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Home My WebLink About032-1063-50-000 o N " 3 y o > 0 3 r° A -0 cam, CD ID A~ • ~c v c 3 \ 1 n z II~ Z 0) m o o w oW C v o to ° -4 0 3 3 j N m o 'm 'D W m R N N CD O o N V O N o M 1 A A N ~ CD o c ~ cD W ~ N' O 3 L 6 O 0 CO CD 0 -4 CJ7 lT CD C• * M o r; 3 a CD :3 N p) O O A OC ~ D1 Cn z ~v' o a G O 'D (o O CL D '~J A A CD\C o z co co O n r cn 0 co co 3 y o c N O CD r! 6 !V N p•. I~ 000 C: Ul < z ~ N fA N o 0 D PIZ' Q O O N O (D Ul N CD CD 1 d W a h a N ' tz o z co Q D CL Z v O Cn CD • CD CD w v (n o N. O CD CD (A d 7 O O ' z c p O A z o a n 0 C cnn j r1i W ~ < CL z 3 °o " cn 3 m N Z CD A N f -id z'D N 7 p j, C1. 7 N (D Cl. C G_ O d 7 ~i CD a C to O N N O Z f1 X y o c W ID CS CLO C1 O CD S O 'TJ Vl ~ O F .-r Q N ~ ti ch fD CD N d cr ti O O CD O to m a u, C) ) b O CD o aO Parcel 032-1063-50-000 08/12/2005 01:54 PM PAGE 1 OF 1 Alt. Parcel 23.31.19.3176 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): O = Current Owner, C = Current Co-Owner O - CAMPEAU, GASPER WAYNE & MICHELLE GASPER WAYNE & MICHELLE CAMPEAU 664 200TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 664 200TH AVE SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE SEC 23 T31 N R19W 4A IN SW SE LOT 1 CSM Block/Condo Bldg: VOL 4/973 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-31N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1015/606 WD 07/23/1997 821/109 07/23/1997 804/359 07/23/1997 618/39 2004 SUMMARY Bill M Fair Market Value: Assessed with: 10225 141,800 Valuations: Last Changed: 07/23/2003 Description Class Acres Land (Improve Total State Reason RESIDENTIAL G1 4.000 53,000 I 67,200 120,200 NO i Totals for 2004: General Property 4.000 53,000 67,200 120,200 Woodland 0.000 0 0 Totals for 2003: General Property 4.000 53,000 67,200 120,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 129 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 032-1063-60-100 08/12/2005 01:54 PAGE 1 OF 1 F 1 Alt. Parcel 23.31.19.317C-10 032 - 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): O = Current Owner, C = Current Co-Owner O - CAMPEAU, D/B/A G W CAMPEAU CONST D/B/A G W CAMPEAU CONST CAMPEAU 664 200TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ` 664 200TH AVE SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE SEC 23 T31 N R19W PT SW SE BEING LOT 4 OF Block/Condo Bldg: CSM 8/2395 ALSO PT OF LOT 3 DESC AS COM S1/4 COR SEC 23;TH S 89 DEG E 524.5' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) POB;TH S 89 DEG E 156.67';TH N 00 DEG W 23-31 N-1 9W 663.99 FT;TH N 89 DEG W 158.71';TH S 00 DEG E 664.08' POB Notes: Parcel History: Date Doc # Vol/Page Type 05/27/1999 603893 1429/449 WD 07/23/1997 919/259 2004 SUMMARY Bill Fair Market Value: Assessed with: 10227 68,300 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.000 52,900 5,000 57,900 NO Totals for 2004: General Property 4.000 52,900 5,000 57,900 Woodland 0.000 0 0 Totals for 2003: General Property 4.000 52,900 5,000 57,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch PRGRM Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I ' 0 cn O 'S ~ n c O o o 3 (D 'a Li s 4t c -o m m m r'\ Cn z Z 'v`> rn ~ Cn W o PV e r o o m° C) N c1Jl m n n m C', 3 ~ a m m 0 cn O ro (D (D N m m ° W a Q 0 0 a D o o CD (D * 6 a a o_ (D O O 5 N O O O in 0 C1 ~ A O ~ v z D m°.