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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division Count
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344512
Permit ��e' MICHAEL ❑ C RICHMOND w
on of: State Plan ID No.:
CST BM Elev.: BM Insp. BM Elev.: Description: Parcel Tax No.:
.026 - 1101 -40 -000
TANK INFORMATION ELEVATION DATA 72
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding I St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air l to ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss m ead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type of CHAMBER Mod Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length 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 Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 36.30.18.553B,NE,NE 1451 130TH AVENUE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi SANITARY PERMIT APPLICATION 201 W. Washington Avenue
In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. Cr0
• See reverse side for instructions for completing this application State sanitary P
Personal information you provide may be used for secondary purposes ❑ Check if revision to preJio
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number,
I: APPLICATION INFORMATION -PLEASE PRINT ALL INF MATIQ N
Property Owner Name Property Location
AX 1 / 4 N j14, S 3 6 T 20 , N, R /,�'E (or)
Property Owner's Mailing A dress Lot Number Block Number
3C) Avg
City, State Zip Code Phone Number Subdivision Name or CSM Number
4 , w. -5'/ 7 ( ., .5 ) 2va / 1/ol 2 . 3
II. Y F 6 ILDIN : (check one) ❑ State Owned It Nearest Road
❑ Village
Public IM 1 or 2 Family Dwelling - No. of bedrooms_ A Town of �cl+
III. BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) �7G� �. gC P
1 ❑ Apartment/ Condo �� ���` a ✓
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) ,
A) 1, ❑ New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5,AfRepair of an
Sysstem SystemTank Only ---- Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 Eg Seepage Bed /ax 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 [] Pit Privy
13 []Seepage Pit 4 felm L) f �rt art 43 ❑ ault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION.
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Are 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq_ ft.) Propo J (Gals/day /sq. ft.) (Min. /inch) Elevation
L160 L Feet (, Feet TANK Capacity
:ea NFORMATION in allo s Total # of r Prefab. Site Fiber- Exper.
g Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
n CJdO dcb ❑ I ❑ ❑ ❑ ❑❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
he undersigned, assume respon ' lit f r ins Ilation of the onsite sewage system shown on the attached plans.
Name: (Print) natur o Stamps) IGIP1MiPR5�IV No.: FXs ness Phone Number:
s
Pl umber's Address S reet, City, State, Zip Co
. n L�cJ;
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuin Ag t signature (No Stamps)
Surcharge Fee)
Approved El Owner Given Initial 6 s
Adverse Determination lg�5 /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information_ Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatmenttanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Wisconsin Department of commerce SOIL AND SITE EVALUATION 1
Division of Safety and Buildings Page r of
Bureau of Integrated Services in accordance with s. ILHR 83.09, 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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
acs - tr oy yo oao
APPLICANT INFORMATION - Please print all Information. ev
er wed by Date
Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). G
Property Owner Property Location
1' � OK C Gerry -%a•% Govt. Lot pb)1 /4 Me 1/4,S G T 3L7 ,N,R le E (ore
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
Li 5 4 31, * 1 \ 4\3c- ) I I QOV 2 1 P. y S
City State Zip Code Phone Number
❑ City C] Vill Town Nearest Road
Nom' h ,�► W 5qo) (71 )a ye - s4el h t f5 *� tee
uvGra ror � t
❑ New Construction Use: ®.Residential / Number of bedrooms 3 _ !/ ► v ;JQ n t) to
Replacement ❑ Public or commercial - Describe:
Code derived daily flow 150 gpd Recommended design loading rate bed, gpd1ft ° trench, gpd1W
Absorption area required bed, ft � trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft
Recommended Infiltration surface elgvation(s) 4. 7 It (as referred to site plan benchmark)
Additional design/site considerations 1f% O n e_ Ta L %e. c. W_ v'rtr $ S +@.rc% For r t f u u Pr dc d a r i
Parent material � Q V E-d 4 I _g4 e 4 L. QQ * t,>qS k Flood plain elevation, it applicable it
F S Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U Unsuitable for system S U C9 S ❑ U 9S ❑ U [As ❑ U ❑ S R U ❑ S U U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD / tt 2
g in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh, Consistence Boundary Roots Bed Trench
Ground 3 Is -at 1 0 40 j °` b
elev.
