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a Parcel 030-1044-40-000 03/30/2005 09:35 AM
PAGE 1 OF 1
Alt. Parcel 20.30.19.161131 030 - TOWN OF SAINT JOSEPH
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
FARNHAM, DWIGHT E,& LINDA JACKSON
DWIGHT E,& LINDA JACKSON FARNHAM
1420 47TH ST
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 1420 47TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.700 Plat: N/A-NOT AVAILABLE
SEC 20 T30N R1 9W W 1/2 SE 1/4 LOT 3 OF Block/Condo Bldg:
CSM 3/811 ALSO CUL DE SAC AS DESC IN
792/87A Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1230/156 GD
07/23/1997 1072/521 TI
07/23/1997 792/87A
07/23/1997 713/449
2004 SUMMARY Bill Fair Market Value: Assessed with:
5088 285,300
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.700 107,100 173,600 280,700 NO
Totals for 2004:
General Property 5.700 107,100 173,600 280,7000
Woodland 0.000 0
Totals for 2003:
General Property 5.700 61,400 139,700 201,1000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 311
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
r
Fo rm - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILIIR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Iv
#CU51- f
0 (41- s ,
,tNr ,
/;LX 7y s cxvacc
95
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
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: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,O Rear, O feet
From nearest property line Front,0 Side,0 Rear, O feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Lenith: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Q Rear,O 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: i
License Number:
3/84:mj
4
.DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.J. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
[CONVENTIONAL ❑ALTERNATIVE State Plan LID, Number.
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
Aks-1-7eloI S-/
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Richard Chulyak R. R. 1, St. Joseph, WI 54082 r-
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: JCST REF. PT. ELEV.
NW SE, Section 20, T30N-R19W, Town of St. Joseph,Lot#3, Stout Subdivision
Name of Plumber. MP/MPHSW IN,, County. Sanitary Permit Number
Donavin Schmitt 3205 St. Croix 69648
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
r~ PROVIDED. PROVIDED.
I/ ' AYES LINO DYES LINO
BEDDING: VEP~T DIA.: VENT MATL. JHIGH WATER NUMBER OF ROAD: PROPERTY WELD. BUILDING. VENT TO FRESH
.
ALARM FEET FROM LIMiE.1 /V' / ~ AIR INLET
DYES NO C DYES NO NEAREST l .lu _S
DOSING CHAMBER:
MANUFACTURER :=S LIQUID CAPACITY PUMP MODELJPUMP/SIPHON MANUFACTURER WARING LABEL LOCKING COVER
PROVDEDPROVIDEDLINO DYES LINO EYES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PR OPERTV WELL BUILDING (VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES LINO NEAREST 30
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 FNI,TH DIAMETER IMATIRIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO. OF IDISTR PIPE SPACING COVER INSIDE CIA UPITS LIQUID
I TRENCHES MATERIAL PIT DEPTH
BED/TRENCH 51-2-
DIMENSIONS v GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FH
BF LOW PIPES ABOVE COVER ELEV INLET EI EV. END PIPES. FEET FROM LIN6%~ / AIRLET
jV NEAREST--► C
MOUND SYSTEM:
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-
meets the criteria for medium sand. TIONS MEASURED.
DYES LINO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
DYES LINO DYES LINO
DEPTH OVER TRENCH 'BED DEPTH OVER TRENCH: BED OEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES DYES LINO DYES ENO DYES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV. ELEV.. CIA. ELEV.. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES LINO EYES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY IWELL. BFEET FROM LINE❑ NO OYES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE:
DILHR SBD 6710 (R. 01/82)
i
wisconsin APPLICATION FOR SANITARY PERMIT ;
COUNTY
~-DILHR
(PLB 67) UNIFORM SANITARY PERMIT #
~ OEPRRTTEFIT OF
- inou5TRM,LR60R&"umRn RELRTIons
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS _
17
PROPERTY LOCATION CITY:
1/1, 11/4.5, 1/4, S , T ; N, R %7 E (or) W V1U_ of , = _ f
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME REST ROAD, LAKE OR LAM[ MARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED vo
1 or 2 Family Number of Bedrooms: 2 `J Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification _i
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 J } l'
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total # f Prefab. Site Steel Fiberglass Plastic
Gallons T W, Concrete Constructed
Septic Tank Capacity I/ A4
Lift Pump/Siphon Chamber
Manufacturer: 7
'ty v' f Ir
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Z :S~ V t Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur ( PRSW J.Phone Number:
/~J V r li /T~'" -cc ZrCs-
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
r 7 { .7 _ a < ❑ Owner Given Initial
~6 jay( 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
Location of Property IV.jt,, ~4 ) - _'4, Section s' T l" N - R _ W
Township
Mailing Address 6
Subdivision Name
Lot Number
Previous Owner of Property Pt / _jt&p- - z)
Total Size of Parcel C
Z 2-
Date Parcel was Created
Are all corners and lot lines identifiable? -;k- Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number _ V 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) ee4t,46y that aU statement6 on ,thi,6 6onm ahe tlcue to the bat o6 my (owl)
hnowtedge; ashat I (we) am (cute) the owneA(b ) o6 the pnopetty deacAibed in ,thus
kn6mmafii.on ~onm, by virtue o6 a wa"anty deed neeonded in the 066ice of the
County RegiA-ten o6 Deeds ASS Document No. and that 1 (we)
pnaentCy oun the proposed site bon the aewage pobat 5y~stem (on I (we) have
obtained an eaaement, to hun with the above desnibed pnopwy, 6oh the
con,stcuctiov o6 6a, d system, and the same has been duty necohded in the 06Aice
o4 the Couna y Regi6ten o~ Deeda, " Document No.
