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Wisconsin Department of Health and Social Services
7
Plb. #67 10/69 Division of Health
PER-11T APPLICATION
for
PRIVATE DUt ESTIC SEWAGE SYST-EMS .
---DnL'
A. OWNER OF PROPER Y DSGUe V TY'iE OR USE BLACK INK
Name Address (Street. City, Zip Code)
County
B. LOCATION OF PROPERTY WH"R_E SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTP4'DED
Cheek One: 5L- (^_/4~ '-7
__<j • ~ ~
CITY VILLAGE LEGAL DESCRIPTION:
- TOWNSHIP y 1 ~.S
C. IS LOCAL PER11i REQUIRED FOR THIS WORK? A' YES NO PEWIT NUMBER
1
I
D. SEPTIC TANK CAPACITY L Gallons NEW INSTALLATION \ REPLACEMENT ADDITION I
MATERIALS: Prefab Concrete 1 Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other Specify
Number of Persons to be AccommodatedNumber of Bedrooms
Pe Washer
NO YES F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic
omatic Potato Clothes
YES NO
Dishwasher YES NO Automatic
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW ' EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width ~•Depth Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside diameteriquid 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 Dro in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
19t Wetted Overni ht in Minutes Last Period Last Period Period One Inch
Example
P- 0 360 To Soil 10" Clay 26,11 25 es or no 30 1/2 1 2 1f2 600
y
RECORD DATA FROM MT' MUM OF 3 TEST HOLES
ompute size of absprption area in accord with H 62.20 Wis. Adninistrative Code.
S 0 1 L B 0 R I 11 G S- Minimum 36" Below Pro osad Absorption System
oring Total Depth Depth to Ground Water Lepth to 6edrook
umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xample
- 0 7211 7211 Black To Soll 121• Clay 1811• Sand 18"; Gravel 24"
t ~ r~ !
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
i
I, the undersigned, hereby certify that the ;percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chipter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief
NAME c' /C Lclf' TITLE
~ Ty e or Print) /~f C
REGISTRATION NO or MASTER PLUiu3ER LICENSE` No. L~ ! 1/
ADDRESS
DATE SIGNATURE MASTER PLUNBER MAKING APPE4-C•i9TION
MP
Signature License Numbers
MP RSW
(To be Comp eted by Issuing Agent)
Date of Application l / lFee Paid $
Permit Issued (date ly Permit Number
Agent (name), / For.
Town, Village, City, County, etc.
(Specify)
Notes The application cannot be considered for filing until all of the above questions are answered
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 DEPARTMENT USE ONLY
DATE RECEIVED U ACCEPTED BY Y RETURNED
(Initials) (Date) See orres.
FEE RECEIVED VALID. NO. P£RMIT NO.
(Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS:
Parcel 010-1043-60-000 07i03/2007 02:37 PM
PAGE 1 OF 1
Alt. Parcel 18.30.16.267B 010 - TOWN OF EMERALD
ST. CROIX COUNTY, WISCONSIN
Current X
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 - YORK, GERALD D & KAREN E
GERALD D & KAREN E YORK
1552 220TH ST
EMERALD WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 18 T30N R1 6W 1A S 21/2 RIDS OF SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
18-30N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 687/634
07/23/1997 462/364
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/17/1988
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 500 0 500 NO
Totals for 2007: 0 500
General Property 1.000 500 0
Woodland 0.000 0
Totals for 2006: 500
General Property 1.000 500 0 0
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
EMERALD 1. ~3U N-H.Ifo wr
SEE PAGE
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`/97- -7 d1 i~6/,T SEE PAGE •3 0D cSt orxL'ou~yN%.'s.
SWENBY & SON, REALTOR COUNTRY SQUIRE Lee's Drug
REAL ESTATE & INSURANCE FURNITURE Store
BIGELOW, ROXBURY & MYRON O. LEE
"See Vd. Fe~a2e Zlau F"et, MAGEE CARPETS & DRAPES GLENWOOD CITY,
sett at bazaik.~f loot WISCONSIN
212 SOUTH KNOWLES AVE. 386-2869 Congratulations NEW RICHMOND, WIS. 503 2nd Street To The 4-H
Hudson, Wis. 54016 program
715 - 246-2222 - 715 - 246-2223 (See the Cudd's)
r 07/03/2007 02:32 PM
Parcel 010-1044-10-000 PAGE 1 OF 1
Alt. Parcel 18.30.16.269B 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 - ROSAUER, DUANE F & JACQUELINE
DUANE F & JACQUELINE ROSAUER
2108 CTY RD G
BALDWIN WI 54002
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 2108 CTY RD G
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST A I r~
SP 1700 WITC
PA,t4~L-
Legal Description: Acres: 36.750 Plat: N/A-NOT AVAILABLE
SEC 18 T30N R1 6W 36 3/4A S1/2 SW FR;1/4 Block/Condo Bldg:
EXC BEGIN 2 RIDS N & 2 RIDS E OF SW COR,
TH E 8 RIDS, N 6 RIDS, W 8 RDS S 6 RDS TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
POB 18-30N-16W
Notes: Parcel History:
Date Doc # Nol/Page Type
07/23/1997 1 436/138 '
2007 SUMMARY Bill Fain Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 15,000 103,700 118,700 NO
AGRICULTURAL G4 32.750 5,600 0 5,600 NO
UNDEVELOPED G5 2.000 200 0 200 NO
Totals for 2007:
General Property 36.750 20,800 103,700 124,500
Woodland 0.000 0 0
Totals for 2006:
General Property 36.750 20,800 103,700 124,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 115
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00