HomeMy WebLinkAbout040-1210-30-000
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Parcel 040-1210-30-000 06/04/2007 11:30 AM
PAGE 1 OF 1
Alt. Parcel 25.28.20.998 040 - TOWN OF TROY
Current X 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
O - HELGESON, JIMMY L & HEIDI L
JIMMY L & HEIDI L HELGESON
233 GLEN CIR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 233 GLEN CIR
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.000 Plat: 2495-ST CROIX HIGHLANDS
SEC 25 T28N R20W NE SW LOT 13 OF ST Block/Condo Bldg: LOT 13
CROIX HIGHLANDS
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
25-28N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 958/85
07/23/1997 804/400
07/23/1997 787/509
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/22/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 53,000 257,600 310,600 NO
Totals for 2007:
General Property 2.000 53,000 257,600 310,600
Woodland 0.000 0 0
I
Totals for 2006:
General Property 2.000 53,000 257,600 310,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 314
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
t
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS ZL33 Glrey' C l,A?.
SUBDIVISION / CSM#~ lr CR~~dZgg&/Aj ryS LOT # 13
SECTION___,;Z_,T,,19 _N-R__.Z~oW, Town of Tif o o/
1115. 29. 2" . °Catg
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHI G WITHIN 100 FEET F M
v
Lcr- / yon
~aus~
uec
CIO
C-L,
pew -top 3- ~X 53` iAt ecrcH S
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 721P *L77D AEL lay a
ALTERNATE BM: lL ZAt Cl1E&9)i 71?EC = ,6?L ZaQ,A
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: ~ r- F -A S Liquid Capacity: 1&0
Setback from: Well House Other
Pum turer Model# Size
Float seperation Gallon
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length _5-3 Number of trenches _3
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. 9J~, ST outlet _ 9
PC inlet &A PC bottom NA Pump Off IVA
Header/Manifold 21/1_ Bottom of system 4`y
3
qi~ Cs
Existing Grade Final grade
DATE OF INSTALLATION: " is 9._3
PLUMBER ON JOB: LICENSE NUMBER: 320
INSPECTOR:
3/93 : j t
It9,C n7sI9P:rt T§RyI~ld2us5try28.20,NEz PRTE jE1NA~~S MRD. LOT County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
1756957
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
HELGESON JIMMY TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
ii
TANK INFORMATION EVATION DATA A9200316
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosin ry(; S 66,9/' 10,
Aeration Bldg. Sewer dx;~ /
Holding St Inlet 5 , 11' 97.3 7
TANK SETBACK INFORMATION St/,O Outlet 97,06'
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ~Cr 'a2 NA Dt Bottom
Dosin NA LlOaw. 9,1
Aeration NA Dist. Pipe Gam'
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufa Demand 6J
~G C~ 7 3 , s9
Model Number
TDH Lift Friction System Ft
Loss mead
Forcemain Length Dia Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Widths Length? 3 No. Of trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN 1 N ~ DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O cr ~,/r CHAMBER Model Number:
System:,-/,, r ~GS a7 C,. a9 22,- OR UNIT
DISTRIBUTION SYSTEM
x Hole Size x Hole Spacing Vent To Air Intake
Header / Manif Id Distribution Pipe(s) , C
Length Dia. Length Jed Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over " xx Depth Of xx
-B-~VTrench Center,-3 - ~fTrench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) th Lcc
-77C VI
/a -S
Plan revision required? ❑ Yes 20TO
Use other side for additional information.
