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Parcel 040-1093-80-000 11/09/2005 12:49 PM
PAGE 1 OF 1
Alt. Parcel 24.28.19.3780 040 - TOWN OF TROY
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 - JENSEN, DONALD & JEANNETTE
DONALD & JEANNETTE JENSEN
212HWY35N
RIVER FALLS WI 54022
Districts: SC = School SP =Special Property Address(es): Primary
Type Dist # Description 212 HWY 35 N
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE
SEC 24 T28N R19W PT SW SW BEGIN SE COR Block/Condo Bldg:
SEC 23, TH W 118 FT, N 15 DEG W 160.8
FT, N 42 DEG E 145 FT, S 52 DEG E 432.8 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
FT TO S LN SEC 24, W 366 FT TO POB 24-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/20/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 66,000 132,500 198,500 NO
Totals for 2005:
General Property 4.000 66,000 132,500 198,5000
Woodland 0.000 0
Totals for 2004:
General Property 4.000 66,000 132,500 198,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 147
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
NER -fit. e , TOWNSHIP SEC. TN, R
.0. ADDRESS , ST. CROIX COUN , WISCONSIN
2:2L7 _Z_
.3DIVISION , LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4'
• r '
y
`-11 l
V y
v' w
'F. y r
iS
PTIC TANK(S) Z MFGR. _CONCRE A, STEEL
NO. of rings on cover j Depth r' DRY-ifEm
TENCHES NO. of width length area
D no. of lines width= length--4-:- area
dep%h to top of pipe
"GREGAT
FtK RATE AREA RE UIRED 7-- AREA AS BUILT
'sciaimer: The inspection of this system by St. Croix County does not imply complete
:apliance 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
-tern operation. However, if failure is noted the County will make every effort to
'--ermine cause of failure.
BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
_ s
"INSPECTOR 4 DATE 7/PLUMBER ON JO
LICENSE NUM~ER°._.. fi / 1'5
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San,itatc y Petcm.it-
Sta;te Septic
NAME Township la"cSt. Ctcoix County
Tlf'N, R /:I W
Lvca ian v Section
SEPTIC TANK
Size gattons. Numbers o6 Compatz.tme.nts
Distance Ftcom: Wett it. 12% m gtceatetc ztope it
Bu.itding it. we.ttand.5 ~ .
H,ighwatetc it.
DISPOSAL SYSTEM
Di6tance Ftcom: Glee. 12% ot gneatetc 6tope it.
Bu,itding it. Glettandls Ft.
H.ighwaten it.
FIELD DIMENSIONS:
Width o6 ttcench it. Depth o4 Aoch be.Low tite in.
Length ob each tine it. Depth o6 tc.ock oven tite in.
Numbetc o6 Zines Depth o4 tite below gtcade .in.
Totat tength of tinez it. Stope o4 trench in pen 100 it.
a
D-ustance between .roes it. Depth to bedAocfz 6t.
Totat absmbt.ion atcea 6t2 Depth to gAoundwatetc it.
2
Requited aAea it
PIT DIMENSIONS:
s Numbers o6 pitz Gnavet around p.itz _ye/s no
Outside diametetc it. Depth below .inlet it.
2
Totat absotcbtion area it z
A
A&ea tcequitced it2 rn
INSPECTED BY TITLE
APPROVED DATE 197^
REJECTED DATE 197
9
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EH 11.&
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
LOCATION:- Section TVN, RI _4) E-(aF) W, Township &r-A4a+YieFp~tity'7V'R&`e' 4:1~
Lot No. , Block No. County I - C~12t~1
Subdivision Name
Owner's Name:
Mailing Address: LJI;'e /=7t LLS i j V6~-Z
TYPE OF OCCUPANCY: Residence X No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT SC
DATES OBSERVATIONS MADE: SOIL BORINGS \m0 i 1B PERCOLATION TESTS 11 /osl/
SOIL MAP SHEET SOIL TYPE "Pi LL-0-1-
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 AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P
P-2 S 46 ; b 5/~ 12 v Z ~~b ~~b G alb ! 1
P- ~ JS, fti j a li z z '113i, 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)
B- 1 \GS~ 1vG_i?C. E'---
~b 1•~:•sb n I Brsl,l&~s)4LSR&S.Z6'J3o~/
B
V -s 1) 9 t c 12 ' b ' SI w L 1:3 iY'CI+L.~ J7ts /'L 7~
1C Imo` `7 ic,Y, 7 all Ls R i
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of, suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. -7 -Sv~' 1,71 CHc ( yS' gf--1-3 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) ~~T-/4U L '7ZCertification No.
Address _
~ LL 5:i-J0 RI, A.11' SY011
Name of installer if known
COPY A -LOCAL AUTHORITY CST Signature
State and County State Permit # ( (0-10 f
PLB67
Permit Application County Permt # _ C
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. LOCATION: 54?.1% Section T N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
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 4-10 # of Bathrooms
Automatic Washer A/VES NO Other (specify)
E. SEPTIC TANK CAPACITY /tp Q Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement tip Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) & 2)_/,~ 3) Total Absorb Area esq. ft.
New ' Addition Replacement x-~ *Fill System
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches-------
a Seepage Bed: Length Width Depth _tLe Depth 'Ot
No. of Lines
r f'
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope
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 So*1 Test
er1
NAME `y C.S.T. # _.:5° and other information
obtained from (owner/builder).
