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AS BUILT SANITARY SYSTEM REPORT
C,.
OWNER 1AL ;'I'0WNS111P -----SEC -R/ / W
ADDRESSF ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION =~G LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
! 1 1~ h
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F-E bL-AL
BENCHMARK: (Permanent reference Point) Describe: ~7'
D r~S~Z~fI//1 Qg/ ~Z
Elevation of vertical reference point: Slope at site:
i
SEPTIC TANK: Manufacturer Liquid Capacity: /16C c,
Number of rings on cover =j Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: _ Nuuibet- 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
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 length tile depth
SEEPAGE TRENCH: width length-
PERCOLATION RATE AREA REQUIRED AREA AS BUILTtS~;,~.
INSPEC`T'OR
DATED- ✓ 3 _ PLUMBER ON JOB
LICENSE NUMBER--(, --?-:Z /
IkI&
- -
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABO".', & HUtAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
11CONVENTIONAL ❑ALTERNATIVE State PlanI Number.
❑ Holding Tank ❑ In-Ground Pressure 1:1 Mound (If assign ed In,
OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Robin Buckles RR# 2, Hudson, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV.
NW NW Section 5, T29N-R19W, St. Joseph Township LOT 2
Name of Plumber: IMP/MPRSW No.. County. Sanitary Permit Number:
Roger Timm 3224 St. Croix 34828
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY:-TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
IJ? 11), EYES ENO EYES ENO
BEDDING: VENT DIA.'. VENT MATL. HIGH WA R NUMBER OF ROAD: PROPS RT WE ? A BUILDING. JVENT TO FRESH
l ALARMr FEET FROM t LINEa AIR INLET 1-7 ❑ YES • NO ❑N G❑ NO NEAREST IF
DOSING CHAMBER:
MANUFACTURER BEDDING. L 'UID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YESr' NO. EYES ENO EYES ENO _F / GALLONS PER CYCLE: / PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING.I VENT TEFRESH
(DIFFERENCE BETWEE FEET FROM LINE AIR INLET
PUMP ON AND OFF) r T ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMerER 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:
. DISTR. PI P
E SPACING COVER INSIDE DIA. kPITS BED/TRENCH WIDTHLENGTH N NOO OF Es ' ! L l PIT ]LIQUID
DIMENSIONS T~r
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO STR NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIP 5 ABO, COVER ELEV. INJ L ELEV. END/, PIP AIR INLE
LE _ F FEET FROM <I/ 4L
NEAREST--s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check)~ the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mounA systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
mee s the cr eria for mediiI sand. TIONS MEASURED.
EYES ENO -
SOIL COVER TEXTURE - PERMANENT ARKERS. OBSERVATION WELLS
❑ ES NO DYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TO SOIL SODfi D SEEDED. MULCHED.
CENTER EDGES EYES E NO DYES D NO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF T ERAL SPACING. GDEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE IMA D MAT RIAL. PIP . E LEV ELEV DIA ELEV . DI TR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
. . MA D
ELEVATION AND NIF
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY tVIH MAT HIAL VERTICAL LIFT CORRESPONDS TO APPROVED
EYES ❑N'b DYES NO
COMMENTS: PERMANENT MARKERS: SERVATION EL NUMBER OF PROPERTY JWELL: BUILDING:
FEET FROM LINE.
t ❑ YES ❑ NO ❑ ES ❑ j , NEAREST
(t ( ~ LL yJ7
..T 1C~ ~ • ~ c ~ ~.1'~ ~•v>`~~ ~ • , ~ Som./
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Sketch System on xx
cj C Retai Iourlty file for audit
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD6710 (R. 01/82) tt' -
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'/Z 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. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Address:
Property Location: City, Village or Township: County:
/v `'/aS ~T 25 NCR ~'9 (or)I /~c _
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
r/ Number of
❑ Public* ❑ Variance* ❑ Other (specify)*c_ ~j,c/, ~J -/6ld -~2c Lrc 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 & X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: L 15 L,_ LC ;C
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ® New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ` Seepage Trench
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 afPlumber: Signatyca- MP/MPRSW No.: Phone Number:
Plumber's Addr s: Name of Designer:
e r~.
A,/
COUNTY/ DEPARTMENT USE ONLY
Signatur of Issuing Agent;, e' Date: Sanitary Permit Numbbpr:
&11)_Zq-_1_) Q ' ~ ~ ❑ DISAPPROVED T O 0 Q
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
D!LHR-SBD-6398 (N.03/81)
Form - S T C 100
Owner of Property jRUbin L: 4uc-kle!~, anci br(,-n o-
Location of Property Nl~ 4 Section ,T-,-~q-N R I(ji-W
Township
Mailing Address oc de- ,-31 }~.~Ca~nrirl Vi~CUr151r~ S~I~~I1~
Subdivision Name - - -
Lot Number tl ,
Previous Owner of Property L~cur~ N, ~;f Cane I~E'ra rlc=tf~ t F
Total Size of Parcel - 15 ,
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 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 I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty d ~ogdrin the Office of the
County Register of Deeds as Document No.0 s 7 / ; 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 SIGNATURE OF C"WNER (IF APPLICABLE)
DATE SIGNE DATE SIGN j
EH 115 Rev. 9/78 A~wlc1' a~ Z
• REPORT ON SOIL BORINGS AND PERCOLATION TESTS 1!46, S
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN>53701
LOCATION:A/&1 '/4.IV& Section 5 T ?l N,R ~~E (or Township or Municipality
Lot No. 2^ , Block No. County (W
a me
Owner's/Buyers Name: Subdivision
Mailing Address:
TYPE OF OCCUPANCY: Residence x No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEMOTHER
DATES OBSERVATIONS MADE: SOIL BORINGS_ 7 PERCOLATION TESTS 7 Iq,?Q
SOIL MAP SHEET 5C-57 50 NAME OF SOIL MAP UNIT B t~2KJ~r112~T-'
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- l 3 sAkE s ~a 36, ~
P-
P- P_" Eo, o~ s,
P- 3 t1'' w, /_g U'l3~v 'ice l ~ l~~
P- C44 ~,e .
