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41
AS BUILT SANITARY SYSTEM REPORT Me.
OWNER j TOWNSHIP -R W
ADDRESS... ST. CROIX COUNTY, WISCONSIN
(A?~F. 4
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIH-R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM:
A" 1~
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: 0
Number of rings used: Tan manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,o Rear, O feet
From nearest property line Front,0 Side,0 Rear, O feet
Number of feet from: well buildin :
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
f
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: I l_ Trench:
Width: Length: Number of Lines:- Area Built:
Fill depth to top of pipe:
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).
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 & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
XXCONVENTIONAL ❑ALTERNATIVE StatesigPlanI mbe,
llf asn edl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTIO DATE
d
Da,ueU Dunn R. R. 2 , PUvetc. Fa. a , W1 / / 9/
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. JCST REF. PT. ELEV
NE SW, Section 30, T28N-RIX, Town a~ P&a~sant Valley
Na,oe of Plumber- IMP, MPRSW No.. County x e Sanitary Permit Number.
Th.amaz A. Wang 3231 f,,'''St. CAoi.x 58887
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOU CAP CITY TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL JLOCKING COVER
j PROVIDED'. PROVIDED'.
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.. VEN. MAT L, e I WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING'. VENT TO FRESH
r ALARM LINE'. I AIR INLET.
❑YES ❑NO y, FEET FROM
❑YES ❑NO INEAREST- 0o
DOSING CHAMBER:
MANUFACTURER 7ING
L
IQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING. I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FRLINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO INEAREST)M~
SOIL ABSORPTION SYSTEM. Check thesoil moisture at the depth ofplowing JLEN(,IH JIIAMETER 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:
WIDTH'. LENGTH NO. OF DISTR. PIPE SPACING; COVE. IN'.310E QIIA. -PITS LIQUID
BED/TRENCH e C,. TRENCHES . MALEH I A I PI-I• - DEPTH.
DIMENSIONS it f
GRAVEL DEPTH FILL DEPTH, DISTf PIPE -DISTH. PIPE DISTR. PIP MATERIAL. NO S R NUMBER OF PROREiidY WELL. BUILDING: VENT TO FRESH
eELOwP.I,PFS ABCy{ECO EHEv IN Er E vENrF y~_ PIPE FEET FROM LIcdEt nIaIN~.ET,!
t 46jj 7 NEAREST ~
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.
❑YES ❑NO _
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
IDIPTH OVER TRENCH BED IDEPTH OVER TRENCH BED DEPTH OF TOPSOIL j7Y SE EDED MULCHED
CENTER EDGESES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING. JGRAVEL 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.-. PIPES CIA
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS: IMBER OF PROPERTY JWELL: BUILDING:
ETFROM LINE
❑YES ❑NO ❑YES ❑NO NEARES
e } L l t L'r
s S J€(( r
f
Sketch System on Retain in county file for audit.
Reverse Side.
. ,
ITITLE
77E
DILHR SBD6710(R.01/82)
wls~onsln APPLICATION FOR SANITARY PERMIT 14 COUNTY
DILHR
(PLB 67) UNIFORM SANITARY PERMIT #
~ oEPRRTmEnT of
Inr1USTRV, LRBOR 6 HUMFIn RELRTIOns
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
r - e l pea lei CT
PROPERTY LOCATION (:ITY:
1/4501/4, s je) , T,2j N, R E (a W) OLLN P~lellf Ile .
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME AR ST 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.
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~1-1)
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: 1,0
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):
3 L-~C //;0 'y
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name f Plumber (Print): Signatur . MP/MPRSW No.: Phone Number: r
( .Ol t, ~ ?1 ~ ( 1 i~/;' 1 ;s' -1 /
Plumber's Address: Name f Designer:
PA r
COUNTY/ DEPARTMENT USE ONLY
;;I
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
Owner Given Initial
lye
-7 X 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, Oavner, 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.
