HomeMy WebLinkAbout038-1096-60-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
567222 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: Village X Township Parcel Tax No:
Ber et, Franklin D. City Star Prairie, Town of 038-1096-60-000
CST BM Elev: BM Description: 19b La D SectionlTown/Range/Map No:
M A1e,cti. 13 M 23.31.18.401 C
TANK INFORMATION ELEVATION DAT
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Be chmark Ib2.2
1666 Alt. BMr-
5z5 ,
l c a. gs 49.3
P6 LI-4 I ?'I
Aeration Bldg. Sewer
Holding let 5.3
TANK SETBACK INFORMATION St/Ht Outlet
5'•`7 `~(r• S
TANK TO /L WELL BLDG. 1 Air Intake ROAD Dt Inlet \ \
Septic Dt Bottom
15 IV5 a~ 75 \
Dosing Header/Man. r
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover Z 9 q G
GPM f►; 1 J 1 f
Model Number
TDH Lift Friction Loss System He TDH Ft
Forcemain Length Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO )e~ G WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: , I n UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent Kir Intake
Pipe(s) J 44,
Length Dia Le Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade-System r
Depth Over De th Over xx Depth of eeded/Sodded xx Mulched
Bedlrrench Center Bed renc ges opsoi
Yes No Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 2016 Cty. Tk. CC New Richmond, WI 54017 (NE 1/4 SE 1/4 23T31N R1 8W) metes & bounds Lot Parcel No: 23.31.18.401C
1.) Alt BM Description A/Qi-e CoA/A17'i OF Sf~Pi4 'E 3Eb
w/ --q,-k
2.) Bldg sewer length
-amount of cover= ~~C't5~~~ ' wb ~ a a lLweoue-
Plan revision Required? Yes No , O -7
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No.
Safety and Buildings Division un a
if
r ! 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled m by Co.)
~I Madis P7
fj) ~-7 Z27i
Sanitary Permit Application hN., State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate 6vem unit L~IA
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are suu to Project Addre s (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide. bets d for secondary
purposes in accordance with the Privacy Law, s. 15.0 1 m , Stats. (j j '
1. A lication Information - Please Print All Information / Sal),
Property Owner's Name R°/X Parcel #
z f "~C°Ury7), Off- i v - a ~
40
Property Owner's Mailing Address Property Location
Govt. Lot
City, tate Zip Code / Phone Number !~/J Gy &AgE ya, Section
1 TN, R circlEone~
cU
IL Type of Bui ding (check all that apply) Lot # f
3 Subdivision Name
LKor 2 Family Dwelling Number of BedFoo~ /
GY I S ~~1J Block # MQ i cS B~LOt J
❑ Public/Commercial - Describe Use ❑ City of
CSM N her ❑ Village of
❑ State Owned -Describe Use ~
L7 Town of a i' i s
III. Type of Permit: (Check only one box on line A. Co line B if applicable)
A. ❑ New System ❑ Replacement System rtn~Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal Permit Revision Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
❑ ~ Q
❑
Before Expiration Owner /t, t
IV. T of POWTS S stem/Com onent/Device: Check all that a
,ype
on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
L d /
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (f) Dispersal Area Proposed (sf) System Elevation
a- 5e- VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units /
New Tanks Existing Tanks 41- L
J n
6617 a U w co a
Septic or Holding Tank
Dosing Chamber GJ
VII. Responsibility Statement- I, the undersigned, assume ponsi ility for ins Ration of a POW TS shown on the attached plans.
Plumber's Name (Print) Plumber' gna MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip ode)
V Coun /De artment Use Only
IR/Approved ❑ Disapproved Permit Fee Date Is u2ed Iss g Agenttture
$
El Owner Given Reason for Denial /0 IJoi~proval/Reasons for Disapproval
1. Septic tank, effluent filter and 03 NL ~ /~P)
dispersal cell must be setvic~cl./_malntainc /q-J /
as per management plan provided by plumber.
2. All setback requirements must be maintained f!~~u 4Jl (2t
Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size
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\ In WLP1000-MR
iS DRAWN BY: SME SCALE: 1/4"=l'-O" PRE-POUR:
CCIICRETE REV.
° m SEPTIC MANUAL MIESER
\ Z W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2010 DATE:. POST-POUR:
o REVISED JAN. 2010 800-325-8456 FILE: V IOW-MR
{f HL-525 EFFLUENT FILTER Y
_325 Filter is rated for
_ " 0,000 GPD (gallons per day) 1/16p Filtration Slots
AWm
g it one of the largest filters
Mass. It has 525 linear feet
6' filtration slots. Like the
y v ok PL-722, the Polytok
Ammpvc
25 has an automatic shut
tail installed with every filter.
- the filter is removed for
e_=Wing, the ball will float up and
-7porarily shut off the system so
effluent won't leave the tank. WS FL of other filter on the market can
Rawdfor&w
-c¢ that claim.
PL-525 Maintenance: MROP'ip y
e PL-525 Effluent Filter should
:,aerate efficiently for several years - -
der normal conditions before
- quiring cleaning. It is recom-
-ended that the filter be cleaned
=emery time the tank is pumped or
_ least every three years. If the
:_-stafled filter contains an optional
51arm, the owner will be notified
by an alarm when the filter needs
servicing. Servicing should be
done by a certified septic tank 5z cnn
Dumper or installer.
us_ Patent Nab 6,15,488?-v
7 BAVAM is
_ Locate the outlet of the
5,871,&10
septic tank.
2. Remove tank cover and pump
tank it necessary.
°5 Aejo 3. Glue the fitter housing to
3. Do not use plumbing when the 4" or 6" outlet pipe. If
filter is removed. Ideal for residential and com- the filter is not centered
4_ Pull PL-525 out of the housing. mercial waste flows up to under the access opening
10,000 Gallons Per Day (GPD). use a Polylok Extend &
5. Hose off filter over the septic Lok or piece of pipe to
tank. Make sure all solids fall L Locate the outlet of the center filter. See page
back into septic tank. septic tank. 19-21 for Extend & Lok
6..Insert the filter cartridge back 2_ Remove the tank cover and information.
into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter
the filter is properly aligned into its housing.
and completely inserted. 5. Replace and secure the
septic tank cover.
7. Replace septic tank cover.
Fr.?-17 ~~i ' '7'
U !_o e a aC KNUDTSON PLUMBING &
4.1 CONTRACTING, LLC
N
e- r~7p fz~ 927150TH ST.648447MPRS
ROBERTS, WI 540234526
CELL 651-470-1737
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer Franklin D. Berget
Mailing Address 2016 County Rd. New Richmond Wi.
Property Address same
(Verification required from Planning & Zoning Department for new construction.)
