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Form- S T C - 104
Y
AS BUILT SANITARY SYSTEM REPORT
OWNER ft~/~~ ;TOWNSHIP SEC. 33 T S--?N-R ~W
ADDRESS / ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT /l~i✓ LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILItR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
React 1-;d 97.3
-Lk
s
,tins t / 70 3S
~ I~sFccf, r
/000
sa t; c:, h ,'s~
G" In
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used,<-,
Elevation of vertical reference point: ' ro pose c~d` sloppee i at t
sit
e: , .7
SEPTIC TANK: Manufacturer: /CL )e-& Y Liquid Capacity: -_le~00 OAS
Number of rings used: Tank manhole cover elevation: 115,,70"
Tank Inlet Elevation: / J Tank Outlet Elevation: 111.2
Number of feet from nearest Road: Front,0 Side, Rear, O ~n feet
.From nearest property line Front, 0Side, 0Rear, 0 zC3~ t feet
Number of feet from: well 90 f building: „ 17Cj
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
r
PUMP CHAMBER
Manufacturer: Liquid apacit:
Pump Model: Pump/Siphon n acture~ Pump Size
6
Elevation of inlet: t om of / elevation:
Pump off switch elevation: Ga ons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of 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: ' ~j Trench
Width: Length: C~ Number of Lines: %149 Area Built: CO
Fill depth to top of pipe: y
~t
Number of feet from nearest property line: Front, O Side, ® Rear,0 Ft
Number of feet from well: Z160 tl'y
Number of feet from building: 5,20
(Include distances on plot plan).
SEEPAGE PIT
r
Size: Number of pit: iameter:
l
Liquid depth: Botto' o eepag elevation:
Area Built:
Has either a drop box O or distr' ution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Ele ion of bott 4 tank:
Elevation of inlet:
Number of feet from nearest prop t l ne: /Fr~t, O Side, O Rear, O Ft.
Number of fe from well:
Number of feet from building:
:dumber of feet from nearest road:
Alarm Manufacturer:
I
I
Inspector:
Dated: - ~ `d Plumber on job: 11L
License Number: 3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
KXCONVENTIONAL ❑ALTERNATIVE State Plan I D. Number
_ Holding Tank ❑ In-Ground Pressure ❑ Mound (It ass,gnedl
i
NAME OF PERMIT HOLDER (ADDRESS OF PERMIT HOLDER
INSPECT( N DATE. I
Malcolm Nielsen R. R. 1, Hammond, WI 54015 I _ j
BENCH MARK IPermane nt re to re nce point) DESCRIBE IF DIFFERENT FROM PLAN
SE NE, Section 33, T28N-R17W, Town of Pleasant Valley RF. PT. ELE V. CST REF PT ELEV
Name of Plr
MP,MPRSW No. County ry Permit N.mber,
Dale dson 6629 St. C roix 64918
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED-
BEDDING: VENTJDIA.VENT MATL. HIGH WATFHyr
YES LINO DYES NO
ALARM NUMBER OF ROAD' PROPERTY WELL. BUILDING: VENT TO FRESH
DDYES LINO FEET FROM uNE LAIR INLET
ES NO NEAREST
OSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL
PUMP,SIPHON MANUFACTURER WARNING LABEL IP EOV G COVER
DYES ONQ PROVIDED ED
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL OYES LINO ES LINO
(DIFF ERENCE BETWEEN NUMBER OF PROPERTY wELL BUILDING IvENTTOFRESH
PUMP LINE AIR INLET
ON AND OFF) FEET FROM
DYES NO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NEAGTH REST DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH. LENGTH NO. OF DISTR. PIPE SPACING. COVER
TRENCHES INSIDE CIA zPITS LIQUID
DIMENSIONS MAr~al L P;T DEPTH
GRAVEL DEPTH FILL DEPTH UISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL NO
. , ISTR
BF LOW PIPES ABOVE COVER ELEV INLET ELEV. END. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
PIPES
FEET FROM uNE; r~ AIR INLET
NEAREST-
MOUND SYSTEM: i
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES LINO
SOIL COVER TEXTURE
PERMANENT MARKERS. L-T NATION WELLS
DEPTH OVER TRENCH BED DEPTH OVFRTRENCH BED DYES LINO DYES LINO
CENTER EDGES DEPTH OF TOPSOIL . SODDED SEEDED
MULCHED
DYES LINO DYES LINO DYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE
TRENCHES. FILL DEPTH ABOVE COVER.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. DE DI STHIBU TION PIPE MATERIAL & MARKINELEVATION AND ELEV. ELEv DIA ELEV DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING. GRILLED CORREC T LY COVER MATERIAL,
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENTMARKERS~YES LINO DYES NO
OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
LINE.
DYES LINO OYES LINO NEARESOM
Sketch System on
Reverse Side. Retain in county file for audit.
SIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82) ' 1l `/r
L~ Wisconsin -7 APPLICATION FOR SANITARY PERMIT
COUNTY
DILHR (PLB 67)
~ OEPRRT7T
IEnT OF UNIFORM SANITARY PERMIT #
InOUSTRY, LROOR 6 HLJMRn RELRTIOnS
-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
PROPERTY OWNER MAILING ADDRESS
a l
cc 11n ZVI /2 PROPERTY LOCATION
S t 1 /4/x/1 /4, S T 3; N, R
'70 (Or► W TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST OAD, LAKE OR LANDMARK STATE PLAN I D. NUMBER
/ t f/ R,,J 141
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 3 [J Public (Specify): J
THIS PERMIT IS FOR A:
E-1 New System El Tank Replacement E-1 Repair
.irk Replacement Soil Absorption System L_J Revision J Privy
L Alternate System LJ Reconnection I Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
LY Seepage Bed ❑ Seepage Trench Eli 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
1 An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Steel Fiherglass 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 BLOC : ❑ Mour4 ~ In-Ground Pressure
Total f Prefa . Site Steel Fiberglass Plastic
Gallons k Con e 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):
9-,y Private L_1 Joint L] Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: ~j MP/MPRSW No.: Phone Number:
:1LLt `,1✓l=fit, =2 e
Plumber's Address: Name of Designer:
'lei
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
_j Disapproved
61o~~L~z~~Z Approved ~-i Owner Given Initial
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, Plumbei
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APPLICATION FOR SANITARY PERMIT
S T 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/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.
Owner of Property l C1 J 42C'
Location of Property Section ✓ -3 .
TZ9 N -R%7 W
Township 2 '5-/ / /c `
Mailing Address tsr✓CR- S
y
Subdivision Name / V A
Lot Number
Previous Owner of Property
Total Size of Parcel 0 t
Date Parcel was Created
Are all corners and lot lines identifiable? Yea No
Is this property being developed for resale (spec house) ? Yes i/ No
Volume and Page Number 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) eenti,6y that att d-tatemen.ta on -thi,d 6ovn ahe .tAue to the but o6 my (ouh)
k.nowtedge; that 1 (we) am (aAe) the owner (4) o6 the pnopen ty du cAi,bed in t1az
in6o,matc;on 6o4m, by viAtue o6 a wak&a.nty deed heeo&ded in the 066ice o6 the
County Reg-ie-ten o6 Deed6 ab Document No. ~00 6 L P ; and that I (we)
pneeentey own the pnopoaed Aite bon the dewage pod zyAtem (on 1 (we) have
obtained an ea.bement, to &an with .the above described pnopenty, bon the
cond-tAucti,on o6 chid dys-tem, and the tame had been duty neco&ded in the 066ice
o6 the County Reg.id.teA o6 Deeds, as Document No. )
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DA E SI ED DATE SIGNED ,
H
H
STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT F-4
St. Croix County °
z
OWNER/BUYER
zla
ROUTE/BOX NUPER Fire Number
l`4"I y c re, 4 1/s
CITY/STATE ZIP
7 r
PROPERTY LOCATION:.., Vf Section 23 , I N, R /7_W,
Town of St. Croix County,
Subdivision All 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, f
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
E
I /WE, the undersigned, have read the above requirements and agree z
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- u
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 9s"
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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I,NEPAT'RY, T OF REPORT ON SOIL BORINGS AND SAFETY
INDUSTRY, ul~ ial.~
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS 1 / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCFTION
:~/~C SECTION: TOWNSHIP/rdttNtefRAl 4. : LOT NO.:BLK. NO.: SUBDIVISION NAME:
'/4 '143-3 /6Z?-N/R171(or
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
5/_ If
USE - ~ -
NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBS RVAT'IONS MADE
PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence /1 ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system 1
CONVENTIONV~L:M ~NiD~
IN -GROUND-PRSSURE: SYSTEMINFILL HNK: RECOMMENDED SYSTEM:(optional)
Ck7S ❑U ❑S ®
U DS DU ❑S CCU ~a e2 7
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: /!i
,41X 414 PROFILE DESCRIPTIONS
BORING TOTAL
D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV ON BACK.)
B- 9f 1 11
/5 I'D
B- ~ CJ•`~~ / / ~f.'/ I , ~+l!}~~C , /C~ L3I S~/F } 7 /l Y 1 Ri1!
5 /7 c J i~>
B-3 -1°33 14,0193
57
..B-
B_
B-
PERCOLATI
ON TESTS
P_
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD 3PER INCH
P_ !2
- 2 1-21
P- 3
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 A
4-1
47
TN
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: VVisconsw
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:
ADDRESS:
CERTIFICATION NUMBER PHONE NUMBER(optionall:
CST SIGN/ URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
01LHR-SBD-6395 (R. 02/82) - OVER -
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Parcel 024-1042-60-000
01/25/2007 10:47 AM
Alt. Parcel 33.28.17.276A PAGE 1 OF 1
Current X 024 - TOWN OF PLEASANT VALLEY
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
MARK A & CAROL A TR LEBO O - LEBO, MARK A & CAROL A TR
1784 CTY RD M
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1784 CTY RD M
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 9.960 Plat: N/A-NOT AVAILABLE
SEC 33 T28N R17W S 446 FT OF E 987 FT OF Block/Condo Bldg:
SE NE EXC P276C AS DESC 819/392
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-28N-17W
Notes:
Parcel History:
Date Doc # Vol/Page Type
04/23/1999 601899 1421/264 QC
07/23/1997 851/87_
07/23/1997 708/265
~
L) 4VALo_e~
2006 SUMMARY Bill Fair Market Value: Assessed with:
156753 Use Value Assessment
Valuations: Last Changed: 04/21/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 28,200 151,500 179,700 NO
AGRICULTURAL G4 7.960 1,100 0 1,100 NO
Totals for 2006:
General Property 9.960 29,300 151,500 180,800
Woodland 0.000 0 0
Totals for 2005:
General Property 9.960 29,400 151,500 180,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 310
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00
0.00 0.00