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Parcel #: 042 - 1051 -10 -084 12/08/2010 03:29 PM PAGE 1 OF 1 Alt. Parcel M 19.29.18.289A -17 042 - TOWN OF WARREN Current [X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 04/08/2009 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner 0 - HAUGEN, MARLYS A MARLYS A HAUGEN 957 HWY 12 ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description 957 HWY 12 SC 2422 SCH D ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 10.329 Plat: 5616 -CSM 24 -5616 042/2009 SEC 19 T29N R18W PT NE NE & PT NW NE; Block/Condo Bldg: LOT 02 BEING CSM 24 -5616 LOT 2 (10.329AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 19- 29N -18W NE NE 19- 29N -18W NW NE Notes: Parcel History: NEW FOR 2010; TAKES ALL 042 - 1051 -10 -080 Date Doc # Vol /Page Type (289A -16) NKA CSM 24 -5616; 10/23/2009 905869 TI 042 - 1051 -10 -084 (289A -17) LOT 2; & 04/08/2009 892781 24/5616 CSM 042 - 1051 -10 -086 (289A -18) OL 1 12/12/2005 813966 2941/580 WD 05/17/2002 679348 1893/324 AFF more... 2010 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations' Last Changed: 08/06/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 8.329 66,000 190,500 256,500 NO AGRICULTURAL G4 2.000 400 0 400 NO Totals for 2010: General Property 10.329 66,400 190,500 256,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: pecla s. • User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 31.75 Special Assessments Special Charges Delinquent Charges Total 31.75 0.00 0.00 RECE1VEDI llfll! I!II` I'jIi llf {{ Iffl l * zi 2 8 1111 I!I! f lll f fll fffi MAR - 2 892781 BETH PABST ST. CROIX COUNTY REGISTER OF DEEDS CERTIFIED SURVEY Mr VEYOR'S RECORD RECEIVED FOR A RECORD LOCATED IN PART OF THE NW 1/4 OF THE NE 1/4 AND IN PART OF THE 04/08/2009 03 :15PM NE 1/4 OF THE NE 1/4 OF SECTION 19. T29N. R18W. TOWN OF WARREN, CERTIFIED SURVEY MAP ST. CROIX COUNTY, WISCONSIN. VOL: 24 PAGE: 5615 REG FEE: 13.00 COPY FEE: 3.00 €�a,Z m z PAGES: 2 i < N t7f THE NORTH LINE OF THE NEI /4 OF SECTION 3 s 19 BEARS S89'42'5VE AS REFERENCED TO d p i 0 i v T HE ST. CROIX COUNTY COORDINATE SYSTEM ti a+ W pp b\ �� I \ I 1 N UNPIATTED LANDS ` 00'19'1 1165.24' Iz -+ 1 I � � �� s 1Z f r r- I a -\ .. ..,, r ,�,q )• {® �`� � Olt t o 1 J I SOD'19 47 W 1125.04 rq [E rn I a S� R 6 1" �� 1® O m S I N g V H j � I � � y � � � � � � f v V I iP 1 P Z vi oc If rc V's aa.oW I I O W �d - - -- F 8 { 8 is . 11 15 r Ir I N -+O S2 C A Il M EAST LINE OF THE NE 1/4 33 SHEET 1 OF 2 1 of 2 Vol. 24 Page 5616 n to p n co O - D 0 tv rn o m m m y w T n l< T •'• o c :r � m v ID 3 3 4 cn z X v z -p- .. S - S to O w to O ^T 41 7 <_ C C 3 C O -4 m N N N p.t [ ir l CD CD 7 m 7 (D IQ O m N O CD Z n o A N > > N W t C � ? Oo < N g 7 Q N p O m N X O N \ 4 _ U W O O C n 7 n Q 7 O A7 3 °i 0 CD � m o D 0 7 N m� 7 N ;:3. O 'I O C O m m m -4 w Z D ('p CD CL c (D c m W 3 = o o Cn �* N J ! O L v N N C Z 0 0 co co < n r to 0 1 m w w N N m N N N N! N rT S =r 3 lY m l�l • p Z 0 0 0 0 o o a o z - p nD =h m E m aq - 3 C) n N N N A p to U! N ! m ^� < a T 0 G cr < a G G y a) an d N a 1 CD m m v o 90 S y _ A y S y CA) O N ,. N CD w m C CL CL z ' A N r O Z a 0 w O D Cl) 0 :. (D N N m N (D • CD CD (a CD m CD a) CA 11 C m N C N N CD w a a a 3 7 3 7 z CD (o CD (b "{ CO) p ? Z m N n c �_ M v a a �'' G 0 rA T m m CD CL (�D a z 0 3 0 3 Z - z m W N N m a n w o w O N N O N 7 > CD p to S D N N p .-. O. C f0 7C 7 Q O O F N 7 m m (A N N < 7 7 ^ G 3 7 N d 'O 7 �1 N� m. y ° n N CL N m n O) � N m T m C , 3 _ C CD a N m 7 O G 7 d N O d I 0 < cnd 3 a 7 N N N O < W N N 3 w vp 0 1 � fnS rn gg nib da- > >zv 0 m D N m a s 7 0. 