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002-1015-70-000
Stt. Croix County Planning and Zonin Monday, March 07, 2005 at 8:39:09 AM Detail Sanitary Information Page 2 of s Computer #: 002-1015-70-000 Sub/Plat: metes & bounds Section: 7 Parcel #: 07.29.16.1008 Lot: TNIRNG: T29N R16W Municipality: Baldwin, Town of CSM: 1/4 114: NE 1/4 SE 1/4 Owner: Nelson, Dale & Joann 1028 220th Street Baldwin, WI 54002 State Permit: 430630 Issued: 12/29/2003 POWTS Dispersal: Mound less than 24" suitable s Permit: Replacement County Permit: 0 Installed: 09/29/2004 POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Inspector As Built Plumber Other Reouirements Additional Notes Monev Owed Mark Iverson (contr >4/1/00 -Required due Hudson, Dale Should have an original red-stamped state 4/28/04 -tanks installed and inspector found $50.00 Signed Off: No approved plan and revision fee for changes conventional system to be wet at proposed to system components, etc. elevation. Postponed installation until further evaluation done. Leroy Jansky did on-site 6/7/04 and said no below grade system can be allowed. 9/29/04 -Mark did inspection for mound system, but paperwork had not been submitted to county to sign the revised application or review the state plan. Need to contact Dale and get revision fee and original stamped state approval. 10/1/04 -Revised plan for mound sent in, but missing the revision fee (gave us $100 to change up from conventional) and only a copy of the red- stamped state plan approval. Kevin Grabau >4/1/00 -Required due Hudson, Dafe State approved plan and complete/sign the 1981 system was a replacement for an existing $0.00 Signed Off: No permit revision -paperwork in Boldt's red file system, but the 1981 failed system is the one being replaced now in 2004, so state couldn't approve the WI application. Revision not completed yet -Dale provided a copy of red-stamped plans and paid $100 for difference in fees on 9/29/04, but we need the original plans on file. He will contact owner, who may have ended up with a set of red-stamped approved plans Mainfenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/29/2007 S't. Croix County Planning and Zonin Monday, March 07, 2005 at 8:39:09 AM Detail Sanitary Information Page 3 of S Computer #: 002-1015-70-000 Sub/Plat: metes & bounds Section: 7 Parcel #: 07.29.16.1008 Lot: TNIRNG: T29N R16W Municipality: Baldwin, Town of CSM: 1/4 1/4: NE 1/4 SE 1/4 Notes Inspector As Built Plumber Other Requirements Additional Notes Money Owed Mark Iverson (contr >4/1/00 -Required due Hudson, Dale Should have an original red-stamped state 4/28/04 -tanks installed and inspector found $50.00 Signed Off: No approved plan and revision fee for changes conventional system to be wet at proposed to system components, etc. elevation. Postponed installation until further evaluation done. Leroy Jansky did on-site 6/7/04 and said no below grade system can be allowed. Kevin Grabau >4/1/00 -Required due Hudson, Dale State approved plan and complete/sign Signed Off: No permit revision -paperwork in Boldt's red file 9/29/04 -Mark did inspection for mound system, but paperwork had not been submitted to county to sign the revised application or review the state plan. Need to contact Dale and get revision fee and original stamped state approval. 10/1/04 -Revised plan for mound sent in, but missing the revision fee (gave us $100 to change up from conventional) and only a copy of the red- stamped state plan approval. the 1981 system was a replacement for an existing system, but the 1981 failed system is the one being replaced now in 2004, so state couldn't approve the WI application. Revision not completed yet -Dale provided a copy of red-stamped plans and paid $100 for difference in fees on 9/29/04, but we need the original plans on file. He will contact owner, who may have ended up with a set of red-stamped approved plans $0.00 Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/29/2007 St. Croix County Planning and Zonin Detail Sanitary Information Page S of 5 Computer #: 002-1015-70-000 Sub/Plat: metes & bounds Section: 7 Parcel #: 07.29.16.1006 Lot: TNIRNG: T29N R16W Municipality: Baldwin, Town of CSM: 1/4 1/4: NE 1/4 SE 1/4 Notes Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Mark Iverson (contr >4/1/00 -Required due Hudson, Dale Should have an original red-stamped state 4/28/04 -tanks installed and inspector