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' AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP-(-)"- S4r SEC. TaN-R~W
7 ?
ADDRESS ( ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION_ LOT _ LOT SIZE r
PLAN VIEW
meet requirements of H63
ns to
Distances and\~nsic
VERYTHING WITHIN 1.00 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe: 1.;•ar "";7
Elevation of vertical reference point: z7Z' c Slope at site:
i
SEPTIC TANK: Manufacturer: Liquid Capacity : !j1
Number of rings on cover _ -Tank manhole cover elevation: 4 S,o
Tank Inlet Elevation: y~t0 7 Tank Outlet Elevation: ~,7 7
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
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 LL- _ width / length the depth
s!J /
SEEPAGE TRENCH: width lerygth__
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
INSPECTOR- _
DATED PLUMBER ON JOB ~5
LICENSE NUMBER r d
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MAD;SON, WI 53707
❑CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number.
El Holding Tank ❑ In-Ground Pressure ❑ Mound (Ifassigned)
/'S' I,
NAME O (PERMIT HOLDEFy- ADDRESS OF PERMI _sHOLDER: INSPECTION DATE.
BENCH MAR (Permanent ferenc. pointI DESCRIBE DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF PT ELEV
Narne of be MP/MPRSW No.. County: Sanitary Perma Number:
SEPTIC TANK/HOLDING TANK: 9. 3 a . 1 S
MANUFACTURER. C LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELE V.. WARNING LABEL JLOCKING COVER
~ C, ,l PROVIDED: PROVIDED:
/ U ❑YES ❑NO ❑YES ❑NO
MBS OF ROAD: PROPERTY WELL. ABUILDING: VENT TO FRESH
BEDDING. VENT DIA.: VENT MATL. HIGH WATER EAREST;.
ALARM. ET FROM LINE AIR"LET'
❑YES ❑NO ❑YES ❑NO O~ G~U c7cl
DOSING CHAMBER: 6
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: ;reutc~tivon NDCO oLS ERATIGNAr NUMBER OF PROPERTY JWELL euILDING vENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE R INLET
PUMP ON AND OFF) YES ❑NO NEARESTSOIL ABSORPTION SYSTEMCheck the t dept fPlowing LLNGTH DIAMETER MATEHIALANDMARKIN(,
or excavation. (If soil can be rolled int wishat cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA. 11ITS LIOUID
TRENCHES ry1A L', PIT DEPTH
DIMENSIONS 12 p C
GRAVEL DFPTH FILL DEPTH JDIITH PIPF DISTR. PIPE DISTR. PIPE TERIA L. DI R NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
BELOW PIPES ABO E V R ELEV. INLET EV. E D PIPES LINE.
FEET FROM l AIR"LET'
'e v G 2- NEAREST s (J D
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 eerta~n that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium nd. TIONS MEASURED.
❑YES ❑NO f' I A.I
SOIL COVER TEXTURE PERMANENT MM KERS OBSERVATION WELLS
❑YE ❑NO ❑YES ❑NO
DEPTH OVER TRENCH B
ED DEPTH OVER TRENCH: BED DEPTH OF TOPSOI L. SOD ED SEEDED MULCHED
CENTER EDGES
134S ❑ 6y ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF LATERAL SP ING. GPI FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES F
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIP MANI O D MATERIAL. IN0JISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA. ELEV. PIP DI A.:
ELEVATION AND
DISTRIBUTION I
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PR OPERTV WELL: BUILDING.
FEET FROM uNE
❑YES ❑NO ❑YES ❑NO NEAREST
Y,
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Sketch System on Retain in county file for audit.
Reverse Side.
