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Parcel 034-1084-10-000 09/15/20 P06 04:46 PM
AGE 1 OF 1
Alt. Parcel 28.29.15.555A 034 - TOWN OF SPRINGFIELD
ST. CROIX COUNTY, WISCONSIN
Current I X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KOSTMAN, LEROY E
LEROY E KOSTMAN
2926 73RD AVE
WILSON WI 54027
Districts: SC = School SP = Special Property Address es): * = Primary
Type Dist # Description D AVE 4'6
SC 2198 SP 1700 WITC GLENWOOD CITY 2 L q 2it~ A 7 `7 .
SP 7059 SPRINGFIELD SAN DIST #1
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 28 T29N R15W LOT 1,2,3, & 4 OF BLK 8 Block/Condo Bldg:
VIL HERSEY
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-29N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 841/44
07/23/1997 454/612
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/25/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 3,500 39,300 42,800 NO
Totals for 2006:
General Property 0.000 3,500 39,300 42,800
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 3,500 39,300 42,800
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
' AS BUILT SANITARY SYSTEM REPORT
1
OWNER E / D J~D 1`-/y1 AN TOWNSHIP I f,- SEC ._7-,?_T2tN-RAW
ADDRESS )Pf 44, ST. CROIX COUNTY, WISCONSIN.
S~yo. 7 2/aGlc - 0 3Y- /Ofd 4006
SUBDIVISION LOT1~ L_ _ LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
-EVMTHING WITHIN 100 FEET OF SYSTEM
< N q .t-
6 A
I di a e o th Arrow
SC L ~
BENCHMARK: (Permanent reference Point) Describe: ~',e
Elevation of vertical reference point: 1,4e Slope at site: o
SEPTIC TANK: Manufacturer : pS Liquid Capacity: /o do ±14 -
Number of rings on cover Tan manhole cover elevation: z
Tank Inlet Elevation: r S'! Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: tep umber of gallons
Number of gal. pu=set-Sor gallons;tota capacity o
distribution lineize o pump head;
gallon per minute er ra n name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: um er o pits feet diameter
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit evation feet. ,
SEEPAGE BED SIZE: number of lineswi thy ! _length the dep
SEEPAGE TRENCH: ,width length -
PERCOLATION RATE a & I L-j: REQU D. RE BULL p
INSPECTOR
DATED /D PLUMBER ON J B
LICENSE NUMBER .mod 9'y
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM `w~
Sanitary Permit
State Septic
AME_ TOWNSHIP /./St. Croix County
OCATION 4fw SectionoW Lot # Subdivision
EPTIC TANK
Size' gallons Number of compar)pents
istance from: Well J Building: _ 12% slope
Highwater
'UMPING CHAMBER
Size gallons Pump Manufacturer Model Number
IOLDING TANK
Size gallons Number of Compartments
Pumper Alarm System
)istance from: Well Building 12% slope
Highwater
,BSORPTION SITE
Bed Trench
)istance from: Well Building--,,;.,, - 12% slope
r
Highwater
' rf
ABSORPTION SITE DIMENSIONS E["
Width of trench . ft Required aroela ft.
k below the r' in.
Length of each line 'L. ft Depth off roc
Number of lines Depth of rock over tile ice'.
e,
Total length of lines ft Depth of tile below grade - in.
4-
Distance between lines" ft Slope of trench in. per 100 ft.
Total absortption area ft Type of Cover:
'IT DIMENSIONS
Number of its /`ravel around pits yes no
Outside diameter ft Depth below inlet ft O
Total absorption area ft
l
Area required % ft
TITLE Y-f><d .
INSPECTED: BY
APPROVED - " DATE
REJECTED DATE _198_`
REASON FOR REJECTION -
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
(ND.UST•RY; 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 81/2 x 11 inches in size. Include a plot plat) 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.
Property Owner: Mailing Address:
d
Property Location: 6111111p Village orTJ County:
'/aSW'/aS,2I? /T NCR 15-E (or) e S' r C t Number: Blk No.: Subdivision Name: Nearest oad, ake or dmark: State Plan I.D. Number:
(if assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY QDQ
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: &I Ze -f & I P Q
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New ® Replacement ❑ Experimental A Seepage Bed ❑ Seepage Pit
O ❑ Alternative (specify) E] Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than resent owner):
Private ❑ Joint ❑ Public p to
I, the undersigned, hereby assume responsibility for installation of the private sewage syste shown on the attached plans.
Name of Plumber: Signature: P PRSW No.: Phone Number:
C;P-AA,e k)
Plumber's Address: Name of Designer:
A2 6~4 e Ndvoo al 1` / o/
COUNTY/DEPARTMENT USE ONLY
i t e of Issuing Agent- Fee: Date: APPROVED Sanitar ft it Number
❑ DISAPPROVED
OAoO~
e son 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)
DEPARTMENT Y,, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
MD,IJST#iY; C DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
LOCATION: SECTION: /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
YJ T N R ~a
/ / z O H~
COUNTY: WNE BUYER'S NAME: MAILING AD RESS:
X a o Al Z, i o r
USE DATES OBSERVA IONS MADE
NO. BEDRMS.: ICOMMER AL DES RIPTION: PROFILE NS: ERCOLATION TESTS:
~~Residence ❑ New Replace I 9,-
'm -
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: ros YSTEM-INK: RECOMMENDED SYSTEM:(optional)
ZOAVA
®s C7u ®s ❑u W s ❑u ❑u ❑ s ❑u o
SYST ELEV. Percolation Tests are NOT required DESIGN RATE: If any portion of the lot is in the
under s.H63.09(5) (b), indicate: Q i~/ 93 i jO . Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
My 4 &d
B- ;2 .7 8'' 0 `f 4 v . r~ J ii s'
B- _ql7s ro fsg j 7 A/0 > 77 IjLtS f a ZB- ov Ryr ji XA-
B-Vex mrgmc
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER WVKJTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P OD 2 P R CH
P-
P
P d
P
Z
P-
P- _
PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. red;irectKn~ancl t a th hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings aercent
of land slop. SYSTEM ELEVATION M ~F ~e d
ive4
8.2- Y4,7117,
. _
'ZI
z =
T
3
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein accord with the procedures methods specified in the Wisconsin
Admimistrative 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 optionaq:
2 0 A / / F
CST SIGN T RE-
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DI LHR-SB D-6395 (N. 03/81)
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Smith Plumbing PHONE (715) 265-4838
v° R o y Jro ff .41 f N AvIASam k, ,j y a.x 7 GLENWOOD CITY, WISCONSIN 54013
lo eLL
1 INK
Nd use
goo Af~~ r 7e'
se
7'
_ ;me s
Bed 93'/0 "
Np %L i+~ ''Red d,'Aee v~: C:;-RauNd
oAn ?fie 4
PRoAeRty ) Ne,
Plb. t-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES
Division of Health
Section of Plumbing & Fire Protection Systems
ON-SITE WASTE DISPOSAL INSPECTION REPORT `
Name of. Premises
_ r
Street City County
Master Plumber Address
Owner Address
❑ County Permits ❑ Appropriate State Permits
Type of Building: ❑ Public Single Family
CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM
❑ Building Sewer ❑ Conventional Soil Absorption System
❑ Septic Tank ❑ Conventional System-in-fill
❑ Holding Tank ❑ Alternate Mound System
❑ Seepage Bed ❑ Holding Tank
❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System
BRIEF, FACTUAL COMMENTS AND SKETCH;
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❑SEE ATTACHED
DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary)
DATE OF INSPECTION
Signature of Insoector
White - Inspector Yellow -`Local Inspector Pink - Plumber or Responsible Party
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