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Home My WebLink About030-1057-95-000 n cn o -0 0 0 d o g o m o (D 0 ~A (D -0 0 (n 0 Z O Ul (D N O ~ v O v C? Cn CD co W • CD 7• 3 I'C7 n C W O ICI N Q Z O n Jn W j CD- ~c-n ° n N O QJ - N 0 C:) CD O C) CD 7 C1 n O 3 N ~I O O CD (n G 1> (D CD •_7 CD ~w a 2 o 7) 0 m m 2 CD N N CD (0 cc (D t- N N O C N A co co o ? 3 CD o O O O m "VIA• o _v 3 Qr~ 0 cn cn m CD ° CD v o o Cn m 0 CD 2) 'a ci) 9o (~D CD P) w c lv iv m a CD a N N z z z Q D m o O H o 0 CD CD • CD N l~l (D CD c C O N co W ~ O {Z (D Z e Cra ~ N O Z CD v c .a n W W co -0 O O O C1 Z 0 ZJ O r: N ~ (D N 0 CD va)CD - 0~'r CD Q m r oc I CD c o~N' "O =r CD N O CD N = CD = CD Co -1 .N. ,'v C 7 Cll N Co CD N o CD =3X Z d (T N 11) N O W CD ~ 0 N CD CD O Cp O Z CD M N CD N X n O Q 7 W S ' R Cv N CNp N R7 ~Dn~CD~o o m m a o ~ t 0XOm 0 C, m c o 9L o N CD < (D C N o O CD S CD 0 O O O N 3 w A 3 d CD N• C1 O 0 CD N p 0 v w C) m .rya Parcel 030-1057-95-000 02/24/2005 10:05 AM PAGE 1 OF 2 Alt. Parcel 23.30.19.202C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner " PACKARD, THOMAS J THOMAS J PACKARD 771 WEST SHORE DR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 771 W SHORE DR SC 5432 SCH D OF SOMERSET SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 1.720 Plat: N/A-NOT AVAILABLE SEC 23 T30N R19W PT GL 5&6 COM NW COR SE Block/Condo Bldg: SE SEC 22, TH E 2701.5 FT TH N 614 FT, E 279.5 FT, N 21 DEG E 887 FT, TH N 33DEG E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 972 FT N 10DEG W 268.8 FT TO POB N 10DEG 23-30N-19W W 375 FT TO SHORE BASS LAKE, SELY & SLY ALG SHORE TO A PT S 84DEG E OF POB, TH N more... Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 694/16 07/23/1997 495/163 2004 SUMMARY Bill M Fair Market Value: Assessed with: 5219 407,000 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.720 220,600 179,800 400,400 NO Totals for 2004: General Property 1.720 220,600 179,800 400,400 Woodland 0.000 0 0 Totals for 2003: General Property 1.720 148,100 154,000 302,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 107 Specials: User Spacial Code Category Amount 040-OTFIER ASSM'T SPECIAL ASSESSMENT 619.31 Special Assessments Special Charges Delinquent Charges Total 619.31 0.00 0.00 L Parcel Ix: 030-1057-95-000 02/24/2005 10:05 AM PAGE 2OF2 Legal Description: cont. 84DEG Y,l 220 FT TO POB + s Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT f C LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM P I I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: i Proposed slope at site: SEPTIC TANK: Manufacturer:; f Liquid Capacity: % Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: J, / Number of feet from nearest Road: Front,O Side, Rear., feet 0 From nearest property line : Front,O Side,(i)Rear, O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to snr;~ tank) e i 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, 0Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: 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 lit.,-/ 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.f Plumber on job. License Number: 3/84:mj DEPA.9TMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS 1- 14 ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX-79fD BUREAU OF PLUMBING MAL?