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EH 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
~l ZG S7` SasE-ph~ LOCATION: l;, ~u-Section ,T_.N,R_E (or) W, Township or Municipality
Lot No. , Block No. ~IE~E eaF Y LE,t;'rL F,4RM sf DEG/1( County
u ivlsion ame Owner's/Buyers Name: WC5. LEG ~'EPM ►4/~
k1ailing Address: 61_~_ y/,vim 57'- 1f VD~_eiiV
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOILBORINGS /%7f PERCOLATION TESTS//'GET QyA~~F/Eb
SOIL MAP SHEET NAME OF SOIL MAP UNIT #313 #V 136,4eI)
PERCOLATION TESTS
TEST DEPIH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL RATE MINiIN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD
2 PERIOD 3
F- - G [ 4 5 AOA ,1 S o
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zex7- 0/a
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SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
R 7z 12 "AA1 /s /Z Fir G113N. s "f. lwcr /31/. SAID 20".iii
B BN W BT 75% rIA4t hlE /91V. .54AJ D (w~T .
36 Fi L 7 L 3 VE ~S /L ` L7+ U/V tiE S /D " 74A1 IPI --e
B- 22 S.gND W/ET . 2 "Lf•BA1 SI 41~T "_3e/au U-~ Mc
B / -7 .36~ ~3"6v. 1. ! 3 Gil /)AJ. • ~S /2 ` ~+E S~ cv6r / ~ " fS B- D-G' Ho tt 12'' C . LvCoM. Dish d Ro/y
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy /War qUA%.~ieD Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. I OA Ae_41iV1171tcs?
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I, the undersigend, 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. ~`L~ L/
Name (print) , , *.e- r ~7 Certification No.✓J Gl/ ~Z
Address 3 f ~'psafv Ga/S 6~yo/~
Name of installer if known
Copy A -Local Authority CST Sign 2;Ure!~~ u 1 !
EH 115 ReL. 9 78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
f/ 5~-szv LOCATION: '1 Section T_N,R_E (or) W, Township or Municipality
County Sf - !~I C X Lot No. ,Block No.
Owner'siBuyers Name: LI U ~iubclivision Name
Mailing Address: 61,4_ U~~E /T V~S~'~ ~C s•
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 2E~'Z /%7 f PERCOLATION TESTS
SOIL N1AP SHEET SC S Y/ NAME OF SOIL MAP UNIT /TS 1/ UJQ?b?fll-F i
PERCOLATION TESTS
ES I HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL RATE MIN/IN I 3FR INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES
PERIOD 1 PERIOD 2 PERIOD 3
P-
P-
P- 4A Z
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED
HIGHEST IF OBSERVED IN INCHES
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a- f .1 S l "wET XvE / f.f. O ors ,z"Sc w Co~+• D/ST. Hat
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8- Z tiiN Z y'' 9N S 3 ~f Sc / co DrfT c°o. y O - 6 .ye,fs
B_ c% w RCN, eDAj. O •G ~'fo S PI AN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and
square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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i, the undersigend, 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}-~CA5Eq I Certification No.s s ~oi y~z~
Address X/-- 1 ~~5o'v &;I f. r7"yv~r/
Name of installer if known
Copy A - Local Authority CST Signature
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S T. CROIX COUNTY CERTIFIED SURVEY MAP
LOCATED IN PART OF THE NE 1/4 - NW I/4 OF SECTION 26 , T30N , R20 W,
TOWN OF ST. JOSEPH , ST. CROIX COUNTY , WISCONSIN
_QN?L&TTE Q
-LAND
m m o ~ n I
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ro 2 33' _ _ - - - - -
G m m ( PRIVATE 66' ROAD EASEMENT 140 O O 458.44'
b N02°-36'-58" W
n ? 431.19' r 4~ti m c m I L~
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I OJ I SJ . ° A R/W APPROVED
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ti y w u, N z
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i ~u -
m rn :E I TOTAL, w
o 8.04 ACRES
LEGEND I z 350,103.4 SQ. FT.
