amount of cover {� Plan revision Required? ❑ Yes to 0, T� I _ Q 1 75 Use other side for additional information. V YJ v SBD -6710 (R.3/97) Date Insepctor's Sign ure Cert. No. Safety and Buildings Division County ` 201 W. Washington Ave., P.O. Box 7162 S I ��O��a�� Madison, WI 53707 - 7162 rota Permit Number (to be filled in by Co.) De artment of Commerce (608) CE�VE 11 5<Q State P I.D. N mlxr Sanitary Permit A a i Q 20 5 A In accord with Comm 83.2 1, Wis. Adm. Code, pers p�L S ona fo 0 ou pro 2 may be used for secondary purposes Privacy Law, (I ) Project dress ( different than mailing address) TY 1. Application Information - Please Print All Information ZONING ORFI f • (f /9 G (� tr U/EW % 2, Property Owner's Name Parcel # t 1 Block 0 Property Owner's Mailing Address Property Location . �R3 ` 7 S %, SZ - Section City, State Zip Code Phone Number ir t7 S 21 - 5 'tia7 T 3O N: REo II. Type of B eck all that apply) Subdivision Name CSM Number ®l or amilyDw ^fling- umberoCBedrooms / ' ❑ Publ' to - Describe Use ❑ State Owned - Describe Use ❑City_ ❑Village ®Townsh p of $! . /y III. Type of Permit: (Check only one box on line A. Complettline B if applicable) A ' ❑ New System ■ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration 1% Plumber Owner 1 -� -71 q 2 -7 l IV. Type of POWTS System: Check all that ap 1 N - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Gro d 11 Holding Tank E) Peat Filter 11 Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Ching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other x V. Dis ersaVrreatment Area Information: S� . gn Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required 7(sf) Dispersal Area (sf) System Elevation V ' 3oa . 4135, y q9 1 4 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank — eatn it r 20 ( 1 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installs ton o e P S shown on the attached plans. Plumber's Name (Print) Plu s Signature M umber Business Phone Number Plumber's Address (Street, City, State, Zip Code) t /F Z VIII. ount / cpartmentltse Onl Approved ❑ Disapproved Sanitary Permit Fee includes Groundwater D Issued Is mg Agen Sign ure o tamps) Surcharge Fee) CPO ❑ Owner Given Reason for Denial S IX. C d' o ' /Reasons for Disapproval s�°I°1�R�v�F1� 1 p tank, effluent filter and dispersal �� V- � a t cell must all be serviced /maintained � t.-4 as per management plan provided by plumber. 2. All setback requirements must be maintained • ' as per applicable code/ordinances. / �`�A (� Attach complete plans (to the County only) for the system on papa of less than 81/2 it 1 inches in i SBD -6398 (R. 01/03) I pi/C 0i;: o�- ZN S//cc rlO v -43 r3� o ai o SC/j t o p f ya f u'ecc- N 1y r G G GiCs/2 2 flop 't Aeo � J SLOPIF /O /e QU aKgg 96' oa` vAf-L w& rR, f�i x Cce- ge7lye �ZAL,27 6 G / (/iFU-) 2 _ S-BG . IIAG t-E y vIerlU �• cSCJ 1" /? _5 t T l-CJ.' ,� yo,Z .s cS 017E S'� T _ U'� S ®, _ 0 2 2 /-y 4v :r !!e o Rio i �4 [� /"' s y0 wec� is _ - l %t Ex r AwpC� T ,A� r '�d� .2 1�liji��GC� cvvc/1 = 9B,SZ �Z � l © Sc.o � 3 _ I — o0 orrg 96 . - - V A C� w '- _�11���� _ __,Qty; - _ - - __�:�P �1►r� �y � -- -- � - -- -- - -- -- - 7V3 r REC q 1375 '' SOIL N REPORT Wisconsin Department of Commerce J Page 1 of 3 Division of Safety and Buildings -` ordanwitFi Co. Code Tom Schmitt County Attach complete site plan on paper not less n 8% & ' iQ St. Croix include, but not limited to: vertical and horizo al refer") (B percent slope, scale or dimensions, north a ntl did. Parcel I.D. 0 6 — /OS U J Please print all information. � Re m Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Colbeth, Rick And Marie Govt. Lo SW 1/4 SE 19 S 22 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # i Subd. Name or CSM# 661 Valley View Trail CSM Z 1 City State Zip Code Phone Number J City Village 0 Town Nearest Road Somerset I WI 1 54025 715 - 549 - 6701 St.Joseph Valley View Trail New Construction Use: J6 Residential / Number of bedrooms 2 Code derived design flow rate 300 GPD ! Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd /sgft rate. Possible system elevation is 94.85'. Slope of area is 10 %. a Boring # j Boring sm Pit Ground Surface elev. 98.95 ft. Depth to limiting factor 96 + in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft *Eff ll *Eff#2 1 0 -8 1Oyr3/3 none grsl 2fsbk mfr as 2vf .6 1.0 2 8 -23 1Oyr4/4 none grsl 2msbk mfr gW 1vf .6 1.0 3 2344 1Oyr5/4 none grs Osg ml cs — 1.6 4 44 -96 1Oyr5/6 none s Osg ml — — .7 1.6 c1 a Boring # Boring 16 Pit Ground Surface elev. 98.95 ft. Depth to limiting factor 98 + in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF *Eff#1 *Eff#2 1 0 -9 1Oyr3/3 none sil 2msbk mfr as 2vf,2c .6 .8 2 9 -28 1 Oyr4 /4 none sl 1 msbk mfr gW 2c,2vf .4 .7 3 28 -37 1Oyr4/6 none grsl 2msbk mfr gW 1vf .6 1.0 4 37 -44 1 Oyr5 /4 none gds 1 csbk mvfr cW 1.6 5 44 -98 1Oyr5/6 none grs Osg ml -- 7 1.6 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <,0 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt , 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 7/19/05 715- 247 -2941 Property Owner Colbeth, Rick And Marie Parcel ID # Page 2 of 3 a Boring # Boring Id Pit Ground Surface elev. 97.10 ft. Depth to limiting factor 97+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GEDN *Eff#1 *Eff#2 1 0 -8 1Oyr3/3 none sil 2fsbk mfr as 2vf .6 .8 2 8 -16 10yr4/4 none sl 2msbk mfr gw 1 of .6 1.0 3 16-42 1 Oyr4/6 none grsl 1 csbk mvfr gw .7 1.6 4 42 -66 1Oyr5/4 none cos Osg ml es — .7 1.6 5 66 -97 1Oyr5/6 none s Osg ml — — .7 1.6 F—I Boring # I Boring I Pit Ground Surface elev. ft. Depth to limiting factor in. Soil application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 F—I Boring # Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. ` Page 3 of 3 Conducted by: Conducted For: Schmitt Soil Testing Inc. Name: Rick and Marie Colbeth Thomas J. Schmitt, CST 227429 Address: 661 Valley View Trail 1595 72nd St. City, State, Zip: Somerset, WI. 5402.E New Richmond, Wl. 54017 Phone: 715-247-2941. . ,.;' Subd.Name: NA Lot No.. 7 - OJ' Legal Description: SW1 /4 SE1 /4 S22 T30N R19W ® Backhoe pit Township, County: St. Joseph, St. Croix County ® Bench Mark El. 100.00' Top of 1 1/2" pvc pipe Q Alternate Bench Mark El. 98.52' top of 2' manhole cover on existing septic tank Slope= 10% b. Scale 1" = 40' ® � 6 r ,a xil P r f \ ta' s 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 COL17,6 7 ( AS.1VrAI residence located at: Sec. _ , T JQ N, R W, Town of ST', �7o r TA ll St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No_X (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: 16,06 Construction: Prefab Concrete Steel Other Manufacturer ( if known) : tj 1 5 C , Age of Tank (if known) : 3> ��� s l 7 8' — L-- 'z abr4 LW - 2 (Signature) (Name) Please Print _ %,OI?S gZ17 3 - (Title) (License Number) 7- 7 -o ''r (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . �L Name a)VAO,nr r5C#1Vz7 7 Signature - MP(!n .01/7Sr3 r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSEEP CERTIFICATION FORM i t Owner/Buyer &C r oz 17A& fL-7 �' 7 /V i Mailing Address 11A 1_& O S - T Property Address 4 L ^ � (Verification required from Pla (ming Department for new construction) City/State r5 MAR S'e!F T Parcel Identification Number 030 - /D50 - lo" LEGAL DESCRIPTION Property Location 5W '/4, 5E '/4, Sec. AJ . T _2Q_ N -R_Z__�_W, Town of SL o Sd2;4om Subdivision lV A . Lot # Z Certified Survey Map # (e . Volume _ , . Page # _. Warranty Deed # �5��2 . Volume 132 , Page # 123 - Spec house ❑ yes ® no Lot lines identifiable ® yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. i The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. i I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 'pp L�� K_ 7 / 05 E' SIbNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. -k s e7 /a27/ O SIGNATURE OF APPLICANT DATE � e * * * « ** Any information that is mis- representedmay result in the saffitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed i i } ` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of ? � FILE INFORMATION SYSTEM SPECIFICATIONS I Owner R C _ Septic Tank Capacity al ❑ NA !1 — 7 Eb d Permit # Septic Tank Manufacturer O NA DESIGN PARAMETERS Effluent Filter Manufacturer O NA Number of Bedrooms O NA Effluent Filter Model O NA Number of Public Facility Units M NA .Iii Tank Capacity A j7 a l ❑ NA Estimated flow (average) J g al/day jbwp Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer Of NA Soil Application Rate , gal/day/ft' Pump Model ® NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ® NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD,) 5220 mg /L ❑ NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cells) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L R In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ® NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: O NA Other: O NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA ! MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ® ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal At least once'every: ® mon th(s) e (Maximum 3 years) ❑ NA Clean effluent filter ��� At least once every: ® month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA O yearlsl ❑ month(s) Flush laterals and pressure test At least once every: ❑ year(s) NA ❑ month(s) Ocher. _ At least once every: ❑ year(s) Y NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications ,� f Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Servicing Operator.' Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, a, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface F' The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding ^a of effluent on the ground surface. The ponding of effluent on the ground surface may,indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume . 'the entire contents of the tank shall be removed by a Septage Servicing Operator.and disposed of in accordance with chapter NR 113, .Wisconsin Administrative Code. - All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer. 3 , A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. i Page Z f _L__ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or-must be taken, to provide a code compliant replacement system: —r kll . /S ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to identify a suitable 'replacement area. Upon failure of the POWTS a soil and site evaluation must be P P performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. « WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTA Name C _ A-1j, Name Phone – fo Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ° Name 11 etj "Q r Phone Phone p' -. This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.540), (2) & (3), Wisconsin Administrative Code. t.. Parcel #: 030 - 1050 -10 -000 08/02/2005 10:42 AM PAGE 1 OF 1 Alt. Parcel #: 22.30.19.193C 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 * RICHARD A & MARIE C COLBETH COLBETH, RICHARD A & MARIE C 661 VALLEY VIEW TR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 660 VALLEY VIEW TR SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 1.956 Plat: N/A -NOT AVAILABLE SEC 22 T30N R19W SW SE LOT 2 OF CSM Block/Condo Bldg: 1/143 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 06/03/1998 580271 1328/523 WD 06/03/1998 580270 1328/522 WD 07/23/1997 1143/182 07/23/1997 1062/600 WD 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.960 40,100 112,100 152,200 NO Totals for 2005: General Property 1.960 40,100 112,100 152,200 Woodland 0.000 0 0 Totals for 2004: General Property 1.960 40,100 112,100 152,200 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 1014 i ►�� STATE BAR OF WISCONSIN FORM 2 — 1982 58 O2 ! WARRANTY DEED . I ; DOCUMENT NO ITL 1 Dip' Kevin J . Harmon and Karen K. Harmon as �I his wife and in he own right i St ,"Q O S O W1 I g � ST'.