HomeMy WebLinkAbout032-2046-20-200
n N O 3 n d r1
O c d o
m
1
CD v ^
v
C v O O (W ~C
O
O N '
cn d 3
m
Z CD (n
~ a m Q o ~
c W O N (D cD A O
CD 0)
:3 m
O n cr co N O
CD o cn c O N O N
=O O O
N N 2 co
C y co
c D a
(D N w a rn
C)
CD C:
CD- j
i O O
{ (D (O z
orv~
N Co f cn v
z O O O 3
o ~r a: =3
w z
v ~c rr3-
~ ((D w N N
S; -0 O i D CT T
Z7 - y j O
N 3 d V N
N (D
O_
- UO7
Cl-
z
z 07 z 0
O D a =
0 0
ZT -n
s CDCn
;o N
(D
CD
w a
a (D
(D C6 --j cn
C p CD
=3 z O
a p 0 ~
w
W T m CO
(D M 0
C z
3 4~-
O c0
Y Z
3 M g
z
(D A
w ~
N (D Cr D
-o x (D S ci
v v L
=3 3f
7 (n (D N T
j W
F ~
;L O z a
O S
O
(D O = U
C) a 1v
m 3
co cl) :T
N O y
C
T CD p
C N
CD (7 (O A
O S (O=
DJ -4
a , *
N a =r p
I
CD CD
A
c o Z
T e
C z o
o N m
ti
m
co
c4 A
w
0
(D do a
O
csr O e
i_
ti
AS BUILT SANITARY SYSTEM REPORT
OWNER! TOWNSHIP i7Zr.r SEC. /j3_TjGN-R
ADDRESS vv /yj c ~t ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
a
PLAN VIEW °
Distances and dimensions to meet requirements of H63
[OW EVERYTHING WITHIN 100 FEET OF SYSTEM
I J)
i
I di a e No the Arrow f
SC
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point:Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:H
Number of rings on cover :Tank manhole cover elevation
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of aa1lons _
Number of gal. pump set for a cycle gallons; total capacity
distribution lines gallon: size of pump head;
gallon per minute, horsepower brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover'
Type of warning device
SEEPAGE PIT SIZE: Number o pits feet diameter
feet liquid depth seepage it in eft pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines ;2_ width length -5 file depth
SEEPAGE TRENCH: width -AREA length
PERCOLATION RATE ,1. - REQUIRED fir/ 5" RE AS BUILT 44 ~
INSPECTOR
PLUMBER 0 JOB rJ-
DATED
LICENSE NUMBER iii 5 i
z,
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
' . San.i-tahy Penm.i-t
State Septic '
NAME-. Township S$. Cno.ix County
Location Section
SEPTIC TANK
I .
Size t gattonz. Numbers o6 Compan.tment.6
Diztance Fnom: Wett S . 12% on greaten 4tope it
Bu.itd.ing it. Wettand-6 ~ .
a
DISPOSAL SYSTEM Highwazen it.
.
D.ia.tance Fnom: Wett 12% o4 gnea.ten 6tope
Bu.itd.ing it. Wettands Ft.
• H.ighwaten S.
FIELD DIMENSIONS:
Width o6' then ch it. Depth o6 no ck b etow ti.2e - in .
Length o6 each tine it. Depth o6 tock oven xite in.
Numbers og tines Depth o6 z.ite below grade 2 in.
Totat teng,th o6 tines it. Stope o6 trench in pen 100 it.
Distance between tines a it. Depth to bedrock it.
Totat abz onbt.ion anea ,,i jz2 Depth to gnoundwaten - ~ .
Requited anea it2 Type of Coven: Papers on Straw
PIT DIMENSIONS:
Numbers o6 pits Gnavet around pits yea no
Outside d.iameten it. Depth b etow .inZet it.
Tota.t abaonb.tion anea it 2
z
A
Area requited it2 3Z
INSPECTED BY TITLE
APPROVED` , DATE 19'7
r
REJECTED DATE 197
01
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
n f- REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: L_E/4,4_]E1/4, Section TAN, R !YE (or) W, Township or Municipality ~y?~
Lot No. , Block No. < iTZ / ie^ 1: / "b Ci FI County 57- r i,.
Subdivision Name
Owner's Name: - c"
Mailing Address: l ~f `1 >>c sc~
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS /3 Z % PERCOLATION TESTS I j 2Z-
SOIL MAP SHEET---- SOIL TYPE~~f~
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-'
3
L
P .y y t y / )
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)
1Y 5
e, /I 5Z
7
`
L J~ si L
r 7 ZA- /
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square fee of suitable rea . In irate numbe ~of s are feet of absorpltion~rea
needed for building type and occupancy. J1 ' - p ; c 7 lrr>dicate e
or distances. Give horizontal and vertical reference p `nt . Indica slope.
€ I I i
1 aL j' t
O'n
,
L i
, ) I {
,
I f i I
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.
Z y
lr' Certification No. /
Name (print)
Address /C
Name of installer if known
r
Signature ' E G%` -c% ll ~ ~ c ~
COPY A - LOCAL AUTHORITY CST Sign
w~
State and County State Permit #
PLB 67.
Permit Application County Permit #
` 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:
~ -~n /moo-r-. 7~ , ~Gt.,J ~ t~i~--~---n~ ~ 2.~~..-~'
B. LOCATIQpt 4-- '/a A12 '/4, Section 13 , TA N, R-Z-'~ E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village _
t Township it.oy
C. TYPE OF OCCUPANG . *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 No. of Persons 2_
D. SEPTIC TANK CAPACITY /4'17'z~ Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation G-- Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area r sq. ft.
New ~ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: _Length_ _Width 7,Z Depth- Tile depth (top) L' 41 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 Certif d Soil Tester,
NAMEL c~u "Z.c1r~,,~,~ C.S.T. # and other information
obtained from (owner/builder). g
Plumber's Signature P/MPRSW# /n Phone #-;,y~-
Plumber's Address
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 ,
s
~I
a
e
~ a
t 1
t t
t `
m .i e <<5., tea.. '
F
t
l
Do Not Write in Space Below -r FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State' County Date - ' '
Permit Issued/Reed- (date) 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
Parcel 032-2046-20-200 02/01/2005 03:16 PM
PAGE 1 OF 1
Alt. Parcel 13.30.19.662D 032 - TOWN OF SOMERSET
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
" RUSTAD, KIM M
KIM M RUSTAD
887 160TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 887 160TH AVE
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 3.913 Plat: 0531-CSM 12/3295
SEC 13 T30N R19W PT NE NE BEING LOT 3 Block/Condo Bldg: LOT 3
CSM 12/3295
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/24/1997 1253/290 WD
2004 SUMMARY Bill Fair Market Value: Assessed with:
10976 175,800
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.913 52,500 96,600 149,100 NO
Totals for 2004:
General Property 3.913 52,500 96,600 149,100
Woodland 0.000 0 0
Totals for 2003:
General Property 3.913 52,500 96,600 149,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 140
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00