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Parcel 026-1086-60-000 01/24/2007 08:50 AM
, PAGE 1 OF 1
Alt. Parcel 30.30.18.456F 026 - TOWN OF RICHMOND
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
0 - BERENSCHOT, RANDALL
RANDALLBERENSCHOT
1378 100TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1378 100TH ST
SC 3962 NEW RICHMOND
SP 7040 RICHMOND SANITARY DIST 1
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.610 Plat: N/A-NOT AVAILABLE
SEC 30 T30N R18W PT NE NE COM SE COR TH Block/Condo Bldg:
W 578' TH NELY = E R/W CO HWY A 217' TH
ELY 514' TO E LN S 200' TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
30-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 494/503
2006 SUMMARY Bill Fair Market Value: Assessed with:
177326 50,100
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.610 17,100 22,000 39,100 NO
Totals for 2006:
General Property 2.610 17,100 22,000 39,100
Woodland 0.000 0 0
Totals for 2005:
General Property 2.610 17,100 22,000 39,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 208
Specials:
User Special Code Category Amount
II
I
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
I
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 El ALTERNATIVE State Plan l.D.Numbe
PRIVY (If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER'. INSP CTION DATE
Berenschot, Randall RR# 4, New Richmond, WI ~-30- K3 - /0 0-q
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
NE NE, Sec. 30, T30N-R18W, Town of Richmond
Name of Plumber. MP/MPRSW No.. County Samtary Permit Number:
Gary Steel 3254 St. Croix 38536
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
Id PROVIDED PROVIDED
DYES ENO DYES ENO
BEDDING'. VENT DIA.: VENT MAT L.'. HIGH WATER NUMBER OF ROAD: [ROPERTY rLI_: BUILDING'. (TO FRESH
ALARM FEET FROM INE: AIR INLET'.
DYES ENO DYES ENO NEAREST-
DOSING CHAMBER:
MANUFACTURER BEDDING'. 11-1011111 CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL JLOCKING COVER
PROVIDED. PROVIDED.
DYES ENO EYES ENO OYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY JWELL BUILDING. I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES ENO _ NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL ENCrH JDIAMETER 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:
BED/TRENCH WIDTH LENGTH TR EONCHES IDISTR PIPE SPACING MATERIAL PIT JINSIDE CIA UPITS DEQTID
DIMENSIONS
GRAVEL DEPTH FILL DEPTH [STR P IPE DISTRPIPE DISTR. PIPE MATERIALNODISTRNUMBER OF PROPERTY WELLBUILDINGVENT TO FRESH
BELOW PIPES ABOVE COVER EV. INLET ELEV. END. PIPES FEET FROM ,LINE. AIR INLET.
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-
D meets the criteria for medium sand. TIONS MEASURED.
YES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ENO EYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED.
CENTER EDGES
❑YE:S ENO DYES ENO DYES 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. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA.. ELEV.' PIPES. )IA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑ YES 1:1 NO ❑ YES 1:1 NO NEAREST
AR
INA.
U
Sketch System on Retain-in, county file for audit.
Reverse Side.
TITLE. /
DILHR SBD 6710 (R. 01/82)
77- wlsmnsln APPLICATION FOR SANITARY PERMIT _s~
DILHR C COUNTY
E (PLB 67)
UNIFORM SANITARY PERMIT #
InOUSTRV,LRSOR&HUMAnRELRTIOns
-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 instruction for completing this application. PLEASE PRINT
PRO RTY OW ER le, MAILI DDR ASS
PROPERTY LOCATIO ?I{^
Y'l 114, S 3C' , T3 6/1 N, R f~ W} o0 OF:
1 /4 ;
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME- NEAREST ROAD, L E OR LANDMARK STATE PLAN I.D. NUMBER
14,14 /(41 - A loco /s/
TYPE OF BUILDING OR USE SERVED
k1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacemenl: ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision >5--erivy
❑ 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 KPit 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):
❑ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Nam of Plumber (Print): Signature MP/MPRSW No.: Phone Number:
Plumber's Address: Name Design
G
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
Owner Given Initial
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.
ARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
JUSTRY, c DIVISION
_UB AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATI O N~'/ S ~o10~~~ 1 ry~(or) W T01N}SE11pJ1~?d}SI~L-HTY. LOT NO.: BLKINO.: SUBDIVISION NAME:
T N/R/(/
COUNTY: QWDIER'S/BUYER'S f~ME: MAILING ADDRESS:
l
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOL, TION TESTS:
14, 1 Residence _ ❑NewReplace -
c 1 " 'mac
RATING: S= Site suitable for system U_= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK: RECOMMF7NDED SYSTEM: (optional)
❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U >
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: ICA Floodplain, indicate Floodplain elevation:
E S//)Al , PROFILE DESCRIPTIONS 4-3
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER pW4H_ ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
00 '00
ZQ_
B-
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
P r,
P-
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
/V L,
e
rn -R nP' ba n-,&f,+ OA4i o _
~y C6- mn4r+ bl 00--k VA-S) C~r~rn
!1
E
E _
,
-----T ~ T N
,
3
i
Ste, j
E t
' t
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:
- ti
ADD ~QE3SS: ,f~ ~j CERTIFICATION NUMBER: PHONE NUMBER (optional):
A z~6 'lo zDd
U~ m'(/ fhfi ~L i GV 1 1d / Z Z P
CST SIGNA UR
DISTRIBUTION: Original and one copy to Local Authority, P operty Owner and Soil Tester.
Dii_HR-SBD-6395 (R. 02/82) - 0',./FR -
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Locatiua of ProperLY See tiun k/FW
Towt►dh1p
Mallir>g Addredy kl.
Subdiviaiun Naule
Lot Number
Previous Owner of Property
't'otal Size of Parcel
Dote Parcel Wad Created
Are all corners idenLiflable? Yes No
ILIClUde with this application one of Lhe fullowil :
.Certified Survey Map
n Deed
.Land ContrULL, or
.Uther I:egal DULUUIeLIL whlCh describes the property
PROPERTY OWNER CEHTIFICATION
(Wa) certify that all stdtumdnts on this torn aru true to the best of my (our)
knowludUa; that I (wu) 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.1 ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
SIGNATURE OF OWNER
SIIiNNTURE OF CO-OWNER (IF ANPUCAtlLE)
DATE SIUNLO UATE sICNLD