=~I OD OD N ,
O = 1" X 24" IRON PIPE SET 14
WElGHlNG 1.68 LBS./L1N. FT. I z w EXCLUDING ROAD R/WI, W
0= FOUND I RON PIPE I O Z 2 7.25 ACRES m
-i I z OD 315, 978.2 SQ. FT.
m = `D o cn
rn D D, O7
TNA~KS d < A w `D
to Z = OMNER
m HENRY L.ENTZ
%%'k c. GuM,~~,'~ A BOX 316, ST. jOSEPH TOWNSHIP,
WI. 54082 ALLEN 0. I L APP
ROVED NYHAGZN
S-1a37 [401- R/ W
m'iD-f)0w, so' SEP 1 5198 3 011)ti
611. O? R/ wl 14" o
`sS►~~ i ~'«...r. ' \L St. CROIX C Ty
=U COMP.,EHENSIVE r i ruNN11 u p M 7* I 207. 90' co
a~a ~tl ~ ti AND ZONING COM.%WTEE z n i
O ti
DATE S 00°-31'-32°W 264.00' i9o a lu 1' cu 1 O .P eOc~
A 56.10` .11 0 \ti 0
SIGNED~~ev. O L s, O m z,
ALLEN C NYHA N 191.20' R.L.S. 1407 I 5MALL KS I'
TF1AC S 00°-31-32 " W i
S CO°-31'-32"W, 866. 25' _,'V 89°-38' 23"W 165:00--
r VOLUME 5 PAGE II 5~ 1
CER7 fFfED SURVEY MA TNi INSTRI/MFN7 WA.S PRAFTEr RY PARRY PAI.MrR ST. CROIX COUNTY, v,
Parcel 030-2043-40-000 Fact oFr
Alt. Parcel 26 31X.497F C30 - I ,)'r SA.IN I JOSEPE I
Current X S` CROIX COUN`Y 'ivlSi::)NSIh.
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0
Tax Address: Owner(s): O = Cjr en: Owner = Cjrrenc C C:vn r O - RENEAU. JEF,:REY K & VIRGIN A
JEFFREY K & VIRGINIA RENEAU
136 CTY RD E rOULTON W1 54082
Districts: SC = School SP = Special Property Address(es): Pr n»'Y
Type Dist # Description " 136 CTY RD E
Sc 2611 SCH DIST OF H'JDS:).N
SP 17C0 b'v'ITC
Legal Description: Acres: 7.920 Plat: 1352-CSK1 05-13;;2 030-83
SEC 26 T30N R20W 8.04A NE 1!4 NIP!V4 LOT 1 BlockiCondo Bldg: LOT 01
CSM VOL 5/1352 EXC TO HWY PROJ '550-00-21 Tract(s): iSec-'
Notes: pars'! history. Date Doc # Vol"Page Type
J7!2311'J9; 20J J5
01!23,' 1 c 9 751619
2011 SUMMARY Bill Fair Market Value: Assessed with: 0
Valuations: Last Changed: C5;1' 2c`1
Description Class Acres Land Improve Total State Reason
RESI"EN 1AL G1 % 920 111 400 216.500 327.9C0 NO
Totals for 2011.
General Property I y2C "1',400 216,500 32 900 Woodland 0 COG C 0
Totals for 2010:
General Property 7.92C I"81.50.-j 716 5:7U 3~ Woodland 0.000
Lottery Credit: Claim Count: 1 Certification Date: Batch 221
Specials:
User Special Code Categor; Amount
Special Assessments Special Charges Delinquent Charges
Total C 00 C 00 5 UC
I
Parcel 030-2042-95-000
PAGE 1 OF 1
Alt. Parcel 26.30 20.49116 030 - TO'vVN OF SAINT JOSC7
Current X ST. CROIX Ci UNTY, ,%'ISCONSI%
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00
Tax Address: Owner(s): U = :;urren. Owner. C = Ci.rrei
NICHOLAS R & MICHAEL J OLSEN 0 - O''LSEN, NICHOLAS R X. MICI-'AEL J
142 CTY RD E
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): r -r.1
Type Dist # Description 142 C",` RD E
SC 2611 SCH DIST OF HUDSON
SP 1700 'dVITC
Legal Description: Acres: 1.350 Plat: NiA-NOT AVAILABLE:
SLC 26 T30N R201AI S 264' OF E 165' OF NE BlockiCondo Bldg.
N'vV EXC E 25' ALSO 50ACRES DESC AS. C0M
N1/4 COR SEC 26 TI I S ALG E LN 1320.91 Tract(s): (Sec T;:n-kng 40 ';4
TO S LN OF NE NV TH N 89 DEG W 165' TO 26 3CN 2U'd:'
POB TH CONT N 89 DEG VV 82.50' TH N 264',
S 89 DEG E 82.50 TH S 264' TO POB (DESC
more
Notes: Parcel History:
Date Doc # VoliPage Type
10/06i2008 882404 CT TR
11'06i2008 882403 11)
04i0112002 674889 '863/349 cc
IOil1!1995 534833 1143/'S12
2011 SUMMARY Bill Fair Market Value: Assessed wits.
0
Valuations: Last Charged: L)--;1 L.
