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/d2D APPLICATION FOR SANITARY PERMIT
f or
INSTALLATION OF A SEPTIC TANK
(Sec. 144.03., Wis. Stats4)
A. OWNER OF PROPERTY..
Name Address (Street, City,/Zip Code))
B. LOCATION,OF`PROPERTY WHERE.SEPTIC TANK IS TO BEvINSTALLED
Check 1, -City Mil address County
one: 2. Village
% S
3 . Town S 4c-/./
C. INST1JXX.R Give license7numde held:
Wisconsin Restricted
Licensed 7 Sewer
Plumber. Services
Name Address
D. SPECIFICATIONS OeEPTI TANK
Size in gallons:(check one)
1. 1,000 gal. 5. 4e400 gal,
2. _ 1,,500 gal. 6. 5,000 gal:
3. 2,000 gal. 71 If over 5,000 gal., give capacity.
4. 3,000 gal.
Materials: 1. Prefab concrete 2. Poured concrete 3._ Steel
E. TYPE OF OCCUPANCY
1. Single family residence 36 -.4 Commercial establishment
2. Multiple family residence 4 Industrial establishment
F. APPROXIMATE NUMBER OF PERSONS SERVED DAILY
G. PERCOLATION TEST MADE 1« Y s 2. No Date D G O
7 7
By whom
(To be completed by County Clerk)
Date application is filed and fee paid
Permit issued (date) Permit Number
County Clerk
NK4 /or Z/ ~s~ ~3 /3(o sx
Percolation Rate Minimum Absorption Area in Square Feet per Bedroom
Minutes Required Normal With With With Both
For Water to Fall Plumbing Garbage Automatic Grinder and
One Inch Fixtures Grinder Washer Automatic
Washer
2 50 65 75 85
3 60 75 85 100
4 70 85 95 115
5 75 9o 105 125
5 - 10 100 120 135 165
10 - 15 115 140 160 190
15 - 30 150 180 205 250
30 - 45 180 215 245 300
45 - 60 200 240 275 330
60 - 9o 240 290 325 400
i
~r~rOrT OF INSP ` CTION---INDIVIDUAL j iiG'-~-DISPOSAL SY` T_ll
1R,1D1 AY T-R-, TK'11T consists of Septic tank. Cther (Describe)
i
t> : PTIC TAPdK : Distance from: 'ell ft. Lot Line ft. Building 7%5 ft.
High watermark ft. 129% or greater slope ft. - etland ft.
Cistern ft. No. compartments . Liouid capacity gal.
EFFLUENT DIS 7CSAL SYSTIE consists of -Tile field. Z.Seepage pit(s).
Tile Field:Distance from: 'Jell ft. Building ft. Lot line ft.
Cistern ft. High watermark of water course ft. Slope 12% or
greater ft. -etland ft.
Total length of tile lines ft. Number of lines Length of each
line ft. Distance between lines ft. `idth of trench in.
Total effective absorption area of trench bottom sq. ft.
Depth of filter material below the in. Depth of filter material over
tile in. Cover over filter material
Depth of the below finished grade in. `lope of trench bottom in.
per 100 ft. D.nth to bedrock ft. Depth to ground water ft.
I
Seepage "its:Distance from: `ell ft. 3uilding ft. Lot line ft.
Cistern ft. High watermark of water course ft. "-lope 12 or
greater ft. 'etland ft.
Number of '-'its , Cutside diameter ft. D nth below inlet 6- ft.
Lining material Gravel around pit:-4-Yes.
No. Total iascrption area^. Ft.
Squ=are feet of seepage trench bottom area required
Square feet of seepage pit area required
?re-construction Inspection
Date of Inspection, 19 ,
Inspected by:
Title:
Construction Inspection
Date ,19_
Date ,19
Dat e,19ZT.
nproved__ ! ~Lh G Date f~i 19L ~ .
Rejected ------.Date ,19 ,
AHIBIT NC. 5 - 1000
County, Town of
Sanitary Permit Applicaticn No. Cwneri7,r G l~s
Sanitary Permit 140. ;1roperty Address
Land use Permit No. Street or Highway
Septic Tank P-rmit No. -ubdivision
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NA MC OF'BUSINESS Z 41 Xo l/~' / C) 1j
F
LOCATION rll
street or highway ( city or tow~tship ~ county 1
OWNER ~~J!-t ailing address
ARCHITECT OR ENGINEER A/x- w Address
PLUMBER L-Y
Addresses L
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed;
Existing building New building Addition
if addition to existing building attach detailed memo for each.
