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Wisconsin Department of Health and Social Services
:lb. #67 10/69 Division of Health
PEFtUT APPLICATION
for r
t PRIVATE DOMESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY ~Vl~- TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
/k County
B. LOCATION OF PROPERTY W11AE SYSTEM WILL BE CONSTRUCTED ALTERED ..+R EXTLNDEDoA,
Check One: ~n7 CD
CITY VILLAGE LEGAL DESCRIPTION: / r~/ t
TOWNSHIP b
E. IS LOCAL PERM REQUIRED FOR THIS WORK? YES NO
T PER" IT Nt I°IDER
D. SEPTIC TANK CAPACITY 1Z Gallons NEW INSTALLATION A, REPLACEMENT ADDITION
MATERIALS: Prefab Concrete A Poured in Place Steel other
NUMBER OF TANKS TO BE INSTALLED: I
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence/V- Commercial Industrial Other
i Specify
{ Number of Persons to be Accommodated_ Number of Bedrooms_
F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES Y NO
j
Dishwasher YES NO Automatic Potato Peeler YES 'c NO
i Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM j NEW EXTENSION ADDITION REPLACEMENT
Tile Size t No.Lin.Feet Trench Width Depth W7 Number of Lines
E /
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside diameter Liquid Depth
P S R C 0 L A T I 0 N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Iinutas
Number Inches
I Thickness in Inches Since Hole in Hole !Interval Second to Next to (Last To Fall
1st Wetted Overnight in Minutes test Period Last Period Period One Inch
Example
P- 0 3611 To Soil 1011 Clay 2611 25 es or no 30 1/2 1/2 1/2 60
C 4Z
-T-T
RECORD 'DATA FROM MINIMUM OF 3 TEST HOL&s
Compute size of absorption aree in azoord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 30" Balow Pro osad Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock
umber InohRs Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xample
- 0 72" 72" Black To Soil 1211• Cla 18"; Sand 1811, Gravel 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
nnrwnr cmc nmvr. n crno
1, the undersigned, hereby certify that the percolation tests reported on this form were made by me
cr under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
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 PIASTER PLUMBER LICENSE No.
ADDRESS
- i
DATE SIGNATU, Y7...v ~=r-~ r ,f
MASTER PLUM3;R MAKING APPLICATION
MP
Signatu i ~'I1LL / LCZ License Numbers
MP RSW
(To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date) '12 Permit Number
Agent (name)-/~ : '4k,_t For: Sa ( / C
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 $10.00 and Copy (b) of the
Permit (yellow copy) 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
DATE RECEIVED o A :z 1-76 ACCEPTED BY RETURNED
(Initials) (Date) (see Corres,
FEE RECEIVED ~ VALID. NO. PEFSIIT NO.
Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS:
v
Parcel 006-1009-10-050 06/26/2007 02:57 PM
PAGE 1 OF 1
Alt. Parcel 5.31.16.65A-10 006 - TOWN OF CYLON
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 - HENKE, DENNIS L
DENNIS L HENKE
2398 220TH ST
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2398 220TH ST
SC 0119 AMERY
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 35.150 Plat: N/A-NOT AVAILABLE
SEC 5 T31 N R1 6W PT NE NE FRL; N 1160 FT Block/Condo Bldg:
OF NE NE FRL
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
05-31N-16W NE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
06/12/2002 681505 1908/466 PR
02/02/2000 617762 1487/453 LC
04/14/1999 601248 1418/472 PR
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 09/08/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 31.150 4,800 0 4,800 NO
UNDEVELOPED G5 1.000 100 0 100 NO
OTHER G7 3.000 12,000 45,100 57,100 NO
Totals for 2007:
General Property 35.150 16,900 45,100 62,000
Woodland 0.000 0 0
Totals for 2006:
General Property 35.150 16,900 45,100 62,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 550
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
C Y LO NT 31 N7-R. 16 59
POLK COUNTY W
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SEE PAGE 45 SEE PAGE 47
<s o ~ co~,~ y 3
PLAT BOOK COMMITTEE
SALES COMMITTEE Cont'd. on page 61
Mr. James Ray Mrs. Charles Smith Mr. Jim Ruemmele
Mrs. Gordon Mueller Mrs. Ross Pierson Mrs. Miles Casey
Mr. and Mrs. Bob Phillips Mr. Robert Haler Mr. Al Franko
Mrs. Guy Wilbur Mr. Don Matysik Mrs. Judy Ferguson
Mr. and Mrs. Merton Vrieze Mrs. Joe Lohmeirer Mrs. Willard Johnson
Mrs. Robert Gardner Mrs. Robert Hanson Mr. and Mrs. John Steele
Mrs. Freida Fellinger Mrs. John Lavelle Mr. Robert Condon
Mr. Leon Holle Mrs. John Glassbrenner Mr. Del Polzin
Mr. Steve Thompson Mrs. Harlan Johnson Mr. LaVerne Karastes
s67 l
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