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Parcel 038-1157-20-000 02/10/2006 11:05 AM
PAGE 1OF1
Alt. Parcel 22.31.18.732 038 - TOWN OF STAR PRAIRIE
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 - CARLSON, CHRISTOPHER B & TRACI J
CHRISTOPHER B & TRACI J CARLSON
2082 114TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description * 2082 114TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 1.320 Plat: 2230-NORTHWOOD
SEC 22 T31 N R1 8W PLAT OF NORTHWOOD LOT Block/Condo Bldg: LOT 12
12
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
22-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/29/2001 663416 1774/313 WD
11/29/2001 663415 1774/312 QC
10/07/1997 566592 1269/113 WD
07/23/1997 1206/138 QC
mor
2005 SUMMARY Bill Fair Market Value: Assessed with:
119980 174,800
Valuations: Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.320 27,200 144,600 171,800 NO
Totals for 2005:
General Property 1.320 27,200 144,600 171,800
Woodland 0.000 0 0
Totals for 2004:
General Property 1.320 27,200 144,600 171,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 114
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP ~.,SEC.-' ~T_SN-R_Z," W
OWNER
ADDRESS- - ST. CROIX COUNTY, WISCONSIN.
SUBDIVISIONLOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 1.00 FEET OF SYSTEM
J
I di at N r 1h rr<
BENCHMARK: (Permanent reference Point) Describe: -A~ ~
Elevation of vertical reference point: _SloPe at site:
~
SEPTIC TANK: Manufacturer' Liquid Capacity:
Number of rings on cover . Tank manhole cover elevatio` n:,'~,,
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, 'tile depth
SEEPAGE TRENCH: width length--
PERCOLATION RATE AREA REQUIRED AREA AS BUILT INSPECTOR-
DATED_ ) PLUMBER ON JOB ,
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABO{Rf& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
'P.O. BIJX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
LX CONVENTIONAL ❑ALTERNATIVE Lffa te P lan L)D. Number:
assigned
El Holding Tank El In-Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDER JADDRESS OF PERMIT HOLDER INSPECTION DATE.
Lat,,t, Hams on RR, New Richmond, W1 1110-8-3 a
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELEV..
NW NF Sec. 22, T 3]N-R18W, Lot NG.12,NGtcthwood, Town vb
Narne of Plumber. MP/MPRSW No.. County Sanitary Permit Number.
Cat Powetcs 1563 St. CAoix 43645
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOC COVER
r t PR VI ED. P _
ES ❑ NO YES ❑ NO
BEDDING: JV . " VENT NJATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. 1.~LDINGVENTTOFESH
LINAINLE
FEET FR
EYES ENO S ENO NEARESOM DOSING CHAMBER:
MANUFACTURER 7INGCITY PUMP ODEL MWARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES ENO OYES ENO OYES ENO
GALLONS PER CYCLE: PUMP A CONT LS ATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE ^f' AIR INLET
PUMP ON AND OFF) ❑Y O NEAREST Z
SOIL ABSORPTION SYSTEM. Check the soil moi e at the of plowin ENGTH DIAMETER IMATIRIAL AND MARKwG
or excavation. (if soil can be rolled into a wire, nstructio all cease u it FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: _
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA. LIQUID
BED/TRENCH TRENCHES Mp.TE IA L: PIT DEPTH
DIMENSIONS S Y ~t.
GRAVFL DEPTH FI LI- DEPTH UISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DI NUMBER OF PROPERTY WELL. FE1_DING. IV ENT TO FRESH
BE LOW PIPES ABOVE COVER EI EV. INLET ELEV END. PIPES LINE AIR INLET:
~Z FEET FROM
/ / NEAREST--r -
MOUND SYSTEM: I
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 certain that it ON REVERSE SIDE. SHOW ELEVA-
E meets the criteria for medium sand. TIONS MEASURED.
YES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
_ OYES ENO EYES ENO
DEPTH DYER TRENCH :BED DEPTH OVER TRENCHBED THOFTOPSOIL SODDED SEEDED'. MCENTER EDGES
EYES ENO EYES ENO ES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF ES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCH
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL'. NO. DISTR. [STR P IPE DISTRIBUTION PIPE MATERIAL & MARKINGELEVELEVCIAELEVPIPESA.'.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
a EYES ENO EYES ENO NEAREST
77/
Sketch System on n
fetaln in ounty file for audit.
Reverse Side. `1 I
SIGNATURE TITLE.
DILHR SBD 6710 (R. 01/82)
r
Wisconsin APPLICATION FOR SANITARY PERMIT
+ DI L H R p1 GCOUNTY
~ oEVARTmenr ov (P LB V~) UNIFORM SANITARY PERMIT #
InoUST R V, LABOR 6 HUMAn RELRTIOnS
-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 OWNE MAILING ADDRESS j
PROPERTY' LOCATION F CITY:
VILLAGE:
1/4' 1/4,$_,, , T' , N, R E (or) W TOWN OF:
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:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
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.
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):
,i
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: j Fee: Date: ❑ Disapproved
❑ Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
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.
L uiw - 1' C 1UU
Owner of Property
t7` Locution of Pro erty I~~:' tl~ `-G, Sactiort 5 el (7
,T3' N R
c
Township
Mailing Address
Subdiviuion Nawe
Lot Nuwber
Previous) owner of property SZ~Total Size of Parcel
Date Parcel Waa Created Z~
Are ull corners identifiable? Yes No
Include with this application one of the fulluwiILL
:
.Certified Survey Map
.Deed
.Land Contract, or
Other Legal DOLUweilt 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 dee recorded in the Office of the
County Register of Deeds as Document No. :2 4,,1 and that I (we)
presently own the proposed site for the sewage disposal system (or I (wit) have
obtained an pasament, 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 Canty Register of , ads, as Document No.
SIGNATU OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DAT SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORING ANWFIVErl n% ETY & BUILDINGS
IN(7USTRY, ~ DIVISION
FIPUMAN,RE LATIONS PERCOLATION TESTS (W)JAN 29 1982 P.O. BOX 7969
'r UMA ZONING ADISON, WI 53707
nrcirc
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT BLK. BDI I NAME:
1/4L1/4 /T 3t N/Rj ~ E
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: 161 y1_1
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R R TONS: ER OLA ION TESTS:
Residence krNeW ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system _
CONVENTIONAL: MOUND: IfV-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL if any portion of the lot is in the n j
under s.H63.09(5)(b), indicate: A /,k Floodplain, indicate Floodplain elevation: 1 b
PROFILE DESCRIPTIONS `-q C tl
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IIG~HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-Z
6 16 .2 015 1-
B-'/ 513 T5 4,
B ~4 0 Y, S
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWE LI INTERVAL-MIN. PERIOD t PERIOD 2 77EET17003 PER INCH
P I q
`
P- 21 - / q
P-WL5 A~
P-
P-
P-
PLAN VIEW: 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 slop.
SYSTEM ELEVATIONS
A, -&-e r) C~lk Y~ K(3
I1 ~ j5o e
T
t
> xrYo
.
s>
b-
ti
13
v
f~
e
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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 methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
L LL,i Gw'0 .27
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
3 R, cars<_ _ SS`- 3 7/5--2-L/4-s~3
CS IGNATUR
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
M61hi~
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