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Plb. #67 3/70 Wisconsin Department of Health and Sooial Services
Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
i
t -7
A. OWNER OF PROPERTY
Name
~~)f Address (Street, City, Zip Code)
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR FXTENDED
Check One= _ / COUNTY r,
CITY VILLAGE LEGAL SCRIPT ON TOWNSHIP /7
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? y NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT
z-~~-°-- ADDITION
MATERIALS= Prefab Concrete poured in Place Steel Other
NUMBER OF TANKS 70 BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence ~ Commercial
Industrial Other
Number of Persons to be Accommodated (Specify)
Number of Bedrooms `
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer
Dishwasher YES NO
Y NO Automatic Potato Peeler YES^ NO
Other (Specify)
rNN-a-me: ER PLUMBER MAKING STALLATION
5.~,-'~l'°~ Address$
y`i~ / Lioenso Number:
MA
ture of Applicants ~ RSW ress:
H. (To be Completed by Issuing agent)
h
Date of Application % - L1- J / Fee Paid / C '
Permit Issued (date) -21 _ Permit Number
Agent (Name) / 1 ✓ C ,S
For: 1,
Town, Village, City,-County, etc.
Note: The application cannot ba :cnsiderad for filing until all of the above (Specify)
questio
ptle t ns are answered and the
fee paid. Agents will forward application, the fee of $1.00 for each see
of the permit (canary) .o the Division of Health. Checks and msney ordersshou d be made third copy
the Division of Health. payable to
Do not write in space below T FOR DEPARTMENT USE ONLY
I. DATE RECEIVED rl
ACCEPTED BY RETURNED
FEE RECEIVED (Initials) S (Date) See Corr s)
VALID. No. PERMIT NO. 1cLli
REVIEWED BY APPROVED
(Initials) DATE
Yes or No -
COMPLETE OTHER SIDE
' r SEPTIC TANK PERMIT N0. f 7`~~)
R Y P 0 R T O N S O I L P I R C 0 L A T I 0 N T E S T
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLLMING SECTIb>J
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P E R C 0 L A T I 0 N T t S T
Test Depth Character of Soil Hours Water Test ime Drop in Water Level Inches utes
Number Inches Thickness in Inehoa Since Hole in Hole Inte.'-Tval Second to Next to Last To Fali
1st Wetted Overni in Minutes Last Period Lest Pe d
Perio Inch
On* ,Inch
Example
P - 0 36" To Soil 10" Cla 2611 25 Yes or No 30 1 2 1/2 112 60
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 361+ Below: pro osed Abso tion & stem
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed tatimated Observed Estimated Character of Soil with Thickness in Inches
Pxrmple
B d 72r~ 7200 Black Top Soil 1211 Clay 18" Sand 1811• Cravel 24111
r
RECORD DATA FROM MIN DIUM OF 3 BORE HOLE'S
YPE OF OCCUPANCY:
RESIDENCE: Nmber of Bedrooms OTHER: (Specify) Number of Persons
FOOD WASTE GR L"7DERs Yes No Dishwashers Yes No X Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW S( EXTENSION ADDITION REPLACEMM
Tile Size No.Lin.Feet Trench Width_ Depth ? Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter _ = Liquid Depth 5-
Ie the undersigned, hereby certify that the percolation tests reported of 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)2 Wisconsin Administrative Code, and
that the da recorded and locatia of test holes are correct to the best of my knowledge and belief.
NAME 1 `
TITLE
Type or Print
REGISTRATION NO. i or MASTER ?LUMBER LICI SE NO.
