HomeMy WebLinkAbout038-1076-20-000
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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T--?/ N-R W
ADDRESS --17( ST. CROIX COUNTY, WISCONSIN
SUBDIVISIONs;yl~`= LOT t L02 SIZE i
/.Z-
PLAN VIEW )
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
E i
f
1
Js INDICATE NORTH ARROW
L
BENCHMARK: Describe the vertical reference point used ,-,i%
Elevation of vertical refere.ce point:
Proposed slope at site: IZ4
SEPTIC TANI:: Manufacturer: 1 Z Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation:, Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side (A Rear, O feet
From nearest property line Front,0Side-,0Rear,( feet
Number of feet from: well Vii- 'building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE 1 4'V1,'NSF S 1 hl`
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, 0 Ft.--
Number of feet from well:
Number of feet from building:
(Include.distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Z Length:_ Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear, O Ft.
Number of feet from well:
Number of feet from building: /s
(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, n Rear, O Ft.
Number of feet from well: /
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: L/ Plumber on job: JZ
License Number: r 3
3/84:mj
I
Parcel 038-1076-20-000 06/14/2006 04:42 PM
PAGE 1 OF 1
Alt. Parcel 18.31.18.312A2 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
O - SHIMON, THOMAS E & MARY J
THOMAS E & MARY J SHIMON
2164 90TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2164 90TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 9.650 Plat: N/A-NOT AVAILABLE
SEC 18 T31 N R1 8W 9.65AC SE NE LOT 2 OF Block/Condo Bldg:
CSM 3/681
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
18-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 966/272
07/23/1997 795/473
07/23/1997 735/580
07/23/1997 684/566
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 9.650 53,600 104,100 157,700 NO
Totals for 2006:
General Property 9.650 53,600 104,100 157,700
Woodland 0.000 0 0
Totals for 2005:
General Property 9.650 53,600 104,100 157,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 137
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
Ilf LABOR'& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 79C-9 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE St.I, Pi- lD.N-t-
(II
❑ Holding Tank ❑ In-Ground Pressure ED Mound ass lgned
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Anduw Betiste Someuet, W1 54025 0aV/ _P/ _ 9p
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.
NB SF, Section 18, T31N-R18W, Betiste Miwt,Twn.o6 Statr. Ptc,aitiie
Name of Plumber. MP/MPRSW No. Coun[y Sanitary Permit Number_
Cat Poweu 1563 St. Cuix 49471
SEPTIC TANK/ DING TANK:
MANUFACTURER. LIQUID CAP ACITV. TANK INLET ELEV.. TANK OUTLET ELEV.. IWARNIN ABEL LOCKIN COV
~nt L~ Q PROVI YD ES D
lJf+~.~ ' V I. ~ S Q . ! YES ❑ N O 1' ❑ O
BEDDING: VENT DI FC[TL HIGH WAT NUMBER OF ROAD: PROPERTY [VELL: BT FRESH
AIR IN T
ALARM FEET FROLIfttoo ]VENT
DYES NO l DYES ENO NEAREST
DOSING C A BER:
MANUFACTURER BE D111 NG. LIQUID :Try PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL COVER
PROVIDED. ~LOCKING
ROVIDED.
DYES ENO DYES ONO DYES ENO
GALLONS PER CYCLE: PUMP ]AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ENO NEAREST 10 1
SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth ofplowing LENG;TH DIAMETER IMATIRIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FFORCE
N
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGTH INOOF DISTR PIP SPACING] COVER INSIDE DIA. #PITS LIQUID
BED/TRENCH ry G~ TRENCHES IAL: PIT DEPTH
DIMENSIONS C,
GRAVEL DEPTH FILL DEPTH UISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DI NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE /COVER ELEVrINLET ELEEV. END ` PIPES. FEET FROM LIN AIR
L_ ~0 I r 15 1 DD Z Z NEAREST i► f rs
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-
D meets the criteria for medium sand. TIONS M URED.