� QRQ(1C C�. VI►I �{ lied fur Aroonl conveys and warrants to �z, A. Colbeth a_ Marie C _ ;� JUN Q 3 19� Colbeth 0 a- as survivorship I� 8 30 A ;A narii al property -o - - -- I Utter of CNds i ii THIS SPACE R ESE RV ED F R DATA NAME ANC RETURN ADDRESS the following deschb?d real estate ir, S t. Croix County, Fri. c, State of Wisconsin: " li I II i 030- 1050 -10 PARCEL IDENTIFICATION NUMBER ft k� I II That part of SWkSEk Sec. 22- T30N -R19W described as follows: Lot 2 of Certified Survey Map recorded in Vol. 1 of Certified Sury s, page 143 as Doc. No. 327 I , l ii BRA VPFER �I i! .I This i s not homestead prvpeny. Im (is not) ty ' Exception to warranties: Existing highways, easements and rights of way of record. ' I ii Dated this day of M ay A. _ 19 i C \� (SEAL) 11 g1,4 `r (SEAL) evin J. H rmon i� (SEAL) lQ� 1 I SA/ _2 (SEAL) " Karen K. Harmon i II AUTHENTICATION ACKNOWLEDGMENT I Signature(s) State of Wisconsin, St C / 0 t 2E Count • ss� authenticated this day of 19_ Personally came before me this - day of May 19 the above named —� Kevin J. Harmon and Karen K. ' Harmon hushand and •taH'ftj�.•~ TITLE: MEMBER SLATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person : �_ whti exeaned-flit -y ping instrument a ow[edge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney David J. Estreen 304 Locust St., Hudson, W I 54016 Notary Public, e S_fCr lX° t r Wis. i (Signatures may be authenticated or acknowledged. Binh are not My commission is permanent. (If cot, §late ewpfr Lion date: necessary.) • Nunes Of persons signing i.: any capsiiy should by i% ped Or print:d below their slKnanues. ; WARRANTY DEED STATE BAR OF WISCONSIN 'Niscoren Legal aw* Co.. Inc. For-it No. 2 — 1982 Mn. auee. Wa. i.. s a c ..` i...ti •, 9 •i - { r S ,, .i - ° i1, f ^.rA ,. r X . F ._ t o ,� A 8 y � Ix S1 CROIX COUNTY SURVEYOR'S RECORD 3`7°' I CERTIFIED SURVEY MAP I, Arthur L. Wegerer, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and under the direction of Lyle Langness, owner of said land, I have surveyed, divided and mapped said parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed; and that this land is located in the SW4 of the SE4 of Section 22, T 30 N, R 19 W, Town of St.Joseph, St.Croix County, Wisconsin, to -wit: Commencing at the Southwest corner of Section 22; thence East along the Section Line 2640.56? to the point of beginning; thence N 0° 55 ? 00' W 295.17?; thence East 583.88?; thence N 00 00 SIT 640.23 ? ; thence East 454 .43'; thence S 0 °38 W ? • - t eT nce'7 S 89 0 33 t30tt E 280.61 to the Centerline of C.T.H. "It'; thence S 0 ° 4 8?00I 1 E along said Centerline 232.00 to the o of- centerline Section 22; thence West along said '3zuttr 1299.34 to the an existing Tov.T point of beginning. centerline Road Subject to existing Town Road Right -Of -Way and existing C.T.H. "I" Right-Of-Way. p Dated this 15th. day of May, 1975• a ltt L Arthur L. Wegdrer R.L.S. No. S -963 , ,,��.•`��� C O / S y'•,,�� EAST 454.43' 0 ARTHUR L. • t $ S• �`L� WEGERER S co ' 04 0 ELLSWORTH Wis. ir •....••' ND N£t 1 2 SUR 3 _ � 4 bntttttt O q LO 1$ JUN �� , c If .000 ACRES O S >u o ' co ,+wu Q yr. am , Z cn 6 SL CW- C.- h, Cq Wyowsi� O J K EAST 583.88 3 &q 295. 295.17 288.7?' o S 280 6 3 30 E: o f� t- W `(S. \q,. 