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REPORT ON INSPECTION OF SANITARY PERMIT #
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
Name, Addre icense NO. o installing P1 VT Time of Inspection
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:
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 ❑ N0;
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:
PLB 6 7 State and County State Permit #
a~.
Permit Application County Permit #
for Private Domestic Sewage Systems County S7` C R p / X
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
'PA L L A tj
B. LOCATION: Section T, -yo N, R
6 (or) W Lot# _ City
j6~2 -'k
Subdivision Name, nearest road, lake or landmark Blk# Village
7 r{ 7 -7 / Township -Me-IZ 4 /.,c{
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X, Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks 0/V e_
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete x Poured-in-Place Steel Fiberglass Other (specify)
New Installation X Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate_.-Z4T_Total Absorb Area 9Y 71* sq. ft.
New X Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No _
Seepage Bed: -X_Length Width Lt? -Depth &X # Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 112 Distance from critical slope
'tNATER 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 -.~ol Tester,
NAME f d L C.S.T. # 61--,6-'P74 and other information
obtained from ~JE?2 (owner/builder).
Plumber's Signature MP/MPRSW# S~S~~ ~1 Phone
Plumber's Address C wi:.i C.tJ' S
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.
3,0 _M .
a
Do Not Write in Space B low FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application / c-l Fees Paid: State /y, 4-e County Date / / G'1
Permit Issued/R"6fec~ed ( ate) l~ Issuing Agent Name CZ
Inspection YesNo 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
EH 115 (11-74)
✓ WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
LRE ORT ON SOIL BORINGS AND PERCOLATION\TE
LOCATIO '/4, Sectio -N, R _ E (or) W, Township or Municipality A/
Lot No. Block Count q~b
Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMEhIT---
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION T TS
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS )?-Q Kicr- ~~2 C ~L t pe-e/M77
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-
P-
P-
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-
B-
13-
PLAN VIEW (Locate percolationtests;soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. Indicate scale
or distances. Give reference point. Indicate slope.
I,
~ I
t N
1, 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) Signature
Certification No.
Name of installer if known
Copy C - Local Authori,,7
Parcel 002-1010-50-000 01/10/2007 05:20 PM
PAGE 1 OF 1
Alt. Parcel M 05.29.16.74B 002 - TOWN 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
MARVIN LOOCK O - LOOCK, MARVIN
2217 115TH AVE
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2217 115TH AVE
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 17.670 Plat: N/A-NOT AVAILABLE
SEC 5 T29N R1 6W IN NW SW COM NW COR SW Block/Condo Bldg:
1/4; TH S 660 FT; TH S88 DEG E 1164 FT;
TH N 2 DEG E 648 FT; TH N 87 DEG W 1198 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
FT TO POB TOWN BALDWIN. 05-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
03/01/2006 819561 QC
07/23/1997 1007/32
07/23/1997 692/6322 - G[vc 5 D~
07/23/1997 C p 612/265 ~~j f fG d
2006 SUMMARY Bill Fair Market Value: Assessed with:
153322 Use Value Assessment
Valuations: Last Changed: 10/25/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 25,100 185,100 210,200 NO 00
AGRICULTURAL G4 12.170 2,000 0 2,000 NO 00
UNDEVELOPED G5 3.500 4,300 0 4,300 NO 00
Totals for 2006:
General Property 17.670 31,400 185,100 216,500
Woodland 0.000 0 0
Totals for 2005:
General Property 17.670 11,600 119,300 130,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 510
Specials:
User Special Code Category Amount
010-GARBAGE SPECIAL ASSESSMENT 45.00
Special Assessments Special Charges Delinquent Charges
Total 45.00 0.00 0.00
St. C,.& Caoity Pla-Mg mid Zoning