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HomeMy WebLinkAbout002-1026-30-000 a o ° o °co 0 I WI Luo a b i a) O I .L-. Cu N a 3 3 as N d.yol EoQ ? O tl y w r I i in Ol N C co Z c'Z a Z ii is z LL C p 0 IL C _ C 3 mia � Q v 2 m E Q ` 8 .� M la M 0 � z [I o .: g v Z € v E v` a) a) a) m CO N Z I a m a m o C z g C c CO oz 2 I o o ai v E c ' CO I- w- c a) co Z c E E v a -o a) co C = C • • o o 7 o o •� a ' N N ' N 0 c 0 a c 0 C Q o 2' <• F- ` Z Z I- _ z N 0 0 c .. 1 .. V . To +a' a tr, .. R N ' y co a a b I C. CO - W •N d O ' co .0 d > a) W C O I I , G G a m G o a N a n m z I I § aaa aaa• I N O ` Z 0. _B o h � am rn > rn rn W JU ' rnrn Z I � rnrn Z I a 44 Lu N CV . m y o) T m Co 07 o I U ,a _� Q U) U .o d Q >- if) m I • r,� 7 ate+ co co r 0 CA Od C N C C co C �. I • a' 4 I N O a) O O J C I O M 9 Q 0 C C I Q N e C C p r \ 6. H i 0 o01 p N to t6 N v N R p o f Cm U) y Z 1 c ch 6. -0 ei rnI F. c• >, o rNi m 17 1 m ani o CI) con o o m °0 o m o �+ o m �' o Z H Z a' u Z S Z 2 0 = I .. 4. 1 r \ ` .- £ a 1 E a I V m = m Co) you ! co v o a3 A c.) a 2 , o , ) c _ A r CM-e-Cec- !ZZ D t • AS BUILT SANITARY SYSTEM REPORT OoL- /6Zt0-3a-ceo -,ER /944e-A/ �i4dvn/Z e L , TOWNSHIP'61c1wu,JsEC. /3 Tc N, R /� W --- ADDRESS 6066ci■ i//-e i (.49,•S , ST. CROIX COUNTY, WISCONSIN. • 3DIVISION , LOT LOT SIZE - • PLAN VIEW •Distances & dimensions to meet requirements of H62.20 _ _ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 1111111MNMI— IIM I IIHIIIIH III I I , • • + 1 1 i i r �r ! _ ! 1 EEV �� - ��� ' 1 -- t , iii 1 1 1 i ! NM ! ! I ! I I _ I ; I 1 G'1'S� ( i 1 1 ' ! '1 r. Indicate Non h Anttow ,'TIC TANK(S)IP0O MFGR. We-e-As CONCRETE X STEEL S ca.2e NO. of rings on cover Aon P_ Depth 6d" DRY WELL A n e- .`,INCHES NO. of - width length area • • no. of lines w o width /A/ length ' area-2;71.7- depth to top of pe 2g aREGATE / di ��, l _ l> 0"-4. ',. •;.K RATE, AREA REQUIRED Q ,/S' AREA AS BUILT - 6a'S4 ,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 .:em 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 1 —v+Z®— 7 PLUMBER ON JOB 4--4Oe, LICENSE NUMBER .I P z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.i.any Pe.nmLt 477; State S e p+t.ic C` c3 NAME A . , > �¢ �,/. Fownah.ip 0-e St. Cno.i c County / /._ Section /5 L o ca�.co a /��� c;� /L � SEPTIC TANK Size ga.e.eon4 . Number o6 Compantment4 Datanee Fnom: Welt 12% on gnealen a.eope Bu.i.ed.ing 6t. Wet and4 6t• H ighwa.ten DISPOSAL SYSTEM i. D,i.4tanee Fnom: We-U • 12% on gnealen t .eope 6t. Bu.i.ed.ing 6t. W et.eand4 Ft. tl.ighwaten 6t. FIELD DIMENSIONS : Width o6 trench • 6.t. Depth o6 nocfz below t.iZe in. Length o6 each tine 6t. Depth o6 'Loch. oven ..i.ee in. Number o6 £.ine4 Depth o6 t.i.ee below grade .in. To.a.0 £eng.h o6 tine4 6z. SLope o6 trench in pen 100 it. D.i4 fiance between .e.ine4 6t. Depth to b edno cfz St. Tota.e abhonbt.ion area 6t2 Depth to gnoundwaien 6 . 