HomeMy WebLinkAbout036-1047-90-100
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Parcel 036-1047-90-100 01/25/2007 03:54 PM
PAGE 1 OF 1
Alt. Parcel 20.31.17.298A 036 - TOWN OF STANTON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - ANDERSEN, WALTER E & RITA M
WALTER E & RITA M ANDERSEN
2075 150TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2075 150TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 39.980 Plat: 4675-CSM 18-4675
SEC 20 T31 N R1 7W PT NW NW; NE NW & SW Block/Condo Bldg: LOT 02
NW; LOT 2 CSM 18-4675 (39.980 AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-31N-17W NW NW
Notes: Parcel History:
Date Doc # Val/Page Type
12/19/2003 749543 18/4675 CSM
07/23/1997 759/148
2006 SUMMARY Bill Fair Market Value: Assessed with:
166705 Use Value Assessment
Valuations: Last Changed: 06/04/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.980 5,900 0 \ 5,900 NO
OTHER G7 2.000 10,000 126,100 136,100 NO
Totals for 2006:
General Property 39.980 15,900 126,100 142,000
Woodland 0.000 0 0
Totals for 2005:
General Property 39.980 15,900 126,100 142,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 036-1048-20-000 01/25/2007 03:50 PM '
PAGE 1 OF 1
Alt. Parcel M 20.31.17.300 036 - TOWN OF STANTON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KRUSCHKE, DAVID A
DAVID A KRUSCHKE
716 N SHORE DR
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 20 T31 N R1 7W 40A SE NW EZ-U-1208/238 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
02/09/2005 787124 2746/574 WD
02/05/2004 753796 2506/147 LC
07/23/1997 759/148
07/23/1997 320/419
2006 SUMMARY Bill M Fair Market Value: Assessed with:
166707 Use Value Assessment
Valuations: Last Changed: 05/27/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 36.000 5,600 0 5,600 NO
AGRICULTURAL FOREST G5M 4.000 3,400 0 3,400 NO
Totals for 2006:
General Property 40.000 9,000 0 9,000
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 9,000 0 9,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 036-1047-70-200 01/25/2007 03:48 PM
PAGE 1 OF 1
Alt. Parcel 20.31.17.297A-20 036 - TOWN OF STANTON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KRUSCHKE, DAVID A
DAVID A KRUSCHKE
716 N SHORE DR
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 24.400 Plat: N/A-NOT AVAILABLE
SEC 20 T31N RI 7W PT NE NW NW NW EXC Block/Condo Bldg:
18-4674 & EXC CSM 18/4675
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-31N-17W NE NW
Notes: Parcel History:
Date Doc # Vol/Page Type
02/09/2005 787124 2746/574 WD
02/05/2004 753796 2506/147 LC
12/19/2003 749542 18/4674 CSM
05/25/2001 646489 1646/253 EZ-U
more...
2006 SUMMARY Bill Fair Market Value: Assessed with:
166703 Use Value Assessment
Valuations: Last Changed: 06/04/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 24.400 3,600 0 3,600 NO
Totals for 2006:
General Property 24.400 3,600 0 3,600
Woodland 0.000 0 0
Totals for 2005:
General Property 24.400 3,600 0 3,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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' Parcel 036-1047-90-100 11/22/2006 01:48 PM
PAGE 1 OF 1
Alt. Parcel 20.31.17.298A 036 - TOWN OF STANTON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
WALTER E & RITA M ANDERSEN O - ANDERSEN, WALTER E & RITA M
2075 150TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2075 150TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 39.980 Plat: 4675-CSM 18-4675
SEC 20 T31 N R1 7W PT NW NW; NE NW & SW Block/Condo Bldg: LOT 02
NW; LOT 2 CSM 18-4675 (39.980 AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-31N-17W NW NW
Notes: Parcel History:
Date Doc # Vol/Page Type
12/19/2003 749543 18/4675 CSM
07/23/1997 759/148
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/04/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.980 5,900 0 5,900 NO
OTHER G7 2.000 10,000 126,100 136,100 NO
Totals for 2006:
General Property 39.980 15,900 126,100 142,000
Woodland 0.000 0 0
Totals for 2005:
General Property 39.980 15,900 126,100 142,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
