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AS BUILT SANITARY SYSTEM REPORT
OWNER ~1,' fI til,~ TOWNSHIP SEC T_'.N-R< W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION r ri~.u LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
RI(THIN , eI 100 FEET OF SYSTEM
49
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I d-i}-a a oath Arrow- I
SC LC
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: /,:~'4:' Slope at site:
.SEPTIC TANK: Manufacturer: Cr Liquid Capacity: /a
Number of rings on cover 6 Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower bran 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: um er o pits feet diameter
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit r, evation feet.
SEEPAGE BED SIZE: number r.,,f lines width leiigth_3, the depth5/'o"
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED i REA AS BUILT
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS DIVISION
PRIVATE SEV~IAGE SYSTEMS P.O. BOX 79'59 BUREAU OF PLUMBING
MAQISON, WI 53707 GILLS TTgC '
L CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Numbe,
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION/DATE.
Bj ornstad Builders RR#3, Hudson, WI " e -Y3 %-6
BENCH MARK (Permanent reference pour) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
NE4 NE4, Section 8, T28N-R19W, Lot #2, Town of Troy
N-e of Plumber JMPIMPRSW No. lCounty. Sanitary Permit Numb,
Roger Timm 3224 St. Croix 43716
SEPTIC TANK/HOLDING TANK:
MANUFACTURER / LIQUID CAPACITY. / TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL JLOCKING COVER
I /J PROVIDED: PROVIDED.
Cr a. /C t t l' C .r UC1 4i YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL. HIGH WAT R NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH
ALARM'. LINE. AIR INLET.
FEET FROM J\ E
❑YES ❑NO DYE / NO NEAREST _
DOSING CHAMBER:
MANUFACTURER BE DUING 11_111111D CAPACITY PUMP MODEL r7MANL11ACT UREN WARNING LABEL LOCKING COVER
N PROVIDED PROVIDED.
❑YES ❑NO I ❑YES ❑NO ❑YES ❑NO
G ' LLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBEdR OE' R ERTY WELL BUILDING I VENT TO FRESH
TFERE,NCE BETWEEN FEfT,hR )M LI AIR INLET
PUMP ON %ND OFF) ❑YES ❑NO NEA EST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE JLFNI, TLIi DIA ETEH MATERIAL AND MARKING
,y
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue,)
CONVENTIONAL SYSTEM:
TR PIPE SPACIN(; COVER DIA ttpITS LIQUID
WIDTH. LENGTH N!EO
F DIS
BED/TRENCH TNCHES Nw ERIAL PIT j1EPTH
DIMENSIONS GRAVEL DEPTH FILL DEPTH ISTH PPE DISTR. PIPE MATERIAL NO. 1 R. FEET FNUMBERROM OF PROPERTY WELL BUILDING: jT TO FRESH
BELOW PIPES ABC)V COV ER El EV. INL T ELEV. END PIPE LINE. _ INLET.
/ ~ / p
1. f/`I~ J f~ T L j 3 NEAREST
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 certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV. DIA. ELEV.- PIPES. DIA.:
ELEVATION AND -
IDISTRIBUIION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PR OPERTV WELL: BUILDING-.
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
-ICS~t ~ Aj 1-TA Q,
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHRSBD6710(R.01/82) ( 1
DERARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PL13 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.
614 ?
Property Owner:
9 p Mailing Address:
Pro
fVr per Location: $ City, Villa or Tow i
t ! g t 9 nspp: County:
~a a
/T A Ni R (or) ty , Cry l
Lot umber: Blk No.: Subdivision Name: Nearest Road, L ke or Landmark: 'State Plan I.D. Number:
(If assigned) _
TYPE OF BUILDING c' r
Number of
❑ Public* ❑ Variance* ❑ Other (specify)*~. Bedrooms:
1 or 2 Family *State Approval Required. ® s ~y
TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify)
SEPTI&TANK CAPACITY /4 v
HOLDING TANK CAPACITY &
LIFT PUMP TANK/SIPHON CHAMBER IVA
MANUFACTURER: &_1 4 C
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 2C Seepage Bed ❑ Seepage Pit
[/(a ❑ Alternative (specify) ❑ Seepage Trench
J C
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public - r G /7GZL
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name_af)Plumber: Signatur MP/MPRSW No.: Phone Number:
Plum er' ddress:~ t Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signa re of Issuing Agent: F e: Date: Sanitary Permit Number:
~.4) X APPROVED
❑ DISAPPROVED
112136
,71
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form to be sub
(67-T) mltted 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 - T C 100
r
Owner of Property r,--c-e
.Location of Property: Section T N R ( C, W
Township
Mailing Addressl-
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Data 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 I:egal 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 pipor ed, n the Office of the
County Register of Deeds as Document No. 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 Deads, as Document No.
