HomeMy WebLinkAbout042-1105-60-000
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Parcel 042-1105-60-000 09/30/2005 09:16 AM
PAGE 1 OF 1
Alt. Parcel 20.29.18.586 042 - TOWN OF WARREN
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 - VARELA, CARLOS R & PAMELA J
CARLOS R & PAMELA J VARELA
880 110TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 880 110TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 5.590 Plat: 2334-PLEASANT ACRES
SEC 20 T29N R18W 5.59A PLAT OF PLEASANT Block/Condo Bldg: LOT 14
ACRES LOT 14
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2000 630146 1543/607 WD
07/23/1997 1240/202 TI
07/23/1997 631/594
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/20/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.590 50,300 128,400 178,700 NO
Totals for 2005:
General Property 5.590 50,300 128,400 178,700
Woodland 0.000 0 0
Totals for 2004:
General Property 5.590 50,300 128,400 178,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Fo rm - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. p T N-RIf W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION '
t~ <<lac LOT LOT S17,E
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
l'
1
kp'
aINDICATE NORTH ARROW
BENCHMA Describe the vertical reference point used ekAz jjJ
Elevation of vertical reference point:
&d1 ~9 Proposed slope at site:
SEPTIC TANK: Manufacturer: G' 1e-e/ Liquid Capacity: a~
Number of rings used: Tam manhole cover elevation:,] 7
Tank Inlet Elevation: l~ t ~ •C//~ ?7
Ta. Outlet Elevation:
Number of feet from nearest Road: Front,O Side,aRear, 0 per feet
From nearest property line Front,Q~Side,O Rear, O feet
Number of feet from: well ~j building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
, J,
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, 0 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: Len th:_K Number of Lines: 3 Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft
Number of feet from well: Aw
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT 4,`W
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 14'W-
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet: -
Number of feet from nearest property line: Front, 0 Side, 0 Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest load:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number: 3/84:m_j
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.Parcel 042-1105-60-000 07/14/2005 09:37 AM
PAGE 1 OF 1
Alt. Parcel 20.29.18.586 042 - TOWN OF WARREN
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
CARLOS R & PAMELA J VARELA VARELA, CARLOS R & PAMELA J
880 110TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 880 110TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 5.590 Plat: 2334-PLEASANT ACRES
SEC 20 T29N R18W 5.59A PLAT OF PLEASANT Block/Condo Bldg: LOT 14
ACRES LOT 14
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
it
20-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2000 630146 1543/607 WD
07/23/1997 1240/202 TI
07/23/1997 631/594
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/20/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.590 50,300 128,400 178,700 NO
Totals for 2005:
General Property 5.590 50,300 128,400 178,700
Woodland 0.000 0 0
I
Totals for 2004:
General Property 5.590 50,300 128,400 178,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
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
LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON, WI 53707
PPCCONVENTIONAL ❑ALTERNATIVE statesPlanl.D Number
)
❑ Holding Tank El In-Ground Pressure E] Mound (if as igned
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER' INSPECTION TE
Sam Valera P. 0. Box 276, Roberts, WI ~r
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV. CST REF. PT. ELEV
E2 of the NE%, Section 20, T29N-R18W, Lot 14, Pleasant Acres, Twn.
Name of Plumber: MP/MPRSW No. County Sanitary Permit Number:
David Fogerty 3289 St. Croix 54982
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. q fl LIQUID CAPACITY. TANK INLET ELEV.. JTANK OU T ELEV. WVYES G LABEL ILOCKING COVE
'1 11 P EDPHOVID
" . ❑ NO ❑ S NO
BEDDING: VENT CIA VENT MATL. E HIGH WATER NUMBE OF ROAD. PROPERTY WELL 1BUIL11 JA
E TT O FRESH
ALARM
INLET.
I 4), FEET FROM ~+q~1 LI IR
❑YES NO ❑YES ❑NO NEARESTt o
DOSING CH MBER:
MANUFACTURER JBEDUING- LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFAC TIIRER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL JBIJILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE I AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLEN(,TI- DIAMETER MATERIAL AND MARKING
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:
WIDTH LE GTH NO. OF DISTR. PIPE SPACING. COVER 111,11111 CIA -PITS LIQUID
BED/TRENCH C~ TRENCHES TRIAL.
i / PIT DEPTH
DIMENSIONS
~ e ~
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. R NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES AB C VER ELEV INLEI ELEV. IND PIPES
1LINE. AIR INLET
.
FEET FROM
/
NEARESTs
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-
❑ YES NO meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH.' BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL. IN0
MARKING
ELEVATION AND . DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL &
ELEV.. ELEV.. DIA. ELEV.. PIPES. DIA.:
[DISTR I BUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
d t;~ ❑ YES N ❑ YES ❑ NO NEAREST
I IF L) -7
Sketch System on Re unty file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82) '
DEPARTMENT OF APPLICATION
SAFETY & BUILDINGS
,IND1jSTRY,, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAIt RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'h x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Maili Address:
100" 70v_ 1 9
a
r ~.2
Property Location: City, Village or Township: o2~x /.11 A A 11
'/4 /4S ~T NiR E (o W S Lot umber: Blk No.: Sub ision Name: earest Road, Lake or Landmark: tate Plan I.D. Number:
Y* (If assigned)
TYPE OF BUILDING
Number of
❑?ublic* ❑ Variance* ❑ Other (specify)*~Q~j'~. Bedrooms: ILI) 5' 1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: 1,
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): EP ew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
/ 5' ❑ Alternative (specify) ❑ Seepage Trench
Water ply: Own is Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public X W_-
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
e of Plumber: Sig MP/MPRSW No.: Phone Number:
er's Address- Name of q~j~lte~
L
C4 fW~
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: El APPROVED Sanitary Permit Number:
s'~~ ❑ DISAPPROVED PAZ/
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
Form - S T C 100
Owner of Property I ~ _l I-1
Location of Property 14, Section T N R_,&W
Township 2
Mailing Address d..
