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Parcel 004-1046-20-000 10/04/2006 11:35 AM
PAGE 1 OF 1
Alt. Parcel 20.28.15.314A 004 - TOWN OF CADY
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 - PETERSON, JEROME C & RUTH
JEROME C & RUTH PETERSON
2842 25TH AVE
SPRING VALLEY WI 54767
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2842 25TH AVE
SC 5586 SPRING VALLEY
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 20.000 Plat: N/A-NOT AVAILABLE
SEC 20 T28N R1 5W 20A S 1/2 SE NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-28N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 788/440
07/23/1997 652/396
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 09/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 28,000 168,300 196,300 NO
ENTERED BEFORE'05 CLOSE W8 18.000 57,600 0 57,600 NO
Totals for 2006:
General Property 2.000 28,000 168,300 196,300
Woodland 18.000 57,600 57,600
Totals for 2005:
General Property 2.000 28,000 168,300 196,300
Woodland 18.000 57,600 57,600
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 511
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
, -..yam
VL#o+sinDepartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION SE, SW Sec. 20,T28 -R15 25th Ave.
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
Jero C. Peterson Cad
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
20-28-15-314A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark , 5
Dosing o 0
Aeration Bldg. Sewer e no. to'
~
t / s• J 40- 1o0~
Holding StIr Inlet - 6
TANK SETBACK INFORMATION St/Yt Outlet dpi a
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
irl
Septic 1 >IdD ,zV V/ NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
~K, 03
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. hi Dist. To Well
SOIL ABSORPTION SYSTEM C
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model 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.)
66
Ile
Plan revision~required? ❑ Y
Use other side for additional information. .91
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
D1LHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couN
~ ~.wn,~rs
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El ~ 7,vIous 8% x 11 inches in size. ek f risito 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 ref ~y» 5L--% L✓'/4,S~v T~~, N,R /5 E(or)W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
9X, z ~vY '2 mkt
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
IL TYPE F BUILDMor (beck one CITY NEAREST ROAD
) State Owned VILLAGE C 4 ❑ Public 2 Fam. Dwelling-# of bedrooms 3 PARCELTAX
Nu ( )
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo •C l
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. ❑ Replacement 3. Replacement of 4. El 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 R Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
12 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
<< ~w l O 6-L 10 S G Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New lExisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank 0(~l w t c
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb 's Signature: (No S 77 ) .MfrMPRSW No.: Business Phone Number:
St el G 4 S' G `l 2 2G~
Plumber's Address (Street ity, State, Zip Cod
tIX C. 6,
IX. COUNTY/DEPARTMENT USE ONLY -
I E] Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Issuing ent Signature
Approved ❑ Owner Given Initial/ p~ Surcharge Fee) n
Avers Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber
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e
. APPLICATION FOR SANITARY PERMIT
0TC-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 patmlt Issuance. -Should this development be intended lot resale by
owner/contractor,(spec house), than a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property y,} I~
Location of property ''_/4 .1/4, Sectlon T 2..N•R1=-y
Township
Nalling address L~
Address of site 54""'
lubdlvision name (J/4 •
Lot number (J /4
Previous owner of property k rot f c ri k .
Total slse of parcel
Date parcel was created (jM-
Ate all cotnets and lot lines idsntIllablet 0
is this pcopetty being developed for resale (spec house)? as PO
r
Vol"" ? nd Page Humber as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION T118 FOLLOWINGt
A WARRANTY DRID which Includes a DOCUMZHT NUNBBR, VOLUMS AND PAGE NVHAZR, and
the BRAL 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 Ceitifled Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(Ve) certify that all statements on this form are true to the best of my (out)
knowledge; that t (we) am (ate) the owner(s) of the property described In
this intotmation form, by virtue of a warranty eed teFotdad In the office of
the County Register of Deeds as Document No. ~.`;l n,~ 2 and that t (We)
presently own the proposed alto for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of id system, and the same has been du~ltr ~a,d in the office
he count a a r of Deeds, as Document No.
! atvte of owner gnatute of Co-Owner III Applicable)
-7114rhl Date [ signature Date of Signature
SEPTIC TANK MAINTENANCE AGREEtIENT
St. Croix County ~
a
x~. 7r . ' ; fT
OWNER/BUYER
ROUTE /BOX NUMBER Fire.Number
r ~
CITY/ STATE ZIP 4 V26
PROPERTY LOCATION:'Section_ - T N, R_
Town Of-(- - St. Croix County,
Subdivision Lot number__.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen's'ed' 's'e' t'ic tank um er. What you put into
the system can a ect t e' unction a 'septic .tank as a treat-
ment-stage in the waste disposal system. •
St. Croix County residents maybe eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
wh c was in operation prior to-July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all'new 'sys't'ems agree to keep their system properly
maintained.
