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Wisconsin Department of Health and Social Services
Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (street, city, zip Code)
0)4 1 L 1_'T u j% -3 ar R.
AIM90001- M a Cr2i+w c%..NL-iR
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY -1-r. C R.C"f
Check One:
CITY VILLAGE LEGAL DESCRIPTION 9 /V 2 ~(p Lc~
TOWNSHIP
13 A), 0
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK?_ YES NO PERMIT NUMBER
c>c' C7 G
D. SEPTIC TANK CAPACITY I S~+C1 Gallons NEW INSTALLATION REPLACEMENT A_ ADDITION
MATERIALS: Prefab Concrete _X poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
~Cheok one: one or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated 3S- Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES X NO Automatic Clothes Washer ~C YES NO
Dishwasher YES NO Automatic Potato Peeler YESX_ NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: Rer3rgY y. l71A bF c..✓ Address: ~c b.-A /E: `f License Number:
Signature of Applicants MP RSW ,9 Z
Address: A- j_jS . S' S'`c e, 2---
H. (To be 'C'ompleted by Issuing Agent)
Date of Application Fee Paid / U U
Permit Issued (date) Permit Number,;)+,~ 77,5
Agent (Name) ~ ;,_i9,~ Fors
I
Town, Village, City, ounty etc.
(Specs
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 tarot 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.)
FEE RECEIVED VALID. No. PERMIT N0.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT N0. / w .
R E P O R T O N S 0 1 L P E R C O L A T I O N T E S T
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLUMBING SECTIt"N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P 8 R C 0 L A T 1 0 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 - 0 361, To Soil 10" Cla 26" 25 Yes or No 30 1/2 1/2 __Y2 60
r-,s
ri yY 7
k. .
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 Below o posed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thiekness in Inches
Example
B - 0 7210 72" Black To Soil 1211 C 18111 Sand 18^• Gravel 2411
fey
d
-,3 -y
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCYs
RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons
D WASTE GRINDERS Yes No yt - Dishwashers Yea No Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW ."S EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length < Width J Depth 3 Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth_ / O D
q n
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 i SIGNATURE.,_..
Plb 60
• JUL 22 1971
` NAME. OF BUSINESS /f/ 1 x 'y n ~ ..r- C' T P~ »1 t-? ] nl ~ C j'>+ w ~ ' '
LOCATION ?il L~rly / J3fS a f•i/ ~'f^•,,A>~ , CCr T~~ .1
street or highway city or township county
LEGAL DESCRI.PTI ON 5".F c'- T i .t Stir n
OWNER 4- et -5 r clq Mailing address : r~ ; • r c. y c . ; S
ZIP
ARCHITECT OR ENGINEER Address
ZIP
PLLQ13ER is r3. R % -j- - /7.-1Z Addrear v'r k / G~'j~AYE:~• ins, ~~~,5 ~:~i: ~
1. Check appropriate building usages) and fill in the information requested opposite each usage listed:
Existing building New building Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant Car spaces
( ) Restaurant . • . . . • . Seating oapacity 10 si, ft./person)
Dining hall . . • . Per meal served Toilet w%ste Yes No
O Motel O Hotel ( ) Cottages Number of units: 2 persons/im it 4 persons unit
TOTAL NUMBER OF UNITS
( ) Churches . . . Number of persons Kitchen Yes No
Bar or oooktail lounge . . . . Seating capacity (10 9q, ft./person)
( ) Nursing or rest home . . . • . Number of beds
( ) Mobile home park . . . . . . . Number of units - dependent (camper trailer)
- nondependent (mobile home)
Retail store . • ..Number of employees Number of customers (10 sq. ft./person)
( ) Sbrvice station . . Number of oars served-(daily)
( ) School . . . Number of classrooms - Meals served Yes No
Showers provided Yes No
( ) Factory or office building . Number of persons (total all shift-
( ) Residence . . . . . . . • . Number of bedrooms
( ) Apartments . . . . . . . . . Number of bedrooms
( ) Other . . . . . . . . . . Specify
2. Indicate whether or not the following facilities are connected: Food waste grinder . . . . . Yes No k
Dishwasher . . . . . . . . . Yes No 31'
Automatic clothes washer Yes_ No
3. Fill in the appropriate information for the following as indicated:
Septio tank capacity planned • y-r c GGTOTAL Septic tank. capacity required
Percolation test results - ATTACH 1100LA7,10N TEST REPORT SgEET
Seepage trench bottom area pled width linear feet depth
Seepage bed area planned width lel;l linear feet ;Y-7.5' depth ~+c ~r
Seepage pit planned 13.. e,,x outside dicuneter y / _ depth below inlet st' depth Sc -
Seepage trench bottom area required width _ linear feet - depth
Seepage bed area required width linear feet depth
Seepage pit required outside diameter _ depth below inlet
Signature of person completing forme STATE DIVISION OF HEALTH, PUR[L" v SECTICN
P. 0. BoMadison, _r`ZsconS~n 5301
'JU
Addres~t ; - Approved:
ZIPi a
Lats:
THIS APPDVAL IS BASED ON S T A r PLM31NG
CODE REQUIREMENTS AND DOES NOT EXE'P, THE
INSTALLATION FROM CITY, VILLAGE, TNN-
SHIP OR COUNTY REGULATIONS OR PEit~LIT
(OVER) REQUI F221ENTS.
Parcel 002-1064-50-000 03/20/2007 0412 PM
PAGE 1 OF 1
Alt. Parcel 26.29.16.394B 002 - TOWN OF BALDWIN
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
RICHARD M KIESOW O KIESOW, RICHARD M
2508 HWY 12
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 2516 HWY 12
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 4.380 Plat: N/A-NOT AVAILABLE
SEC 26 T29N R16W PT SW SW BEING LOT 1 Block/Condo Bldg:
CSM 12/3480 4.380AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
26.29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
04,'05/2004 758617 2541/174 LC
04,'05/1999 600634 1416/144 TI
284604 423/582 WD
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/27/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.380 16,900 56,100 73,000 NO
Totals for 2007:
General Property 4.380 16,900 56,100 73,000
Woodland 0.000 0 0
Totals for 2006:
General Property 4.380 16,900 56,100 73,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 09/16/2005 Batch 05-15
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00