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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707 ~y
R9CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
❑ Holding Tank ❑ In-Ground Pressure 1:1 Mound (11 assigned)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Steven Kumm 637 W.8th St.,New Richmond
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF, PT. ELEV..
SW-14 SW4, Section 34, T31N-R18W, Star Prairie Township
Name of Plumber: /MPRSW No.: County: Sanitary Permit Number:
Calvin Powers 1563 St. Croix 34797
SEPTIC TANK/HOLDING TANK: , J /
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKIN COV-"---
((~j, PROVIDED: PROVII~E~.
'U, Q 6., / LJOVYES ❑NO YES O
BEDDING: VENT DIA.: ENT MATL.: HIGH WA NUMBER OF ROAD IrL R OPERTYWELL, BUILDING: EN T E4ESH
ALARM: FEET FROM INE / ) / IV Al N
DYES ❑NO DYES ❑NO NEAREST P~' IJr
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIOUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER_-- WARNING LA LOCKING COVER
PROVIDED;.- PROVIDED:
DYES ❑NO ❑Y-1 S NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROL OPERATIONAL NUMBER O PROPERTY WELL/ BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FRO L 'NE AIR INLET
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE I. NGTH (JAN EH MATE IAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH. LENGTH. IND. OF ID, STR. PIPE SPACING QYE-R INSIDE DIA *PITS LIQUID
BED/TRENCH THENCRES I of ERIAL DEPTH
DIMENSIONS PIT
GRAVEL DEPT H FILL DEPTH UISTR PIPF DISTR. PIPE ISTR. PIP MATERIAL . NO rR. NUMBER OF ROPE TY WELLY BUILDING: V NT TO FRESH
eELt~W PIP ABA`' COVER ELEV. INLET ELEV. END. PIP FEET FROM LINEr/ AIR INLET.
d5 1, S1 2,1 NEAREST,,
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill mat~rial for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certaip that it ON REVERSE SIDE. SHOW ELEVA-
meelts the criteria for medium sand. TIONS MEASURED.
DYES ❑NO
SOIL COVER TEXTURE JERMANENT MARKERS OBSERVATION WELLS
DYES ❑NO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH W TOPSOIL' SODDE T7YES MULCHEDCENTEREDGESYES NO ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM
WIDTH LENGTH NO.OF LATERAL SPACING A V EL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOL,MATEHIAL NO UISTR UISTR. I DISTHIBUIION PIPE MATERIAL & MARKING
ELEVATION AND ELEV. ELEV.. DIA ELEV. ,A PIPES DIA.,
DISTRIBUTION
INFORMATION HOLE SIZF HOLE SPACING DRILLED COHRECIt y ZWELLS R MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
7 PLANS
DYE 0NO / DYES ONO
COMMENTS: PERMANENT MARKER : OBSER ATI : N UMBER OF PROPERTY WELL: BUILDING
.
uNE
Z 'R ! FEET FROM
DYES I_1N0 L IYES ❑NO NEAREST
--7- -
~A
Sketch System on Ret n county file for audit.
Reverse Side.
JSIGNATURF TITLE
DILHR SBD 6710 (R. 01/82)~~._r
DEPARTMENT OF APPLICATION'S 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'/2 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:
L) (a Y-) 0 C YI-1 ?I P9,J/ S,
5, -44
Property Location: tlnr;-Vi#ege or Townshi County:
,S LU/aSt,,_)'/4S T31 N/R S (or W (Ile 0
-
Lot Number: Blk (vo,; Subdivision Name: N Est ad, Lake or Landmar State Plan I.D: Number:
Vanr7 EY LrJ / (If assigned) I?
to
TYPE OF BUILDING
1:1 Public* El Variance* El Other (specify)* Bedrooms:
'Q 1 or 2 Family *State Approval Required. 5
TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY G i
i
HOLDING TANK CAPACITY ✓I
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet):} New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
L ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owne ' Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public //1
I, the undersigned, hereby assume responsibility for installati the private sewage system shown on the attached plans.