-Ya 7.54 RyI
Depth to
limiting y . J �! �- /.. S - `°" "-.. - `..` • 7
factor
a0v
Remarks:
Boring #
14
FN
hd .
Ground
elev.
tL
Depth to
limiting `
factor
in. Remarks:
CSName (Please Print) Signature Telephone No.
,� S - -1 y8 -358
Address .,,� 1 Date CST Number
® S-halr bra, t - o -g 1 Y In
�aa �
I
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of '
PARCEL 1.01
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground
elev.
ft.
Depth to
limiting ,
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots /f
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
In ' Remarks:
Boring #
0
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
SBD -8330 (R. 07/96)
1Y1 K e. G e r r,. a', h pq _l e_
.. �ilw'1 N E / $2c . 3 � '1"" 30� �' I w - ----�-
I v rr
`� o, �„3 ar re lca+) C 5 ata t-j qb
�—_ __- --- 130"
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1'ot n
r ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Addres
Property Address L
(Verificatioa required from Planning Department for new construction)
City/State _Ld,4c X11, cA an d 1-"' Parcel Identification Number
LEGAL DESCRIPTION
Property Location Y4, ;, Sec. 3 e,'& . T,X_N RAW, Town of c
Subdivision
Lot # ,_;/ -
Certified Survey Map # 6 3 !v Volume _ Page #
Warranty Deed # L1.C3 boa Volume . Page # d? a
Spec douse ❑yes ❑ no Lot lines identifiable. ❑ yes ❑ no
SYSTEM DANCE
Imgwpauseandmaintcaanoeofyovrseptiiasystrmcouldresaltimitsprr aturefaauretoband [evvastMPr0jcrmaizroeaanx
can
coud sft O � tank �Y drtte Y� or sooner; if rreededby 9 pumper; What yua pat into the system
�.i stage is the Waste Evosal_syst=
MIC Property ow= age ces to submit* to St Croix Zoning Dgwtment a cmtificatioa fawn, signed by the ewnec and by a
P : l�yna pinmberrcstoictedphumbcxorah=sed
is is props operating condition and/or after • �t(1) tlu oa�aitc arastewaterdrspersai systear
(2) inspection and pumping.(if necessary), the septir tuk teas than U3 6H of sludge..
Uwe, the vndcrsigacd have read the above required sad agree to &e private sewage disposal system wi& the standards
set fork hmin. as set by the Dgwtmed of Commerce and the
stating 69 y� optic Department of IZatruaI R,csourocs State of Wisconsin.. Certification
has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
N MGNAF
M ration date.
APPI ICANT
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 P ve. by virtue of a warranty deed recor� ed in Register of Deeds Office.
e�
SIGMA CANT / 9
DATE
« « « « «« Any information that is mis- represented may result is 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
V CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the _ * && residence located at: 4,
Sec. 0 N, R ? x _ W, Town of �&A l 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 S : e�� /999
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 J/ Steel Other
Manufacturer (if known) : A�VPk It �* y- AW
Age of Tank if k own) :
(8tqffature (Name) Plea e Print
i SPh s.t -t� _- 0 ® S`S�
(Title) (License Number)
(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) .
Name /� Signature
'j" MP /MPRS
1 ,"1<;UMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
{ STATE BAR OF WISCONSIN FORM 2 —1982
1�
_5-.__
' _ _ P- AGE - &?—
• REOISTERS OFFICE
Leonard P. Martin and Pauline E. Martin, husband ST. CROIX CO., WIS-
. ................................................•--•--•---•------•--......................................--•-•-
4451.w f.e i a$_.j.Q nt- .tenants.- .- ...-- -_ -• -• Rec'd. for Reoord -_. -30 th
_---- •• - - - -- day of June A,0. 19 86
..........................••------•-------------------._...-----•------..........---------- ......-- •- •-- ••....... I1: U0 A
conveys and warrants to ....Michael .. J._ Germain . ... and . JoAnri
•_.. ........... . •- ••- - -....
