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Parcel 026-1013-70-100 05/24/2005 05:06 PM
PAGE 1 OF 1
Alt. Parcel 4.30.18.48C 026 - TOWN OF RICHMOND
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
LIPSKY, KEVIN A
KEVIN A LIPSKY
1736 112TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1736 112TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 4 T30N R18W LOT 1 OF NW 1/4 SW 1/4 Block/Condo Bldg:
AS IN CSM 5/1498
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 964/162
07/23/1997 703/617
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 42,800 99,600 142,400 NO
Totals for 2005:
General Property 2.500 42,800 99,600 142,400
Woodland 0.000 0 0
Totals for 2004:
General Property 2.500 42,800 99,600 142,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 160
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 , 2&2z TOWNSHIP SEC. T` N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
' sy~7
SUBDIVISION ?[~r~ LOT LO SIZE
c7Z~- l0~ 3"~v-tvc~
PLAN VIEW
Distances and dimensions to meet requirements of ILH,R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM t l 1
a9` S7' dzc I
90'
/OS
i
!3n
I
fI
I -
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ,),t~,~
Elevation of vertical reference point: - Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: G S' Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side 0 Rear, feet
From nearest property line Front,O Side,O Rear_ feet
14
Number of feet from: well '41141, , building: =2Z Zl~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
w
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
•
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear, 0 Ft
Number of feet from well: 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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & WJMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BO:: 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE Slate Plan I.D. Number.
E] Holding Tank El In-Ground Pressure [:1 Mound (If assigned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Dave PeueUz R. R. 2, New Richmond, W7 -Y- 41 . P-70a
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT ELEV
NOJ SG), Section 4, T30N - R18W, Town o~ Richmond, Lot#1
Name of Plumber. MP/MPRSW No. County. Sanitary Permit Number.
Cat Powers 1563 St. Cnoix 58937
SEPTIC TANK/HOLDING TANK: }
MANUFACTURER . LIQUID CAPACITY. 7\NKI_NLET ELEV.. TANOUTET ELEV.: WARNING LABEL LOCKING COVER
tJ~ OVIDDPROVI/ DYES ENO O°5
NO
BEDDING. VENT DIA.. VENT MATE. HIGH WATER NUMBER OF RQ AD PROPERTY WELL. BUILDING VENT TO FRESH
ALARM LINE. AIR INLET
FEET FROM Y " 1✓~,
DYES LNO DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAP ACI TV PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
EYES ENO r^ DYES ENO DYES ENO
GALLONS PER CYCLE: e- PUMP ND CONTROLS OPERATIONAL: NUMBER OF PROPERTY JWELL IBUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM INE AIR INLET
PUMP ON AND OFF) DYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1FNGTH JIIIAMITIEH JMATERIAL 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 JINSIDI DIA UPITS LIQUID
TRENCHES MATE IAL' PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. STR NUMBER OF PR OPE RTV WELL. BUILDING. VENT TO FRESH
BF LOW PIPFS ABOVE COVER ELEV INLET ELEV END PIP FEET FROM LINE. AIR INLET
f
/ ! ~ Mfr/, ~ I s NEAREST---s Id
MOUND SYSTEM: 1
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-
DYES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
a
ES LINO DYES ENO
DEPTH OVER TRENCH'BED 7DEPTH OVFH TRENCH BED DEPTH OF TOPSOIL. SODD D SEEDED MULCHED
CENTER DGES.
❑Y ❑N F:1 YES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
W I DTH. LENGTH NO.OF LATERAL SPACIN IGR71EL DE TH BELO IPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE M . NO. D TR. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV.. DIA. ELEV.: PIPE DIA.-.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATER!, VERTICAL LIFT CORRESPONDS TO APPROVED
J PLANS
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM
\ DYES ENO EYES ENO LINE
NEAREST
n
Sketch System on Retain in county file for audit.
Reverse Side.
DILHR S B D 6710 (R. 01/82)
ION FOR SANITARY PERMIT
FinouS consin APPLICAT
D' L H R (PLB 67) COUNTY
TRLR Y,LA BOR6 HUTRn RELRTIOnS UNIFORM SANITARY PERMIT #
9137
-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/ M RING ADDRE S
1
PROPERTY LOCATION f C1-TY:
"IL.A G E : r,r
LL~ L/ 1/4.ir /4,S , TN, R i f(or) W TOWN OF: _
LOT NUMBER JBSUBDIVISION NAME NEAREST OAD, LAKE OR LANDMARK STAT/ ,PLAN I.D. NUMBER
T- 2~
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:~ 7 -/Ud
Y 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 ❑ 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 f " p T
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 El Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation oft rivate sewage system shown on the attached plans.