TOIJNSHIP p SEC. T j Fi / W
0. DREJS 3 . , ST. CROIX COUNTY, WISCONSIN.
V V
'I3DIVISION LOT LOT SIZE ,
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVrRYTIIING WITHIN 100 FEET OF SYSTEM
'1/
'IV
"TIC TAINK(S) ( MFGR.~ CONCRETE STEE
NO. of rings on cover Depth /2 DRY WELL
,NCHES NO. of~ width length area
no. of Zine.s Z width/? length z area
depth to top of piped '
,-LEGATE ~-a RATE AREA REQUIRFD _ n" AREA AS BUILT ,~z~'
-claimer: The inspection of this system by St. Croix County does not imply complete j
iance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
tem operation. Ho,7ever, if failure is noted the County will make every effort to
-ermine cause of failure.
-:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
"INSPECTOR -_..°_.,.r
DATED~ PL'a1BER ON JOB ~ ~
LICENSE MIBER v
f
c
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.i.tan y Penm.i,t
Sate Sep.tic/,?..'
NAME rownbh.ip St. Cno.ix County
Location /<~J _ i Section
SEPTIC TANK
S.iz C 9a.ttOn.6. Number 06 Compan.tmen.tz
I
ViA Lance Fnom: WeZZ 1,,,C) it. 12% on greaten zZope it
Bu.itd.ing Wettands ~ .
N.ighwaten - it.
DISPOSAL SYSTEM
D.iatance Fnom: WetZ 6t. 12% on greaten zZope 6t.
Bu.it ding it. WetZandd Ft.
• H ighwaten it.
FIELD DIMENSIONS:
Width o j trench it. Depth o4 no ck b eZow t iZe-ZL .in .
Length of each tine y~'~ it. Depth o6 xock oven Cite .in.
Numbers of Zinea ~ Depth o4 tiZe below grade .in.
Toxat, Zeng.th of .i.ine.6 it. Stope o6 trench in pen 100 it.
Distance between Z ines it. Depth to b edno ck it.
To.tat abz onbt.ion anew 6t2 Depth to gnoundwaten ~ .
.,Requited area it2 Type of Coven: 1"Papen Straw
PIT DIMENSIONS: y
Numbers of pits +GA vet around p.it/s ye.a no
Outz ide d.iameten epth below .inlet it.
`2
Total abzonbtion`aAea F it A
Axea nequ.i,ned' ~t2 n'
INSPECTED By a TITLE
APPROVED DATE _ 197 - .
REJECTED DATE 197
• r
01
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: Section Q1O , T.;f/-N, R /7$ (or) W, Township om- Mtim:ewP8'Wty
Lot No. , Block No. County
Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence L-' No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS Z/2-_//-77 -PERCOLATION TESTS 75
SOIL MAP SHEET SOIL TYPE--5//.A
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
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P l 5" ~eri~ l ~o Ca , S
P Z 36 At)d 3
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
/ r 7 L
R_ 3 7Zf 11 > Z.,
72 ,r a "g; k,
7Z- Zz,j 15, " A.1, S, Z2
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. lS`& l/3 0o iotnyr Iigh16 Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
i
V_ 5
- -k - - - - - Q +
t N
-I I-- a ~o
a ~ I Z ( ~ ~ ~ I l~I
05
7 -t
_ _ _ .
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) 0,4-v, v s< Imo. Certification No. Z Z~/Ff
Address 9 A) k
Name of installer if known
CST Signature
COPY A - LOCAL AUTHORITY
State and County State Permit #
PLB 6 7 w Permit Application County Permit # j
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY J Mailing Address:
1 /4'r
A ~,T) B. LOCATION: jQX) Section Z-0, TFL N, R~ k (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township O~
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY /27Zf-0 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel L/ Fiberglass Other (specify)
New Installation L---- Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate t Total Absorb Area sq. ft.
New c---- Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length S z Width z z Depth 3 " Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land O - Z 0;r7 Distance from critical slope
WATER SUPPLY: Private ❑ Joint Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester, /
NAME ie C *q-k- / C.S.T. # M 9Y and other information
obtained from (owner/builder).
