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Wisoonein Department of Health and Social Services
Plb. #07 10/69 Division of Health
PERMIT APPLICATION
for
PRIVATE DO,,1ESTIC SEWAGE SYSTEMS
01 - 3 7- 60 - . ~27 l A
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
County
B. LOCATION OF PROPERTY WKEPE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
Cheok One:
CITY VILLAGE LEGAL DESCRIPTION:
TOWNSHIP SE i -SGJ/'G~'
~f -ZAll /7 f..J//IZ' L%
C. IS LOCAL PERIIT REQUIRED FOR THIS kDRK2 YES NO J PERMIT NUMBER
D. SEPTIC TANK CAPACITY f Gallons NEW INSTALLATION REPLACEMENT ADDITION
MA'T'ERIALS: Prefab Concrete ~ Poured in Place Steel Other
NLQ'tdER OF TANKS TO BE INSTALLED: i
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commeroial Industrial Other
(Specify)
Number of Persons to be Accommodated t Number of Bedrooms I-~?
F. A?PLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer X YES NO
Dishwasher YES NO Automatic Potato Peeler YES 7- NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT .G
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length j' Width Depth- " Tile Size No. Lines
Seepage Pits Inside diameter Liquid Depth
P E R C O L A T I O N T E S T
Test Depth i Characte;• of Soil Hours Water f7 Test Time Drop it Water Level Inches !linutes
Number Inches Thickness in Inches Since Hole in Hole 'Interval Second to -'Next to Last ";o Fall
1st Wetted Overni.ht in Mlraites Last Period Last Perio Period One Inch i
Example
P- 0 36" To Soil 1011, Clay 26" 25 es or no 30 1 2 1/2 1/2 60
RECORD DATA FROM M INIMU"I OF 3 TEST HOLES
ompute eize of absorption area in acoord with H 62.20 Wis. Administrative Code.
i
S O I L B O R I N G S- Minimum 36" Below Proposed Absorption System
oring Total. Depth Depth to C•round Water Depth to Bedrock
umber Inches Observed EstiTated Observed Estimated Character of Soil with Thickness in Inches
xample
0 72" 72" Black Toy Soil 12" Cla 18"• Sand 1811• Gravel 24"
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
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 Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and locItion of test holes are correct to
the best of my knowledge and belief. /
NAME J A/l/ TITLE C ~ /C It IZ' c
(Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No. } J
ADDRESS ~Z«!~?~~ s0-
DATE Z76- SIGNATURE
i
MASTER PLiPT3 R MAKING APPLICATION MP
Signature: !1.11611t- -~L' License Numbers
MP RSW
(To be Completed by Issuing Agent)
Date of Application J 7 Fee Paid
Permit Issued (dat Permit Numbcler/
Agent (name)-~ i.~f _ j Ct< Fore/
Town, Village, City, County, eto.
(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 ? - D ACCEPTED BY RETURNED _
/ (Initials) r (Date) (See Corres.)
FEE RECEIVED VALID. NO. I J PERMIT NO.
(Yes or No)
REVIE74ED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS: f
Parcel 014-1037-60-100 07/03/2007 03:57 PM
PAGE 1 OF 1
Alt. Parcel 17.31.15.271A 014 - TOWN OF FOREST
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 - MOEDE, RUSSELL R & LINDA L
RUSSELL R & LINDA L MOEDE
2758 210TH AVE
DEER PARK WI 54007
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 2758 210TH AVE
SC 1127 CLEAR LAKE
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 20.015 Plat: N/A-NOT AVAILABLE
SEC 17 T31 N R1 5W PT SW SE THE W 660.5' Block/Condo Bldg:
OF THE SW SE1/4
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-31 N-1 5W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 936/450
07/23/1997 879/369
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 10/18/2005
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 17.515 2,100 0 2,100 NO
UNDEVELOPED G5 0.500 100 0 100 NO
OTHER G7 2.000 10,000 80,300 90,300 NO
Totals for 2007:
General Property 20.015 12,200 80,300 92,500
Woodland 0.000 0 0
Totals for 2006:
General Property 20.015 12,200 80,300 92,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
.FOREST T 31 N--R. 15 W 61
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l SEE PAGE 49
E PAGE 47'-'
PLAT BOOK COMMITTEE
SALES COMMITTEE Mrs. Arlo Johnson
Mr. Floyd Fouks Mr. Carlyn Lund Mrs. Gerald Schwan Mr. Herb Turner
Mr. Ben Sachsenmaier Mrs. Robert Leaf Mrs. Arlo Kunze Mr. Irv Holzer
Mr. Duane Berends Mrs. Walter Faber Mr. Doug Thompson Mrs. Ray Anderson
Mr. Wm. Ullom Mrs. John Slotevig Mrs. Emmett Langness Mr. Bruce Harris
Mr. Robert Draxler Mr. Eugene Larson Mrs. Jack Bean Mrs. Harold Beer
Mrs. Gerald Johnson Mr. Lavern Timm Mrs. Ed Cody Mrs. Carlye Nerbe
Mrs. John Feryereisen Mrs. Talley Rouquette Mrs. Charles Vanda Mrs. Ivan Vickerman
Mrs. Maynard Larson Mrs. James Johnson Mrs. George Barringer Mrs. Robert Hartmon
Mrs. Douglas Werner Mrs. Don Gabrielson Mrs. Oliver Erickson Mrs. Francis Fouks