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Wisconsin Departront of Health and Social Ssrvioes
Plb. '3 1 3/10 Division oa Health
SEPTIC TANK PERMIT APPLICATION
TY?F, or USE BLACK INK
A. O'31U.:R OF PROP:,'~R'r'Y
Namo Address (Street, City, Zip Coda)
B. ROGATION OF PROPERTY WH-RP, SYST M WILL BE CONSTRUCTED ALT RED OR FXTEi-DF.D COJNd'Pt
Check One:_ A111"
CITY VILLAGE LEGAL DESCRIPTION
TO•vaiSHIP r t ' 'r
C. IS LOCAL PERMIT kECUIRED FOR THIS WORK? YES NO PERMIT IUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLAC0:FN.'T ADDITION
MATERIALS: Prefab Cone;•ete _ Poured in Place Stecl Other
NLiMD%R OF TANKS TO BE I1'STALLED: 1 _
E. TYPE OF OCCUPANCY
Cheok One: One or Two Family Residence Coa.:~ercial Industrial Other
Specify)
Number of Persons to be Acconlwodated Nuzber of Bedrvoms
F. APPLIANCES, ETC: Food 1.'asts Grinder YES NO Automatic Clothes Washer YES NO
Dish:^rasher YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. Nu1STER PLUPBFR MAKING INSTALLATION
Name: i Address: License Nvmbert
MP
Signature of Applicant, MP RS"i
Address: -
H.' (To be Coapieted by Issuing Agent)
Date of Application -7` 0 -7 Fee Paid $
4.F.'
g" Permit Issued (date) - a Permit Number a
Agent (Name) For: r ~
Town, VillaF,o, City, Coun y, etc: i
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee p--id. Agents will forr.ard application, the fee of $1.Ov or each soptic tar:;: and the tnird copy
of the permit (canary) to the Division of Health. Checks acrd morcy orders should be ma-de payable to
the Division, of Hea:.th.
Do not write in sra.ce below - FOR DEP i ;ENT USE ONLY
1. DATE RECEIVED ACCEPTED BY 71 RETUP.'LTJ
(Initials) (Date) See Corri,s~ )
FEE RECEIVED VALID. No. L-1._',' 4--C-1 PERI-11T NO. L/
~B s or NO, ~ i
REVIEWED BY APPROVED DATE
(Initials) Yes or No)
COMPLETE O?He.R SIDE
SF?TIC TANI; PIt:Riili' NO.
RF1P0R T 0V S 01L PE;F,C 0 L A 7 I013 T ES 1'
A N D S O I L B O R I N G S
TO
DIVISIC 1 01' UFAL7H - PLLa1B1h`G Sr-;•T-163
P.O.Box 309, Madison, Wis. 55701
Ptu°sixzrat is H 62.20, hots. A ni.nistrativa Code
r"
P9RCOI,AT1011 TEST
T69t Depth Ch~r°rao2.^r oP S03.Ji Ha~~*.ao Water 2'e9t 'iarsDroh in w2.tar_L~:vet, _Zn.hes Sr_utos
Nuraor In,.%hoa Thic3-ness in D2ohos Sinco Hclo in Hdlo Interval Second Nast to Last To Fall
~ ,•0 1st Wetted C.orr:ight in Minute; Last Po,i_od Vst Period Period Ctac~ Inch
l x_Z_Vlo
P - 0 36" Tv Soil 10" Clay 261, 25 Yes or No 30 a~2 1 2 1 [ 60
i tt ,CORD DATA FRf, 3 NUNIr7T}i O? 3. BEST HOL•.S
Compute 9izo of absorption twee in accord with H 62.20 Wis. Ad-:,iniAtrativo Coda.
S 0 1 1, B O R I N G S- iitnln- r 33611 Belo r Prooosed Absoa ion Systcri
Boring; Total Dopth Aepth to Grvvd i?ter Dth to f3odrvcS_
Ni.reber Inch eWy~ o - Cbservod hstiwated Obseved Erti^.s.t d Character of Soil with Thiotness in Inches
Examp1.a
B - 0 72" 7211 Black Top Soil 12"; Cla,V i8l'; Sand 1811• Gravel 2V"
R1',CORD DATA FROM M1NIMUM Oc 3 BORE HOL
YPE OF OCCU?ANC'f:
RESIDENCEs Number of Budrocras OTHER: (Specify) Number of Persons J
OD WASTE GRINDS : Yes No Dishna!thGrs Yes No Y Automatic Clothes Washer: Yes No
FFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC!21ENT
Tile Sire No. Lin. Feet/0~_..m Trench Width Depth Number of Lines
Seepage Bed: Length _ Width Depth Tile Size No. Liner
Seepage Pits Inside D1;7ter Liquid Depth
1, the undorsiDied, hereby certify that the percolation tests ro+ported on this fot-m were made by me or under ray super-
vision in accord with the pro>eu.zres and method specified in Chapter H Q2.20 (13), Wisconsin Adainistrative Code, and
that the data recorded and location of test holes are correct to the best of rV knowledge and belief.
NA1,1 ( r: i TITLE 111 r`/ 7
(Type or Print
REGISTRATION NO. or MASTER PLUMBER LICF.AIS£ NO.
ADDRESS
DAiE i - -
SIGNATURE
II ~
Parcel 002-1082-40-000 06/25/2007 09:58 AM
PAGE 1 OF 1
Alt. Parcel 33.29.16.483A 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
O - LUND, THOMAS R & JOAN C
THOMAS R & JOAN C LUND
PO BOX 217
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2365 HWY 12
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 20.000 Plat: N/A-NOT AVAILABLE
SEC 33 T29N R1 6W E 1/2 NW NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1090/431 QC
07/23/1997 1090/430 WD
07/23/1997 711/536
07/23/1997 445/86
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/16/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 25,100 327,900 353,000 NO
AGRICULTURAL G4 17.500 3,800 0 3,800 NO 00
UNDEVELOPED G5 0.500 100 0 100 NO
Totals for 2007:
General Property 20.000 29,000 327,900 356,900
Woodland 0.000 0 0
Totals for 2006:
General Property 20.000 28,700 327,900 356,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 510
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
IN T 29 N--R. 16 W • 33
! D D SEE PAGE 47
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