7 O :E =r (D �G N ? F r tp a p m O S Ct m m -{ ~ y o t S O O N? O O 'O m 'y O C m A O. CD m v m O N 3 d N 7 N Q O _ m O 7N_„ .3-0 N N 0 y O N 7 A OD O O7 b N A m m to O en O a a p � O a- ti ? AS BUILT L►ANVrAKY SYSTLM 1 kLVU 1 " \A, UWNER 1 U WN SHII SLC 11-1( w ST. LRUIX CUUNTY, WISCUNSLN subDIVISLUN LUT PLAN VIEW to MOCL requirctlictiLti U1 Hb3 RUI)w L h N(; WITHIN IUU FE"E"T UU1' SYSTEM xk'-A 0 Irlade NoithiArrow i s hLt. � -w � -zz rdforanct PUiLIL) DCULfibc: R&Aj. Elevation of verCjcm�,reftKancc pultit.-__Z 0 L s i L e . SEPTIC TANK: Manufacturer;- L I L l U I d Ca pa L; I L y Mu"wr of ringa on cover /,L,4. _ Tank jiwidmic C.L)VCr ClCV"L101k Tank Inlet Elevation: Tuilk OULIcL EleVaLluti PUMP CHMUR Man uf ac turer: NUUjbCL -A L 6,,'1A11Uikb Number of gal. pump uo or 6 "110116, LULA capaciLy t)f diULribution linism LA Lill bi/-C Ur PLA►11P 1►L:,►d I j. gallon per winUL6 , UracpUWC1 bral►d twilic: of pump and modisl nwubor lt Typo of warning day - fets HOLUING TANK; Manufacturer_ Numbul Ut gallult:3 Elevation of UMLRhOle cover '4 " 'ry - of �airnln& device SUPXE PIT SIZE: of pitz' E04CL liquid d6 uLe pit, Ildel jjij)c - bULLO111 Of badpaKe pit e lti vut, iUlk Sk.EPAGE BLD SIZg; nuzubar tit 11twu icct wLd(h /g' 1, LICpL11-3 SEEPAGL'TRENCH: widch '4"- IL:Li6 LIL 4� PLILCULATIUtj MIEA RLQU TRE D S BUILT UAII'ED—/&,/ PLUMBLk ()N LICLNSL NUMBLIk 73 DEP,ARTMr' OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS 1-91iOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX, 7969 ^ BUREAU OF PLUMBING MADISON, WI 63707 Pf CONVENTIONAL ❑ALTERNATIVE stme Plan ID. Number: (it aseelywid ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound AME OP-PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: ( SS BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: A Name of Plumber: MPIMPRSW No' coum nary mit Numbr: y SEPTIC TAN /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: ARNI LA LOCKING ,n 63 PR ED: PRO / G / z - 'VV /� -� ory' YES ❑NO E NO BEDDING: VENT IA.: VENT MATL.: HI NUMBER OF ROAD: ROPERTY WELL: BUILDING: VENT TO FRESH 1 AIN AI ET FEET FROM 6 ❑YES NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: NUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIOEO: ❑ ❑ ❑YES NO YES ❑NO ❑YES ❑NO. GALLONS PER CYCLE: PU M AN N L o PUMP /SIPHON MA NAL: NUMBER OF PROPERTY W LL BUILDING: VENT H (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) ❑YES 0 N NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: TAME TER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH N DISTR. PIPE SPACING INSIU DIA. *PITS. IL IQUID BED /TRENCH TRENCHES M PIT DEPTH DIMENSIONS `--� GRAVEL DEPTH - FILL DEPTH UIS R _ P IPF DISTR. PIPE IDISTR. PIFIE MATERIAL: N DISTR. NUMBEFIC F WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER. E V N ELEV. END. w PIPE 11 E AIR INLET. [L^Ts FEET FROM / -• �� NEAREST MOUND SYSTEM: O Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ OIL OVER TEXTURE: PERMANENT MARKE S: OBSERVATION WELLS. ❑YES 1:1 NO DYES 1:1 NO t.EPV:1:R TRENCHISED DEPTH OVER TR H(8 D DEPTH OF TOPSOIL DDED: EEDED: ULCHED: EDGES: ISO [- YES ❑NO ❑YES ONO ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH, NO. OF LATERAL ACING GRAVEL DEPTH BELOW PIPE. FILL H ABOVE CO VER: BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD U MANIFOLD DISTR. PIPE MANIFOLD MATERIAL : I ND DISTR OIS 1 DI THIBUIION 1 E MATERIAL & MARKING ELEVATION AND ELEV. ELEV. DIA. ELEV.. PIPES DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING I4ILLED CORRECTLY COVER MA ERIAL VERTICAL LIFT O ESP NOS TO APPROVED PLANS ❑Y NO DYES ❑NO COMMENTS: P ERMANENT J OBSERVATION WELLS NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES L_1 NO ❑ YES EI NO NEAREST t3 ri 13.5 t, . Sketch System on Retairyin county file for audit. i/��'�"`�' • �' Reverse Side. FGNATURE TI DILHR SBD 6710 (R. 01/82) DEP-AR TNT OF A PPLICATION SAFETY &BUILDINGS INbUS'FRY, FOR SANITARY DIVISION LABOR,AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. L� S , / / SD a w ArQ. c. it f ,t fr Property O wner: C I Mailing A p 1 ddress: s$O �s - / �i`bSF �aN site c` h y?0 a.k C r Property Location: City, Village or Township: 'Z %P St /3 s County: l✓UJ"' /a AEG' /aS /' /T p N/R jS E(or)ft Lot Number: Bik No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Num er• //i .f �- 4iy ! :2- (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance ❑ Other (specify) Bedrooms: 2tor 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: e — C— EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental E Seepage Bed ❑ Seepage Pit ' ❑ Alternative (specify) ❑ Seepage Trench Water Supply: ! Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: _ Signature: MP/ o.: I Phone Number: (71V 7 - J3 Plumber's dress: Name of Desig er: COUNTY /DEPARTMENT USE ONLY Si tFTure of Issuing Agent- Fe : (Do Date: PROVED Sanitary Permit Number: g ° l — I "$ ❑ DISAPPROVED `1 Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) { ..DEP ATMENT O REPORT ON SOIL BORINGS A f A r SA Y & BUILDINGS ' MUSTRY, /p DIVISION LABOR AND PERCOLATION TESTS 1 11 ?�,.�"�, ." P.O. BOX 79G9 HUMAN RELATIO S \ �MAD1 ON, WI 53707 (H63.090) & Chapter 145.045) LOCA ION � 1 /4 SECTION T OT NO. . NO.. 16 N NAME— tiw '/ /9 /T i9 Nip IF COUNT 0 WNE`RW8_ UYE A N M A DDRESS: Sal ai / � �o H�J E L I MAILING 7szS_ l'y,e c/ /31-vP \� .� W AIDE USE DATES OBSERVA NO. BEDRMS.: COMMEFlZ`IAL DESCRIPTION: PROFILE IL NCRIPTI NS: LA I N TESTS QyNesidnnce SC ❑New a lace a e / 2� / G I O e ,,4 . 3o / S'� 0 St/o / B41 440,01- H_A Sue suitable for system U= Site unsuitable for system \ /jo /j rc 0AIY -.a4 I ' ONVENTION/1L: MOUND: IN•GROUND•P ESSL""T STEM -IN -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ��S ❑U I ©S ❑V ®S LJU ©U I ❑S ®U ED 60/5 j -- -- II Perculauun Tests are NOT uired re DESIGN RATE: Q If any portion of the tested area Is in the under s.Hb3.U91b11b1, in Floodpla indicate Fl elevation: PROFILE DESCRIPTIONS BORING TOTAL H R ATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION TO BEDROCK IF OBSERVED (SEE A88RV. ON BACK.) EST. ERVED s- � •^ 0 3.9A y .- >d'' ` f /'� Q Ti � "' P. -t ". S'- . w .'04, I oc.ce s - � ■ W / to 3. owF �, / /, "op, • 4- v ` , / & / '• tl - .V. F.. Sa "ffL) , • r; �� L_ 11.41&k oCK � -S- s- 3 7 q f 1o" r a� ,;�, ��" Qa ZS Oe , 5/�7 ZoAM 33 / 0 /D�. 5 )for- 0 /Q`13.v , TI' ' h iNt SL F1 8 "A� p v • C. , /.I " .S.u, t_ , /( ' A. 1 , , /� ,• fW s w s- /00 9 7, /P -- > /or0 (rR "mix - d?- 04 ?Iwj 6 Cs w 104, pw- y/e . F , oK. /j,V. A p't 13 ••,e .).L, Il 41 A•I. - [,'o,.- 0A'. S. ' ; UR 7 ° rtr x . o f )"d p f1 /f,t) , 1 L , /( ,• w!, 9-, .12 "Z•1/ ,,J, IfL, /( i Alftr $. w B- /d 97 do . /o y -qfa M,x. es 3 . 11_ t. APC PERCOLATION TESTS is FT• TEST DEPTH WA T IN HOLE TEST DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER h4QA:S AFT SWELLING INTERVAL -MIN. — 1 1 PER INCH P. , P- P P- 0 s i O�- P- PLOT PLAN: Show locations of percolation tests, soil 0orings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hurt euntal and vertical elevation reference points and show their location on the plot plan. Show the surtace elevation at all borings and the direction and percent ul la slope aorlo m of iiip 7'D LiE &,mc ri y Fr 8 UEi4'T/ CifL /P6F. Poi.J SYSTEM ELEVATION /: e. 17- d2e 04 r /o.v of 9'1, ,p;� f r. rw F1414 TA0'0J lu AY �./ry b Wr 11�% , J s TN 4 Q� I' I f � h(o.Px •M ; l 3v' I IN h7 if r � :. i.l . u 0 nul 1,11 .f..17. n..,l ul..l .0 ul tf le IUUUInn ..1 Ilu Ir,:t., .0 1. ,.: , .. of :i . hl LLlvV u: LLJ IJnl u:l F � r : , w Af Arl s � s v _ uw,"« � GOr:�j�s� Ormlc vp i u s; 12- /CSI County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN G p In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(l )(m)] _ Hudson, Carmichael 54016 -7710 �j L —Q Z 3 a� L (715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system n pa - /2 x 1 1 inches in size. County Sanitary Permit # ❑ Check f revision to previous applicatio I. Application Information - Please Print all Information J Location: Property Owner Name /v �/ q� ST. CROIX COUNTY ff 1/4 Al 114, Sec � DoJ4 I M arm 1 ZONING OFFICE T . N R/ 8 WW Property Owner's Mailing Address Lot Number Block Number q5 ? u S t4 w City, State Zip Code Phone Number Subdivision Name or CSM Number �io 6e� -4 1�J�. SY�a.3 7/S 749 3 11 Type of Building: (check one) amity ❑ Village Mown of ❑ 1 or 2 Family Dwelling - No. of Bedrooms: , \\ ❑ Public/Commercial (describe use): W c6- r 0 State -owned Nearest Road IL Type of Permit: (Check only one box on line A. Check box on line B if applicable) 1 ,L C P L-3 °L Parcel Tax Number( J) A) 1.0 Repair 2. 0( Reconnection 3. ❑Non-plumbing . []Rejuvenation 0 q - 1.0 / / C' Sanitation Permit Number Date Issued B) State Sanitary Permit was previously issued 3.q 7 5 D << ' / g _ 8 -2 - IV. Type of POWT System: (Check all that apply) M. Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min. /inch) Elevation y� 6 - 738 '4 9"2 gS.yA6 I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks Lo 1.4, 10 0c, W ❑ 1 ❑ ❑ =0 / AW 241 13 -."1 la ❑ ❑ ❑ ❑ VII. Responsibility Statement 1, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationfinstallation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non - plumbing sanitation system. Plumber's Name (p ' t) f Plumber's Sig ature (no slam ): MP RS No Business Phone Number �- r�vr _ - 33� Plumber's Adress (s5rpt, City, State, Zip Code) B VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) x � Approved Owner Given Initial Adverse ED etermination IZ o ` �^ -" IX. Conditions of Approval /Reasons for Disapprovvaal� n �1 e ✓a/umo., pry ,2�� ` B ♦ Elcdaf,'on ZI U ""per WSd'n q ncsidtnC � QX, SE %�J �t o o,(' do v,4 d dent dccK I cJel/ G rade e q6✓ c-n-6 = 98. S e la = 9q.09' we wQy !7r Z70' i Kef•' /� 5� ■ 50; I e ✓al�� o,, p; � -�E- e /34 ,fence /'ne © , w .5ca /e 40 ' lit o o-' d ray; � 4'.-cW ()end residenc L c� e.t/ n� Stac.K. Ass",ncd e,le . = /Gb, cif' Grade elegy- 4 &✓e„t- = M-qz' SYsfcw, e leu' - 9q. 09" w /7r 1 70 '± 1 1556 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel LD. Please print all infonnadon. By Date Personal hdormabon you provide may be for sel ( Law, s. 5.04 (1) (m)). Z Z Property Owner R raperty Location Q. Dale & Ma Haugen ovt. Lot NE 1/4 NE 1/4 S 19 T 29 N R 18 W Property Owner's Mailing Address # Block # Subd. Name or CSM# 957 US Hwy. 12 OUNTY City State Zi CodeI City j Village or, Town Nearest Road Roberts WI 023 715 - 749 -3634 Warren I US Hwy. 12 New Construction Use: 16 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ;e Replacerme it Public or commercial - Describe: Parent material Glacial Till Flood plain elevation, if applicable na General comments and recommendations: Evaluation completed to determine conformity of existing conventional system and soils with current codes to allow addition /replacement of existing residence. Boring # A Boring 16 Pit Ground Surface elev. 98.26 ft. Depth to limiting factor > 108" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= *Eff#1 "Eff#2 1 0 -15 10yr3 /2 " none sil 2fsbk mvfr as 2f 0.5 0.8 2 15 -22 10yr4 /6 none sl 2fsbk mfr cs 1f 0.5 0.9 3 22112 7.5yr4/6 none sl 2msbk mfr gw 1f 0.5 0.9 4 42-65 7.5yr4/6 none Is/sl 1 &2msbk mvfr di - 0.5 0.9 5 65 -108 7.5yr4/4 none sl 2msbk mfi - - 0.5 0.9 Existing em = 94.09' at 52" below existing grade. * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 _150 mg/L #2 = BOD <30 mg/L and TSS < mg/L CST Name (Please Print) Signatu : CST Number James K. Thompson �� 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 540' 0 5/31/02 715- 248 -7767 SOIL AND SITE EVALUATION 1556 Page 2 , of 3 PROPERTY OWNER: Q. Dale & Marlys Hauge PARCEL I.D.# A.C.E. Soil & Site Evaluations REPORT MEMO Property owners are proposing to add onto existing structure or raze it and rebuild new residencr in its place. Existing system consists of a 1,000 gallon concrete septic tank and an 18'x 36' drainfield. Existing sytem elevation = 94.09' and is located in soils meeting the requirements of Comm. Chapters 83 & 85. All setbacks as required by Comm. 83 have been met or exceeded. a Key• `/� s� � r JCi ( e ✓�cca.� o.� �D � Elu/a�'on 00 rtisicknc st- o 04' cll^ v, e oen1L d¢cK i c7el/ Sbac -K. Ass"mcd /cb.co. 5y.r ena 21W. = 9y.09' 61 w Qy 17r Z70 �± A Q 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 o0 Number of Bedrooms Y .3 Design Flow - Peak (gpd) 0 Estimated Flow - Average (gpd) co Septic Tank Capacity (gal) /o 0 Soil Absorption Component Size (ft) Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 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 I . Se Management Plan for a tic Tank and Soil Absorption Component 9 p 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. � A d G � // t b 8 w :. 386 P - -7 P �- -►•�a, �Q S �.� S �.w� -e-� z44 - o / s. 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer D 14 Mailing Address U S W U / Z !� W• `�� " 14 s, to W gat, // Property Address 1,1-O 5C a 3 (Verification required from Planning Department for new construction) City /State Parcel Identification Number ° LEGAL DESCRIPTION Properly Location /V t V,, A/ E i /., Sec. 19 . T Lq N -R L W, Town of L-) Subdivision . Lot # Certified Survey Map # , Volume , Page # Warranty Deed # y 7 414 fl , Volume . Page # AW Spec house ❑ yes B Lot lines identifiable [a 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a maw journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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. 11we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system'% the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. cation 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. 7 1 , 7 1421-- IGNATURE 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 owner(s) of the roperty descri / D �. bed above, by virtue of a warranty deed recorded in Register of Deeds Office. 7 / ,R IGNATURE OF APPLIC DATE ** * * ** Any information that is mis- represented may result in the sanitary 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 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 � l�(a cc 9 le w/ residence located at: Al F—%, � Sec. ��, T _ N, R �p Town of d �j��� , 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 - (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: / Construction: Prefab Concrete v Steel Other Manufacturer (if known) : Age of Tank (if known): 3" (Signat e) (Name) Please Print cry oV�' 1, 7 g/ (Title) (Lic nse Number) p. : 7 — (Dat ) 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) . 