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Parcel 042-1058-60-000 01/20/2006 03:06 PM
PAGE 1 OF 1
Alt. Parcel 21.29.18.324A 042 - TOWN OF WARREN
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 - WALTZ, HALLY & GLENN
HALLY & GLENN WALTZ
848 110TH ST
ROBERTS WI 54023
Districts: SC School SP =Special Property AddreSS(o
s): ' = Primary
Type Dist # Description ` 866 HWY 65~~.
SC 2422 ST CROIX CENTRAL
SP 1700 WITC V
Legal Description: Acres: 10.700 Plat: N/A-NOT AVAILABLE
SEC 21 T29N R18W 10.7A IN SE NE COM Block/Condo Bldg:
1331.7 FT S & 50 FT W OF NE COR SEC 21,
TH W 495 FT, S 1033.8 FT, E 485 FT TO W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
R/W HWY 65, TH NLY ON R/W 1047.4 FT TO 21-29N-18W
POB EXC PT TO HWY AS DESC IN 862/575
1.10A
Notes: Parcel History:
Date Doc # Vol/Page Type
07/29/2004 770214 2627/278 WD
07/23/1997 944/575
07/23/1997 _ _928L25407/23/1997 862/575
more...
2005 SUMMARY Bill Fair Market Value:
79392 295,400
~
Valuations: Last Changed: 10/22/2001 L
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 9.700 54,000 131,500 185,500 NO
COMMERCIAL G2 1.000 10,000 43,100 53,100 NO
Totals for 2005:
General Property 10.700 64,000 174,600 238,600
Woodland 0.000 0 0
Totals for 2004:
General Property 10.700 64,000 174,600 238,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
Parcel 042-1058-80-100 01/20/2006 03:25 PM
PAGE 1 OF 1
Alt. Parcel 21.29.18.324D 042 - TOWN OF WARREN
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical (Date Map # Sales Area Application # Permit # Permit Type
0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - ROBERTS CONCRETE PRODUCT
ROBERTS CONCRETE PRODUCT
856 HWY 65
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 0.073 Plat: N/A-NOT AVAILABLE
SEC 21 T29N R18W PT SE NE COM E1/4 COR Block/Condo Bldg:
SEC 21;TH N 89 DEG W 1180.89' POB;TH N
89 DEG W 146.76';TH N 00 AEG E 43.36;TH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
S 73 DEG E 153.27' POB 21-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/11/1999 602953 1425/517 WD
Bill Fair Market Value: Assessed with:
2005 SUMMARY
0
Valuations: Last Changed: 12/23/2002
Description Class Acres Land Improve Total State Reason
MANUFACTURING G3 0.073 0 0 0 YES
it
Totals for 2005:
General Property 0.073 0 0 0
Woodland 0.000 0 0
Totals for 2004:
General Property 0.073 0 0 0
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
AS BUILT SANITARY SYSTEM REPORT
OWNER TO
WNSHIP SEC _W_TjjN-R1 T.W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE_j,~,/t~W~-°~
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
•
I di at N r h rr w
1-ia
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:.SQ
Number of rings on cover Tank manhole cover elevation:_
'l'ank 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. I
SEEPAGE BED SIZE: number of lines width length ~_tile depth
SEEPAGE TRENC'H: width length
PERCOLATION RATE1p!~3 AREA REQUIRED- AREA AS BUILT
INSPECTOR
DATED° PLUMBER ON JOB 1^r-'
LICENSE NUMBERZ P
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
` CRCONVENTIONAL ❑ALTERNATIVE state Plan) D. Numbe.
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Glenn Waltz RR J. Box 325 , Hwy 65 , Roberts , W -~S LY ~J- /V
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. R F. PT. ELEV.: CST REF, PT. ELEV.'.
SE NE, Sec. 21, T29N-R18W,Town of Warren
Na- of Plumber. IMP/MPRSW N... County. Sanitary Permit Number.
Thomas Wang 3231 St. Croix 38483
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. 5~w
LOWE PR(NO NO
II f
BEDDING I VENT CIA. VENT fy ATL. HIGH WATER NUMBER OF ROAD: BUILDING. VENT TO FRESH
r/,
ALARM EET FROM AIR INLET.
❑YES NO ❑ S NO NEAREST
DOSING CH NIBER:
DING. LIQUID CAPACITY PUMP MO EL. PUMP/SIP N MANUFACTURER. NING LABEL LOCKING COVER
MANUFACTUR R BED
~ PR VICE O. i PROVIDED.
❑YES ❑NO YES YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPEFt, DNAL NUMBER OF ELOPE. WELL BUILDING'. VENT TO FRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) ❑YES ❑.NO NEAREST Y
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of AVIV0 I FN(JI1 D Ere M RIAL AND ARKING
or excavation. (If soil can be rolled into a wire, construction shall cea a until F RICE
the soil is dry enough to continue.) M IN
CONVENTIONAL SYSTEM:
WIDTH- LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA. =P S LIOUID
BED/TRENCH I TRENCHES RIAL: • PIT r TH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH JDPIPE DISTR PIPE r11 NUMEF PROPERWELLBUILDBELOW PIPES C ER EEV. INLET ELEV. END. PIPE I LINE'" AIR INLET.
