HomeMy WebLinkAbout014-1041-80-100
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01112120 PAGE 1 OFn1
Parcel 0`14A041-80A00 014 - TOWN OF FOREST
Alt. Parcel 19.31.15.304B ST. CROIX COUNTY, WISCONSIN
Permit # Permit Type
Current X Sales Area Application #
Creation Date Historical Date MO # 0
p = Current owner, c = Current Co-Owner
Owner(s):
Tax Address: O - DEAN, RANDALL E & GINGER A
RANDALL E & GINGER A DEAN
2694 200TH AVE
EMERALD WI 54013
* =Primary
SC Special Property Address(es):
Districts: =School SP = • 2694 200TH AVE
Type Dist # Description
SC 1127 CLEAR LAKE
UPPER WILLOW REHAB DIST
gp 8020 WITC
Acres: 6.240 Plat: N/A-NOT AVAILABLE
Legal Description: Block/Condo Bldg:
SEC 19 T31N RI 5W SE114 SE1/4 LOT 1 CSM Sec-Twn-Rng 40 114 160 114)
611719 Tract(s): (
19-31 N-1 5W
Parcel History: Vol/Page Type
Notes: Date Doc #
07/23/1997 943/403
07/23/1997 756/623
Assessed with:
Bill Fair Market Value:
2006 SUMMARY 160644 185,800
Last Changed: 10/18/2005
Valuations: Land improve Total State Reason
Class Acres 145,000 177,500 NO
Description G1 6240 32,500
RESIDENTIAL
145,000 177,500
Totals for 2006: 6,240 32,500 0 0
General Property 0,000
Woodland
145,000 177,500
Totals for 2005: 6.240 32,500 0 0
General Property 0.000
Woodland
Batch 105
Claim Count: 1 Certification Date:
Lottery Credit:
Specials: Amount
Category User Special Code
Special Charges Delinquent Charges
00
Special Assessments 0.00
Total
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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC ./ET3 ~N-R
ADDRESS / ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
0
Distances and mensions to meet requirements of H63
HOW_EVERYTHING WITHIN 100 FEET OF SYSTEM
. ,yam
I di a e otth Arrow
r f
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
r
SEPTIC TANK: Manufacturer:., Liquid Capacity: / i..
Number of rings on cover _ c ~Tank manhole cover elevations:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
(.lumber of gal. pump set for a cycle- gallons; total capacity o
distribution lines gallon: sized pump__ head;
gallon per minut_e_ horsepower ran 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: _ mT~er oTF pits --Teet3'iameter.
Feet liquid dept seepage pit in et 'pipe-elevation-
bottom of seepage pit elevation feet.
SEEPAGE BIED SIZE: number of lines - width ' le,igth iJ file depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIREIi2 AREA AS BUILT / 7
INSPECTOR ,
DATED PLUMBER ON JOB/ f
LT CI NSF; NUMBER
4 , Af
' RI VOR`I 01 INSVt CTION INDIVIDUAL SIWAGt NKH M
Sun( tang PAW \ State Septic'
apt 0._ Township St. Cnoix Count/
,,tiran gy Seetion Lot # Subdivision
I PI IC LANK
r r' gallons Number corn ►antments
~n (~'ru►n: WeYl_
Hi ghwa ten
MINK CHAMIR
gallon4 - !f ump Manu(►a ,tune.n Model Numben
DING LANK
e gallon umb n Q ( ompan.tme nt.6
1',r mpe q
1! r l.anm Sys t.m
tance {nom: well 8 ilding 12% dope
H.i ghwa.ten
';',ORI'TION SITE
Cied Tn.ench
tanre, Oom: Well Su4lding__ r2o elope
Hi_ghwa•ten
',URI'I IpN SITE DIMENSIONS,
2-
W( filth oA tnench~i-- At Req&'i ~ a
lenrlth o6 each line ,101 C At Depth o6 nosh below tile
- -
Nurnf,en o6 Wee ~ - Depth o6 sock oven We in
I , taf length oA U ne.e t At Depth Q tile below gnade
K%tanve between line. At Slope ot( tne.nch in. pen 100 At
Ir1"l,liinlJt(UYI ane,l 1 6~ Type o6 Coven.: 1~aJ on btn(IW
i t D I MI NS IONS
Nurriben o6 pit4-_ Gravel atoand pity yes no
0utArde diameter At Depth below inlet 6t
local Wonp.tlon area --~~t
Area nvquined____- At
N 4 P I C I 1 D 8V TITLF
ROV1 U DATC 19 B
I II C I I L) DATE 1
I AKON I OR RI JFCTION ~,i
1
State and County State Permit #
PLB 6 7
111 Permit Application County Permit # 2
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: ;c '/a Section 2~_, T_~)j N, R (or) _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_ k" Poured-in-Place Steel Fiberglass Other (specify)
New Installation _ V Replacement
Lift Pump Tank or Si~phon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate > Total Absorb Area sq. ft.
New k Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. WidthDepth Tile depth (tqp) No. of Trenches
Seepage Bed:_Length l f Width Depth Tile depth (top)e` No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- r f Distance from critical slope
VATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
1, 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 Tfster,
NAME C.S.T. # l / and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# Phone
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 el w FOR COUNTY AND STATE D PARTMENT USE ONLY
Date of Application Fes Paid: State 4 G" County Zf w Date '
Permit Issued/Rejected (date) Issuing Agent Name t
spection Yes No State Valid# Date Recd
county ( ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
state (pink copy) 4, plumber (canary copy) Revised Date 7/1/78
EH 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: '/4, Section ~ ,TT,' N,RLS (or) W, Township or Municipality
Lot No. , Block No. County
Subdivision Name
Owner's/Buyers Name: -
Mailing Address: + ,.►-L
TYPE OF OCCUPANCY: Residence X_No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW_REPLACEMENT ALTERNATE SYSTEM -OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET _1;` ! NAME OF SOIL MAP UNIT ,-t11 rl,')
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD21 PERIOD 3
3/
P-
j4 Ah- Air
P-
IL &4A14
11L _3 C~
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-
B- _
B-
2 V-52 S4L,- 7,j
B- r ? _s
B- '
B-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slopes
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I, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
7
Name (print) 1,41 1A Certification No_' ~ s
/V All
AAddress. 4
Name of installer if known ` ~
s
Copy A -Local Authority CST Signature
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REPORT ON INSPECTION OF SANITARY PERMIT # 1~~ 7c/, 1" 7
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
Time of
i Inspection
ame, ress, 1cen NO. o install ng Plumber
(3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
(4)BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO
8 HOLDING TANK: Manufacturer o gallons
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? ❑ YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? [:]YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-6095 N.05/80
Signature of Inspector: