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AS BUILT SANITARY SYSTEM REPORT
OWNER
I TOWNSHIP-7-I' SEC. Z TZSN, RZ
ADDRESS ST. CROIX COUNTY WISCONSIN.
SUBDIVISION r}/1 r,/ C'-:; LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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I di, ate orthi Arrow !
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SEPTIC TANK (S) MFGR. CONCRETE. X STEEL
N0. o7 rings on cover 7,1 Depth
PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO. -
GALLONS Per Cycle
TRENCHES NO. of width length ~`j o area 5 OCR t ,
BED NO. of lines width length area
depth to top o pipe "
NUMBER OF SEEPAGE PITS Outside diameter total pit area
AGGREGATE
PERK RATE fx > ° AREA REQUIRED 4Y5 ;Q`T , AREA AS BUILT
Disclaimer: The inspection of this system by St. Croix County does not imply
complete compliance with State Administrative Codes. There are other areas that
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.
INSPECTOR
DATED- PLUMBER ON JOB~"~/I ,c.
LICENSE NUMBER
Parcel 040-1193-20-000 12/14/2005 10:59 AM
PAGE 1 OF 1
Alt. Parcel 24.28.20.868 040 - 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 - SCHLETZ, HOWARD J & BEVERLY
HOWARD J & BEVERLY SCHLETZ
208 PLAINVIEW DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 208 PLAINVIEW DR
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.280 Plat: 0234-CROIXRIDGE
SEC 24 T28N R20W PLAT OF CROIXRIDGE LOT Block/Condo Bldg: LOT 22
22
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-28N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
103555 252,900
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.280 65,400 178,000 243,400 NO
Totals for 2005:
General Property 1.280 65,400 178,000 243,400
Woodland 0.000 0 0
Totals for 2004:
General Property 1.280 65,400 178,000 243,400
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
z
REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM
San.itany Penm.i.t
• State Septic 7_
j NAME - rownbh.ip St. Cna.ix County
Locatiox Section
SEPTIC TANK
,I
Size gattone. Numbet o6 Compan,tmen.tz
z nce 12% on neaten a.~ope_ Lit
A^ ~.E it. a - Fnam: we
z
Bu.itd.ing it. Wettanda ~ •
H.ighwaxeh it.
DISPOSAL SYSTEM
Distance From: Wett 12% ot greaten stope.,~r!
Bu.itd.ing G b W et.Eanda Ft.
• H.ighwaten it.
FIELD DIMENSIONS: -
Width o5 tr.ench ' it. Depth oS r.ock below t.ite-,/ gin.
Length a6 each tine it. Depth o6 r.ock oven .t.ite.in.
Numbet o6 tines f' Depth o6 tite b etow grad z , r in.
Totat teng.th o6 tines it. Stope o6 trench in per 100 it.
Distance between t inea,' t. Depth to bedrock it.
Totat abz onbt.ion area jt2 Depth to groundwater ~ .
..Requited area gt2 Type o6 Cover: Paper or S nacv
PIT DIMENSIONS:
Number o6 p.its~ Gravet around pits yea no
Outside d.iamet r~,. 5t Depth below .in.Let it.
2
Totat absorb can are it
Area required it2
r .
INSPECTED S-Y ~ TITLE
19
APPROVED DATE /
REJECTED DATE 197.
~l
EH 115 ,
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH ;:C f Jv v~;
P.O. BOX 309
MADISON, WISCONSIN 53701
/'REPORT ON SOIL BORINGS AND PERCOLATION TESTS I t
LOCATION: Section fA_ T, R Z W, Township oF Mwiaiciaaauy 'r V Y
Lot No. 7~~27Block No. ' Ix-91 c7Z County
t Subdivision Name
Owner's Name: ~l OieH)nl_ r Mailing Address:
TYPE OF OCCUPANCY: Residence _ No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW `ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOI L MAP SHEET SOI L TYPE ( t! = r Iv ri i''t ri ( rf i r x
PERCOLATION TESTS
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- I 5" 5 FW," 140&4v E44-T4 ( I
Z_ Y civc 3 3 ?3 3
P- K t~ N N 6 /Z /U~~
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_ i `7/Zc~ Bic 5,f.1 8n 5 r~~8:, L >f` $ 54F.tty6
Is
Z 120 159Sit.
~y LS f3 LS' rR 4 Stc`ie L~
B_j (ZL% /((V/1i~ -7/2-z.o $Ksr~l'z +3~ 4~~/&~ ~,LSdc ~4~ •,t ~ IGj7C!
4- r'"?, ~ ONE z is d -S_ ,ti =E54►.C
B_ 7 4 elf S«~ Z7r
~r SIL Z&„ fan S So L S $-6e 4, n 5 72-
PLAN VIEW (Locate percolation tests,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. "f 'e t 3 fir P" `Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slop
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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.
Name (print) (t ' / t), Certification No.
Address ``'cl
Name of installer if known /
i Signature
COPY A -LOCAL AUTHORITY CST
State Permit # PLB 6 7 r State and County
u Permit Application County Permit # i On- &Z
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A OWNER PROPERTY Mailing Address-
C
C~ % lam"-
tl) KO.
B. LOCATION: Section , T , R V- (or) W - Lot# 4 47- City
Subdivision Name, nearest road, lake or landmark Blk# Village
Q-~ ` C` C, Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family 4 Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 1 Z 7)C) 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 Pref b concrete Poured-in-Place Other (Specify)
E. EFFLU T DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.'
New Replacement Alternate (Specify) ~a
Seepage Trench: ~No. of Lineal Ft. 1 Width O" depth (top) No. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside d eter Liquid Depth No. of Seepage Pits
Percent slope of land- !Q 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 rtified Soil Test >>"~ct~am
NAME ~2- j
C.S.T. # a!5- e~IF~Q and other information
obtained from L?' (owner/builder). t
Plumber's Signature t ~ 2-LP Phone ;4L5 ~D~77
Plumber's Address 1
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord w/H1 0. Well loca-
tion shall be included on the sketch. Indicate or dimension locatio of all wells on the r neighbors O
property. If well has not been drilled please indicate. ,c- 4-,lk LL-
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application 3 4-3 ~1f o Fees Paid: State ~y County (~-t~ Date
Permit Issued/BAgeeted (date) Issuing Agent Name L - i
Inspection Yes4No State Valid# Date Recd 7
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