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HomeMy WebLinkAbout020-1013-20-000 n Cl) O z •9 0 d • m O ~C 1 M I 3 rY ~ O co O N (ND z p. OO O N C C C O • 3 p o m N ~1 0- z Q. N O O N O 3 N N C 0 Cn O N CL O O n 7 Q CD N m 0 ° c CD ° O C) w o o 3 7 N N D O CN_ N -I r~ CD Cp D CD a CD (n I N W a D 3 m Ul a) V O m ° CD w CD C CD co to ° 2,0 C N O C (A cn za z 0 0 0 N• Z 1~,~~ill o n p< w z `i \I U! fn (A o o D n ~-3 °1 a C, m a O O~ ° O rn w m O N N 3 N :3 CD N Z c 0 v O_ o_' C CD (D N • CD N CD v c can m C1 O CD O A K O A z 0 v n 3 Q, Z N W ~ (T1 O Z CL z a 3 X O C/) 3 m N z C CD ? W ~ III D CL CL 0 :3 -n m c z a 0 CD I I y a. 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CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - ELMQUIST, STEVEN K & KRISTIN A STEVEN K & KRISTIN A ELMQUIST 1027 TANNEY LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1027 TANNEY LN SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.300 Plat: N/A-NOT AVAILABLE SEC 11 T29N R1 9W NE SE LOT 3 C.S.M. V Block/Condo Bldg: III P722 ORD AND A 60' STRIP LYING IMMEDIATELY S OF SD LOT 3 AS DESC V 615 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) P279 11-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 12/06/2000 634808 1565/161 WD 07/23/1997 1121/404 WD 2009 SUMMARY Bill Fair Market Value: Assessed with: 24943 290,600 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.300 80,200 203,300 283,500 NO Totals for 2009: General Property 3.300 80,200 203,300 283,500 Woodland 0.000 0 0 Totals for 2008: General Property 3.300 80,200 203,300 283,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 124 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 020-1013-20-000 09/27/2006 10:57 AM PAGE 1OF 1 Alt. Parcel 11.29.19.57E 020 - TOWN OF HUDSON 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 - ELMQUIST, STEVEN K & KRISTIN A STEVEN K & KRISTIN A ELMQUIST 1027 TANNEY LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1027 TANNEY LN SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.300 Plat: N/A-NOT AVAILABLE SEC 11 T29N R1 9W NE SE LOT 3 C.S.M. V Block/Condo Bldg: III P722 ORD AND A 60' STRIP LYING IMMEDIATELY S OF SD LOT 3 AS DESC V 615 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) P279 11-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 12/06/2000 634808 1565/161 WD 07/23/1997 1121/404 WD 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.300 80,200 203,300 283,500 NO Totals for 2006: General Property 3.300 80,200 203,300 283,500 Woodland 0.000 0 0 Totals for 2005: General Property 3.300 80,200 203,300 283,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 124 Specials: User Special Code Category Amount i Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY WISCONSIN ZONING OFFICE Bullion lia ifN ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 May 11, 1995 Mr. Dave Anderson Century 21 706 19th Street South Hudson, Wisconsin 54016 RE: Water Inspection for Steve Fuller Address: 1027 Tanney Lane, Hudson, Hudson, Wisconsin Dear Mr. Anderson: Enclosed is the original test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure ~ ~ . f~ It COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 cz: w FAX-715-962-4030 . T4i;RU X CTI GOV.CI'l REPORT DATE! Fi/49, 101 CARMICHAEL ROAD )TION, 1027 Tats ~a ,ECTORI M. .Jerk i COLLECTED: 5-03-K"' COLLECTEDa 11:45am r fai : p PRETATIOW Bacter; Pi we 10 RESUL"c; FAX'D O,J: PHONEC) f + .J; ENDEGENp CALLER: 9d ' O a U s a J 'b 4 PROFESSIONAL LABORATORY SERVICES SINCE 1952 05/09/95 TUE 14:26 FAX 1 715 962 4030 COMM. TEST LAB 2001 COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962.3121 800 - 962 - 