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Forms and Documents Page 2 of 2
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Plb. t-A WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES
Division of Health
' Section of Plumbing & Fire Protection Systems
ON-SITE WASTE DISPOSAL INSPECTION REPORT
Name of Premises
Street City County
Master Plumber Address
Owner Address
❑ County Permits ❑ Appropriate State Permits
Type of Building: ❑ Public ❑ Single Family or Duplex
CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM
❑ Building Sewer ❑ Conventional Soil Absorption System
❑ Septic Tank ❑ Conventional System-in-fill
❑ Holding Tank ❑ Alternate Mound System
❑ Seepage Bed ❑ Holding Tank
❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System
BRIEF, FACTUAL COMMENTS AND SKETCH:
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❑SEE ATTACHED
DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary)
DATE OF INSPECTION
Signature of Inspector
White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party
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Parcel 106-1094-10-000 10/11/2006 12:54 PM
PAGE 1 OF 1
Alt. Parcel 30.29.16.803C 106 - VILLAGE OF BALDWIN
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 - HEEBINK, ROBERT C
ROBERT C HEEBINK
PO BOX 135
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 8.170 Plat: N/A-NOT AVAILABLE
SEC 30 T29N R1 6W N 1/2 NW FRL. N 32 RDS_ Block/Condo Bldg:
OF W 47 1/2 RIDS UL- ART_QONVEYED TO
8fi752 26/26 SSESSED WITH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
P443-B1 ASSESSE EPT OF REV-MFG 30-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/ 1997lc~
07/23/1997452/526
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/27/2005
Description Class Acres Land Improve Total State Reason
MANUFACTURING G3 8.170 0 0 0 YES
Totals for 2006:
General Property 8.170 0 0 0
Woodland 0.000 0 0
Totals for 2005:
General Property 8.170 67,500 291,000 358,500
Woodland 0.000 0 0
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
Parcel 106-1095-30-000 10/11/2006 12:55 PM
PAGE 1 OF 1
Alt. Parcel 30.29.16.805E 106 - VILLAGE OF BALDWIN
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 - CEMSTONE READY-MIX INC
CEMSTONE READY-MIX INC C - SUITE 300
SUITE 300
2025 CENTRE POINTE BLVD
MENDOTA HTS MN 55120
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 2.938 Plat: 1795-CSM 06/1795
SEC 30 T29N RI 6W PT NWFRL1/4 COM E R/W Block/Condo Bldg: LOT 1
HWY 63 & NLY LN SUMMIT ST, TH S 86DEG
12'E 285 FT, N 369.2 FT, S 87DEG 35'E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
96.95 FT, N 330 FT TO POB: N421.99 FT S 30-29N-16W NW
87DEG 59'E 363.4 FT TH N 528 FT TO CL TN
RD; S 87DEG 44'E ON CL 220 FT, S 953.28
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
04/16/2001 642736 1618/32 WD
07/23/1997 632/259
07/23/1997 558/405
07/23/1997 513/192
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/27/2005
Description Class Acres Land Improve Total State Reason
MANUFACTURING G3 6.783 0 0 0 YES
Totals for 2006:
General Property 6.783 0 0 0
Woodland 0.000 0 0
Totals for 2005:
General Property 6.783 63,300 19,700 83,000
Woodland 0.000 0 0
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
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c/968 Qoc Ffond F Pub/s Inc Pam /97y SEE PAGE
FRETiS PIMP SERVICE WOE
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PUMP REPAIR AND t Ci
NEW INSTALLATION
We Sell TRW - Redo Frank
Submersible Pumps r i
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Phone: 698-2959 5
WOODVILLE, WISCONSIN 54028 691
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REPORT Of- fNSPLCTION - INDIVL"DUAL St-WAGE SYSTEM
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NAME' Town,ship- St. C~Loix County
Latx"on lVb) Sv. ction,30 Lot Su6d~vti~tian
SEPTIC TANK
S(zV ga~~an~ Numbe_n o6 c.ompanamen;tl
D.t~Iavrec (n_orn: (fie-1'k t~ui~d~_v~q 12° ~,(aC~e,
H~"ghwatV~r
PUMPING CHAM6( R
Si-ze ycciPovi4 Pump ~1gav~u 1i~cunV!t M~,~~~~' Nurn(,clr
HOLDING TANK
Si z(1, - -----gae('ovi3 Nufn bcli of Conip<<1r tin cvi (N
Pumpers Akanm SrI~ tern
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A6'SOR PT ION SITE
