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Wisconsin Department of Health and 59oial Services
kb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
30- tosl- /0-cob
TYPE or USE BLACK INK 7 3 -b r'
A. OWNER OF PROPERTY
Name Address (Str9et, City, ~uin re%AA1
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check Ones
CITY VILLAGE LEGAL DESCRIPTION
I-- TOWNSHIP
i
C. IS LOCAL PERMIT YRQUIREIFOR THIS WORK? L--YES NO /i PERMIT NUMBER
D. SEPTIC TANK CAPACITY -~L Gallons NEW INSTALLATION - REPLACUIENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS 70 BE I`iSTALLEDs X
E. TYPE OF OCCUPANCY
Check Ones One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms L/
F. APPLIANCES, ETC: Food Waste Grinder YES L-"NO Automatic Clothes Washer YF:S NO
Dishwasher %--YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTLR PLUMBER MAKING INSTALLATION
Name: Addresss Lioensa Numbers
MP
Signature of Applicants HP RSW r
Address: ` C
H. ( o be Completed by Issuing Agent)
Date of Application ~vC / 17 p Fee Paid 0
Permit Issued Zz'~( S 70 Permit Number Z, 9,
Agent (Name) A Fors t-4
Ili Town, Village, City,'County, etc.
(Specify)
Note; The application cannot be considered for firming until all of tho ah:,ve questions are answered and the
fee paid. Agents will for- and application, the fee of $I.0u for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks a& money orders should be made payable to
the Division of Health.
Do not write in bpace below - FOR DEPARTMENT USE.ONLY
I. DATE RECEIVED U ACCEPTED BY L RETURNED
(Initials) (Date) ee Corr S.)
FEE RECEIVED ✓ VALID. No. _ a ~v - PERMIT NO.
Yes or No
REVIEWID BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R Z P O R T O N S O I L P= R C 0 L A T I 0 N T Z S T
A N D S O I L B O R I N G S
TO
DV ISION OF HEALTH - FLLMBM SBCTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P Z R C 0 L A T I 0 N T Z S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches utes
Number Inohes Thickness in Inches Since Hole in Hole Interval Second to Next to Last ~T!nftll
lst Wetted Overni t in Minutes Last Period last Period Period nsr Inch
Example
P - 0 361, Too Soil 10". Cla 261, 25 Yes or No 30 1/2 I L2 1/2 60
4-1
L
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 3611 Belay Pro osed Absorption S stag
Boring Tota]. Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thiokness in Inches
Example
B - 0 72'1 72" Black To Soil 1211 Cla 181' Sand 1811, • Gravel 2411
12
RECORD DATA FROM MINIMUM OF 3 301RW HOL23
YPE OF OCCUPANCY:
RESIDENCE: Number of Bedrooms OTHER: (Speoify) Number of Persons
FOOD WASTE GRINDER: Yes Nu ~ Dishwashers Yes C -No Automatic Clothes Washers Yes No
FFUJENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACLIIENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length ? `1r Width ?I Depthr r Tile Size No. Linas
Seepage Pits Inside Disaster Liquid Depth
I, the undersigned, hereby eert_fy that the pe:neoiation tests raported on this fora were made by me or tvider my super-`
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisoonsin Administrative Code, and
that the data recorded and location of test holes are eorr3ct to the best of my knowledge and belief.
i
NAME r _ TITLE
Type or Print
1. -
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE SIGNATURE
1 - e
PP 120 r~ PS .z ad waman I 40 8 r R 36 ' 39 n`t
RIGHT Donavin John & 2 2 T B ;tee 24 n 2 d g John & I
S Georgine
( AKE iudith Georgine WEST P&L IIDDEN z
J Schmitt Schottler I
John & SHORE R&c tr 1 C 7 OAK TR W m Schottler
_ D 6 C 200. O ~y
Kathleen s&K W 5, W Gray N G.i
228 John O R&L 142
tr tr VALLEY 119 365 I1,key 39 120 m is B D&B S 6
o VIEW TR tr ri tr 36 TERRIE E20 N tr 140th AVE O
°a SK 15 DJ 3 LN 016 4 &ma~y z
Edward
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r .BBM 8 S
5 POND 25' Kluan 38
w u BW S o Sontag q 28 B& VanDyk
LN ° iv zo >
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®1 Steven Richard M 65 qtr LAh:E 23 Lan e20 16 Mp
Q' Kuslich Schmitt 3 g
} I 79 m R 117 MR CW 10 4j y HOWAR I 60
8 cl e A&M S W Rs 5 w RD 7 ~
s1e~<n & a s+ &
S (k-ulRl hard DO'P B1re31 113 & si~o I stron640 ~'k- 13 R Ar Isback 11 64 V
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jL u7 i pcrizlt - - Bell
a , +d 3 v " B tt & Lester 110 1
M 3 u ~n PETC~ LAKE " B n <u28 30 - -61
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1 Lewis
31~.~ Ds 1" ~1 JM tr tr j8 1o 0 00 w 4 24 F&P C McKa y.
