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Wisconsin Department of Health and Social Services
Plb. 1+67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name 7 Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY 1 L /1 .
Check One:
CITY VILLAGE LEGAL DESCRIPTION N~~N~ Sic- Z~
TOWNSHIP '
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? ~ YES NO C1 9..5~ PERMIT NUMBER
D. SEPTIC TANK CAPACITY D 0 Gallons NEW INSTALLATION A"'
REPLACEMENT ADDITION
MATERIALS: Prefab Concrete X Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: ~7 tfL~
E. TYPE OF OCCUPANCY
-Cheek One; One or Two Family Residence Commercial Industrial Other
r~ (Specify)
Number of Persona to be Accommodated cam. Humber 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. MAST ' P MAKING INST LLA ~ON
Name: 7 J.a J_e
~L~Address; License Number:
MP 77
Signature of Applicants MP RSW.,C
Address:
H• (To a Com feted by Issuing Agent)
Date of Application 7 Fee Paid j
Permit Issued (date) Permit Number L 1
Agent (Name) C~,•1 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 tanx 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 Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED - Id --7/ ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. S Z-.30 O PERMIT NO.
es or No)
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
Y '
f
SEPTIC TANK FERMI? NO.
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
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTI6H
P.O.Box 309, Madison, xis. 53701 .
Pursuant to B 62.20, Wis. Administrative Code
P Z R C 0 L A T I 0 N T Z S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inohes Minute3
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One" Inch
Example
P - 0 3611 To Soil 10" Cla 2611 25 Yes or No 30 1/2 I L2 1 2 60
JAC
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S Minimum 3611 Below Pro osed Abso tion System
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" 7210 Black To Soil 1211 C1 18" Send 18"; Gravel 22411
RECORD DATA FROM MINIMUM OF'3 BORE HOLES
TYPE OF OCCUPANCYs ~y
RESIDENCE: Number of Bedrooms o _ OTHER: (Speoify) Number of Persons rf~,
FOOD WASTE GRINDER: Yes No --X Dishwashers Yes No k:tomatio Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trenoh Width G~ Depth =-M Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines '
Seepage Pits Inside Diameter Liquid Depth
Is the undersigned, hereby eertify that the percolation tests reported ox: 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), Wisoonsin Administrative Code, and
that the data reoorded and location of test holes are correct to the best of my knowledge and belief.
NAME LyA LC .4C t 1. )F-ST I- //I) n TITLE L[t E
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ~ A-ZI
ADDRESS
DATE / 0 Z 70 SIGNATURE
Parcel 006-1055-10-000 06/27/2007 09:17 AM
PAGE 1 OF 1
Alt. Parcel 25.31.16.374 006 - 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 - ARNDT, WILLIAM J JR
WILLIAM J JR ARNDT
2595 200TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2595 200TH AVE
SC 1127 CLEAR LAKE
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 25 T31 N R16W 40A NE NE EXC HWY R/W Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
25-31N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/11/1998 580822 1331/059 WD
07/23/1997 1029/34 PR
07/23/1997 704/587
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 23.000 3,600 0 3,600 NO
UNDEVELOPED G5 15.000 7,500 0 7,500 NO
OTHER G7 2.000 10,000 63,500 73,500 NO
Totals for 2007:
General Property 40.000 21,100 63,500 84,600
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 21,100 63,500 84,600
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
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SEE PAGE 45 SEE PAGE S j
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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 Harer 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