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Parcel #: 020-1124-90-000 03/31/2005 03:38 PM
• PAGE 7 OF 1
Alt. Parcel#: 07.29.19.565 020-TOWN OF HUDSON
Current X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): *=Current Owner
*
JOEL J &KIMBERLY A JOHNSON JOHNSON, JOEL J&KIMBERLY A
406 KRATTLEY LA
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *406 KRATTLEY LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.770 Plat: 1925-EAGLE RIDGE
SEC 07 T29N R19W PT SE1/4 EAGLE RIDGE Block/Condo Bldg: LOT 36
LOT 36 EZ-U-1398/301
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
04101/1998 576144 1310/414 WD
07/23/1997 640/256
2004 SUMMARY Bill#: Fair Market Value: Assessed with:
48655 285,800
Valuations: Last Changed: 10/26/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.770 44,600 176,500 221,100 NO
Totals for 2004:
General Property 2.770 44,600 176,500 221,100
Woodland 0.000 0 0
Totals for 2003:
General Property 2.770 44,600 176,500 221,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 309
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
kv
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER �,y�, E y TOWNSHIP /��/QSO,t� SEC. r T �N-R /� W
ADDRESS /,/0/, 4ATTL 4 V ` ST. CROIX COUNTY, WISCONSIN
DS o c> 6'JJsc .
SUBDIVISION )f jQGE LOT �fo LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
��eS ;]GRJcm -- — — —
IT
1 I I W
� y
1 I I yy;i a'fi.r.M'
I
_ I -,V,. '
f !
-
So Af oER^ry Y- DICATE N RTH ARROW
BENCHMARK: Describe the vertical reference point used Gi
Elevation of vertical reference point: /Dm'` Proposed slope at site:
SEPTIC TANK: Manufacturer: �X�ST�MG W��Sffquid Capacity: ls.0%ST/mac.
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,O Rear, feet
From nearest property line Front,0 Side,0 Rear,0 feet
Number of feet from: well /0 T" , building: __9 .
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
T172e7""P" PTTN"
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,O Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: t- E,e i J Trench
Width: wed Length: GSA Number of Lines: Area Built://74;sy,{�!
Fill depth to top of pipe: 02
Number of feet from nearest property line: Front, O Side, O Rear,(D"P-t . 3.C.
. Number of feet from well: i vs,
Number of feet from building:' 4C.
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Z/,/-Z " Plumber on job: .
License Number:
3/84:mj
DEPARTMENT OF INbUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&'146MAN RELATIONS DIVISION
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
MADISON,WI 53707 State Plan I.D.Number:
NGI%,SE%,S7,T29N-R19W ® CONVENTIONAL ❑ ALTERATIVE (If assigned)
5, H d�S on ❑ Holding Tank ❑ In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
CtaiAe Kinney 406 KAatteey, Hudtson, W1 54016 , SIS /'� ;Od
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PTELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Gary Zappa 3300 St. Cnaix 119371
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: I TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY I WELL: BUILDING:I VENT TO FRESH
ALARM: FEET FROM LINE. AIR INLET:❑YES ❑NO [--]YES ❑NO I NEAREST---
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑YES ❑NO NEAREST---100-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: I 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 DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH IT—ILL 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:
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:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION
APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERT I WELL: BUILDING:
FEET FROM LINE:
EYES ❑NO ❑YES ❑NO NEAREST----00-
J
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710(R.06/88) Zoning AdmiVl iz t ato1L
=J�Ln SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT#
// 7
-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES XNO
PROPERTY OWNER PROPERTY LOCATI
4,S T , N, R E (or)®
PROPERTY OWNER'S MAILIN ADDRESS L NUMBS BLOCK NUMBER SUBDIVISION NAME
- L
CITY,STATE ZIP CODE PHONE NUMBER CITY AGE NEA T ROAD,LAKE OR LANDMARK
:
II. TYPE OF BUILDING OR USE SERVED: 007o—
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ❑ New b.S Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. Conventional b. ❑Alternative c. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a.S Seepage Bed b. ❑seepage Trench c. ❑Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
0 v JOU Feet S Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
Mriks n allons Total #of Prefab. Fiber- Exper.
