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01/12/2007 03:29 PM
Parcel 136-1064-10-000 PAGE 1 OF 1
Alt. Parcel 33.29.17.677 136 - VILLAGE OF HAMMOND
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
04/04/2005 00 0
Owner(s): O = Current Owner, C = Current Co-Owner
Tax Address:
O - GARDNER,GEORGEJ
GEORGE J GARDNER
1747 CTY RD J
HAMMOND WI 54015
* =Primary
Districts: SC = School SP = Special Property Address(es):
Type Dist # Description * 1747 CTY RD J
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.451 Plat: 3709-CSM 13/3709
SEC 33 T29N R17W PT NE NW BEING LOT 2 Block/Condo Bldg: LOT 2
CSM 13/3709 (1.451AC) ANNEXED 04/04/05)
FItA 018-1072-50-100 (504A-10) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
33-29N-17W NE NW
Notes: Parcel History:
Date Doc # Vol/Page Type
04/04/2005 791206 225766/3626 ANNEX
07/23/1997 441 /462
07/23/1997
2006 SUMMARY Bill Fair Market Value: Assessed with:
173966 131,600
Last Changed: 05/30/2006
Valuations:
Class Acres Land Improve Total State Reason
Description
RESIDENTIAL G1 1.451 23,000 107,200 130,200 NO
Totals for 2006: General Property 1.451 23,000 107,200 130,200 Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 10/03/2006 Batch 06-15
Specials:
Category Amount
User Special Code
Special Assessments Special Charges Delinquent Charges
00
0.00 0.00
Total
Parcel 018-1072-50-100 01/12/2007 03:21 PM
PAGE 1 OF 1
Alt. Parcel 33.29.17.504A-10 018 - TOWN OF HAMMOND
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
04/04/2005 00 5
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - GARDNER,GEORGEJ
GEORGE J GARDNER
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.451 Plat: 3709-CSM 13/3709
SEC 33 T29N R17W PT NE NW BEING LOT 2 Block/Condo Bldg: LOT 2
CSM 13/3709 (1.451AC) ANNEXED 04/04/05)
NKA 136-1064-10 (615) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
33-29N-17W NE NW
Notes: Parcel History:
Date Doc # Vol/Page Type
04/04/2005 791206 2776/326 ANNEX
07/23/1997 956/96
07/23/1997 441/462
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 03/09/2006
Description Class Acres Land Improve Total State Reason
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
it
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
0
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AS BUILT SANITARY,SYSTEM REPORT
OWNER ALnA, TOWNSHIP SEC ~Tst11i-RI~LJ
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
K-
[nI_aVERYTHING WITHIN 100 FEET OF SYSTEM
a
I di a e oath Arrow I
,
n- t
~j - - SC L
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: Zo 0 0
Number of rings on cover f4 Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Nianber of gal. pump set or a cyc e gallons; total capacity o
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: um er o pits eet diameter
feet liquid depth seepage pit in et pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED'SIZE: number of lines width le~igth 3 6 le depth
SEEPAGE TRENCH: width length
PERCOLATION RATE 6* _ AREA REQUIRED REA
INSPEC.TO~1
DATED / e~ l PSI ER ON JOB
7-e ~0"n sa e e7 idn e,rt a C 11An xE NUMBER r
4T4 It
/''eQer0
a '
I:I POET 01 INSI'1 CT ION INUI V1 DUAI SI wAGI SVS It M
ti to tc S c pr 0
r
ti n t a w n h i. _
-St. Cltu<x Cuunttl
I r t c Alf, _--~Sect~,on3_.?_Lot # --_Subdiv,i.15
~'t ~'I 1(' TANK
afton,6 Numbers o6 comp cvi tme.nte
1)(" t,mcc (Itom: WeU, 8u4'_('d4_vtg--- 120 s eopv,
Highwa.ten
PUMPING CHAMBER
C gaTToms P M n 4 c.taIt eA Modvt Numbest
H0 LDING TANK
S c qa fon6 Numbeti-o(l
Curnr >c trncn t6
