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Parcel 010-1002-90-000 01/19/2007 11:04 AM
PAGE 1 OF 1
Alt. Parcel 1.30.16.15A 010 - TOWN OF EMERALD
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
DOUGLAS E MILLER O - MILLER, DOUGLAS E
1732 CTY RD D
GLENWOOD CITY WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 6.890 Plat: N/A-NOT AVAILABLE
SEC 1 T30N R16W PT NE SE E 283FT OF N Block/Condo Bldg:
105OFT
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
01-30N-16W NE SE
Notes: Parcel History:
Date Doc # Vol/Page Type
10/11/2004 776592 2672/452 WD
04/06/2004 758872 2543/102 LC
04/06/2004 758871 2543/101 QC
10/21/1999 612494 1465/70 mWD
ore
2006 SUMMARY Bill Fair Market Value: Assessed with:
167684 178,500
Valuations: Last Changed: 07/29/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 15,000 132,300 147,300 NO
PRODUCTIVE FORST LANDS G6 4.900 10,000 0 10,000 NO
Totals for 2006:
General Property 6.900 25,000 132,300 157,300
Woodland 0.000 0 0
Totals for 2005:
General Property 6.900 25,000 132,300 157,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch
Specials:
User Special Code Category Amount
010-GARBAGE SPECIAL ASSESSMENT 30.00
Special Assessments Special Charges Delinquent Charges
Total 30.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPOR'i
lOWNSlit Sl;C. J `I' ' •N l:/jW
ST. CROIX COUNTY, WISCONSIN.
1 c rf ~'iT F
SUBDIVISION LOT LOT SIZE
- -
I' I.AN VIEW
uini, ncus and dimensions to "wri icquiremuni_s of R63
1LDW L:VL10'CH1NG WITHIN 100 FEET OF SYS'1EN
r
y
IC i
/G
I di nd, ~or-rA A
BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: i" Slope at
_Quid Capacity:
SEPTIC TANK: Manufacturer: Li
Number of rings on cover Tank manhole cover elevation ~
Tank Inlet Elevation: e 1, ;Z y Tank Outlet Elevation.
PUMP CHAMBER
Manufacturer: _ Number of gallons
Number of gal. Pullp s-- et-for a cycle gallons; totem--capacity-of
distribution lines gallon: size A 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 _ p
SEEPAGE PIT SIZE: _ Number o - its-----feet iameter _
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage p1 elevati.on feet.
SEEPAGE BED SIZE: number of lines width _ le~rgth _ rile dept
SEEPAGE TRENCH: width - length__ _s-' 2 -
PERCOLATION RATE REA REQ[JIRE~JR _AREA AgBUILT .6 my,
DATED INSPECTOR
PLUMBER
LICENSE NUMBER
DEPARTMENT OF INdUSTRY, INSPECTION REPORT FOR to J SAFETY & BUILDINGS
LABOR&.HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 U f BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE state (If assPligneand I I D Number
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER'. INSPECTION DATE:
BE CH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.'. CST FILE PT ELEV
N,,,--f Pi utter. JMP/MPRSVI No. Coumy. S--,y Permit Number
colaAe- S' o4~V -I t2 `~1 e
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY jTANK,IiNLFT ELEVIANOUTLET ELEVWARNING LABEL LOCKING COVER
f / L PROVIDED'. PROVIDED
v(~IL2~ ~CL ❑YES ❑NO ❑YES ❑NO
BEDDING. VENT Dt__ff~_A HIGH WATER NUMBER OF 1ROADPR DPERTV UILDING VENT TO FRESH
ALARM FEET FROM LINE AIR INLET
❑YES ❑NONEAREST--
❑YES ❑NO
DOSING CHAMBER: _
MANUFACTURER BEDDING ILIQUID CnPnCI I V 1,77/. PUMPSIPH ON MANUFACTIIR EWARNING LABEL LOCKING COVER
PROVIDEDPROVIDED❑YES ❑NO 1 ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND jf s OPERATIONAL NUMBER OF PROPERTY WELL Bun DING VENT To FRESH
(DIFFERENCE BETWEEN , =FEET FROM NF AIR INLET
PUMP ON AND OFF) ❑❑NO NEAREST--0
SOIL ABSORPTION SYSTEM. Check the soil ?istu rk at the plowing i'•~r, l - ulna^r TLH MAT(RInI AND MARKwG