INFORMATION ew xisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks structed
Septic Tank or Holding Tank lr,06 D T
Lift Pump Tank/Siphon Chamber I Lj I ❑ I ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Stamps) I P/MPRSW No.: Business Phone Number:
Plumbefs AddressAWeet,City,State,Zip Co(le): Name of Designer:
VIII. SOIL TEST INFORMATION Itl
Ce ified Soil Tester(CST Name CST#
L G O'
CST's ADDR S(Street,City,State,Zip Code) Phone Number:
srce�.o r-r. 16 3' ) fo
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial urcharge Fee
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/s 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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground
included the creation of surcharges (fees) for a number of regulated practices which Wisco ih'S a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried restrw
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
0
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
r I
" APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor, (spec house), then 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 I 4 Al+l1c y �. iniiv l y
Location of property 41tOl1/4 s6' 1/4, Section 7 , T .29 N-R l f W
Township /w 0Sc1J
Mailing address
Address of site - oZ 1&,47TUEy L,a�� NyT75on1 �✓ � S oiCo
Subdivision name—Z/46 4. [-
Lot number
Previous owner of property
Total size of parcels
Date parcel was created
Are all corners and lot lines identifiable? X' Yes No
Is this property being developed for resale (spec house)? Yes No
Volume Z 4o and Page Number -5�l as recorded with the Register of Deeds.
-------------------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. ; and that I (We)
presently own the proposed site for the sewage disposal• system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. ) .
Signature of Owner M gnature f Co-Owner f Applicable)
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN—FORM I
WARRANTY DEED
3754,'70 �VO� 640 pA�f5g THIS SPACE RESERVED FOR RECORDING DATA
RE045TORS OFFICE
THIS DEED, made between Sam E. Miller, a single man ST. CROIX CO., WI&
Rec'd. for Reoxd 96 20th
Grantor day of ,lan AD. 19M
and Claire E. Kinney and Nancy A. KEH-Hey, Husban I at 2.10 P i M.
and Wife as Joint Tenants
Gr ntee,. R*01 w of Deeds
W i t n e s s e t h, That the said Grantor, for a valuable consideration ( 7 5 .4 0 .0 )
-Seventy-Five Thousand Four Hundred and no/100 Dot NTO
conveys to Grantee the following described real estate in St.Croix
County, State of Wisconsin: �^
Lot Thirty-Six (36) , Eagle Ridge
located in Southeast Quarter (SEk Of Section
Seven (7) , Township Twenty-Nine (29) North, Range Tax Key No.
Nineteen (19) West, Town of Hudson.
Subject to easements , restrictions , and rights-of-way of record, if any
T
Thisis not homestead property.
(M) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Sam_ F Miller - a single man
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements , restrictions , and rights-of-way of record, if any
and will warrant and defend the same.
Dated this 19th day of J4nuary
(SEAL) ' ^" (SEAL)
* * Sam E. Mill r
(SEAL) (SEAL)
* a
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this day of STATE OF WISCONSIN
19 ST.CROIX ( ss.
County. J
Personally came before me, this day of
198 t the above named
TITLE: MEMBER STATE BAR OF WISCONSIN Ram E Mil l Pr , a cinal p man
(If not,
authorized by §706.06, Wis. Slats.)
This instrument was drafted by ,,�,��•••.....
Leo A. Beskar, Attorney
to me known to be the person +'whh eettted,"ttte fare-
125 North Main St. going instrument and acknowledged the sane(,}
River Falls , Wis 54022 .
(Signatures may be authenticated or acknowledged. Both
are not necessary.) Notary Public st: crni3t tn;�• Cciflnty, Wis.
