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Wisconsin Department of Health and Social Services
" y Plb.6) 10/c9
Division of Health
PERMIT APPLICATION
for
PRIVATE DCY":ESTIC SEWAGE SYSTc.h1S
G - h j .S~ 2-J
A. 3417ER OF PROPE.iii'Y TYPE On USE BLACK INK ago'of
,;ame Address (street, City, Zip C_odo~ /
f 61 C
County
B. LOCATION' OF Pirj?EPi'Y ntC. PT, _ SYS7'4':' WILL BE CONSTRUCTED, ALTERED OR EXTF'+DED
Check One
CITY VILLAGE LEGAL DE:CRIPTION:
TO'ridSHIP
C. IS LOCAL PERIIT REQUIRED FOR THIS WORK? YES NO
D. SEPTIC TAN: CAPACITY Gallons NEW INSTALLATION RE?LACEiLM7.T ADDITION
MATERIALS: Prefab Concrete X Poured in Place Steel Other
NU"DER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Ti--c Family Residence Comip.eroial Industrial Other
~ (Specify)
Num~, er of Persons to be Accommodated r 1~ Number of Bedrooms
F. APi'LIANCES, ETCS Food Waste Grinder YES ii NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet ii '-Trench Width Depth Number of Lines
v
Seepage Beds Length _ Width Depth Tile Size No. Lines
Seepage Pits Inside diaineter -rte= Liquid Depth -f
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Nmutes
Number Inches Thickness in Inches Since Hole in Hole Intar:al Second to Next to Last ^.o Fall
wj 1st Wetted Overnight Jin Mi_nttes Last Period Last Perio Period One inch
Eya:,pl e
P- 0 36" To- Soil 101, z Clay 26,11 25 es or no 30 1/2 112
J Y2 60
RECORD DATA FROM 111N UM OF 3 PEST HOLES
I
ompute aiza of absorption area in acoord+ with H 62.20 Wis. Administrative Code.
S O 11 B O R I N G S- Minimum 36" Belay Pro osad Absorption System
Boring Total Depth Depth to ;round Water Depth to Dedrock
umbar Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches j
xample
0 72" 72" Black To Soil 1211• Cla 18"• Sand 18"• Gravel 2411
/f ,
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests roporter? en this forr. were made by me
or under by supervision in accord with tho procedures an-,l method specified in Cin Ater H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location or test toles are eorroct to
the best/ of my knowledge and belie/f.
NAI`E TITLE
(Type or Print)
REGISTRATION NO. or MASTER PL;2112EiR LS!ENSE No.
ADDRESS "M DATE? r 1,~ SIGNATUillE
MASTER PLi:i3~~< MAKING APPLICATION
I4
Signature; _ ' / License Number; P J
MP RSW
(To be Completed by Issuing Agent)
Date of Application Fee Paid $ ,
Permit Issued (date) / 17 Permit Number T f
.-l
Agent (name) For.
Taim, 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 for-Hard 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 DF.PARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY RETURNED
45 .J
(Initials) (Date) (See Corres.)
FEE RECEIVED VALID. No. PEI~MT lh~~ L -
(Yes or No)
' REVIERED BY APPROVED DATE
(Initials) (Yes or No)
Con'&NTS:
Parcel 022-1081-10-000 07/11/2007 04:17 PM
PAGE 1 OF 1
Alt. Parcel 28.28.18.440C 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 - LAVALLEY, ROBERT L & BRENDA
ROBERT L & BRENDA LAVALLEY
1142 RIFLE RANGE RD
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description 1142 RIFLE RANGE RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 5.330 Plat: N/A-NOT AVAILABLE
SEC 28 T28N R18W S 270' OF E 825' OF SE Block/Condo Bldg:
NW ASSM'T INC 022-1079-50
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-28N-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 5.330 80,000 153,100 233,100 NO
Totals for 2007:
General Property 5.330 80,000 153,100 233,100
Woodland 0.000 0 0
Totals for 2006:
General Property 5.330 80,000 153,100 233,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 114
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 022-1079-50-000 07/11/2007 04:19 PM
PAGE 1 OF 1
Alt. Parcel 28.28.18.P435B 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): C, = Current Owner, C = Current Co-Owner
O - LAVALLEY, ROBERT L & BRENDA
ROBERT L & BRENDA LAVALLEY
1142 RIFLE RANGE RD
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 28 T28N R18W S 270' OF W 35' OF SW Block/Condo Bldg:
NE 612/19 ASSESSED W/022-1081-10
Tract(s): (Sec-Tvvn-Rng 401/4 1601/4)
28-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0 022-1081-10-000
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00