Description Class Acres Land Improve Total State Reasor
RESIDENTIA_ G1 1.35C 40,1OC 86,400 126500 NO
Totals for 2011:
General Property 1.3-0 4J 1C0 r,~3,400
Woodland O.OUJ 0 r
Totals for 2010:
General Property ':.350 53.400 86.400 129,830
Woodland 0 %OC Cl 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 122
Specials:
User Special Code Categorf AnlOUrt
Special Assessments Special Charges Delinquent Charyes
Total U.CU U.CU i; 5cj
CD
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Parcel 030-2043-40-000 09!22,'2005 t 1:27 Ann
PAGE 1 OF 1
Alt. Parcel 26.30.20.4971` 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-owner
O - RENEAU. JEFFREY K & VIRGINIA
JEFFREY K & VIRGINIA RENEAU
136 CTY RD E
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 136 CTY RD E
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 7.920 Plat: NIA-NOT AVAILABLE
SEC 26 T30N R20W 8.04A NE114 NWV4 LOT 1 Block/Condo Bldg:
CSM VOL 511352 EXC TO HWY PROJ
1550-00-21 Tract(s): (Sec-Twn-Rng 40114 160114)
26-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07?23;1997 2001 i95 WD
07!2311997 675, 619
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07i0912004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 7.920 148,600 216,500 365.100 NO
Totals for 2005:
General Property 7.920 148,600 216,500 365,100
Woodland 0.000 0 0
Totals for 2004:
General Property 7.920 148,600 216,500 365,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 221
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Lorin - I C - 101
00
AS BUILT SANIIAkY SYS.T1'EM REPORT
OWNER-W• TOWNSH1,P S/ ~OSE P H- ,,L(,. Z 6. I ~Q N-R .2-6 W
ADDRESS -P/ ' S`1'. CROIX COUNTY, WISCONSIN
LOT T_ - LOT SIZE
SUBDIVISION
PL,,N VILW
Di SLalICUS and ~iweli i n5 rte mt-• t rU(piII- au<-nt~ of 11 63
5110W EVERYTHING WITHIN WO FEPT OF SYSTEM
SU;TAQ /,15- A-P aAAa-- EXiSTi~JG wE/~
Ec~C c,,. 2P.~ 1 flDDi4 "0Ajd -Q y 6D fr
4,-3e s # Z , rA,v e
OL~A 0
c AbQ 30f C~.
I 32. + rl
1 , , r
r ; I 1 1 3y-
I I I r ' r 9°
~ I~ I ~ r r I ~
+ I r '
34;'
3 ~c% U• ~ ~ ~ , ~ ri v,t1GG.,
+ r I
5C.4 le
I'
13AI
,;ENCHMARK: llcaL:ribe the vertical reterence point
w
i'lihlp Cli~1M1iL'R
Mcoiul:i _ Curer: Liquid Capaci tyI
Pu:nl Model: `Pump/Siphon Manuf urer: - Pump Size - 1
Elcvatiou of inlet: oLtom oL tank elevation: 1
Pump Off Switch elevatiot: Cal.lons per cycle: _
Alarm Manufacturer/ _ Al,ir:u Switch Type-: T
Nuiuber of fc:,efrom nearest propcrry line: Frc:iif,0S.ide,Oi<c-:ir,0 Ft,
N,iinber of fuct from w. l 1:
Idimihc-t of feat from building,:
(lu( inLle yii~rancrs oil plot plan). SOIL ABSU1 WHON ';YSTLM
Bud: Trench: \
Width: Le.ngtn: yun;her of Lines: Area Built:
Fill depth to top of pipe;
Number of feet fr;~n, nearest prui,urty line: FronL, NSide,Oll ear, 0Ft .
Nua:)I'r 01 Irc•[ tr,~,❑ well: 00
Nan.l;Lcr of to,,L Iron: building,: -3
(Inc_ludu distances oil plot plan).
Size: - -~NiZm+ik~=pit lii;imeter: - -
Liquid depth: 'Bottom of Seep it e--levation:
Ar.ua 13uiIL
cti uiLher a drop box O or distribution boxO been used utt any of the above soil ^
;urbtion sytems? (CLeck one).
