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Wisconsin Department of Health and Social Serv1,)a3
Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BL CK INK
A. OWNER OF PROPERTY +
Name Address
(Streets City, zip Code)
J-0 F
B• LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY 1
Check One: ~
-9 S CITY VILLAGE LEGAL DESCRIPTION
y (J/.~ /(o
L~ TOWNSHIP
7,^
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: /
E. TYPE OF OCCUPANCY
-Check Ones One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persona to be Accommodated Number of Bedrooms >
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES i NO Automatio Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION /
Names < Address= /-I/-- License Number:
MP
Signature of Applicants ~G t O<x- .~~J ~j MP RSW
Address:
H. o e Completed by Issuing Agent)
Date of Application 17 0 Fee Paid $
/
Permit Issued (date
0 ?emit Plumber
Agent (Name) - L-L i For:~,~
Town, Vlllage, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $I.OG for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Heat`„h.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED ACCEPTED BY ? RETURNED
(Initials) (Date) See Corres.)_•
FEE RECEIVED VALID. No. PERMIT NO. -
es or NO; -
REVIEWED BY APPROVED DATZ
(Initials) Yes or Noj
COMPLETE OTHER SIDE
SIPTIC TANK PERMIT NO.
R=P0RT ON SOIL PI RC0LATION ?EST
A N D S O I L B 0 R I N G 1
TO J
DIVISION OF HEALTH - PLUMBING SECT AN
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P I R C 0 L A T I 0 N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches utes
Number Inches Thickness in Inches Since Hole in Hole Eaterval Second to Next to Last El
Fall
lst Wetted Overni
ght in Minutes Last Period Last Period Period < I
nch
Example
P - 0 361 To Soil 10" Cla 2610 25 Yes or No 30 1A 1 2 1/2 60
h
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N Gs - Minimum 36111 Below Pro osed Abso Lion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thiokness in Inches
Example
B - 0 72 it 72" Black Top Soil 12" C1 18" Sand 1811, Gravel 2411
/I/ r
RPM DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCY:
RESIDENCE: Number of Bedrooms_ OTHER: (Speoify) Number of Persons
D WASTE GRINDERS Yes No ^ Dishwasher: Yes No /Automatic Clothes Washers Yes No
FFLUENP DISPOSAL SYSTEM: NEW 1- EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth °Tile Size No. Lines
Seepage Pit: Inside Diameter Liquid Depth . S
I, the undersigned, hereby oerlfy that the percolation tests reported )n this farm were made by me or under ryy super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of a knowledge and beli.ef.
NAI"W' TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
r- i
ADDRESS ? ? i_ ! 14 F
DATE _ 1; ,7 , J 4 / SIGNATURE
. CYLON 7- 31 59
Thos: POLK COUNTY N.-R. I
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S///E''E+++ PAGE 47 S
PLAT BOOK COMMITTEE
SALES COMMITTEE Cont'd. on page 61
Mr. James Ray Mrs. Charles Smith
Mrs. Gordon Mueller Mrs. Ross Mr. Jim Ruemmelc
o
Mr. and Mrs. Bob Phillips Mr. Robert PHa Pierson Mrs. Miles M Casey
Mrs. Gu Wilbur Mr. Al Frank
y Mr. Don Matysik Mrs. Judy Ferguson
Mr. and Mrs. Merton Vrieze Mrs. Joe Lohmeirer
Mrs. Robert Gardner Mrs. Willard Johnson
Mrs. Robert Hanson Mr. and Mrs. John Steele
Mrs. Freida Fellinger Mrs. John Lavelle
Mr. Leon Holle Mr. Robert Condon
Mrs. John Glassbrenner Mr. Del Polzin
Mr. Steve Thompson Mrs. Harlan Johnson
Mr. La Verne Karastes
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REPORI CI- INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanc' ta11q Pt nm4t 49
State Sep.t.I.e.91-
NAME Township
- - St. c n o-("x e ou n t t~
Eoca.t"ion Section Lot # ubd-iv.ia,i_art
S E P T I C TANK
S-i ze--------------,--9af.t 0n6 Numbers o6 cornpantment4_ '
Ui ta~<<~r ("tom: LUSuitd.ing
H i g h w a te-n.
