HomeMy WebLinkAbout036-1062-40-000
`d ' 1
O O ^r".
> > 3
Z c
v 3
C/) z a~ Q
U o N ° o ~n to °w < L•
N a O N CAD
C1 (D it N O O A
N C.. (D CO ' V N C (
C) 0
:E 0
L O O
O G CD CD W
C' 3 N n O
N C ~ ~
r Z ly A
u m a
O C)
CD
Z OO J Z r- cn
(n O C
O O (D
! a
u.' n r h •
Z =or
0 30
en to cn a (D
O N feed
3 m CD CT o N
y m ' A O
3 w CD C :
N - ~
J d
(D
a -0 3 \
z~k
t
z E2
° o Z Cn Z O
p D D (D 0
_0 Z
o m (D
N
CD N
O N
C N
(D
Q
~ (2. ~ -s rn
O (.N „ z
C z O
a O
o
Cl)
M
ID m w
CL Z
A
+ Cn
O V
N z
( A
co
CO 'O >
N (D Ci
CL C
n 3 T
~ N C
Iz a I
v ~
~ o
(y N
O Q
O O
M C y
CD CS
Cn CD
CD
O (D
cD 3
"O O `
tT
O
O v
3
~ N
_ O
O
O
O
O ~
C `p
CD 7p
p
° t
o m
Wisconsin Department of Health and Sooial Services
-A. #67 10/69Zi Division of Health
Ld PERMIT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name (Streetp CitYp Zip Code)
:=Address
~ NCB ~ r) /l JC
County
B. LOCATION OF PROPERTY WH"RE SYSTEM WILL BE CONSTRUCTED. ALTERED IR EXTENDED
Check One: 5~.~~/Lf
CITY VILLAGE LEGAL DESCRIPTION. n
TOWNSHIP ~sw~~ rJ/A/
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC 'SANK CAPACITY / TG O Gallons NEW INSTALLATION X REPLACEMENT ADDITION
MATERIALS: Prefab Concrete --Xl- Poured in Place Steel other
NUMBER OF TANKS TO BE INSTALLED: lr~ r7 D
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence -4- Commercial Industrial Other Specify
Number of Persons to be Accommodated 11) - Number of Bedrooms ..J
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic ClothesTWasher YES NO
~S._ NO AuV-,"iatio Fc:F. _ , Eeler YES NO
Dishwasher YES _
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ^.DDITION REPLACEMENT
Tile Size NO.Lin.Feet Trench Width Depth, Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
/ Seepage Pit: Inside diameter Liquid Depth ~J
P$ R C 0 L A T I 0 N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Ainutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni ht in Minutes Last Period Last Peri Period One Inch
Example
P- 0 3611 To Soil 10" Clay 26" 25 es or no 30 1/2 _______I Z2 1/2 60
n
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
ompute size of absorption areR in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below Pro osad Absorption System
oring Total Depth Depth to Ground Water_ Depth tp Bedrock '
umber Inches Observed Estimated Observed Estimated Character of Soil with rhickness in Inches j
xample
- 0 7211 7211 Black To Soil 12"• Cla 18"• Sand 18"• Gravel 24"
14
J' 72--
72,
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDS
I, the undersigned, her•aby 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.
NAME ~rrl~ r ! r~/',e TITLE
(Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No.
ADDRESS
DATEL~i7 C~ SIGNATUFS f'L` 'r
MASTER PLUMBER MAKING APPLICATION
MP
Signatures !License Numbers
MP RSW
(To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date E 6 Permit Number
Agent (name) --ell- 14 V el 0- For: V-J 1, ~L~~lt/• 1
Town, Village, City, County, etc.
(Specify)
Note: The applicat v n 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 copy) 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
DATE RECEIVED ACCEPTED BY i>71 RETURNED
(Initials) / (Date) See Cor>re
FEE RECEIVED Z---- VALID. NO. O v PERMIT NO.
(Yes or No) .
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS:
Parcel 036-1062-40-000 06/27/2007 04:07 PM
PAGE 1 OF 1
Alt. Parcel 26.31.17.400B 036 - TOWN OF STANTON
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
LESTER C & BARBARA ROGERS O - ROGERS, LESTER C & BARBARA
1920 CTY RD T
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1920 CTY RD T
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 26 T31 N R1 7W PT SE SW COM NE COR OF Block/Condo Bldg:
SW1/4, TH S 1587' TO POB; TH S 300'W
435.85'N 300', TH E 435.85' TO TOB EXC Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
E 33' 26-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 459/473
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/16/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 22,000 127,800 149,800 NO
Totals for 2007:
General Property 3.000 22,000 127,800 149,800
Woodland 0.000 0 0
Totals for 2006:
General Property 3.000 18,000 127,800 145,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 136
Specials:
User Special Code Category Amount
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00 0.00