Norm - S T C 100
Owner of Property r-r_ 4
Location of Property 115 14 Juj !4' section J-- 1'o -W
'
Township~J~TIG ( PIZ -
)~I /
ailing Address
M 's _6 `/t
Subdivision Name
Lot Number
Previous Owner of Property &ju oupn
't'otal Size of Parcel_ ' ' II-fs
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the followi-nom:
.Certified Survey Map
.Deed
.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 de d re o 0 - 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 easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of~the~County Registe Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
r-J lam ,
DHTE SIGNED -
DHTE SIGNED
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER e Fire Number
CITY/STATE J~r IP 5~
PROPERTY LOCATION: _~4, Section T ~ k N, R _W,
f~ I
Town of St. Croix 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 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 H
three year expiration. °
I/WE, the undersigned, have read the above requirements and agree U)
to maintain the private sewage disposal system in accordance with ro
the standards set forth, herein, as set by the Wisconsin Depart-
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.
SICNED_
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
N
INDUSTRY, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 53709
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: OW SHI /MUNICIPA ITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
'14b)1 ire--NiR/P E ~r~ -
COUNTY: OW R'S/BUY 'S NAME: JM A DRES
USE I 1 DATES OBSER ITAV NS MADE
PROFILE DESCRIPTIONS: PERCOLATION TESTS:
NO,BEDRMS.: COMMERCIAL DESCRIPTION: :IRRe:place
Residence ❑New
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEIVDED SYSTEM: (optional)
Q S ❑U ZS ❑U 1 2S Ell ❑ S ]U ❑ S ®U ,661
If Percolation Tests are NOT required DESIGN RATE:
> If any portion of the tested Brea is in the
under s.H63.09(5)(b), indicate: j S Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH TFIICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) F
i
B- 33
J a~ `~.y~ SJ . DC~ ! 33? G bt ? 33 .
B 9 &1 Asa -5
7
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INC-iES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
p_ 2 ,33 b~
_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
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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 (print): i t TESTS RE COMPLETED ON:
ih3 G? ._7 S ` f
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ADD E S: / 1 CERTIFICATI N NUMBER: PHON ,N~UUM ER(optional):
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Parcel 024-1036-40-000 10/16/2006 03:52 PM
PAGE 1 OF 1
Alt. Parcel M 30.28.17.232B 024 - TOWN OF PLEASANT VALLEY
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 - SWENSON, ERIC & MICHELLE
ERIC & MICHELLE SWENSON
148 CTY RD W
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description 151 CTY RD W
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 30 T28N R17W IN SE NW & IN NE SW Block/Condo Bldg:
BEING LOT 1 OF CSM 2/454,TOWNSHIP
PLEASANT VALLEY. Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
30-28N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1045/374 WD
07/23/1997 783/349
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/03/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 33,000 127,600 160,600 NO
AGRICULTURAL G4 2.000 200 0 200 NO
Totals for 2006:
General Property 5.000 33,200 127,600 160,800
Woodland 0.000 0 0
Totals for 2005:
General Property 5.000 33,200 127,600 160,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 146
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 024-1035-50-100 10/16/2006 04:02 PM
PAGE 1 OF 1
Alt. Parcel 30.28.17.227B 024 - TOWN OF PLEASANT VALLEY
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 - SWENSON, ERIC & MICHELLE
ERIC & MICHELLE SWENSON
148 CTY RD W
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 151 CTY RD W
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 38.000 Plat: N/A-NOT AVAILABLE
SEC 30 T28N R1 7W SW NE 64.19 ACRES THAT Block/Condo Bldg:
PART OF SW NE DESC. AS FOLLOWS; COM S
1/4 COR SEC 30, N 2202.52' TO P.O.B. N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
1749.28' TO NW COR. SW NE SEC 30, S 89 30-28N-17W
DEG E 1173.74',S 2 DEG W 282.59'S 18
DEG E 583.82', S 23 DEG E 398.96',S 30
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1005/341 WD
07/23/1997 828/618
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/21/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 34.410 4,000 0 4,000 NO
UNDEVELOPED G5 1.590 300 0 300 NO
OTHER G7 2.000 6,000 7,200 13,200 NO
Totals for 2006:
General Property 38.000 10,300 7,200 17,500
Woodland 0.000 0 0
Totals for 2005:
General Property 38.000 10,400 7,200 17,6000
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch 216
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00