found $50.00 Signed Off: No approved plan and revision fee for changes conventional system to be wet at proposed to system components, etc. elevation. Postponed installation until further evaluation done. Leroy Jansky did on-site 6/7/04 and said no below grade system can be allowed. Kevin Grabau >4/1/00 -Required due Hudson, Dale Signed Off: No State approved plan and complete/sign permit revision -paperwork in Boldt's red file 9/29/04 -Mark did inspection for mound system, but paperwork had not been submitted to county to sign the revised application or review the state plan. Need to contact Dale and get revision fee and original stamped state approval. 10/1/04 -Revised plan for mound sent in, but missing the revision fee (gave us $100 to change up from conventional) and only a copy of the red- stamped state plan approval. the 1981 system was a replacement for an existing system, but the 1981 failed system is the one being replaced now in 2004, so state couldn't approve the WI application. Revision not completed yet -Dale provided a copy of red-stamped plans and paid $100 for difference in fees on 9/29/04, but we need the original plans on file. He will contact owner, who may have ended up with a set of red-stamped approved plans $0.00 Monday, March 07, 2005 at 8:39:10 AM Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/29/2007 Wisconsin Department of Commerce S~fe*~and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacv Law, s.15.04 (1)(m)l. Permit Holder's Name: City Village X Township Nelson, Dale & Joann Baldwin Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic lUC sU Dosing Aeration W ' /d ~ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~. ~ ~ `3v ~a~ ~7~ ~-- Dosing ~s- ~s~ ~ i ~ ~ 9v Aeration Holding PUMP/SIPHON INFORMATION Manufacturer /1 Demand W `~~5 GPM Model Number ~1. c~ w ~, ~ TDH Lift Frigtio Loss '~a System ea~ TDH Ft / S I Forcemain Length Dia. Rjst: toWell >y ~ t-I - Z S --a t. ~ ~-- . SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 430630 0 State Plan ID No: Parcel Tax No: 002-1015-70-000 Section/Town/Range/Map No: 07.29.16.1006 STATION BS HI FS ELEV. Benchmark ,nt-~ r~.~-.: ~.y~ ~~~.~ ~ 9~.,a- Alt. BM Bldg. Sewer StlHt Inlet 9~. SUHt Outlet 'T~,n-~. ~ ~ ~ ~ b `~ ~ `~o Dt Inlet ~ 44 /~ Dt Bottom ~o. ~ ,~ 40_ ~ Header/Man. I.~ 9~.(~ Dist. Pipe c., t -~ t -~ r., z Qy.~S .S Bot. System ~,'i ~ ~. S~ ~~ ~~ Final Grade St Cover ~ ~ ~~, 3 r~ ~ s* ~f . zG 9 ~ , y-z ~, . yt..~s~ ~ ~,~ .+ ;ASS ~~.3 .~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~~ ^~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM C G Manufacturer: INFORMATION CHA uNER O Type Of System: /'t r, d ' i ~ ' ~? / " q / ~ ~G N ~ ~, Mode ib o ....._... DISTRIBUTION SYSTEM ~~ heir-~ /,~.'~ Header/Manifold t Distribution x Hole Siz e x Hole Spacing Vent o Air Intake y it Length Dia c./ pipe(s) r r 5 Length 3~ Dia l - ~ Spacing / / / Q 2~3~~~~ SOIL COVER x Pressure Svstems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched ~ Bed/Trench Center r Bed/Trench Edges 1 Topsoil ~ Yes CJ No [] Yes I] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:'Y'C/ ~/ `^~ Inspection #2:~_/~_/P~ Location: 1028 220th Street Baldwin, WI 54002 (NE 1/4 SE 1/4 7 T29N R16W) NA Lgt ~~~ ~ Parcel :07.29.16.1006 1. Alt BM Descri tion = ~ ~ v. ~ ~ ~. r~ C:~n v~c.~~~, 2.) Bldg sewer length = Cc :nrtcc~c~ 1ta ~ /c~ Sz c~''-'r _ -amount of cover= ~'-'/ ~~r~`4 ~~ ~~'~~`~ P~,p `^-'°~.~ Svc r~' ~'~-~-'~' ~..~~ !~ - _ - ____ Plan revision Required? ' ~ Yes ,;, No ~ Ise other side for additional information. ~_____L. _. _ -6710 (R.3/97) Date Insepctor's Signature Cert. No. .._--- C $ (~ _ ~ rte` f~' l.~ ~ ~~ ~~ r,~ G1Z.~~- GL `- ~~trt~! S ~~ ~.. ~~ ~~e~ ~ ~ l ~:Ub ~~ ~G„~ <~ ldfs'~ ~c ~ ,/ ~" o~ ~-~ o ~ c ~o `~ ~ ~ ~~ N~ ~( ~K ~.+~ lc !.' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM ,Safettar~d Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: Nelson, Dale & Joann City Village X Township Baldwin Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Q S ~. ,tom (b+'in.~ .~ lUG~ (c UCy` Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic -t ~ , ~~ ~ ~, :.~ ~ Dosing ,..~ Aeration Holding PUMP/SIPHON INFORMATION Manuf cturer Demand PM Model Num r TDH Lift ion Loss System Head TDH F Forcemain Length Dia. Dist. to Weil SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 430630 0 State Plan ID No: Parcel Tax No: 002-1015-70-000 Sectionlrown/Range/Map No: 07.29.16.1006 STATION BS HI FS ELEV. Benchmark ' ~ ~ ~o t '76 ~ uG ~.ce Alt. BM Bldg. Sewer SUHt Inlet L . 