OLUINC TANK
t•anufac:tnrer: lty•
Nuotbcr of riubs used: / Llevation of button of tank: _
elevation of fit:
Nuuihue-"uf fi-.Ot from nearest property line: Front, O Side,nKear, OFt.
Number of feut front we.l l: ~~aa//
,ulher of feet from building,:
DEPARTMEN~kOF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABO,9 & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7669 BUREAU OF PLUMBING
MA0,IS61N, WI 53707
DALTERNATIVE sucPlanlD N~mn
nCONVENTIONAL j11
1.i;;igrwll
L<- Holding Tank -3 In-Ground Pressure ^ Mound
Q
! •`a - 1'_c r.111 11111 r.FF AI:"; 1~ PFFMIT Hnl E'ER NSPFI,-I-) I I
Dr. Teff Reneau 500 3rd SL. S., Buffalo, MN 55313
BLNUHMAHK l+-,rr: r+• r+.++I!I_)1 r11+.~ 1 I1 FIFNT '110-0 '.AN IT FF I-T -1F - P7 E__r
NE NW, Section 26, T30N-R20W, Lot#1, Town of St. Joseph
y'I
Ne of vl.,•. i.+e- iv,'"/PN'V.' r. =.t Sdnl'J'Y F`rrmt Robert Ulbricht 3307 Croix 49422
SEPTIC TANK/HOLDING TANK: _
rAa NUr Ai. TL.IIFII I MillAf.1TY TAN( INLET ELF'J TANK CJTLF r L_EV `NARKING L4-1 1 LOCI \K CriVFn Nl,
r 1 C~ DPGVIDE7 PHUVIUFFI
1(v~`V z-0 /tL/'! J /JO.C-)C YES F7 N0 ~JYES 7NO
R6 UUING VI1T U14 VENT /AAT HER NUMBER OF HUaU PROPEPTV N'E Ll d': r1 uwG VENT TO FRESH
j ALARM FEET FROM jA PET
AYES L_NO l IVES 1.~N0 NEAREST (
DOSING CHAMBER:
I4+=.NUFA~n_HUI F.F UnIVG Iuull: r.PAl.llr ~l!NP M;;DEL vll1AP; SIF F': `1 VA. r. -~c~' IHFR WARNING L:+eEL LOCK WG COb'E4
!PROVIDED PROVICLU"
LJYi CNO L,YFS LINO DYES ONO
GALLONS PER CYCLE Pua+PANDr_ual+~ i_SUeI_ PR FF wElr ~EIUILDING FA I-, •NUIER O vEVTTOFHls11
L I. - AIR INLL I
(DIFFERENCE BFIWFFN FE VT FR
PUMP ON AND OFF) ~ DYES NO N AR
SOIL ABSORPTION SYSTEM. Check the soil moisture at thedepth of plowing j \VF F 1%14TLH A_ 4N11MA IK N:
rll excavation. 11` soil can be rolled into a wire, construction shall cease until FOR E
the soil is dry enough to continue.) M --J
CONVENTIONAL SYSTEM: -
':1IOTH -TH VO ^F+ISiH PIPE SPAC1 h1: - T' FR 17~1LIOVID
BED/TRENCH THE, PIT EPTH
DIMENSIONS rlllDE H IS1~ P CI$TR PIPE M41LHIaL 'Jli I11i MB:1'FRTY Y1=Ir 3UI_OINJ VENT TC_HEil-
!.E \P1 'rIVF CVEF1 ECf 1~E ~ I'I I AIR 'h
` S FEET FROM I b
3 1 NEAREST--► 1
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the till material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systerns to make certain that t ON REVERSE SIDE-SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ~NO
OIL COVER TLxTLRE vLr:V1aN rT^a HLFRS a YA1u N;rr.l
YF ONO DYES _..NO_
'_U MULCHE
D
I.I PT-; F7 TRF V(:H iEC OEPTrI O•:FR TRFti::H RE L .r EPTH OF TOPSOIL tiUL1U1 l: WO
DYE OYES NO YES LINO
PRESSURIZED DISTRIBUTION SYSTEM: _
v1:T1• IFNr,TH NOOF LATEPAL DA AV'EULr" IFI.: DFPTH ABOVE COVED
BED/TRENCH TRENCHES
DIMENSIONS
h: A`JIFCI D DUMP 1 A`1I F-,^,LC 0 STR IPE M NIFOI F.' M TFRIAL UISI1 PIPE DISTRIBUTION PIPE MA-ERIAL & 61ARKINCi
6LE•.' ELLJ. CIA ELE'd UTA
ELEVATION AND
DISTRIBUTION rFRncAI_ LIFTCOReesvoNDS ioavvHU+LL
HOLE SIZE HOLE sDACINC. DPI-LED C^'RRKTw :O'ON PL.\Ns
YE .NO DYES ❑NO
COMMENTS: PERMANENT MARKERS ,)6SEHVATICNNELNUMBER OF LItFPFRTY WELL BUILCING
FEET FROM
YES _ -N_0 YES NO NEAREST
R n in county file for audit.
