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Parcel 182-1023-50-100 03i20i2007 10:42 AM
PAGE 1 OF 1
Alt. Parcel 06.31.17.208C 182 - VILLAGE OF STAR PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
05/19/2004 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - VILLAGE OF STAR PRAIRIE, BALL PARK
BALL PARK VILLAGE OF STAR PRAIRIE
BOX 13
STAR PRAIRIE WI 54026
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 7.943 Plat: 4750-CSM 18-4750 182-04
SEC 6 PT SW SW CSM 18-4750 LOT 1 (7.943 Block/Condo Bldg: LOT 1
AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-31N-17W SW SW
Notes: Parcel History:
Date Doc # Vol/Page Type
05/19/2004 763137 18/4750 CSM
07/23/1997 626/65
07/23/1997 460/395
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/10/2006
Description Class Acres Land Improve Total State Reason
OTHER X4 7.943 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
z 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 Cods)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALSs Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check one: One or Two Family Residence Commercial 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 Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: Addresss License Numbers
MP
}
j
Signature of AppliaEr}t-s \ MP RSW
Addresss
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid fi
Permit Issued (date) Permit Number
Agent (Name) Fors _
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 tank and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Heaath.
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 NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P t R C 0 L A T I 0 N T E S T
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLUMBING SECTAN
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
lst Wetted Overnight in Minutes Last Period Last Period Period One, Inch
Example
P - 0 361' To Soil 1013 Cls 2613 25 Yes or No 30 1 2 1/Z __y2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute site of absorption area in accord with H 62.20 Wis. Administrative Code.
S 0 I L B O R I N G S- Minimum 36f3 Below Pro osed Abso tion U stem
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 72'3 7211 Black To Soil 1213 C1 181' Sand 18'1• Gravel 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCYs
RESIDENCES Number of Bedrooms OTHERS (Speoify) Number of Persons
D WASTE GRINDERS Yes No Dishwashers Yes No Automatic Clothes Washers Yes No
FFLUENP DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size NO.Lin.Fest Trench Width _ Depth Number of Lines
Seepage Bed: Length Width 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
~ e
S 7'I R TDRATRTF
rT,T.A r!T, PART
O 6"Drilled Well
It
SHELTER, REST RnOrs, MD
j WARMTNG HnTTSE
,III 1) 0,
3, 000 gal.
" I Septic Tank
THIS APPROVAL SHALL BE VOI'0 IF
NOT INSTALLED WITHIN TWO YEARS
FROM THE DATE OF APPROVAL
iHIS IJ Cr c:" C'nl PLIN1.10 5.51 X 51
INN Dry Well
En'.;~hi I It1E i`iV,lh L It' r, I t"ilY ~',;iS
Lf,GE 103'INI'~ 0.. t, _~Y n[i
OR PERMIT ItLQn, L"u is.
C t
2P1 lOC1 X31 deep
1)ra:in Red
I
E
I
t
I
7§1
7
I
i
11 T- I A-# i/CN7-
ran
_rl
Plb 60
1 fi % JUL 12 191
NAME, OF BUSINESS
LOCATION /J f P T
street or highn-ay city'vr taonahip county
J,,
L5GAL DESCRIPTION
DESCRIPTION
CWNr.P, I, i Mailing addrotss
ZIP
A"CHI rCT CPR ENGINEFR Address _
zip
_7 Address
2 ,
1. Ch=.ck s.p}rupriat bzi;d,ry a, u, (s) tans fill in the information rLgquues~ted^-opposite each usage listeds
Exinting building Nee building_ Addition
If addition to existing, building attach dct,:.iled memo for caoh.
( ) nrivm in r.,:°1,_ uva nt- c . . . s Car sp•3Ge$
( ) Rstt~arnnt~ . a . . e • . ♦ . Seating cape:nity 10 sq. ft./person)
( ) Dir:ing hall . . . . . . . . . . Per meal served Toilet waste Yes No
( ) Motel ( ) Hot~rl. ( ) Cotta cr4 . . . Number of units: 2 poisons/unit 4 persons unit
TOTAL NU."~I;R OF UNITS
( ) Crrarhes . • e . . . . . . Number of par:3ons Ki__
n Yes No
( ) Bar or cock'tnil lounge . Seating, oapacity (10 sq. ft./person)
( ) Nursing or rest home . . . • ?lumber of bsc?z _
( ) Mobile home parik . . . Neater of Usiitss - dependent ((ramper trailer)
- nondependent (mobile home)
( ) Retail store . . . . . . . Nut)er of emOIOo' es Nuc.ber of customers (10 sq. ft./person)
( ) Service station . . . . . . . . Number of oar, served (daily)
( ) School . e e . ♦ e a • Numb er of cl-2ssrooais Peals served Yes No
Shrrrrera provided Yes No _
( ) Factory or office building . No=ber of persons (total all shifts)
( ) Residenoo . . . . . . . . . . Number of bedrooms
( ) Aplartr„cnts . . . . . . . . . . Ma,mbar of ber.ro.Sms r.
Oher . . . . . . . . . Specify
2. Indicate whether or not the following facilities are oonneeteds Food waste grinder . . . . . Yes No
Dishwasher • . . . . . . . . Yes No
Automatic clothes washer Yes No
3. Fill in the appropriate infonntiors for the following a5 indicatedt
Septic tank capacity planned TOTAL Septic tank capacity required
Percolation test remelts - ATTACH PER'OLATION TEST REPORT SHEET
Seepage trench bottom area planned width linear feat depth T
Seepage bed area plea.ned width ?,,Y linear feet depth J
Seepage pit planned outside diameter depth below inlet depth
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
Signat'Ire of person omplbting form, STATE DIVISION OF HEALTH, PV21BING SECTION
/ P. 0. Box Madison, Wiscons 53701
Address: V\ Approved: _,A4 11
Data t ` c Date 1311? 1 72
THIS APPROVAL IS BASED ON STATE PLUMJING
CODE REQUIrHe.M; NTS AND DUES NOT EXE,iPT THE
INSTALLATION FROM CITY, VILI.AGE, TOWN-
SHIP OR COUNTY REGULATIONS OR KriMIT
(OVER) REQUIh 'IKNTS.