My Commission is permanent. (Tf,ilpt,':stafA,exI�Ration
date: i -I'i"+7,' •)
*Names of persons signing in any capacity must be typed or printed below their signatures.Notary A. to of W •'"'''' °"'
M c State of W
WARRANTY DEED—STATE BAR OF WISCONSIN, FORM NO. 1-1977
9TC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERASUtn &Lf 0?6_ L -4 NO Ale-y A. f r'1 nliy c; y
ROUTE/BOX NUMBER `7C ,f'gA- rl Lcy LAAji FIRE NO.
CITY/STATE_ 41 ��� � LrJ, ZIP✓-5'�/�
PROPERTY LOCATION: 1/4 c51/4,. Section , T;�'/ N, R W,
Town of /9'0,OS rte' , St. Croix County,
Subdivision i9G h�aGc: , Lot No. _.
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.
SIGNED L�%C -c r C�%� .�-✓�
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
DEPARTMENT'OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, � C DIVISION
LABOR AND , PERCOLATION TESTS (115) MADISON W1 63 07
HUMAN AELATIONS
(1-163.09111&Chapter 145.045) ,
L A ' : , TOWNS IP/M.W"'I'MMtiT'Y: T Y. LK.NO.: SUBDIVISION
N W I4 - /T�N/R 1741 for a.'&SU N 3S , •■- E AA, ZalS Ir
COUNTY: OWNER' //
�JrCRo►x C<A,t0� lN►vt% qb6 >.4-rTaY �Y�DSaN �✓,
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL,, ,,�� .. I w c�
dResidenca uN ❑New Replace NO V'. 2 /?Tf�
Spits t6t K H6. 49' SolLs c NTICao 'X' WNALAN
RATING:Sr Site suit"for system Un Site unsuitable for system (� Q
V L: M U D: 1. -FILL OLDI G A K:RECOMMENDED SYSTEM:top 'onal)
r IAJ! ❑U S Ou S ❑U S U ❑S WU �av Vs W1uMC
lIf Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ��
under s.H63.09tb1ibl,indicate: L L-145S Fioodplain,indicate Floodplain elevation:
NdC ';:7r PROFILE DESCRIPTIONS
BORING AL TOGR A -1 CH S RA 1 THICKNESS.COLOR, X URE,AND DEPTH
gER ELEVATION g E V TO BEDRQCK IF OBSERVED EE ABBRV.ON BACK.)
B- I Dl.
.1 -4y
9"BccrS �G"$a S, &S Ms�' E ies R4 �s
B- Z g 9Z 101"S '/ /4cr ijf q.9Z 9'&1-r' ZZ" e S, 88"&N AlS $RNA st S 94TS L A
B- .ag 99.65 r4c,N c ? S.08 "E«TZ 29 S, Ms
B-
B-
B-
PERCOLATION TESTS
TEST TH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINU
NUMBER AMINIVS AFTERS ELLING INTERVAL-MIN. PER INCH
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PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable coil 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 9,5,00
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I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with rocedures 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): n TESTS WERE COMPLETED ON:
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TDDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
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�ge CST SI ATURE: i
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
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4" CAST IRON 'VENT PIPE
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TES T IS C()UPLING TERMINATING
_ '9`S oo _.._._. FT.- .-- I r,i i OTT M 6F'="-YSTEh4
AS BUILT SANITARY SYSTEM REPORT
OWNER k TOWNSHIP Iq a 5 ,0n SEC - 7T 2-4-Rj_IW
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION F 454 tlC'J4/1 LOT LOT SIZE 3 171 '
PLAN VIEW
Distances and dimensions to meet requirements of H63
EVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe r r 90 No
Elevation of vertical reference point : / 0 Slope at site :
SEPTIC TANK: Manufacturer: 0 SOA . Liquid Capacity :
Number of rings on cover : Tank manhole cover elevation:
Tank Inlet Elevation: Z t7 Tank Outlet Elevation : 6` �
PUMP CHAMBER
Manufacturer : Number of gallons
Number of gal . pump set for a cyc e_ gallons ; total capacity ot
distribution lines gallon: size o pump head;
gallon per minute horsepower bran name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device 5er ot -pits feet diameter
SEEPAGE PIT SIZE: Num
feet liquid depth seepage pit inl-etpipe-elevation
bottom of seepage pit eleyation feet .