Sketch SVs-em on
Reve :e Slde
I:NAT JRE 777 TITLE
- '
DIL:IR SBD 6710 ',R. C1;'821
DEPARTMENT OF t3 APPLICATION SAFETY & BUII_DINC;S
INDUSTRY, ' FOR SANITARY DIVISION
LABOR ANLY PERMIT P.O. BOX 7969
HUMAN REL-ATIONS (PLB 67) MADISON, WI 53707
s
Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner:
DAP . j MBPS . fF ~E,VE~2 Mailing Address:
S/ -sa . /~tt~ . ss3/3
=o 3.,
Property Location: City, Village or Township: County: -
S~ TbsEpyL S ~/~d~X
41 '/QNUh.S -2 ~T 30N,R Z° E (o r)
I of Number: Blk No.: Subdivision Name: ? A Nearest Road, Lake or Landmark: State Plan I.D. Number:
I/3SZ (If assigned) V4
TYPE OF BUILDING
Number of
❑ Public* U Variance" ❑ Other (specify)' Bedroo
1 or 2 Family "State Approval Required.
TOTAL NUMBER PREFAB POURED IN STEEL FIBERGLASS NEW REPLACE- OT14ER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify,
SEPTIC TANK CAPACITY IZ OO _ ~C
HOLDING TANK CAPACITY )C
LIFT PUMP TANKiSIPHON CHAMBER
MANUFACTURER: ~JEf~ D UG
77$r /4 - /Q~iff O ~AZ' LU
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
IMinutes per inchl: PROPOSED (Square feet): New ❑ Replacement ❑ Experimental L Seepage Bed ❑ Seepage Pit
Alternative (specify) X Seepage Trench
12, /009
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature MP,`MPRSW NoPhone Number:
R0 BE.e % Z/78~P / c 6i7 ' 3347 171.5) 316-J01Ps
Plumber's Address: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signatu a of Issuing Agent: Fee: O Date: APPROVED Sanitary Permit Number:
d 'rX l-'S'~ ❑ DISAPPROVED IV ;t Z
Reason for Disapproval:
i
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHH SBL)h3y8 (R_07!81)
1
Fo rw - S T C 1 00
S
Uwner of Pru},ercy - ~JC J f~[iV1(
Location of Property ~(lc) SeCC1DnZ~' ,'1' ~L1 N RW
Township_ JcS~~ ff`
Mallln};
7
Subdivision Name
Lot Number
Previou6 Owner of Properry
Total Size of Parcel ego, (-JY S
Date Parcel Was Created 2-
Z- -
Are all corners ldeacifiable?
Include with thin app]ication one of tike following:
CertlfiCd Survey Map
. De~ci
.Land CUfLrriCC, or
UCher legal DULU0:a11C winch deucribey the NruperCy
PROPERTY OWNER CLHTIFICATION I
I (Wa) curtify that all statements on this form are true to the bust of my (our)
know(udge; that I r-ju din (are) the uwnar(s) of the property described to this
intormation form, by virtue of a warranty daed rdc read in the Office of the
County Hsgistur of Deeds as Document No. K ; and that I (wu)
prdsantly own the proposed site for the sawayu disposal system (or I (we) have
ubtainud an pasumunt, to run with the above described property, for the
construction of said aystum, and the crime has been duly recorded in the Office
of the County Register of Deeds, ai Document No. )
!.Iu 1 E O OWNER 514NArURE OF CO-OWNER (IF APPLICABLE)
DATE s1UNED
DATE SIGNED
i . _ .:7$ OFFICE
r !X CO., WIS.
Henry J. Lentz,
e tr, i~• ttawrd 1hi3.25t1h
any 4f- Oct p.D, i 9 83
t 2:55 P 1111.
..m~wy < ar.,t S, ..rrr:.ta t• Jeffrey K. Reneau and..
