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Parcel 032-1082-60-100 02i22i2007 09:14 AM
PAGE 1 OF 1
Alt. Parcel 28.31.19.398C 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - BELISLE, CAROL M
CAROL M BELISLE
457 192ND AVE
SO
SOMERSET W1 WI 54025
Districts: SC = School SP = Special Property Address(es): Primary 71
Type Dist # Description * 457 192ND AVE
SC 5432 SOMERSET ~
SP 1700 WITC /'~6 ~ , ,
o/0K 1-4 rm sJ-(f4 s~f
Legal Description: Acres: 5.550 Plat: N/A-NOT AVAILABLE /
R1 9W PT SW SE BEING LOT 4 CSM Block/Condo Bldg:
SE 28 T31 N
11/3017
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.550 60,700 118,400 179,100 NO
Totals for 2007:
General Property 5.550 60,700 118,400 179,100
Woodland 0.000 0 0
Totals for 2006:
General Property 5.550 60,700 118,400 179,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 223
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER q OF) C,-r V(-- L &F, TOWNSHIP 5 el SEC. a 8 T N-R C W
ADDRESS ST. CROIX COUNTY, WISCONSIN
a~ LOT LOT SIZE
SUBDIVISION A
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
~ !fib
r i
r
sd
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used x/1
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Az! fX5 Liquid Capacity:
O°
Number of rings used: 6> Tank manhole cover elevation: "11,061
Tank Inlet Elevation: Tank Outlet Elevation:
T `
Number of feet from nearest Road: Front, Side 0 Rear, O feet
From nearest property line Front Side 10 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pu Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch el ation: Gallons per cycle:
Alarm Manufac rer: Alarm Switch Type:
Number o feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM /
Bed: Trench:
Width: S Lenth:~ Number of Lines: Area Built:
„
Fill depth to top of pipe: 7-U
Number of feet from nearest property line: Front, O Side,cQXSI) 1 Rear,
0#t-
Number _ 411 Number of feet from well:
of feet from building: /949
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Buil .
Has either drop box O or distr ution box 0 been used on any of the above soil
absorbt n sytems? (Check one
HOL NG TANK
Manufacturer: Capacity:
Number of ings used: Elevation of bottom of tank:
Eleva on of inlet:
N ber of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: 4~p Plumber on job
License Number.
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
l.D. Number.
CONVENTIONAL ❑ALTERNATIVE (lStfate Pl assig anned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
P(d
NAME OF PERMIT HOLDER: DDRESS OF PERMIT HOLDER: INSPECTION DATE.
R Be.e 6te AR. R. Someuet, W1 54025
BE ARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST R F. PT. ELEV..
SW SE, Section 28, T31N-R19w, Town of Someuet Name of Plumber. MP/MPRSW No. JCounty: Sanitary Permlt Number:
GavLy L. Steed 3254 St. Cnoix 75045
SEPTIC TANK/HOLDING TANK: D• 09
MANUFACTURER: L QUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
® .C / ^ ^ PROVIDED: PROVIDED:
7Q~ (7j O(„ YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL HIGH WATER NUMBS OF ROAD: PROPERTY WELL BUILDING.VENT TO FRESH
p ALARM FEET FROM / LINE / AIR INL T
YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER O:QROPERTY WELLBUILDINGVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ILEN1,TH 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 SYSTE :
WI - LE JNO.OF DISTR. PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID
BED/TRENCH TREN'X A RIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISJJJJ~~~~R PIP IS ~j~ gPI➢~f~ATERIAL TR. NUMBER OF PROPERTY WELL: BUILDING: J VENT TO FRESH
BELOW PIPES ABOVE COVER. EI ~ T L fJ7 9J lJ PI FEET FROM LINE: L~ , +S AIR INLET.
Q//\f {{{{{{YYYYY ^ NEAREST-~ F/~J t/q/ ~i!'~(J//
169
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
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOI L. SODDED-. SEEDED. MULCHED:
CENTER. EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
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. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.. ELEV.: PIPES: DIA..
ELEVATION AND
DISTRIBUTION
HOLE SIZE HOLE SPACING. DRILLED CORRECTLY: COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
04
SI A U E: TITLE:
DILHR SBD 6710 (R. 01/82)
consln APPLICATION FOR SANITARY PERMIT
TY
•D' L H R COUN
(PLB 67)
TEnT OF UNIFORM SANITAA/
RY PERMIT U5TF14, LRBOR 6 NUTFin RELFiTIOns -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches
in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
P TY OWNER MAILING ADDRESS
1'e' - Dm .5eE-
PROPE TY OCATION CITY:
N. R ~ (or) W OWN
1 114SSG1/4, S 9,;0,
LOT NUMBER BLOCK MBER SUBDIVISION AME NEAREST ROAD, LAKE OR LANDMARK STATE P N I.D. NUMBER
I - ~y A / 4
TYPE OF BUILDING OR USE SERVED - W~ -1Da ov, -6CJ -DO,
1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
. New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holdiny Tank
J System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur /MPRSW No.: Phone Number:
PA"-,/ Al, - -7LA-r--4
Plumber's A ress:1 ` Name of Designer:
IL ,
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
p/ I❑ Owner Given Initial
fi~ ~~~pb XApproved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include: .