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code co
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than Sd S
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
e-_ S-0 A/ ME .5W - '/a '/a, S A 5- T , N, R 600*W
PROPERTY OW ER'S MAILING ADDRESS LOT # BLOCK #
c
CI TIT, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
LaEg 5,4ed 7 7 / 5, ) v2?T_,1yq-7 5TCktj4)C W _t 5
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned ❑ VILLAGE :
y*h-,,e1j 7- &P,
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PAR uMe
111. BUILDING USE: (If building type is public, check all that apply) ® jrO
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. N New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
12 M Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch)-~ ELEVATION
(f
7RO U U,fcl Feet 3 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank jji&
11~_ A s
Lift Pump Tank/Si hon Chamber. VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plu 1S, :(N; S m s) MP/ PR Business Phone Number:
Plumber's Address Street, City, State, Zip Code :
yo
5-96 olA-iljj ;U
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
54 Approved ❑ Owner Given initial 2_ 9•.93
Adverse D rmination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 the 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 cr plumber requires a Sanitary Permit Transfer/Renewal Form (SB0 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 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new arid/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.
VIII. 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 Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8'h 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 treatment tarks; building sewers; .vel;s, water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas, and the location of .he building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; fr:ction 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
'983 Ksconsis? Act 410 included the creation of surcharges (fees) for a nunn42,r of
regulated practices which can effect groundwater.
Th ;otlftlif ; ihiough these surcharges are used for mo=nitoring grouridv,~.:iter, y. 01,111d-
water K_,ontarnhioiiori investigations and establishment of standards.
SBD-6398 (8.11/88)
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SANITARY PERMIT Si . Ukt -p COUNTY
DILHR TRANSFER/RENEWAL UNIFORM PERMIT
(PLB 67-T) 17 5 b S 7
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
PROPERTY LOCATION: CITY: -rfic
VILLAGE:
'/a S10 %,S.251T.Z N,R 4 EsW W TO
WN OF:
tyr LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK:
3 •C L
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
ADDRESS: PHONE NUMBER: ADDRESS:
1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
pro erty.
PLU ER'S SIGNATURE- PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBER'S ADDRESS: ` S
PREVIOUS PLUMBER'S ADDRESS:
r
L TA 4Q 4,;L
M W NUM PHONE NUMBER: MA~RSW NU PHONE NUMBER:
32 o0. 57- ( ►5'0- 4 cs ( ► Z/
SIISSU GENT: DATDISTRIBUTION: Original - County
/ Copy - Bureau of Plumbing
Copy -Owner
DSBD-6399 (R. 5/82) Copy - Plumber
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION:-PW , SECTION: TOWNSHIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME:
2 S O
N, / / /TLP N/R lOE (o( W 77e y 113 Sf• ix f/r/9,ups
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: SS30
1f'CiPp! Mw T~USEi✓ ~/A,vc ~ P/~so~/ /L/, 2 o z L) ff ~
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFIL DESCRIPTIONS: PERCOLATION TESTS:
Residence 7 V.
A , ANew ❑Replace I
/v•
SC" ~l" ~Hti f ' ,6
RATING: S= Site suitable for system U= Site unsuitable for system
ICEJS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLD G TANK: RECOMMENDED SYSTEM: (optional)
❑U ~S ❑U S ❑U ❑S E9U ❑S MU CoNVTro~~4 L - T R~NC 4-9- S
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: CL/~ Ss Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- j /f l Ail - 12.0 w~ T-4. H &S' ~ Port 3.6 ' -f o y. S " ZS JN . v-ie CS ~ k
7S' py- o. anti .75 a • o~4rl 2, 0 ' OAP- A)
B 2 9p, 2-(o o /Q' o , 67' w Qa . ;Art S/ S, 0 ' T,}N vEe cs
7S'Af- 6a . /DAM 9.z
S , ' ~N. loAr+, s' Si ,
0 1 ~4r > O 7 7~ u v c s
B- / S 3G 5 , G, 3 ` IV cs' PEA G R .
o'" > / Z d . S > O ' a'~Y c 5 } 7~F
B 24 36
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 P PER INCH
/ 2-
P-
P_
P- 2, Z < Z
P
P- L
P-
PLOT PLAN: 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 slope.
SYSTEM ELEVATION
- -
A4
I
~
V 11
_rQ a_ . o FO~~ G
f:Z
ern. i
o I lys
S.
