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HomeMy WebLinkAbout002-1043-80-000 N ~ O O oa I o o 0 p aoi`r b C O tp d N w O C 0 N O O 3 7 2 p d) ry N m U N N � -co "'L O VO m M O) w Q. > m O N C L >V C N n L E ul C E M N US ?D y :3 a W L p O L E E c z W O C Z N D N d N 7 6 C U. c 4)M a c m O L 3 ° acorn- - c 3 °_ yLSa° y N O y.' O L -O 7 Cl) � L Q F-L d a) Q H tOp L LL c I C NN N N Z y y CD ?� O !' O Z ! _ O O zN € 'o v rn d m a m rn C'4 z 0 o z c a ° c c o w o w o d Z c c Z cn H r O) N rn O C E C E 'd O N -O N M ` O N O N y CL tq N U) CD N N C O o m Q o 0) Q z m z z m z o Nz ' cl y N O !�1 06 W O V a oca aco ooa -0 w E �FyA {fyA fF/y� j N O fn {fyn U) E 0 W`J O i > S a m O S > FL m .O Z • o, aaa ' aaa� IL c W W C U) J U rn rn } 3 rn rn Z � � I "V m o 0 o o ai o o = �o > m c a m Q N) y O) L O N O L p ar Q } (n o C Q z 00 n = rn m = D o m R �i 'O Y iO.i pdp• m ~ 0)_O t 9 7 C + p Ul , n� H V d E co N 3N C C'e p 70 C4 N N N c7 , o N ayi o f `m °: = Z' c c r • y °o m Yi Z Ln 2 H Y rn o Z Z 0 CL IL • cl a d .2 d m c c m c r`I�l E c .. 0 3 Parcel #: 002-1043-80-000 09/22/2006 11:44 AM PAGE IOF1 Alt.Parcel M 19.29.16.280A 002-TOWN OF BALDWIN - Current I Xj 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-FRAME, EDWARD&CAROL EDWARD&CAROL FRAME 2117 90TH AVE BALDWIN WI 54002 Districts: SC=School SP=Special Property Address(es): •=Primary Type Dist# Description "2117 90TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 20.530 Plat: N/A-NOT AVAILABLE SEC 19 T29N R1 6W N 1/2 OF NW FRL 1/4 EXC Block/Condo Bldg: COM NW COR NW FRL 1/4,TH S 27 RDS,TH E 14 1/2 RDS,TH N 27 RDS,TH W 14 1/2 RDS Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) TO POB&EXC CSM VOL 4/922&ALSO EXC 19-29N-16W P280D AS DESC 741/289 TOWN BALDWIN Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 795/564 07/23/1997 734/440 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 17.530 1,800 0 1,800 NO UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 2.000 4,000 79,100 83,100 NO Totals for 2006: General Property 20.530 5,900 79,100 85,000 Woodland 0.000 0 0 Totals for 2005: General Property 20.530 5,900 79,100 85,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 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&BUILDINGS LABOR&HUMAN RELATIONS WI 53707 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,W P.O.BOX 7x BUREAU OF PLUMBING NWT, NW-4, S19,T29N—R16W )MCONVENTIONAL RECONNECE]ALTERNATIVE IState Plan I.D.Number: Town of Baldwin (lf assigned) ❑Holding Tank ❑ In-Ground Pressure ❑Mound WY 63 NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Marlin Krear CTY TK JJ Route 2, River Falls, WI 5402 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: Everett Boldt 4489 St. Croix 95982 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV: TANK OUTLET ELEV,. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 1OYIES ❑NO ❑YES ❑NO IN BEDDING: VENT DIA.: VENT MA TL: HIGH WATER VMSER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: lAIR INLET: ❑YES ❑NO ❑YES ❑NO 11fE REST DOSING CHAMBER: MANUFACTURER: BEDDI�ONO UID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: 1V'E1YES ARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑Y ❑NO 1OYEs ONO GALLONS PER CYCLE: PUMP AND CONTHOLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING.JVENTTOFRESH (DIFFERENCE BETWEEN FROM AIR INLET PUMP ON AND OFF) ❑YES ONO MEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowingf)RC�E LENGTH DIAMETER, MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) MAIN! CONVENTIONAL SYSTEM: WIDTH. LENGTH: NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA4. #PITS: LIQUID TRENCHES. MATERIAL: FIT DEPTH: �I�I�KA4WI,CINIS GRAVEL DEPTH FILL DEPTH DISTR,PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR BER p PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV.INLET.ELEV,END: PIPES. NOM FROM'6I LINE: AIR INLET: NEAAAEJ�. MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTURE JPERMANENT MARKERS OBSERVATION WELLS 1:1 YES ❑NO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER. EDGES. DYES 