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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Ow net(s): O = Current Owner, C = Current Co-Owner DONALD.,IPd NIEL DALTON O - DALTON, DONALD, BELINDA & DANIEL f~ 1637 100TH ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description ' 1643 100TH ST / j ~-1--- SC 3962 NEW RICHMOND 1( SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC An, Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 8 T30N R1 8W 40A NW SW DONALD AND Block/Condo Bldg: DANIEL EACH HAVE AN UNDIVIDED 1/2 INTEREST IN AND TO NW1/4 OF THE SW1/4 OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) SECTION 8, TOWNSHIP 30N, RANGE 18W 08-30N-18W Notes: Parcel History: Date Doc # Vol/Page Type 01/18/2001 637032 1577/030 WD 01/18/2001 637031 1577/029 WD 02/08/1989 445312 833/482 LC 02/08/1989 445311 833/480 LC 2008 SUMMARY Bill Fair Market Value: Assessed with: 283109 Use Value Assessment Valuations: Last Changed: 09/09/2008 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 35,000 190,400 225,400 NO 05 AGRICULTURAL G4 35.500 6,000 0 6,000 NO 05 UNDEVELOPED G5 0.500 100 0 100 NO OTHER G7 3.000 27,000 256,200 283,200 NO 05 Totals for 2008: General Property 40.000 68,100 446,600 514,700 Woodland 0.000 0 0 Totals for 2007: General Property 40.000 25,300 354,300 379,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 120 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 9 c7 d 0 to O 0 CA O 1m o 0 d F d F ° C ° (D o -0 I c~D ~ ~ 3 I ~ ~ ~ ` 1 = v z o A p o o • o 0 O w N O A N O M N O A N Ci 0o ONi c0 CD B- 3 Z a m N W 0 Z Q CD N c° o 3 0 0 ~l c CD CD O N M N D) a v 90 N N N (Wy N N CO "o o :3 u M :3 CD 3 N CD N 0 N O O w C cD N O 8 ' F (D .N. 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Parcel 8.30.18.112 026 - TOWN OF RICHMOND ST. CROIX COUNTY, WISCONSIN Current X Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Owner(s): O = Current Owner, C = Current Co-Owner Tax Address: O - DALTON, DONALD, BELINDA & DANIEL DONALD, BELINDA & DANIEL DALTON 1637 100TH ST NEW RICHMOND WI 54017 * =Primary Districts: SC = School SP = Special Property Address(es): Type Dist # Description * 1643 100TH ST SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 8 T30N R1 8W 40A NW SW DONALD AND Block/Condo Bldg: DANIEL EACH HAVE AN UNDIVIDED 1/2 Sec-Twn-Rng 40 1/4 160 1/4) INTEREST IN AND TO NW1/4 OF THE SW1/4 OF Tract(s): SECTION 8, TOWNSHIP 30N, RANGE 18W 08-30N-18W Notes: Parcel History: Date Doc # Vol/Page Type 01 /18/2001 637032 1577/030 WD 01 /18/2001 637031 1577/029 WD 02/08/1989 445312 833/482 LC 02/08/1989 445311 833/480 LC 2006 SUMMARY Bill M Fair Market Value: Assessed with: 176808 Use Value Assessment Last Changed: 06/22/2006 Valuations: Total State Reason Description Class Acres Land - Improve RESIDENTIAL G1 1.000 13,500 155,9000 1649,400 NO 05 AGRICULTURAL G4 35.500 4,600 100 NO UNDEVELOPED G5 0.500 100 205,800 NO OTHER G7 3.000 7,400 , 198,400 Totals for 2006: General Property 40.000 25,600 354,300 379,900 Woodland 0.000 0 0 Totals for 2005: General Property 40.000 25,400 354,300 379,700 Woodland 0.000 0 0 Batch 120 Lottery Credit: Claim Count: 1 Certification Date: Specials: Amount Category User Special Code Special Assessments Special Charges Delinquent Charges 0.00 0.00 Total + s Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER] TOWNSHIP SEC. j( T ' N-RW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to tlieet requirements of ii 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM llous~ /©00 &R a -70 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site:, SEPTIC TANK: Manufacturer: r!xa Liquid Capacity: y ~r Number of riiigs used: Tank manhole cover elevation: Tank Inlet Elevation:___- Tank Outlet Elevation: Number of felt from nearest Road: Front , Side, 0 Rear, C) Feet From nearest property line Front,0 