1 10K Name /��y(/(�-y ��c V t��� S n ure -;'� / e� M PR ��Z !Z 4 d{!'r1os I�`> 4 ,. f K � 4 T � a - 11�Sprnta - te r AMINI�19i1�1.d°1F1%VWMWUI at m ,• � r � � 4- '�. •�• � -r ���' —; � yY! fir• �r ^.l�i!� rr a ♦ 1 • r. 1 1 •o co..�.cr- Iseaaaee t is lrs /t as WncMar —Four Na Is Melt Nw 141 ` 496160 This Article of Agreement, vot 097"4W pled& and eowit:ded :eb — ,_ __ �� �— — - � d _ 94 — _.n a.a93 i Alla E. Siak t old O. Hu E . She -- — and John i R ay s Inc., ", der No put. Ouin A-a,Bas�en_An�liarlysl! ` ttauQea,hnaband aadstif i as j oint te an d not as te nan ts :n commo pre i�_d tas So prt. wrrxs cm; slier. Tbat me sad part iai of tho "Mond part busby apse _teed mud _ themsa] Stl4 t heir boa repres.ntatine. tow. m a.m. to w paw. to the ad putietd the ens wt. _ �hQir bo;aaaeps. The , o, �i irtY Thousand and not 100- - - - - - _j� Qa��QQ�_Odisri. Four Thousand Five Hu ndred and ro /100 -- 4$4,500.00 D attbseesYbotowddleseybenol. and the balance of $2S,S0 intere thereon at the rate of ten percent 4101) per annum, pa ble • as follows, a to -Witt $250.00, or more, on the /•t. day of 1993, and on the /om" -t day o each an every mor.t t Brea ter until the October 1, 1997, ww en t entire remaining balance, together with accrued interest; shall be due and payable. It being understood that said st:inthly payments shall first be applied to interest and the balance applied toward the reduction of the principal. It being understood that interest on deterred payments is to commence on ` ACA- as YS3aLdOMLnp.r as sellers' designation use eb Sasso bftg mteded to sppir. wbM tuft eompbud Y ebs ptuebSSe maoq tom an ton wad aast..peese or land of Iced. a1esW. to cite Oo®q of St. Croix and &sate d wMeorwm. Sewn: See Exhibit *A hereto attached and Meade a part hereof by reference. This property is not homestead property. S —TS FM i no aid put ieA d the mooed pat ftztbw spes_Uom th e i wul pw. when due and Pushb, ag tears teed ' Yaemm.em wnleh hYe iteea aSaMSed u lsrled an tba ahols deesebsa pren+bee dnct+ the 1st dw d Jaoteaq. a- D..1&�_. a" WM 0 Itch Y te•y b b"Saher anowd or IW d tber-os or upca the Interest of am Partimeff the mess part to tam pntalMe: and abs 1JA aMS •ad Y.esmtents now of betsatter mean" ar Is"ad Sp no W MWgads whisk my ulst Samoa said Munba o r aptna tbo now — tae tedshtedesss assured by mob martpje Of Samoa the sseee" to Sam prsmWs d W puV bomtu/ a mortow apW: am peamlSY chain& the term at " cmtrset. teed I I ISe _ ad spas — thaS the MM.0 d %p part iffl d the &tat Mn and the totere t ON the pa rti€,Y_ of the n000d put m aid reel estate ad the tour," d err pW • mortasp eaatnse team tea! 10tate dormm the tweet d thts ooeeeaat. shad w amsu" ter tri o&& ad taM3 tapeher. witbout MPaate taloatlon Y onbaenmOmad 1101 Nate and sbM h• Paid bF tits Yon parti@Itd the Mead put and the maw, islet the sword pat busby waft—all riots of othwtts at dotuotlms boomws d the winiat d W smdt3 tun teed v men %Mtn CI at S storeoid Purchase many Shall bs we the maee.r d." e» mend. 216 PotigU d Nether Sam —th the am PartiBd p0-ut MOO teams teed bug maned spirits loss at daum p the bulm6le MM en am promises and such Y my beredtar hs e/YSeJ tbmsm d"rbt{ tae we asehisereusstt■amsons ofAtMost _i unoa balance of this Land Contract 8"" *O a,domssobyan the sum 9t at least the unpaid balance of this Land Cont�ac� - _ . m the a.m. of She pre i e! d the asst part as owner to tee. wlh moue& in team Pelirs than ehg tam put its d tee usmd Wfft& v! . Lem aootren bans" aw"M and the 1SS. r W. U"W ash loneaaee sban be Perk te the team pars LOA d the Brie Mt a the eaters d their tataera am the m:rpios. U W. to the sold Posti.4ld the Mooed part. seblat. boos M. to the rides d ssmtparea. ll