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s AS B,U^ILT PLAN OF SANITARY SYSTEM
{Q~
ANK COUNTY
SEPTIC TANK PERMIT , w G
ADDRESS L~- <-LiL- _ZIP.:"~_
LOCATION OF ~YSTEPI;. ; %,U,jp of Section
Town L N, RANGE W
Gov. Lot # , Lot #i5~ Subdivision
PLAN VIEW 0-M/~yV
Distances & Dimensions to meet Requirements of I162.20(1)(d)(2)
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1107
i
v `SEPTIC TAN;{: Concrete Lteel P2fpr. 'Ac _ r Depth to manhole -51
-
SOIL ABSORPTION SYSTEM: Drywell~Depth Inside Dia. Depth Below Inlet
TRENCHES, No. of Width Length Area Depth to Pipe
BED, No. of Lines . Width jc9 'Length -d Area ~Depth to Pipe
AGGREGATE,3 ~j Inches Area Required 1 ~?u AREA AS BUilt sy
DISCLAIMER; he inspection of this system by Poll; County 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. Polk County assumes no liabil-
ity for systemlIoperation. However, if failure is noted, the county will make
every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DIS-
POSED OF THROUGH THIS S,~TEIZ! ! !
PLUMBER ON J
-LICENSE/
'
INSPECTO ~)ATED 1~
REPORT OF ITISPECTION--INDIVIDUAL SEIJACE DISPOSAL SYS
Sanitary Permit
State Septic
TOCTIISHIP
t. Crofx CouIhty
ST;DTIC TA77K'
S ze -1 _ gallons. 'cumber of Compartments ,
Distance Front: Weli
ft. 12% or greater slope Wit.
Building ' ft. Wetlands
Ilighwater ft.
DISPOSAL SYSTL:1 Tile Field or Seepage Pit(s)
Distance :prom: Well _ft. 12% or greater slope ft
BuiIdinF--, eft. Wetlands f~
FIELD Nighwater ft.
Total length of lines
rft. Number of lines Length of
each line eft, Distance between lines ft. Width of the
trench _ft. Total absorption area sq, ft. Depth
of roc'=s below tile in. rip-pth of rock over the in. Cover
over.ro, ck Depth of tile below grade _in. Slope of
trench in per 100 ft. Depth to Bedrock ft, Depth to
ground water £t.
PICTS
Number of pits Outside diameter ft. Depth below inlet
ft. Gravel around pit: -___yes no. Total absorption area
sq. ft.
.Square feet of seepage trench bottom area required
`square feet of seepage nit area required
Inspected by.-
44 'Tfitle: x
Approved
t • , Date 197
Rejected Date 197`.
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS,
LOCATION: 1Ya, Section ✓ , T"N, R1 1 E/((or) W, Township or Municipality 1/L/e
Lot No. , Block No. 5 ~ r"a7 n_ c. S County >
/7/ Subdivision Name
Owner's Name: Q L<-/ c!i / (ff a / sa / t~ 4
Mailing Address: ~Z W_':r Q VJl
TYPE OF OCCUPANCY: Residence L~ No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW + ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS t - ERCOLATION TESTS 7
SOIL MAP SHEET SOIL TYPE
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 AFTER INTERVAL
MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- J f 3
P-
-3 i )
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
i
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
1 2-
i-B 12
7A 5
7,2 ° a S D.,
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable ar as. Indicate number of square feet of absorption area
needed for building type and occupancy. ~.204~ Indicate scale
or distances. Give horizontal and vertical reference poin s. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) > 6- l Certification No.
Address
Name of installer if known
CST Signature
COPY A - LCCAL
. PLB67 State and County State Permit #
Permit Application County P it
for Private Domestic Sewage Systems County e
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
t
e) IV C:J h / h L' /S ey )-r
B LOCATION: Su/'/,, Section $ T~`~ N, R / E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village _
/ Township (~nrr r_
C. TYPE OF OCCUPANCY: 'Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms t{ No. of Persons 3
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder G~'€S NO # of Bathrooms-/2-
Automatic Washer //DES NO Other (specify)
SEPTIC TANK CAPACITY_-/ 4Z7 -Total gallons No. of tanks
'Holding tank capacity -Total gallons No. of tanks
',Jew Installation Addition Replacement _ Prefab Concrete _
'Poured in Place Steel- Other (specify)
FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _3_ 2) ` 3) A Total Absorb Area
'Jew ~dition Replacement- *Fill System
Seepage Trench: No. Lin. Feet --Width Depth Tile Depth No. of Trerr
;seepage Bed. Length 7f~A Width Depth :34 Tile Depth ;7 V ~ No. of Lines
Seepage Pit: Inside diameter -Liquid Depth Tile Size Z/
Percent slope of land Distance from critical slope
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
`,'vfisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
5V the Certifi Soil Test
NAME /G `j~~ r C.S.T. # 3 and other information
obtained from (owner/builder).