PUMPING CHAM61-R
---ga e,eona Pump Manu Aaetuit.e.n - Mo de.t Numb e ,t 11 C "101NO I AN& ~ -
gaf, e0 n,6 -.Numbers o6 Compantment~
Vu mpert Atanm Syetem
tanc v (ttum: fueeZ-_--T 13uikding _ 12o a.Lope -
fttighwafien
r11iSORPTION SITE
1"vd DLench
lain tan~~v (nom: Wee
HighwateA
AI;';ORPIION SI-11 DIMENSIONS
W(dth trench.
6t Requih-ed anea - ~t
Lvn~ath 06 each t4ne. t Dep-th. o4 n0ek be(Ciw tiPe
Nurribe~i c,{~ d'iyte.5 Depth o6 hock oveh t~Qe In
Iutae eenyth o6 Uvlels _ -,_6t Depth oA tite beeow grade <n
Ui _s tuncv between. I t.ne3` _ 6t Stope o6 - `
tneneh - ---tinp e rI 100 6~ . .
7r,tae absolLpttion an-ea
-__--fit Type o6 Cave.n: Paper on atnaw
I'll DIMENSIONS
Nurr,I> e n a pi t5 Gnavee around p.ite yea no
Out, i de d~ ame-t,eh._---_-- 6t Depth below in. et - ~t I
- I
TotaE' absonpt,i.on anea- 6t
Ali ea 4(,((u,( iL e d----- 6 -t
INSPECTED 1~
A V/1 R O V E D DATE - 19 8
RI. JECTED DATE 19 8
I
RI A S 0 N V 0 R REJECTION--- -
REPORT ON INSPECTION OF SANITARY PERMIT # 2 v
(1) Name and Address of Permit Holder Person/Persons at Site 2 Date of Inspection
M_ J
ame
A ress icense o. o ns a ing plumber Time of Inspection
NSTALLATION C ISTS OF:
❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanen re erence olnt escri e:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle _ gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO
8 HOLDING TANK: Manufacturer of gallons construction
depth to the cover ft; If septic tank is
being used are baffles removed? ❑ YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material
Distance from building to vent '
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
li.neal feet tile; ft 'to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TREN H: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115?~ ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES NO
DILHR-SBD-6095 N.05/80
Signature of Inspector:
6 7 State and County State Permit #
v
PLB
Permit Application County Permi #
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 j Mailing Address:
B. LOCATION: Section J(O, T`0 -7
N, R_Z4z,E-+&, W; Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
a
,f Township
VYI~ IBS p'~ 1, i 'ice ~ ~ VM • ..3d:~~~ ~~er~~rK
C. TYPE OF OCCUPANCY: *Commercial _ *Industrial -Other (specify) -Variance
Single family _V Duplex No. of Bedrooms 3. No. of Persons
D. SEPTIC TANK CAPACITY,16LO~ Total gallons No. of tanks
HOLDING TANK CAPACITY IVIA, Total gallons No. of tanks
Prefab concrete Poured-in-Place _ Steel Fiberglass Other (specify)
New Installation Replacement _
Lift Pump Tank or Siphon ChamberTotal gallon Prefab concrete Poured-in-Place Other (Specifv) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate- 10 Total Absorb Area
sq. ft.
New ✓ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. jWidth Depth Tile depth (top) No
Seepage Bed: Length -T Width__t't~" Depth-3 - 7_Tile depth (top) 2 No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- c:~a_ Distance from critical slope
WATER SUPPLY: Private 016 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
'11-•-i..:~' C.S.T. # and other information
obtained from owne /builder).
Plumber's Signature & P SW# ~ r - Phone #7(~ - f T
Plumber's F.ddress = ~~A l t r "I- u ~y
i
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.
