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Wisconsin Department of Health and Social Services
Plb„•#67 Division of Health
PER'CIT APPLICATION
for
PRIVA`,.'E DUIESTIC SEWAGE SYSTEMS
4-z P(im Ax, rm' 260 Z 0/0 - D S - U--000 •3(02
A. GWNER OF PROPERTY TYPE OR USE BLACK INK
Name Adds (Streets Cif p Zip Code) r- County
B. LOCATION OF PROPERTY WHE E SYSTEM WILL BE CONSTRi1CTED ALTERED C I EXTENDED
Check One:
CITY VILLAGE LEGAL DESCRIPTIONS
TOWNSHIP
C. IS LOCAL PERMIT RE4UIF~D FOR THIS WO..W? YES NO r, :r. er
LJ
D. SEPTIC TANK CAPACITY /fir------=_-- Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete / Poured in Place Steel Other
NUMBER OF TANKS TO BE IN3TALLEDs
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other
Specify
Number of Persons to be Accommodated q
F. APPLIANCES, ETCs Food Waste Grinder YES X NO Automatic Clothes Washer X YES NO
Dishwasher YES X NO Automatic Potato Peeler YES _ NO
Other (Specify) _
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size NO.Lin.Feet _2' - Trench Width Depth _ Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pitt Inside diameter 77 Liquid 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 Drop in Water Level Inches Minutes
Number Inches l) Thickness in Inches Since Hole in Hole Interval Second to Next to Mast To Fall
lst Wetted Overni L in Miraites [act Period Last Peri Period One Inch
Example
P- 0 36" To Soil 1011, Clay 26" 25 es or no 30 1/2 1/2 112 60
/ l
RECOI;V DATA FRal MINIMUM OF 3 TEST HOLES I
ompute size of absorption area in acoord with H 62.20 Wis. Administrat'.ve Code.
S O I L B 0 R I N G S- Minimum 3G" Below ProP sad Absorption System _
oring Total Depth Depth to Ground Water Depth to Bedrock
umber Inches served Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
- 0 721t. 7219 Blaok To Soil 12"• C12 18"• Sand 18"• Gravel 24"
t 1.'
RECORD DATA F^OM MINIMUM OF 3 BORE HOLES
i
_ COMPLETE OTHER SIDR
. L
I, the undersigned, hereby certify that the peroolation tests reported on this form wero made by me
or under by supervision in accord with the procedures and method spooified in Cr:apter 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 TITLE
- Type or Print)
REGISTRATION NO. / or MASTER PLUTS ER LICENSE No. ~S 1
ADDRESS • / < -
DATE SIGNATURE ~.r l F
MASTER PLUI'S'3ER MAKING APPLICATION
License Number: _
Signatures MP RSW
(To be Co ted by Issuing Agent)
Date of Application / ? Fee Paid $
Permit Issued (date) Permit Number
~ i
.
, ; 7 i' For:/ (t ! ' (/C
Agent (name) _
Tomas, Village, City,'County, etc.
(Specify)
Notes The application oannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the
Permit (yellow oopy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
Do not write in space below FOR DEPARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY ~RETURNED
(Initials) (Date) See Corres,_r
FEE RECEIVED VALID. NO. PERIIT NO.
Yes or No)
REVIEXED BY APPROVED DATE
(Initials) Yes or No)
COMMENTS:
~ 1r
Parcel 010-1056-70-000 o7io3i2oo7 02:02
PAGE 1OF 1
Alt. Parcel 24.30.16.362 010 -TOWN OF EMERALD
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - HENRY, MICHAEL J & KATHLEEN M
MICHAEL J & KATHLEEN M HENRY
PO BOX 234
WILLERNIE MN 55090
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 2654 140TH AVE
SC 2198 GLENWOOD CITY
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 24 T30N R16W 40A SW SE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-30N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/23/2002 691353 1986/60 WD
07/23/1997 453/580
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 15,000 84,300 99,300 NO
UNDEVELOPED G5 18.000 21,600 0 21,600 NO
PRODUCTIVE FORST LANDS G6 20.000 40,000 0 40,000 NO
Totals for 2007:
General Property 40.000 76,600 84,300 160,900
Woodland 0.000 0 0
Totals for 2006:
General Property 40.000 76,600 84,300 160,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch 222
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
.EMERALD 1. JON H. 10 w VI 1
SEE PAGE 59
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SEE PAGE •3 cStC' oix C ..nfJ.il1%.s.$
SWENSY & SON, REALTOR COUNTRY SQUIRE Lee's Drug
REAL ESTATE & INSURANCE FURNITURE Store
BIGELOW, ROXBURY & MYRON O. LEE
"See Va Fe~aore I/au Fact, MAGEE CARPETS & DRAPES GLENWOOD CITY,
seee an vaorot" ba4a44,9~ I& WISCONSIN
212 SOUTH KNOWLES AVE. 386-2869 Congratulations
NEW RICHMOND, WIS. 503 2nd Street
Wis. To The 4-H
Hudson, W 54016 P
715 - 246-2222 - 715 - 246-2223 rogram
(See the Cudd s)