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Home My WebLink About022-1093-90-200 0 N 0 3-0 0 d 1 O :E y O M O _ 7 ID 3 ~ n q rr 2 W I » co Z O co N N N cC • w o ~l N 7 3 D O C 7 N N I~1 00 d A Z n N ? NO n; 1~ .`3 ° j co N w a ^ o C) o (o C c 0 n o 0 rn3 CD m 0 p° ~ 0 C N C ON _ !V N Cn D a (D (a CD (n G. n 3 cn w 0 CD 3 a ow C) O n ~ ^ m l~ tb d O 8 Z? 0 r to O W H. p p~ (n Co co l cn 0 cP G ~ C ~ G (D N N• T to to N Ul o D y b ~ r v O N CD I- W Ul N O d L N W 00 m 3 CD 0 cn n Ln ~ co o 3 E :3 00 z W N (D z z z z D D o rn ~ cJ I H CD (J w o j ~ O E w I n 3 Oo Z m -1 fn :3 Z (D s H cn v a L7 N N 00 cn C/) --i w '~"-a W A M 0 N O r3 7J ' 3 ~ N x~~ N 00 (D _ W 0 Qo n w N 3,-o Z? ? D 3 0 < CL CD CD 9~ ` v a yh m ~p N M N Q~-4 M (n N < . (n ti N fi t S n o 0 ~0 Om W O (D T O= b 5~O°~ N --n CD X Q' n (D O O. 7' - N ~ o a p O N v Oi 7 ~ _ O O 3 0 ^ O C ti 0 b tv ~0 V 0 0 ~ C> (D 0 CL I ~ Parcel 022-1093-90-200 12/29/2005 12:30 PM PAGE 1 OF 1 Alt. Parcel 32.28.18.508D 022 - TOWN OF KINNICKINNIC 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 - SYLLA, ANNEXED ' 4/09/03 ANNEXED ' 4/09/03 SYLLA C - KUSILEK, CHRIS M ET AL Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 12.063 Plat: N/A-NOT AVAILABLE SEC 32 T28N R18W PT SE SW (12.063AC) LOT Block/Condo Bldg: 1 CSM 7/1983 ASSESSED W/022-1093-90(508B) ANNEXED 04/09/03 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) NKA (979) 276-1108-60-000 32-28N-18W SE SW Notes: Parcel History: Date Doc # Vol/Page Type 04/09/2003 716542 2200/012 AX 06/19/2002 682123 1913/105 WD 07/23/1997 814/345 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/05/2004 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS 1?UL'T SANT'J'ARY SYSTEM REPORT OWNER T0WNSHIPSEC. T N-R W ADDRE'SSr' - ST. CROIX COUNTY, WISCONSIN. a - SUB1)1V1S10N LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of- H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM IJO f - IT, t i i at N r h rrc w BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer:- _ iquid Capacity: ~Qt~F Number of rings on cover ank manhole cover elevationG: 'l'ank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER A-- I I 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 ; Type of warning device z=-. T:=- - - HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover- ; Type 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 lines width- l length tile depth tt SEEPAGE TRENCH: length _ PERCOLATION RA`T'E _ _ AREA REQUIRED - AREA AS BUILT _ - c~ INSPECTOR CAuWL-V- -14 DATED PLUMBER ON JOB- - LICENSE NUMBER -r 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 ❑CONVENTIONAL CT-ALTERNATIVE state Plan LD Numbe,: r~I (If assigned ❑ Holding Tank ❑ In-Ground Pressure LJ Mound 8302532 lZd M. ) i029 C' ~ NAME OF PERM HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE: Leslie N. Paulson Box 74, River Falls, WI Y,q"f - BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. E SW, Section 32, T28N-R18W, Town of Kinnickinnic Name of Plumber. IMP/MPRSW No.. County. Sanitary Permit Number: homas Wang 3231 St. Croix 38504 SEPTIC TANK/HOLDING TANK: _ MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. 66 ES ❑NO ❑YES CJO BEDDING: VENT DIA.: VENT MATL HIGH WATER FNEAREST- DOSING BER OF ROAD: PROPERTY WELL: 11111-11NI: VENT TO FRESH T AIR ALARM FROM L ❑ YES ❑ NO ❑YES NO CHAMBER: MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL PIUMP~S, PHONMANUFACTURtER WARNING LABEL ILOCKING COVER / i PROV IED P E 11 ❑YES NO c. 1 YES ❑NO X11 ES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PR OPERTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN f FEET FROM E AIR INLET PUMP ON AND OFF) / / -f- tYES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NGTH 1111AMIT111 