City/State Wi. Parcel Identification Number 038-1096-60-000
LEGAL DESCRIPTION
Property Location NE i/ , SE 14 , Sec. 23---, T 31 N R 18 W, Town of Star Prairie
Subdivision Plat: ~1/~~ Lot #
Certified Survey Map Volume , Page #
Warranty Deed # 2 NOS ro fot-e 007 Volume , Page #
Spec house Oyes Ono Lot lines identifiable El yes[] no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms 3
k 10/03/13
IGNATURE OF APPLIC T(S) DATE
I
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
III
f
APPLICATION FOR THE II IIIIIIIIIIIIIIIIIIII
~ II IIIIII
TERMINATION OF DECEDENT'S INTEREST 8 0 4 4 6 3 0
AND CONFIRMATION OF APPLICANT'S INTEREST IN PROPERTY Tx:4032567
DECEDENT'S NAME DATE OF DEATH 947319
1 Leona B. Berget, a/k/a Leona Beatrice 5/24/2011 BETH PABST
Ber et REGISTER OF DEEDS
ADDRESS OF DECEDENT AT DATE OF DEATH CITY TW T ZIP
2016 Co. RD. CC NEW RICHMOND I54017 ST. CROIX CO., WI
RECEIVED FOR RECORD
12/1 : PM
38
PRESENTATION OF DEATH CERTIFICATE EXEMP T #
I certify that I have viewed a certified copy of the decedent's death EXEMP
cer. REC FEE: 30.00
PAGES: 8
REGISTER OF DEEDS SIGNATURE DATE Recording area
THE INTEREST OF THE DECEDENT IN THE PROPERTY NOTED HEREIN Name and return address:
IS HEREBY TERMINATED/CONFIRMED UNDER THE FOLLOWING STATUTE:
(please check appropriate statute)
Leah E. Boeve
® s. 867.045 which pertains to real property in which the decedent was a joint Remington Law Offices, LLC
tenant, had a vendor's or mortgagee's interest, or had a life estate. (You must 126 S. Knowles Avenue
provide a copy of the document establishing interest in the real property.) New Richmond, WI 54017
❑ s. 867.046 which pertains to property of a decedent specified in a marital
property agreement; survivorship marital property; or a third party confirmation; or See Attached
a nonprobate transfer on death as described in s.705.10(1).
(You must provide a copy of the document establishing interest in property.)
Parcel Identification Number
Presentation of recorded document establishing interest in real estate. SEND TAX STATEMENT TO:
DOCUMENT # VOLUME/REEL PAGE/IMAGE RECORDS/DEEDS Franklin D. Berget
See Attached 2016 Co. Rd. CC
New Richmond, WI 54017
Description of the real estate. ® See Attached
i
j
i
Description of personal property (if any) being transferred.
You may list savings accounts, checking accounts and securities on attached pages. Indicate person(s) receiving property.
DECLARATION: I(We) declare that this document is, to the best of my(our) knowledge and belief, true, correct and
complete and is in conformity with the provisions and limitations of the Wisconsin Statutes.
i Name and Address Applicant's Applicant Signature
(List all remaindermen/ Interest in Property (Notarized) Date
beneficiaries. If more space is (Is: spouse, remainderman, (Print or type name below signature)
j needed, attach pages.) beneficiary)
Franklin D. Berget, a/kia spouse 12/14/2011
Franklin DeJerome Berget
2016 Co. Rd. CC
s ranklin D. 4'rgef-
I
New Richmond, WI 54017 ~NUn++n+~
i This document was drafted STATE OF WISCONSIN, County of St. Croix X
911 8c);
by: (print or type name below) Subscribed and sworn to before me on: December 14, 2011
Leah E. Boeve by the above named person(s): Franklin D. Berget 9
Remington Law Offices, LLC .
Signature of Notary or other person CL I F A~ G `
~'SuUJT 8L~ ? .
NOTE: SEE DIRECTIONS. authorized to administer an oath (as per ~'.0 - . 0 4
Wisconsin Register of Deeds s 706.06, 706.07) i ~1
As
Website sociation Fon 09/2010 Print or type name: Leah E. Boeve 4~~rrUV1$GO,~♦♦`
Title: notary public Date Commission Expires:is permanent.
THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
i
i _
1 of 8
DocumENT NO.