1
ADDRESS i
7
DATE - _ ? i SIGNATURE d iC C~Z < <~r~~•_
06/27/2007
Parcel 010-1011-95-000 10:06 AM
t PAGE 1 OF 1
Alt. Parcel 5.30.16.70AT ir? 010 - TOWN OF EMERALD
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 - HENDERSON, LATON N & RANAE J
LATON N & RANAE J HENDERSON
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Addressjes): = Primary
Type Dist # Description " 1790 220TH ST
SC 3962 NEW RICHMOND i 2
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC '
Legal Description: Acres: 44.250 Plat: N/A-NOT AVAILABLE
SEC 5 T30N 6W 44.25A GOV LOT 4 EXC Block/Condo Bldg:
P40B IN
1 S Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
I 05-30N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/19/2004 763018 2575/161 WD
1114/080 WD
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 30.000 5,200 0 5,200 NO
UNDEVELOPED G5 2.000 200 0'1., 200 NO
PRODUCTIVE FORST LANDS G6 10.250 12,300 0 12,300 NO
OTHER G7 2.000 10,000 t: 46,000) 56,000 NO
Totals for 2007:
General Property 44.250 27,700 46,000 73,700
Woodland 0.000 0 0
Totals for 2006:
General Property 44.250 27,700 46,000 73,700
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
Parcel 010-1011-90-000 06/27/2007 10:05 AM
PAGE 1 OF 1
Alt. Parcel 5.30.1 .69F 010 - TOWN OF EMERALD
Current X 2 ST. CROIX COUNTY, WISCONSIN
Creation Date Histori _a ) ate Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - HENDERSON, LATON N & RANAE J
LATON N & RANAE J HENDERSON C - ERICKSON SAMUEL C
ERICKSON SAMUEL C
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1790 220TH ST
SC 3962 NEW RICHMOND 11
SP 8020 UPPER WILLOW REHAB DIST~- I (/l yt ; lS
SP 1700 WITC
2 Z i Cry 1c'd J
Legal Description: Acres: 0.570 Plat: N/A-NOT AVAILABLE
SEC 5 T30N R1 6W W166' OF N 150' OF GL 3 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) I "
? .a Yv~~~1 [ tr? ~ 05-30N-16W
Notes: Parcel History:
tU Date Doc # Vol/Page Type
07/23/1997 1114/80
07/23/1997 765/168
07/23/1997 751/611
07/23/1997 457/339
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.570 5,000 39,300 44,300 NO
Totals for 2007:
General Property 0.570 5,000 39,300 44,300
Woodland 0.000 0 0
Totals for 2006:
General Property 0.570 5,000 39,300 44,300
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
EMERAL NE°V,~~)l T 30 N:-R. 16 W 47
S SEE PAGE 59 S SEE PAGE
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SEE PAGE y!-Y•a. $
SWENBY & SON, REALTOR COUNTRY SQUIRE Lee's Drug
REAL ESTATE & INSURANCE FURNITURE Store
"See ZlQ Fe one au Fu Rl6ELDW, RDXRURY & MYRON O. LEE
q~ MA6EE CARPETS & DRAPES GLENWOOD CITY,
Seel a2 Funk WISCONSIN
212 SOUTH KNOWLES AVE. 386-2869 Congratulations
NEW RICHMOND, WIS. 503 2nd Street
Hudson, Wis. 5401 To The 4-H
715 - 246-2222 - 715 - 246-2223 Proffffram
I (See the Cudd's) b
Parcel 010-1014-10-000 06/27/2007 11:15 AM
PAGE 1OF1
Alt. Parcel 6.30.16.83 010 - TOWN OF EMERALD
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 - HENDERSON, LATON N & RANAE J
LATON N & RANAE J HENDERSON
1790 220TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 1790 220TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 44.000 Plat: N/A-NOT AVAILABLE
SEC 6 T30N R16W 44A GOV LOT 1 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
06-30N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/19/2004 763018 2575/161 WD
1114/80
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 40.500 6,500 0 6,500 NO
UNDEVELOPED G5 1.500 150 0 150 NO
OTHER G7 2.000 10,000 149,300 159,300 NO
Totals for 2007:
General Property 44.000 16,650 149,300 165,950
Woodland 0.000 0 0
Totals for 2006:
General Property 44.000 16,650 149,300 165,950
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 209
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00