- N ~~1` ~ p O -U c S N N D kZD O o C) 0 -4 :z Z ~~(D O N O 0 p 3 O MMe O O O 1`,lill CC Np g -pp O N N < O D N ~L '-c O p~ 0 (D C), ri u (D (D Ul N N =r Qc) N N 3 E Cl) O O_ CD C1 m z r O z m z D m o h' O n ~ v Cn h e a ro m N ~o v F (D (D C (D (D W (D O_ z -t Cn O l O A Z N p Z CL O 0 O (n { N C~ W W CL z ° 3 O ~ cn 3 m Z C N Z r O D d O < V (D X 7 a } T W Qj N O Q; C N ~ 7 (D d z L1 N N O O N O' (D c N N (D Q E 6 (7DD (D O 2 3 O T N 7 < c O O O O Q con Q a N co O~ N O p ~ c N sv - ~ t w (D 7 O !tea (D tp O 4 ° 9 O CD 0 O V r 00'0 00'0 00'0 lelol saWeLlo;uanbulla(] saBaeyo leloadS s;uawssessy leloadS ;unowb AjoBa;eo opoo leloadS jasn :sleioedS MONd LIOWS 866M70/Z6 :a;e(] uol;eowliao 0 :;unoo wlelo :}!paao AJO410-1 0 0 000'0 puelpooM 006'L9 000'5 006`Z9 00017 A7pedoJd le-jauao :£OOZ col sle;ol 0 0 000'0 PuelpooM 006`L9 000'9 006'Z9 000'17 A;jadoJd leJaua0 :1700Z aol slelol ON 006'L9 000`9 006'Z9 000'17 19 IVIlN3GIS3H uoseaN a;els le;ol anoidwl pue-1 saaoy sselo uol;dlaose(] EOOZ/£Z/LO :paBueyo ;set : suoljellleA 00£'89 LZZO 1 :y;!m passessy :enleA;aMJew J!e3 IHEI Aadwwns ti00Z 69Z/616 L661/EZ/LO 0M 61717/6Z171 E68E09 6661/LZ/90 adA l aBed/IoA # 00(] ale(] :AaolslH I03Jed :sa;oN 80d ,80'1799 3 930 00 S Hl',1L'891 M 930 68 N Hl'13 66'£99 M61-MC-CZ M 930 00 N Hl'19'991 3 930 68 S Hl'80d (17/1 091 17/1 017 6u~]-uMl-oaS) :(s);oeal 9't Z9 3 030 68 S Hl'£Z 03S HOO 174S WOO SV OS30 £ 10l 30 id OSIV 96EZ/8 WSO :BpIa opuooplool8 30 1710 9NGS 3S MS Id M6IH N 1£1 £Z 03S 91OVIlVAV lON-V/N :leld 000'17 :seiod :uol;dliose(] leBe-i ~,o m mm XIM OOL1 dS 13SH THOS 30 Cl HOS ZE179 OS 3AV H100Z 1799. uol;dljosa(] #;s!(] ads i tiewiad . , :(so)ssaappV AljadoJd leloadS = dS IooyoS = OS :slo!jls!0 9Z0179 IM 13SH3WOS DAV H100Z 1799 1SN00 f1V3dWVO M 9 V/8/0 `f1V3dWVO f1V3dWVO 1SN00 nV3dWVO M 9 V/8/0 jaumo juaaino . , :(s)jaumo :sseippv xel 0 00 ode .L l!w.'ad # l!waad # uol;eollddV ee iV sales # deW ale(] Ieouo;slH ale(] uol;eaao NISNOOSIM '.11Nnoo XI02iO ,1S X luaajno 13S2EIMOS 30 NMOl - ZEO M-0L1E'6V1£'EZ laoaed III L d0 L EI9Vd Wd99:ZL 9ooz/W90 004-09-£90VU0 IOOJBd } Parcel 032-1063-50-000 05/18/2005 12:53 PM PAGE 1 OF 1 Alt. Parcel 23.31.19.317B 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 CAMPEAU, GASPER WAYNE & MICHELLE GASPER WAYNE & MICHELLE CAMPEAU 664 200TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ` 664 200TH AVE SC 5432 SCH D OF SOMERSET SP 1700 WITC VOI ~ Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE SEC 23 T31N R1 9W 4A IN SW SE LOT 1 CSM Block/Condo Bldg: VOL 4/973 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-31N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1015/606 WD 07/23/1997 821/109 07/23/1997 804/359 07/23/1997 618/39 