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Parcel 040-1064-30-000 01/12/2007 04:50 PM
PAGE 1 OF 1
Alt. Parcel 16.28.19.240C 040 - TOWN OF TROY
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 - NELSON, ARNOLD A, & M J ANDERSON
ARNOLD A, & M J ANDERSON NELSON
381 N GLOVER RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 381 N GLOVER RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 4.300 Plat: N/A-NOT AVAILABLE
SEC 16 T28N R1 9W 4.3 AC IN E 1/2 NE 1/4 Block/Condo Bldg:
LOT 2 OF CERT SURVEY MAP IN VOL III PAGE
796 Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 783/472
2006 SUMMARY Bill Fair Market Value: Assessed with:
158216 308,700
Valuations: Last Changed: 07/20/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.300 68,000 213,600 281,600 NO
Totals for 2006:
General Property 4.300 68,000 213,600 281,600
Woodland 0.000 0 0
Totals for 2005:
General Property 4.300 68,000 213,600 281,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 205
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
TOWN SifI1) SEC. , T N, R
ST. CROIX COI1N Y, WISCONSIN
;l[>. X10,7 V/
PLAN VIEW W 3 r~~~ '?IQ6
Distances & dimensions to meet requirements of H62.20
C~c ~y e Spa I~ z
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
1 0,1
~ F
-'TIC TANK(S)_/P~ MI'GR.-4 CONCRETE
NO. of rings on cover Depth_ 4/ DRY WELL
'.NCHES NO. of width length area
no. of lines widths length are
depth to to 'p of pi:~J~aj~
REGATE
'.K RATE A ' E IRED AR
EA AS BUILT
* 744,n I claimer: The inspection of this system by St. Croix County does riot imply complete
pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes Ti() ].lability for
tem operation. However, if failure is noted the County will make every effort to
ermine cause of failure.
ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED PLUMBER ON JOB _
LICENSE NUMBS`__ _
PLB - 6 7 State and County State Permit # 3
Permit Application County Permit # ZZ&
~~Rn
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:
& X E &
B. LOCATION: C '/4 N /4, Section, T N, R E (or) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family >~N_ Duplex No. of Bedrooms j No. of Persons_
D. SEPTIC TANK CAPACITY ~QC~i 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 4"~ Total Absorb Area- 5 sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of meal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: x Length Width /9' Depth t` Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- 161 Distance from critical slope
WATER SUPPLY: Private X 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 Soil T/e~ er,
NAME =r~' l.O C.S.T. and other information
obtained from r./ (owner/builder). of
Plumber's Signature ,MP/MPRSW# 75 7 Phone
Plumber's Addresses t~'t-
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 7-: - C-1 Fees Paid: State`, County C-7)
Date
Permit Issued/Rejected (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
f -
REPORT ON INSPECTION OF SANITARY PERMIT #
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
ame, r SS, tense o. Installing Plumber Time of Inspection
(3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanent reference Point) 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 ❑ N0; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ N0; 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; t- to lot
property line; ft to ordinary high water mark of lake or stream; ft to
of slopes greater than 20% falling away toward lakes, water courses or drainage ditche
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:
E m, 1 15 Rev. 9/78
4 REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: ` 1/4, 1/4, Section__i_L,T N,R-.2 E (or) W, Township or Municipality
Lot No. , Block No. Subdivision Name County n-, Ck.01x
Owner's/Buyers Name: _ FspnLon_)
Mailing Address: + ~E-
TYPE OF OCCUPANCY: Residence- No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW 0-5 REPLACEMENT -ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS / ?Q PERCOLATION TESTS /lJeA)F- kro /p
SOIL MAP SHEETe t NAME OF SOIL MAP UNIT Clp_ Jy/ ~AP_o r
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES V
NUM- INCHES s THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL RAT;_ BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
I
P-
AL&NEE
P- tr
P-
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- .5L 6.4-"
B- q(1
99
B- 3 Q4P
B- CI)
B- 7 7 7 ti- 7
54. AI
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate the an the locati 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 horizontal and vertical reference points. Indicate slope.
PP-w WAY
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19
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I, 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 the data recorded and location of test holes are correct to the best of my
knowledge and belief.
Name (print) ` 0 Certification No. _17,1---- fivr'
Address _ LL
.Name of installer if known A OL ` i _ _
Copy A -Local Authority CST Signatu~, , f
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
San.i.tanl PeAm,~t--//61
State Septic`
NAME Township St. Cka-('-x
LocationA &E Section -4~- Lot # Subdivision
SEPTIC TANK /zlOr cit.(
Size gattons Numbers 06 eompantmnt.
Distance 5nam: Wet Z /A✓o Building c ~ 120 6f-ope
H.ighwaten
PUMPING CHAMBER
Si ze ga~~oManu,6aetunen Made. Numb en
HOLDING TANK
Size gattons. Numb n a6 Compantments
Pumpers A arcm Sy,S tem
Distance 4ham: Welt Bu.itding 12% shape.
H.ig hw aten
ABSORPTION S I T Bed T).eneh F .V~ e;v
D.i6tanee 6nom: Wet /VZ $ui2d~n
Highwaxen,
ABSORPTION SITE DIMENSIONS
Width o6 tneneh Z 6t Requited area
Length o6 each tine_ 6t Depth o6 %ock betow
f
>.2Numbet ab tti~nes Depth o4 tack ove)L ti. e.
Total .length a6 Una ~ Z 6t Depth o6 -tile betow ghade
Di4tanee between tines G 6,t Shape a6 tAench .in. pe.rl 10
Taxat ablsotcption a.cLea ~6 Type a6 Coven: aperc~ate ~s t,~aw
PIT DIMENSIONS
Numb eh o6 pits Gnavet around pi-t,5 yep
Outside diameter Depth below .intent
Totat ab,6onption e St
Area nequ.ined bt
INS PEC^~~~ TITLE
APPROVED DATE l
REJECTED DATE
REASON FOR REJECTION