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- j ?L /1✓O,(1L` 7 7.2 & SL a "a 6N. L f 011f'• 1~P S.
B- L 72- NO E ? 7 "L1~ (3v 6y A "0A1 . x. ~0" sC~v' By ~f
B- lVaMF > i3' L / Cw. G / 1,06 ' d -~•v . 1s w p, "SL
B- J /V10VE > 7 0"10 13,j.L 11''041-S So` ht--,h, Of, S.
B- 72. NoMf > 7.2, 7'6f a~ [s /6 ^o. ~s z~,,, o~P s~Nv, 28" do -,Q,) Qs
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 263-42-!-3= Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. &N
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e~1 • D(
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I, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) / J` a T" ` Z~ MA /f~~~ Certification No.
Address OPT-3
Name of installer if known 74
Copy A -Local Authority r CST Signature_~Z/14 i
EH 115 Rev. 9/78
• REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: AW '/4, N4)
'/4, Section ,Tf1_N,Rd E (or) Township or Municipality
Lot No. _2 , Block No. _Di L-t S 5V (?P i V I S !O -j County C,~a/
CG,4/~E Subdivision Name
Owner's%Buyers Name: ,,L[.// ;y
Mailing Address: k . L ffupsoro ez/S'
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT-ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS-#fy 2 1 1790 PERCOLATION TESTS -AlO/ ~o4 Z-/E~
SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
RATE
NUM- SINCE HOLE HOLE AFTER INTERVAL
MIN/IN
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-
P- - a Elcs w / o
P- o io ✓ /EL p
P- fC c ® NO LEO .E/N / A,1 OitlA
SOIL BORING TESTS S117i ieA746 Z>
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 74 d a "AA) . S/ / f1'/3N -OR. 2-Z
B- L w;0te, ~ MOPS. ,0(,5Vrc_t CcaHrtoN
B- 72 n r. Y„~W-G SL 0514, 13; ,S 32 SL w f
B- . Mot's .
B &2. s' /J-" RA;-6y.S /0 '°Z:'41.S4 1 "QiP l2iI/,.
B_ k. F f. Of.ft fS 2-4 C-4 wl_f cu P157. nom.
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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1, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) /C he Z(//9,6'~-47- Certification No.
Address 1~T (2A,) `
Name of installer if known-.
a ~Q
Copy A - Local Authority CST Signor ure
JOB
ROHL & TIMM EXCAVATING / OF 2
- SHEET NO.
310 Arch Street
HUDSON, WIS. 54016 CALCULATED BY DATE
(715) 386-8664 DATE _
CHECKED BY
SCALE
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PRODUCT 204-1 ~ esJ Inc., Groton, Mass. 01471.
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r JOB .i?o, J /i
ROHL & TIMM EXCAVATING SHEET NO. ~ OF
310 Arch Street - z
HUDSON, WIS. 54016 CALCULATED BY l y . f 1 y~~ DATE Z
(715) 386-8664
CHECKED BY DATE_
SCALE
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PRODUCT 2041 s~ Inc., G,dm Mass. 01471
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Parcel 030-1018-95-000 08i28i2006 10:35 AM
PAGE 1 OF 1
Alt. Parcel 05.29.19.79D 030 - TOWN OF SAINT JOSEPH
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
ROBIN & BRENDA BUCKLES O - BUCKLES, R BIN & BRENDA
1181 TROUT BROOK RD N
HUDSON WI 54016
I
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1181 TROUT BROOK RD N
SC 2611 HUDSON
SP 1700 WITC
i
Legal Description: Acres: 6.490 Plat: N/A-NO AVAILABLE
SEC 5 T29N R1 9W NW NW LOT 2 CSM 5/1267 Block/Condo Bldg:
663/328 ALSO COM NW COR SEC 5 S 919.05
FT-POB S 89DEG E 657.89'S 210'N 89DEG Tract(s): (S c-Twn-Rng 40 1/4 160 1/4)
W 657.5'N 210' -POB 05-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 911/548
07/23/1997 693/257
07/23/1997 663/328
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 09/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.320 24,700 191,000 215,700 NO
PRODUCTIVE FORST LANDS G6 3.170 81,800 0 81,800 NO
i
Totals for 2006:
General Property 6.490 106,500 191,000 297,500
Woodland 0.000 0 0
Totals for 2005:
General Property 6.490 106,500 191,000 297,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 116
Specials:
User Special Code Ca egory Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00