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 ;17 L7 3 CONVENTIONAL SYSTEM: _ W___[_ I IDTH. LENGTH NC. OF DISTR P SPACING' COVER INSIDE DIA 'PITS LIQUID BED/TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS j GRAVEL DEPTH FILL DEPTH IDISTR PIPE DISTR. PIPE STR. PIPE ATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES ABOVE COVER ELEV. INLE I ELEV. END / PIPES FEET FROM ,LINE AIR INLET. I ___1(4 NEAREST- MOUND 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- ° meets the criteria for medium sand. TIONS MEASURED. -'YES ❑NO SOIL .`OVER. TEXTURE. JPERMANENT MARKERS. OBSERVATION WELLS N YES ❑NO OYES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED IMULCHFD. CENTER r ` EDGES 'j 1 ❑YES NO ES ❑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 MANIFOLD MATERIAL NO. DISTR. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV. DIA. .7 ELEVe-, PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOL/~S E HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS YES ❑No OYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING. FEET FROM Idye. OYES ❑ NO LVYES ❑ NO NEAREST C L~ t Sketch System on Retain j>1 county file for audit. Reverse Side. O - ' 7RE fLE D I L H R S B D 6710 (R. 01/82) e f DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 67) W MADISON, WI 53707 Attach plans for the system on paper not less than 8% 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. Propert Owne Mailing Address: fi5 fa Say tc)x Property Location: City, Village or Tow ship: County: % iT C20' Ni R Y" E (or«~ vI ✓l CQ1en I 37t. o/'d / Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (lf ne I~yi7~ d~ J TYPE OF BUILDING Nmber of ❑ Public* ❑ Variance* ❑ Other (specify)* Buedrooms: S] 1 or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY d(j('f x HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New ® Replacement Experimental [:1 Seepage Bed ❑ Seepage Pit 1:1 Alternative (specify) k6a d ❑ Seepage Trench G' Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature MP/MPRSW No, Phone Number: Plumber's Address: p / Name of Designer: /0 0 COUNTY/DEPARTMENT USE ONLY Signat re of Issuing A ent: Pe: Date: Sani arypPermit Number: APPROVED • 9~O 1 ❑ DISAPPROVED 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) ppppppr Wisconsin Department of Industry, PLB-1 INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection Name o remises Date an o. Street city County Sanitary Permit Master Plumber Firm Name dress Journeyman Plumber Address Owner Address iscusse wi igna ure ( )See Attached. DILHR-SBD-6192(N.09/80) Signature o is Plumbing up. n- i e White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible P Parcel 022-1093-90-000 12/29/2005 12:30 PM PAGE 1 OF 2 Alt. Parcel 32.28.18.P508B 022 - TOWN OF KINNICKINNIC 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 - SYLLA, ANNEXED 4/09/03 ANNEXED ` 4/09/03 SYLLA C - KUSILEK, CHRIS M ET AL Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 11.507 Plat: N/A-NOT AVAILABLE SEC 32 T28N R18W PT SE SW LYING S OF HWY Block/Condo Bldg: M EXC CSM 6/1762 ASSESSED WITH (508D) 022-1093-90-200 ANNEXED 4/09/03 NKA Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 276-1108-40(977) 32-28N-18W SE SW Notes: Parcel History: Date Doc # Vol/Page Type 04/09/2003 716542 2200/012 AX 06/19/2002 682123 1913/105 WD 07/23/1997 1045/433 WD 07/23/1997 830/268 more... 