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" AS BUILT SANITARY SYSTEM REPORT
OWNER_!= / "TOWN SHIP
SE/~ `SEC . TAN-R~(
ADDRESS ST. CROIX COUNTY, WISCONSIN.
fil)" f'j
SUBDIVISION LOT _ LOT SIZE / j
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~G
-tf+
1
CT T.1;
,
Irdi at N r h rr w
BENCHMARK: (Permanent reference Point) Describe T/-'z1=
Elevation of vertical reference point :
Slope at site:
SEPTIC TANK: Manufacturer: ~r S Liquid Capacity:
Number of rings on cover / Tank manhole cover elevatior,:_
_ 'l'ank Inlet Elevation: ~ Tank Outlet Elevation:
P , CHAMBER
Manufactur _ Number of gallo
Number of gal. pump set or _ ons; Total capacity of
distribution lines size of pump head;
gallon per minu- horsepower
;brand na pump
and mo lumber
e of warning device
UL.DING TA NK: Manufacturer _ Number of
Eleva e cover -
Ty pe of warning device-
SEEPAGE PIT SIZE; Number of pits eet diameter
feet 1. epth_ seepage pit inlet pipe-elevatio
tom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines- c/ width length '1'2 tile depth
Stsf-L'E1.G1. LI2I N('H wicjih -_-1enT,th - -
PERCOLATION RATE AREA REQUIRED- AREA AS BUILT j/,,l ?
INSPECTOR__
DATED - PLUMBER ON JOB
- - - - - - 1~, iv S/i/ 7-
LICENSE NUMBER ;~v3.% ~ 4--
Parcel 032-2070-50-100 06/15/2005 04:38 PM
PAGE 1 OF 1
Alt. Parcel 13.30.20.770D 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): * = Current Owner
FATHEREE, WILLIAM D
WILLIAM D FATHEREE
254 ANDERSEN SC'T CP RD
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 0.100 Plat: N/A-NOT AVAILABLE
SEC 13 T30N R20W NW NE THAT PART OF LOT Block/Condo Bldg:
1 OF C.S.M. PHAT LIES NORTH & NORTHWEST
OF BOY SCOUT ROAD, SAID CSM 4/104 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
CONTAINS.1AC MOL 13-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 929/501
07/23/1997 705/483
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.100 1,600 0 1,600 NO
Totals for 2005:
General Property 0.100 1,600 0 1,6000
Woodland 0.000 0
Totals for 2004:
General Property 0.100 1,600 0 1,6000
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
Illi
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
DIVISION
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
P.O. BOX 796,9
MADISON, WI 53707 3 state elan I.D. Number:
Cg7 CONVENTIONAL ❑ ALTERNATIVE (lf aaaigned)
D Holding Tank D In-Ground Pressure D Mound
JADDRESS OF PERMIT HOLDER: INSPECTI N DATE
NAME OF PERMIT HOLDER: :
Earl Fatheree 16825 Upper 17 St.,Lake1and, MN
REF. PT. ELEV.: CST REF. PT. ELEV.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
NW4 NE 4, Section 13, T30N-R20W, Somerset Township Sanitary PermtNumber:
Name of Plumber: X"rRSW No.: County:
Donavin Schmitt 3205 St. Croix 34801
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIOUID CAPACITY: TANK INLET ELEV. TANK OUTLET EL€\h: PAR ID Ell--- LL~OCCKI EDC
0 > 4C?-~ YES DNO S NO
BUILDING: ~VAE ER NT F ESH
PE
BEDDING: VENT D VENTAT~.: AHIGH L AR : R ROAD: PRONUMBER OF j LINE:
FEET FROM
DYES NO 1 S.' N NEAREST,
DOSING C A BER:
PU /SIPHON MANUFACTURER. WARNING BEL L CKING COVER
MANUFACTURER . BEDDING. LIQUID CAPACITY PUMP MOD, L. PgOVIDE .7 P OVIDED:
DYES ❑NO ❑ "DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA4: U A OF PROPERTY E B ILDING: VENT TO FRESIi
LINE / AIR INLET
(DIFFERENCE BETWEEN a ET FROM
PUMP ON AND OFF) DYES ❑ O NEAREST
r LE Nf,TH DIAME TER I MATE LANG MARKING
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing F CE
or excavation. (If soil can be rolled into a wire, construction shall cease until IN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: INSIDE oln svlt
BED/TRENCH WIDTH LENGTH TNO. 0 HEN UISTR. PIPE SPACING OV - DEPTH
TRENCHES M IAL: PIT
l
DIMENSIONS r "10
ROP TV WELL BUILDING V NT TO FRESH
GRAVEL DE H FILL DEP H UISTR PIPE DISTR. PIPE ISTR. PIP RIAL. ~ PE IS NUMBER OF LINE. AIR INLET.