1:1 NO ❑YES 0 N ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: a WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER TRENCHES: )MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. JDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA,: HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS'. ❑YES ONO ❑YES ONO COMMENTS. PERMANENT MARKERS: OBSERVATION WELLS: ttWI�3FxR WELL: BUILDING: " LINE: ❑YES ONO DYES ❑NOT Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) Zoning Administrator SANITARY PERMIT APPLICATION COUNTY � DILHR In accord with ILHR 83.05,Wis.Adm.Code � �""" STAT SANITARYPERMIT# —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 A] NO PROPERTY OWNER 'J PROPERTY LOCATION areL / 7 f5"?e- A ,2 Gt1'/4A/'G 144, S / T �` cf, N, R 16 Is(or)W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER 11 BLOCK NUjvIBER SUBDIVISION NAME ct v T J-J- Rl-- Z 11,114 CIT STATE C ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK 1✓2R 1 ,S�QG9 Z /Sr `�71-- 7/ ❑ VILLAGE: �i'�J i—Ltl�9 6 3 II. TYPE OF BUILDING OR USE SERVED: /f Number of Bedrooms if 1 or 2 Family 1i OR El Public(Specify): /(/j7 III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.❑ Replacement c. ❑ Replacement of d.X Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System / Existing System r 2. A Sanitary Permit was previously issued. Permit# Date Issued u .4 y /279 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. MSeepage Bed b. ❑seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PRePeSED(Square Feet): ,�/ COQS'r � / 4� 7� IV,4 Feet ❑Private OJoint ❑ Public VI. TANK CAPACITY Site in alions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdincl Tank 14ao moo Z e S ® ❑ Lift Pump Tank/Siphon Chamber ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for inst tion of the private sewage system shown on the attached plans. Plumber's Name(Print): mbe S gnature:(No S p ) MP/MPRSW No.: Business Phone Number: ✓eye�� 1�0� f- 46i4X7 h - j7P Plumber's Address(Street,City,State,Zip C e: Name of Designer: ��o M i�) 974 - L &L/ lc/iS 614 0 Vlll. SOIL TEST INFORMATION Certified Semester(CST)Name CST# ,L- veP_eff W �.d � O�5 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa ttary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial 12b 11 rSu�harge Fee Adverse Determination �G't)'©C) '°'•�C W­iV— 97 71J. � X. COMMENTS/REASONS FOR DISAPPROVAL: �L° i nS 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 revigions 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; 11. 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'/2 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 Ater'', included the creation of surcharges (fees) for a number cf regulated practices which Wisco in` a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha buried fes"suit 4 is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- terec by the Department of Natural Resources. These funds are used for monitoring cround- " water, groundwater contamination investigations and establishment of standards. Grcundwate=, it's worth protecting. S3D-6398(8.03/35) 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 c F Pr_per_r_y Iyar 4 Location of Property NiV 14 IVI ;4, Section T�� N - R W Township Bo laa 1?2 Mailing Address n1-y Subdivision Name A1,4 Lot Number Previous Owner of Propertyo �7 Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume -5'F5- and 'Page Number S'67 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - PROPERTV OWNER CERTIFICATION I (We) cvLU6y that att statement A on th,i,d 6oAm aAe true to the but o6 my (ouA) knowledge; that I (we) am (aAe) the owneA.(s) o6 the pnopen,ty de4cAi.bed in th.iA in6oAmati,on 6oAm, by viAtue o6 a wavanty deed Aeeonded in the 066ice o6 the .,County RegiAteA 06 De.edd ad Document No. 3.533" ; and that I (we) peed entty own the pnopod ed 4 to bon the d ewage di.6po.6aZ a ydtem (oA I (we) have obtained an easement, to Aun with the above de cA bed phopen ty, bon the cond.touce ton o6 ea4.d system, and zhe dame had been duty AeeoAded in the 066ice o6 the County Regi,6ten 06 Deeds, as Document No. j 861GNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 7 DATE SIGNED DATE SIGNED 4 F t VFW;,MWN f... ♦ q V '#" S ♦ �� r !4 'f,.