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Wisconsin Department of Health, and Sooial Ssrvicas
. Plb.t#67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK / / ! v~ Lru2~, /J
-7 3 A. OWNER OF _ PROPERTY
Name Address (Street, City Zip Coda)
"Ileh rn'YiQ ~ /LJ. 3
B. LOCATION OF PROPERTY W:TRE SYSTEM WILL BE CONSTRUCTED. ALTERK) OR EXTE`1 1^ COUNTY
Check One: -
CITY
TOWNSHIP VILLAGE LEGAL DESCRIPTION V,'11 6t..)Z
O•
C. IS LOCAL PEPUNIT RECUIRED FOR THIS WORK? x YES NO 1 1;~/ PEi MIIT NIU71BEZ ,
D. SEPTIC 'TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete X Poured in Place Steel Other
NUMBER OF TANKS TO BE .,NSTAL!4D: 0
E. TYPE OF OCCUPANCY
Cheek one: one or Two Family Residence ! Cow--ercial Other _
(specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES .5 ?!G Automatic Clothes Washer Ye S_ NO
DishKasher YES NO AutumWla PutF•tc Peeler YES
Other (Specify) ~ (Specify) NO
`
G. MASTER PLUP3ER KXKING INSTALLATION
Name: f j `{h /-I Address: License
o~f~ / !z rt
Signature of Applicant: ~1,t , MP RSW _
Address:v
H• ( o be C rnpleted by Issuing Agent)
Date of Application /Z J 0 Fee Paid
Permit Issued (date) l Permit Number -~-L _
Agent (Name) Fort 7
tG .
_L~-
Towns Village, GEC L r
City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of th- r'ova questions are answered and the
fee paid. Agents will fomard application, the fee of $1.00 for each. septic tanx and the third copy
of the permit (eanary~ to the Division of Health. Checks an,' money o=rders should be made payable to
the Division of Health.
Do rc. write in apace below - FOR DEPAR'c_`IENT USE ONLY
I. DATE-RECEIVED ACCEPTED BY RETURNED ~
f~ (Initials) i (Date) See Corras.)
FEE RECEIVED r 'Yes or HT VALID. No. 1 ~ ~.I; PERMIT NO. 7
-
REVIEWED BY APPROVED DATE
(Initials)
Yes or No)
COMPLETE OTHER SIDE
SYPTIC TANK PERIiI'T' NO. / .J
R Y P 0 R T O N S 0 I L P& R C 0 L A T I 0 N T E S T
A N D S O 1 L B O R I N G S
TO
DIVISION OF HV-LTH - ?LLtMING SFXTI64
P.O.Box 309, M.ulison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P B R C 0 L A T I 0 N T T S T
Test Depth Cheraetar of So~il Hours Water Test T'
108 Dt' ,ins to: L+vel inches uNumber Inches TYjc-nass i:, Inches I Since Hole in Hole Interval Second to Next to Lzst rT~..llaas
ll
1st Wetted Overnight in Minutes Last Period Last Period Period Inch
Ex&mple `
P - 0 36" Top S011 10'x', C1-4,26111 25 Yes or No 30 1 2 1/2 1/2 60
RECORD DATA FROM MINL'IUM OF 3 TTST HOLES
Compute size of absorption area in aoeord with If 62.20 Wis. Administrative Code.
