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Wisoon0yi Departront of Health end Social. So-vices
Plb. #467 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYYa, or USE BLACK Z11K
A. C'livER O PROPERTY C J F~ (J
Name Address (Street, City, Zip Coca)
i
B, LOCATION OF PROPF.";Y WfLS'P% SYSTEM WILL BE CONSTRUCTED1ALTERFD 07: EXTR,DrD COUNTY !
Check One: {
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP,
'7
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES .~r. NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACESNT ADDITION
MATERIALS; Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY,
Cheek One: One or Two Family Residence Commercial Industrial other II
> (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 NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name
_ Address: License Number:
Signature of Applicant: :1%s MP RSW
i
Address
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number
i
Agent (Name) % For: 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 for-Ka.rd application, the fee of $1.OG for each septic ta= and the third copy
of the per=it (canary) co tha Division of Health. Checks and money orders should be Lade payabls to
the Division of Health.
Do not write in spaco below - FOR DEPARTMxNT USE ONLY
1. DATE RECEIVED ACCEPTED BY RETURITED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. PERMIT NO.
I
es or No)
REVIEWED BY APPFOVED DATE
(Initials) Yea or No
i
COMPLETE OThER SIDE
SEPTIC TANX F :RMI'T NO.
R E P O R T 0 11 S O I L P E R C 0 L A T I 0 11 T E S T
A N D S O I L B 0 R I N G S
To
DiYISTCA OF EEALTH - PLLrMBI::G SI:CTId-71 y
P.O.Box 309, tLidisnn, Wis. 53701 411
1
Pursuant to H 62.20, Wis. Ad-inistrativo Code :ISIOP, _
EA. r-
P E R C O L A T I O N T E S T
Test Depth Charactor of Soil Hours Water Test Ti:ao Drop in Water Level Inches inutes
Nur..bor Inohos Thic<moss in Inohos Since Hole in Hole Into:°val Second to Next to Last To Fall
1st Netted G✓vrri ht in Minuto^t Last ooriod Last Period Period Qax Inch
Example
P - 0 36" Too Soil 30" C by 261t 25 Yos or No 30 1 2 1L2 1/2 60
RECORD DATA FROM MINDMI OF 3 TEST HOLES
Compute size of absorption araa in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Mini--um 36" Belo:a Proposed Abso tion S stcm
Boric Total Depth Depth to Ground Water ~ Depth to Bodroe!:
Number Ineha:; Cbzorvod k,stir_atod Cboerved Estic_atod Character of Soil with Thiokness in Inches
Example
B - 0 72" 72" Black To Soil 12" Cla 18" Sand 1811, Gravel 24"
_1 , 7
RECORD DATA FROM MINIMUM oa 3 BOP HOL"
TYPE OF OCCUPANCY:
RESIDENCE: Heber of Bodroces OTHERS (Specify) Number of Persons
FOOD WASTE GRI1NDER: Yes No Dish:vasher: Yes No Automatic Clothas Washer: Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT'
Tile Size No.Lin.Feet Trench Width Depth N=ber of Lines
i
Seepage Bed: Length Width Depth. Tile Size No. Lines
Sespaga Pit: Inside Diameter Liquid Depth
I, the undersigned, hereby eertify that the percolation tests reported on this for= were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Coda, arl
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAIS TITLE'
Type or Print)
REGISTRATION NO. or MASTYR PLUTiBER LICENSE NO.
ADDRESS
DATE - - SIGNATURE
Parcel 008-1051-20-050 05/29/2007 02:28
PAGE 1 OF 1
F 1
Alt. Parcel 17.28.16.264B 008 - TOWN OF EAU GALLE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
03/29/2005 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - HANSON, KEVIN M & AMANDA J
KEVIN M & AMANDA J HANSON
308 230TH ST
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 308 230TH ST
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 5.000 Plat: 4954-CSM 19-4954 008-05
SEC 17 T28N R16W PT SE SE CSM 19-4954 Block/Condo Bldg: LOT 01
LOT 1 (5 AC) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
17-28N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/01/2006 826566 WD
03/29/2005 790751 19/4954 CSM
03/22/2004 757173 2530/479 QC
458/309
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/06/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.500 18,800 105,900 124,700 NO
AGRICULTURAL G4 3.000 400 0 400 NO
UNDEVELOPED G5 0.500 50 0 50 NO
Totals for 2007:
General Property 5.000 19,250 105,900 125,150
Woodland 0.000 0 0
Totals for 2006:
General Property 5.000 19,250 105,900 125,150
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/16/2007 Batch 07-01
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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~ I I H MAP OF SURVEY GLEN r HLKMA
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m a NEE1 nnE x21 O'N=I Road • t-t~ds~n, YJI 5-E 306 230TH ST_
~1 W = ?IS-Sil?525'666.599-oe2~•Fas?15.`31.052~ BALDWIN, WI 54002
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