~SON, WI 53707 ®CONVENTIONAL ❑ALTERNATIVE Sate PlanI ID N„mber. (If assigned ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DAT ' ,D e0b Bruce D. Penman R. R. 2, Box 313 A, Somerset, WI .fi~' BENCH MARK (Permanem reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. SE NE, Section 23, T30N-R19W, Town of St. Joseph, Lot 526 Name of Plumber_ JMPIMPRSW No.. County Sanitary Permit Number. Cal Powers 1563 St. Croix 54973 SEPTIC TANK/HOLD NG TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER gF,20V ED: PROVIDED-. ~OX h~ YES ❑NO ❑YES ❑NO BEDDING: V NT DI VENT MA L. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH AIR INLET ALARM. FEET FROM ~f - LIN` % DYES ❑NO ❑YES ❑NO NEAREST -t DOSING CHAMBER: MANUFACTURER. jBEDDIjG. LID ID CAPACI TV PUMP MODEL ( PU /SI HON MANUFA .1~FfER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS PE AT 10 NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH I (DIFFERENCE BETWEEN II FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YE NO NEAREST SOIL ABSORPTI SYSTEM. Check the soil moisture at the depth of pl g Nl;n{ DIAMETER MATERIAL AND MARKING ORCE or excavation. (lf s it can be rolled into a wire, construction shall cease until AIN the soil is dry enough o continue.) CONVENTIONALSY TEM: WIDTH LENGTH IND OF DISTR. PIPE SP LING COVER INSIDE CIA -PITS LIQUID BED/TRENCH * / TRENCH MR`fFifllAl ' PIT DEPTH DIMENSIONS GRAVEL. DEPTH FILL DEPTH UIST H. PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. OLd SINUMBER OF PRO PERTV WELL. BUILDING. VENT TO FRESH BFLOW PIPES AE1 EVINLET EEPIPf FAIR INLETFEET F NEARESTOM ❑ C MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROV E A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain hat it ON E RSE SIDE. SHOW ELEVA- meets the criteria for medium sit T NS EASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANE T MARKERS OBSERVATION WELLS ❑ ES ij ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED /t SEEDED. MULCHED CENTER EDGES - ❑YES NO S l ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW IPFF. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD} MATERIAL. NO D TR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. CIA. ELEV.: PI S DIA. ELEVATION AND DISTRIBUI ION VERTICAL LIFT CORRESPONDS TO APPROV EC INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS ❑YES ❑NO F ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMB R OF PROPERTY WFEET ROM uNE Ll ❑YES ❑NO ❑YES ❑NO NEAR ST _ r ~ ut ~ i I Sketch System on ain in county file for audit. Reverse Side. NATURE nTLE r, DILHR SBD 6710 (R. 01/82) wls~onsln APPLICATION FOR SANITARY PERMIT '.(r,DILHR COUNTY OEPRRTMEnT OF (PLB 67) UNIFORM SANITARY PERMIT # .r InDUS TRY, LRBOR 6 HUMRn RELRTIOnS ry9 g2- -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNE MAI NG ADDRESS PR RTY LOCATION CfT-Y: i VII-LAGE: 1/4 1/4, S , TN, R (or) W TOWN OF: r-~ LOT NUMBER BLOCK NUMBER SUBDIVISI N NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 1A J r \.F-1 TYPE OF BUILDING OR USE SERVED / 0116 & 7-a -1506 -5;t_ orx Co~~ 1 or 2 Family Number of Bedrooms: Public (Specifyl,): J 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. Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: ,)s 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): "J/ 16 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of riv e sewage system shown on the attached plans. NaN of Plumber (Print): Si re: MP/MPRSW No.: Phone Number.- Plumb s Address: J Pam Designer: "`i / - COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved j) ❑ 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 TOR SANI'T'ARY PERMI'T' S T C - l00 This app] i_cation form is to be comp]eted in {ul! ~iiid si -gned by the owner (s) ()I- tile 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 Location of Property -4 4, Section T ii N - R ! W `T'ownship - 1 r~1' Mai]_i-ng Address Subdivision Name Lot Number = 1~" Previous Owner_ of Property Total Size of Parcel Date Parcel was Created Are a11. corners and lot lines identifiable? Yes No i is this property being developed for resale (spec house) ? Yes_ No Volume- and Page Number 1 - 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) eehXti{y that a-" ~tatementA on tha Aonm ane true to the best oA my (ot0) fznowtedge; that I (we) am (ane) the own.en (b) o~ the pnopenty dese r,%bed in ,tlu ~ tinoohmation Aonm, by v-vttue o{ a wamanty deed tecoAded in the O{Oice off) the County Reg-,s:teA o{ Dee.d~s a,5 Document No. and that 1 (we) v)teesentXy own the proposed site {ion the sewage dE~poAat /~yste.m (on I (we) have. obtained an e_ahement, to n.un with ,t_he, above. d"n- bed pnopeAty, {ion the con,5.thucti.on oA 6aid Ay, .tem, and the tame h" been duty n.e.eonded in the. 04(),gee, o{ the. County Re.gi/sten o~ Deeds, aA Document No. ) . SIGNATURE OF 0 NER SIGNATURE OF CO-OWNER (IF APPLICABLE) DAVE ST_,NT?D DATE SIGNED H VJ y S T C - 105 r r y SEPTIC TANK MAINTENANCE AGREEMENT • o St. Croix County 0 OWNER/BUYER M ROUTE/BOX NUMBER ,1~x/ Fire Number CITY/STATE 'L 1P PROPP:R'1'Y LOCA'T'ION: Section '1' N, R-~,-W, Town of St . Croilc County, Subdivision, L,u~t number Improper use dnd 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 punter. 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 riew 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, jJourneyman 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. r, I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v 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 d'ate. SIGNED--~ DATE St. Croix County `Loving Office. P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. v_ N s m (J1 m f...) my =r 0O ~ v g (D a 0 X ~p n n (D 7 °3 -a-'ww0) `Zw t- 0 =r~ 3~COCDz o (DCD°o? " n ~ c M W CD a~ N O a v 0 0- c M cD N o o o. o co ~[mxDj -4 (D , , = ~ CO " -0. (D n O M 0 CO o 3 a 0 " to °w o (D c owo ~ r > - O O O C- c r- = cn. 3' Z? c 0 ca 1 O -4 M _O O a (ID O_ CD co D .r (a Q O ° ~ ~ 0 - ~ ~ C O n= w n 0 p N n CD 0 =r -t O a Q O N N C v~ m 0 y N Cl) (D SD(D W to Z ? W W = Z CD CD 0 =r CD U) CD M CD s a°0 3-4 (a O a CO- s C = O CL = viva a c s ~ CD C m (n CD IV M 3 1-*. 10 M :3 = N = 0 CD M 0 ~ CL CO - c~ %o C0~- N_O C = C~ M'W vj W (D 1 N d p n M a~w m=~acn3 - r- aaa.o ao o.3 f a~C c ~ ~ u" ? c ~c co ~ 3 n m.~C - coa O N~0NO g a 0 O CO c -1 CD c m S-i CL =r a) .o =r c co o c ` a~ 3 ° o 3 w a3 am ° 3 cn' co o z - 0 • .E 3 ST. CROI X COUNTY WISC0NSI N ~ r ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 August 15, 1984 Bruce D. Penman Route 2, Box 312B Somerset, Wisconsin Dear Mr. Penman: This office has reviewed the recorded affidavit, of which a copy will be included with the sanitary permit paper work. At this time, I am returning the original document for your personal files. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Thomas C. Nelson J Assistant Zoning Administrator TCN:mj Enclosure: Affidavit r, Rru-ce Pe-n rroA . X55.9 5 Z pzrne- tr-~c. RAe - Sow er~ef, 2.1r. SAD j ~j L~1 715f 519 be d G F 3 ST. t. . S August 13, 1984 ~ c cl fr,~ k• , .r f r~~ , 14 I ~jy (jf__ August _._1•.. t~. f 84 . s 4:.2-5 P James O'Connell f.ftGspdt tsf Affidavit The below described property contains a guest cabin on the property which is and will be in the future utilized as a single bedroom unit.. Tli-23 Bruce D Pen,!ian P202B Ho,tc 2 Bo), 31?8 Somerset, Wi 54025 Sec 23 T?-')N 19W c t GL 5 F. 6 om ti NW cor SE SE sec 22, th E 2701.5 ft th N 614 ft, G 279.5 ft, N21020-E 887 ft, N33020'E 694 ft to POB: th N33020'E 278 ft. th N10°53'W 268.8 ft, th 514"73'I? to 7130 !.,.cl.. Ig shore to of 376°4c,E of P09, t5 N76°40'W 312 ft mol to POB Bruce Penman Subscribed and sworn before me this lJ day R. G. LIVESAY - NOTARY PUBLIC Bruce Pc-n n .395 5: $ ~nzrrc tree- Rxje - Sox~erbet, 24'r. 67-foas 715/ 519 , VOL IPA G E 4"frRs OFFICE [ August 13, 1984 14 y u August ,.I 84 4:25 Py fol. James O'Connell Affidavit `he below described property contains a guest cabin on the property which is and will be in the future utilized as a single bedroom unit. Tl i-23 Bruce D Pen,!ian P202B 1'0-)a t,: 2 Bo>- 31'1.9 Somerset, Wi 54025 Sec 23 T3-?'J agvi Ft GL 5 p. 6 on NW cor SE SE sec 22, th E 2701.11 ft th N 614 ft, E 279.5 ft, N21°20'E 887 ft, N33020'E 694 ft to POB: th N33020'E 278 ft. th N10°53'W 269.8 ft, th S'34173'1: to 7;ss 5~ °1g shore to of 37604G'E of Pr)5, t'j N76°40'W 312 ft mol to POB i Bruce Penman ~-Y Subscribed and sworn before me this day o f 19 r R. G. LIVESAY NOTARY PUBLIC PAGE OF 1) <~Y`` '<;Sit/ r o S `c r I ~7 11 p /"l V r r~ J 1 4~l C~.A ~ Fresh Air 1111416- And Obcervollon Pipe Approved Vent Cup Minimum 12" Above Finul Groae 42° Above Pipe _ 4" Coo iron lo Final Grrode Vent Pipe Monh Moy Or SyNAetlc Cu ering min 2" Aggregate Over pipe Ulelrlbalion Pipe 0 0 0 0 0 - Tee b Aggregole Beneath Pipe o Pertoroied Plpe Below o Covpling Terminoting At Bosom 01 Syclem SOIL FILL DISTKIBUTI0v1 PIPE APPROVED S41J H-TIC COVER 2" OF A6 GRIE GAl E MAT~RI/~I OR 9" OF STRAW \\\OR /~ARSN HAy t fEF-T-[z (oOF 1Z-21/2 AGGREGATE ELE. V. DISTR1f5UTIOtJ FIFE TD BE AT LEAST 11JCHES BELOW ORIGWAL GRADE Al,IU AT LEAST 20 IAICHES BUT 1J0 MORE -T-HAIJ HZ IKICHE5 BELOW FINIAL GRADE M`1AXIMUM DEPTH OF F-XcAVATIDkJ ROM 0WINAL 6RAnF- WILL BE IJCHES MINIMUM! 19Eprh of E'ACAX/ATI(i fKOM, c4<161114AL C3RaOF- WILL BE INCHES SIGAIED: LIC EIJSE IJUMBEF': DATE . + C - - 4:- - I I I I ~ i I i 1 i u j' _ I I { i ~ IND ZJJST OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iJTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: T/M UflffE TY: LOT NO.:BLK. O.: SUBDIVIS}ON NAME: 1/4'1/ (or) W _ i r✓ COUNT/Y:: NER'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE TNO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: [SfResidence / ❑ New RZI Replace - f RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FIL