SEEPAGE BED SIZE: number of lines i d t h leiigth � Mile depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIUDDI t 15- RE S BUILT 7 7
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER /1q_ -f
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251
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� • a ~ REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit&X_
State Septic-,/, _
TAME TOWNSHIP _ St . Croix County
.00ATION 4(Z -Section-_ Lot #;�a___ Subdivision
;EPTIC TANK
Size ID- gallons Number of compartments_
) i-stance from: Well � �--- . Building �_1_ 12% slope
Highwater_ J _
i'UMPING CHAMBER
Size gallons Pump Manufacturer ,_ Model Number
IULDING TANK
Size gallons Number of Compartments
Pumper Alarm System
.) istance from: Well Building 12% slope
Highwater
ASO_RPTIO(N` SITEn
Bed �6 � U Trench ,p
Buildin 12% slope
iistance from: Well 90 g—_
Highwater .�
',BSORPT ON SITE DIMENSIONS
Width of trench �d ft Required area ft .
i
Length of each lines ft Depth of rock below tile in.
-
Number of lines 3 Depth of rock over tile in.
Total length of lines ft Depth of tile below grade_,_?� in.
Distance between lines `P ft Slope of trench o-7-lin. per 100 ft .
Total absortption area ft Type of Cover :
PIT DIMENSIONS
Number of pits _ Gravel around pits yes no
Outside diameter ft Depth below inlet ft
Total absorption area ft
Area required A ft
INSPECTED B y TITLE
APPROVED _ DATE
REJECTED DATE
REASON FOR REJECTION -----
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7 ' State Permit # w
PLB 6 7 State and County
Permit Application County Per #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
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B. LOCATION: Al '/4 Z '/4, Section , T 21 N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
IT a l,' A r,44P Township u t.�S o1
C. TYPE OF OCCUPANC *Commercial *Industrial *Other (specify) Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY_ 1600 Total gallons No. of tanks
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 Total Absorb Area sq.ft.
New fig Replacement Alternate (Specify)
Seepage Trench:-�—No.of.Lineal Ft. Width D9ph Tile depth (top--No.of Trenches
Seepage Bed: Length ?_Width Depth Tile depth (top)- No.of Lines--3
Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits
Percent slope of land_ 3 76 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 Soil Test r,
NAME /1 I ef A r on S.T. # _ /lp2fd other information
obtained from o I Ite (owner/builder).
Plumber's Signature MP MPRSW#/titr S� 3 2 Phone
Plumber's Address P w ' c � o+►
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.
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Do Not Write in Spac Be ow FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fee aid: State Cou ty Date —
Permit Issued/ (date) Issuing Agent Name
Inspection Yes Y No State Valid# Date Recd
1. county (whit 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
rEH4 115 R& x/78 v
REPORT ON SOIL BORINGS AND PERCOLATION TESTS ` n Oj
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES /, tEIVE(I
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P.O. BOX 309,MADISON,WISCONSIN 53701 1988'
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Off1�
LOCATIONAWM 19%,Section---7_,Td;_!2N,RZ,(or)daownship or Municipality
Lot No. -36 Block No.
�+ County
Owner's/Buyers Name: //tr Subdivision Name
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Mailing Address: . - It- /de-ook ifid, as0"
TYPE OF OCCUPANCY: Residence X No.of Bedrooms J COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS .�oZd � PERCOLATION TESTS S- 02/—OF/
—OF/
SOIL MAP SHEET NAME OF SOIL MAP UNIT �w T"GO Sit/ �o•4M
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NIUM_ INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
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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 .yam IF OBSERVED IN INCHES
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the I cation and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy l P :T1DA�Indicate scale or distances.
Give horizontal and vertical) reference points Indicate slope. S".,-/0404 Ate, Fdv
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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. l
Name (print) t °s� ^�f Certification No. ,�J ,
Address
.Name of installer if known It
Copy A—Local Authority CST Signatu
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