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• Wisconsin Department of Health and SOOial Services
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
i
TYPE or USE BLACK INK
A. E,"rtNER OF PROPIRTY
Name Address (Street, City. Zip Code)
B. LOCATION OF PROPERTY WEERE SYS1- WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY \ c/
Check One:
-CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? A/' YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY % Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steal Other _
NUMBER OF TANKS TO BE :INSTALLED:
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence Commercial Industrial other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder V YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUBKR MAKING INSTALLATION
Name: Address: - License Number:
7 MP~
Signature of Applicant: MP RSW
Address:
H. (To/be Completed by Issuing Agent)
Date of Application 4 L' Fee Paid
Permit Issued (date) Permit Number
Agent (Name) Fort /
Town, Village, City, County, etc.
(Specify)
Note: The applicltion canno be considered for filing until all of :he above questions are answered and tYz
fee paid. Agents will forward application, the fee of j1.OG for each septic taruc and the third copy
of the permit (canary) 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
- -_7 L ACCEPTER BY RETURNED
I. DATE RECEIVED
(Initials) (Date) See res.)
FEE RECEIVED VALID. No. W ~U PERMIT NO.
Yes or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P I R C 0 L A T I 0 N ? E S T
A N D S O I L B 0 R I N 0 S
TO'
DIVISION OF HEALTH - PLLMBING SMCTIG`'N
P.O.Box 309, e",Aison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P I R C 0 L A T I 0 N T I S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches inutes
Numb Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
lst vatted 0Vorni in Minutes Last Period Last Period Period. Q- s, Inch
Example
P - 0 36:1 ?o Soil 1G14 Cla 26;* 25 Yes or No 30 1 2 1/2 1/2 60
RECORD DATA FROM MINL';UM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 3611 Below Pra osed Abso tion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 721f 72" Black Top Soil 12''s Clay 1811; Sand 18"; Gravel 2411
~ /IVF
RECORD DATA FROM MINL'4UM OF 3 BORE HOLES
PE OF OCCUPANCYt
RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons
t.~
FOOD WASTE GRINDERS Yes No Dishwashers Yes No Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NGI / EXTENSION ADDITION REPLANT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Death Tile Size No. Lines
Soepags Pitt Inside Diameter Liquid Depth
I, the undersigned, hereby oert'fy that the percolation tests reported on this form were made by me or under n• super-
vision in accord with the proceuures and method sp3olfied 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 TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS A'," , i
DATE SIGNATURE
G ✓
Parcel 020-1052-60-100 02/02/2005 04:33 PM
PAGE 1 OF 1
` Alt. Parcel 20.29.19.196E-10 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
NASSEFF, STEVE
STEVE NASSEFF
844 DORWIN RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 844 DORWIN RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.210 Plat: 1353-CSM 15/4172 020/01
SEC 20 T29N R19W PT NW SE BEING CSM Block/Condo Bldg: LOT 01
15/4172 LOT 1 3.210AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W NW SE
Note Parcel History:
q V3, .L ( Date Doc # Vol/Page Type
01/08/2002 667544 1809/244 WD
12/13/1999 615476 1478/090 WD
06/01/1999 604023 1430/130 WD
I2-
2004 SUMMARY Fair Market Value: Assessed with:
48013 321,500 l Z
Valuations: Last Changed: 04/26/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL / C~1~ 2 3.210 47,300 201,400 248,700 NO
d
Totals for 2004:
General Property 3.210 47,300 201,400 248,700
Woodland 0.000 0 0
Totals for 2003:
General Property 3.210 47,300 201,400 248,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
001-WATER SPECIAL ASSESSMENT 0.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00