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HomeMy WebLinkAbout028-1016-60-000 00 m f 3 w c d `+1 'U 0 (D 3 1 1 F >v 1'. C31 - z ° -t~ z ! A N ° co z z 0m m O W C C N .ti °C • CL C O O CD CL N w a d S OD O N c 3 CO W~ ~ O v O ^ m N m m =r a = 0 CD a ° O C' r A (CD CCD m W O ! 3 a m O ° 7 N A ° O a1 r N O .7 !r m C D m a CD G CD N a =3 N W c a ° ° w a 0 20 2? co lot O 0~ cd 'x N m W - i H a c ¢ . z CD m :5,' ° ww~ No c rt n N. 3 T T H Y N• a 'I tr O :j rt o O O O ao ~ N v 0 co co (n F, p, v . 3 v v o 5 • O m I A y (n W _ A Q H (p ~O C .a) N c m N t7~ :3 m ~ a N w d ~ I z ° zco z D CD 0 a O ~ r3 W W O ~ h • N rt I (7 CD m Z N F - CD m f7M 1-0 0 I 1 O c m~ 00 00 rn w m a W W H n 3 ~'d N Cam] z m -1 to G 00 ° N o p ? U) Z = c L=J n j' 3 N. v U' (q I rrJ W M 0 N co a~ ztz td O : z O 3 m ¢ N m ? rr ca n (D as a m m m nv a ° a, 3 o'i c z ~a W O 0 m CL m S :3. CL x 0 CD N m N 0 O O V pj A 0 b 6p ONo O <fl O to ° O 0 OW AS BUILT SANITARY SYSTEM REPORT i 1 OWNER `T'OWNSHIP SEC. T~N-R /7/W ST. CROIX COUNTY, WISCONSIN. t_iI SU*j YIJS~ AN;;. LOT LOT SIZE ,s C e PLAN VIEW a_st r~ e, and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C, .h ~ y Ve o Ty V T_ 4 J I di at N r 1h rrc w BENCHMARK: (Permanent reference Point) Describe Elevation of vertical reference point: Arlo1~= Slope at site: SEPTIC TANK: Manufacturer:- //-,),f& ' Liquid Capacity: /~00 0 Number of rings on cover ^nlf Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer:- Num~er of gallons Number of gal. pump eta for a cy~l°- /6alluns; Y tal capacity of 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 IfIx Elevation of manhole cover A ; Type of warning device SEEPAGE PIT SIZE; i Number of pits feet diameter feet liquid dep-t~~`~` seepa e it inlet pipe-elevation bottom of seepage pelevation_/~ feet. SEEPAGE BED SIZE: number of lines 1b,"ed width_ __length 7 the depth i SEEPAGE TRENCH: width- length PERCOLATION RATE AREA REQUIRED AREA AS BUILT INSPECTOR DA'Z'ED-~ PLUMBER ON JOB ~n G' Gf S~i'~ LICENSE NUMBERP ~~3 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. 0OX 7969 BUREAU OF PLUMBING • MADISON, WI 53707 E2 CONVENTIONAL DALTERNATIVE StatePI"I.D Number: ❑ Holding Tank El In-Ground Pressure ❑ Mound Of assigned) NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPEC ION DATE: Thomas Klund Baldwin, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. SE NE, Section 12, T28N-R17W, Town of Rush River Name of Plumper'. IMP/MPRSW No. County. Sanitary Permit Number: Everett Boldt 4489 St. Croix 43639 SEPTIC TANK/HOLDING TANK: MANUFACTURER. ^ LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARN( G LABEL LOC E V /~fj 11 • /q~/ "T f PR ED PRO DE A) _L0 fk 0.. j ,/0 YES LINO NO BEDDING'. VENT JVT M TL.. JHH WATER NUMBS ~ROAD F: LINE WELL'. J J BUILDING'. VE T TO FRESH A. F EET FROM LNE: INLET. ❑ YES NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING'. LIQUID CAPAC ITV M - O L PUMP/SIPHON MA ff-A 1 liortlitt LABEL LOCKING COVER PROVIDED: PROVIDED'. EYES LINO DYES LINO EYES LINO GALLONS PER CYCLE: P P D CONT o OPERATIONAL UMBER OF PHOPERTY WELL BUILDING I vENT ro FRESH EET FROM NE AIR INLET (DIFFERENCE BETWEEN ANEAREST__~ PUMP ON AND OFF) ❑ S O SOIL ABSORPTION SYSTEM. Check