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HomeMy WebLinkAbout038-1060-95-000 t n(n O g m n r~ O y G O r1 7 (D j n (D L K T 7! 6 C CD D7 CD A CD ►t o ~ Cl) (n o Cl) --I 2 2 h g N • co ~ cn w `C III 3 ° a z Q m ccn - 00 :3 00 C, CD a) cn a) cn CL o ° O m O O A Cn A~ CD CD m O_ O O 3 N r o O y N O C D ro a 0 CD O ro N O O N W c ro o. ~ o 0 CD O rn c\ r 3 m (7 (n Z TJ (n 1 l~+ lot O R (o G i. - CD c ~i rn o A 00 n o \yS~ n C N z ro -0 -0 T TJ O O O Z? h• o c v It- W z Q A E N cn ti o a D .p 7.y v n a. -0 O O D o d p S CD N d 7 C V't H O CD CCD < (D CD a)' N '-1 to 71 ? N d j O N p ° z co z Q r D o o O d to CD v o' ro ID • ro tv v~ oo m v C~ O CD O -p ~ ~ Z o ro Q i cab w rn n 3 CD cn z Z z O N O A n 7d n j; z o' 00 v G? Z -i m m a 3 41 °o z o trr N z ~ ~ ro v n w I ~ a ~ o ° n 3 m c z a 0 o CD n N v t i A I o- I ~ A `4 V N O O a A O v CD dq O W I Efl ~ ti .q O (D ~y O O L ti Q, * Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 11Pl TOWNSHIP STfI~' ~~/P/~ SEC./1 T 31 N-R W ADDRESS RT -2- ST. CROIX COUNTY, WISCONSIN n SUBDIVISION LOT LOT SIZE PLAN VIEW N6X o1(, Go T G- ~ i Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM v (3M = Scv )e 2. CrJEk' cr• ~ 3 ~ . o r YIo~S1= J I ~ C yL ' - ~ pop W- D N / I r ,s r INDICATE NORTH ARROW BENCHMARK.: Describe the vertical r.uterence point used Elevation of vertical reference point: / 00 . 0 Proposed slope at site: w SEPTIC TANK: Manufacturer: ~Ee/` / -Liquid Capacity: ti. Number of riigs used: _ / Tank manhole cover elevation: 7 Tank ] nlet E.evation: 0' Tank Outlet Elevation: a f. Z Numbei, of feat from nearest Road: Front, Side,0 Rear, 0 feet From nearest property line Front, 0Side, 0Rear, 0 / feet Number of feet from, well building: /(P (Include this :information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SfD1 PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufa• rer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevatio Ga per cycle: Alarm Manufactur Alarm Switch Typ Number of eet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include Lli.stances on plot plan). SOIL ABSORBTION SYSTEM Bed: TrPnr- h Width: Length: 37 Number of Lines: Area Built Fill depth to top of pipe: AA)(Ih Number of feet from nearest property line: Front O Side, Rear, Ft Number of feet from well: A707- /,y O yO Zp Number of feet from building: (Include distances on plot plan). SEEPAGE PIT \ Size: Num of pits: meter: Liquid depth: ottom seepage pit elevation: Area Built. Has either a drop box 0 or distribution box O been used o any of the above soil absorbtion sytems? (Check one). h HOLDING TANK Manufacturer: Capacity: Number of rings used: El 11 on of n of tank: Elevation of inle N 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: L Dated: Plumber on job: A%~E/P License Number: 3 J d 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 SI`f ,PIGIiD.Numbe,. assiq,e ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT AR ADDRESS OF PERMIT HOLDER: INSPECTION DATE. RichwLd Spou R. R. 2, New Richmond, W1 4--,20- 3.4 BENCH MARK IPermanem reference omtl DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. NE NW, Section 15, Lot#3, T31N-R18W, Town of Stwc PtcaiAie Name of Plumber. IMP/MPRSW No. County. Sanitary Permit Number. Robert UtbAicht 3307 St. cuix 49485 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER / PROVIDED: PROVIDED / ~ L z ~0 YES ONO ❑YaES BEDDING: VENT DIA.. VENT MATL. JHIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH ALARM. FOM LINE:, H Z AIR INLET. ❑ YES :ET FR O ❑ YES ❑ NO NEAREST f jV DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED PROVIDED OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY [ELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR=LE PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LEN(~TII 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 LENGTH NO. OF JDISTR. PIPE SPACING COVER INSI OF DIA. #PITS LIQUID BED/TRENCH TRENCHES MA IAU PIT DEPTH: DIMENSIONS 3 o lam GRAVEL DEPTII FILL DEPTH ~FLFTJ` S. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DIS NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH BF LOW PIPES ABO VE COVER . INL ET ELEV END PIPE (LINE / AIR INLET r,f ')I os,4 f s qS 2 C, NEARESTO-i 2 V S~ 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 f me m sand. TIONS MEASURED. DYES ONO 1 ) 11.41 SOIL COVER TEXTURE PERMANENT KER=EN OBSERVATION WELLS OYES OYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL JSSEEDED MULCHED CENTER EDGES YES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING: G D H B LOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE IMANI O IA N. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.. 110ES DIA.: ELEVATION AND DISTR IBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVE MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED OYES ❑ O I/ 1 PLANS - OYES ONO COMMENTS: PERMANENT MARKERS: SERVATION WELL : NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE El YES El NO ❑ YES El NO INEAREST 2 "D (7) T, 0,6 3g Sketch System on Retain in county file for audit. Reverse Side. SI GNA3VR E. TITLE. DILHR SBD 6710 (R. 01/82) m wisconsin APPLICATION FOR SANITARY PERMIT (~IDILHR ~ COUNTY (PLB 67 OEPRRTMEnT OF UNIFORM SANITARY PERMIT # In OUSTRY, LABOR 6 HUmRn RELRTIonS 419 1V Y5- -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS i GGd4zt )el-. 2- PROPERTY LOCATION CtfiT" NE N~ 5 p 114 1/4, S I , T,?/N, , R I a E (or W TOWN OF: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, ' ""E 9R I DMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED k 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: Yl 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. X1 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 ZIA- Manufacturer: & E6_I-S C fL / ,440V v ltd / 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 IManufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet 7X /f XPrivate ❑ 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: MtP~ MPRSW No.: Phone Number: i 3 (71Y) ?6-,?1J 14OUFS'IF SEPTIC PLUMBING G9. ~~L - 1 Plumber'sOd11MIL RD., HUDSON, WIS. 54016 Name of Designer: ROBERT ULBRICHT iNN. INSTALLER & DESIGNER LIC. NO. 00663 COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved /71~ ~LL~ ❑ Owner Given Initial r ✓ " /r Approved Adverse Determination FT-eason 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 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/contracLQV,("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 R~ 00&,k Location of Property Section S , T 3 N - R Township 5r1fR Mailing Address 1 ?T- Z Alt-k) 11 is x0-t)d yo Subdivision Name Lot Number 3 Previous Owner of Property Total Size of Parcel Date Parcel was Created l0 3 f D Are all corners and lot lines identifiable?