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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County -
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitaml!ermitNo.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 370353
Permit Holder's Name: ❑ City ❑ Village _0 - wrtnt I State Plan ID No.:
Northey, Paul I Somerset Townshi
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax Nn
too �' f cso • o ' . b: = CQ gwt 2 032-1038-80-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �4L Benchmark la 1• (5
Dosing Art,BM 4 (-4 IoZ•90 2.ZO Iro.�o
Aeration Bldg. Sewer
ding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet - —
Air Intake
Septic S� / �. cfp' -� -, ` NA Dt Bottom
Dosing Header / Man. 0 - q 5 '4401
(o • S' o
Aeration N Dist. Pipe ' (5 -- qs•O`
Ho g Bot. System ; 3•` 0'
PUMP / SIPHON INFORMATION Final Grade .�
Manafteturer Dema St cover
St cover
Model Number GPM tj , [ 5
TDH Lift o System TDH Ft L-j 57,1 qs- 71 r
H ead
For ain Length Dia. Towe11
SOIL ABSORPTION SYSTEM
RE Width Length r N . O re
f nches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS 3 °I3 - ?'S DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu �'" t u r r
SETBACK :
INFORMATION Type O p�,,,�pp����j, o e Num er:
System: C �NW, lam/ - .5 - T 7 }� r —�• CHAMBER OR UNIT CA
DISTRIBUTI N SYSTEM ,b ,� �'�`��"
Header / M / Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake
v
Lengt Dia. I
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 Bed /Trench Edges Topsoil C] Yes 11 No El Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection 4 1: 11 / I �Ll 0 Inspection #2:
Location: 652 215th Avenue, Somerset, WI 54025 (SW 1/4 NE 1/4 14 T31N R19W) - 143119194F -Lot 10
1.) Alt BM Description = �zt � d" 2.) Bldg sewer length = JP "� i5 �' "�/ l ) A (�0i s�
- amount of cover = 2
j " U pp
Ian revision requIY [:]Yes (0 No
Use other side for additional information. l l 2q- ap 6
�/ SBD -6710 (R.3197) Date Inspectors Signature Cert. No
S
�N
E4
V
Sanitary Pertnit APPUMtiola s. tlut It{tDWltiot
1 W. WAJItNKtON ova
to accord with Comm 63.x1. Wis. AQm. CWW pQ Dpu 7302
Sot roverac aide lbr buiuUttl-al rer cmrnplattnS this application MMOW rt. W1 33707.730'
ii.:e may '"' y , km$ for va"t' ary pnrpom
oaeiaru►es or C �/* rermai inforrnaaon. you prov
w e i 5 4 (�v0�u► aorr,ploud fbnn to ooarpy r
(PrivacyLaa J 0XM)}, _ tfw i
Attack eons itt tint (to the cunt ca r h rot lI 1-112 x i . nrit in lttl.
at . S4nit tt Nua"bor D t: �(revislon 0 prevtaut appllrati ltap Plan I. D. N WDW
T /
n- e P t all inormo on _ t"
�y t � La
uWalft j
1 5- - s2 21 S -,4
Cdr, zi Coft '�` Aliop� Nvm .r �t�I Ndiviri0n Or tl
0P C M , sy a l City
D V 111111 0 111 IuMW10mmer"�dewribt,veto)! of D
3'pf t1 (NM oft ' at boat on 11A+1 A, Clwalc a. on title 8 :! appiioablcl Na4rAta
A) 1. Q New S 0 RAplti.cmtni Of, 4. C AcIftep to P )
i tlril 5 k !atom
t Nurnbe�
wu ou 1
of POW T &**oa I (Cho& alt that uppiy) 'due s s'Z.
D Mound C Sand'Btlter C3 Conttntetad W40md
Lt•poind 0 Hotft Tank C 9inllt pool Q Drip Use
Aerol:ia'Cromintt 4a' Q i ui O Olher.