���up}��,�.�,,,�� .+c y !. � �Yre.too+, -.�.a'.:. '�'� �" ;'q� `+hulk.. '•* ,: '��It 1} A t r 4 3 rra a fi • � y�p� .rF.i. f" N `fW `#'. YSaI 3ra.� y z , H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d OWNER/BUYER H ROUTE/BOX NUMBER �! �� Fire Number .CITY/STATE /S. V�y- 115- ZIP �" X22 PROPERTY LOCATION: .ZZI Section �� TZ% N , R _W, Town ofr � uJ✓/7 St . Croix County, Subdivision Lot number AIX Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed, by a licensed septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment 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 . SIGNEDv DATE - ,�- St . Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address . I DEPARTONT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS DIVISION INDUSTRY, G P.O. BOX 7969 'LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN RELATIONS (H63.09(1)& Chapter 145.045) LOCATION: E ON: TOWNSHIP/MU ICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: / r USE DATES OBSERVATIONS MADE NO.BEDRMS : COMMERCIAL DESCRIPTION: PR F E P ONS: TESTS: Residence Replac I _ a /_ 7 RATING:Sa Site suitable for system U-Site unsuitable for system CONVENTI NAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM,(optional) S ❑U ❑S ❑U ❑$ ❑U ❑S ❑U ❑S ❑U n e If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the t, �) under s.H63.09(5)(b),indicate: �/ �� I Floodplain indicate Floodplain elevation: //,V!4 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION O,�BJSERVED EST. IGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B B B- B- B- PERCOLATION TESTS TEST DEPTH.; WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER10132 PERI0133 PER INCH P. P. Aff P- P-.:: P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. <- SYSTEM ELEVATION A ............. I i � I i tt I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): � � TESTS WERE COMPLETED ON: we ,-•e o ADDRESS: �ST ERTIFI ,ION NUMBER: PHONE NUMBER(optional): al SIGNATURE: K. DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02/82) —OVER— No � . ° ~ INSTRUCTIONS FOR COMPLETING R]RK8 115 ' SBO 0385 To be xompleteand ocoontoa`i! 1. Complete legal description; 3. The use section must clearly Indicate vneho,rhio i,u *,sidenoourcommercial project; 3. MAXIMUM number of bedrooms nr'omn-�mua/ u� v|unnnd; 4. |o this a new o, replacement system: 5. Complete the Suitability odngbo^e*. AS/TE |S3U}TABLE FOR AHULD|NG TANK ONLY IF ALL OTHER SYSTEMS ARE RULEDUUT 8ASEG ON S0L �OND|T0N3: 0. PLEASE voothe abhraviodnn` oknmn ^n*'Unmfi|n descriptions and completing the plot plan; ` 7. MAKE A LEGIBLE dimgom a�ou,a�|v |�,uu``n vno, ,m, �omuionc Drawing to ma|a is preferred. A separate sheet mav be opy i|d+uimu' 8. Make sure your benchmark and vmbca� c|ou/|y d`mwn'and xre permu,am; 9. Corncdmo all appropriate boxes an �o Ua/e�. n�mn,' adv,eee`' flood plain daza, pox*|a`ion test exemp- tion, it appropr iate; 70, If the information (such as f|ood n|oin. e|c""nv�> �o= ,n« xrn|v. n|acm N�4. in the appropriate box; 11. Sign the form and place your runcmaddmoand your certification number; 12. Make legible copies and dig,ihv/, Sn/L TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYSQF CO�PLET|ONL r�' ^ S(}YL TESTFIS SoUS epam two end, Twxto,~, d'�or3ymbd, S^an(e <ovw, 10'') B.d,och cob — CobN(� {3 10^) JS — Sandstone Or — Gravel. (under 3^) Limestone °s — Sand HGVV — High Groundwater u — CooneSend Pu,o — Percolation Rate med ModiumSa^d vV — VVe!| f's — Fine Sat`d r3/dg — Building Is — LoamvSand / — Greater Thar) °d — Sandy Lnom / — Less Than °! — L.am °oi| — Silt Loam �| — Black xi — Si|l °o! — Clay Loam � YeUom so| — SandyC!ay Loam, nin| — Silly Clay Loam .`o' — k/iotde, ' m — Sandy Clay mid` �io — Si|ry �|ay f* � fnm' Iine' fainr °c — Qov :c — oon`mvn. covno pt — Peat mm — Many' medium m — Muck * — distinol p — pnnnincnt |//r� kiyhwam, |wv|' ° Six gonem| ooi! um"m,� surface water lot !inoid �"y� u.