- Yes No is this property being developed for resale (spec house) ? Yes No Volume g and Page Number 6166 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. PROPFRTy OWNER CERTIFICATION I (Cite) eeA.ti6y that a.U statements on -thiz 6ohm ane VLue to the bat o6 my (ouA) knowtedg e; that I (we) am (ane) the owneA (,6) o6 the pno pW y da n ibed in ,thin in4oremation 6oAun, by vic ztue o6 a waAAanty deed A.ecoA.ded in the O~6ice o4 the County Reg-iA-teA o6 Deeds as Document No. 312-1 Sl ; and that I (we) pAe,sentXy own the pAopobed site boA. the sMaQ-e--cM-rjoAat system (oA 1 (we) have obtained an eaeement, to nun with the above descAbed pAopeA.ty, 6olc the cons aucti.or, o6 baca by/S.tem, ana xhe Bayne i'tu,l ho.en duty tin the Oj6.ice o~ the~gw Deeda, as Document No. ) . SIGN ER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED d ' t ST, C IX COUNTY CERTIFIED SURV EY° MAP LOCATED W THE NE V4--NW 1/4, SEC 15, T 31 N, R 18 W, 4TH P. M. LEGEND THE NORTH LINE OF THE NW-1/4 OF SEC. 15 IS i"iON PIPE SET lNF;Ci"H:NG 1.68 LBS./LIN_ FT ASSUMED TO BEAR ' I" IRON PIPE FOUND S. 890 38' 57" W. 100' 5C 0 I00 200" CUI?V DATA CURVE r SOT RADI- UST-C HORD CHORD BEARING CENTRAL ANGLE CURVE N4 NQ LENGTH LENGTH LENGTH 1-2 4 162.17' 205.74 N. 500 48'26"E. 780 43' 03" 222.81' 3-5 - 1542.86' 690.72' N. 240 23' 00" E. 25° 52' 12" 696.63' N 3-4 3 225.93' N. 150 38' 50" E. 80 23' 52" 226.14' 4-5 2 " 128.84' N. 220 14' 20" E. 4° 47' 09" 128.87' 5-6 1 ~_-_,i___ r---_ 340.92' N. 300 58' 30'" E, 12° 41' 11° 341.54 LlNPLATTED_ -LANDS OWNED _ BY OWNER tJ'N SEC. COR. SECTION LINE N. 890 38' 57" W. 829.41' N. 890 38' ►J-I/4 COR. 57" W. 502.80' N. 6911 38' 57"W 0 d S/ 788.10' N. 37° 19'06" E. - e4 8 .03' J?~/ ..`v LOT 53o'pt'56 /iy3?41.31' / Oo .3 192° 50-'06:' 2' 8 0 /a• O 3.836 ACRES',INC.'R/W 06, 1 O•. 3 i F c 11 F 3.505 ACRES EXC. R/W J, _I r~ 643 v CURVE 11-12 R =1509.86', L- 337.00; LOT G F9 6?s 60, 0', A=12047' 18", C=N 30°5527" E, 336.30 3.594 ACRES INC. R/W 5 3.503 ACRES EXC. R/W 33 177 / CURVE 10-11: R=1509.86', L=111.51', 12C, N. 900 00' 00° E. 549.18' 4 8=4013'53",C=N22024'52"E,111.48' r~ 10 ' 514.05' 3513' ~ 0~i - - LOT -3 00 i9 CURVE 9-IO;R=1509.86',L=233.22', 'J z \7 4.008 ACRES INC. R/W r'os 8=8051'01", C= N 15052-24"E, 232.99" 1 w v 3.736 ACRES EXC. R/W 6p 1 i` w co X34 39, h' g s N. 900 00 00" E. 460.79' CURVE 9-•12 R=1509.86', L=681.73', 427.68' f 0~: A= 25°52' 12", C= N 24°23'00" E, 675.95' 33.11' r 4.1 GJ o LOT 4 r 4. 512 ACRES INC. R/W A~ 3.938 ACRES EXC. R/W o z D PA, ALLN G. d IQ, (V HMAGEN ~P X36 R/ W LINES HUDSON, v oO - -1 d cUv~ ~ad'~ S F390 50'03" E '2' 203.43' ~ty!?$6} : 203.455. S. 89° 50' 03"E 7 SIGNED C - DATE 1o 33.07 CURVE 7-8 R=195.17', L=268.15', ALLEN C. NYHAGEN' RLS 1407 r 0= 78° 43' 03", C= N 50° 48' 26" E, 247 55' THIS INSTRUMENT WAS DRAFTED BY KEN liOO1:iE,N!CZ. ..,_---...-....._-..o..-.-_~ .108 hi a 80_-PS - H r-1 • y • r S T C - 105 r y • H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County d y I H OWNER/BUYER \ 1 N~ ROUTE/BOX NUMBER,,, ,/2--- _Fire Number CITY/STATE UR~ R CA A40 tn -'LIP 5'Gol(P PROPERTY LOCATION: A) S4, Section 'r- 31 N, Rfg _0 Town of St. Croilc County, Subdivision SSM Lot number ~J Vo-~ `I y - Coo 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 pgin r. 