(1a Restaurant or dining room . . . . Seating capacity (10 sq.ft./person)
Motel O Hotel (j Cottages Number of units; Regular Housekeeping
2 persons/unit
4 persons/unit TOTAL N"ER OF UNITS
O Bar or cocktail lounge . . . . . Seating capacity (10 sq.ft./person
Nursing or retirement home Number of beds
Mobile home park . Number of units - dependent
- nondependent
O Service station . . . . . . . . Number of ears served (daily)
O Sohool . Number of classrooms Meals served Yes- No r Showers provided YesNo
Factory or office building Number of persons (total all shifts)
O Residence . Number of bedrooms
( Other - specify
2. Indicate whether or no /~~Vel' , follow facilities are connected: Food waste grinder . . . Yes No
Dishwasher . .Yes 'tio
Automatic clothes washer Yes No
x,
3. Fill in the appropriate information for the following as indicated:
Septic tank capacity planned Normal septic tank capacity required
506 increase for FWG or AN r mil, ~ Total septic tank capacity required
j percolation test results - ATTACH PEFCOLATION TEST MWRT SHEEP
j See a ranch bottom area planned , width , linear feet , depth
Seepage pit planned4~~ /Wiside diameter depth below inlet -i`depth
Seepage trench bottom area required width _ linear feet
Seepage pitsrequired , outside dizusater depth below inlet
Signature of person completing form; STATE BOARD OF HEALTH, PLUMBING DIVISION
j P. 0. Box 309, Madison, Wisconsin 53701
Address; Approved;
Date G C~ ` Date / 02. z fb zr
.01
j
Parcel 040-1101-50-000 01/15/2013 09:22AM
PAGE 1 OF 1
Alt. Parcel M 25.28.19.397J 040 - TOWN OF TROY
Current ❑X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
CHRIS & LINDA JENSEN 0 - JENSEN, CHRIS & LINDA
139 HWY 35
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 131 HWY 35
SC 4893 SCH DIST RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.508 Plat: 3658-CSM 13-3658 040-99
SEC 25 T28N R19W PT NE SE & NW SE BEING Block/Condo Bldg: LOT 4
LOT 4 CSM 13/3658
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
25-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/13/2011 937458 WD
06/13/2011 937457 QC
01/29/2008 867924 QC
11/14/2007 864120 WD
more...
2012 SUMMARY Bill M Fair Market Value: Assessed with:
186343 208,700
Valuations: Last Changed: 08/20/2012
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 1.508 62,700 175,500 238,200 NO 05
Totals for 2012:
General Property 1.508 62,700 175,500 238,200
Woodland 0.000 0 0
Totals for 2011:
General Property 1.508 62,700 109,900 172,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 040-1101-50-000 03/20/2007 10:24 AM
PAGE 1 OF 1
Alt. Parcel 25.28.19.397J 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 - KUSILEK, CHRIS & DIANA
CHRIS & DIANA KUSILEK
N8618 1090TH ST
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.508 Plat: 3658-CSM 13/3658
SEC 25 T28N R19W PT NE SE & NW SE BEING Block/Condo Bldg: LOT 4
LOT 4 CSM 13/3658
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
25-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/26/1997 569095 1279/309 LC
07/23/1997 901/587
07/23/1997 825/408
07/23/1997 797/265
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/06/2002
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 1.508 40,000 163,500 203,500 NO
Totals for 2007:
General Property 1.508 40,000 163,500 203,500
Woodland 0.000 0 0
Totals for 2006:
General Property 1.508 40,000 163,500 203,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
r
x"99
CERTIFIED SURVEY MAP
LOCATED IN PART OF THE SW 1/4 OF THE NE 1/4, IN PART OF THE
NE 1 /4 OF THE SE 1 /4 AND IN PART OF THE NW 1 /4 OF THE SE 1 /4
SECTION 25, T28N, R 19W, TOWN OF TROY, ST. CROIX COUNTY,
WISCONSIN.
N1/4 CORNER
SECTION 25 NORTH LINE OF THE NE1 /4 NE CORNER
S 89'12'53" E SECTION 25
-ti S 89'12'53" E
4
1077.51' 1574.38'
\
OWNER
CHRIS KUSILEK
\ N8618 1090TH
\
IN, RIVER FALLS, WI 54022
\ O 0)
j~ 00 C--) 1 IRON PIPE FOUND
N62'58'21"E, 0.43'
p N Q ~1 FROM LOT CORNER
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WIDTH \O SEPTIC
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LEGEND g
ALUMINUM COUNTY SECTION CORNER\
MONUMENT FOUND
I ~
• 1" IRON PIPE
FOUND \
\
G,
1" X 24 IRON PIPE SET WEIGHING
1 ~F G 1--
O
1.68 LBS. PER LINEAR FOOT \ \
• • • • • • • 42' ROADWAY SETBACK LINE \
SCALE IN FEET 1" = 100'
\
0 100 200 300
"CAUTION" -HIGHWAY SETBACK RESTRICTIONS PROHIB!T IMPROVEMENTS. SEE BACK OF THIS SHEET
THIS INSTRUMENT DRAFTED BY MICHAEL ERICKSON JOB NO. 98-159 DATE: 4/02/99
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