HomeMy WebLinkAbout028-1009-20-050 1
Parcel #: 028-1009-20-0550 03/18/2005 01:31 PM
PAGE 1 OF 1
Alt.Parcel#: 3.28.17.48A-10 028-TOWN OF RUSH RIVER
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
ELMER W&MARIAN M JOHNSON JOHNSON, ELMER W& MARIAN M
1884 50TH AVE
BALDWIN WI 54002
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description * 1884 50TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 29.430 Plat: N/A-NOT AVAILABLE
SEC 3 T28N R17W PT SE SE EXC CSM 7/1828 Block/Condo Bldg:
&CSM 17-4445&CSM 17-4625
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-28N-17W SE SE
Notes: Parcel History:
Date Doc# Vol/Page Type
10/01/2003 742083 17/4625 CSM
01/16/2003 706131 17/4445 CSM
07/23/1997 947/305
07/23/1997 766/39
2004 SUMMARY Bill M Fair Market Value: Assessed with:
6861 Use Value Assessment
Valuations: Last Changed: 06/04/2004
Description Class Acres Land t98,900 rove Total State Reason
RESIDENTIAL G1 2.000 12,600 111,500 NO
AGRICULTURAL G4 15.930 1,800 0 1,800 NO
UNDEVELOPED G5 5.500 1,400 1,400 NO
PRODUCTIVE FORST LANC G6 6.000 5,400 0 5,400 NO
Totals for 2004:
General Property 29.430 21,200 98,900 120,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Computer#: 028-1009-20-050
Parcel#: 03.28.17.48a10
Municipality: Rush River, Town of
Address: 1884 50th Ave
Baldwin, W 1 54002
0311812005 Johnson, Elmer Pam Quinn
prospective buyer for land called and requested information regarding septic system
requirements for replacement, etc. Craig Schmitz-612-961-8189 was notified of both permits
and age/size of POWTS at this time
'DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILD GS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
Ez, SE1,4,S3,T28N-R19W OCONVENTIONAL 1:1 ALTERNATIVE Stf ass a Plan I.D.Number:
Town of Rush River El Holding Tank El In-Ground Pressure ❑Mound
50th Avenue
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION-DATE:
Elmer Johnson Route 2, Box 193, Baldwin, WI 54002
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:
Roger Timm 3224 St. Croix 92563
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: IWARNINGLABEL LOCKING COVER
I PROVIDED: PROVIDED:
ot-ro DYES ONO DYES ONO
BEDDING: VENT DIA.: VENT MATE.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
LINfr: �� AIR INLET:
ALARM: FEET FROM ,S
DYES ❑NO DYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER: Ia EDDING: 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 PR OPERTV WELL- BUILDING.JVENTTOFRESH
LINE. AIR INLET.
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) ❑YES ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH TRENCHES DISTR.PIPE SPACING MATERIAL' INSIDE DIA it PITS DEPTH/ PIT DEPTH
DIMENSIONS d�
GRAVEL DEPTH FILL DEPTH DISTR.P'P' DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH owl BELOW PIPES I I ABOVE COVER. ELE V.INLET ELE V.END. PIPES: FEET FROM LINE: AIR INLET:
)-,7 NEAREST
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES NO
OIL COVER TEXTURE: PERMANENT MARKERS OBSEHVATIONWELLS
1-1 YES ❑NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED IMULCHED
CENTER. EDGES: ❑YES EE
YES ❑NO ❑YES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATEHIAL&MARKING
ELE V.. ELEV.: DIA.: ELEV.. PIPES. OI
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLARITSCAL LIFT CORRESPONDS TO APPROVED
❑YES 0 N OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: {
FEET FROM LINE:
DYES ❑NO El YES El NO NEAREST
�,,,.-..�� �� 5 ..�.��:� . ►\I � � .nos�u ��� � cA� ev,�,P1 y l�� ,�
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
t
DILHR SBD 6710(R.01/82) Zoning Administrator
i
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
j 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 8Y2 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 ma,
included the creation of surcharges (fees) for a number of regulated practices which WiSdo ER's °
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried teas+ re'
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.
c
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)
=ZZOM, R SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code
....-.— STATE SANITARY PERMIT#
–Attach ca'Fn lete plans to the count co only)for the system,on paper not less than 3
p p ( y copy y) y p p STATE PLAN I.D.NUMBER
8%x 11 inches in size.