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 ma_ 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 three year expiration. o 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- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning € in 30 days of the three year expiration date. SIGNED 1) ATE 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. EH 115 Rev. 9/78 , REPORT ON SOIL BORINGS AND PERCOLATION TESTS, 1 ,3 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SER ' P.O. BOX 309, MADISON, WISCONSIN 53701 DEC LOCATION: Section1.L,TIL //N,RJYA (or) ownshi r Mmimiip~ u"' I 19iki, kvk Lot No. Block No. County division ame .Owner's I~os Name: k © Mailing Address: l .S Gd TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS a22 OCT 11,20 PERCOLATION TESTS Y17 POU j ! 0842 SOIL MAP SHEET ! NAME OF SOIL MAP UNIT CIgLZIX- 0a1-14iA 61QMPLZ~X PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN!/IN BER ~ 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P / 3¢ v, F 5 0 /r M It') P- 5 4-2 MIA) ~2 AL -3 1A) 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- e-7 1Y A)oki s f ,1 ~ q-69*60,8 B- 3 4/11 S,,r iJ , Dig ri B_ q it A), c S' a2 0" 1/9 "L f-r if nen S C B- Yaze "'61 113- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the pia the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy C+ J r .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. i T -SCAL, ~ ~ ~WCk _ 100E 47- -41 lDb XuZy I RloNII a.-_ S (Tfl BL -SO/L.5 .......W llu - P jDgliUG O a _.x.. _3.. _ .a- mq. _r_ fS 5 1/C .f - m- , F i P:3 D.i4 , % ✓41-L . I T t w I, 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. 6 Name (print) L1~ V Certification No=it Address L' ; Whikiff 5 ` =6 SGN 401 C-d S Name of installer if known a Copy A -Local Authority CST Signature (2 PLB ~7 PR~Po PLOT and CR05 SEcTION PJANS X01- 3 N a oO 5 ~ 1 4 v y~ yo' F 00 501 4,1 F SEP`tC Pl UN'$`yN ~C54018 JCE/VSj,---33,o-7 c tt, ~ N3 0 NE~pO~g~t~DaR` NO 3341 M 00 03 - ~ vc. 1~G tao. .T4 TE" _ r 7 ~S ~ASt 1AlLER~& ~ S1G~E4t ..~.....~w _ M~N.;,1NS Fresh Air Inlets And Observation Pipe Approved bent Cqp, Minimum 12°1 Above Final Grade pl+' ,4oM of 4'° Cast Iron ` ~ 2- Above Pipe -i o Final Grade Went Pipe Marsh Hay Or Synthetic Covering Min. 2°° Ape ggregate o~~'( Distribution Over Pipe Tee I V Pipe 0 0 0 0 0 l Aggregate 0 Perforated Pipe Below ,mss/ Beneath Pipe S~~L / 0 Coupling Terminating At /S 16Y. 36 2,-----z7- Bottom of System Parcel 038-1060-95-000 02/17/2006 11:02 AM PAGE 1 OF 1 Alt. Parcel 15.31.18.264D 038 - TOWN OF STAR PRAIRIE 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 JESSE A SKRAMSTAD O - SKRAMSTAD, JESSE A 2192 GOOSE LAKE RD NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 2192 GOOSE LAKE RD SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE SEC 15 T31 N R1 8W 4AC NE NW LOT 3 OF CSM Block/Condo Bldg: 5/1290 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31 N-1 8W Notes: Parcel History: Date Doc # vol/Pa a Type 07/23/1997 835/ 07/23/1997 /126 2005 SUMMARY Bill Fair Market Value: Assessed with: 119057 187,200 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.000 42,000 142,000 184,000 NO I ~I Totals for 2005: General Property 4.000 42,000 142,000 184,000 Woodland 0.000 0 0 it Totals for 2004: General Property 4.000 42,000 142,000 184,000 Woodland 0.000 0 0 I Lottery Credit: Claim Count: 1 Certification Date: Batch 306 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00