w. rispSCtled aaeb teaueasee: soeh PdiW Y Pdb1Y a a hem hr the team pet its_ d the Brie Nn. their haeta, btsal tepeYaetattrea ter uSlps, Y eonawal te thY ameteer teed the team p+rt is=d y -- t G 7 Port $belt pal III* premium an Saab polity of pulmles lead" td". and m wes tee the fafr4m rK noplert d the wM d eM omn4 pert to py sueb pnmlums whsn due, esld p d th rtilLe flat part. i ' ot1.w or wlpte my pay the "me mid sbery tae Beet the ed wttb tatereat tb~ at tM 10414 tote. to tM tall pot WL of kiss wooed put, wd the isms tbaE be eMntlesed end taken to to w eddltbsiel part of kiss ew• wldeaded d this eeatrast. no part x.41 of tM wound pert forth« agree - -ft w beld tax MM paabw treaM Me date hereof. a tM teawl !_ y ous►nses d the saw pert is k d the ant "art, "App" a be resawme ed tenant ale beltled a*. by I . teal« the statute in ercb aoe ma& wed 7Mwd/sd. whose.« detwu died be mss OR the pymsnt el W et the hNteEmonw d pwabaw atone Mg* week tare, aomPmmsete of lmunum preminttr Y allow sseslsdt add am t• bop the bafldh04 _ _ , Yaws» aid itnw"I ante as wM >ewuas to M good re"M wad ""tuft u ebq sow sew adept «dtag" wear and dewy. add vet to do att7 oat w"woaa ward► wads ft dcpnda eM was d aM p wom. MM". That the said part"& of tb a line part. here" a0ee _ add bted — hmadlvis I . their — W", esceuV es sea wmbalstraton, that is ad" the aftftowd ass• d __Ziirty_Thau"ad An&,nQL100•-_ .00 1----- - -------- DelfMn. ------------------------- - - - - -- - - -- - - I $MOQQ wttb the towel" and other =one" sb an be " Poll and an ate ploodow bwdn pro.Wed emu M My owf«mwd at as etrwee one Id" tM wooer aMao apss0lrt, _ thAY . _ �n r Iosnartd, eharaahor sues mba era rod and dMtwred to tM alim brat W or tM mooed part. « _ tbair - --be" or low npressatatMe. a food M4 sasbbst efiwnnt7 Deed. to too simple. of the pamtses abed" dwmrtlAd, Rae mad ebv of W bPo1 Ilene wad Omura bmwa, saspe the taxes and Maremammus herein screed to be pawl s. for put lea of the weead Cale'+. and wasp+ w Eaba w pMembranoo awted by the act or default ON the part Jim of trxa m od pare. _ _� S it +tare. bpi rsprsssetathss « awfpta • __ - -- T omn.1t b dbtlndl/ eatead mad un tentwA b7 and bo 7 wed" r putle bera te. thet If V.e §LM Cwtila of the wo=4 Wt "a bin to e macetded «mi e to, • c a7 the t p�ym&M ssYwm e� aw keep Insured the premises beres abuts allp- baed, of fad' w par say or all buunnee wemtums beeln speCUINI - 41I rlmlaca aa7 other terms w oonastie a Male ecatafMd. this 04tecmeat wban at the option of the esfd pardgLef the 11ma part be henceforth uttetq wM wtthofet wy aotles wlrt- wrer. mad aE ps7mcets tb «dos torfclecd. suhJoet w be rwtted sod +�cwed aet� b� the art r the pats ie sof the MR put, a We mutual Wecsr ent or both p artled: and whcnew such dsfartt t %WWMe MINE suss. rho part 3!l ale eM memo brit dME haw ce ttttthw tls %t to +vilest rash +tern tceaats. If arty. at the old real estate, or =7 pert tiered. but swb nets NNE be cNbaad y. add Mbns to the parties el Me pant Tba AN "njga.of the Merced port tunb or pexabe_Md MOeo_tbot tM secs d tM emmmmesmat Of w wtba to breelow an waaast and also O Mao at UM foread«un toes-/. _UL E py in sddltles to tM gamble coca and »peens tnewnd, a naweable ram of many as at"w "W st for_ IN tYb'rWM SwzLRZor. the maid purl» have bNaunte act toot+ MOM and seal thaw dot -f . A. M. Is 701gttttelmdYeOfRlfwr•/aot 4�� NEAb) an 6. (sItAL) �j_2p inton D . Hate en �fsafJ Joh aly, T (itiAL1 Marlyn A. Haugen �1>;,t>. wtsoonslr. Its avety. y fessoaE7 same bete" me. ebb _ ay �. L M. ta? 3 *oebwe,amd _Quiat D. Haug an and Mar A. V tugen husb4a and rife - ee esa keewa w be w pesos L wbe aeatted fansoters Iasaaiat t SE ADDITIONAL ACKNOWLEDGME ATTACHED :iERETO * 7awr7 pubtte. County. tow. c�U ' d�, err Oaamlelaa eaplew �� A. O.. U T al.