262805
This Indenture, Made this 12.............................. day of......... 41~y~1_g tr............. A. D.,
between Al-Lan 1 avis...and...M.e.rG. .,.....t_lq and n e. -
1 part J,.e s_.......of the first part and
hus_l2ankA.. ...w _f e
----...-----•---------•-•---........................---°°------•-------•--------•---....................--•-•-.._..-••••part of the second part,
I Wltnesseth That thesaid part .t..Q r.e°......of the first part, for and in consideration of the sum of
_._0ne....dollar- C&I..-.QQ.).----A-~l ----4- ~X'...y 1u b1e---consideration - -
to...... US ................in hand paid by the said part 1 P.........of the second part, the receipt whereof is hereby confessed and acknowledged,
ha._...V..e..... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do...-.......... give, grant,
bargain, sell, remise, release, alien, convey and confirm unto the said part ------18 s........ of the second part,_..._t 9 A r--•----heir. and assigns
l forever, the following described real estate situated in the County of..._5t_e_.__~e?'~I ......and State of Wisconsin, to-wit:
i Commencin6 at tae Southeast corner if Lhe 1Vortneast quarter of southeast
quarter (A&4 of Sh--) of 6eetion Aumber Twenty-three (23), Township
Number Thirty-one (31) Aorttl of han6e Bumber P_ij~,hteen (lei) rr'est; thence
meat One hundred seventy-six (170 feet; thence IJortn One hundred forty
I (140) feet; tthe?flaoeEastbOrl6tlhian[qred seventy-six (176) feet; thence South
une hundred forty-1140) feet to d1ace of beginning.
i i
i
i
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all estate
right, title, interest, claim or demand whatsoever, of the said part___e.S,.__._.of the first part, either in law or equity, either in possession or
expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances.
To Have and To Hold the said premises as above described with the hereditaments and appurtenances, unto the said part 1.E)'s............
of-the second part, and to :tilel-_L'-_.-._--_--_----...--heirs and assigns FOREVER.
And the said ___.._..A.11an-.-Ua.v_is_..a_nd___iv er.ae_dss..._11au3 s,.__~luaband.... aL2d.... ar.e
for t.hA.]_r`_----_.-.-_.-_...---.__-heirs, executors and administrators, do.................... covenant, grant, bargain, and agree to and'
with the said part..isS------------ of the second part U.Lel r.........._...heirs and assigns, that at the time of the ensealing and delivery of
these presents._t-hBlT___F lr'H_._._....._.well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of
inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever
and that the above bargained premises in the quiet and peaceable possession of the said part Li5Z-------- of the second part,__.:W:l e.lr.._heirs
and assigns, against all and every person or persons lawfully claiming the whole or any part thereof _____________-tlae.y__ww forever WARRANT
AND DEFEND.
In Witness Whereof, the said part..l Q_R .............of the first part ha_. V _e_.-__--__---•-hereunto set_____t1a8 j..X:...__..-.hand•_•- 9..and
seal B.... ...this 3,-Z111............ day of..... kgg.U,.4.fi----------------------- A. D., 19t2_Q......
(SEAL)
Tam AND E LED IN PRESENCE OF Allan Davis
- ._..._.1
Z~._. - - ----(SEAL)
E-sthor I'lielancl ercedes Davis
- _ _-.(SEAL)
~ H 1 S ~e be f
(SEAL)
Prepared by tiVm. '.r. Ward, Attorney
STATE OF WISCONSIN, .w
as.
r.
JJ. ~rQ County.
Personally came before me, this 12117 d'ay of -------1~J.]„J.LJ, t._._.__.-............. t.,..~
the above named --.--.Al.].-s> -•:19av3s•--arad.__iYter_dads.s_..A)ayis-•----;~ixs_11ar1, and.... Wj f_e::.._:
?
= _ = t`= :
to me known to be the person._._s_.who executed the foregoing instrument and acknow}6dked the s z~ .ah Zf
? Received for Record this......_.___211tik1.............. day of
60 :00 o'clock-A• M.
` - (SEAL) Notary Public ounty, Wis.
Re aster of Deeds
g M Commission ex `
Dfirwq•=kul,lien&~-~rdfx-f~' ~,v.19
...................._.--•---.._..._.er o_.....D_.eed___..---- Av Lcrnr*~,f:c.~:; .'i:•;r.n+:' .;'L7 •jJtgl
of 8 Deputy Registf s
WARRANTY DEED-STATE OF WISCONSIN, FORM ~s Y. C. MILt[[ CO.. YIlM11YR[[
~Ho k ~ PA G E~ tJ
t
+di#tof engnring company
CIVIL ENSIN>EIt# INS • LAND OOVEYING BUILDING DESIGN
Eau Cleire and River 11e116, Wisconsin
Name Tranklin DeJero o 13 r g e t
1
Address t 2
n M>, .