Virginia L. Reneau, husband and wife«
as joint tenants,
the lollowind de.crilwd real estate in . St. Croix _ ........counts.
state of Wisconsin:
Tax Parrel No:
Part of NEJ of NWI% of Section 26-30-20 described as follows:
Lot 1 of Certified Survey Map filed September 29, 1983 in
Vol. "5", page 1352, as Document Number 388159.
j ~ O • o0
1 ..L
is not horlestcad prulwerly.
t.-) win not)
t'.. .n t•• ~er,rrantie•••
Subject to easements, reservations and restrictions of record.
1~,• t, 21st da, at. October 19 83
•
tS E:1 Lt l:gr\1.HFN ,C r
r LET .
oEAI.r
AUTHENTICATION ACKNOWLEDGMENT
Si; natnrefe) of Henry J. Lentz... STATF: OF WISCONSIN
RS.
- ('ol.nty.
n if,•..;;u !hc. 2!~iSfa; of la 83 1'•-, • i-al . rune hefntt• me 0-4 due of
M the above namc,i
STI: PREN J :`ill[; NLAP
•
~~'t5('Oti~l
?ITI.F:: NIF NIBER STATE: BAR OF
t,- me kw-wn to he the per~an %0,4. exreMed the
.uremin, in-trument and acknowlewl.e the same.
. , r,-. uiiw~c Vt .VA4 n"•.r
STEP11LN J. L)UNU.1'
liudson, Wisconsin
wL•,•c 1'ut.lir ('aunt)-. Wis.
(Sit•nati:rr• way t-e nuthentirated or :,rkn,nclr•d,.-I C..t'•. ?I, C'.rrmi-wn i, tr rm:ment. t if newt. ~ta'o rcp.ratior,
are n:,t nrr-,.;ry'I d'.te; 19 .1
• V~mre nr r..•w.n. r•[n.na .n wy ra a..N + •t h. t. e••! •.r ..•r ..t h. i •h-n , .r..r.
-
S T. CROI~: rOUV T Y CER TIF/ED SURVEY MAP
LOCATED IN PART OF T/-fE NE 114 - NVI 1/4 OF S':C 410N 26 , T30M, R20W,
TOtii1/N OF ST. JOSEPH ST. CROIX COUNTY , M,10 %;ON51 N
r w czi J-h
P/w
0 m D • - ~ 33 - - - ! r ~ PRIVATE EASEMENT, w
y.eh D c ( N02°-36'- ~1tt 458.44' _ rA-, N 2 r 119' v
V t9- a ° . K m 2 m 7.25'
400
~yw tD No t A»=' ,k' f .-1l to F. O ' nmif cn - tr a 'i t eft f ]b. -7;'" rn r
f 1 r=tt 1 W v✓ s ° 7 7 r
,4s V n I . 1~• I - ~ . J i ~ 1. i.r
W 7 a kM1 1 N O c: 0
E _ I L- .
N Y; r
m z 'IE 1 i rn
f I N 8.0# tRES
LFG~NC. z 350:JI ,.4 S4. FT. M I;x
C: 1"X 24 `IRON PIPE SET
WEIGHING''-` 1.68 LBS./LIN FT. ' m w L LA C.l1Dl1~t~ ~;'~A~ ,h~t/4vn
J = FOUND• IRON \ PIPE F O z CR ES L ` .aiM t u rn o
z:, r~ may' ,x1.51 tJ' 8,2 SQ~FT. * I z
ay'~J< 'Rl o t U -t f 13 ' s tr' f r
SMAL r tr , t m
oar ~lke< .ACKS, f' •"m R D l~0 s- p Y f,. t~ ' - , j (3 i i o f
.i! ; -Z O a •(~14f (alit-~h`g ~1[[~ ~i ( - ~4~'•r-T• -l Sf
ENT
•~'aNST82. JC•'SEP~r ?1 P,
AA
rte) 1~~.~~t _ 1
IV, 9z
Jr j) RI VIP a
y{~'h~J' ~•I~~y~.,~ - I , ~ 'mss', f:. ~ , o
20
1 si 207- 90' ` m c7~
S O0°-31'-32"W 264.00' Co DATE `flo cu I
r _ a tD O ~3 c1 N O. ' ~ 56.10' ti ati, O
~!!,t ` „s._._~
ALLEN C- NY HA - 1 ` -
191. 20• R.L.S. .'407 s S -31' .32
s . _ 00° 31 32"1Y, fib f, 2~ r S
z. N899-38-23"W > 165.W--
r CERT I FI CD SURYq-
C ROJY. COUii 7Y► STRUaEn'T WAS CRRF7 Ef~ : f3Y ST. . ~?.1RRY___P4!_h,:7R_ f