-Ak
~v a I
I
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/OS~
r _ 12-.0,__
"IF
I, the undersigned, hereby certify that the soil tests reported on this form made by me iri; ccbokd vvith the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests ire icorr7trte tk)ees987 y knowledge and belief.
It a L 1
NAME (print): " u TES E E COMPLETED O
HOMESITE SEPTIC PLUM8IMG CO. OFFICE Fo " /f97
ADDRESS: E IFICATION NUMBER: PHONE NUMBER (optional):
ROBERT U18RICIi7 .3P6
W16- WWR PLUMBER 86. NO. 3307 M.P.It! MINN. INSTALLER & DESIGNER UC. NO. 005M cs IGNATU E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
d
SANITARY PERMIT APPLICATION
■
R M accord with IUtR 83.05, Wes. Adm. Code
"I L
STATE SANIT PERMIT
- 4ftch complete plans (to the county copy only) for the system, on paper not less than ^
IPA x 11 Inches In size. LI--See reverse side forinstructions for completing this application. STATE PLAN I.D. NUMBER
L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
c l fti/ r% 5 w S c' T o, N, R v or W
PROPERTY OWN S MAILING AWRESS LOT / BLOCK 8
13.4 C. 411 F Vs I V
CITY, STATE ZIPCODE PNONE NUMBER 8UMMION HUE OR CSM NUMBER
ti 3 4 a Z , 1 14 1/0 w+1 /t- ,e 'Ca 1 II N. TYPE OFBUILD~SgKi: (Check one) ❑ State Owned CrTy NEARESTROAD
`
vatwGE : T
tX"ofbed room8 tr
1 or 2 Fam. Dwellin PARCEL TAX
❑Public
W. BUILDING USE: (H building type is public, check all that apply) ~t O , 1 Z) 4 `
1 ❑ Apt/Condo
2 El Assembly Hall 8 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 El campground 7 El Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
Mobile Home Park 12 ❑ Service Station/Car Wash
4 ❑ Church/School 8 ❑
5 El Hotel/Motel ry 13 ❑ Other. Specify
9 ❑ Office/Factory
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
-
A) 1. Da New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System ExW%ng System
B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued
Y. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental .3c
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type < Roldirig Tank
II
12 Seepage Trench 22 ❑ In-Ground 42
13 Seepage Pit Pressure 43 V TIVY
14 Syst"An-Fill.
VL ABSORPTION SYSTEM WFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ASSORP. AREA. .4. LOADING RATE. 5. PERC. RA7F & SYSTEM 0". 7t; FWIAL GRADE
REOUIRED (sq. ft.) PROPOSED (sq. to (GaWday/aq. Jt.) (M nJitRC .Y ELEVATION
best `r-, Feet
VM. TANK C~ vow owa Ilhom s Total 0 Of Prefab. ~s Fiber- E)qer>
WFORMATION...___ LL Mar - adac-ture . r's Name Con- StsN
-.New.. liailons -Tanks : _ ConcreW ....Qlaslt AN.
Tanks Tanks _
Swft T i T
Lint Pum T Chamber
VBL RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of ft, 'ti hits Eewage system sfartni on the attsc tedp~yut : _ _ , ,
Plumber's Name (Print): Plumber's Signature: (W Stamps) MP 8tninsas Phtsls NumDsr
1 14 92 P211
,
_P W
e ess my, ts. p Coder
C NTY
(No StanW)
Permit Fee ( bluing Agent Signature &WU Grounpoiar DIM WL*dy
Sanr~ d4
Disapproved
d F-)
Approved ❑ Owner Given Initial
X CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
a >z o. lima*
&rnwty Pb4l?) (W 11/8%, DISTAIWTION: Original to Co". One CopyTo: $d f t BuNdhW OlrWon. Owner. P110*sr `
t t.~:.