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel.
Date Parcel Was Created
. Are all corners identifiable? --AZyes No
Include with this application one of the following:
.Certified Survey Map 1
. Dee d 11eZgj s.'~~ /mot G~ c
Sr ~i ~7 o-{ . 5~
.Land Contract, or
.Other K ument which describes the property
12 - -4 D-
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described ProPertY, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. _
SIGNATURE O
F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE '`SIGNED E
~ H
'L.
H
;y
S '1' C - 105
' y
H
SEPTIC TANK MA I N'I ENANC E nt,lil%EMFNT
0
C'ru ix Count Y
0
.H
f .
R0UTL b 0 X NUM13FIt I 16Q /l - Fire Numb, r
C I T Y / STATE
PROPERTY LUCA`1'LUN:,61L ' SeCL iuu N It W
Town ofd-- Cruix CuunLy,
Subdlvl81L)LI Lot number
Improper use itad maintenance of your Septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out thu septic tank every three years or suuuer,
if needed, by a licensed septic tank Jumper. What you put into
the sysi-em affc~ r 011 of the SUPT i" tank as a treat-
ment stage ill the waste disposal Sy.,L~::::.
St. Croix County residents maw be eligible Lu ruccivu a grar►L 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
ULCepted this program in August of 1980, with the reyuiremeiiL that
owners of all new Systems agree Lo keep their Systems pruperly
maintained.- - -
'File property owner agrees to submit to St.. Croix County zoning; a
certificatiun form, signed by the uwnur :and by a masLer plumber,
journeyman plumber, restricLed plumber or a licensed pumper veri-
fying that (1) the on-bite wastewater dispusal SySteu> is in proper
operating; condiLiun and (2) ill ter i.nsliecL fun and pumpiiig, (it nec-
essary), the Septic tank is less Lhau 1/3 lull of Sludge and -;cum.
Certification form will be sent approximateLy 30 days prior to
three year expiration. H
0
z
I/WE, the undersigned, have read the above requirements and agree V1
to maintain the private Sewage disposal system in accordance with x
H
the standards set forth, Herein, as set by the Wisconsin Depart- b
went of Natural Resources. Certification form must be completed
and returned to the St. Croi-x County Zoning; Office within 30 days `
of tlae three year expirati,jli data. F
N
St. Cruix County 'Lun:ing Office
P.O. f'ox 98
Hammond, W1 54015
715-7~ 6-2239 or 715-425-8363
Sign, date and return to above address.
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k'i 77
DETMENT OF REPORT ON SOIL BORINGS AND SAFETY"& BUILDINGS
INDUSTRY, DIVISION
LABOR AN° PERCOLATION TESTS 115 P.0,BOX791
HUMAN RELATIONS- ) `MADISON; Wl 53707
PLOCATION:
Ill
SE TION: TOWNSHIP/MUNICIPALITY: T LK. NO.: SUBDIVISION NAME:
1/ a /T~ N/R jf1(or ~UNTY: OWNER'S BUYER'S NAME: MA LI ADDRESS:
c ru o
USE DATES OBSERVATIONS MADE
N
O. BEDRMS : COM R O
6,idence T New , ❑Repl
FP
ace
e
G-3- i d x..12
RATING: S- Site suitable for system Us Site unsuitable for system
CONVEN I1 NAL: MOUND IN-GROUNDPRESSURE: S STE -IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
r
~s au as ou 2s ❑u ❑s au rEJS ❑u
If Percolation Tests are NOT required DESIGN RATE:
any portion of the lot is in the
under s.H63.09(5)1b1, indicate:
0,0 F
1a ? 1 oo
dplain, indicate Floodplain elevation:
p~E .
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WI THIC NE S, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- jo
LB- ;Z"
• `
Z6 ;ie j
B- '7 r r H ` a S
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. D 1 P R D / PER INCH PERIOD PP- / 7 pit
'M / M S
P-
P- olUE ~t r
P
P_ p 3
P-
PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions•of suitable soil %jeile dicate scat or d tan as. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot pl n. ShoQw the vatjnn at all ring and the direction and percent
of land slop. y(, S } i1M~
f-4 -
SYSTEM ELEVATION q,0 /0 € {
o p - o .P s
hill zV
Ole
1 iN L J`
14
r~ y A~~
y
27
irc • bN S/
'a D 44
s - • ~ ° ~ ~ cks,
INS
m 5 a r _
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with ~tures methods s in t nsin'
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
40
NAME print
a TESTS WERE COMPLETED ON:
1b A-
v `~3 c~ -12-- g 1
ADDRESS:
CERTIFICATION NUMBER: PHONE NUMBER opt' nal):
C) S a 02 - ?yq bs9
CS NATURE:
TRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th pageSoil Tester. -
RSBD-6395 (N. 03/81) '
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