.
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Do Not Write in Space B to FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application e1 Fees Paid: State , c-Z) Co n y D'tJ to 1
Permit Issued/Ra0eted ( ate ~ Issuing Agent Name
Inspection Ye, X No 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
• EH• 115Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O.. BOX 309, MADISON, WISCONSIN 53701
LOCATION: Section % T N,R%~ '
E-for) W, Township or Municipality
Lot No. , Block No. ,
ubdlwsion ame County sX
Owner's/Buyers Name: I Ct.
Mailing Address: Vif e C,
TYPE OF OCCUPANCY: Residence- ✓ No. of Bedrooms
COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW J REPLACEMENT ALTERNATE SYSTEM
DATES OBSERVATIONS MADE: SOIL BORINGS J'''ib f E(> OTHER
PERCOLATION TESTS
SOIL MAP SHEET S'4 I
NAME OF SOIL MAP UNIT . ~C?
TEST ar d 1 PERCOLATION TESTS
IS,SF ~S(~,~.
BER FDEPTH
NUM- CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, IHE
NCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL RATE
1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PER I0 3 MIN/IN
P-
3
P- 6;
P_ - N~lc .
P-
P-
N
4~
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,i
NUMBER INCHES OBSERVED ESTIMATED HIGHEST TEXTURE, MOTTLING AND DEPTH TO BEDROCK
B- IF OBSERVED IN INCHES
elf,
B 3E It 3 Fr
~
I I •~-10
B- I~ t~ sf.f i S,<
B-
5. 10
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locatidn and square feet o suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy
Give horizontal and vertical reference points. Indicate slope. ,--Indicate scale or distances.
~ I dlsl~ ,GAS r
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I, the undersigend, hereby certify that the soil tests reported on this form were made by me in specified in the Wisconsin Administrative Code, and that the data recorded and location
of test (doles are correct to the best odf ray methods
knowledge and belief.
Name (print) v U ~t''4 Y 1 ~L
Certification No.
Address
a
Name of installer if known
Copy A - Local Authority CST Signaturg _(c_ .
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Parcel 006-1035-70-000 09/19/2006 03:55 PM
PAGE 1 OF 1
Alt. Parcel 16.31.16.245A 006 - TOWN OF CYLON
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 - SIEDOW, SCOTT E
SCOTT E SIEDOW
2280 210TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2280 210TH AVE
SC 0119 AMERY
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 17.320 Plat: N/A-NOT AVAILABLE
SEC 16 T31N R1 6W 17.32 AC SE SE EXC THE Block/Condo Bldg:
N 500' AND THEE 400'
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-31 N-1 6W
Notes: Parcel History:
SMC-EXC S/B N 50OFT AND THE E 400FT/ NOT Date Doc # Vol/Page Type
EXC THE E 400FT/05/1/05 10/05/2005 808614 2903/382 WD
11/23/2004 780779 2701/498 WD
01/05/1999 595085 1393/030 WD
01/05/1999 595084 1393/029 WD
more...
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/26/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 25,000 151,000 176,000 NO
UNDEVELOPED G5 8.320 8,000 0 8,000 NO
PRODUCTIVE FORST LANDS G6 5.000 10,000 0 10,000 NO
Totals for 2006:
General Property 17.320 43,000 151,000 194,000
Woodland 0.000 0 0
Totals for 2005:
General Property 17.320 43,000 151,000 194,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/1712001 Batch 512
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
0 W N Ef1,~ ~ TOWNSHIP _
SEC T_T_/_N - R_/•E~ W
ADDRESS-% ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
T
IL L
i
I
- - i v
I di at N :)r h rrc w
BENCHMARK: (Permanent reference Point Describe
Elevation of vertical reference point: `OD Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: ~
Number of rings on cover • O Tank manhole cover elevation: 0
Tank Inlet Elevation: lp , 77 Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of pump set for. a cycle gallons; Total capacity of
distrib ion lines gallon: size of pump head;
gallo per minute horsepower ;brand name of pump
a model number
ype of warning device '
HOLDING T Manufact,lror - Number of gallons
Ele tion of manhole cover - -
T pe of w rning device
SEEPAGE P SIZE; Number of its
fee liquid depth see a e p - feet diameter
p g pit inlet pipe-elevation
b ttom-o-f seepage pit elevation feet.
