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Parcel 026-1080-10-000 01/30/2007 03:15 PM
PAGE 1 OF 1
Alt. Parcel 27.30.18.423 026 - TOWN OF RICHMOND
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
10/06/2006 00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
RICHARD,ROBERT,JOAN,JUDY DERRICK O -DERRICK, RICHARD, ROBERT,JOAN,JUDY
1247 HWY 65
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1310 HWY 65
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 38.350 Plat: N/A-NOT AVAILABLE
SEC 27 T30N R18W SE SE EXC CSM 11/3241 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
27-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/06/2003 704696 2101/193 LC
2006 SUMMARY Bill Fair Market Value: Assessed with:
177281 Use Value Assessment
Valuations: Last Changed: 06/30/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 31.040 2,400 0 2,400 NO
UNDEVELOPED G5 2.310 100 0 100 NO
OTHER G7 5.000 16,800 189,900 206,700 NO
Totals for 2006:
General Property 38.350 19,300 189,900 209,200
Woodland 0.000 0 0
Totals for 2005:
General Property 38.350 19,300 189,900 209,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 133
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
UL~ -l Ob'U~l o ovv Cf
wlsconsln APPLICATION FOR SANITARY PERMIT LA DILHR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
-40EPRRTTT1EnT OF n
~ InOUSTRV, 4R80R 6 HUTRn RELRTIOnS i
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
,.,.`~..~.-)/~:r~ /f ;lr; 1, y s i~ / •
PROPERTY LOCATION CtTy: )
VIL-LAGE:
~I 114 & 1/4, S N, R 1,~ (or) W TOWN OF: i„Y! , -1 _..a
LOT NUMBER BLOCK NUMBER SUBDIVISION N/j E NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBEF'
} _ - Jl
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System L:1 Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total -#o f Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
1
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installatio of the private sewage system shown on the attached plans.
Name Plumber (Prin Signature: MP/MP RSW No.: Phone Number:
Plumber's A ! Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
,CS Q~ Si 41 Owner Given Initial
p / Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
i
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6338
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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SANITARY PERMIT
.~DILHR County
WousTww"Lc3 GROUNDWATER SURCHARGE
tee- ,Veos+c► iw ~or~s Sanitary Permit No.
`1
_j- 19, 7 On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly known as the groundwater protection taw. This change in statutes was the result of over
2 years of steady negotiation and public debate. The groundwater bill included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Ground ;
Sign pure of Issuing Agent: Groundwater Fee: Date: WISCO fft~
DILHR SBD-7289 (N. 05/84) io
i
,
64f~, jJ~S; ~/~1r1
Lam( / "L
i
j
Wisconsin. Dep^:':-Aont or Health e^-d Social Sorvie.es
Plb„ X67 370 Division of Health
' SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
da°® Address (Street, City, zip Coda)
B. LOCATION OF PROPERTY WIERE SYSTEM WILL BE CONST'RLrTED,'ALTERED OR EXTENDED COUNTY 57~/
Check One: - ~
CITY VILLAGE LEGAL DESCRIPTION
X TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? r YES NO PERMIT NU:4B^-
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACE±:,NT ADDIT;ON _
MATERIALS: Prefab Concrete. Poured in Place Steel Other _
NUMBER OF TtYKS PO BE !NSTALLe.D: t `
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence Commercial, _ Industrial Other
Spe •ify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food ;haste Grinder YES NO Automatic Clothss Washer NO
Disk-masher YES NO Automatic Potato Pealer YIS NO
Other (Specify) V -
G. MASTER PLUMBER MAKING INSTALLATION
I I
Name: i e / 1 ^i,) _ / + 1 ✓✓J1~~i? Addrass= / I License l umber:
r
Sigr_ature of Applicant:
MP RSW
Address:~
+
(To-be Completed by Issuing Agent)
Date of Application .2 Fee Paid
Permit Issued (date) Permit Number
(Name). Fors Agent
Town, Village, City,•County, etc.
(Specify)
Nets; The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $I.CU for each septic tarx and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health..
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPT 'D BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. n Ss (~Cr~ PERMIT NO.
'lez or Ho
REVIEWED BY APPROVED DATE
(Initials),
Yes or No)
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R$ P 0 R T O N S O I L P Y R C 0 L A T I 0 N T E S T
A N D 5 0 I L- B 0 R I N G S
TO
DIVISION OF HEALTH - PUM-31I?G S?CTI6-H
P.O.Box 303, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Ae inistrativo Code
P S R C 0 L A T I 0 N T E S T
Test - i, y i~ Charaoter of Soil Hours Hater Test gL:3 Drn Ln r I T '.i ;rutos
Number Inches Thiclmes3 in Inchas Since Hole in Hale Interval Second to hart/to Last To Fall.
°'"°"`""1st Wetted OvarAiwht ir' Minutes La3t Period Last Perin~ eriod !On-, I .ch
P - 0 367' Top Soil 10". Clay 2611 25 Yes or No 30 112/ 1/2
f i
~ is J r, `:~j~. f-~ 1~~! I
RECORD DATA FROM MINDi h 07 3 VZST HOI,~.S
Compute :size of absorption area in accord with H 62.20 Wis. Administrative Codj.
S 0 I L B O R I N G S- uini=un 36" ^c y Prcoo3 :d ti;rt $v w j;.r
Boring Total Depth Rie h~to Ground }eat---n Daoth to Badroc
Number Inehas Cbsrrvad E3tiM~;ted Obset^aad Esti3ted Character of Sail with Thic'::Pe3s in l ichos
Exa~.a?la I - - -
B 0 72" 72" Bla..k Top Soil 1211; C1y 18"t Sand low Gravel 2-4"
21.
R "OR,D DATA F GM MINI UM G3~~ HOt.FS
,YPE OF OCCUPANCY:
R::SIDENCEt Nmber of Bedrocaas ' - % O_TH_R: (Specify) Number of Persons
+F^OD WAST:; GRINDr-R: Yes No DisYnrasher Yes ' MF
: Y3 -No Automatic Cloths!) ziayho, j Yes
FFLUF.ST DISPOSAL SYSTEM- NFV1 f' EXTENSION ADDITION REPLkC2.'IENT ~
Tile Size if No. Lin. Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width _ Depth _ Tile Size No. Lines
Seepage Pit: Inside Diameter Liquid Depth
I, the undersigned, hereby eert'fy that the percolation tests reported an this fora were made by me or under rr• super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Adainistrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NA?M l i I C_I4 G r I r /1 ! +7 ~~/,d TITLE
Type or Print
R$GISTRATION NO. or MASTER PLUNIDER LI6ENSE NO.
ADDRESS d • ~a; ' } ~1, f~ r:'!+ f ! / / a
DATE / -711 7 C SIGNATURE ?_i