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Parcel 004-1025-50-000 03/19/2007 03:56 PM
PAGE 1 OF 1
Alt. Parcel 11.28.15.173B 004 - TOWN OF CADY
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 - EVANGELICAL LUTHERN CH, CHURCH
CHURCH EVANGELICAL LUTHERN CH
401-310TH ST
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5586 SPRING VALLEY
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.870 Plat: N/A-NOT AVAILABLE
SEC 11 T28N RI 5W .87A S 159. 72 FT OF W Block/Condo Bldg:
238 FT OF SW SW VOL 630/193 CHURCH
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
11-28N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 630/193
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/03/1997
Description Class Acres Land Improve Total State Reason
OTHER X4 0.870 0 0 0 NO
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
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
LN Ml3VV11U133 La}'Ai;YWOUY Vl nV-&V-X lu 4VWA-A. JVl"~lli0~
Plb. #67 370 Division of Heal
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK /T It ~,/lA O~/~ n ~ ~ /?6 f
V~
l/tJ [
Name
A. R OF PROPERTY
Name =j Addres..; `(Street, City, Zip Code) f~
Be LOCATION OF PROPERTY WHERE SYST:FM WILL BE CONSTRUCTED, ALTERED OR EXTF1'DED COUNTY",-,-, Check One;
CITY VILLAGE LEGAL DESCRIPTION o
/a TOWNSHIP
C. IS LOCAL PERPIIT REQUIRED FOR THIS WORK'? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY f > 7.7 Gallons NEW INSTALLATION REPLACE-ENT ADDITION
MATERIALS; Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
1
E. TYPE OF OCCUPANCY
Cheek One: one or Two Family Residence Comerc al Industrial Other
;(Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO ~Automatic Clothes Washer YES NO
Dishwasher YES NO Autor,.atio Potato Peeler YES HO
Other (Specify)
G. MASTER PWL 3ER MAK1,tG INSTALLATION I /
Name: N_ _r Address; License iucber:
Signature of Applicant: MD RSW
Address:
(To be Completed by Issuing Agent(id$
xx.
Date of Application /7 l Fee P
Permit Issued (date) Permiber
Agent (Name) e ' For: sr ,
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered &nd the
fee paid. Agents will fore+ard application, the fee of $1.OU for each septic tanic and the tnird 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 O - 13 ` ~6 ACCEPTED BY RETURNED
(Initials) aq (Date) See Corres.)
FEE RECEIVED VALID. No. PERMIT NO. f~'< 2 l O
or No /
j REVIEWED BY APPROVED V DATE
(Initials) Yea or No
COMPLETE OTHER SIDE
t.
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P Y R C 0 L A T I 0 N T Y S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLIMBIW. SSCTJ.6X
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrativ: Code
P E R C O L A T I O N T E S T
Test Depth Character of Soil+ Hours Water Test Time Drop in Water Level Inohas inutes
Number Inches Thicknoss in Inolies Since Hole in Hole I.Lterval Second to Next to Last To Fall
1st Wetted OverniAt in Minutes Last Period Last Period Period One, Inch
Example
P - 0 3611 To Soil 10" Clay 26" 25 Yes or No 30 1 2 1/2 1/2 60
~ RECORD DATA FROM MDiIMUM OF 3 7EST 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- Minima" 36" Bel PPro osed Absor-tioi~ n S;.a
Boring Total Depth Depth to Ground Water De th to B=drock ~~4
Number Lnches Obsarv?d Estimated Cbsarved Estimatad Character of Soil with Thiokness in Inohes
Example
B - 0 72" 72" Black To Soil 12". Clay 18"; S_aLnd 1211; Gravel 24!x'
R.SCORD DATA FROM MINEi'NNi 0' 3 nORW HOLES
t'pE OF OCCUPANCY:
RESID-;rNCEs Number of Bedrooms OTHER: (Specify) Number of Persons
OD WASTE GR DiDERs Yes No DisIvashers Yes No Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLA=I.EN'T
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Diameter Liquid Depth
Is the undersigned, hereby certify that the percolation tests reported on this fora were made by me or under ray super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Adasinistrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LIC7_4SE NO.
ADDRESS
DATE SIGNATURE
1
j Wiaoottaln Department of Health and Social Services
Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK 0041- -(J&7
A. OWNER OF PROPERTY
Name Address (street, City, Zip Code)
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUN - ' 1
Check One:
JOITY VILLAGE LEGAL DESCC~IPTION f
_owNSHIP ) / CC> 5d /C..Z~iC~ / •1 ~o
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY ` ls-v Gallons NEW INSTALLATION REPLACEMENT ADDITION -
MATERIALS: Prefab Concrete k Pou d in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: i
E. TYPE OF OCCUPANCY
,Check One: One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms y
F. APPLIANCES, ETC: Food Waste Grinder YES /j ' NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatio Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER I7VG '~STAON%
Name Addresss License Number:
MP
Signature of Applicant: MP RSW
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number
Agent (Name) For:
Town, Village, City, County, etc.
(Specify)
Note: 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 $1.00 for each septic t&nx and the third copy
of the permit (oanary) 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 ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
f FEE RECEIVED VALID. No. PERMIT NO.
es or No
I REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT N0. L2 / L
R E P O R T O N S O I L P E R C O L A T I O N T E S T
A N D S 0 I L B O R I N G S
TO
DIVISION OF HEALTH - PL"ING SECTI6M
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One, Inch
Example
P - 0 3611 To Soil 10" Clay 2601 25 Yes or No 30 l h 1/2 1/2 60
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 361' Below o posed Abso tion Sys-tam
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 72 It 72" Black To Soil 1211 Clay 181% Sand 18fl• Gravel 2410
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCYs
RESIDENCE: Number of Bedrooms OTHERS (Specify) Number of Persons
FOOD WASTE GRINDERt Yes No Dlshwashert Yes No Automatic Clothes Washert Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width 0 Depth) Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE SIGNATURE
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