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/05/2004 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 022-1093-90-000 12/29/2005 12:30 PM PAGE 2OF2 Parcel History: cont. 07/23/1997 724/144 Parcel 022-1093-90-100 12/29/2005 12:30 PM PAGE 1 OF 1 Alt. Parcel 32.28.18.508C 022 - TOWN OF KINNICKINNIC 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 - RIVER FALLS, ANNEXED * 4/09/03 ANNEXED * 4/09/03 RIVER FALLS Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 10.930 Plat: 1762-CSM 06/1762 SEC 32 T28N R1 8W PT SE SW (10.930AC) LOT Block/Condo Bldg: LOT 01 1 CSM 6/1762 ANNEXED 04/09/03 NKA (978) 276-1108-50-000 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 32-28N-18W SE SW Notes: Parcel History: Date Doc # Vol/Page Type 04/09/2003 716542 2200/012 AX 07/23/1997 764/612 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/05/2004 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING=S INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN RELATIONS LOCATION: SECTION: TOWNSHIP/T"v°ro;d-F~T~• LOT NO.: BILK. NO.: SUBDIVISION NAME: sE_S[61/ 1/ 3z /TAN/R)aE(or W Yct>r~r l~ ~~)tiu )e - - - COUNTY: OWNER'S BEER'S NAME: MAILING ADDRESS: •CTZUIX ~h ~ C\,c RovTf_z G R1U F~LLS tUI. S✓aZZ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: ZResidence 3 ❑New .Replace lO /Z-, /g~ 8 Z/gz RATING: S= Site suitable for system U= Site unsuitable for system c-r CONVENTIONAL: M(OOUUND: IN-GROUNND-(PRESSURE: SYSTEM-IN-FILL HOLDING TTAANK: RECCOMMENDED SYSTEM: loptional)_ ElS ILA S❑ J ti v u Fbre r E:] S Z U ❑ S BSI MPi C IAJA-zR T 3 LE ~Z81}c If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. I If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 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.) °srG~Bns~)TS 2 6y~31N6 uySi);~`~ns1~ 9` 6yC 3S y6` W\ YA 4 Z _ ~r C~r( r ZO rr t 3 it J i ~1~1Jk~_L_ B Z 4 rI kA W) - U/g4 rr J 1 r~ J ~'r ~J lZ' Z6rr- 38 / Y" ko 6r L/ 2, J B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES (NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERI0D1 PERIOD2 PERIOD PERINCH i P\ zo ~0 3 o s!~ s~~ s/t3 S~8 I P- Z 7o tVe 3 0 3! 3/ P_ 3? o tv n 3 0l ply o P- P- P PLAN VIEW: 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 slop. L?, \ Sor u SV2v~1 vLSj~ Tc7 Si ' OF 7~et, SYSTEM ELEVATION" t ~2 Ive w lAe,~x>w try .1 oe $k F~UCC II ► i' 'Z So' SST or s rm. S Ma W ewrm Lion; ~ttsl 10 _ _ ..S So ~Slov h! of t~~1 C6Rr~,e,2 P<\ 0F A tb % pl o ; R~" t IOfJ- SPrVts uo bp ~ ' < °f 36" STUt~tP®~~: - i \ \ Tz . 82 0 1Z~ r _ ~Ctoe. j I R3 ~ rv I * I ; "Pt EEL. TO ~ttty X SITS SL~tLE Atl SO' PY A-S S~f 01-vfJ 5~C~1Dla -17- 1, the undersigned, hereby certify that the soil tests reported 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: QIT~S~-lv2 W ~-~12 F~-~ ~ ~ sr l z, 1 S 8 z ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): 12w` "~Lrr~) T7r}/, - S7L 7IS-VZS-938! CST SIGNATURE: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property !D vner„ 4zh page-Soil Tester. DI LHR-SB D-6395 (N. 03/81) Parcel 022-1092-95-000 12/29/2005 12:06 PM PAGE 1 OF 1 Alt. Parcel 32.28.18.P505A 022 - TOWN OF KINNICKINNIC 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 - PAULSON, GRACE A GRACE A PAULSON 1036 CTY RD M RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH I Legal Description: Acres: 12.760 Plat: N/A-NOT AVAILABLE SEC 32 T28N R18W PRT NE SW EXC 2A & EXC Block/Condo Bldg: P505C & EXC HWY & EXC PART SOUTH OF HWY EXC CSM VOL 5/1443 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 32-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 10/21/2004 777670 2680/267 QC 11/19/2002 699072 2052/448 QC 2005 SUMMARY Bill Fair Market Value: Assessed with: 143977 75,200 Valuations: Last Changed: 08/11/2005 Description Class Acres Land Improve Total State Reason PRODUCTIVE FORST LANDS G6 12.760 76,000 0 76,000 NO I Totals for 2005: General Property 12.760 76,000 0 76,000 Woodland 0.000 0 0 Totals for 2004: General Property 12.760 31,700 0 31,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Department of Industry, Labor & Human Relations Division of Safety & Bldgs. State