Name of Plumber (Print) Signature: kW/MPRSW No.: Phone Number:
Plumber's Address: I Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~f? _ f~~" ❑ Owner Given Initial
Approved 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
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 (7~- + c ~V
Location of Property Section , T t N - R W
Township
7
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created s
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes 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.
PROPERTV OWNER CERTIFICATION
I (We) eetti6y that att e.tatemen-td on .th,ia 6o4m ane tAu.e to the b"t o6 my (ouA)
knowledge; that I (we) am ( she ) the owneA (b) o6 the pAopen.ty deal cA bed in thi.6
in6o4mati,on JoAm, by viAtue o6 a wak anty deed A eohded in the 066i ce o6the
County RegizteA o6 Deeds ab Document No. j f( ; and that I (we)
ptuentty own the pnopoded bite 6oA the sewage dispodat 6ydtem (oA I (we) have
obtained an ea-dement, to Aun with the above dedcAi.bed pnopeA.ty, 6oA the
eonAtAucti.on o6 said dye.tem, and the came had been duty Aeconded in the 066ice
o6 the County Reg.i,d.teA o6 Deeds, Document No. 1 .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
' H
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S T C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
d
a
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OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
CITY/STATE LIP
PROPERTY LOCATION k4 Section, T ~N, R J~ _W,
Town of St. Croix County,
Subdivision > r j~, 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
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. 'A
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- 110
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.
J^
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
INDUSTRY, 11 cc DIVISION BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNySHIP/M14N-ICIPALITY: LOT NO.: BLK. N)D,: SUBDIVISION NAME:
N/R, r
COUNTY: OWNER'S/BUYER'S NAME: M!j IN_G ADDRESS:
USE DATES OBSERVATIONS DE
NO.BEDRM8,: COMMEI IALlDESCRIPTION: ~PROF] LEDESCRIPTIONS: PERCOLATION TESTS:
Residence New ❑Replace i
RATING: S= Site suitable for system U= Site unsuitable for system % - /
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING ~TAINI
K : RECOMMENDED SYSTEM:(optional)
Q]S ❑U ❑❑U❑S LOU ❑S U
[under Percolation Tests are NOT required' DESIGN RATE: I If any portion of the tested area is in the
s,H63.09(5)(b), indicate: y!% ~y I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH tS, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-r y
-3 -7
41
B y % - s
-7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER WCH€S" AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D 3 PER INCH
P J
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 percenl
of land slope.
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 (printTESTS WERE COMPLETED ON:
ADDRE S: CERTIFICATION NU ER: PHONE NUMBER (optional):
CST NAJURE:
l~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.,
DILHR-SBD-6395 (R. 02/82) -OVER -
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S L/j 3 v N/F' 1.
~.ruSS S
ZC 1Vr~ pt 11 ~.Jr►~ ..~~5~c'n-1
Fr*sh Air Inlets And Ob6orvallon Pips
^r Approved Vent Cop
qAbovo
12" Above
ade
20- e Pipe _ 4" Cael Iron
To ade Venl Plpe
Mtareh May Or Syvering
Mlagale
OOl
Uribollon
Pipe ' 0 o o Tee
6" ate
Beipe 0 Perloroted Pipe Below
o _ Coupling Terminating At
Bolcom Of Sy&lem
P~~~o)el~ t l~k) gra,c1< E 1
n t~ torl /
~~tJ
SOIL FILL
DISTKIBUT101.1 PIPE
APPROVED S4WT-HETIC COVE!
2u 0Fg6GR~GAT~ o MATERIAL- OR 9" OF -,TPA.,
OR (~ARSN HAy
ELEV. OF G er (o OF 12- 2/2 AGGREGATE
FIEFT -j.
DISTRia!ITIrD" PIPE TO BE AT LEAST ICHES BELOW ORIGI"AL GRADE
AML AT LEAS-F20 IUCHE;, BUT kin MORE THAki L-12- In1CHES FLLOW FILIAL GRADE
MAZIMIUM DEPTH OF EXCAVATIDO FROM OK16WAL 69ADF- WILL BE FICHES
MINIMUM! WrH OF FACAVATImN MOM ORtGIMAL 69APE WILL BE & IKJCHES
SIGUED:
i
L -ICEIJSE Q JMBER:
DAT- E : i 6 -
t t~
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