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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP L All -CALLS _SEC . /j_T~,SN-R/(, W
ADDRESS/ (.c1 C!L?( /41 ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE'
PLAN VIEW
Distances and diinensions to meet- requirements of 1-163 6 cA
SHO.W_ EVERYTHING WITHIN 100 FE1s'T OF SYS''I;19 z~ 0 Fns.
E_ 1
J E ~ ~ a
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W
PLO, A a PIA
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itie ort-hl A ro
SCAII
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site: r^,%
SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: iCF:2. y
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: --------Number of-pits eet diameter
feet liquid depth seepage pit in et pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines width length " / the depth
SEEPAGE TRENCH: width length
r r r
PERCOLATION RATE r lltd V AREA REQUIRED ~:TAREA AS BUILT
INSPECTOR 7e'- V
DATED f r PLUMBER ON JOB ,'4rjci)A 1 O
"K -
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & r`riIMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
®CONVENTIONAL ❑ALTERNATIVE State Plan DD.N.mber.
❑ Holding Tank 1:1 In-Ground Pressure 1:1 Mound urass9nedl
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER:
INSPECTION DATE.
Don Boyers RR#1, Woodvitte, W1 / ~
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
REF. PT. ELEV.. CST REF. PT ELEV..
SW SE, Section 15, T28N-R16W, Town 04 Eau Gatte
Name of Plumber. MP/MPRSW N,, County. Sanitary Permit Number:
Howard Mittte/stadt 2619 St. Ctc.oix 43683
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
C LIQUID CAPACITY TANK INLET ELEV TOU TLET ELEV WARNING LABEL LOCKING COVER
('IpF~/ ~q") PR OVDEDjPY ROVIDE(~ 2 ❑YES ❑NO ES ❑NO
BEDDING: VENT DIA.:. VENT MATL,: HIGH WATER NUMBER OF ROAD. r PROPERTY WELL. G. V ENT TO FRESH
ALARM IFEET FRT OM ~~t LIN (AIRINLET.
❑YES NO ❑YE NO NEARES
DOSING AMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFA TUBER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND, ONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES r%" ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil nr)64Sfure at the depth of plowing LFNCITH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until L FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING. COVER
BED/TRENCH TRENCHES INSIDE CIA -PITS LIQUID
DIMENSIONS MAT PIT DEPTH
GRAVEL DEPTH FIL;DEPTH DISTRPIPE DISTIPE DISIF PIPE MATERIALN DISTRNUMBER OF PBE LOW PIPES ABOOL VNL T ELEV END PIPESLFEET FROM 3 3 Z. 7 Z ~J NEAREST
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 JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED JMULCHED
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING ED DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD p'ISTR. PIPE MATERIAL rNO DISTRDISTRPIPE ISTRIBUTION PIPE MATERIAL & MARKING
L V. ELEVDIAELEVS DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION ROLE SIZE HOLE SPACING DRILLED RRECTLY COYER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
? FEET FROM LINE'
`T ) ❑YES ❑NO ❑YES ❑NO NEAREST
o 2-
L~ - I
I ~ Sketch System on Retain in county file for audit.
Reverse Side.
_ r~__NATURE., TITLE.
DILHR SBD 6710 (R. 01/82)
"Scons'n APPLICATION FOR SANITARY PERMIT
N, ®ILHR 7 COUNTY
(PLB 67) DEPgFITTT1EnT OF UNIFORM SANITARY PERMIT #
~ InDU5SR4+,LRBOR6MUTFin REIPTlOnS A/ 36 q_3
-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
PROP TY O NER MAI R G ADDRESS
PROPERTY LOCATION CITY:
VILLAG :
GL 1 /4-5i 1/4, S N, R `y E (or & wN OF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME INLAKEST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
X1 or 2 Family Number of Bedrooms. ti ❑ 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 0
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: y c _M T 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):
IA u FT Ks4, NTc 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): Sig ure: j Z /MPRSW No.: Phone Number:
C~tC'~RD 1_F MDT I
_.M1 ~Zrz_/I~ I -
Plumber's Address: Name of Designer: C
--COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
El Disapproved
~ ~ ~D ~I APProved ❑ Owner Given Initial
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.
{
Form- S T C 100
I
Owner of Property &x Z
jP
Location of Property 5(t) ~4 ~4, Section 1°5 ,'Fq_8 N R_IkW
Township 0 PALL E
Mailing Address eg
U)oo Dl-11LL&
Subdivision Name A PZj-) 7
~ Lot Number P3
Previous Owner of Pro {1 1, perty E' _A /k/D/
'T'otal Size of Parcel -20
Date Parcel Was Created____ 11
Are all corners identifiable? _Yes No
r
F
x
Include with this application one of the following:
d
Certified Survey Map
it/ -
. Deed
! Land Contract, or
.Other I:egal Document which describes the property
I
PROPERTY OWNER CERTIFICATION
t
iR 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., 2 ; 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 egi ter of Deeds, as Document No.
