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Wisconsin,Department of Health and Scoial Services
Pib„-#67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK l ✓ L 1107 06,9-
2 6 ys 9 - ~S 7 A. OWNER OF PROPERTY
Name C Address (Street, City, Zip Code)
Be LOCATION OF P_ROPE2TY WHERE SYST''Tl WILL BE CONSTRUCTED, ALTER0 OR EXTENDED COUNTY \5
Check One:
CITY VILLAGIR i. uAL DESCRIPTION
TOWNSHIP /
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? :rl YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY 1 C~"fir / Gallons NEW INSTALLATION REPLACEMENT ADDITION
=T-
MATERIALS: Prefab Concrete _ Poured in Place Steel _ Other
NUMBER OF T LNKS TO BE INSTALLED: 4
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence ~ CCfX4GV0ia1 Industrial Other
(specify)
Number of Persons to be Accommodated -11; Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothos Washer YES NO
Dishwasher YES j NO Automatic Potato Peeler YES ~ NO
Other (Specify)
G. Nu1STIR PLUrZIER klAKING INSTALLATION
N=a: Address; License Number:
M? 7 i
Signature of Applio<:nt:
MP RSW
Address: l C r /t t, r? t:
H. (To -be Cooopieted by Issuing Agent)
Date of Application I Ar,- Fee Paid $ ~ L
Permit Issued {data I Jo / Permit Number
Agent Name : } ,L For:
Torn, Village, City, County, etc.
(Specify)
Note: 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 41.00 for each septic tank 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
I. DATE RECEIVED I b -(3 -`7 U ACCEPTED BY RETURNED _
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. ~F~21 PERMIT NO.
Yes or ho
REVIEWED BY APPROVED DATE
(Initials) (Yes or No
COMPLETE OTI[ER SIDE
SEPTIC TANK PERMIT NO.
R Y P 0 R T O N S O I L P T R C 0 L A T I 0 N T Y S T
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLUIBIJ?r, SBCTIN
P.O.Box 309, N.Rdison, Wis. 53701
Pursuant to K 62.20, Wis. Administrative Code
P 8 R C 0 L A T 1 0 N T T S
Test Depth Character of Soil Hours Water Teat Time Drop in Water Level Inones utes
Number Inohea Thiaknesa in I^.=has Since Hole in Holo Interval Second to Next torLast io Fall
1st Wetted Overnight in Minutes Last Period bast Period Per io,3 Crm Inch
Example
P - 0 3611 To Soil 10" Clny 2611 25 Yes or No 30 1/2 1/2 1/2 60
RECORD DATA FROM MLNL`IUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Cod3_
S 0_I L_ B 0 R I N G S- Minir:in 361+ Reic^4 prooosed Abzoation Syctin
Boring Total Depth Depth to Ground v?atar D~tn to Bedroc'.c
Number Inohea Cbservod Estir3ted C'aservzd Estisa,3d Character of Soil with Thin'=ass in inches
Ewa-ple
B - 0 72" 721' Blau Soll 1211: Clay i8'';Sand 1,": Gravel 2411
;J _
R 7,OPW DATA FROM MIY?"!fii OF 3 BORE NC. i~r
YPE OF OCCUPANCY:
RESIDENCE: Number of Bedroorss OTHERS S eoif
( P Y) Near of Persons
FOO D WASTE GRL'IDERs Yes No _ Dishwashers Yes No Autoz~--tic Clothes Was ier: Yes No
FFUJM DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC&M.E.N'T
Tile Size No.Lin.Feet Trenoh Width Depth Number of Lines
Seepage Beds Length _ J Width _2 Depth Tile Size ' l No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under mti- super-
vision in acoord 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 i r R P
,Z: 2
1 F. r b TITLE X
Type or Print '
REGISTRAT10NnNO. j / or MASTER PUJI-OER LICy~t'iSE NO.
f-
ADDRESS - ( C L~,1 f., ~C ;7 Cr
DATE % SIGNATURE 0
i f - t i j
Parcel 020-1081-80-000 01/04/2007 11:23 AM
PAGE 1 OF 1
Alt. Parcel 29.29.19.331 H 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): 0 = Current Owner, C = Current Co-Owner
O - LUEPKE, CARL R & FAYE M
CARL R & FAYE M LUEPKE
407 CTY RD UU
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2611 HUDSON /,l Q /
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 29 T29N R19W NW NW W 208.5 FT OF N Block/Condo Bldg:
210 FT EXC PARCEL 331 M
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 718/509
07/23/1997 547/636
2006 SUMMARY Bill Fair Market Value: Assessed with:
161683 207,000
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.965 44,400 152,900 197,300 NO
Totals for 2006:
General Property 0.965 44,400 152,900 197,300
Woodland 0.000 0 0
Totals for 2005:
General Property 0.965 44,400 152,900 197,300
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
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00