SEEPAG ED SIZE: number of lines width length the depth
S EPAGE TRENCH(~,Jwidth_~
PERCOLATION RATE <AREA REQUIRED ~ngth~U
AREA AS BUILT
INSPECTOR__
DATED PLUMBER ON io~ 7w~
LICENSE NUMBE1,
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MADISON, WI 53707
E~CONVENTIONAL ❑ALTERNATIVE SiarePlanLD.Numbec
(
Holding Tank ❑ In-Ground Pressure ❑ Mound If assigned)
NAME OF PERMIT HOLDER . ADDRESS OF PERMIT HOLDER : INSPEC N DA E
Ben Boe RR#I , Deer Park, WI - i i ~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT ELEV..
SE SE, Section 16, T31N-R16W, Town of Cylon
Name of Plummer. MP/MPHSW No. Count
v Sanitary Permit Number:
Gary Steel 3254 St. Croix 43764
SEPTIC TANK/HO DING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
Ff / PR VI D PROVIDED
610• Cll[ YES ❑NO ❑YES ❑NO
BEDDING: VENT D A VEN AT HIGH WATER NUMBER OF ROAD: PROPER-TY - WEL : BU14DN VENT TO FRESH
IT ALARM AIR INLET:
❑YES ❑NO ❑YES ❑NO NFEET EARESTOM (
DOSING CHAMBER:
MANUFACTUR ER BEDDING. LIQUID CAPACI iV PUMP MODEL. PUMP; SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
P O DED: PROVIDED.
❑YES ❑NO YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: P LIMP AND CONTROLS OPERATIONAL . NUMBER OF PH CEP E RT R WELL BUILDING, VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINI AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 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. LENGTH NO. OF DISTR. PIPE ACING. COVE INSIUE DIA #PITS
BED/TRENCH THEN HES M RIA DEPTH.
'2 7
DIMENSIONS m PIT
GRAVEL DEPTH FILL DEPTH 1) ST PIPE DISTR. PIPE DISTR. PIPE MATERIAL : NO. DI R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
HE LOW PIPFS ANOCOVEH EI EV. INLET ELEV END PIPES FEET FROM LINE.., [ AIR LET.
Z 2.2 `l 1 ~ d !l
NEAREST l c3
MOUNDS STEM:
Mound site plowed perpendicular to slope Check the texture o~ 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 for edium sand. ,,.-~`TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKER JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCHBED DEPTH OVER TRENCH: BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES ❑ND ❑YES ❑NO ❑YES ❑NO
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 NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATFHIAL & MARKING
ELEV.. ELEV. CIA ELEV.. PIPES. DIA..
ELEVATION AND
DISTRIBUTION
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 WEFEET FROM LINE'
❑ YES ❑ NO ❑YES ❑ NO Nc I
1 C It , Z,
2 r„
Sketch System on l'
Cf~r
Reverse Side In county file for audit.
. 1 y
SIGNATURE TITILL.
DILHR SBD 6710 (R. 01/82)
wlscons,rl APPLICATION FOR SANITARY PERMIT
y
1rDILHRN
(PLB 67) COUNTY TEnT OF UNIFORM SANITARY PERMIT #
~ OEPRRT
In DUSTRV, LR60R & HUTRrI 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
PROPERLY OWNER MAILING ADDRESS
PROPERTY L CA ION C-1-15
L-L A6E:
X1/4, S A; , T f , N, R (or) W V-I TOWN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST R D, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
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 L1 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
Gallons #of Prefab. Site Steel Fiberglass Plastic
Tanks Concrete Constructed
Septic Tank Capacity `
Lift Pump Tank/Siphon Chamber _
Holding Tank capacity
Manufacturer:
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 rumber (Print): Signature: IVIP/MPRSW No.: Phone Number:
Plumber's Addd+dr ss: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: n Fee: Date: ❑ Disapproved
~ D Owner Given Initial
L/ <J y 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.
