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Parcel 038-1122-80-000 01/17/2007 12:43 PM
PAGE 1 OF 1
Alt. Parcel 30.31.18.5106 038 - TOWN OF STAR PRAIRIE
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 - BELISLE, MARY
MARY BELISLE
850 190TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 850 190TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 16.330 Plat: N/A-NOT AVAILABLE
SEC 30 T31 N R1 8W PT OF SE SW 16.33 ACRES Block/Condo Bldg:
LOT 1 OF CSM V 4/1147
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/09/1999 604671 1433/97 TI
07/24/1998 583556 1342/438 QC
2006 SUMMARY Bill Fair Market Value: Assessed with:
175751 Use Value Assessment
Valuations: Last Changed: 10/05/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 32,000 43,700 75,700 NO
AGRICULTURAL G4 14.330 1,100 0 1,100 NO
Totals for 2006:
General Property 16.330 33,100 43,700 76,800
Woodland 0.000 0 0
Totals for 2005:
General Property 16.330 33,100 43,700 76,800
Woodland 0.000 0 0
211
Lottery Credit: Claim Count: 1 Certification Date: Batch
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 TOWNSHISEC t_T IN-R W
ST. CROIX COUNTY, WISCONSIN.
ADDRESS
Jr x
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
-EVERYTHING WITHIN 100 FEET OF SYSTEM
y g+ ~
r~
i
-7
I di a e o~ thl Arrow
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: ~Slope at site:
SIY"I'IC TANK: Manufacturer:. Liquid Capacity:
Number of rings on cover Tank cover elevatio
_Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
i4uniber of gal. pump set or a cycle gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower brand 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: Number o pits feet diameter
feet liquid depth seepage pit in eet pipe-elevation
bottom of seepage pit elevation feet. „
SEEPAGE BED SIZE: number of lines__,;. ? width_ lerYgtlL the deptY~
SEEPAGE TRENCH: w'dt length r
AS BUILT
PERCOLATION ]'LATE % A REQUIRED` A]k7
INSPECTOR DATED PLUMBER ON JOB AL
> - -j _
LICENSE NUMBER-,
` R11'OR1 01 INS I'1 CT ION - IAIDIViOUAI- StWAGL tiySI1M
Sav,4 tah,1 1,cItmi r ~
ra t Se1.,.t<
AVIV
NA~II IAV Townbhip67,d! st C~,u x c'uur, t,r
i r r,S ~ V. c.ttio26 Lot ~ ubdi.vie<on
IANK
/ .~-c)_ gaaone Numbers o6 eampanxme.ntb _ - / -
` ()&om: we.2x k3uti~d~ ng~~j' k31296 At opo.
Highwa.ten
i'11M1'ING CHAMBER
Sizeo gatton4 Pump Manu 6ac tuner Model, Numb e. rc
HOLDING TANK
Si 7V--- gatfan. Numbe.n a6 Compan.tme.nts
I'u rnpe n AxaAm S ya tem
x B u L X d t n g 1 2 04 b P o p e
H4:ghwa.t.e4
I ON S I TL
l~.x.~~ ~ Tnench
no m: lvelf 0 Bui. ding ~ r2`~ ekupe.
Ifighwa.ten
I ]ON SITE DIMENSIONS
dth o~ tneneh ~.t Requ.l.ne.d area j7) r
I, „q th uA each line 6.t Depth oA hack bveow t.rke. l 27- 1r,
Numl,en o6 Depth aA rock oven til'e
- I ( t(rY een th a .i,neb I
9 fi X _6t Depth c)6 tiPe bE Yaw yhado it
r✓ 1~, be twee.n 44'ne.6
At Se u p e o h t&e. n c d( 4 L, , - it 1 U U h l
t(,1(in.ption ahe.a At 1 yl-w 0A covenI'ap_(' l u'i ~ I'1;ii+1
i' INIONS
V i!iiI 11 C~( t'J Gave ( aiAo( nd is V. (Iiarrneten ,..,th befow cnevt ~t
i
d - 6t
J I<< i 1 0 6V
A i~'I:i) VI U DATE IN
1915 ilk
i 11 c110. DATE 19 1t ,10 1\
i A, 0N [OR REJECTION I'
I
s
,tea
' State Permit # /
-P B- 6 7 State and County
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
4 r
B. OCATION: Zk Section R (or) 1~1 Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY / 90e-) 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 J Total Absorb Area q. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Linea Ft. Width Depth Tile depth ~(top) No. of Trenches
Seepage Bed: Length Width /9 DepthTile depth (top), No. of Lines
Seepage Pit: Inside diam
_Ste`rr Liquid Depth No. of Seepage Pits
Percent slope of land k , Distance from critical slope
WATER SUPPLY: Private V 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 CerS fled Soil Te er, 0
NAME J r J ' - C.S.T. #and other information
obtained from PNI d A/Ze (owner/builder). /
Plumber's Signature MP/MPRSW# ~SF Phone -if Z3,~
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
Date of Application Fees Paid: Stat e'za County /15;~/ "z to L/I G
Permit Issued/ d (date)-~ Issuing Agent Name -
Inspection YesTN0 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
DEPP„W,VENT OF - REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MU ICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
- 4 /T N/R (or) W szrae
COUNTY: OWNER'S BUYER'S NAME: A N A DRESS:
USE ✓ DATES OBSERVATIONS MADE
PROFILE DESCRIPTION ER LA ON TESTS:
NO. BEDRMS.: COMMERC!AL DESCRIPTION: r~
Residence ~ ❑New tAlReplace
s
c~
RATING: S= Site suitable for system U= Site unsuitable for system ` 4,01.1, A
CONVENTIONAL: JMOUNI IN-GROUND- URE: SY~STE -I~-FILLHO~LDING TA K: REC ENDE ~S')/STE'~ qyO/~)
S U S U S ~U (,~C
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL If any portion of the lot is in th ✓//(/C r
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain is_i tion:OFF/`
PROFILE DESCRIPTIONS K
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNES 2,jT E, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. O
B- r
1 ~
B- s?_ -3 67 ~Xo >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. pE D1 PERIOD 2 PE IOD PER INCH
fr /
P-14
_464&: -30 6
P-
P- r Y r~
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 g2' g
f
A
3
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TN
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✓A
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 rint): TESTS WERE COMPLETED ON:
ADDRESS: / CERTIFICATION NUMBER: PHON NUMBER optional):
r
CST SIGNATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DI LHR-SB D-6395 (N. 03/81)
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