HOLDING TANK: RECOMMENDED SYSTEM:(opt onal) ❑s ❑U ❑S []U EIS []U ❑S ❑U ❑S ❑U l i If Percolation Tests are NOT req/uire DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: F r Floodplain, indicate Floodplain elevation: a. PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH fK, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r' I .5 s B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I'f;944ES AFTERSWELLING INTERVAL-MIN. PER10 1 PER 2 PER OD3 PE INCH P P_ 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 ail borings and the direction and percent of land slope. SYSTEM ELEVATION XaC try 1 a _ , vr_ , I , i~ wr I,< I, the undersigned, hereby certify that the oil tests reporte on this form were made by me in accord the procedures and methods specified in the Wisconsin Administrative Code, and that the data rec rded_and the Ioc ion of the tests are correct to the best my knowledge and belief. NA ;print): ~ TESTS WERE COMP'L~TED ON: ' AD ESS, CERTIFICATION NUMBER: PHONE NUMBER (optional): 7Xi S CST AT `R E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 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" O Q Z 0 3 0 9_ o Z2 O C < N N Z7 O (D Q _0 -a N W ED O O (D (D ° CD Cr O N Cn p 3 O C 3 c0 N CD O CL CD CD ° O 7 C) G S (D CCn O (n C. (D (p 7 CD (D N C -n W 3 O IZ) -n c N Ul 7 W CD a N w~ a° ° m x z a rno 1., N W (T CD '(D CS cn w pi C N D N O CD Q 3 r p I- n Cl Lu. CD N O CD ° CCDD v ? m~v,v O o w° 0 - CD < D A m a n v o v m N v <n CID r- o ~ ~~Nom ~ P w CD CD c -.(a A CD CD 0 7- U) 0 Ox O ~O CD Iv CD ~ c ° CD w CD C) x 00 a o Cn CD F N. o CD ° o v o o 0 N 3m A 3 CD m d CD CD S i° k o 00 L o m o p CO OWNER ;t f> TOWNSHIP SEC. ~ T N-R f.•W ' ST. CROIX COUNTY, WISCONSIN. 14DDRE S S SUBDIVISION LOT LOT SIZE PLAN VIEW I~ Distances and dimensions to meet requirements of H63 1 W EVERYTHING WITHIN 100 FEET OF SYSTEM 't I di ate o th Arrow SCL BENCHMARK: (Permanent reference Point) Describe: C Elevation of vertical reference point:.~z r Slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover Tan manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons ~-Lrber of gal . pump set or a cyc e_ gallons; tcata._ ca', -bi, r4-on lines '.on size of pump miwate r.um.ber F' wa3CiCI:a.TL,~'VYrC f.' } Y o cover._.__.._.___.__..____._. a.: s? ~ ' Q•~, y„aY' ~ N'"",y.- c ~ ya !Z ~ ,i7. 9y' ~ .i. °1 r, ar R r, . P S 1' - T1P.r of -i Tines ~~.9 S ..___......3.._..-' A i\.!.:~.QT -T!k.x"i~ r T / L1 RLPORT OF INSPECTION INUIVIOUAL SI.WAGE SYS 11M ' Sane tuh~/ I'~/(mc.f /ivy State. Sept.ix,..~44x ..y °vn'.)Ii C~✓ _v~ S ( 1,/LU ( 1 l U(AY( 111 Scctiun Lo.r M Subdiv.i,akon yaxeoY(e Number oh eurnC,a~ttment4 m WeU~_- Bu-c.zd.i.ny 12% e Cope Highwa.tea CtIAMBER `pttona _ Pump MaYtu 6ac tuners Mu de i. Numb o t TANK ya e ovne Numbe It o A Compan-tme.Yi tb AEa/(rn Syn tern UIe1'('- _ td.i.ny _ 12$ axope. N(c~1(wa(en :I If T /(e Yt e Ii BuA ~(14ay 12$ 6 eope.