the soil m Is re at the pth of plow; g LENGTH JDIAMETER MATERIAL AND MARKING FOR E or excavation. (If soil can be rolled into a wir onstructi shall cease uAl M the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDT - LENGTH NO. OF IDISTR PIPE SPA ING C E INSIUE DIA =PITS LIQUID BED/TRENCH rRENC M AL PIT DEPTH DIMENSIONS to I V GRAVEL DEPTH F ILI_ DEPTH UISTH IPF DISTR. PIPE DISTR. PIPE ATERIA L: NO. TR NUMBER OF PROP RTV WELL. BUILDING. VENT TO FRESH eFLOwP1PEI ABOVE COVER J Il EI ET E EN /J G PIPE FEET FROM LI AIR LE r Do) Y®,,I~ NEAREST I ~V I MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A A RAM OFSYSTEM and furrows thrown upslope: mound systems make certain that it ON REVS SE S E. SHOW ELEVA-7~ meets the criter or edium sand. 1I0NS EASU ED. EYES LINO SOIL COVER TEXTURE PERMANENT M HKERS OB&ESE] OLS ❑Y S NO NO DEPTH OV ER TRENCH .BED DEPTH OVER TRENCH, BED DEPTH OF TOPS L. SO DED SEED MULCHED. CENTER EDGES EYES NO ❑ S NO OYES LINO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF IRAL SPACING. GRAY L DEPTH BE OW PIPE FIL DEPTH ABOVE COVER. BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD /PISTR. PIPE JMMATER( L'. NO. DISTR. DISTR. PIPE DI TRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. CIA.. ELEV.. PIPES. DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED C ECTLV CO R MATERIAL ERTICAL LIFT COR RSP NDS PPROVED LANS ES NO ❑Y LINO COMMENTS: PERMANENT MARKERS: OBSERVATION LS: NUMBER O PROP TY WELL'. BUILDING: ( FEET FROM LINE 9 EYES LINO EYES LINO NEAREST- 4 izN 4P 5 Sketch System on ty file for audit. Reverse Side. RE. ITL& DILHR SBD 6710 (R. 01/82) r DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/2 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. Property Owner: Mai ddress: o A/2- `,qG dom. " ' 6tj"s Property Location: City, Village or Townshi County: oSE t/a /VFt/aS T~r N/R 7 4 (or) W ~s ✓e,~ f C,2o~ x Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I. D. Number: /\/,q /11,-, cl i/w ~3 (If assigned) TYPE OF BUILDING ~+T /Y Number of El Public* 1:1 Variance* ❑ Other (specify)*~j. Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY o o v e- X X HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: ,CS EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New 1K Replacement ❑ Experimental D< Seepage Bed ❑ Seepage Pit / /s, ❑ Alternative (specify) ❑ Seepage Trench Water Supply: O Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for ins lation of the private sewage system shown on the attached plans. Na,m.~e f Plumber: Signatu 994~;W9 P/MPRSW No.: Phone Number: ee-e_~-4- / 1f (7/5161¢337 Plumb dress: Name of esir: 6JI Z_ v, e- r- e- COUNTY/DEPARTMENT USE ONLY Signa re of Issuing Agent: Q~ Fee:/ Date: APPROVED Sanitary Permit Number: G~~.t//t✓V 9-R31 1 DISAPPROVED Reason for Disapprove 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) Form - S '1' C 100 Owner of Property-- cr),I e;. .Location of Property -S1= 14 NL`- ~4, Section TDF N It/"7 W Township Mailing Address LJf~c Subdivision Name Lot Number 14 Previous Owner of Property Total Size of Parcel 2& Date Parcel Was Created A Are all corners identifiable? XYes No Include with this application one of the following: .Certified Survey Map . Deed .Land Contract, or .Other I:egal 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 1 (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=,3' eL) ; 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 some has been duly recorded in the Office of the County Register of Deeds, as Document No.