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Parcel 022-1069-60-000 07/11/2007 0410 PM
PAGE 1 OF 1
Alt. Parcel 25.28.18.387B 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 - HIGGINS, JAMES A & LOLA
JAMES A & LOLA HIGGINS
1465 EVERGREEN DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1465 EVERGREEN DR
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 25 T28N R18W 1A IN SW NE COM NW COR Block/Condo Bldg:
OF NE1/4 THE S 29 DEG E 1602' TO POB;
THE E 161' ALG S LN TN RD TH S 271'W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
161'N 271' TO POB 25-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/11/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 20,000 171,400 191,400 NO
Totals for 2007:
General Property 1.000 20,000 171,400 191,400
Woodland 0.000 0 0
Totals for 2006:
General Property 1.000 20,000 171,400 191,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 303
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Health and Social Services
Plb, #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
.S GJ N~ ZS~ OZz /D~o %--loo
A. OWNER OF PROPERTY 16 / '/r -7 3F -7
Name, Address (Street, City, Zip Coda)
fr( lYC (/L r
r ,r, ; a r r.-- _ Y
B. LOCATION OF PRO?ER'iY WITRE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTiNDED COUNTY IJ
Check One: ~G 7D SZ~
CITY VILLAGE LEGAL DESCRIPTION (/V~ e
/'~uoF/E/ / -i
TOWNSHIP - -
,rt YES NO 7' _ PERMIT NUMBER
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK?
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION ik REPLACEMENT ADDITION
MATERIALS: Prefab Concrete _ Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED_, X
E. TYPE OF OCCUPANCY
-Check 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 YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler ~ YES ~ NO
Other (Specify)
G. MASTER PLUr3ER MAKING INSTALLATION
r !j License Number,
Naze: , / r.L Address: '
r -
Signature of Applicant; MP RSW
i
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid #
Permit Issued (dat7 l 1'r Permit Number
Agent (Name) ,r, ,i. r ( I S 1 For, 1/
Town, 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 fortyard application, the fee of ;1.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks a.3 money orders should be made payable to
the Division of Health.
Do not write in space below FOR DEPARTMENT USE ONLY
I. DATE RECEIVED - ' -70 ACCEPTED BY RETURNED
(Initials) (Date) eeCorres.)
FEE RECEIVED VALID. No. PERMIT N0. /
-Yes or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PER°iI'T NO.
r
l R S P 0 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 O R I N G S
TO
DIVISION Oi HEALTH - PLLMBING SE.CTI&
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P B R C 0 L A T I 0 N T I S T
Test Depth Character of Soil Hours Water 7aot-Ti:ae Drop in Water Level 7nohes ,inutas
Number Irahes ?hiekn e33 in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st netted Overni:4ht in Minutes Last Doriod 1a3t Period Period 0noe Inch
Example
P - 0 3611 To Soil 1011, La 2611 25 Yes or No 30 1 2 1 2 1 2 60
st '7 f/%,' J Imo. `tom r~
RECORD DATA FROM M114 `i 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- Mini-am 3611 Bsler prooosed Absomtion S at
Borir_3 Total Depth Depth to Ground ieatzr Depth to B3droc.c
Number Inohas Chserved Esti^._t od Observed Est_i-a.ted Character of Soil with Thio?mess in Inche3
Exaapla
B - 0 721, 7211 Black To Soil 12f1; Clay 1811; Sand 18'x; Gravel 2411
r
RFZGRD DATA FROM MINT~`IlJ" 07 1 BGRy HOLES
TYPE OF OCCUPANCY:
RESIDENCE: NLmiber of B9drocros OTKL R: (Specify) Number of Peraons
D WASTy GRL7DERs Yes No Disrneasher: Yes No Autoea.tic Clothes Washer: Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC&MENT
c 4F 4
Tile Size y No.Lin.Feet ~ Trench Width Depth_ Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
/ Seepage Pits Inside Diameter Liquid Depth
Is the undersigned, hereby certify 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); Wisoonsin Administrative Ccde, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME /'f'(l - NQi err//~,~ TITLE
Type or Print
REGISTRATION NO.. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE 1 L-~ SIGNATURZ'1
Vol
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