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+ AS BUILT SANITARY SYSTEM REPORT
OWNER -e S^~ TOWNSHIP ✓>~/(/'i i'17 SEC. S- T,2~'N-R /Y W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
,I
SHOW EVERYTHING WITHIN 1.00 FEET OF SYSTEM
~C
f~ 41W
71 /W"' Ilei, A
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Indic at N r h rr w
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BENCHMARK: (Permanent reference Point) Describe:
6. .uft,%f wr,S1*y ~
y~ r ilttJr~
If
Elevation of vertical reference point: Slope at site: 7l~J
SEPTIC TANK: Manufacturer: Liquid Capacity:__
Number of rings on cover : 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 ;1, _ 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 ,7e____Iength "tile depth
SEEPAGE TRENCH.: width length-_ _
PERCOLATION RATE AREA REQUIRED AREA AS BUILT p INSPECTOR/
DA'.CED 7 PLUMBER 0 JOB- ~t
LICENSE NUMBER---
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS P.O. 60X.7969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MI.AD,30N,`W1 53707
EX CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
El Holding Tank El In-Ground Pressure 1:1 Mound Ilr aes;gnedl
_____j
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE.
Gary Maier Roberts, WI 54023~~•-s _/6-i
BENCH MARK (Permanent reference Toil) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
NE SW, Section 5, T29N-R18W, Town of Warren
Name of Plumber. MP/MPRSW No.. Cnu my Sanitary Permit Number:
Dave Fogerty 3289 St. Croix 43638
SEPTIC TANK/HOLDING TANK:
MANUFACTURER'. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED'.
OYES ONO OYES ONO
BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD'. PROPERTY JWELL'. JBUILDING. JVENT TO FRESH
ALARM. I FEET FROM LINE: AIR INLET'.
OYES ONO DYES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER ~YIN G LIQUID CA PACITV PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOKING COVER
PROVIDEDPROVIDEDES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
'
(DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET
PUMP ON AND OFF) OYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL ENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM-
BED/TRENCH WIDTH LENGTH NO.O
T R E NF DISTR PIPE SPACING COVER,-- NSIUE DIA #PITS LIQUID
^j CHES (Z PIT DEPTH.
DIMENSIONS I .J` 111P RIAL:
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO D R. PROPERTY WELL. BUILDING: VENT TO FRESH
BFLOwPIPE~ ABOVE COVER ELEV INLET ELEV END NUMBER OF
'
PIPEy FEET FROM LINE AIR INLET
• ~6 / NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill mat 'al for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certaih7that it ON F~EVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand 1"I S MEASURED.
OYES ONO +
SOIL COVER TEXTURE PEH ANENT MARKERS J I OBSERVATION WELLS
r
DYES 'SON DYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL ` SODDED EEDED MULCHED
It 11 9 I` CENTER EDGES.
DYES ONO,' ❑rfYES ONO OYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH ENGTH N TROENOFCHES LATERAL SPACING GRAVEL DEPTH BELOW PIP i i FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR MANIFOLD MA ERIAL. IV/ DISTR. DISTR. IPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA ELEV. IPES. DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY C IU//MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES ONO DYES ONO
COMMENTS: PER MANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING
FEET FROM LINE'.
? OYES ONO DYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE. -1
DILHR SBD 6710 (R. 01/82)
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'/z 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 L cation: City, Village or Townshi : County:
14✓e '/as w'/aS / T Z NCR I E (or) e
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
f~ (If assigned)
-C p
TYPE OF BUILDING
Number of
LE]Pu lic* ❑ Variance* ❑ Other (specify)* Bedrooms:
r 2 Fa mily *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY a2o
y
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: G
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New Q~Replacement ❑ Experimental L►K Seepage Bed ❑ Seepage Pit
J_-_ A10 3 ❑ Alternative (specify) ❑ Seepage Trench
Water S ply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plan /
Na a of Plumber Signature: MP/MPRSW No.: Phone Number:
lumber's Addre s: Name f Design
6
COUNTY/DEPARTMENT USE ONLY
Sig~flssuiing gent:Fee: Date: Sanitary Permit Number:
APPROVED
& C7'~/ ' ❑ 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)
1
out rU' etc:, E_...1'r
Form - S T C 100
-i iB - 6'i~ to co,,,:.!,,, .
Owner of Property a ey`
Location of Property N St,) Section_ Tal N R_JW
Township\AaY.r n
Mailing Address
Subdivision Name Lot Number W /a
Previous Owner of Property
Total Size of Parcel O.C~2S
Date Parcel Was Created r'\k" 31
Are all corners identifiable? Yes No
Include with this application one of the following:
yCertified Survey Map
.Land Contract, or
Other I;egal Document 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 deed recorded in th ice of the L
County Register of Deeds as Document No.,- ; and that I we 3 S
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.
SIGNAT E O OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
t
DEPARTMENT_C,c REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AaJD PERCOLATION TESTS (115) MADIS
ON WI 53707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION 'N SECTION: TOWNSHI /MUNICIPALITY: =NOBLK.: SUBDIVISION NAME:
Tz /N/R/I E (or
COUNTY: OWNER'S/BUYER'S NAME: MA LING ADDRESS:
USE DATES OBSERVATIONS MADE
TS:
NO.BEDRNIS.: COMMERCIALDESCRIPTION: IPROFILE DESCRIPTIONS: PERCOLATION TES
Residence ❑New VReplace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVE TIOAL: MO IN-GROUND-PRESSURE: SYTEM-IN
LJV LHO❑LDING TANK: SYSTEM: (optional) S ❑NUU UU _ S Vi ~114 Z-641
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- ?Y4 V' ke 7, f e > C./8 f ~6 j
B
B K 7 ~z v 7 F, /.,P 171, t dr9d / S' 6
B- 6, a ~p -91 s z.
$ ,7
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH
J,
P-
3, 7 z
P-
P- . G e- 2
P-
P- e_ 3 '
P_ B
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
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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 (print): TESTS WERE COMPLETED ON:
AD SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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' Parcel 042-1011-40-000 10/13/2006 03:56 PM
PAGE 1 OF 1
Alt. Parcel M 05.29.18.73B 042 - TOWN OF WARREN
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
05/15/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - OLSON, MYRON K & LORNA E
MYRON K & LORNA E OLSON
1146 105TH ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1146 105TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 9.980 Plat: N/A-NOT AVAILABLE
SEC 5 29N R18W 9.98A NE SW FORMERLY 1 Block/Condo Bldg:
CSM VOL 3/801A FORMERLY LOT 1 CSM 8/2283
N/K/A LOT 1 CSM 9/2471 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
05-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 945/260
07/23/1997 884/551
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 9.980 48,500 136,400 184,900 NO
Totals for 2006:
General Property 9.980 48,500 136,400 184,900
Woodland 0.000 0 0
Totals for 2005:
General Property 9.980 48,500 136,400 184,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 206
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00