-
Plumber's Signature MP/MPRSW# Phone #
Plumber's Address rf C~t•--
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
!Od . lO _ ;
f 3 3 F 7 1
E r ~ i r
~ I
\TN
~v
S
Do Not Write in Sp
10 if - T? ce Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State C unt Date
Permit Issued/ (date) - - ` Issuing Agent Name
lop,
Inspection Yes No State Valid# Date Recd
1. county (w 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 7/1/78
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 7D SL'jf~ TOWNSHIP SEC. T ' N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
jzlz
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•ZIiR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Vj
F r
24
3i C
!t 4 .
I
r I~ .
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: ff~~7,,~) Proposed slope at site:^
SEPTIC TANK: Manufacturer: j~' uid Ca acit
! f ~A P y : j -d1_1
Number of rings used: Tank manhole cover elevation: , 7 7.
Tank Inlet Elevation: Tank Outlet Elevation: 9s" ~ y
Number of feet from nearest Road.: ,
Front O Side Rear O S4' feet
',From nearest property line Front,O Side, 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:
i
Width: Length: Number of Lines: Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front,' O Side, Rear,O Pt j
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:
i _
Dated: Plumber on job:
License Number : J' -Z
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
i MADISON, WI 53707
`e"CONVENTIONAL DALTERNATIVE State Plan I.D. Narnber
If assigned)
❑ Holding Tank D In-Ground Pressure [_1 Mound (
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Dick Kruschke R. R. 3, New Richmond, WI 54017 A5 _4; pp
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF PT. ELEV.
NW SW, Section 20, T31N-R17W, Town of Stanton
Name III Plumber. IMPWPRSW Nei C<~unly Saritarv Perm-! Number
Cal Powers 1563 St. Croix 75003
SEPTIC TANK/HO ING TANK:
MANUFACTURER LIQUID CAPACITY (TANK INLET ELE. V. iANKOUTLET ELEV IWARNING LABEL LOCKING COVER
/✓.,q7-q7 CJi r 1PRIDED PROVIDED. ~~--,~,,//SN
1. X YES ONO
DYES LO
BEDDING. VENT DIA. IVENTMATI 'HIGH WA FH NUMBER OF ROAD. PROPE ,TY 1WELL IBUILDI NG. VENT TO FRESH
/ ALARM FEET FROM NE LAIR IN T
DYES NO L{ DYES NO NEAREST----*-i 7 ~5
DOSING CHAMBER:
MANUFACTURER FED NGPUMP Mtil)EL PUMP Sf 11()N ',IIIIHFf2 WARNING LABEL LOCKING COVER
PROVIDED PROVIDEDES LINO I EYES LINO DYES LINO
GALLONS PER CYCLE: PU MP AND CONTROLS OPERAT IONAL NUMBER OF PEPOPFHTy WELL BuILDIN(1 VENT TO FRESH
(DIFFERENCE BETWEEN _ FEET FROM NE AIR INLET
PUMP ON AND OFF) 1 1YES NO NEAREST-0
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing InnvETER aTrEtIALANDMARKIN(,
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:
WIDTH LENGTH No OE DISrR PIPE SPnclr`I. r)Vr=rl - INSInL:>c1 -PIr~ uoulD
BED/TRENCH IRENCHES ev+iA~~~ PIT DEPTH
DIMENSIONS L 2
911 4 GRAVFL DEPTH FILL DEPTH UIS i PIPE DISTH PIPE DISTR. PIPE MATERIAL N( ){i NUMBER OF PHOPE Y WELL BUILDING VENT TO FRESH
BF L (>1N PIPES AE3JjVE VEH EEV IIN fI ELEV END I I'll,[
LINE ] L AIR INLET
r (L/ l~ -~S (I .l4 1 c- Z`~ I FEET O
NEAR_E_ST-,_ z~
MOUN&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 NO
SOILCOVER TEXTURE 'E[TIANINTMAHKEHS OBSEHVATWNWELLS
-DYES NO _❑IYES LINO
DEPTH OVER TRENCH BED I) DEPTH ()F T()P511IL DfU SEUFMULCHED
CENTER J'EPTHOVFRTH1NCIIBF
DGES
DYES LINO DYES ENO DYES LINO
PRESSURIZED DISTRIBUTION SYSTEM: _
BED/TRENCH WIDTH LFNaTH TR EOCH ES LATERAL SPACING [GHAVEL DEPTH BFLUW VIPI FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANJOLD DISTH PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND FLFV. ELEV DIA ELEV PIPES DIA
DISTRIBUTION
INFORMATION Hr LESIZE HOLE SPACING DHILLED CORRECT t. y CDVFR MATERIAL VERTICAL LJF T CORRESPONDS TO APPROVED
PLANS
_ DYES LINO _ DYES LINO
COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LINE
CI DYES LINO DYES EINO _ NEAREST LB
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATUR E..T''~- Y TI7 LE.