Side, OA Rear, feet Number of feet from. well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) S II)I, SEE RE ',k'SI-' • PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Punlp 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,~Side,~ Rear, Ft. Nufi'~er of feet from well: Number of feet from building: (Include distances on piot plan). SOIL ABSORBTION SYSTEM Bed: 7 - freuch:~~` Width: / Length: Number of Lines: Area Built: Fill depth to top of pipe: L Number of feet from nearest property line: Front, 0 Side, Rear,, 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 0 0 or disc-r.ibution box 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, 0 Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: f,. 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 y-~ XX CONVENTIONAL ❑ ALTERNATIVE slwtae -a ,D. Number (ssi gned ) l/2 U~i• ❑ Holding Tank ❑ In-Ground Pressure L11 Mound I I NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE-. James Datton R. R. 4, New Richmond, W1 54017 i ' BENC ARK (Pe) r a en[ reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF, PT. ELEV. NW SW, Section 8, T30N-R18W, Town o4 Richmond N- ! Plumher. MP/MPRSW No. County. Sanitary Permit Number. Donavin Schmitt 3205 St. Cnoix 49469 SEPTIC TANK/HOLDING TANK: MANUFACTURER.. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET E V WARNING LABEL LOCKI G CCTYER 0,4 jo -ArCt .y ~ ~ P IDES PROV ED. 4V( E{ , YES ❑NO S ❑NO BEDDING. VENT DIA.._ VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL 11111-11TIG FRESH AIR INLET. FEET FROLINEJVENTT' ❑YES ❑NO ❑YES ❑NO NEAREST 1f 3~° ((s DOSING CHAMBER: MANUFACTURER BEDDING. 1-11111111 CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL JLOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NCI ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PHOPERTV JWELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM NE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST 11111, SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 17FNaTH DIAMETER MATERIAL 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. JLENGTH NO. OF DISTR. PIPE SPACING CO INSIDE DIA LIQUID BED/TRENCH THENCHE M ERIA PIT DEPTH DIMENSIONS Z GRAVEL DEPTH FILL DEPTH DISTR PIP DISTR. PIPE DISTR. PIPE MATERIAL. . INUMBERI PR OPER FY WELL. BUILDING. VENT TO FRESH AIR I LE T, J.A 1q, BE LOW PIPE ABOVE COV ELEV-INLk) E1-EV. END P FEET FROM uN l 2-', C',' C, L t: NEAREST- r.► d ✓ ///Z u MOUND SYSTEM: Mound site plowed erpendicular 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 SER NATION WELLS If /I YES ❑N ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH iBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED. CENTER EDGES YES ❑NO ❑YES ❑ ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING. 17L DEPTH ELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE M MAT IAL. NO. ISTR. JD~STDISTRIBUTION PIPE MATERIAL & MARKING ELEVELEVDIAELEV.PIP SDA.: ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY C VER ATERIAL ~ PLANS CAL LIFT CORRESPONDS TO APPROVED ❑YES /NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. MBER OF PROPERTY WELL: BUILDING. FE U ET FROM LINE: ❑ YES 1:1 NO El YES 1:1 NO NEAREST I J 3fO t L~ Sketch System on ain in c file for audit Reverse Side. SIGNATU TITLE DILHR SBD 6710 (R. 01/82) c Wisconsin APPLICATION FOR SANITARY PERMIT (L~DILHR COUNTY (PLB 67) ~ OEPRRTTT 1EnT OF UNIFORM SANITARY PERMIT # In OUSTRV, LRBOR 6 HUmRn RELRTIOns C -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 7 r ~ L 7L 'y TL I LCL~' ~~/C11 "~v I't ) yl/ / PROPERTY LOCATI N CITY: V i z 11/4, 0- 1/4, S , T. N, R LL E (or W/ OWN OF' i s 171~ (,.A,(,0 NUMBER BLOCK NUMBER SUBDIVISION NAME EAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER A NA y LL C iLL_> TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms. 711 ❑ Public (Specify): THIS PERMIT