V901maratillill AM talpmUm. `— �
1. Ami 4. Soil'�on 3, ti�ars . ,yaroAa►i '� on s
�/ Rpuirtd Propon4 Rtr9�quis. •ary�aq. R t /%' lif�Aeioa
Yt Tmk pt' MonuAtetarcr Prchb 14110 PIWO
fltlbltal/tkttp of Iwo Ulom Tanks Can. Corp sun
Now ad cow itR oll
T ub
.rj C3 13
C
tedaiii ilbilti�t
i dm& PANIM d own As
MWWRS Na. B Wlnsfi " WW"
VM Coulty rat "t Urn Only
itl1""
C AW*vsd C Oww (hate Initial Adverse SwrAW Pa)
t7t CboditiM " A f IR,etilons for Dies roust:
A-L
446ts let.
s 4ic_- ('t'M.1c. 1 . 6-0 ?A,
"(It QVW)
PLOT PLAN
PROJECT Paul Northev ADDRESS 652 215th Ave Somerset Wi 54025
SW 1/4 NE 1 /4S 14 /T 31 ' N/R 19 W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/13/00 BEDROOM 3
CONVENTIONAL XXX IN -GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .9 ABSORPTION AREA 514 # of chambers 30
IL BENCHMARK V.R.P. Top of Nail in maple ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 93.5
Alt. BM Top of Nail in Birch Tree @ 100.0'
A Zabel Zeus Chamber
is to be installed to ST 01
contain the effluent
filter 50
Existing 3
Bedroom
15' , House
2 Well
7 •
.5 Vent, system has failed 0 Vent
18' >12" Sidewinder High
° 3' 125' of Cover
Capacity
0
0' Long 16"
6'
3 4" Grade at System Elevation
Alt
0 '
10'
95'
B -3 Site has 0% Slope and thus no contours
2 -3' X 94' Cells with >3' Spacing
35' B.M.
B -1 —E
Vents
100
110' ht
15th Ave
I
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of__
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
+
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). — ) E I 0 —Z3
Property Owner Property Location
' Govt. Lot - f4_) 1 /4 — 1/4 S/ / T / N R E (4 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
l � /D - o �# d Div
City State Zip Code Phone Number ❑ City ❑ Village .Town Nearest Road ,
S r � S ( � ,-b 7 - Sb'�
❑ New Construction Llse;ErResidential / Number of bedrooms �,� Code derived design now rate — _� GPD
eplacement 173 Public or mmercial - Describe:
Parent material _1�U/ a Flood Plain elevation if applicable
General comments
and recommendations: �✓
F-/1 Boring # [] Boring
19 pit Ground surface elev.� ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff#2
D z
3•�
63•� 9`t.
Boring # I-7�t Boring /
pit Ground surface elev., & ft. Depth to limiting factor !�2 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
,j-
t� �
;a .
6 3.1e
Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 m ` Effluent #2 = BOD 1 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signatur CST I Number
Address Date Evaluation Conducted Telephone Number /
Property Owner Parcel ID # Page of
® Boring # ❑ Boring �/
pit Ground surface ele ft. Depth to limiting factor Z in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDffF
in f Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Z -
5131 1 ,
3
F-1 Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth . Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
F-1 Boring # E] Boring
11 Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff #1 •Eff#2
• Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA. • 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.
SBD -8330 (R.6/00) -
Soil Test Plot Plan
Project Name Paul Northey Shaun r
Address 652 215th Ave
Somerset Wi 54025 C #226900
Lot 1 0 Subdivision ------- Date 10/13/00
SW 1 /4 NE 1/4S 14 T 31 N /R19 W Township Somerset
Boring Q Well PL Property Line County ST. CROIX
JC B To p or VRP Assume Elevation 100 ft of Nail in Maple Tree
System Elevation 93.5 * Same as Benchmark
It. BM Top of Nail in Birch Tree @ 100.0'
ST 0'
50'
Existing 3
Bedroom
House
12 WeWell-" 5,
70'
a Vent, system has failed /
a�
30'
30'
Alt 15'
0'
1'
95'
B -3 Site has 0% Slope and thus no contours
35' B.M.
B -1
100
110'
15th Ave
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567-P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number xo 3S3
Number of Bedrooms 3
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd) OV
Septic Tank Capacity (gal) I Vt O
Soil Absorption Component Size (W) Sob ' S
Type of Wastewater omestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Compo en
Design Flow - Peak (gpd) orlp t 7 - `A_
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
. � f
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
ST CROIX COUNTY
SEPTIC - TANK MAIN BNANCE AMEEM$NT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer'
mail" Addrtae � ocl�jq,� -ems S�a2 �!l' � c,� � 5 y d a t�
Property Aa
(Yodfieetion required ft um Pk=k g Department for now construction)
c /st 3a 10 3 y7r o
tY Parcel Identification Number
Property Lac a on Lt� Y4, r lt, Set:. T,,a)/ N -R2LW, Town of & t.— � .
