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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 Hater 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 3 I Wisconsin Depar•ttnent of Health and Social Services d57 10f69 - Divisien of Health y PER"1IT APPLICATION / 3 for PRIVt.TE DOMESTIC SEWAGE SYSTEMS k.7 i S i A. C„'NER OF PROPER11f TYPE OR USE BLACK INK e Name p=~~ Address (St'reet' City, Zip Code) Canty B. LOCATION OF ?ROP'r~R'PY WH FE SYSPEN WILL BE CONSTRUCTED, ALTERED R EXTF-17DE'D Check One: CITf VILLAGE LE,'AL DF.SCRiPTIG1: a TOWNSHIP _ ~s C. IS LOCAL PE ,IT FE2UIFCD FOR THIS W0 :LK? YES NO PFR IT NU2ER y r~; D. SEPTIC TANK CAPACITY / Gallons ' l;:Erl INSTALLATION REPL.ACF.;''F;;?' ADDITION MA itRIALS: Prefab Concreta x poured iri Place Steel Other NUEJER OF TANKS TO BE IASTALLED: f E. TYPE OF OCCUPANCY Check One: One or Two Family Residence Commercial Industrial Other (Specify) Number of Persons to be Accommodated C-3 Number of Bedrooms -S F. A?PLIANCES, ETCs Food Waste Grinder YES / NO Automatic Clo-.hes Washer X. YES NO Dishwasher YES NO Autocratic Potato Peeler YES _ NO .Other (Specify) G. EFFLUENT DISPOSAL SYST,K NEW ~ EXTENSION ADDITION REPLACEMENT Tile Size ~.r! No.Lin.Feet ✓ ta, Trench Width S Depth Number of Lines Seepage Beds Leng=th Width Depth _ Tile Size No. Lines Seepage Pits Inside diameter S 7T Liquid Depth - P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Droo in Water Level Inches inut9s Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to jLaat To Fall 1st wetted Cvernight in Minutes Last Period Last Perio Period One Inch Examp 1 e I P- 0 3611 To Soil lfl" Clay 261t 26 es or no 30 1/2 1 2 1/2 60 7 ~L C b t; < /S 77 RECOFU DATA FROM IMINIMUM OF 3 TEST HiLES ompute aize of absorption are, in accord with H 62.20 Wis. Administre,ive Code. S O I L B 0 R I N G S- Minimum 36" B91ow Prop sad Absorption Systtm Boring Total Depth Depth to Ground Water Deoth to Bedrock i umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Example -.0 72" 72" Blaok To Soil 12"; Cla• 18"; Sand 16" Gravel 2411 RECORD DATA FROM MINIMUM OF 3 BCR~H.9 -S COMPLETE OTHER SIDE I, the undersigned, hereby certify that the percolation tests reported on this fonn were made by me or under by supervision in accord with the procedures and method specified in Ch.1pter H 62.20 (3), :p Wisco;istn Actninist native Code, and that the data recorded and location of test holes are correct to the test of m,/ knowledr;e and b~lief. Nub / / - t / .j TITLE (Type or Print) i REGISTRATION NO. or MASTER PLUi,"BER LICENSE No. DAT SIGNATU MASTER PLUIrJE2 MAKING APPLICATIGI MP Signature - r = License Nu:ber: Wc Completed by Issuing Agent) Date of Application 1, Fee Paid Permit Issued (date) /2 Permit Number Agent (name) I ,(r J 1? t For:/ Tovm, Village, City, County, etc. (Specify) Notes 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 G~ DATE RECEIVED 7 r ACCEPTED BY RETURNED (Initials) (Date) j(See Colrres.) FEE RECEIVED VALID. NO. PERMIT NO. (Yes or S7o) REVIEWED BY APPROVED DATE (Initials) (Yes or No) CMIENTS : Parcel 006-1030-50-000 06/26/2007 03:20 PAGE 1 OF 1 F 1 Alt. Parcel 14.31.16.201 B 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 - BURTON, KENNETH J LE KENNETH J LE BURTON C - HARPER, DAWN M DAWN M HARPER 2156 250TH ST DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 2156 250TH ST SC 1127 CLEAR LAKE SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 13.330 Plat: N/A-NOT AVAILABLE SEC 14 T31N R1 6W 13.33A S 1/3 OF SE NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-31 N-1 6W Notes: Parcel History: Date Doc # Vol/Page Type 02/18/2004 754526 2511/396 OC 01/07/2004 750963 2487/293 TI 02/23/1971 303943 469/264 WD 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 09/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 13.330 35,000 115,600 150,600 NO Totals for 2007: General Property 13.330 35,000 115,600 150,600 Woodland 0.000 0 0 Totals for 2006: General Property 13.330 35,000 115,600 150,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00