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Parcel 038-1149-40-000 08/15/2005 09:04 AM
` PAGE 1 OF 1
Alt. Parcel 17.31.18.664-665 038 - TOWN OF STAR PRAIRIE
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
JAMES J & KATHLEEN L DETTMANN O - DETTMANN, JAMES J & KATHLEEN L
920 BRAVE DR
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 920 BRAVE DR
SC 5432 SCH D OF SOMERSET V~' do
SP 8050 SQUAW LAKE RHAB & MANAGE
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 2617-WIGWAM SHORES
SEC 17 T31 N RI 8W LOTS 5 & 6 BLK F PLAT Block/Condo Bldg: F LOT 5
OF WIGWAM SHORES
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 716/625
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: D155,500 ast Changed: 10/12/2004
Description Class Acres Land Total State Reason
RESIDENTIAL G1 0.000 123,400 278,900 NO
Totals for 2005:
General Property 0.000 123,400 155,500 278,900
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 123,400 155,500 278,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 217
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
- (1/ - C,.t~ Sc TOWNSHIP SEC./ 7 TN-R) Pj
ADDRESS t~ ST. CROIX COUNTY, WISCONSIN
4
1
SUBDIVISION LOT LOT SIZE
cB--
PLAN VIEW
f
Distances and dimensions to meet requirements of II HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
,f
R A['`\A
dv
S0/
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:
Proposed slope at site:
SEPTIC,TANK: Manufacturer: Liquid Capacity: A
Number of rings used:- Tank manhole cover elevation:
Tank Inlet Elevation: -a.-?- Tank Outlet Elevation: 7-4
P
Number of feet from nearest Road: Front,& Side,Q Rear, O
~ feet
From nearest property line Front 10 Side,® Rear, O ~ feet
Number of feet from: well S / , building:
S3`
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
v
PUMP CHAMBER
Manufacturer: S Liquid Capacity:
/
Pump Model: Pump/Siphon Manufacturer: es (9 U-eCL Pump Size
~4 ~j 'p,
®J
Bottom of tank elevation:
Elevation of inlet:
'Vn 47 Pump off switch elevation: S ' Gallons per cycle:
Alarm Manufacturer: Val!nKg&-l~- Alarm Switch Type: JfJ/~.
\ Number of feet from nearest property line: Front, Side, aRear, 0 Ft.
Number of feet from well: ( p
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: ✓ Trench:
Width: Lenjth: Number of Lines: Area Built: Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, ~j Rear,0 Pt.
Number of feet from well: X44!!
Number of feet from building:
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector: O S Sd
Dated: Plumber on job-
License Number :
3/84:mj
r
Parcel 038-1149-33-000 08/15/2005 09:04 AM
PAGE 1 OF 1
Alt. Parcel M 17.31.18.663 038 - TOWN OF STAR PRAIRIE
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
JAMES J & KATHY DETTMAN O - DETTMAN, JAMES J & KATHY
920 BRAVE DR
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 926 BRAVE DR
SC 5432 SCH D OF SOMERSET
SP 8050 SQUAW LAKE RHAB & MANAGE /
SP 1700 WITC \L)
`v '0
Legal Description: Acres: 0.000 Plat: 2617-WIGWAM SHORES
SEC 17 T31 N R1 8W LOT 4 BLK F WIGWAM Block/Condo Bldg: F LOT 04
SHORES ADDITION
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1059/41 WD
07/23/1997 871/200
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: ast Changed: 10/12/2004
Description Class Acres Land I prove Total State Reason
RESIDENTIAL G1 0.000 36,500 0 36,500 NO
Totals for 2005:
General Property 0.000 36,500 0 36,500
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 36,500 0 36,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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_'Oq > o E31.30-i16_69__~_ 118.33. - 9g 0; 2 ~{a
- 60.3;'j Zg2. g2
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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
❑CONVENTIONAL KNALTERNATIVE IS,,,, Planl.D. Number:
(lf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 8601202
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER EC IIJN D)fP
I 00
man Box 44, Downing, Wi 54734 _ _ tdo
1 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV..
SW NE,Section 17, T31N-R18W, Town of Star Prairie,Lot 5&6, Wigwam Stores
Name of Plumber: MP/MPRSW No.. Coun[y: Sanitary Permit Number:
Gar L. Steel 3254 St. Croix 79127
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: J LIQUID CAPACITY: TA I Er LE TAN} O TLET ELEV.: WARNING LABEL LOCKING COVER
t- PROVIDED PROVIDED:
-iC•~ % ES ❑NO DYES CRNO
BEDDING: VENT DIA.: VENT MATLL. HIGH WATER
ALARM NUMBER OF ROAD: PROPERTY WELL BUILDING IAIR TO FR ESH
FEET FROM <1 LINE c'" AIR INLET
DYES NO YES NO NEAREST /
DOSING CHAMBER: D
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODE PUMP/SI ON MANUF TURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVyIDED:
`"j tt.Ilb~ DYES NO ~
CL) 1 ~ `11 DYES ❑NO 5 YES ❑NO
GALLONS PER CYCLE: / PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL JBUILDING IVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE ~,Q / AIrR NLET:
PUMP ON AND OFF) YES ❑NO NEAREST is SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 f N/4TH r 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 G.