7 l 4~•~ SUHt outlet Dtlnlet 7. ~ 0 9~{ . (off Dt Bottom Header/Man. Dist. Pipe Bot. System ~' 8.5Z. `i 3 • ~'~ Final Grade St Cover ~~ wLS} ib.~? ~~ ~ c i,.,, ~ 5y £~: Z~ q 3 y~ ~~Q.n'tt .r ~ '~Tt,r~ QLQS~ -~~ X13 !3 BED/TRENCH Width Length No. Of Trenches- PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR ~ ~ ~ ~ • ~ ~ ~, Type Of System: ' UNIT Model Number: ~ ~V a.nt ~ ~^ ~ S•Fc~- 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 Onlv xx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx SeededlSodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil i.,;.i Yes ] No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: `~ / -2f1 / ~ `f Inspection #2: / / MWJ Location: 1028 220th Street Baldwin, WI 54002 (NE 1/4 SE 1/4 7 T29N R16W) NA Lot Parcel No: 07.29.16.1006 1.) Alt BM Description = 1r ~ lA V e:~.~•1 ~,c_~ c n ~v C~~on~s..-- 2.) Bldg sewer length = 7 (~` -E o ~ a# o.i o-~ Qc~:..a T ~U ~1 O~j g - amount of cover = ~~•el~• Jat1`~: LO.'~~ o,r~ C.J~ ~- A~- '~'~ Z'0~ -- -- - - ~- 4 Use other'side for additions 1n Yes +`. ; No rmatlon. I---- -- ~- -~ - - - -_ _ ----- --- - ~~ SBD-670 (R.3/97) Date Insepctor's Signature - - ~-- ; Cert. No. 0 t ~ r ~' Q-~-., ~- '~ ~~ L'~f ~ `~'7' ~ ".~ a, ~ ^ sus ~~ -~. S , ~ / ~~~ u -j' 1 ,.-r~/t~ M g2 ~ ~~ g5 ti$ S ~ ~--~ , ~~ ~."~.,, ~ ~ ate' 9,~, L ~ 1 Sal ~"~ ~~_ ~ ~~~~ ~ ~ ~~. ' ~~ ~~~ ,~~ ~ r Safety and Buildings Division ~antY ' ~ " 201 W. Washington Ave., P.O. Box 7082 -~ ! Y ~ ~ ~ ` ~+ ~ ~ Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) , ~® ~~ (608)261546 ~ ~ ~3 Department of Commerce Sanitary Permit Appl eat~~CES State Plan I.D. Number personal formation you provide Adm Code In accord with Comm 83 21 Wis . , . , . may be used for secondary purposes Privacy La , s15.04(1 xm) ~ ~ 2 X003 Project Address (if differ nt than mailing address) ~ I. Application Information -Please Print All Information OlX COUNTY / Property Owner's Name // / ZONING O Parcel # Lot # Block # ,, ~~ I ~ 'r ~ ~~ r>< h~ Nz IS o ~ ~~~--/~i'S-~ ~J"C~-- ono Property O//wne(Xry's Mailing Address /JAS/,j ~C G L Property Location n ~V ~' ~~ '/., Section / City, Statle J / ~Ct' 1 ~./'t t~it~ I 1 ~~ G~l t Zip C~od1e ~7~~ ~~ Phone Number~f ,? !~ 7~~ ~~-/ / ~ / ~ l~ T ~ / N; R~E o~) ~~ h k ll th t l ) ildi f B app ec a a y ~ ~ ng (c u II. Type o ,/ ~~~~~. ~ Subdivision Name CSMNumber 1 or 2 Family Dwelling -Number of Bedrooms L ~ U ^ publidCommercial -Describe Use '/ ~ ~ - ' / n ^ State Owned -Describe Use ~ ~ ~T • ~t%t-(~ W/ f ~ (/ ~ ^CitY_^Village ownship of ~ ~ ~t k i~-i III. Type of Permit: (Check o y one box on line A. Complete line B if applicable) A' ^ New System Replacement S s ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. ^ Petmit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. e of POWTS S stem: Check all that a 1 Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter i~/Leaching amber Dip Line ^ Grave -less Pi ^ r (explai ) V. Dis ersalll•reatrilent Area Information: /d / ~ .Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Requi d (s Dispersal Area Proposed (sfJ System Elevafion ,- C7 ~. ~ '/ ~' 0~ 133 9~`~• ~ . VI. Tank Info Capacity in Total Number MMapnu~facturer Prefab Site Steel Fiber Plastic ,~/~ Concrete Constructed Glass Gallons Gallons of Units ~~ / 7~~ /af /""'\ New Existing W Tanks Tanks Septic or Holding Tank ~ / ~,k!) b ! I ~ l~ ~-. Aerobic Treatnxnt Unit Dosing Cbambcr VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number a ~e, ~ , ~~rr~s o ~ ~. ~ ~ z ~ ~ 5`_3 7~.~ = GSA"- .~. Plum~bJer's Address (S~tre~et, City, State, Zip Code) -"-~~ /~ G L~ / " !fit 1 ~ !''~, ~~' ~.l Gi I !~ s' ~ '~.. ~, 1 ~~~t% VIII. oun /De artment Use Onl roved Sanitary Permit Fee (i eludes Groundwater Date sued Issuing Ag t Signature S mps) a d ^ Di A ~ ' pp s pprove SurchazgeFee) { ~,j~S /~ (~ /~ a~/ ~ V ~- ~'-- ^ Owner Given Reason for Denial IX. Conditions of ApprovaVReasons for Disapproval ~ ~ //„~ ~~ ~~p ~,/~~• ~~~~~ ~~ ~ ~` ~ C-~d'n~m. ~3~ 3~ SYSTEM OWNEk: ~° r ~ ~ Septic tank, effluent filter and - ~3• S ~ ~ ~,~~ dis l ll ll ~ persa ce must a be serviced /maintained - as per management plan provided by plumber. ~,t, ~Q~ f ~' ~ aback requirements must be maintained ~ " " AS r1Ar annlirahla rnrio/nrrtinonnoc __ m ' ~ ~ , ~ 3--~ Attach complete plans (to the County only) for the system oa paper ^ot less thm 81/Z s 11 Inches la siu SBD-6398 (R. 08/02) y ~ 'r ~ ~ v1o Q~~~ec;~.6/e Slope -~~o~ 5ysfem 4~ea. i~;s(u.