of V1 P Wiseonsin 6 ~ 7 ° ` Bureau of Plumbing Platting & Fire Protection r ~c9 P.O. Box7969 Madison WI. 53707 jO 2'9 FG> G Tel. 608-266-3815 IN ALL CORRESPONDENCE REFER TO PLAN IDENTIFICATION NO. ox NAME OF PROJECT TYPE OF APPROVAL STREET AND NO. CITY OR TOWN CO N-TY' ZIP OWNER Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In the.event_installation of the plumbing improvements-or system has.not-commenced .within two years from this date this approval shall-beeome-vo+d arid-new-application shall be made for approval of these plans-before -work may commence. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto- matically void this acceptance. For Private Sewage Systems Only: Sincerely, / This approv` l is v~°,Iid iOr two years G. it l';ii be `Jai Urltii t~ e e-pirai;on date of' the initial Sa+ lta'y pef init. James Sargent-Bureau Director PLANS REVIEWED BY: DATE: cc: DPS-OWS Owner DI LHR Local PI Plumber H & R (2) County Mfg. Rep. Bur. of Health Fac. & Services DI LH R SBD-6099 (N. 06/80) Rec- & Env_ Services L Department of Industry, Labor & Human Relations State Division of Safety & Bldgs. Stale of Wisconsin Bureau of Plumbing Platting & Fire Protection P.O. Box7969 Madison WI. 53707 Tel. 608-266-3815 IN ALL CORRESPONDENCE I NC REFER TO PLAN IDENTIFICATION NO. NAME OF PROJECT TY E OF A1PPROVAL C11 1 ~ ST EET AN NO. s 5 3IQ CITY OR TOWN COUNTY STATE ZIP K(NAll OWNER Gentlemen: Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145, Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com- pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted. The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of plans bearing the stamp of approval of the department. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require- ments of the city, village, township or county in which this installation is to be constructed- Failure to obtain local permits will auto- matically void this acceptance. For Private Seviane Systems Only: Sincerely, This ar prov,~i t s val(d for two y 3, , Of it h.:~ v;;i (l i mtil the the initizi James Sargent-Bureau Director TO~_NS REVIEWED BY: DATE: cc: DPS-OWS Owner DILHR Local PI Plumber H & R (2) County Mfg. Rep. Bur. of Health Fac. & Services DILHR SOD-6089 IN. 06180) Rec. & Env. Services Pry MOUND SYSTEM, FOR 3 B ~u.oc~►-i 2E s ~ ~E1 ~ ~ S OF SECTION 3 Z , T Z~ N , R /g W, LOCATED IN THE 'SG-// THE Y COUNTY, WISCOT"SIN. '1' olt"N OF K N N c ~c r~ i c_, c 20 1 x----- PAGE 1 of 7 TITLE SHEET PAGE 2 of 7 WORKSHEET PAGE 3 of 7 PLOT PLAN PAGE 4 of 7 Pl-kN O DISTRIBUTION PIPEE PA GE 5 of 7 LAYOUT PA GE 6 of 7 DOSE CH .M,BER PA GE 7 of 7 PUMP PERFORMANCE CURVE PREP~.RED FOR ~_ES~IE N. PAVL-SUN ' - PREPARED BY JUN 11983 KOZEL, WEGERER AND ASSOCIATES L21 NORTH MAIN STREET kIVER FALLS, WI. 54022 R302532 .•SCpry s CHARLES KUZEL E-09415 _ RIVER FALLS, e` i ' WIS. ONAL EN ~~rrrruru~~~~~ moo 83-6y K CIO 2- 11 v,((i:KSH1. LT [ S`'SIEM C Il. IN ROUND PRESSURE SYSTEM-Continuco- N <,ir, filar L oaG, 1 ntal Dally F luw 10. Force Main: Minimum Dosing kale = 3 Z gr r. U.r tic( tion H G'1.15 (3) (c), Wis. Aom. Code and PROVIDE A DL1 AILED Diameter = In. LIS1 Of SIZING ON PLANS. 11. Total Dynamic Head: [,girth to Limiting Factor = Z~ IT 11I. Svsicm Head = 2.5 ft I andslope = % Vertical Lift = -30- ft Distance from Dose Chamber to Friction Loss ft Distribution System = ID ft. rDr r _ ft E IevatUOn Difference Between 12. Pump Selection: •7 3 2 Pump and Distribution System = ?-3 ft Pump will discharge at least gPm ,t?so,piion Area Siting: al 11-S ft. total dynamic head. IS sq. ft. Pump model and manufacturer: Arr< Required = - 14 kre w-I44+te~+ Length (B) ft. - t~ C ~L-. O~- nri ci' . -i Width (A) = ft. 13. De.,sr Volume: „ 1,,T Spdnng ICI 10 Times A oid Voiumr of N,•und Firigh1: Di,irlhunon Lines= --5~---- gay f it Dep[n (D1 O_ ft Daily W estev,ater Voiumt + 3 ft 4 Doses in 24 hrs. = 1~? 