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Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
4YP£ or USE BLACK INK
A. OWNER OF PROPERTY
Name / Address (Street, City, Zip Code)
1
1
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTFRED OR T DF.D COUNTY
Check One:
CITY _ VILLAGE LYC AL DESCRIPTION
-A TOWNSHIP
C. IS LOCAL PEPUMIT REQUIRED FOR THIS WORK? YES NO C PERMIT Null-bER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPL.4CEM.ENT ADDITION
MATERIALS: Prefab Concrete y Poured in Place _ Steel Other
NUMBER OF TANXS TO BE INSTALIZD: ~ a
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence Commercial Industrial other
Spa:ify)
Number of Persons to be Accorr.-iodate, Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES y NO Automatic Potato Peeler YES NO
Other (Specify)~y
G. MASTER PLUr3ER MAKING INSTALLATION
-ber:
Name:
Address: ;
License Nu
Sigzatura of Applicant: ~ ~ c-= 4,~c•~;~~"~if"-~ MP RSd ~
Address: Imo, i~C'L2=~~
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date)- /-7 Permit Number 71
Agent (Name)
Town, Village, City, County, etc.
(Specify)
,'rote: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will orKard appli-.aticn, the fee of ;1.00 for each septic tarot 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 O 3 d ACCEPTED BY RETURNED
(Initials) (Date) See.Corres.)
FEE RECEIVED VALID. No. PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or Noj
COMPLETE OTHER SIDE
f
' SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P E R C O L A T I O N T E S T
A N D S O I L B 0 P. I N G S
TO
DIYISIGI OF HEALTH - PLL=IBLK3 SYYCTIbi
P.O.Box 309, Madison, Wis. 53701
Pursurnt to R 62.20, Wis. Administrative Code
P X R C 0 L A T I 0 N T I S T
Test Depth Charzoter of Soil Hours Water Test Tina Drop in Water Level Inolies mutes
Number Inches Thio:;nesj in T-no as Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Ovarnizht in Minutes Last Poriod Last Pariod Pericd Ono, Inca
Example
P - 0 361, To Soil 10" Clay 2611 25 Yes or No 30 l 2 1 2 1/? 60
1 K
RECORD DATA FROM MIND= OF 3 TEST HOLES
Compute size of z`bsorption area in accord with H 62.20 Wis. Ae:,ainistrative Coda.
S O I L B 0 R I N G S_- Nini_-•_~a 361t RAC." Prooos.d A ^orptio~t S gtSa
Boring Total Depth Depth to Gro=,d Watt~° Da th to Bedroc% t
Number Inches Cbservad ~s~i.mgted Ob3erved -Est 1: t, Ch racter of Soil with ThloIcness in Inches
Example
B - 0 7211 72" Black To Soil 1211s Clay lE" Sand 1B'', Gravel 2d"'
d -
Iµ t
J 2 zi_
R C6Pv DATA FROM MINTIU:K 07 3 BORE HIJLEa
I
YPE OF OCCi1?ANCYs
RESIDENCES Number of Badroof33 OTHcRs (Specify) Number of Persons
FOOD WASTE GRINDER: Yes No ; DisYwashars Yes No Automatic Clothes Washers Yes No %
EFFLUENT DISPOSAL SYSTEM: NEW ~ EXTENSION ADDITION REPLACLII•.*iT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width _ Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby earthy that the percolation tests reported on this form were made by me or under my super-
vision in accord 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 /:2
TITLE
Type or Print
l
REGISTRATION NO. or MASTER PLUMBER LICViSE NO. ~
ADDRESS
DATE S IGNATl
~ I
I
ck
Parcel 022-1011-90-000 05/03/2007 10:28 AM
PAGE 1 OF 1
Alt. Parcel 5.28.18.72B 022 - TOWN OF KINNICKINNIC
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 - JOHNSON, WESLEY A & JUDY M
WESLEY A & JUDY M JOHNSON
1052 CTY RD N
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1052 CTY RD N
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 2.750 Plat: N/A-NOT AVAILABLE
SEC 5 T28N R18W 2.75A IN SE NW COM CEN Block/Condo Bldg:
SEC 5, TH N 799.5 FT TO POB TH N 413 1/2
FT, W 350 FT, S-269_-FTT9 CL HWY N, SELY Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
ALG CL T~POB 463/621 y 05-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 827/524
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/10/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.750 50,000 241,000 291,000 NO
Totals for 2007:
General Property 2.750 50,000 241,000 291,000
Woodland 0.000 0 0
Totals for 2006:
General Property 2.750 50,000 241,000 291,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00