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Home My WebLink About026-1034-40-000 0 4 O 3 m n C7 3 (D " (D c (D .r \ 1 cn g 0 2 N o w m m A- N `1 • : D, ° m N ° o rn CD ° m N C~Jt N ° 1 O 3 m co 5 w w o N° m N w N O a 0 \ 1 CL 0 CD 0 -0 r(D 7 O m O D O w O 3 O w * O - to 00 N V1 N' _ ° O 0 O d C ~ D a co m ai co d CD 3 n o CD O a Z 'I CL m N 00 00 C o o O T P =r Z 9 z 0 0 0 2 o v r'3= < z a) y in D oD Y o w n -I m v N (D - V (p 7 3 ) N ~ W N Cl. Z DWO O ° O ° N !1 Cl)° V !V (D 0) 11 C N N W (p n 3 z CD (p -4 cn Z (D R CL A o' z w W v m o m CD 3 Z c Z Z y m CO a I N 0D. o a (n o - - CD z N° ° C _ m ~c y A I o a. ~ A X I Q A cr :z m A N I W N O O V A O A CD a CD rfl O (N„ °O Cl y ti Parcel 026-1034-40-000 01/23/2007 04:13 PM PAGE 1 OF 1 Alt. Parcel 11.30.18.151D 026 - TOWN OF RICHMOND 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 - PROVO, GREGORY A & LAURIE A GREGORY A & LAURIE A PROVO 1382 168TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1382 168TH AVE SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 1.270 Plat: N/A-NOT AVAILABLE SEC 11 T30N R1 8W 1.274A NE 1/4 NE 1/4 Block/Condo Bldg: LOT 1 OF CSM V 3/ 763 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 11-30N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/08/1997 1250/276 WD 2006 SUMMARY Bill M Fair Market Value: Assessed with: 176842 211,700 Valuations: Last Changed: 06/19/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.270 35,600 129,500 165,100 NO Totals for 2006: General Property 1.270 35,600 129,500 165,100 Woodland 0.000 0 0 Totals for 2005: General Property 1.270 35,600 129,500 165,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 219 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT OWNER , y~,r ✓ ` TOWNSHIP - _SEC.// Z,3()N-1 6 ~4 v 9 ADDRESS' ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW F.VMTHING WITHIN 100 FEET OF SYSTEM r- I di a e o th Arrow I S C L - i_ BENCHMARK: (Permanent reference Point) Describe:" ; C~.~•-~- ^ Elevation of vertical reference point:[, f Slope at sit6:- SEPTIC TANK: Manufacturer: ' ~~G :.;:X 2>: ~c Liquid Capacity : -~y~-. Number of rings on cover Tank manhole cover elevation : Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; tota.T capa c i i y distribution lines gallon: size oT pump IZea~l; gallon per minute horsepower ran name and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number o pits feet iameter feet liquid depth seepage pit in et pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines __j wilt length LL ` e ep; h 2 SEEPAGE 'FRENCH: width length PERCOLATION RATi, FEA-REQUIRED BUILT DATED PLUMBER ON JOB LICENSE NUMBER cc + REPORT OF INSPECTION - INDIVIDUAL SLWAGE SYSTEM 41-fl Sari tah,y Pe>tm~.t /40 S ,t a .t e. S e p t 4, c/46,/W T o w n s h 4. p- ?ClZ,(j&2d j L>S ,t . C ~L o ,i_ x C o u n l cj S c'ct,in.n Lo,t Sub divisA"0n r a f e (J n,6 N u rn b e,,t o6 c o m p a.n.t m e n -t,6 r ; wekf Bu..ctd'.vig Z.. 126 stope~--- fl r c~ftwa tc III CHAMIit R ga.Ef.on4 _ Pump Manu6dc-tune.A. Mod(,f Numbv~c ( I) i NG TANK { ze gatton4 Numbe.k o6 Compan.tmen-t6 AZahm System t,tcic'e {nom: Wett Buitding' 12$ 4kape._` - H.tg hw a.t en A, t ION -'ITE 7nench > , vi c v h n m W e Y..2 B uitdin 9 t2% s.E o p e Highwato.n ,)N Sl7E "DIMENSIONS (~,avtcft Re.qu-ine,d anea_~ rit „A vac_h C-inv__.__ Sr" 6t Depth o6 hock be.Eaw file rv, ot,, , A k"ine's Depth o6 hock oven t.i. c 1,!(of xeng.th o6 fine. 6t. Depth o6 ti e below gn.ade - r n Uin(ance between i!ine,6J 6,t Stope o6 tit, eneh tn. peg, 100 At I„tof absan,ption anea gt 7ype 06 Cave Pa all A ,MA) PIT __-.n 7 AI F. - C f N Nurnben oA pit6 GA.ave.E alound plc.ts---- tfc,~ r„ 4 c1<'(mete4 De.p-th below -i.nfe.=t A! i t nJ(~.,tiun j~ [;1 6t A,--,; cr~t~( rlec~ 6t TITLE ~ 1,Put I,) DATE fyts~!~ a'r ~ t; r t i~ DATE I y n i'I J1 CTION State and County State Permit # PLB 67 A~ w Permit Application County Permi 3 v, 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 M ling Address: 1 1 a B. LOCATION: Section , T N, R (or) W ot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township 1 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 _,X Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Pr ab concrete Poured-in-Place Other (Specify) E. EFFLUEN DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (to ) No. of Trenches- Seepage Bed: _Length. _Width _Depth J ' Tile depth (top) <i No. of Lines Seepage Pit: Inside a eter Liquid Depth No. of Seepage Pits Percent slope of landp Distance from critical slope t S_ WATER SUPPLY: Private X Joint 1:1 Community El 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 Cert*f ied Soil T ster, NAME _ iU,4f~f ~l C.S.T. # c5 S - `s 1/ and other information obtained from (owner/builder). Plumber's Signature S (3 Phone # Z' S2 3S MP/MPRSW# Plumber's Address z, ,z : 4-//,[ 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. a n... e,.. a _ m E ~ P t i E m 1 7~ 3 E j a t 7 I _ . > ~ a , - _ a...