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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER R~~'f~~~~s,[, r TOWNSHIP ~iy~ r y~ ~l'JF'r'6
SECTION _T 3 co N-R 17 W
ADDRESS /77<P r7G`~%S~° ST. CROIX COUNTY, WISCONSIN
Ail 0.w) ~2(1 AIA*VMd
SUBDIVISION_ , e~dx~~Jls A-/7 LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A , • 'Al
41+
l 'r
01
0
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: (,(/•,~dT~~6_A,14 /4D.
Alternate benchmark
SEPTIC TANK:Manufacturer: Liquid Cap.~(50~(
Rings used: MaCUe~iV-'w'''elev: Final grade elev:
Tank.inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front4- , Side , Rear Ft.
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well .5c) 1- Building: :is
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
Fri
J
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/ phon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: ump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance om nearest prop. line: Front_, Side_, Rear-Ft.
ce from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width:- 15-Length /So* Number of Lines: 2 Area Built 5c)
Exist. Grade Elev._Proposed Final Grade Elev. 1f93
L
Fill depth to top 9f pipe: I , 2-
g o. feet from nearest prop. line:Front , Side , Rear V, Ft. Z ~
r i
No. feet from well: No. f=Capacity:
HOLDING TANK
Manufacturer: lNo. of rings used: Eleva on of bottom tank:
Elevation of inlet:
No. feet from nearest op. line:Front , Side , Rear Ft.
No. feet from: Wall , building , nearest road
Alarm Manufa ure
INSPECTOR:
DATE : - Z. PLUMBER ON JOB : 0~ - -
LICENSE NUMBER : /h'~1 yLScJ 3 Zs 1'
6/90:cj
• V
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
L
LAB BOX U ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
P.O. 7969
MADISON WI 53707 State Plan I.D. Number:
NW a , N)✓ 4 ,Sec . 4 , T 3 0 - R 17 (If assigned)
Town of Erin Prair. Lo rgyXENTIONAL ❑ ALTERATIVE
t Holding Tank ❑ In-Ground Pressure El mound
176
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:J
CT
Merlyn Leslie 1776 176th St. New Richmond WI
BENCH MARKK(Permmanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE G
G O /
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Gar Steel 3254 St. Croix 149048
SEPTIC TANK/HOLDING TANK: a,Lo3
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK O V.: WARNING LABEL LOCKING COVER
PROVID : PROVIDED:
~P E ~S C'D1 r~ ` a /U , 5~~ S NO ❑ YES
c, r l dd
cc
WATER F ROAD: PROPERTY WEL BUILDING: VENTTOF SH filir
BEDDING: VENT DIA.: VENT MATL.: HIGH NUMBER O
-
/ / AIR INLET
I ( ALARM: FEET FROM LINE: ~ _
❑ YES NO- ❑ YES & NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
YES ❑ NO _ ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS AL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN EF_ET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NE
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH ETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.) -
CONVENTIONAL SYSTEM: D,,) o) - _ _)e
'
GTFr- NO. OF DIS . PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TH: LEN
(Ir
/ TRENCHES: I M L: PI DEPTH:
BED/TRENCH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DIS .PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. D R. NUMBER OF PROPERTY WELL: BUILDING: VENT T H
BELOW~IPESABOVFj~OVE ELEV. INLET: ELEV. END: J / PIPES: FEET FROM LINE: / /AIR INLET: /
R'V&~> NEAREST-- a5 '"III ?S -
MOUND SYSTE ,
Mound Ne • w6d perpen Icular - Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
W
~a(
~y etai In county file for audit.
Sketch System on
Reverse Side. SIGNAT RE: TITLE:
r
SBD-6710 (R. 06/88)
or,.. f p~
SANITARY PERMIT APPLICATION -
~jLHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
_,St. Croix
STATE SANITARY PER IT
-Attach complete plans (to the county copy only) for the system, on paper not less than /
8'fi x 11 inches in size. ❑ dnec 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
Merlyn E. Leslie y, +/4, S 4 T 30, N, R 17 xUgor) W
PROP RTY OWNER'S MAILING ADDRESS LOT # BLOCK #
1776 176 th. St. 12-18 76
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
New Richmond, Wi. 54017 1(715 246-4486 Jewett
II. TYPE OF BUILDING: (Check one) 1:1 State Owned VILLLLAGE : erin Prarie N `/~t~iRO t
❑ Public 91 or 2 Fam. Dwelling-#of bedrooms 3 PARCEL AX NUMB ( )
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo It? C.~
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ 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 4.0 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 ER Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
1130 Seepage Pit Pressure 430 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
450 750 750 .60 class 2 99.26 Feet 103.05 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
I Tanks Tanks structed
Se tic Tank or Holdin Tank x 1000 1 Weeks C . P .
