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Parcel 012-2001-50-000 09/08/2006 03:08 PM
PAGE 1 OF 1
Alt. Parcel 04.30.17.566D 012 - TOWN OF ERIN 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 - GLEASON, DALE R & CINDY L
DALE R & CINDY L GLEASON
1785 176TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1785 176TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.300 Plat: N/A-NOT AVAILABLE
SEC 04 T30N R17W PT BLK 74 LOTS 23 THRU Block/Condo Bldg:
26 VIL OF JEWETT MILLS
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 877/542
07/23/1997 668/539
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.300 4,500 173,900 178,400 NO
Totals for 2006:
General Property 0.300 4,500 173,900 178,400
Woodland 0.000 0 0
Totals for 2005:
General Property 0.300 4,500 173,900 178,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 207
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUIL'T' SANITARY SYSTEM REPORT
OWNER TOWNSHIP ~j SEC. T_N-R W
ADDRESS 11-3 ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LO 1' LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVER YTHII~ G WITHIN 100 FEET OF SYS'T'EM
s
1
i
I' 4\
Q
I di at N r h rr( w
- - -
-5-C I
BENCHMARK: (Permanent reference Point) Describe: j7//
i
Elevation of vertical reference point: 'z i0Q__________Slope at site:
4
SEPTIC TANK: Manufacturer: '(/L.- zLiquid Capacity: ~j
Number of rings on cover : _ _Tank manhole cover elevati n
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons _
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number ;
't'ype of warning device _
ROLDI:NG TANK: Manufacturer Number of gallons
Elevation of manhole cover
't'ype of warning device
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of linesT width__ ~ 1ength_ge tile depth
SEEPAGE `.'RENCH: wid length
PERCOLA'T'ION RATE WA~ AREA REQUIRED AREA AS BUILT-
INSPECTOR
DATED PLUMBER ON JOB 2e
LICENSE NUMBER-
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
0. BOX 7969 BUREAU OF PLUMBING
;ADIS("J. WI 53707
CRCONVENTIONAL ❑ALTERNATIVE State Plan L)D. N-bec
❑ Holding Tank El In-Ground Pressure ❑ Mound (if assigned
NAME OF PERMIT HOLDER. ______jA OF PERMIT HOLDER. INSPECTION DATE:
William Ventura RR#3, New Richmond, WI Y,30
BENCH MARK (Pe«nanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.- CST HET. IT ELEV.
NW NE, Section 4,T30N-R17W, Lot "K",Ward Add.Twn of Er.PR.
Name of Plumber. MP/MPRSW No.. Co„n[y Sanitary Permit Number:
Cal Powers 1563 St. Croix 38517
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TAN INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOWINO_
1 PRp OV)6EDPR~(9`y ES ❑NO BEDDING. VENT DIA. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING. JVENT TO FRESH
ALARM FEET FROM LINE. AIR INLET.
❑YES NO ❑YES' ❑NO NEAREST L~
DOSING CHAMBER:
~L[UID
MANUFACTURER 71 CA PACITV PUMP PUMP/SIPHON MANUF AC7UREH WARNING LABEL KNG COVER
PROV D. R VIDED.
S ❑N 1 ~ ES ❑ YES ❑NO
GALLONS PER CYCLE: P PA CONTR SOPERATIONAL NUMBER OF PROPERTY' ELL BU DING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE NLET
PUMP ON AND OFF) ❑Y 50 FIND NEAREST
SOIL ABSORPTION SYSTEM. Check th soi rTl isture at the de th of plowing LENGTH DIAMFTE [IL AND */KING
or excavation. Ilf soil can be rolled into wire, construction all cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH JNDISTR PIPE SPACING,COVJ INSIUE DIA nPITS LIQUID
BED/TRENCH TRENCa HEAL. PIT DEPTH
DIMENSIONS ; 2_
z
f~RAVEL OFPTH FILL DEPTH DIST H. j;F DISTRDNUMBER OF PROPERTY WELLBUILDINGVENT TO FRESH
BELOW IS OVER ELEV I E LINE AIR INLETFEET 1~~a 1 2-NEARESTO--+•- ~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the textur of the fill material for YONS DE DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems ake certain that it VE E SIDE. SHOW ELEVA-
meets the crite
❑YES ❑NO r for ledium sand. ME SURED .