A
TITITLE
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DILHR SBD 6710 (R. 01/82) - =
ui+sconsln APPLICATION FOR SANITARY PERMIT J
COUNTY
DILHR - OEPRRTTT1EnTOF (PLB 67) UNIFORM SANITARY PERMIT #
InOUSTRV. LABOR 6 HUMRn RELATIOnS
-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
PROPERTY OWNER MAI, I. G ADDRE$~
- IL-
PROPERTY L r~ r f
LOCATION Ul I y:
VILLAGE:
1 /4 1/4, S,-,'' N, R 1 (or IN.; TOWN OF: i
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms.
❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
5,7 Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Z Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ 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: yi~i.!: n h J
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.
Namt~f Plumber (Pr/~nt): j Sign yye: i MP/MPRSW No.: Phone Number:
Plumber, 's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature o ng Agent: F
kj~ Dq~2 ❑ Disapproved
- El Owner Given Initial
Approved Adverse Determination
Reason for Disapprova :
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To, Bureau of Plumbing, Owner, Plumber
j
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.
Form - S '1' C 100
Owner of Property
Location of Property
_`-4i Section N RW
`t'ownship
Mai ti.ng Ad dr
3
Subdivision Natne
Lot Nut)rber
Previous Owner of Property
'1.'otal Size of Parcel.
Dat Parcel Was Created
Are ala- corners identifiable? Yes No
In-clude_wiLh than app1_ication one of ttte following:
Certified Survey Map
Deed
.Land Contract, or
Other L:egai 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 warran Lde the Office of the
County Register of Deeds as Document ll ; and that I (we)
presently own the proposed site for the se% sa 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.
a2L~- P , '92 A
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICAULE)
- -
DATE IGNLD DATE SIGNED
h
AL parcel in the NBj of SW* and NW9 of SX1 of Sao 2 T31N R19W
St. Croix County. Wisconsin described as follows: All
that part of the Bast 24 rds of Nk"4 of SYF4~' of section 2
T31K R19W lying Westerly of Highway 36 exoept the South
40 rods; and all that part of the NW-41 of SE4 of Sao. 2
T31N R19W lying Westerly of Highway 36 except the South
40 rods.
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DEPARTMENT
Y, T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR. AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
DIVI,&IONNAME:
LOCATION: SECTION: TOWNSHIP/MUNIC+PALITY: M O.:BLK. O.T
B
'/4 '/a /T N/R (ar) W~
COUNTY: OWNER'S/BU Y th 6 A E: MAILIN ADDRESS:
t y
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
[Residence ❑New Replace I _
RATING: S= Site suitable for system U= Site unsuitable for system
rCONVENTIONVL:M OUND : IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
DS ❑CJS ❑JU ❑U ~S Du ❑s au
If Percolation Tests are NOT required.' DESIGN RATE: If any portion of the tested area is in the %
under s.1163.09(5)(b), indicate: / j~ % Floodplain, cate 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.)
- % iL.11~J
q
B- 7
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SW TN INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- r
P-
P-
P_
P_ P-
PL -rPLAN: 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'
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I, the Qndersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures an methods s ecified 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 belle:.
NAME (print): TESTS WERE COMPLETED ON:
V 42
ADDR CERTIFI ATION NUMBER: PHONE NUMBER (optional):
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Parcel 032-1005-10-000 09/22/2006 11:37 AM
PAGE 1 OF 1
Alt. Parcel 2.31.19.25B 032 - TOWN OF SOMERSET
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 - BELLE ISLE, CLETUS & RAMONA
CLETUS & RAMONA BELLE ISLE
2342 HWY 35
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 2342 HWY 35
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 2 T31 N R1 9W PRT OF NE SW COM AT SE Block/Condo Bldg:
COR OF NE SW, TH W 24 RDS, TH N 40 RDS
TH E TO E LINE OF NE SW, TH S TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
ASSESSED WITH P30B 02-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 415/443
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/22/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.500 60,500 88,800 149,300 NO
Totals for 2006:
General Property 5.500 60,500 88,800 149,300
Woodland 0.000 0 0
Totals for 2005:
General Property 5.500 60,500 88,800 149,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 304
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00