?t S�= mai. la,_...kolas ans3... aild.. Wif e. .as...Mari.ta'l ................
. ghts ...af._.suxvtiv.Q.rshi8..... R v..w
..................... ............................................................................................
........ ......................................................................................................... RETURN TO Northwest Federal S &L
...._..---• ......................................................................... •- •••----- ••- •....._....... -- P.O. Box 160, New Richmond, I
... --- ..............................................•--•--...------------------------.....................--••-
the following described real estate in ......St... roiX ...County,
State of Wisconsin:
Tax Parcel No: ..............................
Part of the Northwest Quarter of the Northeast Quarter (NW4 of NE4)
of Section Thirty -six (36), Township Thirty (30) North, of Range
Eighteen (18) West, described as follows: Lot One (1) of Certified
,Survey Map filed September 27, 1977 in Volume "2" of Certified
Survey Maps, page 468, Document No. 343430.
TMNS
FEE
This ...... s .................. homestead property.
(is) (is not)
Exception to warranties:
Dated this .............. 2.7 .th........................... day of --- ............ Urie.............................................. 19. .8.6...
•---- • ..... ................. .•• -- .(SEAL).. i✓(SEAL)
. Leonard P. Martin
• ---- ........
..............•----..................------- •--- ....••••---- •••. -••.. (SEAL) . . 2 . .. .. -..__. (SEAL)
• ....................• •- ••......--- •---- •....... .. Pain i. ne �iax ta.n.......................
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) ............................ ........... .................... STATE OF WISCONSIN
ss. �
...... ........County.
authenticated this .. ......day of ........................... 19 ...... Personally came before me this ..27th . ..... day of
.......... .......s7 UXIe ........... 1 19.... . the aboye named
•.....--• ...................................•-------- .........--- .....-- • - - - - -• . .M I.0 r) ................................. ::. .............
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not ...............• - -•
• �� Q:...
c -� `
authorized by § 706.06, Wis. Stats.) the to me -k wn to be the person _.. t -jsvt( Q
foregoing i trument and acknow dg' e r 1.
THIS INSTRUMENT WAS DRAFTED BY •�
Reinst an Dyk & Needham • S.C. - •--
...........
New Richmond WI 54017 fat' i. Qua.. A,_5 eab] - Qom ..................... ......
. .......................... Notary Public 5t, ....CrQi;K .............. County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date:.......... 9121 /86 .............................. 19 .........
*Names of persons signing in any capacity should be typed or printed below their signatures.
__... _—_.__�...__,__.
HGMi1lsrCo,rpery® STATE No. 2 WISCONSIN
82 SIN Stock No 13002
W.wk... WMtMW
, -
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Fll.e
E- AAF a7co�
3 4 3 4 3 0
C ERTIFIED suRVE�r M A P R S1 M � ` lliv
w �
JOHN MICKELSON S
Part of the Northwest 1/4 of the Northeast 1/4 of Section 36 Township 30 North,
Range 18 West, Town of Richmond, St. Croix County, Wisconsin.
N E CORNER
APPROVAL OF THIS MINOR SUBDIVISION SEC. 36 T- 3 0 N
DO::S NOT MEAN APPROVAL FOR
R- (9 VV
WILDING SITE OR SEPTIC SYSTEM.
REFER TO H62.20. TOWN R O A D
_ DUE E T
25 6-00, 23 7 1. 26'
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SEP 211971 0 - %n _j
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ST. CROIX COU;�Ty 8
COMPREHENSIVE PARKS PLANNING a � L 0
MI) IONINO COMMITTEE OO�i �Rj 1
Q W
256.00• dz�m�
DUE EA � ST W Uj U
-i _ = Ld
• Indicates 1" x 24" iron pipe stake found l—
o Indicates 1" x 24" iron pipe stake weighing 1.13 lbs /ft. set.