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH INOEOF SPACING COVER INSIDE DIA #PITS LIQUID
TRNCHES' MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH JDISTR. PIPE DISTR. PIPE ST . PIPE T TERIAL. NO. DISTR. NUMBER OF PROPERTY WEL VENT TO FRESH
BELOW PIPES ABOVE COVER: ELEV. INLET ELEV. END. PIPES. FEET FROM LINE L. BUILDING:
: AIR INLET:
_ NEAREST
--t►
MOUND SYSTEM:
Mound site p)6/Wed 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.
ES ❑NO
SOIL COVER T XTURE PERMANENT MARKERS JOBSERVATION WELLS.
ES ❑NO ES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER Cs EDGES.
❑ YES NO YES ❑ NO WYES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES: .rte
DIMENSIONS -7 '/,C /
MANIFOLD P P MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELE ELEV/q O DIA. EL PIPES:) / DI.: Z
ELEVATION AND 7C b y
DISTRIBUTION (•11' Y '
INFORMATION HOLE SIZE HOLE SPA NG DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
~~Q`Y PLANS.
I `AES ❑NO _ [YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE: yr, 70,
YES ❑NO YES ❑NO NEAREST o
Sketch System on Retain in county file for audit.
Reverse Side.
$IGNAT TITLE:
DILHR SBD 6710 (R. 01/82)
lip wlsconsln APPLICATION FOR SANITARY PERMIT
COUNTY
DILHR TmEnTOF (PLB 67)
inDUSTRV, LABOR UNIFORM SANITARY PERMIT #
InOUS 6 MUTPn RELFITIOI"Is
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PR RTY OWNER MAILING'ADDRES /
S O~ L)(.
PR RTY ~~LgqOCATION CITY:
1/4, C' /4,S 7 ,T3/ N, R/ LO) ~(or) W VILNOF: 11` Pr L_
LOT NUMBER BLOCKNUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
`L T k) ^,,n
cS ~t'b'l~~ S yglf U~ c(~ f CJ
TYPE OF BUILDING OR USE SERVED
or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
54 New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
t-A Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ 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 /9)00 r
Lift Pump/Siphon Chamber 8 0
Manufacturer: S ~i9vb ~6 6264
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
17J 0767 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for install 'on of the private sewage system shown on the attached plans.
Nam Plumber (Print): Signat fiL/V /MPRSW No.: Phone Number:
~0 PrVA JL,. t,5 'Pee 5
Plu er's Nd?dr ss: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
5 17 0f El Owner Given Initial
(p Approved Adverse Determination
Reason for Di ppr I:
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.
R
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.
~ DILHR
PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
P.O Box 7%9
r❑ General Plumbing Plans Madison, WI 53707
f Private Sewage Plans Telephone: (608)266-3815
fi
Ptah Identifit.ation No.
~~r!
O - 1 Callon-, Pcr Day
--n
PRIORITY PLAN REVIEW ONLY
Plan Review f ce Received
Petition I or Variance Fee Rec.
$
Project Name Project Location - Street No. or Legal Description
.1 i
County
❑ City ❑ Village Town of:
* k
The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is
based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval
is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the
city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of
plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be
made.
❑ FOR GENERAL PLUMBING PLANS: 3a 3b 3c 3d 3e 3f 3g
This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan
approval must be obtained.
FOR PRIVATE SEWAGE PLANS: (1) (2) ( (3a), i,(3b) (4a) (4b) (6) (7)
This approval will expire two years from the date aproved below or if a sanitary permit is obtained, it will expire the day the initial sanitary
permit expires.
The Bureau of Plumbing has reviewed these plans for plumbing and/or private sewage code requirements only. All other system reviews must be
submitted to the Bureau of Buildings and Structures.