DEPANI-MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDWIY, DIVISION
NUM" 14 RELATIONS PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N, W1 5307
(1-163.09(1) & Chapter 145.045)
LUMATION:.;p 641, SECT[ TOWNSHI f/f4t:P►ifa : SUB VISION NAME:
/Vf 1/4 1/4 2S /11•f N/R lOE ?,P 13 sf ~x fi~~'ttGt /,vDs
COUNTY: OWNER'5111UYER'S NAME* ING ADDRESS:
S.S30
USE DATES OBSERVATIONS MADE
ND. OFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 77 N / New ❑Replap
, " r I I
RATING: S= Site suitable for system U- She unsuitable for system
o®S ❑U IM
~JS:ou ®S ❑U ❑S UL 170 RU NKVECOMM
CONUEf 3-tf0 A L TRV-•uC 44 $
If Percolation Tests are NOT required DESIGN RATE: if any portion of the tested arq is in the
under s.H63.09(5)(b), indicate: c4c sr Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION -._.,.-OBSERVED EST. HIUM-T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/ r y r S' dwe-Jejo. Sr
- "I'rAHots #eoM
B -f4'4 0 y S ' 7 S .m . vE,r C~ aQ - 49
Z I r .75~p~ O, eAAt .7S a 04H a 2.J0 • O AJ r",
47 d. 8.3. 0 7,1 AJ va'_cR CS
r 7S 6j. MAIrt , y~ • /0AM 4( 4.1. S;,
El- iv > I 6, 3 r T-4 A.0 UG/p /P CS Q PEA( 4 R
r g
Z •0 9~• 36 ~ ;ko, 2 . 0 '4• 0.- C313. 1Jrlher C S ~ PRc. Joie .
B- ;
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME WATER LEVEL-INCHES RAT MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER160 1' 2 MUM t PER INCH
2-
P_
P- • L < Z
P- r
P. e
P- .
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe trhat are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings snd the direction and percent
of Iand slope. r
SYSTEM ELEVATION s4'*.4se, p 7.~
li 1
I f '
C--A r-- 110 AS
_ n A e s 't A
a , t--- -1 - -
MOVE
N LID"
^ I
(S em.
116 U,
t
T
Al -.k I 1 r o
- p
E
1
- r
aw-
Zia-
T _
1 6106
t, the undwsWwd, herby W the the s08 tests reported on this brat frttade kt ; a srlth the proco&o" a4 methoeis specNtad M100
Administrative Code, and that the data raocrdad and the location of the wakwil kno4sledp arW W d.:' ' k
NAME WnO:
-9 P
IGNATW;
MuNH In,YmuErt & DEER UC. two
oa/p
D%TRIBUTFONi Original end one alopy to east 4taa+or a484+I1 f#A r 2z s
DILHR 39D4M (A. (?2/d?1 c a*r I # ~ x 3~ i f ` g l
Fresh Air Inlets And Observation Pipe -
-=-PLAX
1!~-
Approved Vent Cap f'or
r
MIn1mum 12" Above
_ yv(~{~- ~~_Z ~gG
Final Grade SO
20 - 42" Above Pipe 4" Cost Iron
. ~ ~~~y t~ Y _ .
Vent Pipe
To Final Grade
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution
Pipe 0 0 0 0 0 - Tee
6" Aggregate
Beneath Pipe o
C-le,z 9a 45
I~
I
p ARP -rvQr>,~e Prd~ L~1o-~
EL, 1oa.o •
1,0
I~ o ~cl.l
I zoo lip Z -
M $3 S~(17~;
PI d ~ve 17 QeQrtlo M
0
~ I + rl~`~ 111
s ` '3 T Il
_921 (q
Vale
~ i
r
G -PV
_ G~pac~
( 5
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
• INDUSTRY, C DIVISION BOX 'LAMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 539069
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.: SUBDIVISION NAME:
2S /TIP N/R LOE (o ► ?~°oy 13 sf. j'x ff~'/,~.vDs
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
51'•Ci ,u,~, T;~tISf ✓ /V~Nc ~ ~~so.~ /L /P z z o 4 z v E ff So3
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI LE DESCRIPTIONS: PERCOLATION TESTS:
Residence 7 ANew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system eo
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: rEIS YSTEM-IN-FILL HOLD G TANK: RECOMMENDED SYSTEM:(optional)
E s Qu as E ❑u EJu os MU Coov"TrooAL- TR>EAic445
If Percolation Tests are NOT required DESIGN RATE: T
If S~ t I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: o Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-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.)
