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' Parcel 042-1023-50-000 01/17/2007 08:21 AM
PAGE 1 OF 1
Alt. Parcel 09.29.18.132 042 - TOWN OF WARREN
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 - LIBBY, BAYARD B & JOANNE
BAYARD B & JOANNE LIBBY
1074 120TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1074 120TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 9 T29N R18W SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
09-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
149132 Use Value Assessment
Valuations: Last Changed: 07/20/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 25,000 200,300 225,300 NO
AGRICULTURAL G4 37.000 3,500 0 3,500 NO
UNDEVELOPED G5 1.000 100 0 100 NO
Totals for 2006:
General Property 40.000 28,600 200,300 228,900
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 28,600 200,300 228,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 217
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
i
AS BUILT SANITARY SYSTEM REPORT
OWNER urn 2, LJ' _ TOWNStIIP rrm SEC
ADDRESS ZO ST. CROIX COUNTY, WISCONSIN.
0
S U B D VISION - _ L O L - LOT SIZE O QG(Q.,a,/
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERY'T'HING WITHIN 100 FEET OF SYSTEM
s
I
x'
IL
'l!~/rg "oNN
77-
~ Gf! , Yd
0
I lndi at N r It rrc w
151{NCHMARK: (Permanent reference Point) Describe: s6 Cce)fer m~ -'y✓Oeen'~
Elevation of vertical reference point: "Ole / ----Slope at site:- !Q
SEPTIC TANK: Manufacturer: wr,~,~s Liquid Capacity:
Number of rings on cover e- Tank manhole cover elevation
r
----'l'ank In-Let Elevatio_n:_ Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
NUlllber of gal. pump set t:or a. cycle___ --gallons; Total capacity of
distribution tines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number
Type of warning device HOLDING TANK: Manufacturu -r _ Number of gallons
1%'Ievation of manhole, cover ,
SHOW EVF.RYTIIINC WITHIN 100 FEET OF SYSTEM
S
FT
la
i
am
q~ir' oaN
wri
_ - 6 71r^
Indi I at N r h rr(I w
Itl!NCHMARK: (Perruanent reference Point) Describe: CO✓)fer
Elevation of vertical reference point: Slope at site:
'-;C:11 T-C TANK: MailUl-acturer: Liquid Capacity: _ _
Nurnher o l rings on cover Tank manho le cover elevatio
e
_ ,rank LnLet I Levation: Tank Outlet Elevation: _
PUMP CHAMBER
Manufn(- turer: --,-.----Number of gallons
Number- of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of pump head;
ga.L l_on per mi_nutc. horsepower ;brand name of pump
and model number ;
'T'ype of warning device
1IOLI)ING TANK: Manufacturer Number of gallons
LAevation of manhole cover-- _ ,
Type of warning device
SEEPAGE PIT S LLI?; Number of pits feet diameter
feet 1_Iqui_d depth- seepage pit -inlet pipe-elevation
bottom of seepage pit elevation _ feet.
SEEPAGE: BED STZI . number of Lines .3 width 1¢length,3r stile depth
,;LJ'11AGG. TRL;NC11: w[dtoll
_ _ length- -
T'ERCOLATION RAT F. _ A1: EA REQUIRED-S^ AREA AS BUILT
INSPECTOR
r~
llAT1;D ZO I 'LUMBER ON .IOB__~~
= - G
LICLNSE NUMBER_
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, Wi 53707
12CONVENTIONAL E] ALTERNATIVE State PIan J.D. Number.
(If assigned)
E Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
I B. Bruce Libbey RR~~1, Box 318, Roberts, WI -0~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PL LEY..
SE NE, Section 9, T29N-R19W, Town of Warren
Narne of Plumber. MP/MPRSW No County. Sanitary Permit Number:
D. Fogerty 3289 St .Croix 43676
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKI CO _
e-, C) q P OV ED. PROV ED
A ) h, S L/J YES LINO S NO
BEDDING. V T D A.. V T MATL. HIGH WAT NUMBER OF ROAD: OPERT WELL. JBUILDING: FRESH
LINE JIENT'rO
AIR INLET
ALARM FEET FROM
❑ /C
O p NEAREST PR
❑ YES XABER:
DOSING 1MANUFAGTURER BEDDING OUID CAPACITY PUMP MODEL 111IMP,S11HON MANUFACTURER ARNING LABEL LOCKING COVER
I f `PROVIDED: PROVIDED:
EYES ENO EYES ENO EYES LINO
GALLONS PER CYCLE: P UMP AND CONTROLS OPERATIONAL. BER O,F' PROPERTY WE L BUILDING .I VENT TO FRESH
(DIFFERENCE BETWEEN ?FFEE1T FROM LINE AIR INLET
PUMP ON AND OFF) EYES ENO REST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ,TH DMMARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until 'Mppo E
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDT L 3GTH No of DISTR PIPE SPACING COVER JINSIDE DIA =Plrs uoulD
. '
TRENCHES C10 A-r OVE- IAL. DEPTH
PIT
DIMENSIONS Ll `
CRAVEL DEPTH FILL DEPTH I)ISTH. PIPE DISTH. PIPE DISTR. PIP.MATERIA NO. R NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
HE Low PIPE ABOVE VEH ELEV. ILLF f ELEV EN-D7 PIP
S FEET FROM ,LINE. AIR IJr1LE
l'~ / NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture :-of the fill material for 4 PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
E Y ES E meets the criteria for medium sand. TIONS MEASURED.