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
ST C- 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/contractpr,("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 4-c-,C, e~2
Location of Property .5.C C) k 50 1z, Section a 8 , T N - R W
Township ~j(y-y r~ ~'~S (-d
Mailing Address J2' e /Z 1
6 !Z22 ~ Ut) i
Subdivision Name /l
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created -'C ~o
Are all corners and lot lines identifiable? _----Yes No
Is this property being developed for regale (spec house) ? Yes / No
Volume and Page Number --7,7<:~) 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.
PROPERTY OWNER CERTIFICATION
I (We) eehtti.6y that att statements on this 6onm a%e ttue to the best o6 my (our)
know•te.dge; that 1 (we) am (are) the owneA(s) o6 the pnopehty deaeh,i.bed in this
in6onmati,on 6onm, by viAtue o6 a wahAanty d ed xeeonded in the 066ice o6 the
County RegiA teA o A Deeds as Document No. 47/ 1461 ; and that I (we)
pnesentty own the proposed site bon the sewage diApo.6 system (on I (we) have
obtained an easement, to Aun with the above descAi.bed p4opeAty, bon the
constnucti.on o6 said system, and the same had been duty hecoh•ded in the 066ice
o6 the County Reg.csteA o6 Deeds, as Document No. ) .
e~ I
SIGNA RE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
z
En
H
9
r
ST C- 105 r"
H
. SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
t7
a
H
ROUTE/BOX NUMBER L Fire Number
CITY/STATE ~0_"n ZIP
PROPERTY LOCATION ~o Section-2 f-] 'Iz-_~ / N, R W,
Town of St. Croix County,
Subdivision Lot number
I
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 {I
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
H
the standards set forth, herein, as set by the Wisconsin Depart- 1v
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
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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
bNdUSTRY, DIVISION
LABOR A!ND PERCOLATION TESTS (115) P.O. BOX 7969
,HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
r
LOCATION: SECTION: TOWNS HIP/MbINFGIf-AtITY: LOTNO.:BLK-NO.:SUBDIVISION NAME:
t..1 /T--~ N/R (or) I[_` r, l E it t1 it : t /y
COUNTY: OWN€R'S BUYER'S NAME: MAILING ADDRESS:
USE DATES O SERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OLATION TESTS:
Residence fid New ❑Replace C c
RATING: S= Site suitable for system U= Site unsuitab ie for system r
CONVENTIONAL: MOUND: IN-GROUND-PRErSURE: SYSTEM-IN-FILLHOLDIING TANK: RE OMME DED SYSTEM: (optional)
S EA ~S c J ~ cJ aU I ~J ZU
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 7 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS/^z
f~l► 'r-II f_% ~ ~
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTPHN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
112-
b 13)
B- 14,
B- 3
ho'
,
B-~) - - Lit j..'r r - ~I'i,~. / ~'i1/ L! N' _ .y,
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVA=MIN. PERIODI PERIOD2 PERIOD PERINCH
P-
P-
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'S
/ /A- y / i 3
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I, the undersigned, hereby certify that the soil tests reparted 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): C, TESTS WERE COMPLETED ON:
l-
ADDRESS: ` CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATL,IRE:
DISTRIBUTION: Original and one copy to Local Autho -ity, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
Ors "a r-O COMPLETING 1 5 - D 6395
T) t, your report rn `
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Parcel 032-1082-60-001 02/06/2007 04:19 PM
PAGE 1 OF 1
Alt. Parcel 28.31.19.3988 032 - TOWN OF SOMERSET
Current X', ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
ROGER W & SUSAN M BELISLE O - BELISLE, ROGER W & SUSAN M
471 192ND AVE
SOMERSET WI 54025
Districts: SC = Schocl SP = Special Property Address(es): • = Primary
Type Dist # Description ` 471 192ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 28 T31 N R1 9W SW SE 5 AC LOT 2 CSM Block/Condo Bldg:
5/1482
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-31 N-1 9W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 736/270
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 58,000 149,000 207,000 NO
Totals for 2007:
General Property 5.000 58,000 149,000 207,000
Woodland 0.000 0 0
Totals for 2006:
General Property 5.000 58,000 149,000 207,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 209
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00