,y
sIaNATA~R¢' f-6wt"* t !ttl arc.
SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
' 1 \
DEPARTMENT OF REPORT ON SOIL BORINGS SA TY & B I ISION
INDUSTRY; D V 7969
LABOR UMAN REDLATIONS PERCOLATION TESTS (1 P.O. BOX
M ISON, WI 53707
H
3707
IpN/ Iy
LOCATION::: SECTION: ~~p p~ OWNS HIP/MUNICIPALITY: LOT LK. DIVI 10, E:
~ _ 1/4 p/ /1.[dN/RJ?&(or T -Frdy ~ v
COUNTY: OWNER'S BUYER'S NAME:! MAILING ADDRESS: /
USE DATES OBSERV TIONS MADE
RIPTION: R TO ER LA ION TESTS:
Residence NO. BEDRMS.: COMMERCIAL DESC New ❑ Replace
/7r-v/ NS:// /
1-3
RATING: S= Site suitable for system U= Site unsuitable for system P1,09 PUICY-
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
®S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U cyuy7~•'0.~.~/
If Percolation Tests are NOT re uired DESIGN RATE: SYSTEM EL
Q , If any portion of the lot is in the I /
under s.H63.09(5)Ib), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
iBORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPT
NUMBER DEPTH IN, OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 0,91, /01y" 0.l( e-> 104F "I /C'' 'J'S /6 " .2 Y"S S"R" C S
B-3 /oo2, A,lo;ue- Y 7 f r ~S / 2 ,4 s4 % 7 C-S
B 0,2" /C3. -P > /C,t o21 ' s. -9-15~ " CS
f S/
B 4~ ' .t~v f~ y /o " 7S 1.2
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P i~ -0-1 F/
~ J
P- d
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 dif ectionand percent
of land slop. ~lc~ S'C~/e ifx J;q-A /
SYSTEM ELEVATION
vES?b l~ !U`s``dl
'
..2S
64 .:r Ad' 6' 77o s/cps. Xtarf-A
6,k '0
19
2~'
~ /tee /4 : &rAaT 71-e.4 6,w0 4, /417' (1_510'50.t4 ear oge,4_)
y X'4'
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:
ADDRESS: ` CERTIFICATION NUMBER: PHONE NUMBER optional):
2 -51,100
NATURE:
A
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DI LHR-SB D-6395 (N. 03/81)
JOB /rl ; ,1'l N~✓v~
ROHL & TIMM EXCAVATING SHEET NO. - { OF
310 Arch Street -DATE
• HUDSON, WIS. 54016 CALCULATED BY ,
(715) 386-8664 3 z `f
CHECKED BY GAiE_ -
IGC SCALE
J'
3 P1 !G Cornet
J
PRODUCT 204-1 LME~s Inc., Groton. Mass. 01471.
• JOB rs ! t li. l.. 14e-,- let /
ROHL & TIMM EXCAVATING 2
310 Arch Street SHEET NO. - OF
HUDSON, WIS. 54016 CALCULATED BY L ---DATE
(715) 386-8664' 3 z z~
CHECKED BY BfFFEn
SCALE
i
.
1 L
.r
-3, 7
3- 3
PRODUCT 2o4-1 s'1-Groton. Mass. 11411
.
Parcel 040-1034-60-000 01/24/2007 03:57 PM
PAGE 1 OF 1
Alt. Parcel 8.28.19.111 F 040 - TOWN OF TROY
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 - MCDANIEL, MARK R & TERESA L
MARK R & TERESA L MCDANIEL
494 COULEE TRL
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 494 COULEE TRL
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 8 T28N R19W 2.50 A PRT NE NE LOT 2 Block/Condo Bldg:
OF CSM 5/1300
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
08-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 670/50
2006 SUMMARY Bill Fair Market Value: Assessed with:
157949 211,200
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 54,500 138,200 192,700 NO
Totals for 2006:
General Property 2.500 54,500 138,200 192,700
Woodland 0.000 0 0
Totals for 2005:
General Property 2.500 54,500 138,200 192,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 218
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00