SIGNATURE CF OWNEK SIGNATURE OF CO-OWNER (IF APPLICABLE)
,;ATE SIGNED DATE SIGNED
H
_ ~ Vl
S T C - 105 r
Y
H
SEP'T'IC TANK MAINTENANCE ACREFIMENT
0
St. Croix Cuunty
u
Jf
OWNER/11 U Y E R
RUU`LE/li0X NUMB hK Number
CITY/STATE' c1~ G L1,
PROPERTY L.UCATION:_1__X_~.-`~, Sectio11 N, 11 CW
Town oI' S ✓~1~/y` , St . Croix County,
Subdivision 1,0 t number ~
I
lfill) ruper use and ❑iaillteriance of your. sc-pt it system could result in
its premature failure to handle wastes. Prupur ntaintenauce cori-
si.sts of pumping out the Septic tank every three years or-Sooner
if needed, by a licensed sel)tic tank 1~uIli LeI- What you grit into
the system can affect the (unction of the septic tank as a treat-
went stage in the waste disposal system.
St. Croix County residents way be cligible to receive a grant 1()I
a maximum of 60% of the cost of replacement of it faiLing system,
which was in operation prior to July 1, 19713. St. Cruix County
accepted this program in August of 1980, wirli the requirement tII aI
owners of aL l new ;y stems al,I- ee to keep the i r sysIII s properly
maintained.
The property owner agree;, L aubuiit to t k:I O i x C:uuuty uu 1 11g a
certification Corm, 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 acid pumping ( L f nec-
essary), the septic tank is less than 1-/3 full of sludge and scum.
Certification Corm will be :,cut approximately 30 days prior to
three year expiration. o
I/WE, the undersigned, have read the above requirements and agree cn
to maintain the private sewage disposal system in accordance with
H
the standards set forth, herein, as set by the Wisconsin Depart- w
Went of Natural Kesources. Certification furor must be completed
and returned to the St. Croix County l.ouilig 011i_ce. within 30 days
of the tlire.e yc<-ir expiration date.
1) ATE
St. Croix County "Zoning Oflice
P.O. Lox 98
It anunord, Wt 54015
715-7~ 6-2239 or 715-425-8363
Sign, date and rt:turn to nbUvc addr
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SAF INGS
DEPARTMENT OF REPORT ON SOIL BORINGS AND p; ,,~:InN
I N DLISTBY,
3707
LABOR AND PERCOLATION TESTS (115) D I .$a,53y07
HLMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIPf19kffd4EifiPcLITY: LOT NO.:BLK. NO. S U B D I V ~AN N rte; j"
'/C 1/4 C-v n
/T.3oN/RC 1(or)W 1 e /U
COUNTY: OWNER'S/BYYER'S NAME: MAILING ADDRESS:
n )
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERGOLA TESTS:
~'~esidence ~r ®New ❑Replace _ C,
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
KS ❑u ~S ❑u M au EIS u EIS [Su
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: I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS:
~~Nil7~a
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER [)FpfF?7dN, ELEVATION OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
_ e7 Z
5 % 17 / C! r7
B /7
B- f7 Vii' n tJc. 5 5,~. 6n,m
LT /
~..5.
B ~Z' r'
00 '75
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INQW S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ 4-a A) b c « ip Y
P_ ~s afo .3 r.Z i
P- 3
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 percent
of land slope.
SYSTEM ELEVATION
3 r I I
D ' ~ - -
_~-w-
,
5
4~~~r'Y110rKGrviGp~
N
ti
{
ix\
lA! 0
F
1, 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 IC (TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): A) r 12f, z._ f3 7l5_~;~~-6z~a
CST SIGNA E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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