2 Type o Pap e& on St'Law Requited a'Lea 6� yp 6 Cove: p PIT DIMENSIONS: Numben o6 p.it4 Gnave.e around pit' ye4 no Outside dLameten fit. Depth below .inlet 6-t. 2 To-tat ab4 orb tion area 6 . z Area neq u.i.'Led 6t2 71 INSPECTED BY TITLE APPROVED - ,DATE 19 7_ REJECTED ,DATE 197 • • EH 115 Rev.9/78 • REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION:.6,4/1/4, 4,Section..11,T.Z1N,R ft (ormTowns. or gBhdW Lot No. , Block No. County +�57'• O/SL /� Subdivision Name Owner's/Buyers Name: A I—1—e ns / 7 t3 c u A/ Z e.1- Mailing Address: WO O dV///' r wic TYPE OF OCCUPANCY: Residence X No.of Bedrooms .31 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 0".5 — 79 PERCOLATION TESTS P- sz- 79 SOIL MAP SHEET ,,3 NAME OF SOIL MAP UNIT #(41Y)e-R1 ANC 2._ PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 ■ P— / 16 -r S — y," S,Lm - a,l " Sw.od 9 " c2 4 i✓o /5' `7< ' P—o ,( t' 4 Ai " „ 9 a - No /5 1_ f, I 7 P-3 t, ` . a 1 L, q .2 lc /1/o /5" 4 y Z 7 P- P- - P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST_ IF OBSERVED IN INCHES B- / 7.-z`/ ✓ �P Se,C. 46' 5;'y , ,L.v7 02/ /r c515 n•4 '7L7 B- ..2 7,2 y 4 /I ,L1(_,, i/ 02/ ,! It 7 B- .3 72 > k /r c -4 ,, aJ "I , ` 7 B- > B- B- PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location d-square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy _ C:f f ndicate scale or distances. Give horizontal and vertical reference points. Indicate slope. I € E x r1 / ' � --�r� � 1 , Ni n_ _ __ ri s = _�� �— - �0' ,._ I § /OO/ r j*\ [ /3d R a` �( t 1 7`� I� i s I 1 6 �_...l� _�.._. ,,.._ a e .^ i k - f___ !r- - ) � i i i g 1 1 4 _ -1-1 rr1" I,the undersigend,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_ - - 4 7L 0 L- 74 Certification No. (5:5-- S<51 Address 4111 P A - a Name of installer if known - — • L' f .• AIM sy A—Local Authority CST Signature �1 • , �- r e �A3 Ilk State Permit #‘-5/1/8 ftj()- 1 9E State and County c PLB- 67 �!'�r ( County Per t # �� i Permit Application County �,_,,•;+�= for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: ALL-e,v e,,,,d,.,„, Z eL (AJOodV/2 le, , Lip's B. LOCATION: 4A. I/4 ME '4, Section /3 , TA9 N, R /(n 6. (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village, ,` � t Township �LAG✓/n7 C. TYPE OF OCCUPANCY: *Commercial *Industrial ��pp *Other (specify) ''// *Variance Single family c Duplex No. of Bedrooms %ftQ�� No. of Persons `71 D. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks Div e. HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete )( Poured-in-Place Steel 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 3' Total Absorb Area 6/5 sq.ft. New Replacement X' Alternate (Specify) Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top)-No.of Trenches Seepage Bed: X Length --5-...2./Z' Width /. Depth_i `r Tile depth (top) ay-rt No.of Lines 7Z"0 Seepage Pit:)( Inside diameter 89-' Liquid Depth L)L No.of Seepage Pits en ti Q Percent slope of land Distance from critical slope WATER SUPPLY: Private X' 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 Silo . Tester, NAME ✓- 0 i... - C.S.T. # S'51.4i and other information obtained from 4111161(r W (owner/builder). `� Plumber's Signature _ i - 4_i .s' MP/MPRSW# /d)- ��%9? Phone #67V .357F Plumber's Address '=� < . _ ■ 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. -- ____ ..A..-.a e- ..-, m,, «.e � m e,...__ b s _,,, a .. ._. .........as ». _.P �. _. 1 3 I 6 , " ' ,0 1 , ' ' , ' ' ' ' , , 7- **''--;-----,.-- -',- ' a � 1' _ r'',(6 / P \� t A9 E it )t )L _ m � , f k i , E Do Not Write in Space Be ow - OR COUNTY AND STATE DEPARTMENT ` E ONLY i Date of Application Fees Paid: State /,5, QQ •unt ,! 1r . 1 Date A7.4 -0 ' A Permit Issued/R (date) 5.-, _-1 I Issuing Agent Name : ,/_n._ /_f AMMAGPIIMI spection Yes No State Valid# Date Rec'd • my (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI 53701 k copy) 4. plumber (canary copy) Revised Date 7/1/78 . • - Parcel #: 002-1026-30-000 09/22/2006 10:38 AM PAGE 1 OF 1 Alt.Parcel#: 13.29.16.185 002-TOWN OF BALDWIN 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-SWANSON, DAVID A&RITA M DAVID A&RITA M SWANSON 2661 CTY RD E WOODVILLE WI 54028-7135 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *2661 CTY RD E SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 13 T29N R16W NW NE TOWN BALDWIN Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 13-29N-16W Notes: Parcel History: Date Doc# Vol/Page Type 12/11/1997 569723 1282/072 WD 07/23/1997 1042/285 WD 07/23/1997 912/637 07/23/1997 873/287 more... 2006 SUMMARY Bill#: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 06/28/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 37.000 2,700 0 2,700 NO UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 2.000 4,000 93,900 97,900 NO Totals for 2006: General Property 40.000 6,800 93,900 100,700 Woodland 0.000 0 0 Totals for 2005: General Property 40.000 6,800 93,900 100,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch#: 510 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 .DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR -IUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: NW 4,NE 4,Sec. 13 ,T29-R16 CONVENTIONAL ALTERATIVE (If assigned) Town of Baldwin I Holding Tank I I In-Ground Pressure Mound CfSnAIGIEnUF PEAMITOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Allen Rudunzel Rt. l Woodville , WI 54028 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Joe Stang 6646 St. Croix 115166 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WROVIDED:LABEL LOCKING COVER ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MAIL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST—i DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIDED LABEL LOCKING COVER ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VE TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF) ❑YES ❑NO NEAREST—+ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: 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: BED/TRENCH WIDTH: LENGTH: NO.OF CHES: DISTR.PIPE SPACING: COA PIT VERIAL: INSIDE DIA.: #PITS: LIQUID: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIPES: FEET FROM LINE: AIR INLET: NEAREST—♦ MOUND SYSTEM: Mound site plowed perpendicular to 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 I 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: WIDTH: LENGTH: TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH CHES: 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 0 N ❑YES 0 N PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE ❑YES ❑NO ❑YES ❑NO NEAREST Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE: SBD-6710(R.06/88) ©ILHR SANITARY PERMIT APPLICATION ouN In accord with ILHR 83.05,Wis.Adm.Code _c M , . STATE SANITARY PERMI # –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 6 8'h x 11 inches in size. h if vi onto p evious application –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION R f/.c it )(?cl d q vt 3 { ( n/p/'/4 /r/6-'/4,S / 3 T 21, N, R 1 1, E(or)W PROPERTY OWNERS MAILING ADD E LOT# BLOCK# CITY,STATE , ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ►✓t,u`f io ( 1(' / W✓r 5 $-t(r,ri. (7 i() 9k.4?P.0 II. TYPE OF BUILDING: (Check one) El ❑ CITY NEAREST ROAD I I State Owned CR„TiOWLNGOFF ' 4 /a. '-' i yf Ce<.,, f, L/w, 1L ❑ Public ❑1 or 2 Fam.Dwelling–#of bedrooms— PARCELTAXNUMBER(9) III. BUILDING USE: (If building type is public,check all that apply) (*) a a. -- /ea cv -- 30 1 El Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 ❑ Church/School 8 El Mobile Home Park 12 ❑ Service Station/Car Wash 5 El Hotel/Motel 9 El Office/Factory 13 El Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) �j A) 1. ❑ New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.Ill 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 El Seepage Bed 21 ❑ Mound 30 El Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 El In-Ground 42 El Pit Privy 13 El Seepage Pit Pressure 43 El Vault Privy 14 El 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 Feet Feet CAPACITY Site VII. TANK Prefab. Fiber- Exper. in gallons Total #of Manufacturer's Name Con- Steel Plastic INFORMATION New Existing Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank . ❑ CI CI ❑ Lift Pump Tank/Siphon Chamber - El ❑ ❑ - ❑ - ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plum is Signature. o Stamps) MP/MPRSW No..:j� Business Phone Number: L titer St Q+, a 0(/ 44x' (`?(S ) �f�' 22� ' Plumber's Address(Street�ity,State,Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) #f Surcharge Fee) I (Approved ❑ Owner Given Initial /47" do Q . 0J711-040 - ��� Adverse Determination: a"• X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.11188) 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 or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be puritped 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: I. 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 test 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 standards. SBD-6398(R.11/88) „_,.__.___.......______- - ----9-'7411 -71"7- ..rA4,4.1 . .- ,, ... ,, ,,,' 4r-.,:i: ,:.-'-. ,-,.!-• - -. . : —1 4: . ., ..,-.-.%... ' . 4..'' .,--.'s,--.:,'' ',r-.:.:.-.-' . .-. „,....~$-. .'''.:,, ,;..00,',14., , -,,,,4,4 ',.,,,.."...., *:-.... ,,.,,' 1.,•,,,,-pj,„%, REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES =' % . ,..,,,i,'.",17,':',;;;;;,.-. -.''''‘e• ';'-'? -"-si:','. ,'.: ' .t. ';'4:4;1.1,, .it 1..,'''`1 itif: P.O..BOX 309,MADISON,WISCONSIN 637011'4” ...,, 14t4 ,,t,7t„1r,;)'...1,": ri *e. .i. , .,-' •.-• _ . • • - .. :‘:-'. : - - .' ,,.. ,...ro .,:. .Ai ,; ..7..,,.:' ,- e'" i *, '''''''.!-''''lc:...1''''4!''''.309'''' I ' .'' - ' - ' • - - ' PLIO 4 4 I efe i 1;r) '• LOC•T4,0 ' Iiiii'A ' 'Section '',Trm..g.N R 4(or)W,Tovvr....2st_e_li or Municipality, , - *04 24.0.14,„,it T-- . ----t 4,1,..1.' 4". „'..,L,;=.'-t'... ;. ,,,..1`.. -,.., -,.,.. .: ..- ."t. ,."--f " • - County - • fl''' 'y I.-...9..}. 9',.-7-"--"--.,..„. .,,,'Bi°ck.N..?,,.!. --t,-.4,-.,;!i,40.-e----.- --,,s'-=- % -" -Subdivision Name 1439 -. ,-..'•. I.ie ",„.s. . . -.,„ ,,..,;„ft, Owneep/Buyers Name, ... - A t ,r 0 P . .c , . . i4„1,-i_z-..;--.....t'-'15'm..."' ','',,-,-_ ..