DILHR SBD 6710 (R. 01/82) - -
WISCOnsln APPLICATION FOR SANITARY PERMIT
~--COUNTY
DILH oEPRRT (P« 67)
mrnT OP UNIFORM SANITARY PERMIT #
- InOUSTRV,LRBOR&HUmRn RELRTI0n5 7 !_7'
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAI ING ADDF SS 1 1
PROPERTY LOCATION CITY:
4" 1/4,.S , T Z/, N, R / E (or W) TOVILLAGE:
WN OF:
LOT NUMBER BLOCKPUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED /
v 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ 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.
X 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
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 ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of rivat sewage system shown on the attached plans.
Name) of plumber( nnt): Sign MP/MPRSW No.: Phone Number:
Plumb~jr's Address: Name of Desigpp r:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: F) Date: ❑ Disapproved
LS
Owner Given Initial
/ f(~ fQl v Approved Adverse Determination
~Aa,.n 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.
j
~i
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application tone is to be completed in lull and s.igund 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
louse"), Lhen a second form should be retained and cowpluLed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
n
Owncr of Property e.~~~jk~ kS
Location of Property //J061 4 4, Section ~C7 T N - R/~ W
Township
fi~r/? v/
Mail ing Address 7:1
JL`~
Subdivision Name
Lot Number
Previous Owner of Property C~ 1 r n
Total Size of Parcel c~
Date Parcel was Created / -
Are all corners and lot lines identifiable? A' Yes No
is this property being developed for resale (spec house) ? Yes No
Volume and Page Number -QC3;' as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Lund Contr"ut
3. Other recordings tiled with Lh" Register of Heeds 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.
_ -
- - - - PROPEU OWNER CERTIFICATION
I (We.) ee` ti6 y that ate statements on this jjotm ate -titue to the best of my (uun )
knowkedge; that I (we) am (ate.) -the owners (s) of the pnopetty de cubed in .t6un_
Ya l onmation J onm, by virtue of a wa&Aan-ty deed tecotded in the 06 Give of the
ON Registers of Deeds as Doc.umun,t No. IS OLIO__; and that 1 (we)
pnesentty own the p.oposed sit, Got the sewage Aspaae system (ot I (we) have
obtained an, easement, to tun w4th the above des ex bed ptopenty, 4on the
eons.tlcuction of said system, and the same has been duty teeotded in the 061.tee
of the County neg c J.,.c/l. of De, ti , «o 1/UC .p~
YK-®r-
,
SIGNATURE Of OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNET)
y
S T C - 105 rr
y
H
SEPTIC TANK MAINTENANCE ACIt EIEMI,] N`i' o
St. Croix County
d
k -C-
__.k
OWNER/BUYER /1, q _r,
ROUTE/BOX N~ ;%-LEIR Fire Number
CITY/STATE
tc 1_---
PROPERTY LOCATION: 41 Section l_N,
Town of s/mot r~ °1 St. Croix County,
Subdivision Lot number____
I
Improper use and maintenance of your septic system could result in
its prematurd failure to handle wastes. Proper maintenance con-
SiSts of pumping out the septic tank every three years or sooner,
if needed, by a licensed sc_ltic tank p-camper. What you put into
the System can affect the function of Like Septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to recei.vu 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 agrefs to submit to St. Croix County/.oninb a
certification form, siy,auof 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 lull of sludge and scum.