Name of Plumber:
Si re `gyp/MPRSW No.: Phone Number:
CIL
in 46 - -.5-135 -
PI tier's Address:
Name of Designer: C_,, 01 to /-I ✓7 ?
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agen Fee: Date: Sanitary Permit Number:
B APPROVED
~~/~O~'! ❑ DISAPPROVED
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 UJ~_ (le /V .Location of Property - Section 2 4- T N 4, W
Township
Mailing Address z/ S 'S A/
Subdivision Name_
Lot Number
Previous Owner of Property //7Fbt zyy/j/r,) l'l q
Total Size of Parcel 0-2 d1i
Date Parcel Was Created /
4:~~.
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 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. ; and that 1 (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.
fSIGNATUR OF OW SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
4
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
• INDUSTRY, 1 C DIVISION
LABOR AN P.O. BOX 796
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53709
(H63.090) & Chapter 145.045)
LOCATION: SECTION: n ~i OWNSHIP UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAM/E::
t 1>/ S {jl /T2/ N/R (or)1u n /1')n a+ y~4/7/7£ 1E InT i
COUryTY; OWN R'S BUYER'S NAME: MAILING ADDR SS:
'E'UX v F u Co37 0,~` ~.dVf ~/tIc'_-Arun 01.540)1
USE _ DATES OBSERVATIONS MADE
- NO. BEDRMS.: COMME"R TAL DESCRIPTION: -PR7j5Lff D1 INNS TESTS!
Residence I- A I LIew ❑Replace h~ _ z j
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUNT: t' I(N-`TA
CAS C~=~NK: RECOMMENDED SYSTEM: (optional)
C J ~Y [3S ~S 4J1 J Zu
If Percolation Tests are NOT required DSIGN RATE:
If any portion of the tested area is in the
Under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS 4~ g /7 o ~ Z
BORING TOTAL ~i EPf'H TO GtiOUNDVVNT ER-iivCr,-GS CF`ARACT'-7~ O- ,"OIL v':TH THICKNES,CLOR, TEXTURE, -,.ND :,,EPTH
NUMBER DEPTH IN. ELEVATION OBSERVED ES . HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- I 8zh o > Z "
IP-7~n.<a.~°
B- 3 . ~ " 05 2) to L > >s5 /D ,
' 'ft Ain an. B- '23 1 D 3 a 0) c- > 73 ",D rt!,g r, S , L, 6,'Z9 1',gn
B vN 2~„ U~ i3 /UU,4v L Z& /j 1, '19A,6,L, 36"At3 o•S,
B-
PERCOLATION TESTS
E. DEPTH WATER IN HOLE TEST TIME DROP I WATER I -VF .-INC:H .S RATF MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL.MIN. p PER INCH RIO P_ I 3 _ 3
P_ Z a !d ,6 <
P- 3 U Cv 6 3
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
07
R Z _
117U t N
> d
4
e, m- IDc-a1"649d PQln ilrix,,l .
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 (print): TESTS WERE COMPLETED ON:
ADDRESS: CER IFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATU
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Parcel 038-1159-95-100 05/11/2006 09:04 AM
PAGE 1 OF 1
Alt. Parcel 34.31.18.751A 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): 0 = Current Owner, C = Current Co-Owner
O - KUMM TRUST A
KUMM TRUST A C - STEVEN J KUMM-TRUSTEE
STEVEN J KUMM-TRUSTEE
446 S KNOWLES AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1817 110TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 1974-GERMAIN & HANNER ADD
SEC 34 T31 N R1 8W GERMAIN & HANNER ADD Block/Condo Bldg: LOT 10
LOT 10 EXC TO HWY PROJ 1559-08-23
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
34-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/04/2000 634586 1564/99 TD
08/31/1999 609593 1453/234 QC
07/22/1999 607332 1444/35 WD
07/23/1997 661/45:5
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 9,200 0 9,200 NO
Totals for 2006:
General Property 0.000 9,200 0 9,200
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 9,200 0 9,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00