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,rFPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE IS,,,, Plan LD. Number
(If assigned)
Holding Tank El In-Ground Pressure -1 Mound
.
BAMENCH OF PERMIT HO DER ~ ADDRESS OF PERMIT HOLDE / SPEC710N DATE
/M/ Wermanent eeef,,-ce point) DE IBE IF DIFFERENT FROM PLAN 1-. PT. ELEV.: CST REF. PT. ELEV.
M° V /V \d die I SO ele_~
Name f PI Tlh~l MP/MPRSZ County Sanitary Permit Number:
~S
IL e
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YES ❑NO ❑YES ❑NO
OPERTY WELL. BUILDING. 1 VENT TO FRESH
BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. P
ALARM FEET FR OM LINE. AIR INLET.
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER: _
MANUFACTURER BEDDING. [1111111 CAPACITY PUMP MODEL 111IMP,SIPLION MANUFACTUFIEH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP ANO CONTR OLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESI,
(DIFFERENCE BETWEEN FEET FROM t_INE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST-0
SOIL ABSORPTION SYSTEM. Check thesoilmoistureatthedepthofplowing D1nrfTR IMATIHIALANDMAHK.NG
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:
WIDTH LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA. -PITS. LIQUID
BEd/TRENCH TRENCHES MATERIAI PIT - - DEPTH
DIMENSIONS
(;HAVFi [)F PT ] FILL DEPTH 1U,SE tl PIP' DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING'. VENT TO FRESH
BF LOVW 11111~S ABOVE COVER ELEV. INLET ELEV. END'. PIPES. FEET FROM LINE . AIR INLET.
NEAREST--s
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
UEPTH OVER THENCHBED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSU_RIZEDDISTRIBUTION SYSTEM:
VV IU [H 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
"v ELEV. DIA. ELEV. PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION 1111 E SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
.
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: :NUM BER OF :-IPR OPERTV WELL. BUILDING
FEET FROM a"E:
❑YES ❑NO DYES ❑NO _ NEAREST _
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE.
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'/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: Mailin Address:
Property Location: City, Village or Township: County:
Se'/a 'G 'XS ~T-3 N/R/ or) W olk~
Lot Number: Blk No.: Subdivision Name rest Road, Lake r Landmark: State Plan I.D. Number:
(If assigned) d
TYPE OF BUILDING'
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY ~
HOLDING TANK CAPACITY
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
4 ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (if other than present owner):
Private E] Joint ❑ Public A)4
I, the undersigned, hereby assume responsibility for installation of rivate sewage system shown on the attached plans.
Nam of Plumber: Sign le: MWMPRSW No.: Phone Number:
'a A~u.1e v- 1.5("3 ( 715) S13-~
Plumber's Address: ff Name of Designer-
COUNTY/ DEPARTMENT USE ONLY
Signatu a of tsuing Age Fee: Date: y~ pPROVED Sanitary Permit Number:
U'-& V DISAPPROVED
.24059
Reason 'I approval:
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)
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Parcel 006-1009-90-000 09/20/2006 08:00 AM
PAGE 1 OF 1
Alt. Parcel M 5.31.16.72 006 - TOWN OF CYLON
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 - KJESETH, MICHAEL J
MICHAEL J KJESETH
2351 HWY 46
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 2351 HWY 46
SC 0119 AMERY
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 5 T31 N R1 6W TH SE NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
05-31 N-1 6W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 741/541
2006 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/26/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 15,000 215,000 230,000 NO
AGRICULTURAL G4 38.000 2,700 0 2,700 NO
Totals for 2006: ~
General Property 40.000 17,700 215,000 232,700
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 17,700 215,000 232,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF REPORT ON SOIL BORINGS AND E ABUIL GS
INDJoTRY,
_ i' j F~1 ON
LABOR AND PERCOLATION TESTS (115) o, O 969
HUMAN RELATIONS "bbl 707
zs' F
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BILK. NO.: SU 1 N NAME-
t '/4 l l /T3i N/R W C Lon
COUNTY: OWNER'S/BY YEFh=S-NAME: MAILING ADDRESS:
USE DATES O SERVATIONS MADE
NO. BEDRMS.: COMMERIIAL DESCRIPTION: R TONS: ER LA ION TESTS:
"-}l
Residence 3 1 Vi ❑New XReplacej _~2 I
RATING: S= Site suitable for system U= Site unsuitable for system ('1 -rC
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM. optiona
f~S ❑U S ❑U S ❑U ❑S ❑S
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V.
~ If any portion of the lot is in the
under s.H63.09(5)(b), indicate: J = l: Floodplain, indicate Floodplain elevation: h"
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-f 'y 712- 2- L
'rs - - rs
B- 26 33'1 12 oil 2- I?r 75/ -3 2 d r S
Q ~/'Sr f Z -Y /'s"
B-
B-
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-
P_ f~ /A
P-
P-
P-
P-
PLAN VIEW: S~ow 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
D SOIL 00ii-1 05
e
J3c-i 1J, r,r~fz-l
T
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4Z Sot
~II
2 1.
tri
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CIS!
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 COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
t 'sS S / - ~!5 t /6 ' vj
CST S ATURE•
X
w y1
'TRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
N&,,R-SBD-6395 (N. 03/81)