Lift Pump Tank/Si hon Chamber --El E] 1 0 El I El El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installat' n of the onsite sew ge system shown on the attached plans.
MPRSW No.: Business Phone Number:
Plumber's Name (Print): Plumber' nature: (No S ps);; r3254
Gary L. Steel ~y 7
15 246-6200
Plumber's Address (Street, City, State, Zip C :
1554 200th. Ave., New Richmond, Wi. 54017
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includerg roeej water Date Issue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial / / p/
Adverse Determination 7 / W,4 ,
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
STEEL'S SOIL SERVICE
Gary L. Steel Merlyn E. Leslie 988 N. Shore Drive
C.S.T. 2298 NW4NE4 S4-T30N-R17W New Richmond, WI 54017
MPRSW-3254 Erin Prarie, twonship (715) 246-6200
21
,5;4-& fa~ t,,ds ~
-i-w4 2 e3, fo
25
.5e' i jbd 0
c
U
~L •
(0.~ D 5
D~ rT~
tS ZZ-)
>'wa6L Ylvc~~
99 z,o
I~-~ r ! sr c
Gary L. Steel
5-6-91
DERARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP Y: OT NO.: BLK. NO.: SUBDIVISION NAME:
NW 1/4 NE 4 /T30 N/R 1760 W Erin Prarie 12-18 76 Jewett
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
St. Croix Merlyn E. Leslie sr. 1776 176th. St., New Richmond, Wi. 54017
DATES OBSERVATIONS MADE
TESTS:
USE PROFILE DESCR PTIONS: E
NO. BEDRMS.: COMMERCIAL DESCRIPTION:
Residence 3 n/a ❑New ~Fteplace 4-18-91 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
ms ENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑U ®S ❑U ~S ❑U ❑ S ®U ❑ S 2U conventional
any portion of the tested area is in the
If
If Percolation Tests are NOT required DESIGN ~TE
under s. ILHR 83.09(5)(b), indicate: claFloodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 29 SIB
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.17 103.05 none >7.17 .25bl.1. 1.00bn.s.l.&gr. 4.92bn.1s.&gr.
B 2 7.25 102.26 none >7.25 .83bl.1. 1.42bn.s.l.&gr. 5.00bn.1s. &gr.
3 17.24 103.40 none >7.24 .00bl.l. .83bn.sil. 1.33bn.1s.&gr. 4.08bn.c.s.&gr.
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAPER INCH ES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R
P-
P-
P se design rate
P-
P-
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 V(` 99.26
t
E
i
-
E
E
f
N
E
- n
sr
E
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and 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:
Gary L. Steel 4-18-9t
ADDRESS: CERTIFICATION N MBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi. 54017 2298 715-24P-6200
CST SIGN E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 5r-
-ROUTE/BOX NUMBER /7 .24r /7/, FIRE NO. 2726
CITY/STATE 1/t c~ ZIP
PROPERTY LOCATION: ~1/4 A!5 1/4, Section T ,?4 N, R,Z_W,
Town of St. Croix County,
Subdivision Lot No. /z -/9
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
$3000 of the cost of replacement of a failing system, which 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 SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master 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. Certification form will be sent approximately 30 days prior to
three year expiration.
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 Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
r
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
• APPLICATION FOR BANITAAT PERMIT
• 9TC-100
This appllcatlon form In to be conplatod In full and signed by the owner(s) of
the property being developed. Any lnadoquacles will only result In delays of
the pzrmIt Issuance. -Should this development be Intended tot resale by
ovner/contractoc,(svsc house), thou a second form should be retained and
completed when the property Is sold and submitted to this allies vlth the
appcopcista deed recording.
Owner of property c Ze r•
Location of property _1/4 kc~ l/1e section T ? ~1•R,_,(,~•V
T o wn s h i p /11~ v° f," Pr c{ r `y- e e?
Mailing address /77& /7h & S-/ ;
Address of site 77/, r1f
,~7(a i ~l 1 a i , ,
UJ 5401-7
1VbdIvIllon nape
Lot nuesbec /7 -18
Previous owner of property _ `/r?kS U, aYi i L~wa2
Total size of parcel RNs.
Date parcel vas created _Iri'J~,<y a
Are all corners and lot lines Identillablet L-1-Yes •__1!0
In this property being developed lot resale (spec house)?- as 0
Volume 7 S and Page Humbes~~ ? as racosded vlth the RegIstat et Caeda.
INCLUDE WITH THIS APPLICATION THE FOLLOWINCI
A VAARANTY DRID which Includes a DOCUHKHT NUMBIR, VOLUMM AND PA01 NVKeiR, and
the 9KkL or T111 AMOUR OF DBBDS. In addition, a eectIIIad survey, ) f
available, would be helpful so as to avoid delays of the reviewing process. it
the deed description references to A Cettllled Survey Hap, the Cattilled Survey
Nap shall also be requited.
PROPBRTY OWNER CBRTIFICATIOH
l(ve) certify that all statements on this form are true to the best of ■y (out)
kmovledgel that I (we) em (are) the owner(s) of the Property described In
thls Intotmatlon form, by virtue of a warranty deed recorded In the office of
the county Reglstet of Deeds as Document No. / o z
and that I (vel
Presently own the proposed alto for the sewage disposal system (cc I e,
obtained an easement, to run with the above described ty, (w[oc have
the
at ons the uc cotiynon at Re lsold leter nya o tem, and th propec
e same has been duly recorded In the office
De ds~ as D meht Ho.
Ignature of 0 ec Signature of Co-Owner (it Applicable)
- t - q
Date of signature Date of Signature
r DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 1 THIS 80-ACE RESERVED FOR RECORDING DATA -7 9:y
WARRANTY DEED
This D$ed, made between ames C. Miller a
sin
- ................•.g.l...e..man
Grantor,
ans......--_. Merlyn E. Leslie and Sandra A. Leslie,
husband and wife as survivorship
,
marital..p?'op Grantee, i
Witnesseth, That the said Grantor, for a valuable consideration....__
One dollar and other valuable consideration ~i -
RETURN TO
conveys to Grantee the following described real estate in St. Croix
Halle Builders, Inc.
County, State of Wisconsin: New Richmond, WI 54017
Tax Parcel No:
Lots 12 through 18, except the East 6 feet of each, and
Lots 21 through 27, all of Block 76, Village of Jewett,
located in Section 4-30-17, Town of Erin Prairie,
St. Croix County, Wisconsin.
This iS homestead property.
(is) (is not)
Together with all and sin ular the hereditaments and appurtenances thereunto belonging;
And........... J8m9s M ller
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
no exceptions
and will warrant and defend the same.
Dated this 26th June
. day of , 19..86...
(SEAL) (SEAL)
James C. Miller
(SEAL) (SEAL)
•
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
as.
St: Croix
.........".....County.
authenticated this daY of 19 Personally came before me ~js ...26th da of
June n y
. 19........ the above named
James C. Miller
•
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not . authorized by § 706.06, Wis. Stats.) . .
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Eric J.
Lundell
" .......t..B......ox ..1 57......... Wesley W Halle
New Richmond, Wisconsin 54017
St:'"Croix
Notary Public County, Wis.
'(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: 19.........)
•Narnes of persons signing in any capacity should be typed or printed below their signatures.
H.CMdlarComparry M ti'1'ATE ItAR OF WISCUNSIN
FORM No. 1 - 1982 Stock No. 13001
Parcel 012-2002-10-000 02/24/2006 10:08 AM
PAGE 1 OF 1
Alt. Parcel 04.30.17.568C 012 - TOWN OF ERIN PRAIRIE
Current )k 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 - HALVORSEN, HARVEY, & RUTH HILFIKER
HARVEY, & RUTH HILFIKER HALVORSEN
1776 176TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1776 176TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.120 Plat: N/A-NOT AVAILABLE
SEC 04 T30N R1 7W LOTS 12 THRU 18 EXC 6 Block/Condo Bldg:
FT OF EACH & LOTS 21 THRU 27 OF BLK 76
VIL OF JEWETT MILLS Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
04-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1088/571 WD
07/23/1997 745/522
2005 SUMMARY Bill Fair Market Value: Assessed with:
105275 217,700
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.120 16,800 208,300 225,100 NO
Totals for 2005:
General Property 1.120 16,800 208,300 225,100
Woodland 0.000 0 0
Totals for 2004:
General Property 1.120 15,100 137,000 152,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 131
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
R , TO1WNSHIP&,1/ A SEC. T_x~ N, R /may-W
.0. AD S , ST. CROIX COUNTY, WISCONSIN. _
'BDIVISION LOT LOT SIZE
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
tt
P
. Y
t
v
S6
TIC TANK(S) _ MF(;R.__ ~r_ CONCRETE ar_~TEEL
NO. of rings on cover r) Depth DRY WELL
INCHES NO. of width length area
no. of lines -7 width j; length area~
depth to top of pipe
3REGATE K RATE w AREA REQUIRED r AREA' AS BUILT lp~ ,all
;claimer: The inspection of this system by St. Croix County does not imply complete %
.pliance 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
Item operation. However, if failure is noted the County will make every effort to
ermine cause of failure.
'ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
"INSPECTOR ~Q
DATED PLUMBER ON pl _ ill
LICENSE NUMBER
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PURPORT OF I1ISPECTIO?1--I:1DxVIDiJAL SEtIAGE llISPOSAI, SYSTEti
Sanitary Permit
fate Septic
T&TIISHIP tii✓
• t.~ oix County
SEPTIC TAN1:
Size gallons. `lumber of Compartments
Distance From: *jell ft. 12% or greater slope
Building* ft. Wetlands f:
Righwater ft.
DISPOSAL SYSTEM
Tile Field or Seepage Pit(s)
Distance From: Well ; f ft, 12% or greater slope* ft
Building ft, Wetlands f
FIELD Hiph-water ft.
Total length of lines
g ft. Humber of lines Length of
each line T Ft, Distance between lines ft. Width of the
trench ft. Total absorption area ZZ - sq, ft. Depth
.of rock below tile in. Depth of rock over the ' in.. Cover
_ -aver . rock,, % M1 Depth of tide below grade S•lope of
trench in per 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS
Number of pits Out de dia /
ter ft. Depth below inlet
£t. Gravel around t • es no. Total absorption area
sq, ft.
.Square feet of seepage "trench ottom area required ,
%:quare feet of see'page~,nit lea required
Inspected hy:_
• Approved Date j~ 197y.
Rejected ' Date 197
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION- fi Section 4__, TKQN, R al!-(or) W, Township or•MimpogipelitY ~'r A rte'
/ S L
Lot Na~Q , Block No.-24-1, ~y~ m I I L5 County
u division Name
Owner's Name:
!~1
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: IL BORINGS ✓ 1!22 PERCOLATION TESTS
SOIL MAP SHEET 3 f SOIL TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- SINCE HOLE HOLE AFTER INTERVAL
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
J~~a~ 40 3) VZ 6t Y2
~i & ia)2c
P:3 It I
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST ~j (DEPTH TO BEDROCK IF OBSERVED)
B- 7 2 7Z- if
3 Z 7 Z if ..i.C..
6~ Co.
Zz , -7 7z-,/
7Z 7 7Z
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. L~/F X43 as r9i: a ir'+~hl~ Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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I, the undersigned, hereby certify that the soil tests reported on this form were 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. ;
Name (print) _ e "fication No. 7,~
Address`
Name of installer if known
CST Signature
COPY A - LOCAL AUTHORITY
PL B67 State and County. State Permit # -
Permit Application County Permit
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
s
A. OWNER OF PROPERTY Mailing Addr s
B. L 10 '/4 N / '/4, Section T ~ N, R iF- (or) W Lot# ~Z City _
Subdivision Name, nearest road, lake or landmark Blk#--;?7Village
~ T
ownship , J C. T E OF OCCUPACommercial *Industrial *Other (specify) Variance
VCY
Single family uplex No. of Bedrooms No. of Persons-
D. TYPE OF APPLIANCES:- Dishwasher C-lit-S NO Food Waste Grinder _YES=fVO- # of Bathrooms
Automatic Washer L--YES NO Other (specify)
E. SEPTIC TANK CAPACITY /,-'e/,',Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Li Addition Replacement- Prefab Concrete
*Poured in Place -Steel Other (specify)
F. EFFLUENT. DISPOSAL SYSTEM: Percolation Rate 1) L 2) 3) Total Absorb Area Z , ,r sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Z i Width 1z • Depth < < Tile Depth Z 3f le No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size 1411
Percent slope of land C - Z Try Distance from critical slope
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 C.S.T. # ~7 Z ~~ek" and other information
obtained from own /builder). _
Plumber's Signature MP/MPRSW# Phone #sZyb S`~}-f
ber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space Il vv - 7F, DEPARTMENT USE ONLY Date of Application ees State hn, C%eCo nt .Date
O
Permit Issuedritecopy) date) P !_Issuing Agent Name
Inspection YeValid* Date Recd
1. county (w 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) R
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