-,..,-,,•.;P;t.744%;1,00,ii, ..,,,,:,,-... ,,.;:l......--,--.. .. ..... - . , :. . .... ,.....,...,:,!...,...„. • . , ,•' ,2Mailing Ad.4r, j, . • ,gt ...T.VieV.;#47140g,, ,,,,....4.c..„,.. .,.. -,..... , _1? . ,... . :;‘;,--' -.:...'.-"...';;:41,''6?"';',' .. TYPE OFOCCUPANC "" esislcnce ' Jr' ' .4 NotpfBedrooms—• ---. ..-- ..COM MERC 1AI , .. . .,.. Y , ` - - . •:•..-.'„ .- ' ' ` ' . ' . ' '.- :EFFLUENT,DISPOSAS-SYSTEM:,,NEW - -"."` REPLACEMENT X ' ALTERNATE SYSTEM " ' r OTHER t,,,,.,;., - ,. : 0.-.,.-lltit? -,,,, - :47--:= '' ,-.r.,,,--$,‘ ,...r %,, 71 ''. - - . P- 4/.= 75,21- --. -' •DATES OBSERVATIONS MADE SOIL BORINGS ...'i•- ...-. - f ", PERCOLATION TESTS - 'F7,..-.• • 1:4' '- '• .'" - 4i .;:f.,-,. .,117.itIN''-cq':•-7- - . - ' ' $ A ' ' ' - I) '_,SOIL MAP SHEET ' - '''' 4 " ' ' ' ''' '' ' ' ' NAME OF SOIL MAP UNIT ' /).N . ft2 -/ . A."f" r:-. '.::.6 ,,,c-;,....+4F.,,,. A. :4*.i....:: 4ii?,...,,,,„ . , . ,.,.„.. .: ,-,,,.. 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'. ,-.• .714,-;11 ..„.::iii,o,,Itt-. -•,'4,,,. ..,.:-...;..',-;,::-=' --.4.. - 4'''''''. - ' .'':-., ,..A.;‘:":".4'sc-ri-4`1:14-;:"':."7:-"'''''''".'-- ' , .." '" ; ' : SOIL BORING TESTS - . .".--' , ----* `-';::: TEST ' TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, tz.ti TEXTURE,MOTTLING AND DEPTH TO BEDROCK •-•NUMBER 'INCHES i., %.., . OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES ' -, -- . ,. .1'41 ti:. B- / ,.44,1t77.2.44" .,: '' :.!,;`5.17-0,,..'ji ' 1'‘47, . > 6 . —r.:7•., <-...,/ .44# .5":-/tr 2-w? -v . el ‘01:7 • "▪ : - ,--. - . f' ‘44. '.- 13- 7 - Vr-- ' ,...fi'.-1+; -- -..,. . ' „ . • ' >, e.- • • 11 4/. h ' ,-, -7 1 .1 - p. a 7 4.,.. .. B-' ..- .' • .-:.' "i. ,V.- - ', •'-Itt,:..' '- 4.' S.„.. , , .';.ii...1- 8- . 3- ::.• 2..--. --' 1 ,- - - . . . .. . PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location nd square feet of suitable area ';':',1'• Indicate number of square feet of absorption area needed for building type and occupancy "1--, / `---47' ,r,-01 gIndicate scale or distance L,.-,1:-':. •_ - ---.-Give horizontal and vertical reference points. Indicate slope. . .- . . ...- ., .,.,-- . • - - ' ' .2.'4.;•• ..:. -:.-Z it'•.:P. ..t.E.I*4ie!„ - :--.:=:k . ;,1;. . ' '.`,"':t;;,-- - ' ' " '*.' -:--• - • • -- -, ' ,■ , . MIN 11111 111.11111111111111111111111111111 . . ...s.::."T-Y!•.:;-. ,. 1;.•'-,.!:ft"' k , 4: -..;. , :::.`, ,,`'. - En.' ...' It11111111111111111111111111111 - . 1111111116103 .II .!.....-,--:.:, ,--•:. .: mia ...,- - ., ,.. - Ifilloopri...luillio_ _. - ......-Ilow 0 • — . .!-:1;L'Ic5':'".`: . NESE ' - IIIIIINIIIIIIIIimiligmmodm.1111.1111111 , ............... , 15:imi ,,ra fit! •t---......„. .,._ .v_...7,i . . •, , . ,..... 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'.t.',--',:,•••I'the un s dersigend hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods • . ,7!&.,•:•....:.-.,--.... .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.--'.;'. f.t1.,.'''.-:-.",. -.- ., .- . ...- , . . . , .,. . ,-„ , / ' • Certification No Address '' '- '-: -7-----ex7.4.w,., ,,,,i ),.f '. ., - - - * . - - ' :-. • - .: '..7.;%,-... ... • - - - N./ea Ap-,0.."4 r5/./ en'''.IL ' (...' '''''......