SCALE i =20(
Description:
That certain parcel of land located in the Northwest 1/4 of the Northeast 1/4
of Section 36, T 30 N, R 18 W, Town of Richmond, St. Croix County, Wisconsin,
more fully described as follows;
Commencing at the Northeast corner of said Section 36, thence go due West
(assumed bearing) along the North line of said Section 36 a distance of 2371.26
feet to the Point of Beginning of the parcel to be herein described;
thence continue due West a distance of 256.00 feet; thence S OOo 05' 13" E
a distance of 510.00 feet; thence due East a distance of 256.00 feet; thence
N 00 05' 13" W a distance of 510.00 feet to the Point of Beginning, the
above described parcel containing 3.0 acres, including the North 33 feet
thereof being subjedt to easement for Town Road purposes.
State of Wisconsin )
County of St. Croix)
I, James L. Murphy, Registered Land Surveyor, do hereby certify that by direction
of the Owner, John Mickelson, I have surveyed and divided the lands shown
hereon in accordance with official records, Chapter 236 of Wisconsin Statutes,
and St. Croix County Ordinances; and that the map and description shown hereon
are a true and correct representation thereof.
Dated: 2 September 1977
Vol. 2 Page i jJames L. Murphy '
Certified Survey Maps red
St. Croix County Records , : ,.;,/VSO %,,��
St. Croix County, Wisconsin �0 ' '••.'�� '';
JAMES
` MURPHY
0 2
0 % RIVER L tS, `.
r
AS BUILT SANITARY SYSTEM REPORT
OWNER A 0 C , TOWNSHI - SEC. T RL&--W
P.O. ADDRESS ST. CROIX COUNTY, WISCONSIN.
Al nlm
;S <�•
SUBDIVISION LOT LOT SIZE ,I)FLG'Y'c- S .
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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q � V
1
%(1 N %
SEPTIC TANK(S) MFGR. 1A Ot , -twe"q &!46 CONCRETE ' STEEL
NO. of rings on cover Depth le DRY WELL
TRENCHES NO. of width length area
BED no. of lines AZ width L,; , length -5 -� , area
depth to top of pipe G Ir
AGGREGATE
PERK RATE i S AREA REQUIRED 1, /,-3 AREA AS BUILT
} 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.
�'INSPE
DATED w C"4 l) PLUMBER ON JOB
LICENSE NUMBER
(, 3 Cl
RFPOI X� OF. IIISPECTIO ?1-- INDIVIDUAL SE?JAGE DISPOSAL SYSTEM
Sanitary Permit A
• • r
State Septic
A! 1E TOtIIJSHIP
St. Croix County
SEPTIC TA' ?I:
:size gallons. `cumber of Compartments
Distance From: Well �� �� ft. 12% or greater slope
Building
ft. Wetlands
Iiighwater A ft.
DISPOSAL SYSTE:1 Tile Field or Seepage Pit (s)
P c
Distance From: Well � � ft. 12% or €reater sloe � ft
Building ft. Wetlands
FIP-,LD
,....& hiFhwater �-�. ft.
Total gth of lines /U (v ft. Humber of lines Z Length of
each line f t. Distance between lines ft. Width of the
trench �ft. Total absorption area
sq. ft. Dept:
of rock below file in. Depth of rock over tile in.. Cover
r.
aver. rock, Depth of tile below grade in. Slope of
trench in ner 110 ft. Depth to Bedrock ft. Depth to
ground water 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 see are required '
Inspected_..' '�„�
Title :
Approved Date 197
Rejected Date 197 .
State and County State Permit #
PLB67 t► Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNE OF PROPERTY Mailing Address:
,s
B. LOCATION: ° 6c. ' / 4 �L Section �f T3,9 N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township l 1
C. TYPE OF OCCUPA Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher O YES NO Food Waste Grinder YES eNG # of Bathroomsl—;��
Automatic Washer f / S(ES NO Other (specify)
E. SEPTIC TANK CAPACITY / t Total gallons No. of tanks G� LPL
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT .DISPOSAL SYSTEM: Percolation Rate 1) _ 2) 3) _1�Total Absorb Area_ oZ sq. ft.
New C Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length f" ' Width Depth 1 3 Tile Depth —'I Y ` No. of Lines ';z—
Seepage Pit: Inside diameter Liquid Depth Tile Size L/
Percent slope of land l !%, Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, v
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil Tester,
NAME e_ C.S.T. # / / 3 and other information
obtained from �— (owner /builder).