Comments:
By: y'
James Sargent /
Bureau Director
If Questions Plans Approved By:
Contact ♦ I Date Ap roved;,`
cc: Private Sewage Consultant ❑ P16mbing Consultant ❑ Environmental Health
f County ❑ Local PI ❑ Facilities Need Analysis Section
❑ L)W-SSWMP ❑ Plumber ❑ Department of Agriculture
DILHR-SBD-6099 (R. 01/85) ❑ Owner ❑ Other
SBD 6678 (R. 08M3) (Plb 100x) (Wis Slats. S. 145.02)
STATE OF WISCONSIN DILHR
DbtacWAnd Return Upper DIVISION OF SAFETY& BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 141
Any Return Correspondence,-.," P.Q. BOX 7969
MADISM, WI 53707
608-266-3815
Cej
DATE: 04/07/86 >a ` 0 PROJECT:
a.~yy~ X90 Me Uettmann s James Residence
Sia,NE,17, 31,188
Tn Star Prairie
Gary Steel St. Croix WI
988 North Share Drive
New Richmond, W1 54()17 PLAN ID.
$5-01202
DETACH HERE
PROJECT NAME Dettaann, James - Residence 86-011202
PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the project.
00
Preliminary review indicates the required fee is $ Fee Received is $ 80.
Plan accepted for review. ❑ Underpayment- Please submit additional fee. Plans will be held in abeyance.
Plans being returned. ❑ Overpayment- Refund forthcoming.
Additional' information required. SEE.BELOW.. ❑ No fee has been remitted. Plans wilt beheld in abeyance.
1. Plan Submission ❑ Soil boring and percolation test data on 115 completed
Additional information'-shall be submitted in duplicate unless by Certified:Soil.Tester. (1 copy)
specifically noted. ❑ Petition For Modification signed by county, owner and
❑ Plans not clear, legible or permanent. notarized. (1 copy).,
❑ All information submitted shall be signed, dated and sealed or El Campletedata relative to anticipated use of building.
stamped in accord with Section ILHR 83.08 (2) `(a) Wisconsin ❑ Deed restriction required. (1 copy)
Administrative Code. ❑ Affidavit enclosed. ❑ Condominiu%declaration. (1 copy)
Plot plan showing location of land parcel (distance from
nearest road intersection, etc.), lot size and all distances from IV. Holding Tanks
private -sewage system to buildings, lot lines, well, -water ❑ Holding tank profile showing vent, manhole,: alarm,
course, swimming pools, water service piping, all weather ser and manufacturer if state approved. Complete'
vice road, etc. Show benchmark with permanent elevation. construction details if site constructed
❑ Holding tank agreement signed by owner and local
11. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed).
Application for Use of an Alternative System signed by owner ❑ Reason for installing holding tank.'Statement from
and notarized. (1 copy) county or soil boring and percolation test data on
County onsite required. (1 copy) ❑ Design calculations. 115 completed by CST, showing that a soil absorption system
❑ Soil boring and percolation test data on 115 completed by cannot be installed on the land parcel.
Certified Soil Tester. (t copy) ; ❑ Affidavit for all-weather service road' {enclosed):
❑ Cross section of system. ❑ Pipe lateral layout.
❑ Plan view of system. V. Dosing Information
Verification fo Exception Status Form by county. (1 copy) Calculations for total dynamic head and gallons
pumped per cycle.
IIL Private Sewage Systems ❑ Size, length and depth of force.main.
❑ Ground slope with 2' contours in entire area of soil absorption- ❑ Detail and model of pump or automatic siphon, including
system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM).
❑ location of area suitable for replacement system - provide soil ❑ Crosssection of dosing tank showing pump(s) or siphon(s).
data.
Construction details of septic, holding or dose tank if site A. Systems in Fib (Fill must be placed prior to plan submission.)
constructed, or tank manufacturer if state approved. ❑ Total area filled (fill-to extend 20' beyond edge
❑ Construction details ' and cross section - of. soil absorption of trench beibm side slopes begin.)
....system. -
Depth and type of fill
Copy of signed onsite report by county or district staff.
ST. CROIX COUNTY
f WISCONSIN
ZONING OFFICE
s 796-2239 (HAMMOND)
r 425-8363 (RIVER FALLS)
i
HAMMOND, WI 54015
April 1, 1986
Division of Safety and Building
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the James Dettmann property located
at the SW4 of the NE4 of Section 17, T31N-R18W, Town of Star
Prairie, Lot #546, Blk. F, Wigwam Shores, St. Croix County, revealed
suitable soils at a depth of 2.50 feet, below which seasonable high
ground water was noted.
This site should be suitable for a mound system.
Should you have any questions, please feel free to contact this
office.
Sincerely,
Thomas C. Nelson
Assistant Zoning Administrator
mj
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location SW 1/4, NE 1/4, Sec. 17 T 31 N, R 18 xlx" W
Town dK,4 %1gU1*y Star Prairie Street Address
Lot No. 546 Block F , Subdivision Wigwam Shores
Landowner's Name: James Dettmann
The application for this site is for:
Elnew construction use.
