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Parcel 006-1046-70-000 01/05/2007 03:13 PM
PAGE 1 OF 1
Alt. Parcel 21.31.16.323 006 - TOWN OF CYLON
ST. CROIX COUNTY, WISCONSIN
Current X
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 - ZWOLENSKI, DAVID C TR
DAVID C TR ZWOLENSKI
2275 205TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2275 205TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 21 T31 N RI 6W 40A NW SE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/27/2006 839456 WD
01/30/2006 817449 EZ-U
09/13/2002 690161 1975/105 CO AF
06/19/2002 682083 1912/580 .2p
2006 SUMMARY Bill Fair Market Value: Assessed with:
144499 Use Value Assessment
Valuations: Last Changed: 07/26/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 15,000 131,000 146,000 NO
AGRICULTURAL G4 17.000 2,300 0 2,300 NO
AGRICULTURAL FOREST G5M 21.000 27,300 0 27,300 NO
Totals for 2006:
General Property 40.000 44,600 131,000 175,600
Woodland 0.000 0
Totals for 2005:
General Property 40.000 44,600 131,000 175,600
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
A OWNERI
tom- \ TOWNSHIP, SEC,- T N, R /y W
ST. CROIX C UNTY WISCONSIN.
SUBDIVTo LUN
LOT LOT SIZE
Distances dimensions to meet requirementsWof H62,20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
l
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rt
a
I di a e o~th~ Arrow
SCAL
SEPTIC TANK(S) MFGR.
CONCRETE STEEL
N0. off' rings on cover Depth
PUMPING CHAMBER SIZE PUMP MFGR.L NO.
GALLONS Per Cycle
TRENCHES NO. of width length area
BED NO, of lines width length
dep -`top`o pipe areal,
x ry
NUMBER OF SEEPAGE PITS Outsa, e i_ameter total pit area
AGGREGATE
PERK RATE y' RE REQUIRED AREA AS BUILT
Disclaimer: The inspection of this system by St. Croix C6unty does not imply
complete compliance with State Administrative Codes. There are other areas thn,
it is not possible to inspect at this point of construction. St. Croix County
assumes no liability for system operation. However, if failure is noted the
County will make every effort to determine cause, ,of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH /THIS SYTEM.
I N S P E C TO
DATED PLUMBER ON JOB
LICENSE NtWER ~ L ,
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sandtam y PcnQ.t.?yy~
State Sept,i.e_,:p
NAMI Townahtip _St. Cnoix County
I „0 tiun Sec-ttion ~J Lot # ubdiv~,0on
IPFIC TANK ~T
< 1e ' gatton4 Number oA compantme.nta
Pf A tanCe Anom: Watt Buitdlvg 12% a l o p e
Highwaten
PUMPING CHAMBER
_ rte)
ti<; c _!W-~ gaflona _ Pump Manu6aetu&eyQwmQy!1 Model, Numb en
"AVINo ;ANK
a long mhnn
9 ,
P,(miJea A.['arm Sy4,tem
05 tuwcv (nom: Weft Building 120 alope
Highwater
ANKORPFION SITE
Tne.nch
O s ramce Arum: Weft t 2 °
Hli.ghwaten
A=RPIION SI7E D"IMENSIONV
W (d th o6 trench , - 4t RequiAed area
I.(,ktgth oA each Una At Depth o6 mock below ttiXe. f cvt
NumW o6 l.ti=a- q Depth o6 mock oven t,i.le
to Of length o6 tines At Depth o6 We below grade. J <n
06tance between lines At Slope o4 trench_ ~ in., pen 100 At
total abaorptton area .{t Type o6 Coven: Papen on atnaw '
Pit 01M1.NSIONS
Numben o6 pc.ta Gravet around pits yea no
t
c u to t dc diameten_~__~' At Depth below infet
io Cal abaorpt.i.o✓n= ani bt
-
Ancce ~~(yu-i~(c.d t f
IN PI C I 1 D BY ~ r TITLE
11'PROVCD 14 DATE ~198
G %
wI 11 CI I D DATE 198
0 WON FOR REJECTION
State and County State Permit #
PLB 67 Permit Application County Perm t#
.x i
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:
14
B. LOCATION '/4 '/4,' '
Section . ~ , T N, R _IL._ ~ (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
31 Township JJ
t
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons-
D. SEPTIC TANK CAPACITY L!.,^( -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 `1Total Absorb Area > sq. ft.
New Replacement Alternate (Specify) J .
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth 4 Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land `a Distance from critical slope -
WATER SUPPLY: Private S~ 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 Cerlified Soil Tester,
NAME C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# Phone #
Plumber's Address i,V
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 elow FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State f County, . e-V Dat / to
Permit Issued/44e}ee4ed (date) ~1 U Issuing Agent Name
Inspection 'Yes 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
REPORT ON INSPECTION OF SANITARY PERMIT
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
x:11 -
2 e? c?(. t ,
ame, r ress, icense NO. o ns a ing plumber Time of Inspection
(3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BENCHMARK: (Permanent reference oin escri e:
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:
M 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 TRENCH: Total length of seepage trench ft; width ft;
tile 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:
w4 I-I V Oi IV rvI~rv I yr nCAI I n AIVU aUv+IA I- ar-nVil-r-O loom
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION:'/4,.. Section ; ` l T.~4N,R//_- q (or) W, Township or Men+e+pality
Lot No. , Block No. `,14L,` i County S7: C1amel
Subdivision Name
Owner's/Buyers Name:
Mailing Address: 104 TYPE OF OCCUPANCY: Residence No. of Bedrooms Z COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW- REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATIO~N~TESTS /[i -
SOIL_ MAP SHEET- NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/ IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
I
P- '
P- /Z9 11L
fs v/
46049i it) P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- J•
B- -Z,:6, -
B-
B- g <,j 4_2 - 2_2 S
B-?
Z ~2 415-4 1
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the lpption and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy J / ; Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
C^AIIJ
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1, the undersigend, 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 t%e data recorded and location of test holes are correct to the best of my
knowledge and belief.
Name (print) Certification No.
Address
.Name of installer if known
r
Copy A Signature
-Local Authority CST f
x.
7- -N 71 jG -Al
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