~ . ` a _ _ .e.._ _ . e ..a.,,-e ,m ..v Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT SE ONLY y Date of Application Fees P id: State Ct in y 0-0 Dat / ` Permit Issued/Uo}_ ett (date) 7 `~Issuing Agent Name v Inspection YesXNo 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 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'/Y 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. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: Mailing Address: Property Location: City, Vi ge o Township: County: '/4S /T N/R (or) W Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: ' f~ 1 or 2 Family *State Approval Required. I TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 1621 HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: - 1.. EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square fees,): X New ❑ Replacement ❑ Experimental 54 Seepage Bed ❑ Seepage Pit I ! ❑ Alternative (specify) ❑ Seepage Trench /A W Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of rivate sewage system shown on the attached plans. Name of Plumber: Signa re MP/MPRSW No. Phone lu,b r: r7~ Plumber' Address: Na of Designer: 61~ oi!tL COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ APPROVED Sanitary Permit Number: ❑ DISAPPROVED Reason for Disapproval: 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 (N.03/81) DEPAR SAFETY & BUILDINGS INDUS TMENT OF REPORT ON SOIL BORINGS AND NDUSTRY, PERCOLATION TESTS 115 DIVISION AABOF3 'AND / 1 P.O. BOX 7969 HUMAN RELATIONS ` ) MADISON, WI 53707 LOCATION: SECTION: pp W TOWNS P/MUNICIPALITY: LOT NO.:BLK. NO.: S BDIVISION NAME: COUNTY: O 'S /BUYER'S NAME: MAILING A D D R E r 1r 9 b, Z4 2: USE DATES OBSERVATIONS MADE r~ NO. BEDR~AS.: COMMERCIAL DESCRIPTION: D R TONS: ER LA ION TESTS: [Lif Residece IX'New El Replace 115ROF1 RATING: S= Site suitable for system U= Site unsuitable for system 1 CO~NVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILCH L ~NGTAN K : RECOMMENDED SYS EM:loptional) ❑ S ❑U ❑ S ❑U ❑ ❑u i - 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: 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.) _yq B- / 7 14 B- 97 B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PE IOD2 PERIOD 3 PERINCH P- ✓l f Y 7 P- 23 1 7 3 3 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 v r 6vgxl TN__ - I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with1he 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: AD CERTIFICATION NU ER: PHONE NUMBER optional): CST SI E: DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) I EM 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: _'/4, Section, TTN, R € E (or W, Township or J%4iQNWy Lot No. , Block No. County t S bdivision Name Owner's Name: ' Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms Other vGw EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMEN DATES OBSERVATIONS MADE: SOIL BORINGS c PERCOLATION TESTS ~rF SOIL MAP SHEET I SOI L TYPE t I ^ f~ i PERCOLATION TESTS I TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS ICHARACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN IA- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) 5-1 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of s ita,blearea . Indicate number of square feet of absorption area needed for building type and occupancy. V 14- Indicate scale or distances. Give h rizontal and vertical reference points. In icate slope. oc,' u 715 AA~ V„ w t N f 1 r i i r j T-T i ' - t fir' Z 2 77 =7 77_~= =-7-1 __7F-T I, the undersigned, hereby certify that the soil tests reported on this form were made me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recor ed and location test holes are correct to the best of my knowledge and belief. ' J, Name (print) Certification No. 3 " - , r Address Name of installer if known CST Signature COPY A - LOCAL AUl HO'; iY AA 1.31)1 44 /vo O'll .~.a•.;iNnAddrIMTAWpGtiY'yrhlLLWywn4U~~~•r.~i~~ x:; „ ~a 6~ 97 l t ~i~~ DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSfRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% 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. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: Mailing Address: Property Location: City, Village or Township: County: '/a '/aS ~T NCR E (or) W Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: ! (If assigned) IIII TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: f ❑ 1 or 2 Family *State Approval Required. i TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY l HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: r EFFLUENT DISPOSAL SYSTEM . PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 0 Seepage Bed ❑ Seepage Pit f ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: [-'j APPROVED Sanitary Permit Number: ❑ DISAPPROVED Reason for Disapproval: 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 (N.03/81) AAA Ak.r4 7co:t~98` ioo " 0 -Al • i 3 .Y 1 i i / •