[Dreplacement system use.
If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
Ikito have one of the first five approvals guaranteed for this year. This is
number 59 - 01 7 of those applications. (Use one of the first five
quota numTrs sued to you.)
]one of the applications needing a quota number. The quota number assigned to
this application is - -
❑ for one additional homesite on a farm to be occupied by a parent, child,
grandchild, sibling, niece, nephew, or first cousin.
F ]for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria established by the
department.
L] for an application on file prior to February 1, 1980.
Llfor a lot that meets the criteria for a conventional private sewage system.
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing:
❑ a failing conventional soil absorption system.
0a holding tank that was installed and in use prior to February 1, 1980.
❑ a privy that was installed and in use prior to February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a
conventional private sewage system, check here
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson Si Ure
County Official
Title Assistant Zoning Administrator Date April 1, 1986
DILHR-SBD-6158 (R 12/82)
STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township/~M=MK-
SW 14 NE 14 S 17 T 31 N/R 18 NUTY6 W Star Prairie St. Croix
Street Address: Subdivision: County:
Landowners Name: Mailing Address:
James Dettmann Box 44, Downing, WI 54734
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county official to
arrange the time and date to begin construction of the system.
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are served
by an alternative system and further agree to give the buyer a copy of this
application.
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
Signature of Applicant Date
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF This day of 19
Notary Public, State of Wisconsin
DILHR-SBD-6413 (N. 05/81) My Commission Expires:
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STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING
P.O. BOX 7969 - MADISON, WI, 53707
APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM
Location: Township /XKffZD5MP0M0
SW 3L NE 141S 1 T 1 NCR 18 ftiedW Star Prairie St. Croix
Street Address: Subdivision:. County:
Landowners Name: Mailing Address:
.James Dettmann Box 44, Downing, WI 54734
I (We), the undersigned, hereby make application for an alternative system on
the above-described premises. I recognize that the above premises are not
suited for a conventional private sewage system. If approval is granted, I
agree to have the system installed in conformance with the Bureau's,approval
of plans and specifications.
I further understand that an alternative system is more complex in nature than
a conventional private sewage system and as such will require detailed
inspection during construction and monitoring after the system is put into
use. I agree to permit both county officials charged with administering county
sanitary ordinances and Bureau employes or other authorized persons to have
access to the above described premises at any reasonable time for the purpose
of inspection the construction of or monitoring of the system. I further agree
to either personally or by my agent contact the proper county bff cial to
arrange the time and date to begin construction of the system. 56012 U 2
I understand that this application does not permit me (the applicant) or my
agent (the contractor) to begin installation. If the system is approved, the
Bureau will send the applicant a letter of approval which authorizes
construction of the alternative system after all necessary permits have been
obtained.
- R+ECE~ED { ,
I agree to give notice to any subsequent buyer that an application for an
alternative system has been made and if installed, that the premises are AP&07
by an alternative.system and further agree to give the buyer a copy of this
application. P1 UMW#^ mss
The Bureau accepts this application subject to this understanding and subject
to all the conditions and obligations set out in this application.
` 1)2)9
Date
gna ure of Applicant .
STATE OF WISCONSIN Subscribed and sworn to before me
SS.
COUNTY OF .C./O! This day of f 19
F
Notary Public, State of isconsin
DI3.HR-SBD-6413 (N. 05/81} My Commission Expires:
ST. CROIX COUNTY
WISCONSIN
~T.h75 ZONING OFFICE
= ref ~ ) ~796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
1
April' 1, 1986
Division of Safety and Building.
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation for the James Dettmann property. located
at the SW3% of the NE;y of Section 17, T31N-R18W, Town of Star
Prairie, Lot #546, Blk. F, Wigwam Shores, St. Croix County, revealed
suitable soils at a depth of 2.50 feet, below which seasonable high
ground water was noted.
This site should be suitable for a mound system.
Should you have any questions, please.feel free to contact this
office.
Sincerely, _
Thomas C. Nelson p~'+O
Assistant Zoning Administrator "APR 07 Ob
mi
per....,.
WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS
DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING
P.O. BOX 7969, MADISON, WISCONSIN 53707
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Croix
Location SW 1/4, NE 1/4, Sec 17 , T 31 N, R 18 XVJ(Z W
Town ~t~ifi~RprxKKt~j1c Star Prairie Street Address
Lot No. 546 Block F Subdivision wigwam Shores
Landowner's Name: James Dettmann
The application for this site is for:
new, construction use.
❑ replacement system use.