-See reverse side for instructions for completing this application. PErlrloN
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO
PROPERTY OWNER PROPERTY LOCATION
t ./U P '/4, S T Zf, N, R / (or)W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER 111LOCKNUMBER SUBDIVISION NAME
Z ,V 011,5 A114 1 A AM
CITY, TAT IiIPCODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
v.Z r( d VILLAGE:
11. TYPE OF BUILDING OR USE SERVED: - /Li . 00? /G —020
Number of Bedrooms if 1 or 2 Family a OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. 1:1 New b. El Replacement c. El 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. C9 Seepage Bed b. ❑seepage Trench c. ❑See a e 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):
Feet ,®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank /O
Lift Pump Tank/Siphon Chamber ❑ 0 1 ❑
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 St mps) MP/MPR�SW_No.: Business Phone Number:
Kq�� ay !t 7,Z,',,I W5
Plumber's t:Ss:4( treet,City,State, ip Code): Name of Designer:
' �s 7 m�
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate ls:su�in Agent Signature(No Stamps)
Approved F-1 Owner Given Initial S charge Fee
'1
r.J
Adverse Determination
X. CO MENTS/REASONS FOR DISAPPROVAL:
�_ � IcSvn
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
e
Owner of Property C
Location of Property C Z�. �6 _It, Section , T 42L N-R W
Township
Mailing Address ..-�.
J
Address of Site /
Subdivision dame
„Lot Number
Previous Owner of ?property �
Total Site of ParcelZ. J
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 and Page Number , as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Bead 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - .. .. -—— - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTy OWNER CERTIFICATION
1 (We) ee�.6y that a t .atatementb on this Sonm ane Me to the beat o6 my (oun.)
knowtedg e; that I (we) am (aloe) the owner(.a) o6 the pnopehty dea chibed in this
.insoAmation SoAm, by v.ihtue os a wdAAanty deed neeonded in the Oss.iee o6 the
County RegiateA og Veeds a6 Voeument No. ; and that I (We) pnebentty
own the proposed site Son the sewage dispoi .syb em (on 1 (we) have obtained an
easement, to nun with the above desehibed pnopehty, Son the eonatnuction o6 aaid
system, and the same has been duty neeonded in the 046.iee os the County RegiAteh. o6
Heeds, as Vocment No. ) .
' S
SIGNATURE OWNER SIGNATURE OF CO-OWNER (IF AP LICABLE)
DATE SIGNED DATE SIGNED
A�
DOCUMENT Nu. WARRANTY DEED 71115 SPACE Rr.i[.RVEU FUR RECORDING DA,A
STATE BAR OF WISCONSIN FORM 2-1982
4
G I I13EI?P J. WES`I'PHAL AND VIOLET C. WESTPHAL,
. . .. .riusba.rid 'ari��_ wife ... _ .
_........... ..........-------------... . .._.
. ................. .. ..... ------ -- --- .. ...... .......--..................
l oity� :ln ( �� u 1 nllt t., - I I MI IB W JOI ftX)N AND) MI11Z'UW M. G;
.vs JUIINISON, liti.sbatid and w.ilc a s survivorship marital
....... .. .. .. . . . .. ... ......... .. ....... . ....... ---... ...... .... ._......
_.....property,..... ............ .............._._ .................. �I
........... .... ... . ..................................................
... .. . ------ .......................... .. ......................... it
........ ........-.-._........................................._...................................... .... II PETURN TO
I
.... .... .... .............................................................................................
... .. ..... ....
........................ . . ............. ................................. .
the following described real estate in ...... ...St....Cr.0iX...................County,
State of Wisconsin: ,
Tax Parcel No: ..............................