Plumber's Signature
t MP/MPRSW# Phone
Plumber's Address ~i. 41
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space . elo FOR DEPARTMENT USE ONLY /l J
Date of Application Fee Paid: State Count Date ( 0
Permit Issued/Re' cted (dat) -Issuing Agent Name
Inspection Yes No Valid# Date Recd
1. county ( ite 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 611 /76
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Parcel 042-1012-20-000 10116i2006 08:32 AM
Alt. Parcel 05.29.18.750 PAGE 1 OF 1
Current X 042 -TOWN OF WARREN
ST. C
CROIX Date Historical Date Map # Sales Area Application # Permit # Permit Type COUNTY, WISCONSIN
00 0
Tax Address: Owner(s): O = Current Owner. C = Current Co-Owner
EUGENE P & DONNA M TRST RUETZ 0 - RUETZ, EUGENE P & DONNA M TRST
1107 100TH ST
NEW RICHN10ND WI 54017
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description • 1107 100TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 4.040 Plat: NIA-NOT AVAILABLE
SEC 5 T29N R1 8'A1 PT SW SW LOT 2 OF CSM Block/Condo Bldg:
VOL 2!546 ASSESSED WITH 107~E. _
Tract(s): (Sec-Twn-Rng 40 1/4 160 114)
i 05-29N-18W
Notes:
_ Parcel History:
Date Doc # Vol/Page Type
V 06/07!2002 681203 19061533 WD
L' 07i2311997 6341221 _
p
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 1011912001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.040 45,500 153,700 199.200 NO
Totals for 2006:
General Property 4.040 45,500 153,700 199.200
Woodland 0.000 0 0
Totals for 2005:
General Property 4.040 45,500 153.700 199,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1
Certification Date: Batch 223
Specials:
User Special Code Category Amount
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00 0.00
1 0
3 C O c3 ST. CROIX COUNTY
V ~G SURVEYOR'S RECORD
1 2 - CERTIFIED SURVEY MAP
s F a~a SW I/4 SW 1/4, SEC. 5, T29 N - R 18 W
o' WARREN TOWNSHIP, ST. CROIX CO. PAO
8~W`" WI S C 0 N S I N
L OWNER ; GLEN E. FRANCIS
NEW RICHMOND,WIS. N
SURVEYOR: MARTIN E. HALVORSEN
HUDSON, WISC.
N 89° 381 00'I E
~i 331 367.00
z I °°~g
0 1.955 AC
z 0 RE o ' o rf) 3 Y
I N 11 9~ N W 90
I~N 89038 00" E 0 c\j 90 3 67, 00' $ _ s ~ MARTIN E.
Q ~p ° 0 p r HALVORSEN of p at 5-1302
O HUDSON, t
L0 p N WIS. Q a 2.020 ACR
d-~ Iq a) t o DATE; APRIL 15,77
3~: 3a 90o U) REV; 4/17/'77
U) N 89 ° 38'00" E 1e ' I
z ,90° 367. 001 $
= 2z- 3 9°3
N - m APPROVED
0 2.020 ACRE y op -
co 0 1 l~ - JUL 2 0 t~
N co
0 ,9
OO ~PR£NENS"E PARKS PLANNING
33 ST. CROL COUPQTY ' AND ZONING CO~iTEE 367.00
S 89 0 38 00 ~W M APPROVAL OF THIS ~~'R SU .u.w;S:LI~
DOES NOT MEAN APPROVAL FOR
I TOWN ROAD BUWtJG SITE OR SEPTIC SYSTEM.
f REFER TO H62.20.
I I - _ LEGEND
• --I I/4" X 2411 IRON BAR, M I N. WT.
1.13 LB. PER LIN.FT, 0 100 200 300
***40
q r A I F' I IAA' I c c r n T U r, o o I n r I a
Volume 2- P~ale ' 546 .vv k0 F- L; v i non 0 ivF- l 1
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