.If this is NEW CONSTRUCTION USE, the alternative private sewage system is:
1.x-Jto have one of the first five approvals guaranteed for this year. This is
number 59 01 - 7 of those applications. (Use one of the first five
quota n~rs~sueT-fo you.)
lone of the applications needing a quota number. The quota number assigned to
this application is -
for one additional homesite on a farm to be occupied by a parent,. child,
grandchild, sibling, niece, nephew, or first cousin.
C71for an individual lot for which a sanitary permit was issued but was later
ruled unsuitable due to new or changed soil criteria.established by the
department.
LJ for an application on file prior to February 1, 1980. 84501202 RECE11/ED
L.]for a lot that meets the criteria for a conventional private sewage system.
APR O ?
If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is
replacing: PLUAAMM •+0 w..~.U
.
0a failing conventional soil absorption system.
a holding tank that was installed and in use prior to. February 1, 1980.
❑ a privy that was installed and in use prior to .February 1, 1980.
If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a
conventional private sewage system, check here. El
I certify that the above information is true and accurate to the best of my
knowledge.
Name Thomas C. Nelson Si re
(County Official)
Title Assistant Zoning Administrator Date April 1, 1986
DILHR-SOD-6158 (R 12/82)
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,jDUST OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
vDUSTRY, ' DIVISION
APO.R AND PERCOLATION TESTS (115) MADISON WI 969
UDAAN RELATIONS (H63.09(1) St Chapter 145.045)
OCATION: / E~7f N:T D TOWNSHIP/fdtl7Nit?FPALITY: TNO.:BLK.NO.:SUBDIVISION, NAME:
tJ. %E71/4 17 /1dl N/n18r(or)W r 1 r"546 - 47
OU TY: OWNER'StBUYE;PS NAME: MAILINU ADDRESS:
n n t o u7 ► s~ 73
SE DATES OBSERVATIONS MADE
NO.
B OR ICOMMERCIAL DESCRIPTION: 7AD-MLE DESCRIPTIONS: PERCOLATION TESTS:
a Ftesidencs 23 y1ew, ❑Replace Gj ~js. -7 ~O g6
ATING: S= Site suitable for system U- Site unsuitable for system
UNVENTI NAL: MOUND: IN-GROUIND-PR -FILL OLD) G TANK: RECOMMENDED SYSTEM: (optional)
❑S QU ®S ❑U ElS_271 0S Re U__EISSU-
Percolation Tests are NOT required DESIGN RATE: [Flo'clpl~,in, any prtion of the tested area is in the
nrler s.H63.09(5)(b), indicate:- / N° indicate Floodplain elevation,:
4S1MAI ° PROFILE DESCRIPTIONS
ORING TOTAL PTH T EDR UNDWATER-INCHE CHARACTER O OIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
,11,MBER DEpR+iN. ELEVATION OBSERV EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ASBRV. ON BACK.)
Z
3. 17
15,17 017 00
o ti? ~3 x
RECEIVE
3.
3 APR 07
PERCOLATION TESTS J,a 0 2
TEST DEPTH WATER IN HOLE TEST TIME DROP 1 AT LEVEL-INCHES RATE MINUTES
MBER AFTER SWELLING INTERVAL-MIN. PER INCH
i _ No 36 Z/ / 6
Z. „7 t~17 No .36 .OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what
are the hori•
,;tal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and perggnnt
land slope.. c3 n 0411, 3 tZ
YSTEM ELEVATION
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thy., 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
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
ME (print) TESTS WE=RE COMPLETED ON:
DCJRES J CERTIFICATION NUMBER: PHONE NUMBER(optGnaq:
ST SIGNAT .
ISTRIBUTION. Originai and one copy to Local Authority, Property Owner and Soil Tester.
t•I11-SBD•6395 (R. 02182) - OVER -
0~ # to
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X. I_so• _
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86- 1,202
53 't.~ NS CEIVED
AP 07 U
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S~' co '-C,~ j~ 1~
OPTIONAL WORKSHEET
1. fNOUND SYSTEM il. IN-GROUND PRESSURE SYSTEM•Continued-
1. Wastewater Load, Total Daily Flown fat• 10. Fora Main:
Dosing Rats ■ a~~ LLLL fpm•
Use s. ILHR 83.15 (3) (c) Minimum _ in.
Adm. Code and PROVIDE A DETAILED Diameter ■
UST OF SIZING ON PLANS. 9'O 11: Total Dynamic Head:
2. Depth to Limiting Factor . , ft. System Head = 2.5 ft.
3. Landslope = 2- % Vertical Lift = ' 9 ft.
4. Distance from Dose Chamber to Friction Loss ■ ft.
50
Distribution System ft. TDH = ft.