Subdivision Lot # �.
p Card W Survey Map* # 6.4' . Volume
Watrmmty Dad: # �.��d . V Page # �` L
Spec house 0 Lot lines identifi*W 13 no
broper un said Hof your septic system could tesolt in its premature faa'lm to bs - -- - , wzd s. Proper mlluftu a
cousins of punqft oust d►e septic took every dwft years or sooner, if needed by a licensed pumper. What you pat into 6e system
can affect dw amuotim of dw septic tank as a treatment stage in the waste disposal system.
The property owner agrees to mAnnit to St. Croix Zoning Deparanent a certification foam, signed by the oww and W a
m i oarplu sim, }r teyrasa pluarbax, tesaiatedptuatber or a licensed pamper verifying that (1) the on-Aft wasWwwardlttposal fytttem
ism proper opentft coedit k a and/or (2) af3er inspection and pumping (if necessary), the septic tank is Idw than 1/3 fbll of sludge.
Ywe, the mdew*ped have road Cho above reWwmw and agree to maintain the private sewage disposal systeaar Willa. the standards
sat , herei4 as set by the Department of Commerce and the Department of Natural Resources, MM of WbO0116. t"„ottlf CISM
std VM your sepac system has been maintained must be completed sad returned to the St. cruix County Zoning Office within 30
days of the tbunae year expiration date.
1o, lz
SIGNATURE OF APPLICANT DATE
QWNF.R QEI =CATM_N
I (we) peitify ftt art statements on this form are true to the best of my (am) knowledge. I (we) am (are) the owner(s) of
rho property despftd above, by virtue of a warranty deed recorded in Register of Deeds Office.
2 t � � � - 2 " 9,5ig:: � � t6 I /z, Qz)
SIGNATURE :(O APPLICANT
s *ass« Any motion that is mis- represented may resuh in the sanitary permit being revoked by the Zouing Dopattmtscrc• �`" � «'"•
Iactatde trkh this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made is the warranty decd
Ub /96 /UU YKI 08:83 FAX 713 386 4686 ST CRX CO ZONING Ia1001
sT. CROTX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UT:LZZATION OF AN EXISTING SEPTIC TANK
This is o certify that I have inspected the septic tank presently serving
the residence located at 2I, A/ — W'
See. T R W, Town of .Sa— , St. Croix
County, Wisconsin. Upon inspection, I certify that i have found the tank and
baffles to be in good coaditi,on, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes_, NX (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: � a
Construction; Prof Steel Other Concrete �
Manufacturer (if known):
Age of Tank (if known
—"'
s
ra (Name ) Please P: nt
S
( Title) (License Num � O
�o --/ -� ✓ d
(Da
Form to be completed by licensed plumber (s. 145.06, Wisconsin statutes) or
licensed dispose' (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 63, wis. Aden. Code (exce t or ins ion opening over
outlet baf fle).
Name signature
MP /MPRB
a 'DOCUMENT NO. TM YOU PEURM FOR F& J71OW VAU1
WARRANTY DEED
c'O STATF, W OF WISCUNSIN FORM 2 -1982
4 72 G 20 vol. Wpm 294 RECISRRI
OFFICE
Edgar 0. Week and Laurel A. Wee"ghand and wife ST. CROIX 00.8 "
_ inint tanants Recd for Record
Ai I M P91
conveys and warrant b T Pa 11 nrthev and Lisa Wetterl ' na — M _ Northimy h mhand and wife as survivnrship marital 0 &,A
Pr RPrtx % N►oi0a06
Century 21 Somerset
Box 415
Ow kftwkV described real estle in St. Croi x Co Somerset Wi . 54025
State of Wisconsin:
Tax Parcel No. 032 - 1038 -80 (194F 1
That part of the SW 1/4 of the NE 1/4 and the SE 1/4 of the NW 1/4 of
Section 14, Township 31, Range 19, described as follows: Lot 1 f
the Certified Survey Map filed April 18, 1975, as Document No. 326436
and recorded in V olume 1 of Certified Survey Maps, P age 112,
according to the recorded plat thereof, Sc. Croix County, Wisconsin.
