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Parcel 040-1061-90-000 01/04/2007 03:53 PM
PAGE 1 OF 1
Alt. Parcel 15.28.19.2340 040 - TOWN OF TROY
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 - SMITH, RENNIE & DEBRA K
RENNIE & DEBRA K SMITH
397 169TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 312 S GLOVER RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.950 Plat: N/A-NOT AVAILABLE
SEC 15 T28N R19W.950A SW SW FROM SW COR Block/Condo Bldg:
GO N 659.5', TH N 63 DEG, E 347.7' TO
CEN TN RD, SELY 150' TO POB; SELY 200', Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
S 63 DEG W 208', NW 200' TH N 63 DEG E 15-28N-19W
208' TO POB
Notes: Parcel History:
Date Doc # Vol/Page Type
08/27/2004 772835 2645/122 WD
07/23/1997 531/596
2006 SUMMARY Bill Fair Market Value: Assessed with:
158199 184,400
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.900 38,000 130,200 168,200 NO
Totals for 2006:
General Property 0.900 38,000 130,200 168,200
Woodland 0.000 0 0
Totals for 2005:
General Property 0.900 38,000 130,200 168,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 103
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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C
Rf FORT OF INSPI CTION - INDIVIDUAL SLGIAGL SYS-ILM
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Town,5h~~1 er I r t it [ V'' S v.ctt'oYi Lod # Subdi.v1A i_on
- 31JdC-- -
1 I'I IC IANK
~yaQ.f on.6 Numbeh o6 eamp(vi tment6
(),liom: LVeU 664-' ding 12"s of (rp e.
Ilighwa.te n
I'11MI'ING CHAMBER
Si ze gaUonh Pump Man ti (ae.tune~c MadeNumbe.lc
IIOLVING TANK
Si gaP.QahA NumberL of Compantment6
f
Akaism SrIAte-rn
Ur takicc (~~tCrmi E C'"~~- 6uild~nc 120 apc
H,i.ghwa:ten
A6SORPTION SITE
Iivd 1'Tench
tart c (~com: LVef t~--- 6 114. cl n9----- 12 Akope.
Ll.i gIt wate"I
Ai:,;( l~l'I ION SITE DIMLNSIONS
W( 11I1 o() tke vcch (.t Keyu4~ced area (,t
LcnII#h of each f4ne t Depth oA rack beeow tike- <v~
Number o(' e ne_A Depth of teach oven ,tike <vi
To-taf teng.th o f Z.i- neA ( a Depth o f -tiev be ('ow grade i n
V.i-Atavnce between fineA nt ti4'uprr,{~ 0LC.vi eIt <n. Lc~ 100
Totat abAOn.pttion area (t fi/pc o{i Covv l: Paper ah At~r~fia~
C] L U I Ml NS I ONS
V Iin 1) It o A K''< to G1rit k'o o'r ounc( I5 rl~'n --yr~, I~ ~
0 (bide (liam ctcti Al Vepth bcfow 4,-kle
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AI'i'Rt)VI D 198 ~
I" 1 11 C I 1 1) OA-1-1 19n
I;1 A.l,ON I OI: Rt JECTIOr
i
PLB State and County State Permit #
Permit Application County Perm 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 Mailing Address:
B. LOCATION: < % '/4, Section A,L, T!2fN, R / ~ E (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 A-7Z
D. SEPTIC TANK CAPACITY Total gallons No. of tanks <
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete L--- Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Pr fab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width_ Depth " Tile depth (top)ACNo. of Lines - 7
Seepage Pit: Inside iamjtter Liquid Depth No- of Seepage Pits
Percent slope of land_ y 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 Cert ied Soil Tester,
NAME tr..t1" C.S.T. # -4-,'5--,15/:f nd other information
obtained from 7v' (owner/builder).
Plumber's Signature Phone Z/
Plumber's Address A/FP~MPRSW# x
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.
E E
3
E
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application - Fees Paid: State GNU ounty Dat - &
Permit Issued/+Refeefed (date) -Issuing Agent Name
Inspection Yes k 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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY; DIVISION
LABOR AND~ PERCOLATION TESTS (115) P.O'. B. 7969
HUMAN RELATIONS MAD150N, 3707
LOCATION: SECTIO~T. N/R For) W TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: r U DIVSM9N NA`AAAE:
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: ~~i S~ ~~11
t"~ .
USE DATES OBSERVATIO
FEBEDRMS.: CIAL DESCRIPTION: PROFIL R TON ON TESTS:
/
lResidence ❑New QReplace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
oS ❑u aS ❑u EIS EA aS E1u E1S ou - - - -
If Percolation Tests are NOT required DESIGN RATE:ISYSTEM.ELEV. If any portion of the lot is in the
under s.H63.09(5)(b), indicaFloodplain, 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.)
B-
B-
`7
B- -
B-
B
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
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. Y
SYSTEM ELEVATION
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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 (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
CST SIGNATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
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