5227 FAX-715-962-4030 ST. CROIX COUNTY ZONING OFFICE REPORT N04: 83658/01 PAGE 1 ST,CROIX CTY GOV.CTR REPORT DATE: 5/09/95 1101 CARMICHAEL ROAD DATE RECEIVED: 5/04/9: HUDSON. WI 54016 ATTR44 THOMAS C. NELSON OWNER: Steve Fuller LOCATION: 1027 Tanner Lane, Hudsor COLLECTOR: M. Jenkins DATE COLLECTED. ~r-03-95 TIME COLLECTED: 11:45am SOURCE OF SAMPLE: Kitchen tap (Retest) DATE ANALYZED:5-04-95 TIME ANALYZED:2:00pm COI_TFORM,MFCC: 0 /100 ml INTERPRETATION: Bacteriologically SAFE NITRATE--N; 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard* Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIAN: Pam Gane WI Approved Lab Noa 19 .RESULTS: FAX'D ON. Sf 1W..r.` PHONED ON: _ CALLER: otaMDe,eNO~M1,. < Means "LESS THAN" Detectable Level Approved by: w PROFESSIONAL LABORATORY SERVICES SINCE 1952 I~ . ,uJ ST. CROIX COUNTY - WISCONSIN - ZONING OFFICE 'Itrrrrrrr ....f ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 540 1 6-77 1 0 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM ~'l Please specify desired test(s) & remit appropriate fee with - a location. PP Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. U~ ❑ Water (VOC's) $185.00 ❑ Septic $50.00 ❑ Water (Nitrate & Bacteria) 45.00 S Nitrate & Bacteria retest $15.00 Owner: Requested by: ~ 2~- D&",e~ Address: 9 NEE L Address: W":-.( A,LS- all) ZIP ZIP Telephone : Telephon) Property ~x s Fire N4 & Street) : ~ Location Sec. ~ T N, R W, Town of Realty firm: -a heck Box Combo: Closing Date: 5 J j2 ' 06 TO BE COMPLETED BY PROPERTY OWN / 9 *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? a Yes ❑ No If vacant, date last occupied: Age of septic system: Septic tank last pumped by: Date: Previous Owner's Name(s): Have any of the following been observed? ❑Y ❑N Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. ❑Y ❑N Sewage discharge to ground surface or road ditch. ❑Y ❑N Foul odors. ()ther comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: DATE: I OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? []Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: OBelow grd ❑At-Grd []Mound Approx. size 'X []Gravity []Dose []Pressurized Ft.' []Bed []Trench []Dry Well []Holding Tank OOutfall pipe OBSERVED DEFICIENCIES []Other []Unknown Septic tank Setbacks: []House []Well []Prop. line []Other Dose tank Setbacks: []House []Well []Prop. line []Other []Locking cover []Warning label []Pump/Floats []Alarm []Elec. wiring Soil Absorption System Setbacks: []House []Well []Prop. line []Other OPonding: []Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION I I it Title I I 10- S T. CROIX COUNTY WISCONSIN - `t ZONING OFFICE 1161111ntlnn■ ne~~u ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 I~I April 28, 1995 Dave Anderson Mr. Century 21 706 19th Street South Hudson, Wisconsin 54016 RE: Water Inspection for Steve Fuller Address: 1027 Tanney Lane, Hudson, Hudson, Wisconsin Dear Mr. Anderson: Enclosed is the original test results from Commercial Testing Laboratory, Inc. for a water inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting me. Sincerely, Mary J Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin mz Enclosure i ,COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 C:I:A:w 4', 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 c ST.CROIX CTY GOV.CTR REPORT MATE: 4/26/95 1101 CARMICHAEL ROAD DATE RECEIVED'* 4/20/95 HUDSON, WI 54016 ATTN*# THOMAS Co NELSON I LOCATION: 1027 Tanney Lane, hv-i Q 10 rl mss. COLLECTOR: M. Jenk i r.,2 ib COLLECTED: 4-19-Y COLLECTED: 10 1Ea % r L1~ ter. 'CE OF SA IP-L r I-J 1chee auce l DATE ANALYZED 44 4-20-,K-, TIME ANALYZED.2*#00pn <<:, COLIFORM,MFCC: I INTERPRETATION: Bacteriologically UNSAFE NITRATE-Nt 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 T, oF.