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• AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP.X' SEC. T ~ % N R_L .W
J. ADDRESS ST. CROIX COUNTY, WISCONSIN.
i3DIVISION LOT LOT SIZE C S M _2
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• _ Cam`
3-1
• I
'TIC TANK(S)~_ CONCRETE_,L STEEL
N0. of rings on cover'_ Depth DRY WELL
'NCHES NO. of width length area
' no. of lines width__ length__ area
depth to top of pipe j-'
" ZEGATE 1 r
a RATE, AREA REQUIRED ; AREA AS BUILT
claimer: The inspection of this system by St. Croix County does not imply complete ;
)liance with State Administrative Codes. There are other areas that it is not possible j
inspect at this point of construction. St. Croix County assumes no liability 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 X` J4
LICENSE NUMBER
i
f
Parcel 026-1022-40-000 03/30/2006 10:54 AM
PAGE 1 OF 1
Alt. Parcel 06.30.18.81 C 026 - TOWN OF RICHMOND
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 - PARENT, SANDRA J
SANDRA J PARENT
922 170TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 922 170TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 6 T30N R28W 2.5A IN S 1/2 SW LOT 2 Block/Condo Bldg:
OF CSM 2/597
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/03/2005 783939 2724/382 QC
12/12/2000 635104 1566/334 TI
09/08/1978 351516 580/572 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
95465 148,200
Valuations: Last Changed: 06/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 42,800 84,300 127,100 NO
Totals for 2005:
General Property 2.500 42,800 84,300 127,100
Woodland 0.000 0 0
Totals for 2004:
General Property 2.500 42,800 84,300 127,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 308
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
Sanitatc.y Petc.mit~--;J(-~_
State Septic
t. Ctoix County
NAME
r"~! TownJsh~p ~`2C1 rr y
Locations&)% 065k!~, Section( T_) k,R,I,tU
SEPTIC TANK
Size gattons. NumbeA o6 CompaAtmentz
Di/sLance FAOm: WeU % 12% oA gAeateA 6tope it
BuiY-ding it. Wettandts
HighwateA it.
DISPOSAL SYSTEM
Distance FAOm: Wet 120 oA gAeateA 6tope it.
Buitding. , it. WettandJs Ft.
HighwateA it.
FIELD DIMENSIONS:
Width o6 ttench it. Depth o6 Aock below tiZe in.
Length o6 each tine it. Depth o6 Aock oveA tite in.
NumbeA ob ZineJs Depth o6 tite betow grade in.
Tota.2 .length o6 tinez it. Stope o6 .tAench in pet 100 it.
Distance between Una it. Depth to bedtock it.
Total abzonbtion atcea 6t2 Depth to gAoundwateA it.
2
Requited atea it
PIT DIMENSIONS:
NumbeA o6 pit3 GAavet around pitz yes no
Out.6ide dia.meteA 6t: Depth below inlet it.
2
Totat abJsoAbtion atc.ea it A
AAea AequitArd it2 rn
INSPECTED BY TITLE
APPROVED ,DATE 197.
REJECTED DATE 197.
0~
PLB67 State and County State Permit #
Permit Application County Permi #
for Private Domestic Sewage Systems County ~=L-<
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
_ L l 1 1 ~~~~z ,
B. LOCATION: '/4 Section T _ N, R E (or W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township . , , c ~s arc
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms I No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms
Automatic WashesYES NO Other (specify)
E. SEPTIC TANK CAPACITY C Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) _ _~_Total Absorb Area 1 sq. ft.
NewX Addition Replacement *Fill System
Seepage Trench: No. Lin . Feet Width ' Depth Tile Depth No. of Trenches
Seepage Bed: Length k JWidth L Z Depth Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size `I
Percent slope of land Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, end that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester, Jl
NAME - 6 L_ L t C.S.T. # j S ST and other information
obtained from C t- own der). / L phone # -
Plumber's Signature T MPRS--
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well). i
114
i 7
Do Not Write in Space Below FOR DEPARTMENT SE ONLY
to
Date of Application Fees 7P 'd: State Cou _ G D 51
Permit Issued/Ra}eeed (date) _Issuing Agent Name Z 5
Inspection YessNo Valid# Date Recd
1. county , i a 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 6/1 /76
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: Section T?~N, R 1~, E (or W, Township or-may- f I'
Lot No. , Block No. County
Subdivision Name
Owner's Name:
i Mailing Address: C I% l l 1 i
No. of Bedrooms Other
TYPE OF OCCUPANCY: Residence ,
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS I 7 PERCOLATION-TESTS 9
SO1L MAP SHEET SOIL TYPE
PERCOLATION TESTS _
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER OF SOIL
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
j BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- e z_
l
4y
^1
~
P_ / t
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)
2 6/,
iB
2-0 j L c)
-'s JI-S
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
indicate on the plan the location and square feet of suitable areas. Indicate number of square =ee; of ab;r,! ption area
r:=eded for building type and occupancy. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope. C_14
I ~
r
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.
Name (print) Certification No. j
Address c
Name of installer if known
CST Signature
Cvf=Y A f.rDCAL At"11- JT ITY