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- r Wisc.;r.ci,; D~;r^r~,~n<a'~.f. of Haa.l,tli e.:r3 Soc'_rl Sr,r ~S;c;
10/69 Division or Hec+ltn
PE VJT APPLICATION
~D12 -U - J-6 &3,12o for G
` ~ PRI'JATE D'>`':STIC SE'ri.','SYSTE:r:L
;7i.Y:Cr IA+ri
0 0 _Pi;!PF)it I TYPE 0r?. U57
A,
4i 2v r:
Na+re Address (Street, City, Zip Cod.o)
Co,r:ty
B. LOCATION OF PROPFRTY W111 w 5 t,TFd, 41II,+, B•__ ~CC?I_ r'' t' q, ALER7.D ~R E:ATK;D'c
CITY VILd.A LEF.L DESCRIPTi0id;
V TOWNSHIP
,I
F j 11
C. IS LOCAL PEFr.,1T Fr-QUIRE-1.) FOR THIS W17Rn? /L YES NO PEic:IT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEB INSTALLATION REPLACEN^1 _ ADDITION
MATERIALS: Prefab Concrete 'L Poured in Place Steel Other
NUIMER OF TANKS TO BE It STALLED;
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence COr.,ZtIeroial - Industrial Other
{Specify
Number of Persons to be Accommodated Number of Bedrooms
F. APi'LIANCES, ETC= Food Waste Grinder _Yr.S NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES f NO
Other (Specify) G. EFFLUFNT DISPOSAL SYST::i"i NEW _ 'f/' _ EXTENSION ADDITION _ REPLACEMENT
Tile Size tj No.Lin.Feet,/')T' Trench Width, ~f Depth Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
f Seepage Pit: Inside diameter 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 Drop in Water Level Inches 111nutes
Nwmber Inches Thic:cn ass in inches Sinca Hole in Hole Interval Se,ond to Next to-~ Last 'o Fall
1st Wetted Ovarni~ht min Minutes LM-3t Period. Last Period Period ten, in,h
P- 0 361" To Soil 10". C1-y26") 25 es or no 30 - _1 1 2 112 60
_ L
~ ~ .~I Jar ' ~ ~ L, F: ✓r 1 / J~ ~ _
R~' O;r DATA FRal MI' L-LM OF '3 TE57 h0LiS
ompute size of absorption are-. in acoord with H 62.20 Wis. Adninist:~ tive Cods.
_ S 0 I L B 0 R I N G S- Minimuu 36" Belo" Prooos_ ed A_bsorot i:: x. System
oring Total Depth D_eoth to Ground Water Depth to Bedrock
umber Inehns Cbserved Estimated O'oserrrzd Estimatad Character cf Soil with Thickness in inahns
xampie w
- 0 72" 72" Blsak Top 5 31 12"; Clay 18"; Sand 13"; Grzval 24"
RECO?+D DATA FROM MI` E-UM 0.' 3 ? 0 :S
COMPLETE OTHER SIDE
1, the undersigned, hereby certify that the perzolation tests reported on this for. were made by me
or under by sup@ vision in accord c,fith the procedures and method specified in Chspter H 62.20 (3),
Wisconsin Admtnistrative Code, and that the data recorded and location of test holes are correct to
the best of my rr wlad(;o and belief.
l
NAt i fJ~ TITLE
(Type or Print)
REGISTRATION NO. or MASTER PL!.I,:3ER LICWNSE No.
ADDRkSS C r~/;
DATE SIGV iU r"I
MASPER PL!R'i3ER PLkKING APPLICATION /
Signature: License um-,er:
rT RSW _
(To be Com leted by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date) Permit Nu,:_ber
Agent (name) For:
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing; until all of the above questions are anseered
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 DEPART.ENT USE ONLY
DATE RECEIVED ACCEPTED BY L R.TU RNED
/ (Initials) (Date) See Corras.)
c < PERMIT NO.
FEE RECEIVED VALID. NO.
(Yes or No)
REVIEWED BY APPROV::D _ DAME
(Initials) (Yes or No)
COCMENTS :
I
I
Parcel 008-1012-10-200 03/30/2007 12:06 PM
PAGE 1OF1
Alt. Parcel 04.28.16.63A-20 008 - TOWN OF EAU GALLE
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 - TORGERSON,ROBERT
ROBERT TORGERSON
2358 50TH AVE
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2358 50TH AVE
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 2.690 Plat: 4180-CSM 15/4180 008/01
SEC 4 T28N R1 6W PT NW SE & PT SW SE Block/Condo Bldg: LOT 02
BEING CSM 15/4180 LOT 2 2.6904AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-28N-16W SE
Notes: Parcel History:
Date Doc # Vol/Page Type
11/09/2001 661718 1759/582 QC
07/23/1997 1093/422 TI
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/13/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.690 23,900 103,300 127,200 NO
Totals for 2007:
General Property 2.690 23 900 103,300 127,200
Woodland 0.000 0 0
Totals for 2006:
General Property 2.690 23,900 103,300 127,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00