\NOEFENOEHT. p \ A ~ D d O J PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY /tj WISCONSIN ZONING OFFICE G Y N U p 11 ■ O ■ .~:.6 ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. / ❑ Water (VOC's) k114- $185.00 ❑ Septic !y14 $50.00 Water (Nitrate & Bact ria) 45.00 ❑ Nitrate & Bacteria retest fV✓ 1 $15.00 ~ r Owner: Cz- Requested by: Address: /2 Address: ~cG- Z I P _5 e/ ' c G- i-s °ZG~ Z I P S~f a /6 Telephone N°: (2/ ,e Telephone NQ: (7/_33~611 i Property address (Fire N2 & Street) : = 7 Location: k,sz Sec. T ~2 N, RAW, Town of /1DSa^J Realty firm:Lock Box Combo: Closing Date: TO BE COMPLETED BY PROPERTY OWNER *ROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? -8-Yes 0 No If vacant, date last occupied: Age of septic system: _ Septic tank last pumped by: Date:' Previous Owner's Name(s): r cr / e2- ~t----- Have any of the following been observed? ❑Y ❑N Slow drainage from house. ❑Y ❑N Sewage Back-up into dwelling. ❑Y ❑N Sewage discharge to ground surface or road ditch. ❑Y ❑N Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. A; -s OWNERS SIGNATURE: DATE: OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? []Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: []Below grd ❑At-Grd OMound Approx. size ox I []Gravity []Dose []Pressurized Ft.Z []Bed []Trench []Dry Well []Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES []Other []Unknown Septic tank Setbacks: []House []Well []Prop. line []Other Dose tank Setbacks: []House []Well []Prop. line []Other []Locking cover []Warning label []Pump/Floats []Alarm []Elec. wiring Soil Absorption System Setbacks: []House []Well []Prop. line []Other ❑Ponding: []Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title ,cpoo-d~ ev~a~~ cooc~~ evo~~ c~vao~ ev~o~~ co~~ c~~ c~oo~~ eoocb~ cooao,~ M E S S A G E GOVERNMENT CENTER 1101 CARMICHAEL ROAD HUDSON WI 54016 DATE: TO: FAX NUMBER: 1 ~ ..J _ fl r ~ LG ~ NAME: FROM: FAX NUMBER: (715) 381-4400 NAME: NUMBER OF PAGES INaMING COYER SHEET: _ j L ( IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, ~a PLEASE CONTACT: lQ~ NAME: TELEPHONE NUMBER: - !j c l AS BUILT SANITARY SYSTEM REPORT OWNER , , TOWNSHIP SEC.)/ T:,-N-R W A ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISIONS LOT - LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 EVERYTHING WITHIN 100 FEET OF SYSTEM vb'a ' YId,W' nrtlYWl/il _ IWIi ♦n. ,,.r b;.MN, WW M~dWR. a;t ,„a... lu.. u,s iY,. u tl. ii t 4. . I di a e o th Arrow SC LE: BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point:,4-4,- Slope at site: _ SEPTIC TANK: Manufacturer: Liquid Capacity: -/i Number of rings on cover " Tank manhole cover elevation:- Tank Inlet' Elevation: f Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; total capacity of distribution lines gallon: size of pump head; gallon per minute 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:- N um er o pits feet diameter feet liquid depth seepage pit in et pipe-elevation bottom of seepage it elevation feet. SEF,PAGE BED SIZE: number of lines width l ' -length 'the depth SEEPAGE TRENCH: width length PERCOLATION RATE(' AREA REQUIRED AREA AS BUILT INSPECTOR DATED PLUMBER ON JOB' LICENSE NUMBER- ; REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM S anti ta.~i if P etcm(' -t ~Z Stare- S e p t~. c.