HomeMy WebLinkAbout032-2038-10-000
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Wisconsin Department of Health and Sooial Servi.es
r Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION.
TYPE or USE BLACK INK ,..L~
A. CWHER OF PROPERTY /J
Name ame //~✓l~x„- Address (Street, City,. Zip Cod,:)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED CR FYT.^_:DED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNS H(1'7 ~l,Zt r %y - ~U (l~~G~~ 1 Lam: o ,y / 9
IS LOCAL PERMIT REQUIRED FOR THIS WORK? AYES NO Y - Yk;fvIT NUMBFR
D. SEPTIC TANK CAPACITY le y Gallons NEW INSTALLATION REPLACEMENT TION
MATERIALS: Prefab Concrete /l Poured in Place Steel Other
NUMBER OF TANKS ?0 BE INSTALLED:
E. TYPE OF OCCUPANCY
Cheek Ones One or Two Family Residence ~ Commercial Industrial Other
Spec fy)
Number of Persons to be Accommodated Number of Bedrooms 1-21
F. APPLIANCES, ETC: Food Wests Grinder YES ~ NO Automatic Clothes W!!si-er ~ YES NO
Dis2tiasher YES_ NO Automatio Potato Peeler YF:S_ NO
Other (Specify)
G. MASTER PLUMBER MAKING #NSTALLATIIO/
Name: - CO, Address IC, - 1 License Numbers
Signature of App/pl/icant: c~•/zC~ FC? i MP RSK `-/)6 1
Address:
H. (T be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date
Permit Number
Agent (Name) Z11 /
For:
Town, Village, City, County, etc.
(Specify)
Notes The application cannot be considered for filing until all of tha above questions are answered and the
fee paid. Agents will forward application, the fee of $1.00 for each septic tanK and the third copy
of the permit (canary' to the Division of Health. Checks an#' money orders should be made payable to
the Division of, Health.
Do not write in space below FOR DEPARTMENT USE ONLY
I. DATE' RECEIVED `70 ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE_ RECEIVED VALID. No. f X07 PERMIT NO. 4 x-4y
(es or No
REVI96ED BY AMOVED DATZ
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO. 7' -3 dr
R I P O R T O N S O I L P I R C 0 L A? I O N ? E S T
r A N D S O I L B O R I N G S i
TO
DIVISION OF HEALTH - PLL`'MZNG SICTI*
P.O.Box 309, Madison, Wis. 53701
PL-,w:an to H 62.20, Wis. Administrative Code
P I R C 0 L A T I 0 N T I S T
Test Depth Charaoter of Soil Hours Water Test Time Drop in Water Level Inohes " utes
Number Inches Thiakness in Inohes Since Hole in N0146 Interval Second to Next to Last o Fall
lst Wetted Overnight in Minutes Last Period Last Period Period CneInch
Example
P - 0 361 to Soil 1011, Clay 26" 25 Yes or No 30 1/2 1/2 ~ 1/2 60
1/0 1141
70 Z
'57 -30 A10 ly-0
RECORD DATA FROM MINIMUM OF 3 TEST HOLES ,
Compute size of absorption area in aocord with H 62.20 Wis..,Adadnistrativo Code.
S O I L B O R I N G S- Minimum 361 Below proposed Absorption Sy2tsm
Boring iTotal Depth Depth to Ground Hater Depth to Bedrock
Number Total
Observed Isti..ated Observed Estimated Character of Soil uiih Thiokness in Ir.ohes
P.xsapte i
B - 0 721 72" Black To Soil 12"• Clay 18111 Sand 1811 Gravel 241
n-v - 7 „
i > 7~
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
YPE OF OCCUPANCYa
RESIDENCE: Number of Bedrorsas OTHER:-(Speoify) Number of Persons
rOOD WAST GRINDER# Yes No Dishwashers Yes No 2-- Automatic Clothes Washers Yes Ir No
FRLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin..Feet Trench Width Depth Number of Lines
~ J a ,
Seepage Bed: LengthaGt7 Width 1~ Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby oert,.fy that the percolation tests reported on this form were made by me or under my super-
vision in acoord with the procedures and method specified in Chapter H 62.20 (13), Wisoonsin Administrative Code, and
that the data reoorded and location of test holes are oorrect to the best of wl knowledge and belief.
NAME C He 2 jo ej 1 l S TITLE tcl.v~
Typo or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS Jell PC. ;0 14 Ay 1)
DATE 0 02 Z2 0 SIGNATURE v
Parcel 032-2038-10-000 04/30/2007 03:57
PAGE 10F 1
Alt. Parcel 10.30.19.618 032 - 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 - BELISLE, VICTORIAN J
VICTORIAN J BELISLE
1693 CTY RD I
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1693 CTY RD I
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 10 T30N R1 9W 40A NE NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
10-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 48,000 33,800 81,800 NO
UNDEVELOPED G5 37.000 74,000 0 74,000 NO
Totals for 2007:
General Property 40.000 122,000 33,800 155,800
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 122,000 33,800 155,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 132
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 032-2037-20-000 04/30/2007 03:57 PM
PAGE 1OF1
Alt. Parcel 10.30.19.616 032 - 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 - BELISLE, VICTORIAN J
VICTORIAN J BELISLE
1693 CTY RD I
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 10 T30N R1 9W 40A SW NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
10-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
UNDEVELOPED G5 40.000 80,000 0 80,000 NO
Totals for 2007:
General Property 40.000 80,000 0 80,000
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 80,000 0 80,000
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
Parcel 032-2037-10-000 04/30/2007 03:57 PM
PAGE 1 OF 1
Alt. Parcel 4.30.19.615 032 - 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
VICTORIAN J BELISLE O - BELISLE, VICTORIAN J
1693 CTY RD I
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 10 T30N R1 9W 40A NW NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
10-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
UNDEVELOPED G5 40.000 80,000 0 80,000 NO
Totals for 2007:
General Property 40.000 80,000 0 80,000
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 80,000 0 80,000
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