'I be h?2 of the SE's, of Section 3-28-17, St. Croix County, Wisconsin, except
that part thereof situated North of Interstate Highway "94".
This .. ...... " _ .......... homestead property.
la �
(is) (is not)
lNeciaion to warranties: easements,restrictions and rlj fits-of-way of record,
if any.
I►ated this �`S- J. day of . October
.(SFAL) � ..y.Y.— — (SEAL)
Gilbert. J . Westpha- l..... .Violet (" WOstphal
........ ..._._.I .. .... .... . ..... — --- .... .......(SEAL) ._ .. .._. . ...... . .._(SEAL.)
AUTHENTICATION ACKNOWLEDGMENT
Signtiture(s) i ' -----------� "I"?.. `.....- STATE OF WISCONSIN
Yi ' s�j1l L�tC ss.
................................... . .._.
i' ................. ...;...............County..
authenticated this .dap of .`.� .......... .._ , 19 Personall ' came before me this ................day of
.....CtObCt'................... IJ . .. ._ the above named
.......................................
Gilbert J. Westphal, Violet
K ° ,C'� c ' z e t-eZ C. Westphal
............... ..............._.............._..........
TITLE: MEMBER STATE BAR OF WISCONSIN
.................................................... -------•---•--...... .
(If not. --•........................................
_.................. .......... .........S................... . ......
authorized by § 706.06, Wis. SLtts.)
to me known to he the person ...._....... who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina0land Lundeen ........................ ..•........_..................._................_.
...........................G......_................
Attorney at Law
•.......................................•-••----------..................--_...-. NotarN, Public ..... .... ...............................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.) )
_
*Names of persona signing in any cap-wily slu.uld he t>�po•l w prinlyd halow thrir signnturc'.
H
H
a
STC - 105 r
a
- H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
H
OWNER/BUYER "
ROUTE/BOX NUMBER/L. Number
.CITY/STATQXfr�-C�� �C.Q,t+ ZIPS
PROPERTY LOCATION:�' , �.� . 3t, Section , To,4c N, R _W,
Town of St . Croix County,
Subdivision Lot number
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. Ho
E
I/WE, the undersigned, have read the above requirements and agree En
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
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 .
SIGNED aa
DATE / O�
St . Croix County Zoning Office
P.O. Box 9&i-
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address .
Timm JOB LZMzf, `1r(
SHEET NO. OF
DATE
Excavating Co. CALCULATED BY�eY Z�-a
R I, Box 192, Wilson, WI 54027 D'Rs�P,es 3�z�
CHECKED BY TE
SCALE
tAit
.
...
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JQ�� j j z- � �lous� /
z �
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! ..i ...._ _ '......_.....
Cpl/
Al :"r WWL Mss.01171.
Go°" "' t'' AS BUILT SANITARY SYSTEM REPORT
p�z,�.ttlenloa►� �, ,
_
OWNER
1- d 4- /AJ TOWNSHIP SEC._ _� `L
T N, R_jjW
ADDRESS,- ST. CROIX COUNTY WISCONSIN .
SUBDIN&IS•I N LOT LOT SIZE a
PLAN VIEW
Distances & dimensions to meet requirements of H62, 20
SNOW EVERYTHING WITHIN 100 FEET OF SYSTEM
e s r n
oCet� o h e
r
_ s Ale a
¢ U
104
�O
1 to
Nd.
I di a e o th Arrow
SCAL o I Slc e
SEPTIC TANK(S)/000 MFGR. ��,-S��,s CONCRETE_ _STEEL
N0. o rings on cover Depth
PUMPING CHAMBER SIZE PUMP MFGR. �L NO .