/ r~ G FEET FROM~~ r ,
1 1 ,
( NEAREST z
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture 0 fill materi for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems t ak certain at it ON REVERSE SIDE. SHOW ELEVA-
meets the criteri~fo me ium san TIONS MEASURED.
❑YES ❑NO / P
SOIL COVER TEXTURE ERM T MA KERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH: BED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL. ODD SEEDED MULCHED
CENTER EDGES.
❑YES ❑ ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATERAL SPACING. GRAV DEPTH BELOW PIP FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MA TO D ATERIAL. N DISTR. STR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA. ELEV.. IP S DIA.'.
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER TERIAL PLANS
❑YES ❑ O ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OB VATI N W Ls: NUMBER OF L OEPERTV WELL: BUILDING:
FEET FROM
1 ` ❑YES ❑No ❑YES ❑N NEAREST
6 f
~
Retain in county file for audit.
Sketch System on '~LJ
Reverse Side.
SIGNATURE TITLE'.
K
DILHR SBD 6710 (R. 01/82) ` r - -
DEPAATMENT OF APPLICATION
INDUSTRY, FOR SANITARY SAFETY & BUILDINGS
LABOR AND PERMIT DIVISION
HUMAN RELATIONS P.O. BOX 7969
(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:
Ma' ing Address
/ewn toe,
Property Location:
or Township: County:
~,IE7 % '/4S iT N/ R E (or r `th S7t
Lot Number: Blk No:: Subdivision Name: r0
Nearest oad, Lake or Landmark: State Plan I.D. Number:
(,v (If assigned)
TYPE OF BUILDING
r
❑ Public* ❑ Variance* ❑ Other (specify)* Number of
Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN
GALLONS OFTANKS CONCRETE PLACE STEEL FIBERGLASS NEW REPLACE- OTHER
INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: Y.
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental
~ Seepage Bed ❑ Seepage Pit
a< 30 L" F/ ❑ Alternative (specify) _zaz Q ❑ Seepage Trench
Wat
J~S er Supply: 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 plans.
Name f Plumber: Signatur .
!P/MPRSW Number:
h) Sys' 99s~
Plumber's Adylress:
Con- Name of Designer: F G/cf/` OhQ 5
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Ag Fee; Date:
APPROVED
F / /}Of , Y
Reason for Disapproval: "v (LJ V lp / DISAPPROVED
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
1 l
Owner of Property (ti".
Location of Property
W r-- 1 1
~.A 4, Section T_,2.~(_N R_I_LW
Township ~_"-1--
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property P"-1(
T~
Total Size of Parcel /Z
Date Parcel Was Created J~' j~ 7
Are all corners identifiable?
Yes x, No
Include with this a lication one of the followin>•
.Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION
i
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 the Office of the
County Register of Deeds as Document No.c=
pand resently own the proposed site for the sewage disposal system (or l (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly record d in the Office
of the County Register of Deeds, as Document No-
SIGNATURE OF OWNER
~al
SJQNATURE OF CO-OWNER APP ABLE)
DATE SIGN
DATE SIGNED
DEP/11RTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY',
LABOR AND P.O. BOX 7969
PERCOLATION TESTS (115 DIVISIOV
~
HUMAN RELATIONS MADISON, WI 5370;
LOCATION: SECTION: OWNSHIP UNICIPALITY: LOT NO.: BILK NO.: SUBDIVISION NAME:
s 1/ ~4 P 1 /Td? N/R/$E (or "rren 1V 4 NR /VA
COUNTY: OWNER'S BUYER'S NAM MA ING ADDRESS:
USE
JNO. BEDRMS.: COMMERCIAL DDATES OBSERVATIONS MAD
JNResidence d ❑New T®Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMME DED SYSTEM:loptional)
DS ®U ®S ~U~ OS ❑U ❑S DU DS DU ~ec~
if Percolation Tests are NOT required DESIGN RATE: SYSTEM EL
under s.H63.09(5)(b), indicate: ~ Iany portion of the lot is in the
ld d. l Floodplain, indicate Floodplain elevation: NA
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 0 Al E > ~ d P Y/ / f `O
, pM 147''k S
B- n1vNE ~bto 66 s` 4
B-
B-
B-
_ PERCOLATION TESTS
NUMBER INCHES' AFTER SWELOLING INTEST TIMMIN. DROP IN WATER LEVEL-INCHES
PERIOD t RATE MINUTES
P , ~3 y0 O PERIOD2 PERI D PER INCH
° b / a
P- .a s , s
P- a9
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 ELEVATION 9~.1 q5='~
P''esenT , ~ ~
o~ I 60-
__J
. - ~t ore
4 . 8
4f. tiev rnj trlct' polea r Fri)f05ej 5ept►~ v G3e_jl
_ ( ~ ♦ - Pere. ~0/es
,~lec, ~d/e ~;'I = s t b to g r e a
Present
Fulr 6%rn P
6 - ,
Fe4&e r
_ ru,nwirtl 9'-S y Ba 0 id _ rJ
F
X~
i
83
E e
1, 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 COMPL~TED ON:
0 q4
ADDRESS: 1
/00"~f' ~'q ~e ~f 6 5 Ois CERTIFICATION NUMB R: PHONE NUMBER optional):
~o' D vas-99r-,
CS NATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
71LHR-SBD-6395 (N. 03/81)
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