-4;4 3d-` SIGNATURE OF OwNftR SIGNATURE OF CO-OWNER (IF APPLICABLE) 7 OAT SIGND ' DATE SIGNED DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 7969 !.ABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) TY: r V CP_ OryANO~ ..BLK/YN~O: SURD IVI SON NAME: L EI ~~N 4 SE/a %Tc"N/R"forlw TOWNSHI O 5 ALI/l COUNTY: OWN R'S/BUYER'S NAME: MAILI G ADDR SS: S j' 0- Ra i tj, S - USE DATES OBSERVATIONS MADE _ NO. BEDRMS,: COMM CIAL DESCRIPTION: V PR F LE SCR;~ON S: P R OLATION TESTS: Residence j ❑New I~Replace - 11 RATING: S= Site suitable for system U= Site unsuitable for system V J ' OLDIINcNG TANK: RECOMMENDED SYSTE M:(optionall` CONVENTIONAL: MOUND: IN-GROUND-PRREnESSURE: SYSTEM-IN-FI-L H t"S ~U ®S Eu ®S LJ~ EIS ®V ~J ©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: Floodplain, indicate Floodplain elevation: f' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 40, ELEVATION OBSERVED ST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) _ B. 1 '7, o ~ ~ > ~ . 75 AFL S, L B- A o f 9/,,95- r > Ste" r 7Y ` ~J L S C S N / U r B- 3 B- 7, v' go.1z_ ? ~ . W9 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER-IiIIIIIIIIIIIIIIIIIIIIIIIII AFTERS ELLING INTERVAL-MIN. PERIOD 1 P-ERIOD2 PERIOD PER INCH P. , o - _ P_ a .0 o-d do P- _ e ee ec/ Gvl9~ ES3 N /l7in1. 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 '2a 6a e-' C_ 4C4 14e , . , i 4-- I 4- TN 1, r - I 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 (printl: TESTS WERE COMPLETED ON: eve 4 4- L4 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): qr - - - - --J - - CS ATURE: / DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER 00 44.' . 4 7 9e ~.1 Q t; - Y. d~a ~3 i nv Val V4 K ~ ~ Y 'i I' ' M ?ego % Ir 41 .a V ~ "Y DC 1~ r. ~ . ti > IZZ Vul --Z x p ° o -1-- v' 3 ri) 2 13 IN. a3 - Parcel 028-1016-60-000 01/24/2007 09:23 AM PAGE 1 OF 1 Alt. Parcel 12.28.17.84B 028 - TOWN OF RUSH RIVER 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 CHRIS A & JULIE E CARSON O - LARSON, CHRIS A & JULIE E 472 HWY 63 BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 472 HWY 63 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 3.500 Plat: N/A-NOT AVAILABLE SEC 12 T28N R17W PARCEL IN SE NE BEGIN Block/Condo Bldg: N 262 FT, S 581.9 FT E 262 FT, N 581.9 T. 10 Hub HHUH ADD 472 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) HWY 63 BALDWIN 12-28N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1120/297 WD 07/23/1997 1112/338 SD 2006 SUMMARY Bill Fair Market Value: Assessed with: 165979 140,400 Valuations: Last Changed: 08/30/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.500 36,800 94,100 130,900 NO Totals for 2006: General Property 3.500 36,800 94,100 130,900 Woodland 0.000 0 0 Totals for 2005: General Property 3.500 36,800 94,100 130,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 218 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00