SOIL COVER TEXTURE / PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO
❑YES
2o;~~
DEPTH OVER TRENCH BED JDEPTH OVER TRENCH BED DEPTH OF TO: L SODDED SEE MULCHED
CENTER EDGES .11 /1 1
❑YES L-JN ❑YES ONO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF L TERAL SPACIN GRAVEL DEPTH BELOW PI
BED/TRENCH TRENCHES FILL DEPTH ABOVE COVER
DIMENSIONS
r`
MANIFOLD PUMP MANIFOLDD DISTR. PIPE AMATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV. CIA ELEV.. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILE'E CORRECTLY ER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO C ❑YES ❑NO
COMMENTS: PERMANENT MAR S: OBSERVATION WELLS: NU BER OF PROPERTY WELL. BUILDING.
FE FROM LINE
❑Y S ❑NO ❑YES NO INE REST
V_T
71) t4l r c;
-tc
Sketch System on in in county file for audit.
Reverse Side.
ISIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82)
wls~onsln APPLICATION FOR SANITARY PERMIT
R COUNTY
DILH (PLB 67)
OEPRRT1TIEnTOF
UNIFORM SANITARY PERMIT #
InOUSTRV, LRBOR 6 HUmgn RELRTIOnS -9f 7
-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
PR PE TY OWNER M ILING ADDjR_SS
19
y /
/°U~te) Gum
-3
PROPERTY LOCATION Ci-T-Y:
V1-LLA-G E:
1/4, S -ij- , N, R (or) W TOWN OF:
LOT NUMBER BLOCK:NUMBER SUBDIVISION NAME NEAREST ROAD, AKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: -ter ❑ Public (Specify):
i
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 El 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: ✓
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):
7 f Q Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of th
f v3
pri to sewage system shown on the attached plans.
Na of Plumber (Print): Sign ur MP/MPRSW No.: Phone Number:
2112- ,S-
Plum b~r s Address: / Name Designer:
,`Z 7
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
El Owner Given Initial
/ (L7 (G'' / 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.
F urw - S T C 100
Owner of Property Location of Property 4 A/C 4, Section T `N R ~ ~W
Township
Mailing Address
Subdivision Name C
Lot Number
Previous Owner of Property C +/i rz c ~crok/LY,
'Coral Size of Parcel.
Date Parcel Was Created
Are all corners identifiable?_Yes _No
Include witl( [his aj)p) i c Rion onL of the f o l lowinL:
.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 4S ; 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.
. J
SIGNATURE OF OWNER
SIGNA'r E OF CO-OWNER (IF APPLICABLE)
t r:
i l ~
"TE SI NED _ C~j!!/l h~ P-3
D SIIiN D
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON, W 7969
(H63.09(1) & Chapter 145.045)
LOCATION: SECT N: N W TOWNSHIPPAA.NICIPALrrY:
LOT NO.: BLK. NO.: SUBDI ISION NAME:
COUNTY- OWNIER'S/BUYER'S NAME- MA LING ADDRESS: /t
USE DATES SERVATIONS MADE
NO.BEDRMS.: COMMERCI DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system %G 314 ms[:] L: JMOUND: JIN-GROUND-PRESSURE: SYSTE-IN-FII'LLHOLDI~N` TnA'NIK\RECOMMENDED SYSTEM: (optional)
EIS EU EIS ❑U ~J Y ~J Ell
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: /
I k /,I- J
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
420,411" Z
j •s , gJ
s~Y s
B- ' J i
6_2 -7B,ds-
'4114 9, k~s
B B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER D 1 PERIOD 2 PER 3 PER INCH
P- 0 .5
P
717, Aloe) _
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 of plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION -
r r _ i I W ~ t 1
d ~'4r/ow O
I
. r 1~ t - I
E
t r
T
Q
7~,~ E ;
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.
NAM (jprint): TESTS WERE COMPLETED ON:
ADD SS: CERTIFI ATIN NUMBER: PHONE NUMBER (optional):
O
5Z 7 - ,-s'
L A4, M,
CST SI AT RE: / 01
i -
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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