`eny Mark Yn� Verhca| Reforence Point TO THF OVVNER- vo,if±atino nf zhio soil nor m d`, +ic�� ,'^ '� ` `"^� ,/o�oro � cnmn!etc ,m� o[ �an� for the p/ivatn �waor svn/em a^d a rermiz orr|iva� �, r ` . , �� *ppmAria, |o�u| o�uho,�y \n o,dor �o N � Owner Ra r /I/I ✓'�Q r� Cfy jrJ—j q Venf 5 3, 81 Ex i s`C� I 0 �g n IVIOCi7,rl e l. shed � �1� ��.Q,I�r /A� Pry P' 5� 5" is tor' \ ' %Z7 ✓'eGOnneCf, oh \ I�o bedroom ;r•a,'Ie r , ex�sf,'n9 syst�n. .3a�n I � �fou5c NO' II , �,^owrl BY • AS BUILT SANITARY SYSTEM REPORTn9I � °R , TOSdNSHIP� SEC. T.,74N, R�W --- �. AD R S_ , ST. CROIX COUNTY, WISCAKT 71DIVISION , LOT LOT SIZE PLAN VIEW Distances 6 dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d ' ! i I / e ! t__t J P11 j I I � I F r � :'TIC TANK(S) / MFGR. . Indicate N nth Annow CONCRET STEEL S cage NO. of rings on cove Depth�� DRY WELL .- r NCHES NO. of - width length area no. of lines_ width length 7 area ZE depth to to of pipe S EGATE !' 1/rQ��N S /$ z is/e •.'.s.: RATE_ 2 AREA REQUIRED AREA AS BUILT t6 ,,(,,iaimer: The inspection of this system by St. Croix County does not imply complete �:.I.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 stem operation. However, if failure is noted the County will make every effort to .-ermine cause of failure. CASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. '-INSPECTOR • P . DATED PLUMBER ON JOB LICENSE NUIMER . 74 . . Z REPORT Or INSPECTION INDIVIDUAL SEWAGE SYSTEM SanitaAy Penm.it ` State Septic �S�_ NAME_ .-L �. / rownship J� �C/ �C��� St. C'%0ix County Locatiox ecti an SEPTIC: TANK E Size� _gatton Number. o6 Compantments� i Di-Atanee ream: Wet boa � fit. 12% on gne.ateA ztope Bu.itd.i.ng Z 0 bt. Wettand.6_ ,�.� fit• H.ighwaten DISPOSAL SYSTEM Distance F&om: Wett 6t. 12% of gAeateA 6tope Bu.itd.ing 6t. Wettand.6 "�'�Et• H.ighwateA 5t. riELD DIMENSIONS : wi dith o i trench. it. Depth o6 Ao ch b etow t.it e_z_&in. Length o6 each tine it. Depth o6 Aoch oven tite Lin. NumbeA. aj tines Depth o5 ti°e below gAade–f—doo in. Totat tength o6 tines it. Stope o6 tneneh in pen 100 it. Distance between tines it. Depth to bedrock t. Totat absaAbtion aAea�it Depth to gAOUr�dcua.teA fit. 2 Type o Covet: a 2t oA StAaw ' RequtAed aAea �� yy 5 p PIT DIMENSIONS : NumbeA of pits AX GAavet around pits yes_ no Outside d.iame t. Depth betow inlet 5t. 2 Total absoAbtion area it 2 AAea Aequk d it "' INSPECTED BY TITLE APPROVED ,DATE 197 REJECTED ,DATE 197_ S 0000 1 EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 " MADISON,WISCONSIN 53701 r''l REPORT ON SOIL BORINGS AND PERCOLATION TEST �� LOCATION: *'/4,#d'/4,Section ,TN, R�tE (or) ownship or Municipality County, K Lot No. Block No. © Subdivision Name Owner's Name: � �E d 400 Mailing Address: _ Other TYPE OF OCCUPANCY: Residence No.of Bedrooms Z EFFLUENT DISPOSAL SYSTEM: NEW- ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS �4 PERLCO TION T STS SOIL MAP SHEET - JsA SOIL TYPE PERCOLATION TESTS HOURS WATER IN MEN EVEL,INCHES RATE TEST DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTER MIN/IN NUM- INCHES THICKNESS IN INCHES 1ST WETTED SWELLING 2 PERIOD 3 BER P-t . � Z4 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES (DEPTH TO BEDROCK IF OBSERVED) NUMBER INCHES OBSERVED ESTIMATED HIGHEST J 0 22Z I 21 I L 3 cT eel-3 z, y PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square fe it�b as. Indicate number of square f of absorption area Indicates le � needed for building type and occupancy. / 'rot or distances. Gi horizontal and vertical reference points. Indicate slope. 