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AS BUILT SANITARY SYSTEM REPORT
1k') y0'yj''~.
r" 1_SQ/k TOWNSHIP -SEC. I'&N-R`7
1~~^'~ f ~ c
*DRESS Ck P64-1i- \ C-_ ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LO'T LOT SIZE
PLAN VIEW
Distances and dimensions to meet NTHIN equirements of H63
SHOW EVERYTHING 100 FF~ET OF SYS'T'EM
i
J~' 14 11 VZ
a
I F,
3
Ii di at N r h rr w
BENCHMARK: (Permanent reference Point) jescribe: S
Elevation of vertical reference point: l~cs, Slope at site:
SEPTIC TANK: Manufacturer: l ~C Liquid Capacity: a c C~
Number of rings on cover : it(C Tank manhole cover elevation:
Tank Inlet Elevation: Tank. Outlet Elevation: ~
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 width -length C) the dept
SEE AGE TRENCH: width _ length
PERCOLATION RATE AREA REQUIRED -R, l1 ~,OEA AS BUILT
3 INSPECTOR
DATED PLUMBER ON JOB _ /k ~1 ll~ /r
LICENSE NUMBE4/
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 79,69. BUREAU OF PLUMBING
MADISON, WI 53707
X:1 CONVENTIONAL ❑ALTERNATIVE State Plan I D Number
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER. I 1 INSPECTION DATE
Kenneth L. Johnson iDD#2, •Np~chniwldr WI "F3 370
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV.
SE SW, Section 2, T31N-R17W, Town of Stanton
Narne of Plumber. MP/MPRSW N,, Couniy Sanitary Permit Number.
Byron Bird 1309 St. Croix 43708
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAP CITY TANK INLET ELEV.: TANK OUTLET ELEV.. 1W, RI II" LABEL LOCKING COVER
PR WIDED'. PROVI~D~~ED`s
tJ YES ❑ NO ❑A ❑NO
BEDDING. VENT s P, VEN-r MAT E. HIGH WATER NUMBER OF ROAD PR OPERTV WELt. BUILDI G._~VENT TO FRESH
_I -1
ALARM FEET FROM LINE AIR INLET
❑YES ❑NO ❑YES ❑NO NEAREST v ` UL 6 01
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAP ACITy PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF E1111AMITE ERTY WELL BUILDING IVENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 ENLIH R MATERIA L AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGTH INOOF IDISTR Pf PE S ACING COVER INSIDE DIA. =PITS LIQUID
BED/TRENCH L TRENCHES MATEWIL,:7 ✓ PIT DEPTH
DIMENSIONS ,1
GRAVEL DEPTH FILL DEPT OIS PIPE ISTH. PIPE DISTR. PIPE MATERIAL: NO'. D 5T NUMBER OF PHQPERTV . WELL BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER ELE V, INLFF EL N PIPE zf FEET FROM LINE. AIR INLET. NEAREST. 76 )
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE IAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make. rtain that it ON REV SE SIDE. SHOW ELEVA-
meets the criteria for,mediuri sand. TI.ON MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS
❑YES-' NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH 11111 DEPTH OF TOPSOIL. O DDED S DED MULCHED
CENTER EDGES
❑YES ONO DYES ONO [:1 YES E] NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO. OF LATERAL SPACIf~G GRAVEL DEP, H BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS I
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIF D MATERIAL. NO. DIS DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. CIA.. ELEV.. / / PIPES DIA.'.
ELEVATION AND j
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑YES ❑NO ❑YES ❑No NEAREST
L`
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Sketch System on Reta)n.rri cquntile for audit..- -
Reverse Side.
SIGNATURE TITLE. j
DILHR SBD 6710 (R. 01/82) y
DEPARTMENT OF APPLICATION'
INDUSTRY, FOR SANITARY SAFETY & BUILDINGS
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 caner: e- Mailing Address:
t d a
Prop rty Location: City, Vil e Towns County:
/4S i-f, NiR l E (or I G/'57, "o
Lot Number: Blk No.: Subdivision Na e: Nearest Road, La or Land ma k: State Plan I.D. Number:
~ (If assigned)}7
TYPE OF BUILDING
/ > Number of
kOPublic* ❑ Variance* ❑ Other (specify) a • too& -Z40 -o9~~Q Bedrooms:
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 06
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Replacement E1 Experimental Seepage Bed 1:1 Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
6. 1 Water Supply: Owner's N me as Listed on,$oil Te t eport (If other than present owner):
Private ❑ Joint ❑Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: r Signature: MP/MPRSW No.: Phone Number:
I ( 3/Z~'C~ !26 > /
Plumb 's Address: Jc) e Name of Designer.
/lq (I A14- (r fl- V T KZ / C
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee:/ O Date: APPROVED Sanitary Permit umber:
GC O ~I_E4 3 ❑ DISAPPROVED ? / D
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
_L~W' eeA Z
.Location of Property;Fc ~.5W k, SectionT_-,3kN R___),7W
Township__
Mailing Address l
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel fQ of _
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 Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
1 (We) certify that all statements on this form are true to the best of my (our).
knowledge; that J (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.'30'66'53 - ; 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.
5 MATURE OQ~WN R SIGNATURE OF CO-OWNER (IF APPLICABLE)
V
DATE SIG ED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, c DIVISION
LADOR AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TLOT NO.: BI_K. NO.: SUBDIVISION NAME:
gi- L '/a w1/a /T~/ N/R 17.E (o r) W ~Sn
COUNT~/)Y: OWN R'StBtPt'C-~'S NAME: MAILING ADDRESS: /
, - 0 ' t a a 1
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑New KReplace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: Jill -GROUND-PRESSuffff: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
ZS [:]U KS ❑u ZS ❑U ❑S ZU ❑S ZU -
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:
10L1-, m"4 , PROFILE DESCRIPTIONS -51,e
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPT44- ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE. ABBRV. ON BACK.)
_5,C5 03 '07 C14 7
B / r/" 27- '0 IL7~
r Ppn.
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B- Z, ` ``l 1~ tJ ? zS 11 CC, 0 co %
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B-tiJ zo ~v ?c~ -Zj>~i.~.d.uJ 6n.. arJ
B-
B-
h 0& + iiE11 r~ 1 4,&-f es - su-'r 4-j"de d-9 B- -Au-1 hJ ,4 J Av , n(74 .
1~E51~ PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 4-1E6 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ 1 I Y- iv D C)
4S p _ S 5
P- Z, 3 e f /U 0
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 y
w7
P
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710,
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00
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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 (pri TESTS WERE COMPLETED ON:
-47
ADDRES : CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNAT E J~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SRD-6395 (R. 02/82) - OVEP
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Parcel 036-1003-30-000 12/02/2005 11:59 AM
PAGE 1 OF 1
Alt. Parcel 02.31.17.28B 036 - TOWN OF STANTON
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 - JOHNSON, KENNETH L & GAIL E
KENNETH L & GAIL E JOHNSON
2306 185TH ST
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2306 185TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 11.020 Plat: N/A-NOT AVAILABLE
SEC 2 T31 N R1 7W 11.02 AC S 700 FT OF E Block/Condo Bldg:
686 FT OF SE SW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
02-31N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/26/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.020 12,000 114,900 126,900 NO
UNDEVELOPED G5 9.000 5,400 0 5,400 NO
Totals for 2005:
General Property 11.020 17,400 114,900 132,300
Woodland 0.000 0 0
Totals for 2004:
General Property 11.020 17,400 114,5300 132,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 204
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00