S O I L 00 R I N G S- Mi_u%m_ um 36_" Balcmrl Prooo>ed Absorption Fy--t n
Boring Total Depth DE 'p«h to Ground Na,7r De th to B7drocs
Nuabar Inches served Sctimated Cr~aarved F5tiwat9d Character of Soil with Thiolcness :Li Inohss
B - 0 72" 72" ~ M Black Too Soil 12"; Clay 16". Sand 13"; Gr,vsl 2411
,7, v41
R=?.D DATA FROM Mltil'~'. m OF 3 BGRB HOr-7
i
TYPE OF OCCUPANCY: -7
R SIDE?iC$s Nuafber of Bedrouns OTHER: (Speoify) Number of Pwraons
FOOD WASTE GRLN'DERs Yea ti,1 Di3t=asher: Yes No Automatic Clothes Wa.shar: Yes Nc ~
FFLUENT DISPOSAL SYSliy*t: NrTiJ EXTENSION ADDITION REPLAs'n'I_EN'T
Tile Size / No. Lin. Feet ~yz') !Trench Width 'Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I,, the undersigned, hereby cart fy that the percolation tests reported ,n this form were made by me or under r.r super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME /<4 ;9 TITLE
Type or Print) REGISTRATION NO, or MASTER PLUMBER LICE-iSa NO. 'p'."
ADDRESS C .Q
DATE Q SIGNATURE
A-}
EMERALD T 3U N:- H. i(0w A+ I 1
SEE PAGE
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SEE PAGE 33 cSf~oir~ ~yl~%z_$
SWENBY & SON, REALTOR COUNTRY SQUIRE Lee's Drug
REAL ESTATE & INSURANCE FURNITURE Store
RLGELOW, ROX81IRV & MYRON O. LEE
"See Va Fe~ate Zlau Piny, MAGEE CARPETS & DRAPES GLENWOOD CITY,
Sete an Furot" bazatk,y - laot WISCONSIN
212 SOUTH KNOWLES AVE. 386-2869 Congratulations
NEW RICHMOND, WIS. 503 2nd Street To The 4-H
Hudson. Wis. 54016
715 - 246-2222 - 715 - 246-2223 Program
(See the Cudd s)
S
VL/
,
Parcel 010-1031-80-100 07/03/2007 03:05 PM
PAGE 1 OF 1
Alt. Parcel 13.30.16.196-1 010 - 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 - COYER, JUDITH M
JUDITH M COYER
2673 154TH AVE
EMERALD WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2673 154TH AVE
SC 2198 GLENWOOD CITY
SP 7050 GLENWOOD & EMERALD SAN 1 J
SP 8020 UPPER WILLOW REHAB DIST VV - f ATM,
SP 1700 WITC
Legal Description: Acres: 0.670 Plat: N/A-NOT AVAILABLE
SEC 13 T30N R16W PT OF THE Nj (7F THE Block/Condo Bldg:
SE 1/4 fQU AT A POINT 60 FT S OF THE SW
R OF LOT 6, BLOCK 6 ORIGINAL PLAT OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
THE VIL OF EMERALD, TH W 210 FT TO THE 13-30N-16W
POB; TH S 127 FT; TH W 168' TH N 127 FT;
TH E 168 FT TO POB; & PARC BEG 60FT S OF
more...
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1216/165 WD
07/23/1997 1126/383 WD
07/23/1997 1126/381 AF
07/23/1997 1013/299 WD
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 0.670 6,000 97,000 103,000 NO
Totals for 2007:
General Property 0.670 6,000 97,000 103,000
Woodland 0.000 0 0
Totals for 2006:
General Property 0.670 6,000 97,000 103,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 207
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 010-1091-70-000 07/03/2007 03:04 PM
PAGE 1 OF 1
Alt. Parcel 13.30.16.559 010 - 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
HARLAN G & JUDITH M COYER O - COYER, HARLAN G & JUDITH M
2673 154TH AVE
EMERALD WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2673 154TH AVE
SC 2198 GLENWOOD CITY
SP 7050 GLENWOOD & EMERALD SAN 1
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 13 T30N R16W LOT 1 BILK 6 & N1/2 ADJ Block/Condo Bldg:
ALLEY VIL EMERALD 1546 CTY RD D, TAVERN
(ADD-L HISTORY 828/544) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
13-30N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 996/223 WD
07/23/1997 954/241
07/23/1997 864/381
07/23/1997 845/101
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 0.000 7,500 104,500 112,000 NO
Totals for 2007:
General Property 0.000 7,500 104,500 112,000
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 7,500 104,500 112,000
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