The property owner agrees to.submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year-expiration.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with 9
the standards set forth, herein, as set by the Wisconsin Depart- :r
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
SLOT 1 LP,\ ly
sc-~LE \t' = 4D '
t-xc~t- hs stitUwn~
_ _ \3 ZQ #
~ ~ ~ ~T uNE z.0 RCEzE PM2cEL)
300 ~ if ~o w
~ s~r~c T~Nk
~`X S T1 G 3~ zb' S
o
tiro i
tuT _-`-O SITE SEWAGE SYSTEM
M o>J \TOR~N G
w~LS APP
DEPARTMENT OF Y. LABOR AND HUMAN RELATIM
OIViSiON SAFETY AND SUUM
SEE CMESP MPICE { 4"
< ! .a
3
IE . luo.p' o~.i
to-MNPI co=
J I L li'✓ U 1 !
6A1RH GE
oes~teoss~~~ ~
® aATHteH L. ~ N'EC:EREA • w ~
2 ELLS4YORTH. i C
z ~ w7s. ~ / AP D
a f
R0?
~S j'~' ~ ► ,~t~~ x ~ ~A~ of 1991
l~p~ a1M` A MFR SYS Yk /A►
9 S
SOO
\o o, g
_ pe+~c _ Rohm C Z5 T)4
State of Wisconsin ` Department of Industry, Labor and Human Relations
i
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
Apri 1 I'D, 1991 P.O. Box 7969 i
Madison, Wisconsin 53707
t
X JEROME C PETERSON
ROUTE 2 BOX 2588
SPRING VALLEY WI 54767 petition No. S91-00447-P
Dear Mr. Peterson:
Re: Jerome C. Peterson - Residence
Onsi to Sewage System'
SE,NW,20,18,15W
Town of Cady, St. Croix County, WI
The petition for a variance requested to section ILHR 83.10 (2) of the
Wisconsin Administrative Code was considered on April 5, 1991.
The petition has been conditionally approved. The conditions are as follows:
the monitoring wells be on each side of and to a depth of 3 feet below the
bottom of the existing soil absorption system and that monitoring be conducted
in accordance with s. ILHR 83.09 (7), Wisconsin Administrative Code, with
results forwarded to this office. In addition, system use must be
discontinued at first sign of failure and a code-complying system be
installed.
The rule requires that there shall be a minimum of 3 feet of soil between the
bottom of the soil absorption system and high groundwater.
The variance requested was to continue using the existing system in mottled
soils found at 24 inches below grade.
to the subject petitioner were
All of the data an variance statements
specific submitted
be
considered. This p
used for any additional modifications.
ncerely,
ichard Meyer, hitec
Director, Office of Di si n
Codes and Application
(608) 266-3080
RM:HS:04971
cc: Leroy Jansky, Private Sewage Consultant - District 6, Chippewa Falls
Thomas Nelson, Zoning Administrator,- St. Croix County
Arthur L. Wegerer
.i;n-,'WHIR 10/87)
Tummy G. Thompson
Governor i
Gerald Whitburn 1
Secretary t. 4, • : 1
State of Wisconsin
of Industry, La^~'
PRIVATE 4EWAng
401 Pilot Court i
Waukesha, Wisconsin 53188
•
'.l
WEGERER SOIL TESTING & DESIGN Owner: JEROME C. PETERSON
P.O. BOX 74 ROUTE 2, BOX 2588
RIVER FALLS WI 64022 ` SPRING VALLEY; X, 54767
-I
RE: Plan -Numbel* -691-00447:. " " Date Approved: April 10, 1981 I
Gallons Per Day: 450 Date Received: April 5, 1991
Project Name: PETERSON,'JEROME C. Location: SE,NW,20,28,15W
Town of CADY County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements This''approval'is based~on Chapter
145, WisCpnsin Statutes and the Wisconsin Administrative Code. The plans are +
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulaVions shown'on the plans. All items that are noted must be corrected.
All per.><nits roquired,0y-:,the city, village, township or county shall be obtained
prior to constructiQn;-.Jhe licensed 'plumber'responsible for this instal ation''~
set:of plans with the department's approval stamp at the`1~1`
shall keep one
construction.site. The-:installer shall notify-the-appropriate inspector when j
inspections can be made. {
This approval will expire two years from the date approved or ifa sanitary
permit is obtained, it will expire the day the initial sanitary permiy',,expire►s. °
The Section of Private Sewage has reviewed these plans for private sewage system`cod
requirements only, These.plans have not been reviewed for-.the code 'requtreft' tf►
'yet forth In Section.ILHR 82.for.general plumbing or in Chapters 50-64 of they.
w.i scons i n.. Adrn i.n i st rat i-ve code,
This apprgval is for the following components only:
- REPLACEMENT PETITION ,
Inquiries concerning this approval may be made by calling (414)''•54$-86104.