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.000 53,000 67,200 120,200 NO Totals for 2005: General Property 4.000 53,000 67,200 120,200 Woodland 0.000 0 0 Totals for 2004: General Property 4.000 53,000 67,200 120,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 129 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION 7969 LABOR AND 3707 MADP.O.ISON, WI BOX 53707 ' INDUSTRY, PERCOLATION TESTS (115) HUMAN RELATIONS p3 2~A -cc(ILH R 83.09(1) & Chapter 145) Uo : TOWNSHIP/QTY: LOTNO.:BLK.N0,:SUBDIVISIONNAME LOCATION: SECTION: r SW 1/4 SE 1/4 23 /T 31 N/R191x(or) W Somerset n/a n/a n/a CC rr~~••nn`` COUNTY: OWNER'S/NAME: MAILING ADDRESS: St. Croix Gasper Campeau 664 200th. Ave. Somerset, Wi. 54025 DATES OBSERVATIONS MADE USE (PROFILE DESCRIPTIONS: PERCOLATION TESTS: NO 1 EDRMS.: COMM ERCIAL DESCRIPTION: . Residence 3 n/a *3New ❑Replace 7-12-91 7-17-91 RATING: S= Site suitable for system U= Site unsuitable for system r2f ONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑U IS ❑U S ❑ U ❑ S ~U ❑ S ®U mound Iare NOT required JDESIGN RATE: f ortion of the tested area is in the .09(5)(b), indicate: n/a Floodplain indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 10 AID2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTI-1XX ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) .83b1.1. .58bn.s.sil. 1.42bn.l.s. B_1 7.83 100.10 none >7.83 5.00bn.s.l, platy hard till .58bl.l. .58bn.s.sil. 1.83bn.l.s. B_2 6.99 100.10 none >6.99 4.00bn.s.l. lat hard till 100.10 .50bl.1. .75bn.s.sil. 1.17bn.l.s. 4.00bn.s.l. B_3 6.42 none >6.42 platy hard till B_4 4.34 99.25 none >4.34 .92bl.1. .75bn.s.sil. 2.67bn.l.s. B- B- decimal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH _RjfkttL P-1 2.00 none 30 3%2 3 3 j p .00 none 30 34 3 3 P_ none 2 2 2 2 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 101.10 r (!r`~~ 3 L b m z371)s' TN t 19 ~~3S _ _ . c'- Dyv a-- - - Z O r. I > . . E »34 I, the undersigned, hereby certify that the soil tests r or n this for e e by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the tibn o tT t 44 orrect to the best of my knowledge and belief. NAME (print): G TESTS WERE COMPLETED ON: Gary L. Steel 7-17-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Ave New Richmond Wi. 54017 2298 7"-246-6200 CST SIGN RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 'it i of 3 Pte` .r ~ 17, E: I f' 3P j a7..i Pf rte. F. ; C" V ca t>;> ~ z . Fz , TO T E N a This soil test repoi verification of this soli k:st €i .tS A f,i3tl<plete set Qi Pull', for the, ~)t=t<.~.:;3 sewage s, stern and a }?e(mit c } [ lE,s)a mu'St e md! tr4-'Cj iii 3 ;?p Il I I C zaUfhs W.V in GYt; 7,fq,~o O N ' m = o - r X m m G) 0 S N rn z 3), O A Z -6 0 0 O _ 71 O C) w u • m N ~ O O O n N O mO~ T' m o cn D r O rn w 0 x ~ i O .v cn m _ p •I- --664.27'-- N00°-45'-39"W (p w 190. k~ z INIpNj 4S. Q ° N ` Z (V OD 0 1; (n to 0 to 0 T M Iul u `J3k D D m n O Iwo ~ ff) o Z w ~ 631.17' BEARINGS ARE REFERENCED (n _ w ---664.17' SOO°-45'-39"E TO THE WEST LINE OF THE m 1 SF 1/4 OF SEC. 