YES ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBS [YES ATION WELLS
DYES ❑ NO
DEPTH OVER TRENCH BED DEPTH OVER THENCHF ED DEPTH OF TOPSOIL SODDED ISE TEY IMULCHED
CENTER EDGES
DYES ❑N YES ❑ O DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DE TH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. D R. D . PIPE DISTRI UTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA. ELEV.- PIPES. JD
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERT .AL LIFT CORRESPONDS TO APPROVED
PLANS.
EYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. JBUILDING:
FEET FROM LINE.
d ❑ YES ❑ NO ❑ YES E NO NEAREST
j -L." 1--/ 0j, 4 Z_
v
Sketch System on in county file for audit.
Reverse Side.
R TITLE
DILHR SBD 6710 (R. 01/82)
APPLICATION FOR SANITARY PERMIT ~
I L H R (PLB 67) COUNTY
E:- UNIFORM SAN ITARY PERMIT #
RV, LROOR 6 HUrT1Rn RELRTIOns
-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 OWNER MAILING ADDRESS
PROPERTY LOCATION CITY:
VILLAGE:
1/45f 1/4, S ~X T N, R r) W TOWN OF:
LOT NUMBER BLOCK NUMBER SUB/DIVISION NAME . NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
A
r
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify): Vf,//
THIS PERMIT IS FOR A:
x_I 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: 1~ J y f r _ - = < <
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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Pri Signature: MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer: /
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: El Disapproved
E Owner Given Initial
.)✓1j`~Lf 3 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 oz
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
S1•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/contractaV,("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 ' , Section, T N - R W
Township
n
Mailing Address.' ~C( t//`? ~L A S Q.
Subdivision Name
Lot Number
Previous Owner of Property ~0V1yN C,-,;
'total Size of Parcel ~C I c
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register 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) eeA' 6y that att s tatemen ,6 on ,tha 6onm w~c flue to the bat o6 my (oun)
knowledge; that 1 (we) am (ahte) the owner (h) o6 the pnopwy deg ni.bed in ,th.iws
in6otanation 4onm, by v-intue os a waJAanty deed neeonded in the 066ice of the
County Regi~steA o6 Deeds as Document No. 3 1 r and that I (we)
pnesentty own the pnopoaed site ~m the )Sewage diSpo.6af Isystem (on I (we) have
obtained an easement, to nun wUh the above deselubed pnopeA-ty, joa the
consthucti.on ob 4aid ays,tem, and the same has been duty necorcded in the 066ice
o6 the County Regis teA o6 Deeds, ab Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
bA E SIGNED DATE SIGNED
i
61
CERTIFIED SURVEY MAP
r
- i
NE COINER 1
7
SECTION 18'
UNPLATTED LANDS T31N Ri8W
-
NORTH LINE OF THE SE 1/4 OF THE N E i/4 -vi
N 89° 27'00" W 1322.00
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THIS POINT IS OCCUPIED \ \ I ~
9.65 ACRFS
n' BY T W IN 8" ELM I REFS
1273166 - -
S 89° 30' 35"E 1327.23 J~
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TH LINE OF THE SE 1/4 OF THE NE 1/4'~ 53.~7 lv ~
SOU
UNPLATTED LANDS POINT OFy
BEGINNING
o~
I-_EGENv
COUNTY SECTION CORNER %10NUtitENT, FOUND.
Li:
O 1" X 24'' 1 RON PIPE WEIGHING 1.68 /L.INEAL FOOT, SET 5E C 0 R L F,
SE CTIOPI I p
F---e-+F- EXISTINv r LNCES
T61N,RI8'1'J ,
EXISTING BUILDINGS
SC;;LE IN FEET ~
\ -XISTING TREE r 7
200 100 0 100, 200 .