Plumber's Signature ' fo;KMPRSW# 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).
,
E
F
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t
S~4
ell
r~
Do Not Write in Space Belo OR DEPARTMENT USE ONLY
Date of Application 7h Fes POW: State /0 County Date
Permit Issued/Rejected (dat / 11ssuing Agent Name
Inspection Yes No Valid# Date Recd
1. county (w rte 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
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON, WI x3707
E CONVENTIONAL ❑ ALTERNATIVE Slate Plan I D Number
Holding Tank ❑ In-Ground Pressure ❑ Mound (lf assigned)
RECONNECT
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Dan Jel R. R. 5, Riven FaM , (UI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFEHENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELE V.
SW Nw. Section 24, T28N-R19W, Town o6 Titoy
Name of Plumber_ MP/MPRBW N,, County Sanitary Permit Number:
Tam Wan 3231 St. Ctoix 54930
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVI DEO. PROVIDED:
EYES ENO EYES ENO
BEDDING. VENT DIA.. VENT MATL. HIGH WATER ]EEA
BER OF ROAD: 11PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM T FROM LINE. AIR"LET'
EYES ENO EYES ENO REST
DO
SING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
EYES ENO OYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JVVELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE I AIR INLET
PUMP ON AND OFF) EYES ONO NEAREST
SOIL ABSORPTION SYSTEM .-Check thesoilmoisture at the depth ofplowing LENGTH DIAMETER IMATEHIALANDwAHKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVER JINSIDE DIA -PITS LIQUID
TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS T T -
GRAVEL DEPTH FILL DEPTH UISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL 71NG
~'JPF VEN T TO FRESH
BELOW S ABOVE COVER ELEV.INLET ELEV. END PIPES FEET FROM LINE. AIR INLET.
NEAREST -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-
E YES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
EYES ENO EYES ENO
ID EPTH OVER TRENCH BED DEPTH OVER TRENCH :BED D OPSOIL. SODDED SEEDED MULCHED.
CENTER EDGES
EYES ENO EYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. IND DISTR. DISTR. PIPE DIS rRIBUTION PIPE MATE HIAL & MAR
ELEV.. ELEV.. CIA ELEV.. PIPES. DIA..
ELEVATION AND KING
DISTRIBUI ION
INFORMATION ROLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES ENO EYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY JWELL. JBUILDING.
FEET FROM LI"E
i DYES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE:
DILHR SBD 6710 (R. 01/82)
consin APPLICATION FOR SANITARY PERMIT
r(77D ILH R ~ COUNTY
~ (PLB 67)
W OEPRRTMEnT OF UNIFORM SANITARY PERMIT #
In OL-TRY, LRBOR 6 HUmRn RELRT101-15 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x l l inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OVER MAIL NG ADDRESS
PROPERTY LOCATION \ CITY:
Q1/4 Al /4, S , TN, R I' E (or W) row N OE: D
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAVE OR LANDMARK STATE PLAN I.D. NUMBER
fr b ^ll r
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: J L- 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):
t16 C j 9 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signat e: MP/MPRSW No.: Phone Number:
kAa s LJO A % (his ) ~~~--y~s~
Plumber's Address: Name of Designer:
//c 7/
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
Y_ ( 4 ❑ Owner Given Initial
ZI / 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
c
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.
r
INDUSTM , OF REPORT ON SOIL BORINGS AND SAS TY &IBUILD GS
INDUSTRY, DIVIS N
LABOR AND PERCOLATION TESTS (115) 115) P.O. BOX 7 69
HUMAN RELATIONS 4AAA[?ISON, WI 5 07
i0-Cl1TIOMi SECT N: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SU tVISION ME:
k) '/4 '/a_ a4' /Tae N/R,9 E or OUNTY OWNF 'STBUYER'S NAME: AI IN ADD,R SS:
USE DATES OBSERVATIONS MADE
I~ NO. BEDRMS.: COMM _R AL DE R TION: I PROFILE DESCRTRTTOW.. [15MCOLATION STS:
/Residence [:]New Replace
HATING: S= Site suitable for system U- Site unsuitable for system
cINVENTIONAI. MOUND: IN-GROUND-I'RESSUFIE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
s outs qu as ouos au _os aU
I I Percolation Tests are NOT required DESIGN RATE: , If any portion of the lot is in the
under s .1-163.09(5)(b), indicate: /
Floodplaih, indicate Floodplain elevation:
O < 3o
7
t PROFILE DESCRIPTIONS
j9
HOHIN(, TOTAL P HT R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
11JUMI3EH DEPTH IN, ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
Ao"B S `8 S d S
B 3 goo 30 " 4~~ 5i
E
B-.
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTEFIVAL-MIN. RIQD _PFRI D PER INCH
A>,
h o i V7
,N a l ~
P-
I>
,P
FLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
untal 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
rt land slop.
SYSTEM ELEVATION. l~~d a~X J e'
AO Ir S,
~ ~ ~ Ptwc b~olcs
A - Cedar Cov-Ptel- osf Sas ~
tes t ;
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I" the undersigned, hereby cerii that the soil tests reports on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative 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:
?J/nq S 4 ~
l
/Vo t) ff
jADDRFSS:
1 , CERTIFICATI~N/NUMBER: PHONE NUMBER optional)
/0C)
Jn~ CST SI UR
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
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