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Wisconsin Dapart!nont of Health and Sooie.l Services
P b.`#67 10/61) Division of Health
PF~4111` APPLICATION
for
j PRIVATE D(:~;ES'TIC SEWAGE SYSTEMS
OF F:J1iC!`. TYPE. OR USE BL^CK INK
p;ara l Address (StrCity, Zip ('ode)
County
B. LOCATION OF PR3 Zr,TY WEr,:RE SYSTEM; 11ILL, BE CONSTRUCTED, ALTERED OR EXTP+D%
Check One: T CITY VIILx(fE LEGAL DE CRIPTIQi1;
+l.
TOWNSHIF
C. IS La3AL PEk1IT WOUIRED FOR 4'tilS FDi,K? YES NO `j/~. pgly IT NULPER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLaTIO*! ~ REPIACF.i^u:N'T ADDITION
MATERIALS; Profab Concrete Poured in Place Steel _ Other
NL71-:3ER OF TANKS TO BE INSTALLED; E. ~ TYPE OF OCCUPANCY
Check One; One or Two Family Residence Commercial Industrial Other
(Secify)
Nu ber of Persons to be Accer;mod.ated Number of Bedrooms
F. A?0LIANCES, ETCS Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES_ NO Automatic Potato Peeler M YES- NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW \ EXTENSION ADDITION REPLACE1,1ENT
Tile Size !i No.Lin„Feet-! Trench Width Depth Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pitt Inside diameter Liquid Depth -,j`
P£ R C 0 L A T I 0 N T E S T
Test Depth i Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inchesl Thickness in Inches Since Hole in Hole fIntet~al Second to Next to Last ro Fall
1st Wetted Ovarni,Z inf Minutes Last Period! Last Period Period One Inch
` - _ - j
Example
P- 0 36" To Soil 10"~Clar 26't~ 25 Yes or no 30 112
1/2 112 60
RECOM DATA F'ROl P"iINI?,1PM OF 3 TEST HOLES
ompute size of absorption area. in accoru with H 62.20 His. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below Proposed Absorption System
oring Total Depth Depth to Ground Water Depth to 3edrook
umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xemple
0 72" 72" Black Top Soil 12"; Clay 13"s Sand lz"; Gravel 2411
;
7 7, _T
/ F
y r
\3 /
RECORD DATA FROM MINI?'[UM OF 3 TORS HOLES r
COMPLETE OPHER SIDE
w
I, the undersigned, hereby certify that the pe m olation tests reported on this form were made by me
or undar by supervision in accord with the procedures and mothod specified in Chapter H 62.20 (3),
Wisconsin Ad:,inistrativa Code, and tha; the data recorded and location of test holes are correct to
the best of m knowlpd,,e and belief. _
1
NAl 1 1 L TITL°
(2 yp 3 o YPrint) REGISTRATION NO. or MAS:'ER PL~-j!iUER LICEI:SE No.
ADDRESS
DATE 5IGNAT0r7Z t
MASTER PLRL ~wR rii1CIN APPLICATION
rip
Signature: License Nu:n. ,er:
NP RSW
(To be Cor.:ple Ed by Issuing Agent) f / n
Date of Application Fee Paid $
Permit Issued ,(da'e)~ Permit Number
Agent (name)~~ For:
Town,-Village, City, County, etc.
(Specify)
Notoz The application cannot be considered for filing until all of the above questions are anowered
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 rrade
payable to the Division of Health.
Do not write in space belox - FOR DEPARTiIENT USE ONLY
DATE RECEIVED r L ACCEPTED BY RETURNED
(Initials) 22 (Date) (See Corres.)
FEE RECEIVED C/ VALID. NO. ~ J PERMIT NO.
(Yes or No)
REVIE'.IED BY APPROVED DAME
(Initials) (Yes or No)
I
COMENTS:
Parcel 008-1080-70-000 05/29/2007 02:48
PAGE 1 OF 1
F 1
Alt. Parcel 28.28.16.428 008 - 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 - YANG, JERRY & MAITA
JERRY & MAITA YANG
2332 10TH AVE
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2332 10TH AVE
SC 5586 SPRING VALLEY
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 28 T28N R1 6W 40A SE SW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
28-28N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/15/2003 749129 2474/288 WD
04/09/2003 716538 2200/02 QC
07/20/2000 626698 1528/37 PR
12/01/1998 592697 1381/595 TI
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 08/04/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 30.000 3,200 0 3,200 NO
AGRICULTURAL FOREST G5M 7.000 4,700 0 4,700 NO
OTHER G7 3.000 8,800 89,800 98,600 NO
Totals for 2007:
General Property 40.000 16,700 89,800 106,500
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 16,700 89,800 106,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 008-1080-60-200 05/29/2007 02:48 PM
PAGE 1 OF 1
Alt. Parcel 28.28.16.427C 008 - TOWN OF EAU GALLE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
11/08/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - YANG, LENG
LENG YANG C - THAIO, PACHIA
PACHIA THAIO
1009 80TH CT
BROOKLYN PARK MN 55444
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 121 230TH ST
SC 5586 SPRING VALLEY
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 20.000 Plat: 5306-CSM 22-5306 008-06
SEC 28 T28N R16W PT SW SW CSM 22-5306 Block/Condo Bldg: LOT 01
LOT 1 (20 AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-28N-16W SW SW
Notes: Parcel History:
Date Doc # Vol/Page Type
12/05/2006 83992 WD
11/08/2006 838377 22/5306 CSM
12/15/2003 749129 2474/288 WD
04/09/2003 716538 2200/02 QC
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/16/2006
Description Class Acres Land Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00