BELOW P PEF ABOA+E C VER ELEV. NLFT ELEV. U. FEET FROM
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material f PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: moun systems to make certain tha i ON REVERSE SIDE. SHOW ELEVA-
meelS t c 'teria for medium sand. TIONS MEASURED.
DYES ❑NO
PERMANENT MAR IRS: OBSERVATION WELLS
SOIL COVER TIx7uRE ,
El YES ❑NO DYES ❑NO
~151:11IED MULCHED
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/ ED DEPTH OF TOPSOIL SODDED .
CENTER EDGES
DYES F-1 ❑Y & ❑NO DYES DNO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE covlR
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACI GRAVEL DEPTH BELOW PIPF
TRENCHES.
DIMENSIONS
MANIFOLD PUM MANIFOLD DISTR. PIPE ANIF OLD MATER AL DISTH )ISTR. IF, OISTHIBU I ION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA ELEV. PIPES IA..
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS 70 APPROVED
INFORMATION HOLE SIZE HOLE SPACING DIiILLEU OHHECII Y CO FR MATERIAL PLANS
ONO DYES ❑NO
PERMANENTMAR KER , OBSERVA IONW LLS, ref N BER OF PROPERTY WELL: BUILDING:
COMMENTS: FEE FROM LINE
NEA ST
DYES ~_~NO OYES NO
t) LA
r J S
4"V
Retain ' county file for audit.
Sketch System on
Reverse Side. TI LE
SIGNATLMI
DILHR SBD 6710 (R. 01/62)
Fill
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% 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: Mailing Address:
Property Location: City, Village or Township: County:
it'/a '/aS 13 ~T C.' ) N/ R E (or j 61j" ;
Lot Number: Bilk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
Number ❑ Variance* El Other (specify)* L40VZz - ~ , 63j2 - 421770 6'Cf of
Bedrooms:
❑
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 /Vii .4" GS
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: / 3F-M'-~ C
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): X New ❑ Replacement ❑ Experimental LN Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Y Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signat r M MPRSW N Phone Number:
Plumber's Address: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Agee t: Fee: I C) Date: ,j APPROVED Sanitary Permit Number:
tom', ~~~~21 Gf'~~•~~/ ❑ DISAPPROVED~7
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)
Form - S T C 100
Owner of Property 4cu L C ~~fL1ef~~
Location of Property. 441L 4, Section-13 T 30-N R 2OW
Township S~,Mef , Sc
Mailing Address _R C. ; i_J :1 rl'l ROL
Subdivision Name
Lot Number LL
Previous Owner of Property (A1 TC)
e1 ~
Total Size of Parcel ~j a-c"rc
Date Parcel Was Created ,N1 qr L kf I 9 g 21
Are all corners identifiable? Yes_ X No
T-ke- Ive ac're5 Is por+ Of Iy
+L-le ~'i V (:1, 2 C- V e 5 (-v v._ e- Lv C'&. e d_ h o L 6~3 u r U 5 S
Include with this application one of the following:
XCertified Survey Map
.Deed
.Land Contract, or
.Other I;egal Document which describes the property
I
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. 3333 i / ; 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. 3233.5 f
NATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DAT SIGNED DATE SIGNED