~sal ee,ll C~mSiS~~q of 3 ~,rt roc-bp,S a,-t 3't "Y (02.5`8' u S; n~ !,0 and aid ~~' Quo - ~~ FF~se-r//' V 1 ZaG~inG~ (~p•rti.~.lS P~r-tI'ent.1~• 3s6' ~j.OrCor-Eoc.r.~ P~opostd ~ c~o~~~aP. S.T/i~.e. w/ ~a.6c J }}-~ UO eFf Kce~rE ~~ 1~ra~ outl~.. 82 /al~~ r--+~ 81 ~ crd. att,~ .411.33.' n !-~ N~~QX. locad'on oF' -EXi-5~in9 olr'S~U'Sa/ Ce //. ~/ EXi`St~'nqq h o use. .3(0-' EX/Sfi'n~ S~~p~, c~4nJ~, Ta 64 Alf. B.rl.: 80'`'tor'1-) abandonedod.p~' code. oFStie~ srd~nc~, El~~: _~9z: Sti~~ ~ mod. = 98.96 Sh~.d ~,r~ ~~,~, ~6 ~~ ~, ~ s ~x~s~~5 cve/( ~ .Sa.~G/Q~l~CG.t~ian P~'~ _~. EX i St~i mac, F'i nCe/:r-C ~ J Sca/c ~ /'= S!p' I `a ~3 o S%L;,~q, Ass~rnc.d G rd . = 98.1 ~ ~~~c Stir c t- i33' d ri ~ek,a ~' Exis~i~~ ,/ r'bk; /dr n~ 5e~~ to be rcp Ia ce~d ar' lei, in /o IC C2 c~5 ~c.o.,d;~;~.,•, d; ~1~~cs. ~~~ry ;ns~lled 'f'iPd,C. ~be:hswln.~d~sP~icc~de. ~ f~~~ ~ ~~ ~~~M `r' ~~~ N~~ ~~ ~~,~ "~ 2~° ~ ~ o ~~~ a~ s~ h~~ S'~ ' `r " , ST. CROIX COUNTY, WISCONSIN - SHEET NUMBER 5~ ~ 461 ~ R: 17 W. `R. 16 W• ~~r t ., it ~E n M 1385000 FEET ~ ' (loins fheef 62) ~ \n ~ ~~f~~,,~~v ( ~~ ~ /J~ ~~~bs ~°~V" ~ ~ a~ s - ~ RECEIVED .s. ~, ' DEC ~ 4 2003so1 EVALUATION REPORT Wisconsin Department of Com Derision of Safety and Buikiirtgs „T „a~,~p,~,ys,;t,, m as wl~ brim ~~ 1763 Page 1 of 3 A.C.E. Sal & Site Evaluations y ~ .. N~G fi C County s m size. Plan must en~9~'f 1 Attach complete site plan ~ Croix include, but eat limited to: vertical and horizontal reference pant (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and bgtrort and distance to nearest road. . . 00 1015-70-000 Please print all intnrmatwn. Date Personal information you provide may be used for secondary purposes (Privacy Law, s. t5.04 (1) {m)). - a property Owner Property Location Dale & Joann Nelson Govt. Lot NE 1/4 SE 114 S 7 T 29 N R 16 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ~ a 7 Z, 1028 220th Street Na a City State Zip Code Phone Number City vilage V Town Nearest Road Baldwin ~ WI 54002 715-684-3043 Baldwin 220Th Street New Cor~tructtion Use: / Residential /Number of bedrooms 3 Code derived design fbw rate 450 GPD / Replacement l -Describe: Public or commerci a ~ l Parent material Glacial outwash ~~.~ W~~h ly ~SECg-f~iv1~~ ~~~ Flood plain elevation, if applicable na General comments and rer~mmendations: Oversize system to compenste for reduced infiltrative surface area due to concentration of coarse , fro°~,,,,~em_ens. Install 3 trenches at 94.00' using 301eaching chambers. 3 ~ ~~ y / S ~r 1 ^ Boring # Boring / Pit Ground Surface elev. 97.91 ft. Depth to limiting factor >92" in. Soil Application Rate Horizon Depth .Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft~ in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/3 none sil 2fcr mvfr as 2f 0.5 0.8 2 8-16 10yr4/4 none sl 2fsbk dsh cw 1f 0.5 0.9 3 16-29 10yr4/6 none gr sl 2msbk dsh cw - 0.5 0.9 4 29-92 10yr4f6 none g s 0 sg dl - - 0.5 0.9 ~ - ~ Horizon #3 & 4 contain a cobbles and ra Loading rate of H#4 reduced to compensate for reduced infiRrative surface area due to concentration of coarse fragemens. Boring # Boring / Pit Ground Surface elev. 98.00 ft. Depth to limiting factor >91" in. Sal Application Rate Horizon Depth Dominant Color Redox Desrxiption Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 10yr3l3 none sil 2fcr mvfr as 2f 0.5 0.8 2 12-23 10yr414 none sil 2fsbk dsh cw 1f 0.5 0.8 3 23-30 7.5yr4/6 none gr sl 2msbk dsh cw 1vF,f 0.5 0.9 4 30-44 7.5yr4~ none gr Is 0 sg dl gw 1vf,f 0.5 0.9 5 44-91 10yr4/6 none gr s 0 sg dt - - 0.5 0.9 J . ~Q ~ ~ Horizon #4 5 contain appro .2096 0 ~ ~ 7(o'O~ ~ oading rates of H#4 & 5 reduced to c~npensate for reduced infiltrative surface area due io lion of r~arse frames. * Effluent #1 = BOD ~ 30 < 220 mglL and SS >30 < 1 mg/L Effluent #2 = BOD < 30 mg/L and TSS <~0 mg/L CST Name (Please Print) Signatur . CST Number James K. Thompson .s 3602 Address A.C.E. Soil & Site Evaluatons Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane. Osceaa, iNl 54020 12/12003 715-248-7767 / fie -5 0 ~ ~ • Y ~ Property Owner ~~ ~ Joann Nelson Parcel ID # 002-1015-70-000. Page 2 of 3 gonng # Bonng Pit Ground Surface elev. 98.37 ft. Depth to limiting factor >95"rn. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consbtence Boundary Roots G in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/3 none sil 2fcr mvfr as 2f,1mc 0.5 0.8 2 8-21 10yr4/4 none sil 2fsbk dsh cw 1fmc 0.5 0.8 3 21-29 7.5yr4/6 none gr sl 2msbk dsh cw 1fm 0.5 0.9 4 29-40 7.5yr4/6 none gr Is 0 sg dl gw 1f 0.5 0.9 5 40-95 10yr4/6 none gr s 0 sg dl - 1vf,f 0.5' 0.9 `~ Z~~ 2~, Horizon #4 & 5 contain a o 20% les and gravel_ Loading rate of H#4 & 5 reduced to compensate for reduced infiltrative surface area due to concentration of coarse fragemens. Bering # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sal A~ication Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Coni. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots *EtT#1 *Eff#2 ^ 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD ~ 30 < 220 mg/L and TSS >30 < 150 mgJL * Effluent #2 = BODS< 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. ~ ~ t 4 a p~'~ ~ ~/tt~ ~ -~- EX ~ s~'/Iiq ~l nCC/ir~G Sca/c~/"= ~4' ~ ~1o aaP~ec;~.b/Q Slope -~~oc~.( System Q~ea. 82 '~ °sy.sac.ntlsv,~: 99!f.L''- ~ d3 ~ c rd . a1C~: ~ , 33.' ~, 3G ~ ~~ Aioo~a.Y. locaa<ron cf EX/~i'ng drs~/Grsa/ .. .. , Ce//. ~/ EX/Sfiix ~ ~ Aif. B.M.: 8~-t~-~ ~ ~ru[~ ~~'-~j~ -~ a oFsked 5, d~h~. 9 9 : . ~ 9,Z E/c v~ = S ti t d ~~d. ~ 98.9 / ~% .~ Skid 3s6 -Trees Ex~'s~~5 c~e/~ o ~ E/ki sting 3 in rr, -• baccsC. Li C2S4n~ ~G'~~yy rSQG~nc%,S,$ ~7fLt S C~bC ~ ~CCCnn~L~d ~3~ 'o~ s;t;n9. Ass~~c.cr Bled:. /oO.c?~' ~~d . = 48.28: i3~' dr. ~eicla ~F ~' ~~ y Z l Z~ t ed I (~.3of3 ST CROIX COUNTY • ; w , SEPTIC TANK MAINTE2IANGE AGR~EMBNT !. AND. • OWNERSHIP CERTIFICATION' FORM . Owncr/IIuycr ~ C~~~ '~' ~ (~GZ Y//' / V ti ~O Mailing Address ~O ~ g ~~D~ ~~"'~ Property Address .~~/r/ t/ ~(/Vcrification rcqui~~rcd from Planning Department for acw coastructiott) City/State ~G~G,'u~l~~ lN~, Parcel Identification Number 06Z ' I5 ~ -611y r~EGAL DESCRIP~ON -- • 106 / Property Location N~ '/., S~ y4, Sec. '~ , T~N-R ~~ W, Town of L"S~/C'1 ~JI Subdivision ,Lot # ~ ZG~if.~a-/ Cerfified Survey Map # Volume .Page # Warranty Deed # .~ `~L~ ~ ~/ ~ Volume ~~~ P e # 3 - / -/~ Spoc douse ^ yes LQ no Lot lines identifiable [~" yes ^. no SYST~i-~-~ANANCE - ImpmPet use and maia~aaaccof your optic systaacould ~It is its ptearaturefa~urt to handle wastes.. Prnpcr nzai>xbcnazboc oousists of pamping oat the optic tank evay~thrce y~ ~ if ncodcd by at ficenscd What yon pat into the system caa=ffoct-~e-fnnictioa of tip scpti~c tank-u-a tccttmratstag~e ia~e ~astediq~osal~syucai. . - Thy Y-ow>za agcccs tq snbmit~to St: Cnoiz ~ i:aztification form, signed by the ~own~cc and by a P7oarmeymaaplumlx,~ rstactodplumbcror i rieea9odpum~perreaifyiag that (I) the oaf wastc~vatcrd'rsposal system u is proper operating condition andlor (2) after iuspoctioa and pig (if nc~ry), the tcptic.taak~is less .than I/3 toll of sludge. - ~G, ~ ua~duzigncd bane read ttyc above rcquir and agree to maimain the private sewage disposal rystcm with the standards . ~ fob. .-~ ~ by ~ Dcpattmeut ofCammane and tl~c Dcpariurratof Alatural R,cso . ~S ~Y~ ~c ~ uius; State of Wisconsin.. Certification sysLcm bas ban ~ be letod and returned to the St G~vix.Cormty Zoning Offec wi~ia 30 ~of file tbz+ce year expiration date. TUBE OF APPLI DATE OWNER- CERTIRICATTON I (we) oatify that all statements on this form arc true to the best of my (our) knowledge. I (wc) am (erne) the ownex(s) of Ply describod above, by virtue of a wxnanty decd ccooc~dod in ~cgister of Deeds Office. ~- '~ /Z/!//O~ TUBE OF APPI;I DATE «•s«s• s««s«« Any information that is mis-t~cpreseatod may t+ault in the sanitary pumit being rGVOked by the Zoning DcpartmenL " Indude frith this application: a stamped warranty dood tinm the Register of Deeds office a copy of the. certified survey map if r~cfcncucc is made in the Warranty deed v ~ `` . Conventional Septic System Management Plan Pursuant to Comm 83,54, Wis, Adm. Code General The conventional septic system shall be operated in acxordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10567-P (8.6/99). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank The operating condition of the septic tank and outlet filter shall be assessed at l~ once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exc~/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm, Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank'~The nece to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank t may ou off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes 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 individual should ever enter the septic tank as dangerous gases maybe present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface within the system and will promote frost penetration during cold weather months. Cold weather installations (October- February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BODS, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan ff the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing biologically clogged adsorption and dispersal media and replacing said components as deemed necessary or by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to installing plumber, Jim Boumeester at (715) 386-9020, or the St. Croix County Zoning Department. v •" , LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF BALDWIN COMPUTER NUMBER 002-1015-70-000 Parcel Number 07.29.16.100B OWNER NAME: First DALE R & JOANN Last NELSON PROPERTY ADDRESS: Hse # 1/2 PD --Street Name-- Type SD Apartment 1028 220TH ST SECTION 7 TOWN 29N RANGE 16W '/.160 '/440 Line Description Line Description TOTAL ACREAGE 1.880 PLAT LOT BLK 01 SEC 7 T29N R16W IN NE SE S 15 02 230 FT OF E 356 FT TOWN 16 03 BALDWIN 17 G~~ Gr~eGZ-q~ ate/ 04 18 D 05 19 f 9 7 ~-- _ p~bdl~~ 06 07 20 21 08 22 09 23 10 24 11 25 12 26 13 27 14 28 F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exit ,. BALDWIN ' ~' " T 29 N-R. SEE PAGE 47 1 .1. w 6 • 0 `~ l 9S Trsos. rf ~ G~G//7! •/j~p,E~ N.5 w. L . N. W ~~ f! .B N. r.~ w. G ~O/J '~ • C?C8 R~cltcrd r!e/ody o . 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Optlo6/~. „~~~' ,~ x -~ ~ ~~'°t ~~"!"""~e~ ers; < V ., ,, t. - ~, ~ ~~s r ~- ,. ,~, ~ ~ ' alraau alp~le~ ti dl: sgleiq,sifiW be till ar priitl~ bliew deli ~>~tltan~. ~-- %z~' ^~ ~:`~~',~ !D-ITATt twt OR IO~f MR t /Ml `~ ' - ~`` ~ ~ -. "r~~ ^, *`~ '~ - - «.r ~4C.a BALDWIN PLAT T-Z9-N • R-16-W ~~ K fvOV~TYr ~ 'i; #. ' , .z'." : _ See Pase 112 For Additional Names. ,~ (Landowners) EMERALD PAGES4 ~.3i~1 2400 2500 DD 2600 2700 E *' Q,~um 'ms's ~ a 9~ronda Ms-.s~ah1 ao r r " ~qq r g Kaa~ m s~ a ~ ~~ chars Dorw~fn y. a, etai~g 77 F,rl~.a 47 cae.a 0~ 5 gRoF~ ss"Kenn ~ resin tue6emSZ ~~ tzo D ~y µ,,,w, c"i g Marcia o DaMd )am ~~~~ ~ veme.d R lae0m ••m q.°~ O1 ~ I Graf avlckr Gille s 7s ,t •• +0 160 146 y+" 11 Is5 40 ,o ~ 1 b w i<•d as Hdm 11 a a'„'°"t x~ • Lee g o7 _ Patrkia )mph Scott Qt g v ,~~ eVrm~ Vansomeren ~ aa~r w ema.m I .I,~ n 193 Hutt6en Mj~ 0 154 'Z ~e4 s Scott 1~ ar~k+~ °ei~"• ,Bryan Todd q~ ~dweaMasan y CP hire ~'" Green Gahm x-.a ,sly ralma ,g11sa aWd ad- no,+~+n 160 s7 ~~ aarrMaa lr g s 18 pGOeK 0 ° _ _ _ _ _ ~ M +a ~ 0 ~ • 1 3 Cro ~ Graf ~ ~ ~ +0 11 AVE s~ 192 ro..E 160 lzo ex s x ~ £ Ra~Mieen ~ • n p~hylos DH~° ~ "~ 7S ~ ^ e Robin S s 9FF a sbrs,s R R ~ Ma g' ekrea 35 ~ M 8~ gg N ~i~ ~ m R 20'~ I u ~ ~ 40 40 ~ •~ rv r ~ s3 0~ ~ 75 edn ,o a'e Pew 120 a sumo rnj ~ w '~~ t ouglas g ~ ~' T g ,h RobeR,Micheal, ' Ames gE Arvin h Paula John gt Gorman <' ~ B Ilristlnt 7~ ~ w Mula,scott a ~ On l°a'xs' Ramona a 40 > ~ to a Veenendall ~ ffF]]7 « C,re~ 66 .~ H~mc so Hazer 78 a Utec 18 n"9~ Thoresen 93 Gida~kdn l00 >• m lua,a ~ g o Dwayne ~ Paarnea DenaldQ Robert ~m s~ oo ga $ y.,, ~. cosssnr ~ Docotl4 g Faye waa zo oseph 2 emee°"' 120 w e ~ 40 80 r '~' g ~ 160 j ~ mwtlwra Glenn ao N i B0 Garhnann 0 63 g ~~ mat VanDamme Tmimt s Esanbock ~~ ~ 7Vi'S vid g ~ a aw ~c ~m.~ :+ g loans s ~ Christlne KzLSilek a Kuen o't~ Crystal runes $1d C7 Malcein Asmara la~*m Garlmann 137 160 4o ve Fern 80 w n 40 4 ~ E 43 IT'~O' m eo 80 as t v o o as rr'a +a Robert ° '$ Debra ~ a aoo n nmo• n ,5 $ s Ig ~ ° ~o ,p ~ Affolter Exyymm~ 40 ~~Oan y • n a w~ann~ w +0 40 ~"~N ~• Ksssilek R 4f$~ ~9 gpauline ~ra,ms Mentlll ~ $ ~~ Marianna sValoan Ronaldg ~p ohnson croak Lassrie am 169 80 > 3 60 ^ ~ Henke ~3a ~ G ~ ^• $~ 1 95 ly~t 80 Montdth y sp ~ ~~~~ ~' xmdmE aade a m Ruth e g 110 190 ~a J 314 Bavid ,sm k o00 ~ arl m,aer Veenendall o m lax cewa, urge aal ~ ~ 2 ty w w + eae ba ag Alvin bl ~ a laamoe K ro ~, •sa Gtlues g 40 90 4 c u =" -0i u 'd 5'. C M Q roan Pamela ~, Gars a ~ Simmons David g 1~ ~ 'Cd a. p r~n 6i ~ 36 71 = za Peterson F, Fem caaeana IL Doris R~ ~ ~~H w< Q m 152 40 ,o z 3$ x 38 w ~ 0 114 40 Burge 160 +o us~ G G 7b o less e4 gag ~ n N ~ ss °m co`; .S, ~a a °d, ~ 83 race o N PC.eraldine I- to ° ~~ ~ SS ~ 4i • ~ ~ c ~ 40 1 ~p ~ _ ~ 20 M yy~~ Webbu u^ 10 ~ Lokker `£n a ~ o a Timothy g h q ~~ ~ rang