I'o rnp,E, It AZ anrr y6 t) i
U ct u n c e''..~, _
- - in ~ 12 0 6 X a p e
Highwa.ten
Al.;SORPTION SITE
he I 7nench
(!ti It om: (Uefe Butie ding920 (op)c
Ittghwa-teli
A(;tiOlh'Vf ION SITE DIMLNSIONS
w,cdth oh theneh C_ 6t Re.tju.c ved area r
Lt o,gth oA each Erne f,t Depth oA hock be-('ow t to In
Numbvrt o . k4,vie6 2
fi_ D v p) -t It o A It a c h o v v lt fi a v a n
Total' fc.ng,th ofi I'i.ne6 t Depth o t,4''e bE (ow r aadc in
04 6tanc'e between pi v6 t SXup,v c,~ tltv.no Gr 100 (~t
(~lrlI' ab%o 1cp)t.<-on alteCa jt Ft1pc Cr( ('ov(•I1' Pare( h ti thuaP I r D I M I WS I O N s
Ni)tlll)!"t o~ r)-{.tA Ghavc aho14V1d p~ 15 11CA Vfi'
Ou lA <dv d4 amc.tcn 6t DcDth be-tow 4afvt
f
Tutta( ab6o N#tion acre y `---6t
1NSP1 C1ID 14y!~-~ TITLI_
5D
A
I'f'R0VI D" DATL _ I'd h
I:I 1C CH, V OA TL I V
I:I ASON FOR RI JLCTION
PLB State and County State Permit #
67
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:
~Ccrq e 64v n(f r
B. LOCATION: t om'/4 uQ '/a, Section 3a, T 2 N, R / E
(or) 6) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township fhb,MAI.-ild
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY_ .C'C Total gallons, No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete x 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 X115 sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lj'neal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length i Width Depth Tile depth (top) IF No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land_ /`?L1 Distance from critical slope
WATER SUPPLY: Private WT 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 Te~rste l 1 p /
NAME 4cl C.S.T. # 55 ~~`0 E~~ and other information
obtained from X40 (owner/builder).
Plumber's Signature MP/MPRSW# 3a-3 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.
3
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application, Fees Paid: State Al, Count Date
Permit Issued/RjecM (date) Issuing Agent Nam
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
!i1l~ ~l
~L
ry~ -e
vtr A X X X X X. .C ~ )C x~ x
Ov well
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t
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 ht L'14,N 0 Section I L ,T 2 N,Rj~_ E (or)&N Township or Municipality Rai Mc~ i2c°~
Lot No. , Block No. County S7~` (f re I`:Y
Subdivision Name
Owner's/Buyers Name: er-4 e Get L` 9. co r
Mailing Address:_ e ~t 1-Y4 W ;3 C1
TYPE OF OCCUPANCY: Residence-,X' No. of Bedrooms -3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW -REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MA)D-E: SOIL BORINGS Ploa4i ao el PERCOLATION TESTS
SOIL MAP SHEET NAME OF SOIL MAP UNIT 11S 3e0e74t
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 AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- I 36 16,16 , s; as S N N .E ID 13
P- 0 !V%ILs `.1 Ill 't ;L 'Y"A 5gGr 3~`
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- I ">d 11 ~'S ~T r 54Gr
B- c~ W" 15"R " s S4 GI-
B-
B-
B-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the l the loca 'on nd 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 slope.
--A X K X X ?l YL X X, V~ X~
A=eke Kiev; S e-;C R,c~v~r fio
d
• boatDl~s Present
P~res~eht ~
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Ar
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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. } ~p
Name (print) 4 h Certification No.~~
i S kJ • S~S~tJa7y~
Address v
0 57 le
.Name of installer if known
Copy A - Local Authority CS F Sig:, P ture Fw~