Description
A Par.-_-1 (,f` land located in the .Wa4 of the &; (),f'
; r3at ion 23, 31 F, R 18 1,,*, Town of Star Praire,
~t..,r oix ,ount~,, 1~1isaona.n, being further descrz,,i~,d
as 4" ,1.1ows:
't: the South st~~.`c~oz~nerof tbe~'`..7.NE;4' of the
V`{.l••r4 6f ' ooA] ~ 5peti on 23.• ..therree lY 899 ' 1 , W S lt3ng 1, he
z t er) u , Lire thence ;kc th- 14 .00'1,,
t)aence S 890441 E 176-GO? tbi.thel -'Bast vLtka of ectioi
23; thence South along said Last Line 140.00+ to t?le
point of be1J.nrf n&
'he abc>ve described parcel contains 0-566 acres o lar6,
s1z'1L oct to C, A"„I?. 77~;n Right-Of-Way aver the East 337
thereof,
° 44' E 176 .0 B~ 143' 0 ,ra 33~
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.566 ACRES H'
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a\fO t99o cn I
79.15 ^ g~ X43R 33' ) 5E CORNER OF
N 89° 4477V _ 176.0 1/4-s£ 1/4
SOUTH L.I OF THE NE 1/4 -SE I/4' SEC. 2~~±T.31NT
R 18W
. d~
Strte of Wisconsin SUQ Fy~R,S~UN
~ R TY O IRON ST1R'KES I)RT'VE
ECDRp
ss. SCALE OF MAP - I INCH Feet
County of $ T : C Q IX f IRON STAKES FOUND
~ .
1, ARTHUR L., . EG R registered disconsin Land Surveyor, do hereby certify that rr
on II OF JUNE 19 1 surveyed the above described and mapped 'property • according to `f
the official records and that the accornpenyiny map is a correctly dimensioned representation to scale of the boundaries, th
all buildings and inrpro meats <Is wlroily wi n the ` ndary lines, and= thax no, encroachments by, adjoining owners appear
it7 non
from said survey. r+
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4. #1
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'Parcel 038-1096-60-000 12/04/2006 01:53 PM
PAGE 1 OF 1
Alt. Parcel 23.31.18.401C 038 - TOWN OF STAR PRAIRIE
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
FRANKLIN DEJEROME-ET AL BERGET O - BERGET, FRANKLIN DEJEROME-ET AL
2016 CTY RD CC
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 2016 CTY TK CC
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.565 Plat: N/A-NOT AVAILABLE
SEC 23 T31N R1 8W NE SE COM AT SE COR OF Block/Condo Bldg:
NE 1/4 OF SE 1/4 OF SEC 23-31-18, TH W
176', TH N 140', TH E 176', TH S 140' TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
POB 23-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill M Fair Market Value: Assessed with:
175487 137,200
Valuations: Last Changed: 10/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.565 28,700 92,600 121,300 NO
Totals for 2006:
General Property 0.565 28,700 92,600 121,300
Woodland 0.000 0 0
Totals for 2005:
General Property 0.565 28,700 92,600 121,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 109
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
':'ER DRESS , TOWNSHIZ~, P^rje SEC _ T --?IN. I~/ _W
,0. AD CROIX COUNTY, WISCONSIN..
-BDIVISION
LOT LOT SIZE 0' A-
~
PLAN VIEW .