Sincerely,
40OLD T 1 I
Section of Private Sewage
Division of'Safety and Buildings
PPP065/0009n/ 4 ConSUltant'
cc: JEROME 0. PETERSON:., Private Sew499
5M) 64231 a. 07401
ti j WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL.SERVICES
` } - DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O.. BOX 309 .C.E
MADI N WISC6NSIN.43701:
REPORT`ON`SOILBORINGS AND PERCOLATION TESTS
.A171011: E y.,o , ~ction -10, TAN, RL E (or) ownshi or Municipality
,.:ot No.
Block Na►s.~.®, County r' C
-
v s on ame
Owner's Name: 3 A' r`7 cD
Mailing Address: / r-
7S " Sy7~ c
TYPE OF OCCUPANCY ",Residence c..~ No of Bedrooms Other m
EFFLUENT DISPOSAL SYSTEM: NEW- y'✓ r " I
ADDITION REPLACEMENT
DATES OBSERVATIONS'MADE: SOIL BORINGS `1 y M. 7 9 r j
PERCOLATION TESTS 7 - 6' 7 1
SOIL MAP SHEET SO'ILTYPE' A' it l a. ah d
RCOLATiO_ S .
NEST
TEST DEPTH
NUM- INCITES w _
CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE RATE
THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER ; 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P_ 1 w9 7'/TS, ~"sal A""' V ~ ~
7 7 15
p, y
P_ H; r
{SOIL`: BORING ;TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES
NUMBER INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
OBSERVED ESTIMATED HIGHEST - (DEPTH TO BEDROCK IF OBSERVED)
8 3 o n s3 y" y
II II
B __2 1.27 gang. ~w
PLAN VIEW (Locate percolatlbn tests,soii re holes and suite le soil areas.)
Indicate on the plan the location and square feet of suitable areas: Indicate number of square feet of absorption area
needed for building type and occupanA A Indicate scale
or distances. Give reference point. .Indicate slop
r AO 1
F1
r
81 4 i
/Od
40
8 I u i
h'
q
8 07 q 0 I sy
t. •
~f N
f
. M
It I Y,., 7.F
♦ ' I.. eel
4 ~
1, the undersigned, hereby certify that the spoil tests reported on this form' i
wera made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code~-and:that the-data recorded and location of test holes Are correct
to the best of my knowledge and belief:
R
Name (print) A 4 1 Al J0_ d LL r o 1~Q
Signature l • J~'r,,~ Y) , b 1
Certification No. S'a'7. A -T i {
e
Name of installer if known
1py C - Local Authority i€`'"`apt
• 1
_ _ .
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• AS BUILT SANITARY SYSTEM REPORT ;
'iER C ct , TOWNSHIP SEC. TAN, R_li_yl '
ADDRESS -y> ST. CROIX COUNTY, WISCONSIN. '
lv ( '
DIVISION , LOT LOT SIZE
:PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
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VA &PY-
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ell
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6
14
TIC TANKS CCC; _ MFGR. Indicate Nonth Annow
CONCRETE /,-STEEL S ca e
NO. of rings on cover_____/ Depth e DRY WELL
~'CHES NO. of - width length area
no. of lines q width__2 f length area
depth to -top of pipe ~q 1)
' •
;:.ELATE
J: RATE `I AREA REQUIRED 7-/,D AREA AS BUILT /D
:'~Iainer: The inspection of,this system by St. Croix County does not imply complete
.2•?iiance with State Administrative Codes. There are other areas that it is not possible
-inspect at this point of construction. St. Croix County assumes no liability for
stem operation. However, if failure is noted the County will make every effort to
-..ermine cause of failure.
~%ASES AIM OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEII.
`INSPECTOR -
DATED pc. PLU;iBER ON JOB A 4,
In
LICENSE NbIMER -
.REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
San.itaAy Pe:'c►n.it,~~
State SPp.t.le,yZ _5
NAMEL/ LL ~ Township St. C40ix County
Location L` SPSect.i.on
SEPTIC TANK
Size-----,-9 ga.t.tons. Number oS Compantmenta
Distance FAOm: We.t.t _5 12$ on gneateA a.tope it
Buitding-~~it. Wettand4 ~ .
H.ighwateA - it.
DISPOSAL SYSTEM
Distance FAOm: We.tt 12% ot gneateA a.tope it.
Bu.i.td.ing it. Wet.tanda Ft.
H.ighwateA it.
FIELD DIMENSIONS:
Width o6 tneneh ? it. Depth o6 no eh b e.tow ti to .in.
Length o6 each tine _ f it. Depth o6 Aoch oven t.i.te .in.
NumbeA o6 tines Depth o6 t.i.te be.tow grade...in.
J
Tota.t .tength o6 tines it. S.to pe o6 theneh in pen 100 it.
Distance between tines -4--it. Depth to bedrock it.