\ lk_12$1,4,:.,::,... ..,Name of,installer if known _ V.7.i.....--: ; ' , -1;:%'.'.; .',''k-- . .. $. -,.....Y.-:'.. ' - ' i ,..---. #' , 1 H144--:' .; . . - -:•-•;-.‘..'":"'' . --'''-'-'-‘ •..-''' ''' I-- . - CST Signature.,rA. I .0 A 4 rs","--1'4 1 '-'!-- '" Copy C;.--Property Owner -:-•-.. . . . ''...---.- . . - .‘ • ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code CouN / STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 8%z x 11 inches in size. h b cli --:a kil p ewous application –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION .2 I� ,•3 (9/air'/a In/('/4,S l T 91, N, R I Cr E(or)W PROPERTY OWN ' AILING�AD��,yESy, ' LOT# BLOCK# � rlN^c-, ► lS , ( CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER rd . II. TYPE OF BUILDING: (Check one) O CITY I NEAREST ROAD ( III Owned 8.VILLAGE: ,I / 4 OWN OF� �`�J�S id', f N} ;�.(.', i:.(, �i,,, ❑ Public ❑1 or 2 Fam. Dwelling–##of bedrooms— PARCEL TAX NUMBER(S�) III. BUILDING USE: (If building type is public,check all that apply) ;.< 0 v ( – 30 1 ❑ Apt/Condo 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. ❑ Reconnection of 5.g 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 ❑ 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 Feet Feet VII. TANK CAPACITY Site in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New Existing Gallons Tanks Concrete stCon- glass App. Tanks Tanks Septic Tank or Holdinsl Ta nk ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon 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): Plum jar's Signature;,NNoo Stamps) MP/MPRSW N/o.: Business Phone Number: Plumber's Address(Street;.ity,State,Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) Surcharge Fee) El Owner Given Initial �r i �� 7., 1 qApproved Adverse Determination / ".2 r�t "'�) �: `1 ',f-776 �l 1 C 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 or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 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 alicensed 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: I. 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 constr uct ed and tank material.al. Com let 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; close 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 test 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 standards. • SBD-6398(R.11/88) , p 00.-..!..4'----, -i 4''..II-- 8/ 8 4 AtAr,"4.:..414:''''- ' •,=0.,ktt'','S'4' '' ' . 1 • '.'• ids, '• ' .1L. ,, ''''"'"' '' ' •REPORT ON SOIL BORINGS AND PERCOLATION TESTS Wi -t , WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES "},: ' `,''.1.',.''-'.::;:.1;.:,.-.:: i ' ,.;.:440.74.1 ' d;,,P O.BOX 309,MADISON,WISCONSIN 63701 , - }.• ..5*..., „,,Apt,,,,-,.,.,:: 't, X"41 '� ,”: ; R4�'3p^+l� / .4 k..;':4t74*- C: ,1;114.1,-. ,[a -4'.' '� .. �j l�i ,../ r J fi r! - jCA 1. MR� � '4rf'. � 1 '. .' LOC F T4,O *:4.l ' A %.. Section , •T, N,R E(or)W Townshi or Municipality, �ry r •_.• Lot No.., -- Block Nox - �' ' , _,i. .. County. a v Owner'/Buyers Name' g-,a�..