Abstract Property.
r:. A. 'j
�s 7 Yo
1^4_t
'F This i homestead property.
(is) (001)
i
Exception to warranties: Recorded easements and rights of way
Dated this 31 d of— July , 19 91 .
- -� I - e ' • _ t — (SEAL) :.., s E" i E'�' (SEAL)
• Edgar 0. Weck • Laurel A. Weck
(SEAL( (SEAL)
ACKNOWLEDGEMENT
f -
A �
�o FILED
APR Y >;' 1975
3 2 64 3 6 R
643 R 0 CO-eds
Cro
C. s U i
NE CORNE
SECTION 14
T31 N, R 19W
, NORTH LINE OF THE SW 1/4 OF THE NE 1/4 W
SSG 0 54'20 "E 780. 83' 179° 30' POINT OF BEGINNING 0 4.30'
NORTH LINE OF THE SE 1/4 OF THE NW 1/4 ° p N WEST
9 ?e 356.18' 342.02' a ` ^c�2?E'$" 7 ° , 2 „ M O
110' 6 °O� 1052.70' ° a 3
OD
0 � h m -
O
r Z c t0
W W .'.
? — CO
O
a 0 N 0 o III N 8 7 W
a * a 3 13 34.4 9 CE INI
LOT 13_ o LOT 12 Z co T 11 Z I STATE TRMI
u� d W HIGHWAY" 35
Z
5.02 ACRES 5.02 ACRES POND 5 . 02ACRES N` F LOT 9
s W Z
! ! +` Z 4!
148 003'20 p 0 p S MP J =
0.0 o� 00 ., aM SE 1/4 1/4 SW 1 /4 -NE I/_ N U .
0 ' a °� O A I 93 W 0
0
7. 69:A 342.00' 3 0 X33' 0
_N 87 0 31'W 7715."6 . p
80 4 t1� I LU J io in
M M M
70.53' rn M ASSUMED
D = 49°00' 32" NORTHERLY RIGHT OF WAY LINE BEARING
R = 85.00'�
TANGENT, � W � O 6 059'40 y S /w.4��i� +A1L�`rFsA
BEARING= � � FRANCIS H.
S 63 ° 5 9' W LEGEND r O GDB N
RIVER FALLS,
SECTION CORNER MONUMENT WIS. r0=
0. 1" X 24" IRON PIPE We 1" J ;
WEIGHING 1.68 # /LINEAL FOO �irib Ioo' god 300' 400'
SURVEYED FOR Edward Germain, Box 66A, Somerset, Wisconsin 54025
DESCRIPTION: SCALE
A pare -oT land located in the SW1 /4 of the NE1 /4 and the SE1 /4 of the NW1[4 of Section 14,
T31N, R19W, Town of Somerset, St. Croix County, Wisconsin described as follows: Commencing at
the NE corner of said Section 14; thence West 4.30 thence S1 ° 28 1 W (assumed bearing) 1860.88'
along the centerline of present State Trunk Highway "35" and the Northerly extension thereof;
thence N87 ° 31 1 W 1334.42 thence N1 ° 39 1 50 "E 540.72' along the East line of said SW1 /4 of the
NE1 /4; thence N87 ° 24 1 20 "W 1052.70' along the•North line of said SW1 /4 of the NE1 /4 to the point
of beginning; thence S6 ° 28 1 20 "W 636.62'; thence N87 °31 770.02' along the Northerly right -of-
way line of an existing town road; thence N66 ° 59 1 40 "W 132.9S' along said Northerly right -of -way
line', thence Westerly 72.73' along said Northerly right -of -way line on an 85.00' radius curve
concave Southerly whose chord bears S88 °29'40 "W 70.53 thence N26 ° 01 1 W 169.52 thence
N5 0 55 1 40 "E 454.10'; thence S86 0 54 1 20 "E 780.83' along the North line of said SE1 /4 of the NW1 /4;
thence S87 ° 24 1 20 "E 282.00' along said North line of the SW1 /4 of the NE1 /4 to the point of
beginning.
I certify that the above description and map are correct and that I have fully complied with
the provisions of Sec. 236.34 of the Wisconsin Statut s.