ForIII - S T C 100
Owner of Property r 1
Location of Property, _Section ,T-N R Ac W
Township
_ T~•y~y~~
Mailing Address }Z,J ~j< y~Ay.~; N c~~, 7
Subdivision Name
Lot Number
Previous Owner of Property- ~nseah 60'0
Total Size of Parcel- <
Date Parcel Was Created_ 75;'
Are all corners identifiable? X_Yes No
Include with this application one of the following:
.Certified Survey Map
. Deed
.Land Contract, or
.Other Legal Document which describes the property
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.3-C- Z 'F z- ; 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.
SIGI'fAfu F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
f
:2
DATE SIGNED ~
DATE SIGNED
' k
? Yl C: fcuit Court, St. Croy
~ur:t~j:isconsin.
'Xtified Copy of Final udLl,r:_ent.
ated Feb 255 1980.
Cert. Feb. • 26, 1980.
Feb. _ 1980.
.
-85 11rog", page 05, 1362991-
+ _ ,t: t of this estate having
ioner navi~lg appeared in person and by '
u,.,, ~ar ~petit
nP_y.
on a-, 1 evidence, recor6s al_,d proceedings herein, the Court finds
1. The petition carne 0:1 for hearing upon waiver as provided by
persons entitled to notice; 2 . Notice has been-published
1
r
en
or det_r° ..naV on of the hear ~,t` the decedt; 3. The expenses o
funeral, Last k.ne..", and the claims against the
`,ate hr. •Je been oa.i a; the cent ficate of the Department of Revenue
on fi -e and t ?ere is no vnpa i d income tax; the estate is subject Vo
ta-ce tax which ha,; 'r-,(,en )aid. C). There remains pr Y fcr
tr` but; en a: follows • A. TLiez::u of SEA of Section 16-31-16,
'e---'- to an e2 ecae it fo inuress and egress over the E 2 rods
other 1&n,;. ADJUDGED THAT Joseph B
Y,O, THEREFORE, IT I ''t'Y uillu D ATD
1 ~ r Jul-Y., 1978 and the following
--d nt~ a :e on the lti, x.:~,~r c•_
rs r?,.:t-Nepheta, Daisy Hi _be ,
- F r~ of the decedent: :~a),iei Boe, A _3eri;amin C . Boe, Adult T t•1 t, . . T 'I
_t -,E^e; 5etty T. ?sarson, Auu1t-~vY_e ce, personal re
7M T, m- , AD,~ ~DG7;D TI IT A1.1 acco~ is of the pers pre'4. -
fees personal represent^--
ve on file are approved. The attorney ' The propert;
'_-res fees and guarcian ad 1_-iterin. fees are appr .oaed. A one-fourth
s .r_bed at Finding No. 3 is a gn-d a,s t therein to'
.-teres' therein to Daniel el Boe; A one-fourth interest
,ert F_ one-fourth interest therein to Betty J. Larson, A one four w s
_ Ceres therein to Bend Boe. The
property l terminated at ededecedent ath. a
_j
1-t-c to of Wisconsin, De_;artr. nt
o' Revenue, Release of Inhe ' . tarlce
r Tax Lien. 197•
Rec. Dec. 17,
In 11606", page 121, 361863-
3oe, Decedento
,,cite,_-: -Pursuant to s. 72.25(1), Wisconsin Statutes, the
.eri-
_on~in Department of :ievenue hereby releases the lien of the inrA
~cF> tax on any right, title and into est of the above named decedent
i t. The .'1 of SEu of ce^tior.
the i'o11o~•aing d -scr,.be c. r, ert7 -
c. _ `-Y ber ar_ i :ett Quit Claim Deed.