NO
SOIL COVER TEXTURE PERMANENT MARKER OBSERVATION WELLS
EYES ENO EYES ENO
DEPTH OVER TRENC H.'BED DEPTH OVER TR ENC HBED DEPTH OF TOPSOIL SODDED ' SEEDED MULCHED
CENTER EDGES
EYES ENO EYES ENO EYES ENO
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. DIST DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV, ELEV.. CIA ELEV.' PIPES CIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES ENO EYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING:
FEET FROM LINE
o EYES NO EYES ENO NEAREST
Lt
S
IV
Sketch System on R
etas county file for audit.
Reverse Side.
SIGNATUR'wr'' TITLE. i"
DILHR SBD6710 (R. 01/82)
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 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.
Proporty Owner: Mailing Address:
1 4,4&
4111
Z
Property Location: City, Village or Township: County:
1/4 j~t/aS /T~ NiR E (or) Gc1 r. T -
Lot Number: BIlk No.: Subdivision Name: Nearest 'Road, Lake or Landmark: State P4 n I.D. Number:
If assigned)
4
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* - - d Bedrooms:
01 or 2 Family *State Approval Required.
3
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY r;
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: L2,- S
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental ESeepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
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: r s' MP/MPRSW No.: Phone Number:
) 9c?'?)
Plumbers A d ess: Name of DesigpEC:_-
I /V le-1 Z
COUNTY/DEPARTMENT USE ONLY
Signa ure of Issuing Ant- Fee: / Date: APPROVED Sanitary Permit Number:
is 4 ❑ DISAPPROVED
Reason for Disapproval:
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
DILHR-SBD-6398 (R.07/81)
Wisconsin Department of Industry,
PLB-1 INSPECTION REPORT Labor & Human Relations
Safety & Buildings Division
Bureau of Plumbing, Platting & Fire Protection
Name o remises Date an No.
Street City County Sanitary Permit
Master Plumber irm Name dress
Journeyman Plumber Address
Owner Address
- - - -
igna ure
180) Signature o is Plumbing up. On-Site Waste Specialist
Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner
el out. f•c! .lete~ f_ rr Form j
- S L 100
of . IE - 6;' to co. il, .r of-ic'e'
Owner of Property
111111re-
,Location of Property~4 SF Section- 9 TgN R
Township_ 4dyr/-ejj
Mailing Address JZ%
r
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners identifiable? Yes No
Include with this application one of the followinL:
,"Certified Survey Map
e el-)
/ Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an casement, to run with the above described property, for the
construction of said system, and the some has been duly recorded in the Office
of the Co my Register f Deeds, Document No.
i
SIGNATU OF O NER SIGNATURE OF CO-OWNER (IF APPLICABLE)
1
DATE SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS~'`RY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
LOCATION: SEC ION: OWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
F'/~s~1a 1Ta9 N/R rrE (o &ja r1Pek1
COUNTY OW ER'S BUYER'S NAM MAI NG ADD ESS: pp /
USE DATES OBSERVATIONS MADE
r~ NO. BEDRMS.: COMMER~!AL IPTION: R F ONS: ER LA ION TESTS:
AEI Residence r 1:1 New9eplace Q'3 ~i, jU p
RATING: S= Site suitable for system U= Site unsuitable for system (J `Z ! 0
CONVENTIONAL: MOUND: IN-GR)UND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
17-771
S ❑N NS is ❑U ❑S ®U ®U 46~.
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V.
I If any portion of the lot is in the
under s.H63.091511b1, indicate: D QU I` Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B / b''yss > s~ 15v 81 s; I /,so Bn l ~:~'o B atd
13- ?3 Sh 3VIdr
B 3 ~.vU N-9d NA X900 .33 6I si 7 6) 3.6 01 k? 546 r
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN HES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ r a' s O /v 11 / ~ I
P- P d Cd >e~ 1 l P-
P- 3
P
-
P-
PLAN VIEW: 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 slop.
SYSTEM ELEVATION g) .06
Q,t
A'l `
C ew!
S ~A
}fa
tN
e
ra m
G tie 1,
10
pole
d=Red Dow 14 SE, core t- ~ireen hot15-c /vv`. m r3• 83
i, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative 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 C MPLETED ON:
o~fa S lc.~st .l~ S` ~
ADDRESS: t CER F C T ON N BE PHONE NUMBER optional):
`GO ~cvifv F S In It
CST SIGNAT
t~~ /
hhL9395 : Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
(N. 03/81)
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