+. salt m . ale wr.�.r r ..see w kiss e111ta1 PxMd ale wer�rw+ � .... d r. sd"� tree+ .n ■�. w N r A i Z m d 1 3� I m� ` M . • VOL 997ro 272 ass=Brf �M The Northeast t - a ter of the Northeast Quarter of Section 19, Township 29 Borth at Range 18 West, except that part deeded to Quinton D. Naugen and Marlys A. Naugen, husband and vile, by deed dated December 1, 1987 and recorded December 9, 1987 in Book 798, page 512, as Document Number 432850, and by deed dated December 3, 1907 and recorded December 9, 1987 in Book 798, page 514, as Document Number 432859. BOBJOW TO a 66 foot vide roadway easement for ingress and egress located in the N22 /4 of Section 19, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, further described as follows Commencing at the N2 corner of said Seation 19; thence 301.54 a!ing the east line of the said N21 /4, 33.00 teat to the southerly right-of-way of State Trunk Nigh:ray 0 12 0 ; them 244 along said right -of -way, 567.00 feet to the point 0 S9'W o! this d escr ipt ion; thence cos o! Lag ipt l t �� 800 37 along said r trot - way, 66.00 feet; thence SO: 02 01 329.12 feet to the point of curvature of a 309.00 foot radius curve concave easterly, whose central angle measures 12 whose chard bears 807.16 and measures 84.69 feet; thence southerly along the are of said curve 84.85 feet to the point of tangency; thence 313.31 57.59 feet to the point or curvature Of a 1249.83 loot radius curve concave westerly .chose central angle measure• $ whose chord bears 810•11 and measures 145.89 teat; theme southerly a al the arc of said curve 145.97 feet to the point of tangency; thence 306•SO 437.36 feet to the northerly rig of the CA N.W. Railroad; thence 983.09.39 alwq sa id right - -way, 66.00 feet; thence N 06 437.36 feet to the point of curvature of a 1315.93 foot radius carve concave westerly whose central angle measure 4 whose chord bears N10•11 and measures 153.60 feet; thence northerly along the are of said curve 153.64 feet to the point of tangency; thence 0 31 53 57.59 feet to the point of curvature of a 32 3.00 foot 913 , pO radius carve concave easterly, whose central angle measures 12.29 whose chord bears U07•16 and measures 70.32 feet; thence northerly along the are of said curve 70.45 feet to the point of tangency; thence N01•02'01 329.12 feet to the point Of beginning. * • • s s � 0 F 4) o ® E § 104 � CE Ul ^ � 2 , k C @ ' �. . c _� OD k 2 ' ® ° c � ■ / > £ K % = . � � k o L 0 — w 4 0 § Z ® J � � c �- = . 00 9 « Ott 3 § § =r ( ■ CA CA ;o > 42 \ . o / > \ w Q G / / § § _ ■ /a ( § � c6 CL g § ■ E ( # G R � m } C N 8 i Z — � � m m 2 2 # —_,> % ; # s k § EE�§k E C �;Cko % _D CD CD CD C. CD S \82% §j\ k § ECD q CD 0 kQ 3 x 7§ kQ atk Ea§ K 0 � m � § in � B , a WiscorV�,n Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 45 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: Hau en, Q. Dale & Marls I Warren Township 042 - 1051 -10 -050 CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number. DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over IDepth Over xx Depth of ded Mulched xx Seeded /Sod Bedrrrench Center Bed/Trench Edges Topsoil F0 Yes ❑ xx No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 957 U.S. Highway 12 Roberts, WI 54023 (NE 114 NE 11419 T28N R18W) NA Lot Parcel No: 19.29.18.289A10 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes ❑ No I I Use other side for additional information. E - J SBD - 6710 (R.3/97) Date Insepctor's Signature Cert. No.