yy ft r MS 5 M&S 16 L&T PI tb x" pd Y y p k^ t
a X'- 6 D sD s 5- NT DIAL Y C r&E 20
H 26 D5 & ST ' Brett G h'lAq F-- Sandgulst LP
Wi o S x a ocean o u Mag zt 8 TR L a v& Mary u t~/ e0 ee
RB Gordon uw- I Bader o U) Emmett & s
O xD DJ Ea lien <na & 15 x , Q !,largaret A Cc
ti O~B 5 & Ellen & Lewis B barn 00 u8
N O s Rx & xe man 65 7 Cran I or M&v 80 m CL Langness x >
s 'S JffiA M 131 1.11
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3 -14 ee1EI5 &L5R th ,4V tr 0 80 , ,i 3', vX Ml hie ea
y
W' Z Sd~ith xn(, w & Gene & Ray & E Blahs Hood
F D K1o m -c 3 Georgia < q K6hJer /4 Hoalsran Eleanore 20 s 6 76 41 O tr Brown f
schottler L :."t... 56 - O _ 39 1 y rV,,; &SM y J
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C 5 11 RffiLF V 1 h. I 3 CB&P : S"'~ Richard & John
R&L & f ~ - 43
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Kenneth I Arthur II tr
P & Barbara & Nancy F'~~' State Of Richard & 21 I. /301
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Hawkinson r 31~ Philippine ll
Miles $4 70 Wisconsin AN r-j- _ D
wffiv ~gIThom Robe I F ' 1~NR Beer I : j t {CE
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TP KB R 5 & V 1 rIe n r Shirley ! J t
d tC 7S LFh d e Fbh I co Orf 141
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4t, >TF ,1 y 181k as v Hntng a
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State Of K 11 31arI< 1 RI hard .,b a.
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Comm tr tr 46 r 401
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0r~`' rs eroe G 9 MOUND Vona Virginia
CM FA I L~ ~"'M I wtscbusn N Sowt~ DR Nestrud 160
T )B 5 LA .c Sa E D&L
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Kfi1L r 1 40 q J he s etal 40 36 N R 101
ELSON FARM SCOTT RD
LN HUDSON'E' PAGE 30
A part of DURAND BUILD
SERVICE, INC.
Your www.durandbuilders.com
kpart bf GENERAL CONTRACTORS
t for a confidential consultation, conta
r~- 1
715) 6'12-5941 bill @ durandbu:
a t
N6344 State Road 25 Durand, Wiscon
ww ZAP PA BROS. M
WN rA a EXCAVATION CONTRACI
SINCE 1946
Industrial & Commercial Excavati
Installation of Septic Systems
0-472-2815 ASAP ` 715-643-5911 ObL-7 (71 38672850
' All !'tads A. P.,,. A#Ytlr<atn _ _ _ - _
Parcel 030-1058-10-000 06/10/2005 09:24 AM
PAGE 1 OF 2
Alt. Parcel 23.30.19.203A 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
BRAKKE, AL-EN
ALLEN BRAKKE
738 W SHORE DR
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 738 W SHORE DR
SC 5432 SCH D OF SOMERSET
SP 8040 BASS LAKE REHAB DIST
SP 1700 WITC
Legal Description: Acres: 23.710 Plat: N/A-NOT AVAILABLE
SEC 23 T30N R19W PT GL 6 & GL 7 EXC PT Block/Condo l3ldg:
LYING ELY OF FOLLOWING LN: COM S LN GL
7, 2701.5 FT E OF NW COR SE SE SEC 22, Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TH N 614 FT, E 279.5 FT, TH N 21 DEG E 23-30N-19W
887 FT, N 33DEG E 972 FT, TH N 10DEG W
643 FT TO BASS LK BUT INCL COM 2981 FT E
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 725/318
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/31/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 184,800 '57,300 342,100 NO
AGRICULTURAL G4 19.710 2,900 0 2,900 NO
UNDEVELOPED G5 1.000 200 0 200 NO
Totals for 2005:
General Property 23.710 187,900 157,300 345,200
Woodland 0.000 0 0
Totals for 2004:
General Property 23.710 188,100 157,300 345,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 145
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 030-1058-10-000 06/10/2005 09:24 AM
PAGE 2OF2
Legal Description: cont.
& 614 FT N OF NW COR SE SE, TH N 21DEG E 887 FT, E 50 FT, SLY ON LK TO PT 100
FT E OF POB. TH W TO POB EXC P203C SEC 23 T30N R19W 1.2 A IN GL 7 COM NW COR
SE SE SEC 22, E 2701.5 FT, TH N 991.3 FT, TH E 210.7 FT TO POB: CONT E 433.1
FT TO LK, N 55DEG E 174.3 FT W 604.6 FT S 16DEG E 104 FT POB AND EXC LAND
CONTAINED IN CSM 3/644 AND EXC CSM IN 5/1376 EXC PARCEL 203J
Parcel 030-1049-40-000 06/10/2005 09:24 AM
PAGE 1 OF 1
Alt. Parcel M 22.30.19.191A 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
BRAKKE, ALLEN
ALLEN BRAKKE
738 W SHORE DR
SOMERSET WI 54025
I
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 23.170 Plat: N/A-NOT AVAILABLE
SEC 22 T30N R19W NE SE EXC P191B & HWY & Block/Condo 13ldg:
EXC P191 C & EXC CSM 2/595 & EXC CSM
3/644 & EXC P191E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
22-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/31/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 21.600 3,200 0 3,200 NO
UNDEVELOPED G5 1.570 400 0 400 NO
Totals for 2005:
General Property 23.170 3,600 0 3,600
Woodland 0.000 0 0
Totals for 2004:
General Property 23.170 3,800 0 3,800
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
AST
PART STS JOSEPH 1. 29 -30 N.--R. 19 W. 41
SEE PAGE 58
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■ l7
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~j4(~!lL~edly .C~(.QL`Glz~
LINDQUIST MOTORS THE IVY SHOP
303 S. Main St. - River Falls Wis.
122 S. Main - River Falls, Wis.
GERALD JENSEN - PUREBRED JERSEYS TOWNE SHOPPE
Rt. 2 - River Falls, Wis. 54022 126 S, T,,Iain St. - River Falls, Wis.
THE BOOK `SHOP
220 S. VANDA'S JEWELRY
Main St. - River Falls, Wis. 115 S. Main St. - River Falls, Wis.