5 ga' t 111 Depth Downsiopt (E) _ (]Z.~ e Bta a+-3-«~+~b Depth (F) = C>•1~ ft. Backflow = - - . Cap and Topsoil Depth (G) _ 't '0 ft. Minimum Dose = _~_-1_S'_1 Cd Cap and Topsoil Depth (H) ft. 14. Dose Chamber: t: Mound Length: Volume = SO gal End Slope (K) _ \O ft. Total Mound Length (L) = 6-7 ft. 111. NVENTIONAL PRIVATE SEWAGE SYSTEM Mound Width: 1. Wastewater Load, Total Daily Flow = tia" Ltrslope Correction Factor = 89 Use section H 63.15 (3) (c), Wis. L,rsiopt Width (1) _ $ ft. dm. Code and PROVIDE DETAILED Downslopr Correction Factor = V LI OF SIZING ON PLANS. Dnv. n,iopt W rdtn (I ) ft. 2. Require optic Tank Capacity = gal. T.uel Mo,.n" Width (A _ ft n 3. Percolation ate = min /in S 'neon Ar.rd Siring: rrlinralr,'• o; e: r1, W pO~~ V • k er to ~l 2 ir, charter H 63 natural ,or `1c!t ~a1F,; ~'cLtn pf~Rt;,)IDL~@ DETAIL ED 5l OF hdsei Artd krou„ec = Ep?~-fi_ u S LI y., A 1NL CIN PL N h sq 1' = JyC~ s4~OT~_ ' Arte P, e-t)ir 2>e - ~ „r~0erd T anir• t,rn Cr,anle~ ~ ?~l .V~Q rngtr_ ft H F,3 are Usec :r,o,cait Table Ne tt ( n, the Distrinutron Network. Use Numbers 5-14 ir, S i ~ Yy ♦ or, o' rrni t er. _ nch Spdc?f = ft ~,kOUND PRESSURE SYSTEM A V\ rstrioutror stem Depin to Limiting Factor 4\ e.o Lateral ength = tt t anosrope No er of Laterals = 830 Fcrto;ation Ratc L enl Spacing = In Fi ut•.r: Svsttrn Elevation Isianee from Sioewall to Pipe = in. v <,I, , diet load, T otal Daily F low O al / System Eievation = ft List ,rctior H 63.15 (3) (c), Wis. i AGrr. Coo: and PkOVIDE A DE1 AILED IV. /SYSTEM-IN-FILL L !S' OF SIZING ON PLANS. Fill in All Items from Section III 91S ke4uuee Stniic Tank Capacity, = gal. JUN An,urpiion Area Sizing: V. SEPTIC TANK Frtcolation Rate = y8 min./in. 1_ Capacity = CJ~ al. Area Required = 3~ sq. fl. 2. Manufacturer: wl E CTS system Length = L4 -2_ ft. 3. Show Site Constructed Tank Details on ihv(7 8t;,?t. Svslem Width = 8 _ ft 7 Disuiouuon Pipe Sizing: 3/6 VI. DOSING TANK SEZ PAGE 6"- Hole Si/r = In 1. Capacity = SO gal Hole SPdLing = I h • 2. Manulaelurcr Laicril Length - it, 3. Pump Manufacturer _ L.ucl.Il Siir in. 4. Pump Mudcl: I .url.il tipatint l it. 5. Operating Head= ft. Ili.l.rnt.r limn Siilcw.rll -lol'ipc ---i_ ht 0. Flow RAIL= gPm. h Di,irlhuuun PwL Dr.ch,uxc Raw 7. Show Site-t.onstructed Tank Details on Plans Numhei ul I lulcs I'rt Pipr -7 - - 'N G -1 AN K '1 low I'rr Pilo. RI,In. VII. v ~M.uiilold Si<utg. I. Capacity - gal. I ylir Itcmci or end) 2. Manulacl - L ength It. 3. Site Constructed Tank Details on Domeier 3 in. -SHOW ALL INFORMATION ON PLANS- PLOT PLAN Scale 1"=SO' Qw'6 ~Q COV, ~01rONS ST/w~ G SEA17C ~~S'S'~~l 6R ~ TA~bc i ~12`fwe1..L TO ~ 12 PcGP R,o x I ~ n"ft BE 1~6H1Jpo/J~ Ow~ZL Lc~T1°^' IDS s r ~ -To C.T.N. N` G2A uC L $ -o 9~ - O R~VEWh y - - GTLhII.J P Fa3 C-E Q I N cH n Prey # Z S t✓ Pr B A'1' 6~r of a=-E~ cE . T'r+c ~C-i~i==S7' PRQP=1zT , t ~1 O U I ` l+ _ 4 OD ~ x~c-sr of s r7t . e I~ o I r ~ c V l4Q . 4 oo'J ~c 4M Q Q~ 97 - 010 ~ 93 9b°_ N OTES 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install cast iron pipe 3' onto undisturbed soil both sides of each tank. Install permanent markers at end of each lateral. ( 14 required) 4r4. Install 4" observation pipe with approved cap. ( z- required) 5. Septic tank to be - \oc5o gallon capacity as manufactured by w ~ ~ C.cv~ c2~"r>= PTZO~u c-TS _ 6. Bench Mar-ki'FElevation ~.oo' o+.~ SPt1cE of 36"-Z~IW -=TES s u"P, Nv-1&- LL z" aF !t«M DO-+SIY`I_ S?