y
r 1
SIGNATURE OF OWNER SIGNATURE OF--CO--OWNERNNEREf?---;IF APPLICABLE)
DATE SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
AND: PERCOLATION TESTS (115) MADISP.O. BOX 76
ON WI 53707 HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCA ION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
a~a /TAN/R16 E (or ,AL;
COUNTY: OWN 'S/BUYER'S NAME: MAILING ADDRESS:
r. P
USE DATES OBSERVATIONS MADE
NO.IDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS:
Residence ❑New
RATING: S= Site suitable for system U= Site unsuitable for system / 3
rCOZNV N TIONAL: MO ND: IN-GROUNDPRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) S ❑U NS ❑U S ❑U ❑S ~IU ❑S S1U 6 6w~~
If Percolation Tests are NOT required DESIGN RATE: LF fan
y portion of the tested area is in the
under s.H63.09(5)(b), indicate: loodplain, indicate Floodplain elevation:
.o
PROFILE DESCRIPTIONS 9 / AII'I& o
BORING TOT_PL DEPTH TO GROUNDWATER-INCHES CHARACTER OF OIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMB/ER D,Er' IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- %W - S.--) *"r
l19,140
B-
B-
B-
PERCOLATION TESTS
TEST DEP WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IN ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P I
P- 2 V
P-
1
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
0 )3t'9 _E ~ Ll
0
Afft
q
C~S~ rrv Q I" aRcla AREA -1i
0
tyt N1 0 ELECATi0a 51 y S- 00
a A N MAR
l ' " Ili~ o ,F ROM
f n ARJFA- u? CcR-Wk
~f SL y
SEC I
kOA 1)
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): _ TESTS WERE COMPLETED ON:
Cif c~ IR-4- 714 D / 7-11
ADDRES CERT I AT NUMBER: PHONE NUMBER(opti nal):
R iJ c, ~r r p
CST SIGWATURE: n
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester,
DILHR-SBD-6395 (R. 02/82) - OVER -
NIAXINIU ,l YIdrnbe of b,x .rx.;__? or ;__);m;i'',t A on }>ir#mm'
CI !LL R ;Y4 ] L MS ARE r%LfLED OU f. BASE[) ON SOIL CC'NO € IONS;
PLEASE L o 10 a blonoviat:ions s1hus..vn We fot u'{T1r-;Cj prof k, le-ci"iptions atul G'Cl9` plot.inq the plot pla"
MAKE A t t fait'>i l r ianrm n <smwatelY HCAIl1[; i?Ctllt test ittC;ati3C rti. L), i4"„iiq tcscale is preleucd,
rnj I, n dpsk(`',
;igo .,;t.:„a>:, lr'i1.r'trvk and v a' c,,I ration rt,f 'rte i➢xlx('T arp „?,.F ''"i . m,.,
t,).; raI [ ~ts''ro"t~ fz>ox" s j", tx .}~i~,s, nary"w, , i~d e.6S€,t+, r~ooml (.:r;'
t, it xpl )i4a'3,
I', k t;...om (not b $t, -J; o 3t, do os not cPp1 yl p la',.
4 ~Vl 10-40e as retluked, ALL, SOIL TESI S rVILK)"IF BE FILED VV!
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, p ~ (3 - 10")
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ay Coy rA4' at=
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A 0 1 ® C Sewer and Excavating Services
KNAPP, WISCONSIN 54749
FAisT 1A,,- b-)IF// /100 f'qe'm RID) Phone: 665-2112
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(pkAtL,'l11Ve?- No7* R) SCAtZ'
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A• B ' C complete sewer services
KNAPP, WISCONSIN 54749 Plc ne: 6'5-2112
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Parcel 008-1045-30-000 01/23/2007 10:58 AM
PAGE 1 OF 1
Alt. Parcel 15.28.16.231 B 008 - TOWN OF EAU GALLE
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
PAUL D & PAMELA J PECILUNAS O - PECILUNAS, PAUL D & PAMELA J
2460 30TH AVE
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 2460 30TH AVE
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 20.000 Plat: N/A-NOT AVAILABLE
SEC 15 T28N R16W 20A PT SW OF SE W 67 Block/Condo Bldg:
RDS OF S 47 RDS OF SW SE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-28N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 795/412
2006 SUMMARY Bill M Fair Market Value: Assessed with:
171063 Use Value Assessment
Valuations: Last Changed: 07/06/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 29,400 82,300 111,700 NO
AGRICULTURAL G4 5.000 200 0 200 NO 05
PRODUCTIVE FORST LANDS G6 12.000 16,000 0 16,000 NO 05
Totals for 2006:
General Property 20.000 45,600 82,300 127,900
Woodland 0.000 0 0
Totals for 2005:
General Property 20.000 52,100 82,300 134,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 513
Specials:
User Special Code Category Amount
010-GARBAGE SPECIAL ASSESSMENT 192.00
Special Assessments Special Charges Delinquent Charges
Total 192.00 0.00 0.00
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