S '1' C - LUS r
SE PT I C TANK MA I NT I` NANCL; At;RF1-1.M1?NT
L. Cruix CouM( y
U
0 WNEk/It11YKK INa _ L ealc- t~
KOUTE/ hOX NUMB t)C ~i l ire Nuwher
ER c
CITY/S'tA`l'E-~._%'~~~':-
11 IZt)11 KTY 1,0CAT 10N Sec t_ i on N , k l2 W ,
Town of sfq r a I SL Croix CoUaLy,
5uhdlvi_;ik,tt L.ot uuuti.tcr
I
Intprop~+r u;c dud ill it iLt tLt it ait ( c ul your ~ Itt i~ :iysteHt Ck)Lt l rC it in
iLS premature IiailLt re tI It .Iit Lt Lc waste.,. I'rIll tintLt nduce Con -
: 1 itS oI pItlll1) illuUL L• ,,.,pttattlC eV~.'1-y LILi0C'. yL',tr5 t1r ti(1UMer,
it needed, 1ty It tice1 ed t-;eltli.c L:ttl: htttult~ t Whin- you pelt into
the system Catt i LPL LIt c ILt uct iutt of tltc r,el)LiC Lu[tk it:i it ( reaC-
uteuL s tap,Lt iu I. t lie waste di:.f)u;ia.l sysLelit .
St. Cruix Cuttuty rIt sidcut:s illLu bU CLI -t;ihle Lo rL2t-cIve a grant 10r
,
it Ill it xi.ill- Upt UL 000 oT the cUSL u1- replit cctuonL oL a 1 it i 1 i-II SysLCIli
which was in t.tperatiota prior to )Uly I, 1018. Sc. Croix Cut.tnty
accented Lltis 1)rugrit ill LU A(1)r,usL of 1.980, wfUt Lhe rctluir.-' m eat thaL.
owit urs oL .tl_1 Mew sY_s_Lcuts dgFuI to keel, their sySteuts pruperIy
m.tiit taiit Lt III
The property owtaer dgreoi Lo sU1)Ill it L0 St C roix County ZOHiMtr, Lt
t' it F L i I icit I O11 turn, sll,rreLt I.,y LIt c owit ur anti by a tud:;LeI ItiLt Ill lter,
luIt rueylit it tt pLLt lit hLt r', rLt sLrict_od 1) 1 uutbC1 or it li -ccit d ItuIli per vcri -
lyitit; L haL (.l) Llte oit - ;-jLLLt w astewaLcC diS1)1)Shc. syStcIll ir; i I 1 ItIF uper
Uperat tut{ cuttdi -L i on and (2) ;.tI ter iIIS1) CL ion aIt d Itnlltpi 11L, ( i I. nec -
cSSary), t hu septic tank iS I c s s Lhail l/3 l.Ul_I of stoat!, and SCUM
CcrLllicLt L Loll LorIll will 1) C SeuL approx inutt 1-- 1y 30 drtys Itri~-tr t o
tIt rt'Lt year expiI- ati_ort.