`CR1Jrronn 1N$u~Al~uly C)vff~k ~~►-~E Ffzbm sep-nc TA"W- 7a PvNiy C."Al"012k w\iETLE \.T Ctt- sse-s -TIt-AG ~XIST)►JG ~p(~v~WAY. CS<1.c'ipE) ~r NN S-MLkL aKST IRokz PIPE NT DCLIVEWA`( CW;5'11,.1G ^ cr V iJ CJYi i'+. CTc`7 J S1 r ox, 11.0r sh Hoy, Or ^--h_C\ S}'niheiic Covering ribution P ipe Medium Sond I c, Topsoil FE-~- -Tc o!c; or ~Fowe0 ~COf~-cam 1~00r e 001 E r Orr Umr L c y e r p 1.0 •cT E l•3 Cross Seciion Of A Mound System Using F p-11 ~T• A Bed For The Absorption Areo - v \0~5 G 1 • o ~T 6 v 6 y ~7 F JUN 1198 3 L Ti-4 IJ 0 b s e r vat ion Pipe 1 t - - - - K - Al 32 ~Dlsl r1bui ion ~ved Of - `t 2 Pipe Aggr e got e I Observotion Pipe Pe Imoneni Morkers pion View Of Mound Using A Bed For The Absorption Area S Pert oroIed Pipt Detoll' C. C, I \ f s,-T tUD of EA C-l~,7_RAL P ~l i Pv~ X CC 11 f k JUN p ~ iSi . r;;;✓10' •f 1983 En[ Co iJ -.:t Z j u r?t`-AU 4 5 8302532 ~a D meters ] ncr, yLc~eral .I IV inch(es) `,O IFS r`ani old -3 Inches Inches 00 $P tii LT IDLI IJD I,Pc Elf IE/•TINJS - VE ►J7 CfhP C.IJi F IF C I C f FFF.O~'CD WEATHER PKOOF LOCV,Ih1G JIDUCTIDIJ bOX r",/.IJHOLL COVER kG~"'~ DLOR, 12~M►U. I v.' &R FRESH AK C I --T GRADE { I 4 MI F!. _j 4- IIJLE T -l=v. °,y.00 ~ ~ i^ tbJ~ I III APPROVEL ; 1_, JDIFJ7 A ~'X)J \G~/ I III W/C.?. F'IPC TC, SC1J~ ALARM E DFJTG SC IJ t I D „CJ ( C F. N. JuNi 1 1983 _E\ . 9a- so t RISER EXIT PER/"IITFED CG►JLtJ IF T/-%UV t~AJJUFACTUFER h`•`- SU.:." TQPAL 5PECIFICATIDUS lJ ~ !~fr532 IJc P. DAU I_"~.` /',i.►JUf ACT UR I~~~-~~GI~TI' ~ 7 13t1D~+~-T'f IJUMbEk OF DOSCS: PER. _17L - GALLOIJS DD5E VDL UN,E' -5 - GALLO►JS TP,►JF hY J•,AUUFACTURER: ,S'_El~cTIZ«J S~lS~1'rS C/,P<CITIES: t=-._-_16.3 1QLHES Of 3SO GALLO►]5 P10DCL ►JUMBER 1=`- 6 = - --z - IIJCHCS OR - GALLOWS C-_S'I_-1QCHES OR \,S GALLDU5 5WITCH TYPE: MI /'jUUFACTURER'. r_,:.. Lp~S hUr-tI~S, ItiC [ _ _15*6 IAJLHES OR GALLOJ.!S MODEL JJUMBEF,' _ 1`~'S -5~3--G_--------- FJOTL~ PUMP AIJD ALARM ARE TO BE IUSTALLED O►J SEPARATE CIRCUITS 5 w I T C H T-J P E - PUMP DISCHARGE RATE __75 _ G PM hTICAL DIFFLREIJLE BCTWEEM PUMP OFF .4►JD DISTRIBUTIOFJ PIPE_ FEET MI►JIMUM ►JETWDRK SUPPLY PRESSURE . . . , . . . . . FEET F T. J~Q- FEET OF FORCC MAIN X ~YpttFRICTIO►.J FACTOR. FEET - TOTAL Dy1JAMIC- HEAD FEET 1 1 LP►JAL DIME. .JS10►JE. OF TAIJK: LE►JGTH ;WIDTH ~LIQLIID DEPTH / i,.~. tN 3 _ Z3/ _ Z I. S h L GOULDS Model 3870 Submersible Effluent Pumps - ax. SPECIFICATIONS Order No. HP Volts Phase RPM Solids Amps wt. Order No. HP Volts Phase RPM Solids Max. wt Amps WPH1012E 1 230 1 3450 11.0 70 WP0311E 1/3 115 1 1750 9.4 56 i WPH1032E 1 ! 208'230 3 3450. :1/4" 7 70 i PERFORMANCE RATING (GPM) WPH1034E 1 460 3 3450 'G" 3.5 70 60 WP03 ('h HP) TDH GPM 5 100 M 50 Total 10 85 3 Dynamic Head, 15 .62 _ O Feet to 0 40 - - ~'Ay - - Water 20 36 ~O ~ Fly - --25 3 ao A = 30 E MOD WPH10 (1 HP) TDH GPM 20 ~P~3E NP - - - 10 147 ti Total 20 124 to- Dynamic 30 98 10 Head Feet to 40 71 Water 50 I L45 0 20 40 60 80 100 120 140 160 Capacity-Gallons Per Minute 60 18 1983 Capacities to 155 GPM Model 3870 Packaged Heads to 65 feet Effluent Ejector System 3/a., Solids Handling C it 2" NPT-Discharge Corl e 25,12 Package Includes: Goulds packaged effluent ejector system offers both ■ Submersible Sewage Pump ease of ordering and instal- -(WP0311E)or (WPH1012E) lation. A single ordering number specifies a com- ■ Mercury Level Control Switch I plete system designed for (ALS2-5 for'/3 H.P. package) most residential and (ALS2-7 for 1 H.P. package) j commercial sump and ■ Magnetic Contactor effluent pump applications. .Y It"i (ALS3-1 with 1 H.P. units only). The ease of installation is I , ~W ■ Polyethylene Basin enhanced by plug-in power ! cords for the pump and (ALS7 1801 P) level control switch which ■ Basin Cover (ALSB-1822S) eliminates the need for ■ Check Valve (ALS9-2) additional wiring. (Except for 1 H.P. units which have Order No. SWP0311 E 115 Volts, bare leads for connection to r 95 Lbs. f _ magnetic