GALLONS Per Cycle
TRENCHES NO. of I wi tai _ length area
BED NO. of lines 1 width /Z` length 3l' area 5752'b
depth two top of pipe 2
NUMBER OF SEEPAGE PITS Outside diameter, total pit area
AGGREGATE /" /T" 'C'.'C
PERK RATE_ 9:57 AREA REQUIRED */p ° AREA AS BUILT $<S7. "7'
<ST o
Disclaimer : - The inspection of this . system by St. Ctoix, C6unty does not imply
complete compliance with State Administrative Codes . There are other areas that
it is not possible to inspect- at this point of construction. St. Croix County
assumes no liability for system operation. However, if failure is noted the
County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
INSPECTOR
DATED 9` /0 0- eo PLUMBER ON JOB
LICENSE NUMBER ' &L,? 2
i
P
REPORT OF INSPECTION - INDIVIDUAL SELVAGE SYSTEM
. SanitaAy Permit AST
State Septic.2
NAME Town�Sh�p St. Crraix County
Location5l Y Section lot # Sub divi,6ion
SEPTIC TANK J
Si z gatton�s Numbers o6 com ahtment6 l
Distance bnom: Wett p Building 1.2% .6tope
Highwatex
PUMPING CHAMBER
Size gatton u anu6ac,turret Modet Numbers
!i HOLDING TANK
Size gait s umbers a Co &tmen�s
Pumpeh At S stem
Distance 6nom: 22 Bu�..ld.ing 12% �6tope
H.Lghwaten
ABSORPTION SITE
Bed Trench
Di,6tance snom: Wett 5-,00 -,e Building 12% stope
Highwaten
ABSORPTION SITE DIMENSIONS 4
/ 2
Width oA trench �� �c (� Requi.,red area 6t
z
Length o6 each tine �3 6t Depth o4 no ek b etow tite tin
NumbeA o6 Unes Depth o6 rack oven tite in
Totat .length o6 tine.6 � 6t Depth o6 -tile b etow grade L6 tin
Di6tance between tine.6 5t Stope o6 trench in. pen 100 6t p
Totat ab6onption aAea Z 6t Type a6 Coven: Papers on g raw
PIT DIMENSIONS
Numbers o6 pits a round pit.6 yes no
Outside diametet ep h betow inlet 6t
Totat ab6 otption area 6t
Area nequtine `�
INSPE G� TITLE
APPROVED DATE 198
REJECTED DATE 198
REASON FOR REJECTION
I
I
• REPORT ON INSPECTION OF SANITARY PERMIT # a f.;2,k
(1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection
y Time of Inspection e i ense o ns a ing Plumber
(3)INSTALLATION CONSISTS F: ❑ Septic Tank ❑ Seepage Trench [:]Dosing Chamber
❑Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑Fill System
B ermanen reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well
M DOSING TANK: Manufacturer: # of gallons :
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? [--]YES ❑NO Wired? ❑YES ❑NO
8 HOLDING TANK: Manufacturer of gallons ;
construction depth to the cover ft; If septic tank is
being used are baffles removed? YES [] NO; ft from residence;
ft from well ; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑N0; Wired? ❑YES ❑N0;
Locking device on cover? []YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well ; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth.;
lineal feet tile; ft to residence; ft to well ; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well ; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? [:]YES ❑ NO
(13) Has system been installed in floodway? ❑YES [:]NO Floodplain? []YES ❑ NO
DILHR-SBD-6095 N.0 80
Signature of Inspector:
;: . • REPORT ON INSPECTION OF SANITARY PERMIT #
(1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection
Name, Address, License No. of Mulling plumber Time of Inspection
(3)INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑Dosing Chamber
❑Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
ermanen reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well :
(7)DOSING TANK: Manufacturer: # of gallons :
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower brand name of pump and model number
Is the warning device installed? [:]YES ❑NO Wired? [:]YES ❑NO
8 HOLDING TANK: Manufacturer # of gallons ;
construction depth to the cover ft; If septic tank is
being used are baffles removed? YES [] NO; ft from residence;
ft from well ; ft from property line. Type of warning device
Is the warning device installed? ❑ YES []NO; Wired? [-]YES ❑NO;
Locking device on cover? [-]YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well ; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
li.neal feet tile; ft to residence; ft to well ; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well ; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? []YES ❑ NO