DATE: April 3, 1975
FRAM DE S -8 Map No. 5 -43
NOTE: ASSUMED BEARING REFERENCED TO CENTERLINE OF STATE. TRUNK HIGHWAY 11 35 ".
Volume 1 Page 112
0
tR;
V OF INSPECTION- - I4DIJIDUAL SE14AGE DISPOSAL SYSTEM
S 't Y Permit JO
• • r 4 to Septic
T&INSHIP �n
• t, Cro3A County
SKO TA 'M'
a... TI
C
Size gallons. `cumber of Compartments ,
Distance From: Well �� ft. 12% or greater slope ft.
Building ft. Wetlands f
Iiighwater ft.
DISPOSAL SYSTE: Tile Field or See age Pi
s
P
7
it(
P � ( )
Distance From: Well A ft. 12% or €reater slope ft
1, Builainr _� ft. Wetlands f.;
FIP•.LD 2.
Hip hwater �ft.
Total len t -lines AM ft. Number of lines Length of
each line _ ft. Distance between lines _6p____ft. Width of the
trench
ft. Total absorption area � 3 - n d. sq. ft. Depth
of rock below tile / in. Depth of rock over tile Z in.. Cover
over.rock Depth of tide below grade n. SZope of
trench in ner 100 ft. Depth to Bedrock ft. Depth to
ground water ,� ft.
PITS
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 ar a required .
Inspected Title* ?�
Approved Date 2 1970
Rejected Date 197 .
State and County State Permit #
,07 Permit Application County P�� it !6
�+ s for Private Domestic Sewage Systems County _ Cj
STATE APPROVAL REQUIRED
oval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
- F- J&ZAa Cv e, C, M "-
B. LOCATION: 56bA % Ya, Section , TX N, R E (or) Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# Village
CeA 14+k1V I-. ' 0 At Township
_ /Y f/
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) * Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder_YES NO # of Bathrooms
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation X — Addition - Replacement ` Prefab Concrete
* Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1),34 2) O 3) Total Absorb Area ��_ sq. ft.
New Addition Replacement *Fill System 114:96%u
-- v
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches 4 �j
Seepage Bed: LengthJ4 Width G Depth Tile Depth No. of Lines�
Seepage Pit: Inside diameter Liquid Depth Tile Siize
Percent slope of land 9 q Distance from critical slope
I
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 sys tem from the EH -115 prepared
by the C rtified Soil Tester,
NAME -Tn rfl" StaL C.S.T. # S and other information
obtained from (owne builder). __ � Phone # ��3°��� 9
Plumber's Signature M M RSW# -
Plumber's Address 0egG L
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord, with
H62.20, including well).
P, a
P` .
/% self'.
� -C
C
a
Do Not Write in Spa Beloow FOR DEPARTMENT SE ONLY
Date of Application i� ?� Fees Pa'd: State � C u '�` Date 6 ��
Permit Issued /mod (date) �� _Issuing Agent Name '
Inspection Yes -No Valid# Date Recd
1. county (while copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
R Date 6/11/76
'EH -115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH 7,
DD
P.O. BOX 309
t a a MADISON, WISCONSIN 53701
�t EPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION
TAN, AiLy Section , T N, R M E (or N Township or Municipality ''
Lot No. J-0 Block No. County
Suh ciwvrsion Name
Owner's Name: �t�i��l � �4k
Mailing Address: 2! —���� � `< �' —F4 ��-
TYPE OF OCCUPANCY: Residence — No. of Bedrooms — Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
**����
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS _ 26
SOIL MAP SHEET SOIL TYPE
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
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P o 0� 4 5- 1 s 5
2 C�
P— � ;1- 13
� P-
y �
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES ACTER F IL THICKNESS INCH
CHAR O SO WITH ES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
1 r{
a' Ff
Y
s' 7 .3c
k 4- .Z
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
CO Indicate on the plan the location and square feet of suitable ar as. I dicate numb r of square feet of absorption area
needed for building type and occupancy. �_Z ���� —�!� `1— Indicate scale
or distances. Give horizontal and vertical refererick points. Indicate slope.
Mir
ONG Se
Z O
G LA
op
v
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V) 0 t )
tdo 1 1000
£ G
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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) Certification No.
Add ress /
Name of installer if known
CST Signature
v
COPY A —LOCAL AUTHORITY