Plumber's Sig nature MP /MPRSW# G S `� Phone #
Plumber's Address „-0' -r —I—� �,c •--Z
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space elow FOR DEPARTMENT USE ONLY
Date of Application Fees Paid: State O tO O Cou ty / Dat
Permit Issued /Rooeted ate _Issuing Agent Name
Inspection Yes4 Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/11/76 �
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Parcel #: 026 - 1101 -40 -000 03/30/2006 02:53 PM
PAGE 1 OF 1
Alt. Parcel M 36.30.18.553B 026 - TOWN OF RICHMOND
Current X j ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
MICHAEL J & JOANN M GERMAIN O - GERMAIN, MICHAEL J & JOANN M
1451 130TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description ' 1451 130TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A -NOT AVAILABLE
SEC 36 T30N R1 8W 3A IN NW NE LOT 1 OF Block/Condo Bldg:
CSM IN VOL 2/468
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
36- 30N -18W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 745/262
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
96177 162,700
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 45,000 94,500 139,500 NO
Totals for 2005:
General Property 3.000 45,000 94,500 139,500
Woodland 0.000 0 0
Totals for 2004:
General Property 3.000 45,000 94,500 139,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 206
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
b —�
1 ' 0
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ST. CROIX COUNTY S IR 27191 ,a
SURVEYOR'S RECORD r ES o' cot"M
343430 CERTIFIED S iJ MY MAP
Sp CrOtiX CavotY.
wiKO M w
JOHN MICKEISON ,r f
Part of the Northwest 1/4 of the Northeast 1/4 of Section 36, Township 30 North,
Range 18 West, Town of Richmond, St. Croix County, Wisconsin.
APPROVAL OF THIS MINOR SUBDIVISION N E CORNE R SEC. 3 6 T
0015 NOT MEAN APPROVAL FOR
RALDING SITE OR SEPTIC SYSTEM. R_ 19 W
REFER TO H62.e0. TOWN R 0 A Q
2 5 .001 23 7 1. 26'
U_
f r
� �Rp�t �� M O LL 0 1--
APPROVED to 0 ` _ _ in \ °' w
00 oa �
p 0 ACRES p Z cn
SEP 211971 p _ a zus
ST. CROIX COW d 9 z Z = (y) � c
COMPREHENSIVE PARKS PLANNING �� O -- �-- 1,—
MD ZONING COMMITTEE C Cr -c Q
256.00 0 �`'j
' z
DUE EAST 00 W `j N
J 2 W
• Indicates 1" x 24" iron pipe stake found ¢ i- Q
o Indicates i" x 24" iron pipe stake weighing 1.13 1bs /ft. set.
SCALE I =20(
Description:
.That certain parcel of land located in the Northwest 1/4 of the Northeast 1/4
of Section 36, T 30 N, R 18 W, Town of Richmond, St. Croix County, Wisconsin,
more fully described as follows;
Commencing at the Northeast corner of said Section 36, thence go due West
(assumed bearing) along the North line of said Section 36 a distance of 2371.26
feet to the Point of Beginning of the parcel to be herein described;
thence continue due West a distance of 256.00 feet; thence S 00 05 13" E
a distance of 510.00 feet; thence due East a distance of 256.00 feet; thence
N 00 05' 13" W a distance of 510.00 feet to the Point of Beginning, the
above described parcel containing 3.0 acres, including the North 33 feet
thereof being subjedt to easement for Town Road purposes.
State of Wisconsin )
County of St. Croix)
I, James L. Murphy, Registered Land Surveyor, do hereby certify that by direction
of the Owner, John Mickelson, I have surveyed and divided the lands shown
hereon in accordance with official records, Chapter 236 of Wisconsin Statutes,
and St. Croix County Ordinances; and that the.map and description shown hereon
are a true and correct representation thereof.
Dated: 2 September 1977 010�g
Vol. 2 Page 4 James L. Mu rphy
Certified Survey Maps gistered r
St. Croix County Records ,�'\ GI '
St. Croix County, Wisconsin :.� .`� �? 4••�i�,'•
�`�' •' JAMES
L.
MURPHY
V ol S
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