S. Elevation Difference Between 12. Pump Selection: '
Pump and Distribution System, L~ ft. Pump will discharp at Mast- fpm
6. Absorption Area Sizing: at 141, AO ft. total dynamic head.
Area Required = 51.E sq. fL Pump mode and manufacturer: O u
Bed or Trench Length (B) _ IL l-) n
Bed or Trench Width (A) ■ - ft. 13. Dose Volunasr
Trench Spacing (C) _ h. 10 Times Vold Volume of
7. Mound Helght: Distribution Lines ■ IW.
Fill Depth (D) tL Daily Wastewater Volume f
Fill Depth Downsiops (E) ■ _L~ it. 4 Doses M 24 hrs. gal.
Bed or Trench Depth (F) _ ' ft. Sackflow = 4~ gal.
Cap and Topsoil Depth (G) _ ft. Minimum Dose = SZS1 gal.
Cap and Topsoil Depth (H) ■ ft. It. Dose Chamber.
8. Mound Length: Volume = 0 0 gal.
End Slope (K)
Total Mound Length (L) _ ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM
9. Mound Width: 1. Wastewater Load. Total Daily Flow = - gal.
UpslopeCorrection Factor = Use s. ILHR 83.15 (3) (c), Wis.
Upslope Width (1) _ ft. Adm. Code and PROVIDE DETAILED
Downsiope Correction Factor = ~~~Q LIST.OF SIZING ON PLANS.
Downsiope Width (1) = ft. P~1~1 2. guired Se ank Capacity = gal.
Total Mound Width (W) _ 71fiz ft. 4 1 to ~s min./in.
10. Basal Area: 4. Infiltrative Capacity of 17 4/ j0 2 in eh. ILHR 83
Natural Soil ■ ' gal./sq.ftjday A DETAILED 1ST OF
Basal Area Required ■ $4. tt. ANS.
sq. ft.
Basal Area Available= t. t1. red an
11. If Standard Tables from Chapter ILHR 83 ft.
are,.used, Indicate Table #+p` ft.
12. For the Distribution Network, Use NumbersS-141n Sac Trenches
Spacing = ft.
11. IN-GROUND PRESSURE SYSTEM istribution S
1. Depth to Limiting Factor = tt. Lateral Loth V 1 I2/ 0 ` ft.
2. Landslope = % Number of Laterals=
3. Percolation Rate ■ n. Lateral Spacing = in.
4. Proposed System Elevation = ft. Distance from Sidowall to PMEIVSI;•-- In.
S. Wastewater Load. Total Daily Flow: gal. System Elevation = ft.
Use s. ILHR 83.15 (3). (c) ,
A7 19%
dm. Code and PROVIDE A DETAILED IV. SYSTEM4N-FILL APR O
LIST OF SIZING ONTLANS. Fill in All Items from Section III
Required Septic Tank Capacity ■ v gal. P W M E W C :EAU
6. Absorption Area Sizing: V. SEPTIC TANK
Percolation Rate = y`~ min./in. 1. Capacity = ~p,~ _ al.
Area Required = sq. ft. 2. Manufacturer.. 019'Fffs 6 L
System Length = ft. 3. Show Site Constructed Tank Details on Plan
System Width = B ft.
7. Distribution Pipe Sizing: VI. DOSING TANK
Hole Sire = in. i. Capacity = 16 ` Lle /9 gal.
Hole Spacing' ft. 2. Manufacturer: w cr 0' V.
_ W9 ~ Am Lateral Length - ft. 7. Pump Manufacturer: ~jg
lateral Site • in. 4. Pump Model:
Lateral Spacing 3 A. S.• Operating Head= ft.
th%lAn e from Sialawall •tu file. 2 in. 6. Flow Rate= > ipm•
8. Uibldbutban Pipe Discharge Ratr: 7. Show Site Constructed Tank Details on Plans .
Number of Holes Per PIjw
low Per Pipe gpm. VII. IIOI.UING 'T'ANK
9. Manifold Siting: i. Capacity = gal.
'type (center or unit) tr rid 2. Manufacturer:
Length = 3 ft. 3. Show Site Constructed Tank Details on Plans
Diameter in.
-SHOW ALL INFORMATION ON PLANS-
DiLHR S904761 IR,031S21
Page - Of -
Straw, Marsh Hay, Or
Synthetic Covering
Distribution Pipe
Medium Sand
G
Topsoil = F.
-.J E 3 D
Ox` a Its
, IBad Of 2 Force Main Plowed
A gate Layer
D / Ft.
r
1 d Cross Secti on Of A Mound System Using E Z Ft.
A Bed For The Absorption Area F , 75 Ft.
QP G Ft.
A Ft. H Ft.
ed: 6 Ft. .