M a +o s~• m _ Robert g N b Bonnie ~''~ R .. ~~ Shirley 80 lu a ~ ~ soyc ~s ~ ~$r ~ Veenendall n w m 1'~ a ~y ~ 40 0 Z 0 Reinhardt RG 10 ~' 264 N G t&D h, Robet £ ~ s ~ • Iw,,aa LE 120 ww 6 [roronp ~ g0 r„ sa zo Timotfipp Luckwaldt ~ m Narm~s d rs " ei N ~ y u Udder Lee as ias :o g Charlo a pgrcltl Inc u su m [nc < 150 ,a a xaon Bazllle ~ r2 ~ ,,,s„a Inc ^ ~t° w loan `Q~~r2~iS~ ~+ Dahy Leonard 8z ~~ ~ ~ 3'~ szmma O z 196 F ~tl~ ~zs ~ ,~„ 180te hAVEO ^'~~ s tr 266 E~ ~n 90 ~S~',~al"' 20 36 h' ~3 155 159 z 240 ~a3 p Kent g ~ ~ ' ,,,1~, a G 8E G pg ' Mldmel atao Euamr. Gs A MeaMa Ronald + a ~ R,M Smith S '~ n arxrn David Ilarban e s Dambwa ~ N )ego a ela.,a ~ ° e0 &S ~~ u Toltefann LLP '~a '^ 8[ Karen az~ r r S \ R~ Y ~ s 68 4~ °x ~_ 5~~ 40 N1et°ID <man 61 f 1 _ 36 qp tea`-tl~35 ~~"J y~~ y C CGGG ~ ~ arc zo ih AV john g ~ I~O~' g PaMWasiszae V Via. ~~ s peso '7 30 ~~> raro asn+e, Sheila 35 r~daaa Meyers Meyers Albrook I ,~ to v Berk;cut 3o n H~ rarx +o ~ o ~ 110 40 40 I~ 41 ^ w ,~< Inc ` ~ )oho a $ e ° ' ~ ~, Thomas ~ Luckwaldt L rewam 135 \ c ~ ~ so 170 ~ ~ ~ ~ ~~ g Sandra y Agrcltl hsc a B"b" _ >f 214 9 "raw 37 ~ .~ yy~ 3 3 ' ~ Q ~ r $ Olson D F, ~ 119 ~°'r ,Io ~~ sloes ~, E~ ~'nTS .Pauli NXyi.., ~ a„"°'Id'e ~° 100 nna.,wn r,,, N ~ '" WaRera Twill .il ^~LI p p 1 Mdbaa RE V W C. m ~ man ~ ~ iM ,p p ~ 6 T,ust aU .a® ~ 1 N~~ 140 12 tr Mnva ,a ass o mm41 1 +~ m ,o t+.a a6 197 •M da 70th AVE g Do,sald 70th R6C ~ « 12 _ _ aG E Ikbmr ivc o i C IS q M -01 np°'id Keven G M 1 1a d 9 i9i C ~ a Sbeml' a lZ 6 Iana~ BALDWIN w '° ~~ ` " ,n $$ ~ s £.wln Cecelia , ~ ~ ~^ =~i~3 ~~~ I~~~ml 4i d: ,. Land 4G aw7N.Nr- R Z~ "~2 senor o .uae a Bruce g~ a 31 35THA E ~. r '" R°°°rir ~ 28 xanksa D ~ V1~~ODVILL J~o~~of ~~ ;: •..m 64 V pp Bads 4s E ~cao• Elrod 1 c70 ~ 160 _~ ~ •xe, w ~~~ Bryon, Lee ~ r". Y ~ 4s " / so,sars ram+ox $ Janet " ~~ Stephen 13 ~ ~•k ~, ~ ~ Camle r ~ Hanson 80 ~g ggg O 72 gR „ s m Olsen : N VANDER- _- Bo~nlha ~eniffer- ' ~~g ••m°s Shelly y ~ ~ ,m pwaadea• Gem BB R 95 3rnvs io _VV?nB >w 66.. w ~h 60 d~ ~ n R 3~ x d8~ tS~SN w ~W 90~g~ ~ 60th AVE EAU GALLE PAGE 22 Your Complete Hardware Store Plumbing • Tools • Housewares • Appliances • Ns Sporting Goods Headquarters for Western Wisconsin Over 800 Guns in Stock Andy Rudesill G R E G E RS O N 1962 Cty. YY ~~, Hardware Baldwin, WI 54002 (7 ~ 5) 684-3246 Phone: 715-684-3881 880 Cedar Street • Baldwin, Wisconsin FAX: 715-684-2834 Full Line of: Miraleloading Supplies & Guns • Fishing Tackle • Reloading Supplies for Rifle & Shotgun S't. Croix County Planning and Zonin Monday, March 07, 2005 at 8:39: 09 AM Detail Sanitary Information Page 1 of S Computer #: 002-1015-70-000 SublPlat: metes & bounds Section: 7 Parcel #: 07.29.16.1006 Lot: TN/RNG: T29N R16W Municipality: Baldwin, Town of CSM: 1/4 1/4: NE 1/4 SE 1/4 Owner: Nelson, Dale & Joann 1028 220th Street Baldwin, WI 54002 State Permit: 18831 Issued: 10/20/1981 POWTS Dispersal: Non-Pressurized In-ground Permit: Replacement County Permit: 213 Installed: 10/27/1981 POWTS Detail: Bed -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Inspector As Built Plumber Tom Nelson Yes Boldt, Everett Signed Off: Yes Other Requirements Additional Notes Money Owed This was installed after failure of original system - $0.00 did 3 perc holes on system plus 3 borings to 72" deep. Bed 12' x 52' and may have used original /'` ~ tank. Will file original permit with replaeemeTR' ~ Tl.(/ri-ci Recmiiin 2004 septic files. The owners applied for WI funding, but were denied due to this replacement occurring after 1978. c _ REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM ~ p - ~ Sanitary Permit ~~~ State Septic ~~~~~_ _.~ ~`~~~~ TOWNSHIP /J/ St. Croix Count NAME ~ ~ G ~/'7 i~. ~ GL~/~~I _ ~ Y LOCATION_~/~ S ~ Section~Lot l~ Subdivi~ion_ SEPTIC TANK Size~"`j~ gallons Number of compartments---, _ /~ Distance from: Well ~ L Buildin~-- `~ ~ 12% slope ~- Highwater ~ .;~ PUMPING CHAMBER ~ ~;,~:"~ Size gallons Pu ~1 ~,. HOLDING TANK ~~`"~~ Size gallons,~~ Numbe P u m p e r--- '~J r'--~ Distance from: We H,tA(hwater ABSORPTION SITE Bed Trench Model Number Distance from: We11 ~ ;`' '~ Building_~ ~- 12% slope Highwater ABSORPTION SITE DIMENSIONS Width of trench ~ Z ft Required area ~i '~ J _f t. ~ Length of each line_~ ~ ~~~ ~ ft Depth of rock below tile_ ;~~' _in. v'1 ~ Number of lines ~ Depth of rock over tile___ __`"'`__ _in. -- .