Certification form will be Sent approximately 30 days prior to
three year expiration. o
ti
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-
ment of Natural. Resources. Certification Corm must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date. CQISQt(~Dnrz2
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, c DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADIS
ON WI 53707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/-MU-NtC1PALITY: LOT X10 : BLK. NO.: SUBDIVIS,YON NAME:
COUNTY: WNER'S/BUYER',S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO,BEDRMS.: COMMERCIAL. DESCRIPTION: PROFILE DESCRIPTIONS- PERCOLATION TESTS:
0 Residence a ❑ New Z Replace
l << . %f -iS S ~iJ_ pS
RATING: S= Site suitable for system U= Site unsuitable for system a a ;
('N~~V7~
COENTION'AIL: MOUND: IN-GROUND-PRESSURE: ISYSTEM-IN-FlI ILL HOLDING TA'NIK: RECOMMENDED SYSTEM: (optional)
~--~i~ S EV ~T:` S EIU [IS EA EIS ZV EIS EJ
If Percolation Tests are NOT require DESIGN RATE: I If any portion of the tested area is in the
under s.1163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH*M. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
i
~iz
BB-
B- I
B- I i
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INC-++ES AFTER SWELLING INTERVAL-MIN. PERIOD PERIOD 2 PERIOD 3 PER INCH
P-
p_ A r
P- ti ?
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 ~ 3
f-
i N
.any
i._.-
x/o
)
:
I
3
a
I
I, the undersigned, hereby certify that the soil tests reported on this fo m were made by mein accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location ~f the tests are correct to the best of my knowledge and belief.
NAME sprint): ^ TESTS WERE COMPLETED ON:
ADD S: CER IFICATION NUM R: PHONE NUMBER(optional):
CS GNATUR `
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
N_, e _c t eas''w rn F
e ttsa :~ectrian ;nm 4:?> mly i`ithwac e vO E:r A W a (".sfd..i n or amnc3 €ei< ml Ctmjmt;
f€,!,,LJM ntArnbm of 44 "f3 ms m cm psi Et„ rZ um pFiiii#wd
<E f,- Fat Ay Y ; g bt I Eiji! ALE FOR A r OL O W `K ONLY IF ALL.
rz
Ma _ SYSTEMS ME .,Lf€_~ OUT ta-,~~'D W,.,f .3~s~€ C. ei4t._ ~ SWNS>
LEASE me o .7 Mvidi€.j< shown We 7,,. , ,7, ng F..,,W t`fr tip>CKsm and c EJfnph: inq th=.'? Not pAn;
e
~j€AKE A Lf_t-,a7€_iE dia l on amu mtcly O mhq my vat ;ical,ow- - Dravti ry l sisale is pi felr f.
Q
_ :,4x7 qyE._, U ap s''protf hoxes as to QM5 f1m s, ash m n, Hood pNir
turn it t3 pi we;
flimm won 1W) RR B&
Wll SS
£ "d L'_. R i
Dour SMA FFCC P"mm
' 1 Mn a .tea W, a
t
Lanni
S" Lom
t.
GV - C
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S,.,
Sow cby M
y PrOly, H
3 ton e
r;1 ~ r
E.iJL'iy~~~/✓i~j°Tl ' ~J/~•it J .ice -16C .2,.+r' ~
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101 '
P A C E OF
/ CroSS Sz~'l Vo ,a &i)
Sys r
Froth Air inlets And Obtervallon Pipe
[=-,)-Approved Vent Cap
Minlmum 12" Above
Final Grade
20- 42" Above Pipe _ 4" Cael Iron
Vent Pipe
To Final Grads
Moan Nay Or SynlMllc Cuwrlny
win 2" AU9repale
Over Pipe
Dl elrlbullon
Pipe 0 0 0 0 0 -Tee .
Benealh Pipe
6" Aggregate Pipe 0 Perforated Pipe Below
a -Co*pllnp Terminollnp At
Bollom Of Syetem
Pau u t ID -'I nk I g ro, cVk G? j ti
SOIL FILL
~,C)ISTIKI13UTIOIk'l PIPE
APPROVED SIJtJTHETIC COVER
MAT~iill~l OR 9" OF STRAW
Z"OFAGGR1EIGA-TE. ~j\\\OR MARSH HAS
\V
F ? 2 A G G REGA,TE oP
LLEV.OF,6FET
DISTRIR.JTIOM PIPE To Bf= AT LEAST -E IKJCHES BELOW ORIGIUAL GRADE
AKJL AT LEAS-T-20 INCHES BUT AIO MORE THAf.I tit INCHES BELOW FINAL GRADE
MAXIMUM WN OF EXCAVATI00 FKOM oKIGIMAL 6KAK WILL BE ~ WCHES
MINIMUM ®EPrtt OF EACAVATImN FKOl" o*1611JAL (3RAVE WILL 6E INCHES
r
SIG►JEO:
LIGEKJ5C AIUMBER:
DATE
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