-- Ni,yhwa.te~~ N 1 I k DI MENS IONS h tne.nch ,t J ' Iiiuc ned ane.a -40 n r e.ae.h tin At 0epth oA aoch below t-<te f oA x(,#,Iee Ve.pth u~ koeh ove./t tl('6, Z ~ i' Pck(yjth uh Zinea At Depth uh titx, b(I 'uw U)(u(Ik, J~ !Y( (Y;he twee.n ei.nea~ _ .t SXope oA t"ce.neh 100 ~t (11!,(,/cpt4:un an.eu ~_.._._At Type. ob Cove ~ P,.apen o/+ s t?Iaw f1{ {/j G,,i.aVee agound pa t,5 (~e!YI,i (,(ni(f r ~ De ptI( be~.uW tinXe~t ~ (1,r t, it 'i III,(( r DATL_ e i t U DATE l l h of I +~i: I:( JLCT ION +g . I I PLB 67 State and County State Permit # Permit Application County Permit # 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: B. LOCAT ON: 54F '/4W '/4, Section3 , T0 N, R E (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family X Duplex No. of Bedrooms -3 No. of Persons _5 D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement A Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: X_Length Width ' Depth Tile depth (top)er No. of Lines -2 Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land ✓ 74 Distance from critical slope WATER SUPPLY: Private X 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- C.S.T. # and other information obtained from 7-&-,,? e tP own /builder). Plumber's Signature MP/MPRSW# Phone #%j,~; Plumber's Address L-Z//' 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. a ~ ,ACC>r,~ - E a , . . E ) . 3 t 1 } E 1 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application Fees Paid: State County /,;2/` D '/6 Permit Issued/Rejected (date) <5? -Issuing Agent Name 49604' Inspection YeskNo State Valid# Date Recd 1. county (white 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 E W ' 115 Rev. 9/78 $ 9 REPORT ON SOIL BORINGS AND PERCOLATION TESTS ix WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES '4' IIEe f/V r~ P.O. BOX 309, MADISON, WISCONSIN 53701 p' 'JUL ](318 u ZONING g1 LOCATION:if %,AAL/,, Section 2- ,T3"1\1,131251(or) g township or Municipality -~~TO ~fFl~ Lot No. , Block No. County Cr d ubdivision Name E' Z, Owner's/Buyers Name: d/4( AG/I 1gAI- 1 , t Mailing Address:-RoX TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 2' Y"-(/ PERCOLATION TESTS 2 c~ -Rl SOIL MAP SHEET___3~ ~e NAME OF SOIL MAP UNIT / ,`e PERCOLATION TESTS /0,4M I~TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE RUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- a- r' .Sow "'t 11L' Ala -3 • P--?,,36,r 0r~ d Y o 3 3 P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH- DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK / OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- CV B- AiCAJ-e- 17 B- of f C, 4 . 70 B- B- 113- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the cation and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy I A' ,Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. $'14- ces 4-r c`sfiAe C~- Res: ~ ,,marts par e__5 rx1Y-7A'_A,& Well r rA 1, N rd f 017 OF MA1cA>~!~ 1 14 16 1/. N 1 sof _ e. °?c CSC e Al• 1, the undersigend, 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) Certification No. Address Name of installer if known Copy A -Local Authority CST Signature r x. Ito e- ~+w / M JJJyyy fl f~ ~ av7i~~ 4 i r ~ f I i Tory` Wisconsin Department of Industry, PLB-INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o remises a e an o. Street city -County Sanitary Permit` Master Plumber Firm Name dress Journeyman Plumber Address Owner Address - - Discussed with ature ( )See Attached. DILHR-SBD-6192(N.09/80) Signature o is Plumbing up. On-Site Waste Specialist White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible Party Green-Owner