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• AS BUILT SANITARY SYSTEM REPORT
,ER 7~eu t~ , r (r ~r TOWNSHIPr 'F . SEC. T ~N, R~~1 -
j• tS,DDRESS ! ST. CROIX COUNTY, WISCONSIN.
tA))
DIVISION _
ja _:f,, LOT LOT SIZE_
PLAN VIEW ~Distances & dimensions to meet requirements of H62.20
SHOW E1.7'R.'THING WITHIN 100 FEET OF SYSTEM
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TIC TAN-K(S) /000 MFGR. EIsid ca_ e NUn Gt Ajt,zUw
of ~,1 t' `'Cci s _CONCRETE V ST:1,
S cat e /fl, sc x ~e
'ACHES .NO. OF,10. GL r~ngS On cover 7s`G i DepthDRY 141ELL
c? cE
width length area -
no. Of lines widthjL;_ length area r. rc~ `c c"
depth to top of pipet r'
S EGATE _
EZ. -WE p IN AREA REQUIRED -J & AREA AS BUILTT
'claimer: The inspection of this system by St. Croix County do-as not imply complete
_1•Diiance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
azem operation. However, if failure is noted the County will make every effort to
--orr.-,ine cause.cf failure.
._:ASHS AIND OILS SHO;;iD NOT BE DISPOSED THROUGH TTIIS SYSTEM.
•
`'INSPECTOR
DATED PLL^nf ER ON JOB
- LICENSE NUifBLR
z
1REJORT '`OF INSPECTION INDIVIDUAL SEWAGE SYSTEM r
San.i,tany Penm.i,t /
_
State Sept.ic_~
NAME s owns hip St. CAo ix County 4
Location r' i Section
SEPTIC TANK
Size gattonz. Numbers o6 CompaAtment,6~
DiAtance Flom: weft 12% m greaten Kope...... It
Buitd.ing_ 6t. Wettands 6t.
Highwaten It.
DISPOSAL SYSTEM
D.i.btanee. Flom: Wet It. .12% on greaten stope ~ .
Buitd.ing Q. Wettands Ft.
Highwaten 6t.
FIELD DIMENSIONS:
Width ob" tneneh It. Depth Q lock below tiZe in.
Length o6 each tine_ ,fit. Depth o6 Aoeh oven We .in.
Numbers Q tines Depth o4 tiZe Wow glade in.
Total length o6 tines It. Slope o5 .tneneh in pen 100 It.
DiAtance between tines I,; . Depth to bedAook It.
To.t a_Z abz onbt ion amea 02 Depth to gnoundwateA It.
2
.Requited arcea Type. oru Coven: Paren on Straw
PIT DIMENSIONS:
Numben o6 pits GAave2 mound pits yet no
Outside d.iameten It. Depth below Wet jut.
2
Totat abz onbtion area _6t A
rn
Area Aequined _42
i
INSPECTED BY _ TITLE
APPROVED DATE 197
REJECTED DATE J97
EH 115
t- WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
t P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: /Yl'!%, S f-%, Section ?4 T3_0N, R 4V (or 1) Township or Municipality
Lot No. Bloc No. ` f k h% ~'rY eff `/~/y l/1.4 W, County 51'
Owner's Name: ~S bdivision Name
h~
Mailing Address: Klie,, to,. , s-3,-d/ ~o v
TYPE OF OCCUPANCY: Residence X No. of Bedrooms -3 Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 4 a» PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE ~Ur9'`'I
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P C G tee. a~ y /VQ~ yyl ~y YCI
P- 36 s-e DMA -3 C
6 -30
13~ Se e- 1~t,-e_ 14
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)
B- ld,i /~f~Ne 79,E r. YS 7,2 A ~r`rtN dIXS ~tC' C" /
,,7y ,2 SG L
lvx~ Cl- y
/ E' /~rNl.4T~~Ja1 C/ B_ 3 ,clcsX~ 7Y~., y,, ".5 / !v/ Ado Ice S,` e/
qQ~ ~/~lt7iiC2 !r is SZ (~Ed~2'f ~ar~24✓i J S.v e.
B- 7, c~ ] ,l Sly ~O^ E / %r 4rt.(l~JL~S ~s~t~
q
~dec! f 7 cZ " 7 " S / !r,? A-1 oo-iP "t FOr ~i/a O us Sr
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate numby~r of square feet of absorption area
needed for building type and occupancy. 2 Y-S Swc, 5..,. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope. ~YS7Asti q ~i e~p~,r,
A k se *x y V I y { f f , I , { ~ i
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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
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.