(13) Has system been installed in floodway? []YES ❑NO Floodplain? ❑YES ❑ NO
DILHR-SBD-609 N.0 /8
Signature of Inspector:
State and County State Permit
P'LB 67 Permit Application County Perm t #
`. 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:
G�I /-Se-00-Jr- e--s A-L- #,4M/7-1) 6.0-7 9/)
B. LOCATION: ' 1/C %, Section T N, R TE 19 (or) W Lot# City
Subdivision Name, nearest rid, lake or landmark Blk# Village
Township
I
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms �c.✓d No. of Persons 611 15
I
D. SEPTIC TANK CAPACITY /D O D Total gallons No. of tanks 0n145
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete,_ Poured-in-Place Steel Fiberglass Other (specify)
New Installation X 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- >< _Replacement Alternate (Specify)
Seepage Trench: No.of Linea Ft. Width Depth Tile depth (top) No.of Trenches
Seepage Bed: Length J6 ' idth Depth c5f6 h Tile depth (top '' No.of Lines �wO
Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits
Percent slope of land- 2ci 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 S Tester,
NAME W6[mod f- C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# 1rJ P �� Phone #��Jr-6 3670
Plumber's Address L e'er
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 Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY t;
Date of Application g 3 �U Fees Paid: State] , � Count �.$- � Da �f -3 �d o
Permit Issued/Rejected (date) _9l -�U Issuing Agent Name
Inspection Yes � No State Valid# Date Recd
1. county (white 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
ELI'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: %4„7 %4,Section 3 ,I2N,R_aE(or)W,Township or Municipality �-
Lot No. , Block No. Name County �j�'• (219 0 x•
� rvi ion
Owner's%Buyers Name: r L Se we-:ST e- L J_ //��Aviv; C, Li oN
Mailing Address: m or
(�i S
TYPE OF OCCUPANCY: Residence K_No.of Bedrooms 7W COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION ESTS
SOIL MAP SHEET 77 NAME OF SOIL MAP UNIT i4Sj v
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 AFTEF INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 I
P- / 34 ,s, 00" 'lrrw tq ,5d. _` 44 O 9 � �
P— ,S. r .1 " MCI-54, -L" o p 71q TR
P-3 3 S �" ,,Lm i v o D 7 3
P- S, tol, .i-rn (P r' -S4. 1.2, aq-
P-e, 134 p " „ /5" " u u .25� I 1 10
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- Z Z Ar rr " rr
B- Z 7
B_ t,4 Z rr O 5 n rr rI
B- r 7-2- 10 a ,f �r < < V
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the loc 'o nd uare feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or di tances.
Give horizontal and vertical reference points. Indicate slope. �V"g L.4 It A¢t�
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I -Rim I,the undersigend,hereby certify that the soil tern reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
Name (print) Certification No.
Address
.Name of installer if known l�el2�++ O L
Copy A—Local Authority CST Signatu4,
Boldt's Plumbing and Heating
• . ;- Plumbing - Heating - Electrical
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Baldwin, Wisconsin 54004
g-28 - 560
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`Plb- t:,k WISCONSIN DEPARTMENT OF HEALTH&SOCIAL SERVICES
Division of Health
Section of Plumbing& Fire Protection Systems
-� ON-SITE WASTE DISPOSAL INSPECTION REPORT
Name-of Premises
Street City County
... .Master:f'lamber
Address. ',..
Address
El County Permits El Appropriate State Permits .
Type of Building: Public ❑-Single Family onBtr;ftx _ .
CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM
❑Building Sewer Conventional Soil Absorption System
❑Septic Tank ❑Conventional System-in-fill
❑Holding Tank ❑Alternate Mound System
❑Seepage Bed ❑Holding Tank
❑Seepage Trench ❑Seepage Pit ❑Experimental System
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BRIEF,FACTUAL COMMENTS AND SKETCH:
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❑SEEATTACHED
DISCUSSED WITH.PLUMBER,, ( "I :Yes ( ) No SIGNATURE (Voluntary)-
DATE OF INSPECTION _-
Signature of Inspector
White- Inspector Yellow- Local Inspector Pink- Plumber or Responsible Party