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• ' 00
• ~ _2S~ Se~P~ E
-TIC TANK(S) MFGR. CONCRETE STEE
NO. of rings on cover / Depth fz `i DRY
INCHES NO. of width length area
no. of lines z_ width Z length area ;j~.a5-"a `
depth to top o pipe 3o"
3REGATE
K RATE ,S AREA REQUIRED 61 AREA AS BUILT 6.27 e_ 4-
;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
DATED qo~7 9_ PLUMBER ON JOB
LICENSE NUMBER
REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
San•itaxy Pexmit-,,)-
State Septic i
NAME c <,z Townahip Cxo.ix County
Location 5 L: Section
SEPTIC TANK
Size gattond. Numbers ob Compaxtmentb I
ViAtance Fxom: Wett it. 12$ on gxeatex b.tope 6t
Bu.i.td.ing it. Wettand.a
H•ighwatex - it.
DISPOSAL SYSTEM
ViAtance Fxom: We.t.t St. .12% on gxeatex z tope 6t.
Bu.itd.ing jt. Wet.tand,a Ft.
• H•ighwatex it.
FIELD DIMENSIONS:
Width o6 txen ch it. Depth o6 xo ck b e.tow t.i.te in.
Length of each tine it. Depth o6 xock oven t.i.te .in.
Numbex . o f .t.in ez Depth o6 t.ite b e.tow gxade in.
Tota.t .length of .tined 6t. S.tope o6 txench in pet 100 it.
Di4tance between tines_Jt. Depth to bedxock it.
Tota.t abboxbt.ion axea jt2 Depth to gxoundwateA it.
Requited axea it2 Type of Covet: Papers ox Stxaw
PIT DIMENSIONS:
Numbex o6 p.it.6 Gxavet axound p.itz ye.a no
Outside d.iametex it. Depth below .inlet St.
2
Total abe oxbt.ion axea it
a
Anea %equk;&ed it2
INSPECTED BY TITLE
APPROVED DATE 197
REJECTED ,DATE 197
%V
V
PL B 607 State and County State Permit o„~ Permit Application County Permit #
for Private Domestic Sewage Systems County aiY
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
--f, 6. 65-~- L~ , Z d
B. LOCATION: G _5(r Section Z,(, TEL N, R (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township~rAA,t_/
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family y Duplex No. of Bedrooms 113 No. of Persons a'
D. SEPTIC TANK CAPACITY /62a Total gallons No. of tanks I
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel t--- Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area G sq. ft.
New. Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length jz' Width I Z" Depth !M' Tile depth (top) _z 6" No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land eb - Z Z1, Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified S Tester, /
NAME a1 C.S.T. # Z Z~B and other information
obtained from (owner/builder).
Plumber's Signature lcJ % MP/MPRSW# d Phone y~ -S y yy
Plumber's Address f 9f
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
E
k I
E
,
E
F F
E
E
All
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3
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE NLY /
Date of Application -116 Fees Paid: State/6,0_0 County S~ Date 5
Permit Issued/fk-oa s* (date) 40 Issuing Agent Name '
Inspection YesNo State Valid* Date Recd
1. county (w ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
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 TESSTS/ -
LOCATION: Section zs', TR&N, RAFF(or) W, Township or cipa i y d
O/ 1C
Lot No. , Block No. County .5>/.
y Subdivision Name
Owner's Name:
Mailing Address: .
TYPE OF OCCUPANCY: Residence yiNo. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS ~12-/z ' 7'> PERCOLATION TESTS Ila Z -7S
SOIL MAP SHEET Z- SOI L TYPE,, ~,o i/ Xeg,,Pr
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER SOIL SINCE HOLE HOLE AFTER INTERVAL
NUM- INCHES THICKNESS IN INCHES
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-
Z 2u
P-
yl''
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B_ "7 FV_ A 74
B- Z_ It
rt pr
PLAN VIEW (Locate percolation tests,soil bore holes and suitable 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 occupancy. e::;.Z~ 4/ Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
t N
*1
1
I L.P.. b2
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) Certification No. Z L 9 fl
Address
Name of installer if known
. CST Signatur _ 01/1
COPY A -LOCAL AUTHORITY