T • Con. None Shown.
Dated Dec. 1, 1979.
Auth. Dec. 1979•
Rec. Feb. 28, 1980.
Jr. "60q", G)a:7" 08, #Q_02 +2
3oe and ;lade R.
isbar a and wi e: as joint.
C.
and :fer jamir.
~e ar_ Eti,ther Y. Boe, ;
c,j- f as. Joint. teY...
6
_'_i tes : Subject; 4-o an easement for ingress and egress over the
thereof .
ie granteos shall hold -Ile as tenants in common, except, that
bed Ta ren husband and L.- tie .rd ~Ti ded one-half interest shall
as, -oint
,angel -hoe an-,! Glade !1 . 1,._ , r la l he'.
_i~-bnnd and wife as jo r ,t ion. None Shown.
Dated Dec. 1, 1U7 ; .
- to- Auth. Dec. 1, 197. .
Rec. Feb. 28, lgc r,
C. E-ce and In "6609", page 10, - :t husband an-] w_.1
-
nu tez~arit: The SEA of SE4 of Section
1E 31-15.
-ete S!ub,ect ar
thereof.
4. , r=u-band anLz i f e Oon. $15.,00C
.
Dated Dec.
Auth. Dec. 1, 197;,.
Rec. Feb. 28, 1980 c
woe and Glade R In. "u0y", page
_band and wife a
• The SE!,of SEu of Section
16-31-1b. -
Teci_tes : Subject to an {easement for ingress and egress over
_:r 's thereof.
_,nh` s i not ^oiieste : ~ property.
(is' _ r 1 t.
-ice 1oi ~J O a e.
. "aim )ee , .
"on.. None Shown.
_ -1 ted Dec. 27,
Auth. Dec. 271 1976',
- - - • ,ec. Feb. ,28, 1980.
In "609" , page 12, ii '
4 v _ JY. -1 •
to:.. Subs c t to e.11 e-
-e .ent for ingress and egres - o-
^CQP •t~ F _''~of.
t !-C ~~I Ee Deaf,' n -7:' rJr 'r.
f '
D~PARYMENT OF 4% * I N DUSTR Y, S R G / 1 REPORT ON SOIL BORING/~ ~ FETY & BUILDINGS
r,,VF[J DIVISION
AND PERCOLATION TESTS (_15) U P.O. BOX 7969 HUMAN RELATIONS / Sr P I n 19$3 -y ADISON, WI 53707
(H63.090) & Chapter 145.045) ZONING L`QCATION:, SECTION/: l/ TOWNSHIP/MttrdfGhP-AL}TY: LO-.NO.:BLK. BDIVISI NAME:
J~~w ~ /
/u/ / N/R,,6j (or) W (~~t -
COUNTY: O NER'S/RU*EWS NAME: AILING ADDRESS: -
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
LZ 1
Residence New ❑Replace (I c LL? 9 17 RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
s ❑u s ❑u s ❑u ❑ s Zu ❑ s ®u
If Percolation Tests are NOT required DESIGN RATE: I If an
IL y portion of the tested area is in the
under s.H63.09(5)(b), indicate: - Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS ~r
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEFrr-H IN OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/ r
07 2~
'67 < A C"
58 5 17
j
B-7 /U01 A)1:5
7 y
Z _7
B -45, Cam.
B 217
G°.: s av S, ,53
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER +NGUE-S AFTERSWELLING INTERVAL-MIN. PERIOD( PERIOD2 PERIOD3 PERINCH
P- 4~R rZl _ 3
< '
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 all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
y ,a
E~ ,
- .e
I .
P
)J
@:,
,
6) /00
W......
E
-
_ i.
0-la, CA
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.
I
NAME (prin o TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
;7
CST SIGNAT E:
E/ L
LD~STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395 (R. 02/82) OVER -