CERTIFIED SURVEY MAP
NORTH-SOUTH QUARTER SECTION LINE
S0°14'33"W N0°I4'33"E 912.41' -------_~BOY
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BEARINGS ASSUMED AND REFERENCED TO • 1" IRON PIPE r►f
THE CERTIFIED SURVEY MAP RECORDED IN s 3/4"STEEL BAR FOUND N Z
VOLUME 4, PAGE 1044 C) m m I
0 3/4"X24" STEEL REINFORCING BAR j 0
SCALE IN FEET I"=200 WEIGHING 1.502 LBS./LIN. FT. SET 0 X
® X zz
0 20Ci 500' SECTION CORNER MONUMENT 0 ~m
- FENCE LINE
THIS INSTRUMENT DRAFTED BY 480-243A
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,)EPARTMENT OF REPORT O SOI . BORINGS AND SAFETY & BUILDINGS
1;4DL75TTT7, DIVISION
?_A3OR AND PERCOLATION TESTS (115) P.O. BOX WI 7969
MADISON,
HUNIAN RE,LAT1ONS
(H63.09(1) & Chapter 145.045)
t SECTION TOWNSHIP) &tEREiSgWRRiCY
OT NO.: BLK NO.: SUBDIVISION NAME:
~~tv ES 13 /13CH/r`20E(or)W ~t~r~'~ J 1'~s~+ Su~,/. NArrF,
COUNTY: OWNER'S BUYER'S NAME: riIAIAi L IN ADDRESS:
!~;5 U('Pa 1?. 17 `~~r . l..%T►=~Lr4N~, i~l~ r~. 55x-3
USE DATES OBSERVATIO14S MADE
~OLATIONTESTS:
NO. BEDRIVIS,:. COMMERCIAL DESCRIPTION: PROOFIIL/ D IONS: IPER
JResidenca j~iNew ❑Replace ~4l pf d S:!)
RATING: Ss Site suitable for system U- Site unsuitable for system
CIO,;VENTIOVAL N10UND: IN•GROIJNdPRanURE: SYSTEM-IN•FILLHOLDING TANK: COMMENDED SYSTEM:(optional)
I :f~ s D EIS ~U JS DU S Zu D QED
If Percolation Tests are NOT required DSIGN RATE:
~f any porUOn of the tested area is in the
under s.H63.09(5)(b), indicate: r~ Floodplain, indicate Floodplain elevation:
flc~Gll/~~L- - PROFILE DESCRIPTIONS
SORING R}... ELEVATION FPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER prPTfa 1N. OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.)
7, Z. ' 9 • 1 I . So' 5 , SO' o, 2 5' f31 G. -7, oa' 3N L w/G z•
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TEST o- WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
C3t3~ABER ynS_S AFTERSWELLING INTERVAL-MIN. PFRIOD 1 PERIOD2 P R PER INCH
F'-^- Z,1~' ~~O'mil = 'ice +n ~J. fe+ 7/rn 7/5
P- V 1 : ? a' A.( D , ;r~ r n + r 0. irlC. 131 Ce 7 Jr.
P-
P- S -Z
PLOT PLANS: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale gr d~tances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevatio al?borings and the direction and percent
of land slope.
IV t
f 40
14
i STS _ ' - ~h •f f SYSTEM. T--- - - -
14- r-- 4
R 4-1
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1, the -7 el -n,ld; herby cerii`fy11TaTthe-soil'" ests reported on is fo Ti.".-Correct made by me in accord with the procedures and methods specified in the Viisconsin
Administrative Cnc e, and that the data recorded and the location ay {eto the bast of my knovvtedga and belief. S~.N~+~-Fr = f 0Q. C)f~
•jC,.OVT f?O•
NAME (print : TESTS WERE COMPLETED ON:
;,UORESS: CEHTIFICATIOiiN! NUMBER: PHONE UUMBER(uptionall
I 1 ~ j 'f-{~i t~ i wl.':~ ~ i , JF'(x .a.-:, ? y ^'^.,~'i). ~,t,.n _ r j
CST SIGNATURE:
DtSTR1P,L"rt0N Or,rlina! 9nr nn,,- -np•; rn 1 rr-i Authority. Prope+ty Owner tn. • nil Tester.
Jii_H~i-~i.: ri;S'.~h :t'/:rf?1 - UVEr1
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