contactor. Order No. SWPH1012E 230 Volts, 109 Lbs. i 416 GOU LDS PUMPS, INC. SENECA FALLS NEW YORK 13148 Form No. A-47BA-WS SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. SBD 6678 (9/81) (Plb 100a) STATE OF WISCONSIN DILHR Detach And Return Upper DIVISION OF SAFETY & BUILDINGS Portion Of This Form With BUREAU OF PLUMBING 201 E. WASHINGTON AVE. RM 178 Any Return Correspondence P.O. BOX 7969 MADISON, WI 53707 608-266-3815 DATE: PROJECT: 6 7 8 ~ 'Jr 1 Kinnickv; 1 o, PLAN ID. # j DETACH HERE PROJECT NAME PLAN ID. # This is to acknowledge receipt of your plans and specifications for the above-indicated project. Preliminary review indicates the required fee is $ Fee Received is $ ❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming. ❑ Plan accepted for review. ❑ Plans being returned. ❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW. held in abeyance. 1. Plan Submission ❑ Complete data relative to anticipated use of bldg. ❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed. less specifically noted. ❑ Deed restriction required (1 copy). ❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy) ❑ All information submitted shall be signed, dated and sealed or stamped in accord with Section H 63.08(2)(a) Wisconsin Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks ❑ Profile of holding tank showing vent, manhole alarm and manufacturer if precast. Complete construction details if ll. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed. ❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of and notarized. (1 copy) government (sample enclosed). ❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement for pressurize distribution. ❑ Soil boring & percolation from county (1 copy). test data. ❑ Plot plan showing location of holding tank with lateral dist- ❑ Cross section of system. L❑ Pipe lateral layout. ances to any building, wells, water service piping, water ❑ Plan view of system. ❑ Plot plan. course, lot lines, swimming pools, all weather service road, ❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point. I11. Private Sewage Disposal Systems V. Lift Pump ❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallo tion system extending 25' on all sides. pumped per cycle. ❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main. ❑ Location of area suitable for replacement system - provide ❑ Detail & model of pump or automatic siphons including soil data. size, pump curves, drawdown and average flow rate GPM. ❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or sewage disposal system to buildings, lot lines, well, water siphon(s). course, swimming pools, water service piping, Etc. ❑ Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission) ❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench system. before side slope begin). ❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill. tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff. ST. CROI X COUNTY r WI SC0 N S I N 1 ~ l ZONING OFFICE W111'' x` l 1 14 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 May 21, 1983 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, Wl 53707 Dear sir: An on-site investigation for the Leslie Paulson property located at the SE-14 of SW'-4, Section 32, T28N-R18W, Town of Kinnickinnic in St. Croix County, revealed suitable soils at a depth of 2.16 feet, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Yours truly, Thomas C. Nelson TCN:mj STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN Rl%LATlONS DI-VISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township/ (}iAAX-KI)~NAX)X: SE - SW `'4 S 32 r_f'L28 _ N/R 18 ~,AkK)W 't'own of Kinnickinnic Street Address: Subdivision: County: St. Croix Landowners Name: _ Mailing