Name (print) Certification No.S -
P o Lt~t~ ~`l a%
Address ///6 e&a
Name of installer if known
L
CST
OPAL AEITHORF Signat-~=:_
State and County State Permit #
PLB67- Permit Application County Per #
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: /4'5 AF '/4, Section o26 T- N, R q & (or) Lot# -/-City
Subdivision Name, nearest road, lake or landmark Blk# Village
f 066::5 L,) y *;I Township xcsp~W
ivy k4 T,-
C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons Z
D. TYPE OF APPLIANCES: Dishwasher < YES NO Food Waste Grinder YES_,>e-NO # of Bathrooms--1W-
Automatic Washer C YES NO Other (specify)
i
E SEPTIC TANK CAPACITY 1,000 Total gallons No. of tanks / -
*Holding tank capacity Total gallons No. of tanks
vv Installation Addition Replacement Prefab Concrete X
Poured in Place Steel Other (specify)
FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _4/0 2) Yp 3) OTotal Absorb Area ~a sq. ft. /
`lew X, Addition _ Replacement *Fill System E~l~~u.~rtd
eepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches
epage Bed: Length-S:1" Widthal> ' Depth -36 ' Tile Depth No. of Lines
S
iee ".,page Pit: Inside diameter Liquid Depth Tile Size 7l/
P'Jrcent slope of land- Distance from critical slope
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
.'%.'isconsin Administrative Code, and that I have sized the effluent disposal system 'Iie l `S repared
'_)y the C ified So' ~s er,
AME r'„L t Sf~ ) C.S.T. # SlS j~and other :nforn,ation
;lrtained from $ eme ` -sC t (owner ~
;'!umber's Signature MP/MPRSW# -Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
I H62.20, including well). / /
/10
~ q le - s 7~A,~n Bs ,r4s .t,7 d rsT e d
-sae
Slo)de-
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cy / er . Cry f, ral
n ~ - 1. ;~r nPasc~ ~ v
T V
14' SLSN C' e J C' n c~ a ~~rZi
104
i~.MP Sea' ~
jgo 6&
ti ~c C r;~~ CA ~ ~
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o
~A 1 76
-^,Co C~r eN r
Do Not Write in Space Below FOR DEPARTMENT USE ONLY n
Date of Application l j 'J f Fees Paid: State L/, G County: Date
Permit Issued (date) _Issuing Agent Name
Inspection YesNo Valid# Date Recd
1. county (w rte 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 611 /76
- TRANSFER FORM 7/z ~
SANITARY PERMIT
State Permit # PLB 67-T
Sanitary Per
County y
Sanitary Permit Transfer Date Original Permit Issuance Date ,
A. Property Location: '/4 Imo`'/q Section cW , T "SEA N,R i q .Q_(ar) W Lot # ~ City
Subdivision 1Name, Nearest Road, Lake or Landmark BILK # Village
•~°a:-~c./ C`~`-~ 1~a /1~~:. f,~'c~~ Township
B. TYPE of Occupancy: Commercial Industrial Other (Specify)
Single Family ,X Duplex No. of Bedrooms Variance
C. SEPTIC TANK CAPACITY &r-) 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/SIPHON CHAMBER - Total gallons Prefab Concrete Poured-in-place " Other(Specify)
D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 14eq Total Absorb Area 24 2 sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No.Lineal Ft. - Width Depth -'-Tile Depth(top) - No. Trenches
Seepage Bed:- X Length Width Depth Tile Depth(top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. Seepage Pits
Percent slope of land P `>tT Distance from critical slope > E. WATER SUPPLY: EA' Private ❑ Joint ❑ Community ❑ Municipal
Present Sanitary Permit Holder Phone No. = Sanitary Permit Transferred To: Phone No. "5'5"
Name . ,')C,_h Name
.Of 4-A
Address ;ZZkAC,- LOA Address
Zips' C
Zipj~72
I, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with
section H 62.20, Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH-115 prepared
by the Certified Soil Tester a r any additional soil tests that may have been required.
Plumber's Signatur~- -M/MPRSW # _0
Phone #1t~- 2G 8
Plumber's Address Jet Y4 k_;10111\ c. 1le- L"'. 119-`/ 7 2 7
Information obtained from .wi`4"ter (owner or agent)- 2
PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord
with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property r neigh-
bor's pro ert , If well as o,t been drilled
I ~P _pleas1
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71
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Signature of Issuing Agent
1. County (Yellow copy) 3. Owner (Pink copy) DIVISION OF HEALTH
2. State (White copy) 4. Plumber (Green copy) P.O. BOX 309, MADISON WI 5370"
Parcel 030-1044-10-000 03/22/2005 05:21 PM
PAGE 1 OF 1
Alt. Parcel 20.30.19.160B 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
GORKE, RONALD R & CAROL M
RONALD R & CAROL M GORKE
1426 47TH ST
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1426 47TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 6.640 Plat: N/A-NOT AVAILABLE
SEC 20 T30N RI 9W NW SE LOT 1 CSM 3/811 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2004 SUMMARY Bill Fair Market Value: Assessed with:
5082 254,100
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.640 112,000 138,000 250,000 NO
Totals for 2004:
General Property 6.640 112,000 138,000 250,000
Woodland 0.000 0 0
Totals for 2003:
General Property 6.640 65,800 110,000 175,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 208
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00