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Parcel 038-1013-40-000 09/09/2005 09:14 AM
PAGE 1 OF 1
Alt. Parcel 3.31.1 .34B 038 - TOWN OF STAR PRAIRIE
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 - JACOBS, ROBERT C & JERILYN
ROBERT C & JERILYN JACOBS
2381 CARDINAL DR
NEW RICHMOND WI 54017 t f
Districts: SC = School SP = Special Property Address(es): Primary I
Type Dist # Description * 2381 CARDINAL DR I r
SC 3962 NEW RICHMOND
SP 1700 WITC
SP 8055 CEDAR LAKE/N R
Legal Description: Acres: 1.110 Plat: 0961-CSM 13/3764 I w -r`
SEC 3 T31 N R1 8W PT GL 1 BEING LOTS 4 & 5 Block/Condo Bldg: LOT 4&5
CSM 13/3764
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
yyy/ i _jL 7 03-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/01/2000 623986 1515/163 WD
04/17/2000 621333 1503/146 WD
12/16/1999 615612 1478/429 LC
j ' 12/16/1999 615610 1478/426 PR
more...
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2004
Description Class Acres Land f' Improve Total State Reason
RESIDENTIAL G1 1.110 199,900 107,600 307,500 NO
Totals for 2005:
General Property 1.110 199,900 107,600 307,500
Woodland 0.000 0 0
Totals for 2004:
General Property 1.110 199,900 107,600 307,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch 120
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 038-1013-40-000 10/12/2006 03:11 PM
PAGE 1 OF 2
Alt. Parcel 3.31.18.34B 038 - TOWN OF STAR PRAIRIE
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 - JACOBS, ROBERT C & JERILYN
ROBERT C & JERILYN JACOBS
2381 CARDINAL DR
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 2381 CARDINAL DR
SC 3962 NEW RICHMOND
SP 1700 WITC
SP 8055 CEDAR LAKE/N R
Legal Description: Acres: 1.110 Plat: 3764-CSM 13/3764
SEC 3 T31 N R1 8W PT GL 1 BEING LOTS 4 & 5 Block/Condo Bldg: LOT 4&5
CSM 13/3764
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-31 N-1 8W
i
Notes: Parcel History:
Date Doc # Vol/Page Type
06/01/2000 623986 1515/163 WD
04/17/2000 621333 1503/146 WD
12/16/1999 615612 1478/429 LC
12/16/1999 615610 1478/426 m PR
ore
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.110 199,900 107,600 307,500 NO
Totals for 2006:
General Property 1.110 199,900 107,600 307,500
Woodland 0.000 0 0
Totals for 2005:
General Property 1.110 199,900 107,600 307,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch 120
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 038-1013-40-000 10/12/2006 03:11 PM
i
PAGE 20F2
Parcel History: cont.
12/16/1999 615609 1478/425 PR
12/16/1999 615608 1478/424 QC
12/16/1999 615607 1478/423 QC
02/16/1999 597862 1404/04 QC
I
I
Wisconsin Department of Health and Social Services
Plb. #67 Division of Health .
V PEFCIIT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYSTEMS
uk [1 I LI
A. OWNER OF PROPERTY_ TYPE OR USE BLACK INK
Name Address (Street, City Zip Code)
County
B. LOCATION OF PROPER'T'Y WHErE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXT&NDED
Check One: j ,
CITY VILLAGE LEA L DES.RIPTIONt
._T/'POWNSHIP T
C. IS LOCAL PEFVITr REQUIRED FOR THIS Vn FX? c YES NO u~' cr
D. SEPTIC TANK CAPACITY I C 0--c- Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete I Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence t- /Commeroial Industrial Other
Specify
Number of Persons to be Accommodated
F. A?PLIANCES, E701 Food Waste Grinder YES NO Automatic Clothes Washer YES L---NO
T -
Dishwasher YES NO Automatic Potato Peeler YES L% NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bedt Length Width Depth Tile Size No. Lines
f Seepage Pitt Inside diameter _ Liquid Depth
P E R C O L A T I O N T E S T
Test Depth Character cf Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness `.n Inches Since Hole in Hole Interval Second to Next to Last I'e Fall
1st Wetted Overnight lin Mt.nmtes Last Periodi Last Perio Period (.na inch
Example
P- 0 36" To Soil 10" Cla- 2611 25 es or no 30 '-12 1/2
_Y2 60
v %vr t
RECOFO DATA FROM MINIMUM OF 3 TEST HOLES
ompute size of absorption area in acoord with H 62.20 Wis. Administrative Code.
S O I L B G R I N G S- Minimum 36" Below Proposed Absorption System
oring Total Depth Depth to Ground Water Depth to Bedrock
umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches 1
xample
- 0 7211 72" Black To Soil 121 • Clay 18"• Sand 18"• Gravel 24"
RECORD DATA FROM MINLI M OF 3 BORE HOLES
COMPLETE OTHER SIDE
4
Z
I, the undersio ed, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
7 1
NAME n 5 TITLE ii P
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No.
ADDRESS
DATE SIGNATUF
MASTER PLUMBER MAKING APPLICATION
MP
Signatures j~t.: f { • !s,. License Numbert
MP RSW f S `
(To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date) Permit Number's/!
Agent (name) A; Fora
Town, Village, City, County, etc.
(Specify)
Notet 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 $10.00 and Copy (b) of the
Permit (yellow oopy) 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
DATY RECEIVED - G ACCEPTED BY RETURNED
(Initials) (Date) See Corres.
FEE RECEIVED VALID. NO. T S C- G PERMIT NO. Yes or No)
REVIEWED BY APPROVED DATE
(Initials) Yes or No)
COMMENTS :