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Wisoonsin Department of Health and Seoial Services
Pib-, #57 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
T'!PE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Coda)
B. LOCATION OF PROPERTY WHERE SYS72721 WILL BE CCNST'RUCTED ALTEREI OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
a
TOWNSHIP
~ ,i 1 ✓ ~ . - ~ _ i - r / ~ ~ l
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACRIENT ADDITION
MATERIALS: Prefab Concrete 1V PoLred in Place Steel ~'~Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Cheek 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 G; NO Automatio Potato Peeler YES r NO
' Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name. ~1~ •,`/f7~d. `A Address License Number:
MP
Signature of Applioant:---~- MP RSW
Address:
H. ! (To be Completed by Issuing Agent;
Data of Application Fee Paid
Permit Issued date Permit Number
Agent (Name) Fors
Town,Village, City; County, etc.
(Specify)
'Mute; The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents wii_ for+.ard application, the fee of $1.0C for each septic tanx and the tnird cop,
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Divioion of Hes.Lth.
Do not write in space below - FOR DEPARTY.ENT USE ONLY
I. DATE RECEIVED ACCEPTED BY ° I C RETURNED
T~r*** (Initials) (Date) See Co4res
` FEE RECEIVED - VALID. No. PERMIT NO.
f es or No _
REVIEWED BY Y APPROVED DATY
(Initials) Yes or N7 '
COMPLETE OTHER SIDE
" SEPTIC TANK PERMIT NO. ri
R Z P 0 R T O N S O I L P Z R C 0 L A T I 0 N T E S T
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLLTSBING SECTIN,
P.O.Box 309, N,dison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P E R C O L A T I O N T T S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches LC
nutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last Fall
1st Wetted Overnight in Minutes Lest Period Last Period Period & Inc
h
Example
P - 0 ~361, To Soil 1010 Cla 2611 25 Yes or No 30 1 2 1/2 1/2 J 60
RECORD BAT:. FROM ML`7ENM 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- Minimum 3611 Below Pro osed Abso tion a 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" 72" a Black To Soil 12" Cl L8111 Sand 18"• Gravel 2411
J
•l
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCU?ANCYs
RESIDENCE: Number of Bedrooms OTHERS (Specify) Number of Persons
D WASTE GRINDERS Yes To Dishwashers Yes No Automatic Clothes Washers Yes X No
EFFLUENT DISPOSAL SYSTEM: NEW ~ EXTENSION ADDITION REPLAC-EXENT
Tile Size_ No. Lin.r^meet, (I Trench Width Depth f/ Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
/ Seepage Pits Inside Diameter Liquid Depth '
I, the undersigned, hereby eerttfy that the percolation tests reported on this form were made by me or under r r- 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 bet of my knowledge and belief.
NAME Y TITLE /111"/" Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
t\
DATE SIGNATURE
Parcel 002-1084-10-000 06/25/2007 09:43 AM
PAGE 1 OF 1
Alt. Parcel 33.29.16.487B 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 - HALLER, JOHN & JANICE
JOHN & JANICE HALLER
673 230TH ST
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 673 230TH ST
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 33 T29N R16W IN SW NW N 220 FT OF W Block/Condo Bldg:
198 FT OF SW NW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 465/110
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 16,800 85,000 101,800 NO
Totals for 2007:
General Property 1.000 16,800 85,000 101,800
Woodland 0.000 0 0
Totals for 2006:
General Property 1.000 16,800 85,000 101,800
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