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I WE, Lhc tt n d I, r s i. g it c d, have read the it bovo rc(I Lt i rc' lit entS and it l;reLt C/)
to Ill it intd.iit Llte private cwitl!,u dIS1)0 iII ySt eIll i_n ;1 CCUrdti IWU wiI.It
H
the StirnLt itrLt set lurch, It erei-11, ds set I)y Lhe WiSCOnsiit HepitrL-
MLt11L of NilLUra -L R. USOUrCeS. CLt rLiIical -ion I UrIli must be culit ltlcLcd
and retit 111ed to the SL. Croix i;uunLy /oit iM); 011.i.cc wi.LIt ln 30 days
uI the Cltlee year ex11iraLion dale
1) AT I`
SL. Croix CouULy Zoning Oil L('e
P.U.' hox )8
11 it uk itd , Lt I 5401 5
115-19 6-2':'31) or 715-425-8363
Sf};11 , dare anti r'Lt Larn to it t,uve it ddre:_;:
H 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
OCATION: X! /4, 11.__'/4, Section 1-4._, T~ N, R < If (or) W, Township or Municipality
of No. Block No.._-_- Count
subdivision Name
)wner's Name:
!ailing Address:
YPE OF OCCUPANCY: Residence Bedrooms Other
I FLUENT DISPOSAL SYSTEM: NEW _ ADDITION REPLACEMENT
ATES OBSERVATIONS MADE: SOIL BORINGS__ _`J_-l1_ -_71 - PERCOLATION TESTS
OIL MAP SHEET SOIL TYPE f
PERCOLATION TESTS
[EST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
'UM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL RATE
-
J R 1ST WEt-TED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
y
SOIL BORING TESTS
11: ST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES
CHARACTER OF SOIL WITH THICKNESS, INCHES
aUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
> f -
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suitable areas. Ingiyate number of square feet of absorption area
needed for building type and occupancy. . Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) a S_:0:~=~' /7> .~tc jr' -
~ Certification No.
Address
Name of installer if known ,t& X'
r
CST Signature
rnnY A - InrAr A iT_r~nr-v
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDIN
INDUSTRY, C DIVISIO
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 76
HUMAN RELATIONS 07
ON WI 537
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. O.: SUBDIVISION NAME:
COUNTY: OWNER'S/BUYER'S NAME: AI ING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
.QResidence New ❑ Replace
2 -
RATING: S= Site suitable for system U= Site unsuitable for system 1_2'y:!
r0dNVjENTTnI_O_NAfL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANKCOM ENDED SYSTEM:(optional)
QS ES EA ❑S ZU ❑S OU
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHM. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- /
3
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4
B-~
B'~'
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
P- -
P-
P_
P_
Y..
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 a; 7
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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): t r TESTS WERE COMPLETED ON:
ADD R SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
s
CST SIGNATURE;
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DII._HR-SBD-6395 (R. 02/82) OVER
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/ PAGE OF
r c) S S J` c 1 v '-1 p i -t IJ r i~ S 0 n- _I
Frskh Air Inlala And Ob6ofvatlon Pip•
Cdr Approved Vant Cap
Minimum 12 Above
Flnul Grada
20- 42" Abova Plpa - 4" Cast Iron
Ta Final Grada Vanl Plps
Marsh Hoy Or Synihslic Covaring
MIn 2" Aggrsgals
Over Pipe
OIUrIDutlon
Plpa 0 0 0 0 0 Too
oulh Aligagals
IP$ o
Ban Psrtoralod Plpa 8s10w
Plps
o _Coupling Terminating Al
8attom 01 Syalsm
~.1ev•.~ .gin
SOIL FILL
DISTkIBUTIOVI PIPE
APPROVED S ETIC COVER
"''-'-MATE{~1/~I- OR 9'' OF STRAW
Z~aOFgGGREGATE OR (~ARSH HAy
v o'
(oC)FGGREGATE og
ELEV. OF FEEL
DIS-I-RIfjUTIOIJ PIPE TO BE AT' LEAST iUCHES BELOW ORIGII,IAL GRADE
AtJU AT LEAST20 ILICHES BUT 1.10 MORE THALI 42 IMCHES BELOW FINAL GRADE
MAXIMUM DkPr►i OF EXCAVATMO FOM 0K16WJg4 6RADa WILL BE INCHES
IA1141MIJM OEPrH OF E'XC.AVATIOW FKOM: C*14GIMAL 694PE WILL BE ~ INCHES
SIGNED:
LIC, EIJSE AIUMBE R: /~II~V1~11.~
DATE:
'rank- - PC, P / 60
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Parcel 038-1076-20-000 12/19/2007 04:33 PM
PAGE 1 OF 1
Alt. Parcel 18.31 .18.312A2 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
O - SHIMON, THOMAS E & MARY J
THOMAS E & MARY J SHIMON
2164 90TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description " 2164 90TH ST
Sc 5432 SOMERSET
SP 17Gu ✓li1TC
Legal Description: Acres: 9.650 Plat: N/A-NOT AVAILABLE
SEC 18 T31 N R1 8W 9.65AC SE NE LOT 2 OF Block/Condo Bldg:
CSM 3/681
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
18-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 966/272
07/23/1997 795/473
07/23/1997 735/580
07/23/1997 684/566
2007 SUMMARY Bill Fair Market Value: Assessed with:
228447 173,600
Valuations: Last Changed: 08/27/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 9.650 54,400 104,100 158,500 NO 05
Totals for 2007:
General Property 9.650 54,400 104,100 158,500
Woodland 0.000 0 0
Totals for 2006:
General Property 9.650 53,600 104,100 157,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 137
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
I
z ~ R~PORT OF INSPECTION-INDIVIDUAL SE(UAGE SYSTEM Sanitaty Petm.i.