License Number: 32 57AI/n P,Yt• U) ' K /D• Ft.
Date: 3 -S L~ L. 6 ! Ft.
J 9 Ft.
Alternate Position Ft.
of
Force Main W Ft.
Observation Pipe
J B ~ K
A I•----------------------
I-- Force Main
Distribution Bed Of iN 2'2
Pipe Aggregate.
Observation Pipe Permanent Markers
R p
APR 0 7198b
Plan View Of Mound Using A Bed For The Absorption Area~lWaIN-0 `%'%EAU
Page _ Of
Perforated Pipe Detail
860x202
End View
Perforated
End Cap PVC Pipe
bye e . ~
ef~e~d~`c Holes Located On Bottom,
Si Are Equally Spaced
r !e"
e PVC N~ G5
Manifold Pipe
G Distribution
V
Pipe
V Last Hole Should Be ~rG
Next To End Cap
`i Distribution Pipe Layout. P A-
R 3 APR 0 ?
S 1986
X J(o Inchesp"Mpl- -T;F-AU .
y 3.~ Inches
Hole Diameter Inch
Signed: C~e I . It
Lateral Inch(es)
License Nlanber: W U). 3 514 Manifold Z- Inches
Date: '~i!- 3 8lA Force ,Main " 2 Inches
# of:holes/pipe__
Invert Elevation of Lateralsu- t•
60
Z
• : t PACE or
' PUMP CHAMBER CROSS SEeT1014 AAIDSPECIFICATIOKIS
VEW tAP '86012 02
'1"C.Z. VENT PIPE
WEATHER PROOF APPROVED LOCKIM6~
LS' FROM DOOR. JUNCTION BOX hSANHOLE COVER'
WINDOW OR FRESH IL~MIU. I q~ V! ~S 1 '
Alit INTAKE I V
GRADE
M' MIN.
memo
COWOUIT IV AIM.
-
la•KIu.~
INLET •`PROVIDE
~ON AIRTIGHT SEAL I i i W~4 P
APPROVED JOINT A P»" 5 I I ~ I h~ 1~ APPROVED J011JTS
v
W/C.T. PIPE o ~¢~~dN I I I( W/C.I. PIPE
EXTENDING 3' I II ALARM EXTENDIIJG 3'
ONTO SOLID 401E 0 tL4 65 ( I ( ONTO SOLID 601L
c ON
S ~ of ` a~ I '
RECEIVED
LL ~
E1t ~L FL q~ME__j
PUMP lob OFF A FR O? 198b
D
COAICRETC BLOCK PLYM
I
. r-m
N
RISER EXIT PERMI-ITED OWL'S IF TAWK MANUFACTURER HAS SUCH APPROVAL MINI;
SEPTIC SPE C.I FI CATIOUS
DOSE WE I
TANK MANUFACTURER: WEE kS L19 0ri it V ee NUMBER OF,. DO;ES: PER pAy
TANK SIZE: 866 GALLONS DOSE VOLUME
ALARM MAAHJFACTURRR: .`I-prm) Al,ft'+ IMCLUDINCs DACK►LOW: 72 410 GALLONS
MODEL 1JUMdCR: CAPACITIES: A= INCHES OR ~pvt GALLONS
SWITCH TRPC: y,.,/ 8 s„~ INCHES OR CALLOUS
PUMP MANUFACTURER: Co •~,LL~ INCHES OR 1174: GA&.LOAIS
MODEL NUTADLK: A) A23 DO.2'INCHES OR 247 GALLONfi
SWITCH TAPE: MOTE* PUTAP AND ALARM ARE TO BE
MIMIMUM DISCHARGE RATE GPM INSTALLED OW ~ EPARATC CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND pISTRIbUTIOIJ PIPE.. 10 FEET
t MIIJINUM NETWORK SUPPLY PKESSURTTE~/ . , FEET 2 Z, Z9b St4~-rh
♦ FEET OF FORCE MAIM Y. ' 0 FYDFRFRICTIOU FACTOR. FEET v x're 2x, D
TOTAL Dy1JAMIC HEAD FEET
R 3.1 seal.
1UTERMAL DIMLW IOWS OF TAIJK: LEAJGTH ;WIDTH LIQUID DEPTH
^
5IGIJE0 LICENSE NUMOER: ~3Z.S DATE.
Model 3870 Submersible Effluent Pumps
140
120
s
~y
100
a
ao.
.,1f.
80
H wp~'
•~tip .
40 56 Jv
WPM03. % H.P.
