HomeMy WebLinkAbout022-1042-20-000
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Wisconsin Department of Health end Social Ser~icos
' s Plb. #67 1069 Division of Health
PERZUT ArPLICATION
for
PRIVATE DOKESTIC SEWAGE SYSTI~i
~ 2 2 - /0
A. OW;ER OF PROPI:iYI'Y TYPE 0;; C,SE BLACK I,;"'
Name Address (Street, City, Zip Code)
County -
B. LOCATION OFPR0P'i.RTY yWEPRE SY-3 cFr WILT. BE CONS"i tJ_ C7':_)~ ALitf c,D ~R E.:TE::;DI.~
Check One:
CITY VILLP-0 LEGAL DE/SCidPTION:
TOWilaMHIP >5 ( : f/ ~ ~f,, r J fr J ; ~ i I / L~
C. IS LOCAL PER11T Fv'OUIR%D FOR THIS WO~LK? X YES _ NO PEi~ iT NLmREP.
D. SEPTIC TANK CAPACITY f Gallons NEW INSTALLATION REPLACES"FNT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
N ~i3ER OF TANKS TO BE IFSTALLED:
E• TYPE OF OCCUPANCY
Check One: One or Two Family Residence / Commercial Industrial Other
- _ _ (Specify)
Number of Persons to be Accommodated > Number of Bedrooms V
F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes 'h'asher YES NO
Dishwasher YES ✓ NO Automatic Potato Peeler YES NO
Other (Specify) G. EFFLUENT DISPOSAL SYSTVI NEW XY EXTENSION ADDITION REPLAOF.wENT
Tile Size NO.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Leng-th Width Depth _ Tile Size No. Lines
Seepage Pits Inside diameter 4! 4 Liquid Depth
P E R C O L A T I O N T E S T
Test Depth i Character of Soil Hours Water Test Time Droo in-'ater Level In he_ an tes
Number Inches Thickness in Zrch..s Since Hole in Hole Interval Second to i Next to ~L;;-st 'o Fall
_ 1st 'netted Overnight in Mi,wtes Last Period Last Perio Per ,o• One_In'h j
Example
P- 0 36" To Soil. 1011, Clay 26" 25 yes or no 30 1/2 1 2 112 60
~ ' ~ I ~ it l I 1 • L / I ~ ~
I ti ~ ~ Fj sal -7 ~ I ( ~ . / ~
RECORD DATA FROM I: -X OF 3 _5_ Li
ompute size of absorption arez in accord with H 62.20 Wis. Adninistra~.ive Cede.
I
S O I L B O R I N G S- Mini:.m.un 36" B_alow Prooosed Absorption System _
bring Total Depth Depth to Ground Water Depth to Bedrock
Zumber Inches Observed Estimated Observed Estimated Character of Soil with Thi kn.,iss ! :n-;h-.s `j
Example _
0 72" 72" Black Top Soil 12111Clav lc"; Sand 1 ;ra;•e2 24"
y
RECORD DATA FROM _-~_:J FS
COMPLETE OTHER SIDE
I, the undorsitned, hereby certify that the percolation tests reported. on this fonn were trade by me
or under by supervision in accord with the proved'-ires -nd method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and th<.t the data recorded and location of test holes are correct to
the bestf of my kno.rledge and belief.
NAI`:E TITLE
(Typo or Print) 7
REGISTRATION NO. or MASTER PL;:'D3ER LICENSE No.
ADDRESS'/
DATE/ L/mar. _.4..
1
MASTER PLj'fFB:R MAKING APPLICATION
rip
Sign tune; License Nu^r'oers
MP Rsld
(To be Completed by Issuing Agent)
Z
Date of Application ✓ Fee Paid $
( ) /Permit Number
Permit Issued dete
Agent (name)
Twm, VillaCe, City, County, etc.
(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 DEPARTIIEPNT USE ONLY
DATE RECEIVED ACCEPTED BY RETURr]ED
(Initials) (Date) (See Corres.)
FEE RECEIVED VALID. NO. PERMIT NO.
(Yes or 170)
rrWIEhED BY APPROVED DAPE
(Initials) (Yes or No)
COMMENTS;
f
r
f.
Parcel 022-1042-20-000 05/03/2007 10:17 AM
PAGE 10F1
Alt. Parcel 15.28.18.228B 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 - CHRISTENSEN, THOMAS W & LISA L
THOMAS W & LISA L CHRISTENSEN
1280 CTY RD J
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 1280 CTY RD J
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.210 Plat: N/A-NOT AVAILABLE
SEC 15 T28N R18W PT SE NE COM E1/4 COR Block/Condo Bldg:
SEC 15, TH S 85 DEG W 1067.37' TO POB; S
82 DEG W 251' ALG NLY R/W HWY "J" N 6 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
DEG W 214.7'N 83DEG E 248'S 7 DEG E TO 15-28N-18W
POB
Notes: Parcel History:
Date Doc # Vol/Page Type
07/17/2006 829693 WD
06/06/2006 826816 TI
11/22/2004 780559 2700/194 EZ-U
07/23/1997 463/38
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 1.210 30,000 153,100 183,100 NO
Totals for 2007:
General Property 1.210 30,000 153,100 183,100
Woodland 0.000 0 0
Totals for 2006:
General Property 1.210 30,000 153,100 183,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 204
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00