23 m (ASSUMED lit 00° - 45'- 39"W.) 0 U) I Pi cf) N C O 0 W < 01 0) 0 to w ° 0o O - CD c - i, D N z m a -A z I r X -A (D A r r C p p C 0 Z Z G 1 G I I G) ` _I ( )U pN a 30, w . ALLEN W ( 0 3,' r 1 D7 ro 3 0.7 5, S-1407 -66 3.75'- - - S 00°- 3 5'- 08 E z n, r _PAGE~~3 ~ ';fZTTI~Tf?l) '>URV%'Y MAPS r•-+ ~/ly/8o 1'. CRO (X COUNTY, WIS Z.0 0 S~ O N ' w -a o - r = 0 - m cn x m 8 N m - D o .1)1 Z Z r cn 6 to rw - ~ O A c_ ap 0 0 0 t, s m m " m N Y z to O 0 -i Q O O cn n N D GD p m m 0 ~ r O ~ ~ n i p - n .r D N -n 0 N 0 n 7C ~ A 0 w?~ cn m o -664 .27'-- N 00°-43'-39"W =m w w y 63,1.27' a (wlw 00 4Ob m N (N v w A r o N z; N ; J O Q 0 U (n m Q D ti~ N m D 001, m 0. 0 00 to w ~ 631.17' _ BEARINGS ARE REFERENCED w ---664.17' S00°-45'-39"E TO THE WEST LINE OF THE rn 71 of p1 SE 1/4 OF SE C 23 \p m (ASSUMED K 00° - 46'- 39"W.) c) ~ I I (n cn Pi N C -41 W~ i 10 C 0 co _4 to rT] O m w ° w to •A co u. OD O ' co J p D D N p w v ? r ;u i4 m _ D -O m - r -4 -I I X n n A C ° ° C p p t C7 Z Z G ...p I I . m W > '1, ~ a [ i~ r 0, ALL C_ P 7 NYHAGEN 1 - 6 3 0. 7 5' k 5-144T HUDSON, r `~eJw► I --663.75'--- SOO 35'-08" E WIS. Z N D r % 's 0-7 ,)I PAGE, -1 1 MTl f'TFD ';URVEY MAPS W ly/ 80 CROTX COUNTY, WIS z.0 v M I 4''n I REPORT OF INSPECTION - INDIVIDUAL SLGIAGL- SYSTEM ~San-i taA y PeAm.i-t 4 State Septcc ;AME Townahip St. CAO4CX County ~c t~iunSec-tion_12?,3Lo.t N Subdivi.6ion FPTIC. TANK .S.C z e gatto na Numb en o S co mpaA.tmen-ta _ )(stance Anom: wett Bu.ttding 12% stope Highwa-teA LIMPING CHAMBER Size gattond _ Pump Manu6actuteA Mudet NumbeA OLDING TANK Size gatton-6 NumbeA o6 Com.pa4.tment,6 PumpeA Axa4m Sge.tem '(16 Lance 6Aom: weft Building 12% axope_ Highwa.teA 6SORPTION SITE Bed TAe.neh (,stance 6Aom: ` weft Building 12% atope H i g hw a.t e A li_SORPTION SITE DIMENSIONS W-i' dth o6 tAeneh 6t Requ.i Aed aA.ea _ -6t Length o6 each tine 6t Depth oA Aock betow NumbeA o6 tinee Depth oA Aock oveA t<te_____ -4-n To taX Y.ength v6 tine.e 6t Depth u6 tt.te below gAade_ - ---_-i.n D.i.etance between tinee 6,t S.l'ope o6 -tAench _4-n. pen 100 6t I o 4 ua aGo 041.0 txun aAea 6.t Type o6 Cove&: PapeA oA e t&aw IT DIMENSIONS— NumbeA u6 pitb GAavet around p4.t6yee _ _nu Oute.ide, d-i.ame.teA 6-t Depth betow intet At Totat abe onp.tion area 6.t Area AequiAed 6.t NSPECTED BV TITLE 11PROVED DATE 19 8 ,t JECTED DATE 1981- 1ASON FOR REJECTION % 93 7 PLB 6 7 State and County State Permit it u 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: B. LOCATION: it/ % S Section 13, T N, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY / G~7s 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) 7- - E. EFFLUENTPOSAL SYSTEM: Percolation Rate ~l Total Absorb Area sq. ft. New--~ Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length S Width t DepthTile depth (top)--i2_42-No. of Lines 2 ` Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land- -2 %p Distance from critical slope WATER SUPPLY: Private ~Z 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 Certifi d Soil Tester, NAME -a-- r- V _ C.S.T. # 02,2 y2iot1 other information obtained from ( (owner/builder►. Plumber's Signature MPIMPRSW# 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. E f E E i i i w .tw ,..gym +,m.. _ 1. m . a a a ...m ,e. e. ..m. m ...r I s , £ k 3 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application ~v?