t
State Sep-tic'
f
NAME i owns hip St. CAO ix County
'Location r' f Section
SEPTIC TANK
Size gattons. Numbers a6 Compan.tments
Diztance Ftam: Wett it. 12% an gteateA 4.2ope it
Buitd.ing it. Wettands ~ .
H.ighwatet
DISPOSAL SYSTEM
120
Distance Fnam: We.2t t gteatet s.2ope it.
0 a
Bu.itding it. W et.2ands Ft.
H.ighwateA it.
FIELD DIMENSIONS:
Width ab trench it. Depth o6 tLock below Cite in.
Length o6 each tine it. Depth ob Aock over ti.2e in.
NumbeA o6 tines Depth o4 tite beXow glade .in.
TotaZ .2ength o6 tines-- it. Stope o6 tteneh in peA 100 it.
Distance between Una it. Depth to bed,%ock it.
Total abs otbt.ion aLea 6t2 Depth to gAOUndwatet it.
Requited area it 2 Type oi Covet: Papeti of Straw
PIT DIMENSIONS:
Numbet o6 pats GAavet around pits yes no
Outside d.iameteA it. Depth below .inlet it.
2
Totat absoAbt.ion area it A
AAea tequ,iAed it2 rn
INSPECTED BY TITLE
APPROVED DATE 197.
REJECTED DATE 197.
r
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
• MADISON, WISCONSIN 53701
deb REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:'/a,Section Lam, T_~IN, R If (or) W, Township or Municipality r/t•~11=
Lot No. , Block No. County
Subdivision Name
Owner's Name:
Mailing Address: R + • of
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS S -h ` '7f PERCOLATION TESTS L y 7~
SOIL MAP SHEET SOIL TYPE 4,
PERCOLATION TESTS
i TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
~ JUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
L
Xs
~P- /
I I II ~ ~ ~
i
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
i
> +
S
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suitable areas. `Inic~ate number of square feet of absorption area
needed for building type and occupancy. ~ Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
9JA
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) Certification No. -
Address 4`3 /Ve:~ i) LL 1 A %
Name of installer if known
CST Signature
COPY A LOCAL /,'_'7': i':-"iTY
PLB 67 I ' State and County State Permit # _
w Permit Application County Permit
County
• for Private Domestic Sewage Systems
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PRPPERTY Mailing Address:
ML NV' 1r\
B. LOCATION: iyr` er Section TEL N, R (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ~r )A'-7t
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance_
Single family- Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY JL+!+2; 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 5,L_Total Absorb Area %,--sq. ft.
New Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: X_Length /i Width i-~ Depth "t Tile depth (top)~/` .-No. of Lines -
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope 5Z
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 T) ter,
NAME jXI C.S.T. # ti:; / and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# /~S L Phone - S-
Plumber's Address
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.
/K C
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State f C County C Datg
Permit Issued/ (date) Issuing Agent Name_
Inspection Yes No State Valid# Date Recd
1. county (whi e 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