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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISI~N, WI 53707 ~pT~
IXYCONVENTIONAL ❑ALTE RNATIVE is,,,, Plan 1,D. Number:
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Gordon Mueller R. R. 2, River Falls, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV.
SE4 NE4, Section 10, T28N-R18W, Town of Kinnickinnic
Name of Plumper. MP/MPRSW No_ Ic'. my Sanitary Permit Number:
Thomas Wang 3231 St. Croix 54927
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
❑ YES ❑No ❑YES ❑NO
BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL BU ILDING. JVENTTOFRESH
ALARM FEET FROM LINES. AIR INLET.
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER 71 LIQUID CAPACITY PUMP MODEL 71PH ON MANUFACTIIH EH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
S ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF FR OPFRTV WELL BUILDING .I VE NT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 FN(ITII jD1AMFTFH 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:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING; COVER JINSIDE DIA =PITS LIQUID
BED/TRENCH TRENCHES MATERIAL. T IT DEPTH.
DIMENSIONS
GHAVFL DFPTH FILL DEPTH DISTR. PI PF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PR OPERTV WELL BUILDING: VENT TO FRESH
BFLOW PIPES ABOVE COVER EI EV. INLET ELEV. END
I PIPES FEET FROM LINE'. AIR INLET.
NEAREST--
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED ~DEPTH OVFR TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
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
ELEV.. ELEV. DIA.. ELEV.' PI PES. DIA.:
ELEVATION AND
DISTR IBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL pLANSCAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: TNLJMBER OF PROPERTY WELL. BUILDING.
ET FROM LIN❑YES ❑NO ❑YES ❑NO EAREST
,ystem on Retain in county file for audit.
,ide.
71~~E. JTITLE.
6710 (R. 01 /82)
ws~onem -7 APPLICATION FOR SANITARY PERMIT ~L' t.~ COUNTY
D L H R (PLB 67) UNIFORM SANITARY PERMIT #
DEPRRTTT1EnT OF
InOUSTRV,LRBOR
&HUMRn RELRTIOnS S a
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
i PROPERTY OWNE MAILING A DRESS / l
%
0 6 w i 6 P . le !
1. )",y PROPERTY LOCATION CITY:
ILLAGE:
S'114 E1/4, S T,2t, N, R It E (or W T O ft l/1
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
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 Cham er
Holding Tank capacity
Manufacturer. Pre "Z`
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):
G' 1l1 1 b 0 1/ A Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installa ion of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signatur MP/MPRSW No.: Phone Number:
'Vto /,-(A 5, G.)a LY I.A-0? U, j 3 (A/s- ) kd djP;SsP
} Plumber's Address- ` Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
/ / / ~~J" ~i~ ❑ 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 I 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
Lou<rt ion ofProperty j LCD i4, Section T N - R W
Township 1 y1 Y1 C t 1r~ vU L
Mailing Address
Subdivision Name
Lot Number
y'v l
Previous Owner of Property
Total Size of Parcel j4 c c
Date Parcel was Created
Are all corners and lot lines identifiable? X_. Yes No
15 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 A 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) cattily that all statements on this jonm ate t.ue to the best of my (out)
bKowkedge; that I (we) arm (ate) the ownen(s) oU the pnopenty descAbed in this
in6onmat on Aonm, by v,&t-tue o6 a waytanty deed teeonded in the 066ice of the
Couo ty Reg.i Ket o6 Deeds as Document No. QI and that I (we)
vteserttYy own the pnoposed site ~on..the. sewage oaae s
p ystem No I (we) have
obtained an easement, to nun with -the above de6ehibed pnopehty, 4on the
con6tAuct,(on, o6 said system, and the same has been duty neeotded in the 016iee
06 the County AQUA o l Deeds, as Document No. ) .
SIGNATURE OF OWNS SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
Cl)
~-i
y
ST C- 105 rr
• y
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County
d
OWNER/BUYER_ GO,"' e
~ jL 3 t Fire Numberz
ROUTE/BOX NUMBER ~ e,
CITY/STATE- j,_L,. ru^I~~, l~ ZIP
PROPERTY LOCATION: `4 ~4, Section T_;~j_N, R_ W,
Town of St. Croilc County,
Subdivision- , 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 p_umper. 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 LuAy be eligibte 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.
0
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- w
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. y
S I G N E D
DATE St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015 I
715-796-22;:9 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN ~iELATIONS \ / MADISON, WI 53707
4 (H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TO NSHIP/MU ICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
!34ff /TPFN/k/?E (o r , - ' -
COUNTY: OWNER'S/BUYER'S NA AILING ADDRESS:
r
USE rv/ C~ c y, S' v h'~
NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVA IONS MADE
PROFILE DESCRIPTIONS: PER LATION TESTS:
Residence
❑New 'Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IIV-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
Funder 7s.H63.09(5) ion Tests are NOT required DESIGN RATE: ,
(b), ind icate: If any portion of the tested area is in the
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. H/IGHEST TO BEDROCK IF-OBSERVED
(SEE A-B+BRV. ON BACK.)
B- If
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES E MN
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PER OD 3 RAPER (INCH ES
P- 58 d 10 12
P-
P_
P:
PLOT P-
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 bl,
-MON
,
I
Q = _1perc poles
ln1 / 1 dtj SIV/
tekyl,eklf FI'WS t &SCkletl t W11j data
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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 rint):
TESTS WERE COMPLETED ON:
n
ADDRESS: l~j - f4 le Fy
CERTIFICATION NU BER: PHONE UMBER(optional)
0-) 1 715-,o, 541 i5Z
CST SIG ~~eRj~E:
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Parcel 022-1028-40-000 11/29/2006 12:05 PM
PAGE 1 OF 1
Alt. Parcel 10.28.18.148 022 - TOWN OF KINNICKINNIC
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 - PEARSON, RICHARD N & JEAN M
RICHARD N & JEAN M PEARSON
1109 CRESTVIEW DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 452 OLD CEMETERY RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 10 T28N R18W SE NE EZ-UT-1333/585 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
10-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/21/2005 807002 2892/561 AFF
09/02/2005 805307 2880/603 WD
11/07/2000 633139 1557/129 TI
07/23/1997 989/59 TI
more...
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 08/10/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.000 5,500 0 5,500 NO
OTHER G7 3.000 25,000 114,000 139,000 NO
Totals for 2006:
General Property 40.000 30,500 114,000 144,500
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 30,500 114,000 144,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 207
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00