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Orh tavicc fft nm: 10c 6(1 (1 11.(f I L'„ h f"v
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A6SORPTION SITt DIMLNSIONS
Width 06 nench _ _ -f t R(rtu~n~d alrca
LevtcI th o~ each ('.i.vl_e- Depth oA 1toc.k bv. ow tike v~
Numbcri o{ Depth (1~ A-oe_fz ovcn
Total Y-ength o 6 Y-Lvne~ Alt Depth oh tiev below q~cadV Zvi
U i_5 ,tan c c b c. tw e e . vi U. n S f o p e o f tn_ e. n c. h i, vl. pen 100
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To(aC ab6oltpttiah a_Ae_a-- --~,t Type oj~ Coven.: Papers on_ ht,~aw
PIT DIMENSIONS
Numbs"n oo Gn.avice an"ou.nd p~-t3 ye"~ vr,
Oufiel.dc d,("amVtV ?I t Depth 1)eOfAr tiv1 ('0t ~E
ToTa_P ab3oicpti"on anea
Anea ncgw0icd
INSPECTED GV TITLE
APPROV(_D DATE 1<)x
RI JE CTL0 DATE 1 h
REASON FOR RfIECTION
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REPORT ON INSPECTION OF SANITARY PERMIT # oN.3
(1) Name arid Ad.dres of Permit Holder Person/Persons at site (2 )Date of Inspection
Time of Inspection
ame, ress, icense No. o ns a jng Plumber
(3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
(7)DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? []YES ❑ NO
8 HOLDING TANK: Manufacturer o gallons
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? ❑ YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TREN H: Total length of seepage trench ft; width ft;
t=ile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-6095 N.05/80
Signature of Inspector:
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State and County State Permit #
P L B 6 7
Permit Application County Permit.#
for Private Domestic Sewage Systems County Sf
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: W'/4 /y 6V Yd, Section i-EO T,7190 N, R ~ F12 (or) W Lot# City J
Subdivision Name, nearest road, lake or landmark Blk# Village
Township /~,C cfL~,.J
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _X Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY /f~GU 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-PlaceOther (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 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 Certified S i1 Testery ~j
NAME L ►e- G C.S.T. # 63 5~4 and other information
obtained from (owner/builder).
Plumber's Signature
MP/MPRSW# 727G7 S/Wy Phone # /-k;~ -~Z `
Plumber's Address tee. C iS
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
4W Q.- Fees Paid: State County 5'
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Permit Issued/Rrtecrud (date) 17-le Ze) Issuing Agent Name
Inspection Yes No State Valid# Date Rec'dec
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
' State of Wisconsin ` Department of Industry, Labor and Human Relations
Please Reply to:
718 West Clairemont Avenue
State Office Bldg. - Rm. 220
Eau Claire, Wisconsin 54701
August 15, 1980 Phone (715) 836-5364
Mr. Everett A. Boldt
820 Main St.
Baldwin, WI 54002 CERTIFIED MAIL
Mr. Boldt:
Re: The Mrs. Calvin Spindler property, NW NW k, SEC. 30, T29N, R16W,
Township of Baldwin
It has recently been confirmed that you are the plumber responsible for the recent
system installation at the above referenced property.
St. Croix County has no record of a sanitary permit being issued for this particular
installation. Your failure to obtain a sanitary permit is in direct violation of
of state statutes and the plumbing code.
In addition, an overflow pipe from the seepage pit was observed to enter a town
road ditch. Such an installation is not permitted by the state plumbing code.
As a State of Wisconsin licensed plumber, you should be well aware of all state
and county requirements pertaining to private sewage system installations.
Therefore, you are hereby directed to correct the above mentioned violations within
30 days upon receipt of this letter. Corrections shall be made at your own expense.
Please coordinate your activities with the County Zoning Office so that th proper
inspections can be made.
If you have any questions regarding this matter, please contact this office.
Respectfully,
Leroy G. Jansky
On-site Waste Specialist
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cc: Croix County Zoning Office cow"
Bureau of Plumbing
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