IS FOR A: K 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 - E] 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 =t , i Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: ! t /C n L ll / 5 IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound ❑ In-Ground Pressure Total #of refab. Site Steel Fiberglass Plastic Gallons Tan .9on.rete 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): 7 -_3 Private L] Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: M MPRSW No.: Phone Number: i44 I 2'Al 51 Plumber's Address: / Name of Designer: X1 T- COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved Owner Given Initial 'yv l y ~~y It 4. r- FF Approved Adverse Determination Reason for Di pproval: 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/contractgz,("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 ~~=s ~~LT(J Location of Property JV60~-4 (V '4, Section T,3 N - R Z,? W Township 91C)}-/-101YO Mailing Address f , L/ R/ Ch, VOWO S-Y01 7 ^ Subdivision Name Al11 Lot Number, Previous Owner of Property T Total Size of Parcel Date Parcel was Created , Q Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes- No Volume i and Page Number l<< 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) eeAti y that aU statement6 on this bonm one true to the best ob my (ouh) knowledge; that 1 (we) am (ore) the owner (,s) o6 the pnopeAty da n ibed in thin ,inbonmation bonm, by viAtue ob a wa4Aanty deed neconded in the Obb.ice ob the County Regii 6teh o6 Deed6 as Document No. C ,Y and that I (we) pnesentty own the pnopobed site bon the sewage d poystem (oA 1 (we) have obtained an easearent, to nun with the above deaehibed pnopenty, bon the co"t&uction ob eaid 6ystem, and the same has been duly neconded in the Obb-ice ob the County Regizteh ob DeeA as Document No. ~1 J ) . SIGNATURE CF OWNEI. SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED nATE SIGNED ' U7 STC - 105 r ~ y SEPTIC TANK MAINTENANCE ACIZEEMLN'T ~ 0 St. Croix County 0 WNER/B1iYEll--- -!~L-T'C~A - ~ Ik 0IJ'1'F B 0 X NUMBER, ~rGh4AlCIAI I~'ire Nuwbcr C I TY STATE _1'ltul'l:lt''Y LuCA'1' luN.. ~'r' "a > 4> S e c L i u it '1' j c'N 1, W, To wit Of St. Croix Count SIt bdivi iuit Lot It Umber lit l,ruper use 'fattd IliaLILL enaucu oJ. your septic system could result in iL.; premature failure to handle wastes. Prober maiutunance CUn- si -std o f pumping Out the septic tank every three ye- ars or sootier, if needed, by it IiCertbed SeLLC L'ait k Y -UmLer. W hat you put into the system c:ait affect Lhe luncLiou of Lite, septic Lank as a Lreat - mt"Air s tage fn Lite waste d~ispusaI system. St. Croix CODUty residents m<1y be eli);ible to rucuivc a );rani Cur a maximum oil 607 01 Lite Cost. of replaCenaenL of a fallfit L; system, which was in operation prior to July 1, 1078. St. Croix COMILy accepted this program in August of 1980, wi_tlt the requiremenL tltaL owners of all uew systems agree to keep their systems 1) ruperIy ma rota -i_ned. 'l'ike 1)ro1) erty owner agrees Lo submit to St. CrOi-x (A)MILy Zoning a certiticatiun forill , si-gucd by LltL- -finer anu t,y a ,Laster plumber, journeyman pLuulber, resLricLed plumber or a liCensed pumper veri - fying that (1) the on-site wastewater disposal system is in pumper upe.raLLug condition and (2) after inspection and pUmpini, (1f tteC - essary), t he septic tank is less than 1/3 full of s1_udge and scum. Certification turn will be seat a1) proxi.mstely 30 days prior to three year expi-rat Lon. 0 1/WE, the Undersigned, have read Lite above requirements and agree Un to utairttaiu Lite private sewage disposal system in aceurclance with r, the standards set forth, herein, as set by Lite Wisconsin 1) eparL - uleut o f NaLura I- Resources. Certit'icat ion I.orill must be Completed and returned to the SL. Croix County Zuni.ng Office within 30 days of the