0 tN Au I t I,the undersigned,hereby ertify 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 b ief. _ ( Certification No. Name (print) Address Name of installer if known CST Signature COPY A—LOCAL AUTHORITY x. i I t x IL k r State Permit # �� :•°,_„ State and and County County Permit # - L 6 Permit Application County P for Private Domestic Sewage Systems F *DENOTES STATE APPROVAL REQUIRED State Plan I.D. # Date Approval Received from State if Required Address: Mailing A. OWNER OF PROPERTY c T N, R E/(or) W Lot# City P 4 X74, Section Village B. LOCATI N: � /'�4 Township �L Subdivision Name, nearest road, lake or landmark Blk# Industrial *Other (specify) __—*Var �c�C� TC YPE OF O CUC PANCY: Commercial_ No. of Persons Duplex__—No• of Bedrooms h Single family YES�NO # of Bathrooms— YES NO Food Waste Grinder D. TYPE OF APPLIANCES: DishwasNeOr Other (specify) __—_- Automatic Washer YES Total gallons No. of tanks E. SEPTIC TANK CAPACITY 1-0 ' Total gallons No. of tanks_ *Holding tank capacity Replacement Prefab Concrete Addition_New Installation Other (specify) ft. Steel sq *Poured in Place Total Absorb Area F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate System No. TrTnc est New_X Addition Replacement_ Depth Tile Depth /Width___ No, of Lines Seepage Trench: No Lin. wedth Depth Tile Depth— Tile Size Seepage Bed: Leng —�— Q 1(t Seepage Pit: Inside diamet rLiquid Depth— Distance from critical slope Percent slope of land with Section H62.20, I, the undersigned, do hereby certify that the information I have reported is in accord prepared ' rative Code, and that I have sized the effluent disposal system from the EH-115 Wisconsin Administrative �. by the Certified Soil Tester, C.S.T. # and other information 1. NAME (owner/builder). 7� 9 Phone obtained from r MP/MPRSW# – =T— Plumber's Signature Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). F _ c i F t y. w f G ' V S f v 1. / E n r f j f _ b � f , t r e r f S ' z f Not Write in Space Below FOR FeDEPP d MStat 4T USE/��NL County m�y Date of Application Agent Name`�� Issuing nit Issued/ (date) Valid# Date Recd -ction Yes No DIVISION OF HEALTH,-P.O. BOX-309' M ADISON,WI 53701 3. owner (green copy) ounty (white copy) copy) Revised Date 6/1/76 ate (pink copy) 4. plumber (canary Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page_of .r " LatRr and Human Relations Divib on of Safety&Buildings in accord with ILHR 83.05,Wis.Adm. Code COUNTY , Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must include,but Ctfc-) not limited to vertical and horizontal reference point(BM),direction and%of slope,scale or PARCEL I.D.# dimensioned,north arrow,and location and distance to nearest road. 00a- /(0 el 3 -- 80 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION r,- GOVT.LOT I)G6, 1/4 /L)lt,�/4,S f T y ,N,R /& E( PROPERTY OWNERS MAILING ADDRESS LOT,# BLOC, # SUBD.NAME OR CSM# 114- CITY STATE ZIP CODE PHONE NUMBER ["..ITY ❑VJL}AGE WN NEARE T ROAD (`7151 X84-- 11 �j �Q�i,�cv.;, D �� 140 [ ] New Construction Use[vrResidential/Number of bedrooms 3 [krAddition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 5/60- gpd Recommended design loading rate bed,gpd/ft2 trench,gpd/ft2 Absorption area required bed,ft2 trench,ft2 Maximum design loading rate bed,gpd/ft2 trench,gpd/ft2 Recommended infiltration surface elevation(s) /t�i� ft (as referred to site plan benchmark) Additional design/site considerations Parent material S'i�� �,�,�� .f;d Flood plain elevation,if applicable 'V4- ft S=Suitable for system . coS 00 U L MOU_ NP/❑U IN GRO- E PRESSURE AT G ❑U SYSTEM I U— OOLSING TANK U=Unsuitable fors stem ��''S$ [� B-9 SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu.Sz.Cont Color Gr. Sz. Sh. Bed Trench Ground - /C3 c c t,,, a v) elev. pp Depth to limiting factor �%Ln Remarks: Boring# h' 4 o Ground = elev. o ft. Depth to limiting factor Remarks: CST Name:-Please Print / Phone: `Sl ,-.7 )-�P 3;7 d Address: AL,/' ( V ignature: l D te: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Pageof PARCEL I.D.# Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu.Sz.Cont Color Gr. Sz. Sh. Bed Trend] �ivv \l Ground elev. ft. Depth to limiting factor Remarks: Boring# hZ.fix.\i•:?:ftiij ip\::i ti Ground elev. ft. Depth to limiting factor Remarks: Boring# f?S' Ground elev. ft. Depth to limiting factor Remarks: Boring# Ground elev. ft. Depth to limiting factor l Remarks: SBD-8330(8.05/92) rAe 'VA a►Q i i I f a �7`t8 rr L � 1 1 i t� Sh coo-e�- c