�°' ^ sY S a � s ui S i ion me , $ 3 JIJfi� Ii/ r-1 • • Nlailing�dde� , F a x �,^ COMMERCIAL.. '._' F ' No of Bedrooms • TYPE OF OCCUPANCY f •edenc -- — f EFFLUENT DISPOSAL SYSTEM NEW .REPLACEMENT ALTERNATE SYSTEM OTryHER DATE$OBSERVATIONS S MADE 1e SOIL BORINGS "" ' /4 PERCOLATION TESTS 7_,• ",7' ' '' r{ 4 a ". ' NAME OF SOIL MAP UNIT ' ' P R ; ?r'r» SOIL MAP SHEET ' (- + 1 'I '� .. r, PERCOLATION TESTS. TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE DEPTH x wy* s CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL MIN/IN • .NUM- + 'THICKNESS IN INCHES PERIOD 1 PERIOD 2 PERIOD 3 INCHES 1ST WETTED SWELLING IN MINUTES BER s 4.-?, r : • P_ • / %e1 P-, ',."' �+•�.+`ni I t' '4,,,e1+ q �1. J� �i, 1' / Q • ,- ... _ „1-,01:' `�, !;14 n. a '„i) 1,: ,1 .._.c 1. i7 %. LL k[/_t. rr_ P_4 34 ; k,. ': , .� _t q Or. /1 /' � j / ��' -"T ;''‘'4%, P— ' -1'.-. -,4=7.. .‘...*:- - r I }Pr4 '•max L te <a �' SOIL BORING TESTS , TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEST TOTAL DM.' EPTH DEPTH TEXTURE,MOTTLING AND DEPTH TO BEDROCK F . NUMBER INCHES,d�! OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES - ' ..s. ..f ! l / '' ►`l4 rV 1. .''/7• a. ter. B-` ` / . T-. B— - 4}40x: zg ,.g :)r G. r. r 11 h 1.L. ✓!1 �: If ?/� ,- / • t: B— 7 k f- ,, i4 >, G. /, ct.. h . /J , / ', . /.. it l /'r B— 4' i i, ye a B- ; B— ',▪ y PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location nd square feet of suitable area ' '` Indicate number,of square feet of absorption area needed for building type,and occupancy l^ / 47f ,,p()Indicate scale or distance•• Give horizontal and vertical reference points.Indicate slope. • ' ” C Zse. :Al:... ,• ♦ ,--.' •t ' "4' IIiLJ1IIIIIII_I .; 1.4-`•,... 100 at witis4 ..- car.i„yagirrmiiii, aii fi :_ T _- !!,10/�% il,1 M111® 111 ".y' """ill111111I= -- • iisiallicilligilelE;6111111111111111111i . — isa,_ Eff117"migre RN- IF,Bill11111111111N111111MIIIIMII I ft„, 4,rellia t ir1 .a r • 1,the undersigend,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, 'r •(p nt C�L,�.,A .- • •'i-)O i r/4• Certification No q F . rY�^ ▪, Name (pant) , Address '' it I,�i /, ir Name of�nStaller if known .��,p,,,./ ^°'"r� r^1 i r ri-.:, CST Signaturt�r J AP-4'��T�I! t > , . _. Copy C-Property Owner `fiz.r..."` ' s,' ., r4 , 6 I .13 t- ef)Avii gy 4e" S'4,4 n /211) • 1044 97' 59' 0 4, 414* y • - Parcel #: 002-1026-30-000 11/29/2006 09:25 AM PAGE 1OF1 Alt.Parcel#: 13.29.16.185 002-TOWN OF BALDWIN Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner O-SWANSON, DAVID A&RITA M DAVID A&RITA M SWANSON 2661 CTY RD E WOODVILLE WI 54028-7135 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *2661 CTY RD E SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 13 T29N R16W NW NE TOWN BALDWIN Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 13-29N-16W Notes: Parcel History: Date Doc# Vol/Page Type 12/11/1997 569723 1282/072 WD 07/23/1997 1042/285 WD 07/23/1997 912/637 07/23/1997 873/287 more... 2006 SUMMARY Bill#: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/25/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 36.000 4,300 0 4,300 NO 05 UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 3.000 12,000 112,800 124,800 NO 05 Totals for 2006: General Property 40.000 16,400 112,800 129,200 Woodland 0.000 0 0 Totals for 2005: General Property 40.000 6,800 93,900 100,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch#: 510 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges Delinquent Charges Total 45.00 0.00 0.00