/`fl/ ~ Fees Paid: State County f , Date Permit Issued/Ruje~, (date) Issuing Agent Name i 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 EH 115 • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION. ~ '/4 a ••'/4, Section T3/N, R/1-E-4or Township o M mFei~Ia~y~LZ ~.Q SyC-~ Lot No. , Block No. County y.7 ~Ci / X u L ~ 04 Subdivision 4 Name Owner's Name: Mailing Address: C -A 5-k TYPE OF OCCUPANCY: Residence & No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT 11 DATES OBSERVATIONS MADE(:: /SOIL BORINGS ? 3_1' 29 -PERCOLATION TESTS 2'" SOILMAPSHEET SOILTYPE PERCOLATION TESTS INCHES HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE TEST DEPTH NUM- THICKNESS IACTERN OF INSOCHILES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P -3o 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_ 02 -.3 B- _ g d~G1C 7 - t 15 '2 -./0 SrL /CP -3 AS L- S '7 t v i 2 j6 B- Sr 7 2 C75 -/6 S,' i 6- s -7q L - - C)2 - 104t 3sfZ 13-33y-SCI 3~- L S PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locationand q re t of suita a areas/ Indicate number of square feet of absorption area needed for building type and occupar Indicate scale or distances. Give horizontal and vertical reference poin . In ate slope. 41 P ,e f fty f r I t , E i I I ~ I , i N , s , I f I i I I ~ t t ~ ` f I I , f 1 1 t , I i ~ M - _ i I t I 1 ; , 1 UW 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 Admi istrative Code, and that the data recorded and location of test holes are correct to the best m know edge and belief. Certification No.S~- Z Z Name (pant) Address O 5J j 12 r Name of installer if known at7P' fZ~_ 4 .:macev S~~z"-R CST Sia6 _ ~ „~y ~ . rt. _ S - - i r. f ;C a j` ~ _ - s ; F sv i4l ~ - s i i i i ~ i 3 i s f i 1 i 1 J i 1 REPORT ON INSPECTION OF SANITARY PERMIT # 5 _-~Z (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Time of Inspection Name, resss, ice se No. o ns a ing plumber (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System BENCHMARK: (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 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, I.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- J T -1 4 r f E .m.m..r.... m 1,..:,€. i _ .Ayr. . ; _ . , . , § e a . 4- 4.-,,._..,, g € E` a ~ r e r r e..,. d r r .r.. y... J e ' 1 E ~ 3 T I i { I i 3 i r r E 3 p.... , _ _ _ e _ r . _ _ ..,wr- - _ _ f ~ t 3 i r... ? A , , a. I I~ f r € ~ i ' r E ~ x 1 R r _ f¢_... s r . t i E , , _.r_ 1-1 3 € i I € 1 r € € a ` e-wpm e a a _ . , ~ , _ ~ -J,,... _ r r 3 t r € € r E t i i i 7 ' r 3 1 E i 1 r € , - r 3 t r € e r r r r r r r € r r , r e - E r r m._ s ` r € r E s ~ F r i _ r x ~ r 4 p 4- SEE I ❑ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party