B- 12.0 Mors +Rom 3.6: y y s ~ s ~N . cs
I I 1S ~.N D. Df!M .7S a • O*m 2.,0 ' 0 4 X V
B-Z ~d'0 9~p 2(p /O.O , 67' ff. Ra tN.~ Sl _r10' T.tAJ yaoe CS
. 7s '1Af< ao . ADAM . fa, 10,gAA, 15"41. &1. si ,
B-3 //0 1,0'a" 74v- > /.0 7 7~1u v' cs
PeA GR
~gg
B-~ 2-0 .36 2,0 AD > //.O' '3 vc-~r cs 7
B- 4
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT 2 P PER INCH
P- /7 2-
P_
P
2,-
P__
P- Z
P-
PLOT PLAN: 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 slope. i
SYSTEM ELEVATION y~' Zfe*1,4af P'rS
_ _
3
1
sjec System.
, W 7-3
r-t
I
I
•
3
1
i ~ S I
_ ...T.
-r
I, the undersigned, hereby certify that the soil tests reported on this form made~J d with~he procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests a corr?VW ty,~`ey.Q y kaewledge and belief.
NAME (print): III TE ERE COMPLETED Q W:
OFFICE 30 IfF7
HOMESIfiE SEPTIC PLUMBING 00L
ADDRESS: E IFICATION NUMBER: PHONE NUMBS (optional):
ROBERT ULBRICHT elps
MINN INSTALLER & DESIGNER LIC. NO. 0060 cs UP#E
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02182) - OVER -
• 4
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test, your retort must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil S and Textures Other Symbols
st - S" ne (over 10'") BR - Bedrock
cot) - Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Percolation Rate
med s - Medium Sand W - Well
Is Fine Sand Bldg - Building
Is - Loarny Sand > Greater Than
sl Sandy Loam < Less Than
*i - Loam Bn - Brown
*sil - Silt Loam BI - Black
si - Silt Gy - Gray
*cl - Clay Loam Y - Yellow
set - Sandy Clay Loam R Red
siel - Silty Clay Loam mot Mottles
sc - Sandy Clay w/ - with
sic - . y Clay fff - few, fine, faint
.c - C cc - common, cc
pt - rnm - Many, rrr ' m
m - M ck d - distinct
p - promir nt
HWL - High vti level,
Six general roil textures surf <Iter
for liquid v disposal BM - Bench rv -k
VRP - Vertical -ice Point
T( OWNER:
I 1 1st first '+n', ~ 'rrin<< a Th- cour*. ~ Est
" rE of 'le I, for to
;te? l o
?C!77t.. 11it mus. F.. .k< a (i.
~ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNTY '
STATE SANIT(PPERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 11 ~
8%x 11 inches in size. c . If isi ntopre~~
ousapplication
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
m n n1 E '/a S WS s' T , N, R a (or) W
PROPERTY OWNE S MAILING A RESS LOT # BLOCK #
Co iL ) 3 L ff
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
t r FrIL5 Li' S ~oZ'`- ~tS S /r14 57. vOIA,
II. TYPE OF BUILDING: Check one CITY - NEAREST ROAD
( ) ❑ State Owned VILLAGE TY d
N OF.