Tota.t abaoAbtion a-tea _6t2 Depth to gnoundwateA 5t.
Requihed area it2 Type o6 Coven: ; Paper.,) on Straw !
't
PIT DIMENSIONS:
r
Numb en os p.itaT GAavet around pits yea no
Depth b e:tow .in.tet
r
Outs Outside diameteA~
Tota.t aba oAbt.ion area ~ ~t2 . z
A
Area AequiAed it2 m
INSPECTED $Y - TI TL E •
APPROVED DATE 197.
REJECTED DATE 197
N
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• AS BUILT SANITARY SYSTEM REPORT .~~G. Zv 6~12T^..,
i° , T01i7NSHIP_ ~SEC. _ T N, R ! S_W
ADDRE3S -P'7 ST. CROIX COU Y, WISCONSIN
3JZVISION LOT LOT SIZE s~ AAJ 54
lq 7 7 WD. &O1-1-7(
PLAN VIEW
Distances S dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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"TIC TANK(S) I f"G;^ MGR, Lt) Indicate Nonth Annaw
ALA.CONCRETE I-~STEEL S cafe
f NO. or rings on cover` Depth r DRY WELL,
~rCHES NO. of width length area
no. of lines y width 2 y length area
;REGATE depth to,top of pipe_ _1 p
RATE lp_ „1,, AREA REQUIRED AREA AS BUILT
;claimer: The inspection of this system by St. Croix County does not imply complete
. oliance with'State Ad.-d-pi
strative Codes. There are other areas that it is not possible
t- inspect at this point of construction. St. Croix County assumes no liability for
i ;tem operation. However, if failure is noted the County will make every effort to
ermine cause of failure.
USES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
`INSPECTCf
DATED 7) r_ -7 / PLU MER ON+ JOB A
LICENSE N'u'TfBER
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REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
` San.i tany Petm.i t~~ 8
State Septic 1-2- 9a --3-
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NAME l rownah.ip dlf-" St. Cno.ix County
Location L S~lSection a
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SEPTIC TANK
Size :7J gattons. Numbers ob Compartments
Distance Fnom: Wet 12% on greaten Atope 6t
Bu.itd.ing it. Wettand3 6t.
H.ighwaten _ it. f,
DISPOSAL SYSTEM
Distance Enom: Wet 120 on greaten stope ' it.
Bu.itding , it. Wettande Ft.
Highwaten it.
FIELD DIMENSIONS:
With o6 trench it. Depth o6 rock below Cite - .in.
{5 Length o6 each tine it. Depth o6 xoc2 oven tite - .in.
Number ob tines_ ~ Depth o4 tite below graded .in.
in .length o6 t inezs it. Sto pe o j txeneh pen 10 0 it.
Distance between tines it. Depth to bedxoek
Totat abdoxbt.ion atea& jt2 Depth to gxoundwatet ~ .
..Requited axea it2 Type o4 Coven: L (Papebt Straw
PIT DIMENSIONS:
Numbet o6 p.ita_~~ Gnavet around pit~s yea no
Outside ide diamete,c / Depth below inlet it.
2
Totat ab.s onbtion axea 6t z
3
Area nequ&Aed it2
INSPECTED BY TITLE
.
APPROVED DATE 197
REJECTED DATE 197
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PLB67 State and County State Permit
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Permit Application County PernIft,
for Private Domestic Sewage Systems County
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*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
C tt, Y / Z a„ "se 1-1 N Bog u 7$- M ~ c+ e h i' e ~ tc1,'S ~''i 7Sl
B. LOCATION: $ E '/4 W '/4, Section ,20 , T,2,4' N, R 16_ E (or) ® Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township C cL
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C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family Duplex No. of Bedrooms -No. of Persons -Z -
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder _YES_&,-NO # of Bathrooms--L-
Automatic Washer ✓ YES NO Other (specify)
E. SEPTIC TANK CAPACITY / C C Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation l/ Addition Replacement _ Prefab Concrete ✓
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 4 3) Total Absorb Area c? j 0 sq. ft.
New-Z Addition Replacement .Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length V0 Width of Depth Tile DepthOA_ No. of Lines _ I
Seepage Pit: Inside diameter Liquid Depth Tile Size q if
Percent slope of land °/a Distance from critical slope x,24""
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 Soil Tester, '
NAME Lv c~,k Cr. 1,~-~ C.S.T. and other information
obtained from (wner builder).
Plumber's Signature MP~PRSW# y~~3 Phone # 7~~
Plumber's Address 4
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well). $ edit 4a
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Do Not Write in Space__ Below FOR DEPARTMENT USE ONLY
Date of Application j Fees Paid: State County Date -
Permit Issued/Rejected (date) Issuing Agent Name
Inspection Yes~No Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
i 2, state (pink copy) 4. plumber (canary copy)
Revised Date 6/1 /76
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