{ .970---- NAME _ Town Ahi St. Croix County Location- _ Se-cti.on~Lot. # Subdivi64'on. - SEPTIC TANK - ~ _ , SizgafZonA Numbers oo eompa~etmen,tA Dti6tanee (wom: (ale,~~ Buiedinc - - - ~ 1.2 0° 6,e o p e H ' ghwa en PUMPING CHAMBER Size _gaU.onA Pump Manu0c(ctu.nen Model Numb elc - - i HOLDING TANK Size. _ gaffon,5 Numbe.n o6 Compantment,5 Pu.mpe-n._ AQ.an_m System DtiALance ()nom: W(,f Bu.ti.Edin.g-- -12s H.i.ghwa.terL ABSORPTION SITE - S. J B e d_ T n" e- n e h r) D.tiA.tanee ~~om: LUe~.e_ Bu~~di ng 1'26 AZope. Htighwa.tv.li ABSORPTION SITE DIMENSIONS Width v( t4eneh _ I Requi-f(ed a nea (~t Length o (j each Q.i-ne. ~t Depth. o6 Aock bef.ow t4' f to NumbelL o{ .U,veA_ - Depth of noe_F oveh, t(,Qe_-~- -tn Taal fengh ao ~tine.b__ ~ .~(t Depth o tt-Qe be P-aw g~cade i„ ~n D.(.A-tance. between. ~line.A (I t SXope_ OA tn.ench ,i_n. peel 100 ft Total abAOA-p.tion anea t Type o(j Covvi-: PapeA. on. A=tlcaw ; PIT DIMENSIONS i Number o(I pi. l~ - Gnave..E aAoun_d pi.%tA yeA no Out6~ de, diameten. ~t Depth b(Pfow .i"nect (l - - Toaa2 abAOnp,t.tion anea (it Area ~,eqa .Aed - INSPECTED TITLE j APPROVED / DATE - 19 8 REJECTED DATE 198 REASON FOR REJECTION i z~ • State and County State Permit PLE$ 67 Permit Application County Permi # _Tt 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: v r~ 7 r .j _ /f/( B. /.OCATION:~Y4 L=Y4, Section _,4_, T,2_XN, RJ~7 E (or) Lot#_City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family i Duplex Nu. 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 s ft. New 1-' Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length Width ❑ Depth ~XC Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 7_21 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, NAMES - Z C.S.T. # and other information obtained from -'m (owner/builder). Plumber's Signature- - PhorleC"r A"/MPRSW# J Plumber's Address ' i 1 .~2 t2 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. % , i , . 7 - , i , , .e. ....f»n. max-- m - , 3 j Do Not Write in Space Be w FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application - Fees Paid: State Co my Date - , Permit Issued/Reeeted (date) Issuing Agent Name r 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 t dft~ 1_ .ft~ 1 ET7 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: t _'/o,~ Section 1 ,TZ-~LN,R1A(or)~ Township Icy Lot No. Block No. 7 z z_ County C -U t ubdivisron amts Gwmer' %Buyer Name: t c-- p~ ~x t '/l F j ( l c r Mailing Address: :6 4oct .w ca ea "~04 /~-k ~ r 1 TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 7~! fU PERCOLATION TESTS SOIL MAP SHEET -`J NAME OF SOIL MAP UNIT G PERCOLATION TESTS x TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIl~:/~^1 BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- Z_ 2>&," t 2t- t.,~. 2--a- s -2 s C, -r - 7- ~c C 1 10' Xy 2~ L L P- 14 S. Aj P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES l t B- ra j Cr r ~ ' B- 2- A) os4e, B- 0 1-4 7~1 C_ Is B- i,.v1~. co .s- ~ icy"'I 33" ' S B- C BB- 7 1 zo i c I c. I r C. PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locapon and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy r Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. (for©~~> 3 a 4/ of 0 DIN v . . ~d$ N P . F%F„-_ . a E p < 4 d I ~4- 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 t~ Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge an belief. Name (print) Certification No. _E 6 Address ~~c5 Vt a 1 n .Name of installer if known Copy A -Local Authority CST Signature REPORT ON INSPECTION OF SANITARY PERMIT # (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Name, Address, License No. o ns a iIng Plumber Time of Inspection (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System BEN ermanent re erence 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 ❑ N0; 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: Zr . ~C\1 i.,,...-~.. 1 + 10 ! Lih n Ck f > I J-1 r' f