❑ Public L1 or 2 Fam. Dwelling-#~ of bedrooms 4 PAR ELTAX NUMBER(S) )
Ill. BUILDING USE: (If building type is public, check all that apply) '10-12-10 --30
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 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 in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ER Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
600 70o 99-S .76 Y 3. as Feet 98.3 Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New istin Gallons Tanks Name oncret Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank i o /;too 1 F] F1 M _I
( 1~tJ Yes
Lift Pump Tank/Si hon Chamber El I El F1 1-1 1 El LJ
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/ R Business Phone Number:
air c " s 337 8 ? /,f 4 ~S- a 17s
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial n surcharge Fee)
(9 Adverse Determination /90 a 7
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A•sanitarty permit is valid for two (2) years.
2. Your'sanitaryt permit may be renewed before the expiration date, and at the 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
submjtted 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 & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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.
VIII. 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 Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% 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 treatment tanks; 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 lest 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, ground-
water contamination investigations and establishment of standar7s:"
SBD-8398 (R.11/88)
S T C - 100
This application form is to be completed in full and signed by
the owner(s) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), thenia second form should be retained and completed when
the property` is sold and submitted to this office with the
appropriate deed recording.
t _
Owner of property 1m , J ; e114 P J
Location of* propertyL.E-l/4 ~ 1/4, Section,_~5_, TJ,8_N-R_aLW
Township
Mailing address
Address of site tot/ e r
Subdivision name SA C,<0/yC few Lot no.
other homes on property? yes _No
Previous owner of property _~~.rJ~~,J /fJArtrr_z, ~it~L1✓
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? ~_Yes No
Is this property being developed for (spec house)? Yes _X_No
Volume and Page Number P~3_ as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded n the office of the County Register of
Deeds as Document No. 5-s-r o , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
ignature o licant Co-applicarit
't-5
Date of Signature Date of Signature
C~~ i b Y wf 1'
iz a
.f
a
.,:5 •
410
fr'' + k
" ...fin 4s .
~ Ry y„ ~ ~ fr •y.~z ~ ~i
a Yp. r
Q.
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYE % h1 saI")- ~ La tc t~
ADDRESS IS'~ C.C~ IC FIRE NUMBER 5 -1
CITY/STATE g ► Je/~u ~15 ZIP ~y~ r
PROPERTY LOCATION :A/5 1/4 _VJ 1/4, SECTION, T2B_N-R 2 _6 W
TOWN OF l K , St. Croix County,
SUBDIVISIONSTUL)11l jG,Jd S , LOT NUMBER_L .
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 septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation prior to July 1, 1918. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
verifying that (1) the on-site wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiration date. ~~,A{ q
SIGNED Q Gt~i
l c i' v~ JJ
DATE:
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
LL ST. CROIX COUNTY
WISCONSIN
i}';n-,~i ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
[y. - - - 911 FOURTH STREET • HUDSON, WI 54016
- _ (715) 386-4680
June 3, 1992
Jim Helgeson
P.O. Box 406
Hudson, WI 54016
RE: PERC TEST FOR FORMER MARK JENSEN & NANCY CARLESON PROPERTY,
KNOWN AS LOT 13 OF ST. CROIXHIGHLANDS SUBDIVISION, LOCATED IN THE
NE1/4 SW1/4, SEC. 25, T.28N., R.20W., TN. OF TROY, ST. CROIX CO.
Dear Mr. Helgeson:
I have reviewed the above mentioned perc test and have found it to
comply with the requirements setforth by the state of Wisconsin and
this office. This report indicates that the site is suitable for
a conventional septic system. Given the information I have
reviewed and my experience with soils in this part of Troy
township, I believe this report to be accurate and acceptable for
the purpose of obtaining a sanitary permit.
If I can be of any further help in clarifying this matter, please
feel free to contact me at this office between the hours of 8:00 am
:00pm, Monday - Friday.
Jame K. Thompson
~Ssistant Zoning Administrator
St. Croix Co. Zoning