247.60',- • o r� N. fti Q — ' — 2 iA ►� O \ o\ - 0 N' lG t0 O N L�O 9 . M ' LO N N N 2.001 ACR S N 1.956 ACRES O to N W. Q to N 01 Q' Z o5y 8 0 ' EAST 9 295.17' 288.1 ?' 682.53' 90 ap 2640.56'""" - ` e O • o, .. ...- r��N... rR4Ap .. COUNTY SURVEYOR'S MONUMENT SW CORNER SAC. 22 - 30-19 N - SCALE • I"= 200' H' 0 = 1" X 24" IRON PIPE WEIGHING U: 1.13 LBS. /LINEAL FOOT volume 1'Page 143 �n 0 �9 ��� Cy o e 3 = N N CD O CD c m O m O � v� A m O v O � v p � N W �• C 3 v C ( 7 (D ' C L W �_ F�1 j Q. z A y O '� U a fD z A y K y CD I p a 0 7 N O� A 7 N 7 ' O 0 ( o n c e n� o o no H (n O 3 N y 7 O O C < c < cn D A o d v> D W a �? CD (n N v, a m n y d m � W W c V CD o o < 3 0 = c c � 3 � to co (D 00 CVO Cn y 00 v N y w Q V) 3 3 3 z O g O O z O g O O 3 I 3 N� N g o N D a ca - m ' y ' 3 1 CD Pt Q A On O N C°Nn t0 'm 3 d d 3 d 4 N<, .. 3 <. W a 7 .w Q 7 .► z z N o z OD z z W � z Qy a O D a CD 0 O D a N C �m c cn (D w _ CD N CD CD CD _ W ' a W Q E- 3 6 n 3 5 z CD (6 z n a a vi d I A z 7 O O :3 m WW N (D N 0 CD CD CL c 3 a 3 3 m `° N � N p 2 M. S Cl O (�/1 Q y< y d O cr Q U) C C N C = N C v v o a ( f o a y O x u y? N y CD p� (D x a < 3 0 CD 7 N 4 " (D D �? x y vC 01 CL o m m zs no m CL Q' N y 7 M. X y y (D N C zni qb CD Q (D -- w 0. O O b (D (D pQ t f0 4 O 0 0 ti �y C C" 0 a. y Parcel #: 030 - 1050 -10 -000 06/10/2005 11:23 AM PAG 7 O F 1 Alt. Parcel #: 22.30.19.193C 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 " RICHARD A & MARIE C COLBETH COLBETH, RICHARD A & MARIE C 661 VALLEY VIEW TR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 660 VALLEY VIEW TR SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 1.956 Plat: N/A -NOT AVAILABLE SEC 22 T30N R1 9W SW SE LOT 2 OF CSM Block/Condo Bldg: 1/143 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 06/03/1998 580271 1328/523 WD 06/03/1998 580270 1328/522 WD 07/23/1997 1143/182 07/23/1997 1062/600 WD 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.960 40,100 112,100 152,200 NO Totals for 2005: General Property 1.960 40,100 112,100 152,200 Woodland 0.000 0 0 Totals for 2004: General Property 1.960 40,100 112,100 152,200 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 4 f S d ST CROIX COUNTY SURVEYOR'S R(CORD i3`'76C)l CERTIFIED SURVEY MAP I. Arthur L. Wegerer, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and under the direction of Lyle Langness, owner of said land, I have surveyed, divided and mapped said parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed; and that this land is located in the SW4 of the SEr of Section 22, T 30 N, R 19 W. Town of St.Joseph, St.Croix County, Wisconsin, to -wit: Commencing at the Southwest corner of Section 22; thence East along the Section Line 2640.56 to the point of beginning; thence N 0 °5510011 W 295.17 thence East 583.8$1; thence N 0 W 640.231; thence East 454.431; thence S 0)°3$ W 1 63 - 5 — .4-60 1 , ' - t eTi _nce: X S 89 0 33 1 30' 1 E 2$0.61 to the Centerline of C.T.H. "I "; thence -- S 0 *48 E along said Centerline 232.00 to the MoUtt-44-a.e ;ofd centerline Section 22; thence West along said - Saattr hi-ne- 1299.34' to the an existing Tow-, point of beginning centerline lioad Subject to existing Town Road Right -Of -Way and existing C.T.H. "I" Right -Of -Way. �p Dated this 15th. day of May, 1975 - Arthur L. Weg rer R.L.S. No. 3 -963 EAST 4 54.43' ,,,�.�`�```��jC .,�� ARTHUR L. WEGERER • 1n — • S -953 c ELLSWORTH p `�. WIS. 3 c 4 - �: sUN Ii .000 ACRES M iP U ') ° y jl�ac O' Comm, O J� O W y�owsi� O 8 L , N EAST 583.88' °' 3 eg 295. 288.71' o S 89 ° 33'30" p: os 280.61 0 ; I w ti • 247.60' - IN' �`� 1 CU LO ro LO N N 2..001 ACR S N 1.956 ACRES oo m ` W. O N N O: y - o• EAST Z �OoS 295.17' 1 288.71 , 682.53' 8 90 2 ap, 2640.56 """ 0 OIL o, M p � !N... :R4Apti ...WULT .....129 34 ........ ......... .. �. COUNTY SURVEYOR'S MONUMENT N SW CORNER SAC. 22 -30 -19 _ H: SCALE I"= 200' o = I" X 24" IRON PIPE WEIGHING 1.13 LBS. /LINEAL FOOT 1 volume I ' Page 143 �n • AS BUILT SANITARY SYSTEM REPORT OWNER , . 3ar Yf� 4 , TOWNSHIP Jj, � SEC. T N, R W P.O. ADDRESS RL' ST. CROIX COUNTY, WISCONSIN. SUBDIVISION , LOT LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 1 V 00 FEET OF SYSTEM N - 33' 1 3� f SEPTIC TANK(S) f f�� MFGR. CONCRETE STEEL NO. of rings on cover jVo Dept DRY WELL TRENCHES NO. of width length . area BED no. of lines 2 - — width length 3G are X32 depth to top of pip AGGREGATE �� �� %2 0J AS.y,&f17 PERK RATE AREA REQUIRED AREA AS BUILT 3 Disclaimer: The inspection of this system by St. Croix 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 THIS SYSTEM. "INSPECTOR DATED f - 7 t PLUMBER ON JOB LICENSE NUMBE 33/ REPORT OF ITISPECTIOII -- INDIVIDUAL SEI�IAGE DISPOSAL SYSTEM Sanitary Permit fie/ State Septic /Z�Z - TOT•INSHIP County SEPTIC TX.. ?K Size (Q O gallons. "Ilumber of Compartments Distance From: T•Jell ��(�_ SG f 12% or greater slope Building' _ ft. /S Wetlands ft ITighwater ft. DISPOSAL SYSTEM Tile Field or Seepage Pit(s) Distance From: hell SU f ft.5'o f 12 % greater�slope ft Building ft. ,5 0 Wetlands f. FIELD Flighwater ft. . Total length of lines t. Number of lines X02 Length of each line ..t. Distance between lines ft. idth of the trench � � �`� �� /�_ ft. Total absorption area O sq. ft. Depth ,S of rock below tile I2 in.Dg!pth of rock over tile i 7 1 Cover over. rock l Depth of tile below grade in. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to around water ft. c "Dumber of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: ___yes no. Total absorption area sq. ft. - Square feet of seepage trench bottom area required Square feet of se re nit ar'a quired e Y Inspected Title: Z Z14• Approved Date 197 Rejected. Date 197 i State and County State Permit # PLB Permit Application County Permi } for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OPFRT �Maili� Address: B. LOCATION: 57k) - 5 ' 4 '/4, Section �_�., T30 N, RJ?& (or) <gL ot# City Subdivision Name, nearest road, lake or landmark Blk# Village — � �� Township C. TYPE F CCUPA CY: Commercial *Industrial *Other (specify) *Variance Single family Duplex -a4k _ No. of Bedrooms Z No. of Persons / D. TYPE OF APPLIANCES: Dishwasher YES _, ?C NO Food Waste Grinder YES K NO # of Bathrooms_L Automatic Washer _YES NO Other (specify) E. SEPTIC TANK CAPACITY /QQQ Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement_ Prefab Concrete X *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _ 2) .X" Total Absorb Area JV3 Z sq. ft. / New A Addition Replacement *Fill System AWOAI Q '/ Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches j Seepage Bed: Length ALWidth Depth yX~ Tile Dept No. of Lines .Z Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land - 7—s - ° !d �', ,4r� Distance from critical slope :Mop 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 Cert' ied Soil Te r, NAME , C.S.T. and other information obtained from AbA4 S Plumber's Signature MP /MPRSW* y��-� Phone Plumber's Address .PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). VM • 4 ` o • � ate.. % m189' Do Not Write in Spa elow FOR DEPARTMENT USE ONLY Date of Application .7 / Below Fees Paid: State 0Q Count�r Date / 7 Permit Issued /agiwAad- (date) 1 ssuing. Agent Name Inspection Yes � -No Valid# Date Rec'd 1. county (ww'K copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) � Re vis e d Date 6/1/7 6 1 5: 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 TES,T[S .} LOCATION /a,��' /a, Section.t �, T—N, R/I Wor)�ownship or Municipality �! � Li a- s d Lot No. , Block County —QAK ubdi Ision Name Owner's Name: Mailing Address: . 42— TYPE OF OCCUPANCY: Residerr6elANOWW No. of Bedrooms Z Other EFFLUENT DISPOSAL SYSTEM: NEW A ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS f-.2-3-27 PERCOLATION TESTS rP SOIL MAP SHEET 2 3 SOIL TYPE Zj�gd!�/ .46AsaN PERCOLATION TESTS TEST I 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_ " S ee QYL / L © 3 S P 2 �� See Oroe /x- Xlb - S /Z .-/ .S P o X2, 0 3 S S' .� SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- 46" otter l6 3 vX S3'' S d-G r Z oKe� a S .2 o" 6 > " 9 I S a PLAN VIEW (Locate perco lat io n tests,soi I bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Ind' to nu b of s are f t of absorption area needed for building type and occupancy. °7 /D -� icatyscale 'A or distances. Give horizontal and vertical reference points. Indicate slope. �y - Sjts' •� f �.�'twtw. C' 9 k f "Air ,R 3 x t N aN V JIV 1 O O � 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) 4$ A ' w��� „"�� / Certification No. 5r /iT f Address 79 v e , a o s "_ v ! Name of installer if known ti.r, CST Signature 1 `nr' AUTHORITY AS BUILT SANITARY SYSTEM REPORT OWNL t _ "��j�'j /3C7! �/%�4�/ , TOWNSHIP - 5 ,T >�� SEC. T N, R W P.O. ADDRESS ST. CROIX COUNTY, WISCONSIN �E.P Is= TT SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM bar Ng� • l� ( V v i9' -6 SEPTIC TANK(S) MFGR. Ee &S CONCRETE STEEL NO. of rings on cove NO AI Depth _/ " DRY WELL TRENCHES NO. of width length area_ BED no. of lines width Zj_ lengt area �>31 depth to top of pipe AGGREGATE ,PERK RATE AREA REQUIRE AREA AS BUILT y� L Disclaimer: The inspection of this system by St. Croix 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 THIS SYSTEM. INSPECTOR _ c DATED _�7 - _ �/� PLUMBER ON JOB LICENSE NUMBER RE PORT OF IMSPECTI ON- - I SMJAGE DISPOSAL SYSTEM Sanitary Permit • • r State Septic 1 - 77 c n `.'.AHE .� } ���` �� , �i. �� L> e,� T&RISHIP St. Croak County SRPTIC TAM\ :size GL3 gallons . `lumber of Compartments Distance From: Well o f ft. 12% or greater slope /U'+ ft Building ' / ft. Wetlands f : liighwater ft. DISPOSAL SYSTEM - Tile Field or Seepage Pit(s) Distance From:* Well t. 12% or greater slope \J ft Building C' ft. Wetlands f ,: FIELn • `rLiFhwater ft. . Total length of lines :`► ft. Number of lines _ : Length of each line eft. Distance between lines i1- ft. Width of the trench ft. Total absorption area sq. ft. Depth of rock below tile in. Depth of rock over the in.. Cover aver .rock , Depth of tile below grade _ in. Slope of trench in ner 100 ft. Depth to Bedrock ft. Depth to Fround water 1 ft. Number of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: yes no. Total absorption area sq. ft. Square feet of seepage trench bottom area required `square feet of seepage nit aged Insnected�`_� - �= �.Y -•t -� � ��` � Title: � Approved Date 197 Rejected Date 197 l� PL'96 State and County State Permit # �! 7 Permit Application County Permit # 22- Z for Private Domestic Sewage Systems County Z ri *DENOTES STATE APPROVAL- REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNE OF PROP RTY Mailing Address: e,G G,e 6 sc,u 44-41' B. LOCATION: 4 Y SE Y4, Section �Z, T3Q N, R1 6 (or) Q Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village - 4,teesS Township Gf@ C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family )� Duplex _ No. of Bedrooms Z- No. of Person D. TYPE OF APPLIANCES: Dishwasher YES X NO Food Waste Grinder YES _&NO # of Bathrooms Automatic Washer _YES NO Other (specify) E. SEPTIC TANK CAPACIT /Q 0 f:7 Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation X Addition Replacement _ Prefab Concrete )C *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _ 2)_/3) _Total Absorb Area sq. ft. / New Addition Replacement *Fill System �f /Op aQu�Srl Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length _ Width iz' Depth je V Tile Depth " No. of Lines P'2- Seepage Pit: Inside diameter Liquid Depth Tile Size ' Percent slope of land .3 �yu Jt�� �j��CI y Distance from critical slope 01 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 C ified Soil ste , NAME C.S.T. # Ste d other information obtained from Plumber's Signature _ <42�r MP /MPRSW# 41/P3 Phone # 7.5� 386 - 362 3 Plumber's Address 0... Lol PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including. well). _Al h Bud • ��� �► /33` 3 Do Not Write in Space Below FOR DEPARTMENT USE ONLY ,• ©` Date of Application Fees Paid: State County Date Permit Issued /Red ( ate► ° Issuing Agent Name AL Inspection Yes No Valid# Date Rec'd 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) l _ Rev D 6 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 LOCATION:' /4, :�k %, Section %2X, UP N, R Z704or)(OTownship or Municipality 19/- JEW - Lot No. -2— , Block N 'V-- County 5x 61-0' 719 W bdi ision Name Owner's Name: Mailing Address: O/ TYPE OF OCCUPANCY: sidenc; / ' No. of Bedrooms 2 Other EFFLUENT DISPOSAL SYSTEM: NEW x ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS / � 7 7 SOIL MAP SHEET c2Fd " �3� SOIL TYPE lYb / if /�' OK -�`��� 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 — / 10 /4 /1C O -3 5 Ar P-3 Y" 5e e ore 3 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- l ig " �� - 7 B _ r.- .4ve- 12 ''s Gi- B _ 6" ocl e� " is W PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. I di to number of so f of absorption area needed for building type and occupancy. y��' 00 °� s:- dgA ziii"d�« Indicate scale or distances. Give horizontal and vertical referent pints. Indicate slope. 1:;21, Sy -6—A, � � er er o r -? 1 t- F S s e T ac s N D2 40 o 3 O 0 0 / k Y 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 an b Name (print) ` Certification No. SIT Address 1& Name of installer if known CST Sign a re ' COPY A — LOCAL AUTHORITY • PART ST. JOSEPH T 29-30 N:- RAI 9 W 41 SEE PAGE 5 - N ich oei4- ,Qicha .Pay Hou /e Emri+ -. CE p�j •� ,� 0 qco Sss s I;pl.:: • /o a. y 90 Ho d A/ 1 ' Ru CiSe -i C /ff 6 • q .eiv rti{ Qu p Wa an ,a 1-R `s, e/.,x ,Basil, e/a/ 17ona wig To hn g ¢ � had eo ine Schmitt �°'� ire o� .a9 6c7 :iy RE � k� LS oi'f/e/' LSchalf /c/• 2.37. •moo :� /:�::: + C • • �A 95 • CS 1 ° Uohn f% � ccde oit¢y tTohn r rr . ti 3a io g 1s.17 .Dyk W /zo • tSchotf /ei- �,c/xa y ` Q /ia Stout A3 NO. /o 6 2 a W o S. • � L, 300 W fZOS ,Picha d 3io btl E 'M Mo.'el z E u'Yawrzrf tl�Ly oo A s L-5 /7 17L 0 4 ° ' s 11 37 �.I • a AKE a }o ¢0 8 zs •� . ' _, b .L7o9 a ` tTDu isi� �s N .::::: ::::.. Se,ira W� ., �a� e a, - ros. •� Emm�tf E � ,9 ii�et :rawaTS / a r` S/oee fo � �� La.,yress so • • Ad V b owos BQ /60'� ' to � � Q Esthr.- w t • Bo �/ae Ray �' ((ff�� 9 ,Brown :: E qF /4SO43 ?te r 1 / /zo T. yy tl • Q (�o JO SOJ! �s :: ry , • iii _ ............. Wi /qam y Chu,- • • • E ,yo r•i/ n y £ Na scy Fe ra/sen HowA;iuon vases n ; � G✓isc ns:.� - yis.,s 7z•z/ zr797 orts f/,is, rchar - d f om (t• T C Ebba Ch�,'sYf pT l�ii7a RV P9 �s SM9A • L, //ia /7 U ,Sc°ei Ali L• q y B °. O • .ie9 N Deor s� N2turtz/ /rs /L . ,ON G ymP e , Pesoerr> =es 9z QtN Hun /,hy C/ub, u o Q, WILLOW RIVER ' STATE PARK ons. X37 URK '' h .: LS P • C/ .vc� �YY 96B FZOC rd Ma Pub /sin �/PCV /97y SEE PA G£ 27 cSf. Cr'ox CouatWie. �I �I �I BIRCH PARK WILLOW RIVER SKI AREA INN WHAT IS 4 -H3 Open 9:30 a.m. - 10:00 p.m. Burkhardt, Wisconsin Daily '/z Mile Northeast of State k Par Area Phones: Old Park 4 -H members choose what they want to do, Twin Cities - No Toll Country Tavern plan how they are going to do it, put their 439 -3723 plan into action, and finally, evaluate their On -Off Sale Liquor progress toward the goals they selected. Wisconsin 386.2201 715 -549 -6777