~` J . Total length of lines __ ft .Depth of the below grade - ~ ~- --- in. - Distance between lines f.t Slope of trenc h in. p er 100 ft. Total absortption area Wi n' '~ ft. Type of Cover: l PIT DIMENSIONS Number of pits Gravel a round pits- yes _ no %. ? , Outside diameter / ft llepth be low inlet __ __ _ ft Total absorption` a~~a Area required I N S P E B•~~•••~__,m;~_ APPROVED REJECTED REASON FOR REJECTION DATE 198 nurtacturer of Comp Alarm S Buildiln ft _ ~ `T'ITLE DATE !~ State and County Permit A lication PP for Private Domestic Sewage Systems State Permit # ~o County Permit # a7 ~ County Sf' G'rclX *DENOTES STATE APPROVAL REQUIRED Date .Approval Received from State if Required State Phan I.D. # A. OWNER OF PROPERTY Mailing Address : ,,~~ // // B. LOCATION: '/< S Y4, Section Z, T_ N, R r' (or) W Lot# City Subdivision Name, nearest road, lake or l andmark Blk# Village Township~p~ Gt7%/f C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family !~ Duplex No. of Bedrooms 3 No. of Persons D• SEPTIC TANK CAPACITY /~~~ Total gallons No. of tanks Q/1/G~ HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement ~ Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement ~ Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)_ No. of Tren es Seepage Bed:_~_Length 52~ Width ~~_Dept h_.~_Tile depth (top- 30~~ No. of Lines ~~o Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land. 2°10 Distance from critical slope WATER SUPPLY: Private ®Joint ^ Community ^ Municipal ^ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I Have sized the effluent disposal system from the EH-115 prepared by the Certified S 'I Tester, NAME ~/~°. ~-'~ 0 Cs 'f" C.S.T. # DSs'~ and other mformation obtained from ~ e (owner/builder-. Plumber's Signature MP/MPRSW#M-~ ~~! Phone # r//S~ .68'~-33~fl Plumber's Address Do .Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT SE ONLY Date of Application ~6 `csZO ~~ Fees Paid:. State /yam Count ~/. ~ D O ^ a O - ~f Permit Issued/ (date) l0 -~0-~~ Issuing Agent Name .Inspection Yes'~No State 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 7/1/78 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN`DUSTR.Y, DIVISION LABOR AN,D~ .PERCOLATION TESTS (11J) MADISON W 53707 HUM~jN RELATIONS LOCATION : SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.• BLK. NO.: SUBDIVISION NAME: ~ C' / y~ COlUNT~~?Y: ~ OWNER'S BUYER'S NAME: MAILING ADDRESS: ~ ~~ / /' Le4'O ~ . ~ ~ ~~S~D i~ Gf/ 4~// ~ ~ ~ O USE NO. BEDRMS.: COMMER..IAL DESCRIPTION: Residence 3 ^New ,Rep RATING: S= Site suitable for system U= Site unsuitable for system DATES OBSERVATIONS MADE I S: R A p TS: lace ~~ -~~~ ~~ ~~ ~'~~~ O CO NVENTIONAL: ©s^u MOUND: asou IN-GROUND-PRESSURE: osou SYSTEM-IN-FILL os^u OLDIN TAN os^ ECOMMEND DSYSTEM:(optionall If Percolation Tests are NOT required DESIGN RATE: S ST If any portion of the lot is in the under s.H63.09(51(b1, indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING NUMBER TOTAL DEPTH IN, ELEVATION. PTH T GROUN OBSERVED DWATER-INCHES EST. HET CHARAC OIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH TO B C IF O SERVED (SEE ABBRV. ON BACK.) B- I 7~ 97 ~ll" . s /2'' / d "' r 4 acs ~~ -, B-~ ~2 98" ~ ~~ ~~ /~,- /2-, B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCH ES AFTER SWELLING INTERVAL-MIN. P RIOD f PERIOD2 R p PER INCH P- ~ // (P ~U 8 ~- ,i G // -- O O P- y „ , , ,,, P- 3G ~ ~- y-- y . P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION 9~ ~ // ~~ _. _~ ~ __ ..._ _ _.... __ w . ~ __ _ e_ a __ __ _ ~ ,~ ~ .~ __ ~ ~_._~.~ ~ . ~._ ._~. w ~ __ ~ - .~ ~ m `Q 2 ~V C~_~or~e,r o~~iouse" d1~ ~. - _~ _-~_ ,.. ~~.a ~ 9~~ ~ e 3 E. ~i~o e r ,~i~; f ~ , * _ .~. . ~~ .k ~~ u , G'a~~rge __ ~,l.tL~'L~ ~ * 55 , ~ _ _ _~ ~~ c~~lL e~ _~ * _ ,; so ~'1~ ~ ~ eA ~i ~ E i V I e,_~_ ~ ~ ~~ _._. _ ~. _ . _. ~ _ ?~ _.B2_ ._ ~ _. ~~ ~ 3 I ~ ~~ i ia~ t `~. , M ~ _~~ ,~~_. ~,~ _~. P __ _ ~_.._ ~ ~.. ~ ~~ _ _ 3 ~ _~ ~ ~ ~ t I ~ t i ~~ ._ .... ~ ~__ „ ___ mm_ ~. _S, .~ : __. _~- - ~. ~~. _ a. _. ~~ s , ~ ~ 6 ~- ~ .. .* .. ~ ~• ~ ~ ~ t` : ----~ __. _~ . .. ~ ~.~~ .. _ ..- _. _ . ~. _.., w_ I I I i _... m _~ ~_._.~ ~ ~ e ~-.._..~1~~.,.. ~ e~..~ ~_e~_wa ~ ~~:~ .~~~ __ ~.~a __. _._ ~ __ cty E' f, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print : ~ TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optionall: CST S N DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page~oil Tester. 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