three year expiration date. S L C N Ell , s~ ✓ `~3 CaZ-~Z~--' DATE St C,-uix County ZonLng Office P.O. 13ox 96 llanunond, W1 5/1 015 715-71)0-2230 or 715-425-836'3 Si);n, data <_tnd rr--turn to above address TMEN _F OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IND-LJSTRY, 1 C DIVISION LABOR AN 0 P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: ITOV7710P4 Mt}N+E IA71z T-Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: '/awe ~/a /T N/R 1 1or1 W xv--\, 0., c6 v /-r' I'd /d COOU\(VT}; OWNER'Sltb-Y-€R'$ NAME: MAILING ADDRESS: ` c> 0 1',_ 1 lth+' l U6 VQ/ 7 USE DATES OBSERVATIONS MADE NO. BEDRI'COMM RCIA L DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ^Jew ❑Replace e p rf y} RATING: S= Site suitable for system U= Site unsuitable for system C1 7 l CONVENTIONAL: MOUND: IfV-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptional) s_ ou ®s ❑u ~ s au ❑ s au a s ®u ~ - [under Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ,5frv~~j PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER 9Effl! d ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) z 3 Sc~ J J ` B- S B-2- 0 1 1~~ _1-L . t3n.r1 '~~~~,~.~~.•s. B- 3 U. rr z l acs , ~ B-41- 7 ,2-0 y J 7 j{J d ~t7 ~ I 13 n. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I"', GIIE, AFTERSWELLING INTERVAL-MIN. PERIOD( PERIOD2 PERIOD3 PER INCH P_ I .t . D 3 C 3 r h P- 3 T-f 6d ) ? V'/ 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 i - - ~1 {v i ~E b~ rlp r P0,54- r lit' E - p 3_) Oij I 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) TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): 7cg8hr9 l ~~fi~/ Z Z_ `>/s" Z~~- zov CST SIGNATU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER F.o _ HUGNAW PC"" 0e.. i m t. ti. _ . i" _ of v.. Q W + 3 t3€. ,3;€`.ahiE.. y v .1 " SITE IS ERIE! 403i OT. E,RSk `"fin., E H LED NJIF R LL D'iN X)iL 4J1e iT!0;_ , 15x 6E we he A r.a.:..,_315 der.... r jd., m,> m a 6 , 14-nm rs* •n TAKE ~~`~att3L. .Fa£j ..F r, r€aci N Ar=MC.FY ;JCYiI" tut P`GE?tirtF'.S. D_ Eg .._e: , ,W ',FS at, Ova [ . vay b c =1 F , fig='d , r <w ire K , and ,"_1 wa., ' r lain! d, , cl E.t y shown, mid are rxnr a xf Q it aFi?n, , asv 5uN",PS as r tY <i. C nz*t2 r.d(,'1 E1_. ,)latry ke", t.,~ if 10 r v . , N u 0ev v , t; tF_,,rte, o _ at ck,F ~ Ao_- R._A_ the Fpp°YIF6afie b =r a a R HNvank Cub0c Q, 05 ES swvmor~m aw6l , m LS Lmons I Swil Ewa Sany! PPam Pu e r Al ~y F Son], B 0m.f _ ict;iSy ff<, ° ) s 3 t~A Lai T .n~ l 3 Los iThads Loan on Enzy- Si ` l G y n) R 10! SOW Clay Lmos, mot Mmov F S ON U K's, -N QUO imp"numt vata,i _ s i, MWO Of 1% n ; 101 in 'mv & x "Al . , -r the onwitij 0 , rn~j 5- d r b 1, e - -a wpm, -'TER r TOWNSHIP SEC. T N, R W 0. ADDRESS ST. CROIX COUNTY, WISCONSIN. `3DIVISFO~V LOT LOT SIZE , PLAN VIEW -Distances & dimensions to meet requirements of H52.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM rr f -'TIC TANK(S) MFGR. CONCRETE STEEL NO. of rings on cover Depth DRY WELL 'NCHES NO. of width length area no. of lines width length area depth to top of pipe ` 3REGATE .a RATE AREA REQUIRED AREA AS BUILT 'Claimer: The inspection of this system by St. Croix County does not imply complete pliance 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. However, 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 DATED PLUMBER' ON J B LICENSE NUMBER Z RFPOPT Or I11SprCTI0'.I--1NDIVIDTJAL SEWAGE DISPOSAI, SYSTEM Sanitary Permit i~ State Septic .'A! T&JNSHIP St. Crolx County S °TI C TA'-11~ :size gallons. `umber of Compartments r - , Distance From: 'dells C'L ft, 12% or greater slope it. • Building` ft. Wetlands f. Highwater ft. DISPOSAL SYSTE'.1 Tile Field or Seepage Pit(s) Distance From: Well-4 2- L 4 ft, 12% or greater slope- ft Building ~`t--ft. Wetlands FIELD Flighwater ft. Total length of lines ft. Number of lines ~ Length of each line ft. Distance between lines ft. Width of the trench ~ft. Total absorption area sq. ft. Depth of rock below fileL in. Depth of rock over file in. Cover nver.rock,, 2 Depth of tile below grade in. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS Number of pits Outsides dia e ft. Depth below inlet ft. Gravel around pit: s no. Total absorption area sq. ft. Square feet of seepage trench bottom area required Square feet of seepa6 nit r a required Inspected hy: Title: . • Approved Date ~12 2 197 Rejected Date 197 , PLB67 State and County State Permit # Permit Application County Perm2#1 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 Mailing/Address: tf e, 0 A/ _ LLJ d,~,lt B. LOCATION: Al 4~j '/4 Section T_3;,'sN, R,4f L (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township 9zz,5,..,~ ' I C. TYPE OF OCCUPANCY: "Commercial `Industrial "Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES_, # of Bathrooms_L Automatic Washer X YES NO Other (specify) SEPTIC TANK CAPACITY_ .V`C Total gallons No. of tanks _ "Holding tank capacity ,t Total gallons No. of tanks '!ew Installation A- Addition _ Replacement Prefab Concrete X `Poured in Place Steel Other (specify) FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) F 2) , 3) ~Total Absorb Area sq. ft. ,,Jew Addition Replacement "Fill System z0", X,eN/GCIllo Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width Depth Tile Depth + No. of Lines -3 Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land 6 x124-, /V t i 4 Distance from critical slope _ the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, 1',!isconsin Administrative Code, and that I have sized the effluent disposal system t. , :he 15 prepared by the Ce tified Soil est r, • NAME C.S.T. # and othe nformation ,btained from (.~.v. ' ' Plumber's Signature MP/MPRSW# Phone Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). i l a J N~ f , \ Ate' .Z \ F~ oZ ' Do Not Write in Space Be w FOR DEPARTMENT USE ONLY ~2. Date of Application Fees Paid: State County .1 D to _ Permit Issued/Rejected (6e) Issuing Agent Name : - Inspection Yes No Valid# Date Recd 1. county (vvto 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 6/1/76 a 1. { i+f I t f1,4 L ~s 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 J LOCATION /'4,Jei'4, Section _ L?0 N, R 1.0.1 (or Township or Municipality Lot No. , Block No. County S ~_r iF D_I yC Subd'v' ion Name Owner's Name: Mailing Address: . l ter- f1 TYPE OF OCCUPANCY: Residence ~K No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW }C ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 4 -A~l-~~~~~,~ PERCOLATION TESTS S°.1 L MAP SHEET SOIL TYPE _ XY C -4 Wk r- ~ 4 e< y. 'f ` Del PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RAic j ILIUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN <74 e- Dde_ Al P-^ I 1P_ 3. SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES 1 NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) / Q(o O tie- J / rs 4 s ~ a jq -e- :5,L 94 it > JI' I n 7 N '~L G er _J PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.) Indicate on the plan the locationand square fee of suita~eoarea . Indica[te umber square feet of absorption area needed for building type and occupanc cst OdIQ (a[ !t ~E Indicate scale c;r distances. Give horizontal and vertical re erence points. Indicate slope. 3 I I _ I.. rer t i 1 N ~ I , ~ 6a" ~ i ~ 1 1 Za f ~I ( I I 1 I j j I ~ 1 , . I I ? P 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 correc* to the best of my knowledge and belief. C- Name (print) Certification No. Address LT p Name of installer if known a CST Signature COPY A -LOCAL /,U7l_jOi;I TY ~ ~,~Y y j b„ p~ ,l I '~,'I :.a e , eft .f !V IVY. L, ~3 r Tai -P/ P14,6P7 i/vT ~2c c~c 1 prI C~ C, ~ ~y5 ° ~ ~ of ~ 1 s 3-3 i V ~ J C? / Ns j I Cl'L'L°4,7 R' 1 n c:: r of A,1 N S ysTe7~i p-z U~ - , _y