20 vim H.P. "01202
RECEIVED
0 20 40 w so . APR 01-06
""M PN Minute
T PLUMQM:~ ~'yi' ;EAU
4
Kim WL
H.P. Oidn NO. Va14 Phaw W
)
W" $010 (ft
WPO311 E
M~itE 115 9.4
Y. 1750
WP0312E 56
W 230 10 4.7
WPH0611E 116 1
WPHW12E 230 6.0
WPHOS32E 2061230 3.4 eo
30
WPHOS34E 460 1.7
WPHO712E 230 10 .9.0
1i WPHOT32E 206/230 5.4
WPHOT34E 460 30 17
WPH1012E 230' 10 11.6' 3450 70
1 WPM1032E 206/230 ,
6.1
WPH1034E 160 3.2
~l WPH1512E 230 10 113
WPM1532E 2061230 92 30 i16 WPH1534E 460 4.6 60
WPHH15/2H 230 10 13.3
1] J WPHH1532E 2061230 9.2
~J WPHN1534E •16O , 30 14
~
FISAWTIONS ME SUBJECT TO CHANGE W fT OVf HOTICE.
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wC, ..0~0~$ 171
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County 0
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OWNER/BUYER' 2/7f~ H
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ROUTE/BOX NUMBERS Fire Number
CITY/STATE-%0Q"),,/7,,/V cam' l~~J' ZIP "
PROPERTY LOCATION:1 , /)G 14, Section / 7 T, R A9 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 se tic 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 t4
z
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
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
~C /
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~
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 inadequaoies 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.
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Owner of Property II c~ /I
Location of Property o~ UA A)k Section T N - R v W
Township ~r►~~'r
Mailing Address
.Subdivision Name s lit n ,-n Lot Number q,-, 6y 12a~411
Previous Owner of Property lyaec ~l
Total Size of Parcel / eq in
Date Parcel was Created 4;~, - X77 Fes'
Are all corners and lot lines identifiable? L/' Yes No
Is this property being developed for resale (spec house) ? Yes 1-~ No
Volume / and Page Number as 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) een ti•6y that a.tt ata tementa on •th i a 6o4m ahe tAu.e to the but o6 my (ouA )
knowe.edge; that I (we) am (ahe ) the owneA (a ) o6 the pnopeh ty de cA bed in .th i•a
in6onmati,on 6oAm, by vixtue o6 a waAAa.nty deed tecoiLded in the 066ice o6 the
County RegiA teA o 6 Deeda a.6 Document No. y 3 -712 ; and that I (we)
pneaenttCy own the pnopoaed .6 to bon the sewage poa ayatem (oA I (we) have
obtained an eaaement, to Aun with the above de4cAibed pnopeA,ty, bon the
conAtAucti.on o6 said aya.tem, and the acme has been duty Aeconded in the 066ice
o6 the County Regia.teA o6 Veed6, ad Document No. ) .
SIG ATU OF O R, SIGNATURE OF CO-OWNER (IF APPLICABLE
;2 L/
DATE SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
"HUMAN RELATIONS
N WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/fbYttl` tE+PA rLITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
,~5w 1/4E1/ 1'7 /T91 N/R ISC (or)W sue A) ash 0~7 s
COUNTY: OWNER'S/BUYERS NAME: MAILING ADDRESS:
ddco - ~A C A. n n 0 Lo "I #14i I uD , , -5"'-/ 7x3
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER TESTS:
Residence I1' ew ❑Replace _ G~ ^ tjs
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: IMPSOUND: IN-GRQOUNDP RE: SYSTEM-IN-FILL HOLDING NK: RECOMMENDDED SYSTE tional)
SS UU S S S U
❑S U /y /y,'
If Percolation Tests are NOT re wired DESIGN RATE:
Q If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: !V q Floodplain, indicate Floodplain elevation:
~s~mRl PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF OIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPf+HN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- o3 17
o r7 Xo 13 6 00 -75
B- L5 '7 t3 I. c-2, -fan /3 n
&I P3 ?Z
B-
B-
B-
/mot ~ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- I 2-.0 NO 30 / G
P- z o7 A-26 30 P- U -3o 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 perpgnt
of land slope.' 17
SYSTEM ELEVATION
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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:
0
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
ST SIGNAT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
ILHR-SBD-6395 (R. 02/82) - OVER -
A
_m STRU TIONS FOR COMPLET:Y a FORM 115 - SRi - 6396
To be c !te curate sail test, your rep) clude:
1. Co
2. ndicate whether thi , a r=, _Ance or commercial project;
3. oms or commer c
4, t_
A SITE ° a s r~rnor TANK ONLY IF ALL
:he plot plan;
is preferred. A
are permanent;
1 test exemp-
di b( x;
_ED WITH THE
YS _ C_
"rl~ tI TI tS FOR CERTIFIED S II T "9S
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