Address: Leslie Paulson 81012, Box 26, Rivcr Falls, Wl 54022 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted, I a ree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature of Applicant !i Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19 Notary Public, State of Wisconsin DILHR-SBD-6413 (N. 05/81) My Conu»ission Expires: WISCUNSIN ULPAkIMLNT OF INDUSTRY, LABOR AND HUMAN RLI_AiIUNS DIVISION OF SAFLIY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53/07 V1'rifI cat. ion of FXception Status for an Alternative Private Sewage System In the County of t . C ro i x L(n.at lull Ci- 174, SW i/it, Sec. 32 T 28 N, R 18 XjXAY~) W Town or fdifiXI~dlty Kinnickiii nic Street /Address Lot NO. block , Subdivision Landowner's Name: Le stie Paulsen the app Iicatjun for tills site is for,: new construction use. rep I dCemont system us(:. If this is NEW CONSTRUCTION USL, the alternative private sewage system is: Ito have one of tide first five approvals guaranteed for this year. hhis is number - - _ of those applications. (Use once of the 1irsC five quota nuiiihcrs I ssueil to you.) ~Olle of the applications needing a quota number. The quota number assigned to this application is - - - for one additional homesite on a farm to be occupied by a parent, child, yrandchiId, sibling, niece, nephew, or first cousin. for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. .fur an application on file prior to February 1, 1980. ~_-for d lot that meets the criteria for a conventional private Sewaye system. If this is a REPLACLMLNI SYSTEM USE, the alternative private sewdye system is replacing: ~a failing conventional soil absorptlun system. d holding tank that was installed and in use prior to February 1, 1980. privy that was installed and in use prior to February I, 1980. If this is d REPLACEMENT SYSTEM USE and the lot meets the Criteria tur• a conventional private sewaye system, check here. I 1 certify that the above ifit ormatiorn is true and dccur-dLe to the bC'st Ot 1Ily knowledge. Nance Tllom as C. Nelson -Signature TCuunty Uftici(1l- Title Assistant Zoning Administrator Date May 27, 1983 DILHR-SBD-6l b8 ,R 12182) Form - S T C 100 Owner of Property -.X C-S l O ~t14 ~3'6 Location of Property ~C ' S 1 (~n n~ 4 Section , T N R11f, W ~ R 1 Township Mailing Address SOX VV I z-~ Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel Was Created Are all corners identifiable? 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. ; 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. ) ,lam SIGNATURE OF OWNER~J SIGNATURE OF CO-OWNER (IF APPLICABLE) 1.. ^ / O DATE I NEO DATE SIGNED Parcel 022-1093-20-000 12/29/2005 12:13 PM PAGE 1 OF 1 Alt. Parcel M 32.28.18.P505C 022 - TOWN OF KINNICKINNIC 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 KEVIN R ELLERTSON O - ELLERTSON, KEVIN R 1038 CTY RD M RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description 1038 CTY RD M SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 32 T28N R18W PRT NE SW COM 7.07'N & Block/Condo Bldg: 585.2'E OF SW COR ON CENLINE OF HWY, TH NELY 220.47'TH NWLY 194.55', TH SLY 220' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) TH SELY 180.07' TO POB EXC HWY 32-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 01/30/2002 669779 1826/270 QC 07/23/1997 746/206 I I 2005 SUMMARY Bill M Fair Market Value: Assessed with: 143979 228,500 Valuations: Last Changed: 08/11/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 20,000 211,000 231,000 NO Totals for 2005: General Property 1.000 20,000 211,000 231,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.000 10,000 158,200 168,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 131 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00