or excavation. (If soil can be rolled into a vvre construction ease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO OF DISTR PIPE SPACIIV~-i;OVFH INSIDE DIA =PITS LIQUID
BED/TRENCH BENCHES ArERIAL PIT DEPTH
~DIMENSIONS BUILDING
II DEPTH [)ISTDISTR PIPE MATERIAL NO DSTR NUMBEROF ERTY WELL VENT TO FRESH
COVER 6v INLF I EL v ND PIPES FEET FROM uNE AIR INLET
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 TEXLUHE PERMANENT MARKFHS ORSEHVAI]ON WELLS
❑YES ❑NO _❑YES ❑NO
OF PTH (1VFH TRENCH BEU UEPIH ()Vf H I HI NCH HF U DEP rH ()F TOPSOIL 5(IUDEU LOYES D MULCHED
F NTIf EDGES
YES NO ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: _
ISJiH LEND IH NO. OF LATE RAL SPACING G RAVEL DEPTH BELOW PIPE FILL DEPTH AHOVE CQVEH
BED/TRENCH TRENCHES
DIMENSIONS
,MAN IFOL.D PUMP MANIFOLD DISTR-PIPE MANIFOL D MATERIAL NO LISTH DISTR. PIPE DISTRIBUTION PIP[ MATEHIAL&MAHKING
FI EV.. ELEV. DIA ELEV- PIPES DIA.-
ELEVATION AND
DISTRIBUTION
I iC1LE SIZE HOLE SPACING DHILLEOCOHREMLY COVER MATFHIAL VERTI('nL LIFT CORRESPONDS TO APPROVED
INFORMATION PLAnIs ❑
_❑YES ❑NO _ YES ❑NO
COMMENTS PERMANENT MARKERS OBSERV ATION WELLS NUMBER OF PROF ERTV WELL BUILDING
FEET FROM
❑YES ❑NO -]YES ❑NO NEAREST-
IOU
o0
7
}
7 711
Sketch System on "Retain in co my file for audit.
Reverse Side.
LIGNATUR ELDILHR SBD 6710 (R. 01/82) - `-mil
- ~ ~ ~ ~ State and County State Permit #
Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY
Mailing Address:
B. LOCATION: JVZ-,'/i Section' 1_, T_7,(' N, R& joj$W~ W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons ,
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate
Total Absorb Area sq. ft.
New X Replacement Alternate (Specify)
Seepage Trench: X_No. of Lineal Ft. G' C Width' Depth-7Y-,Tile depth (top)e No. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land .1 Distance from critical slope
WATER SUPPLY: Private ❑ Joint ® Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME 61^h/-,E' .,SM / C.S.T. # f J,!~ and other information
obtained from (owner/builder).
Plumber's Signature (v P/MPRSW# Phone #,;2-4$ F P
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY n
Date of Application c;-- Fees Paid: State (00 _ County ~Date,Ite, , Cl ~enq->
Permit Issued/RejeeEod (date) Issuing Agent Name (x 16oAlw -
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
Y / ,19
2* 1
DEPARTIVIENTOF C iFE;~ &BUILDINGS
REPORT ON SOIL BORINGS
INDUSTRY, - o o G-) ,-j DIVISION
LABOR AND PERCOLATION TESTS (11 1.4 , 0. BOX 7969
am'
HUMAN RELATIONS
ON WI 53707
LOCATION: SECTION: TOWNSHIP/ LOT NO.: : SUB VISION N~/xME:
/T_?vN/R4/Sr) W
COUNTY: OWNER'S _ MAILING ADDRESS:
C v/i !c d e/.~
USE DATES OBSERVATIONS MADE
1 _7 NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence New ❑Replace I e-/ r9La JP"_ /I P
RATING: S= Site suitable for system U= Site unsuitable for system C S '
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
FV1 $ ❑U [AS ❑U ®S ❑U ❑ S ®U ❑ S ®U o ve ~c
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. I If any portion of the lot is in the
under s.H63.09(5)(b), indicate: ~ y 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- , 7
c 4~7 L ,5" '.Z
B- 1-/ L Ale
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-
r
Ale-,
P-
P-
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 direction and percent
of land slop.
SYSTEM ELEVATION ZZ, 25- N~
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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 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):
CST SIGNATUR/E:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
Smith Plumbing PHONE (715) 265-4838
Rli t"l?d GLENWOOD CITY, WISCONSIN 54013
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