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Parcel 026-1112-60-000 10/11/2006 04:18
PAGE 1 OF 1
F 1
Alt. Parcel 3.30.18.641 026 - TOWN OF RICHMOND
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 - BROICH, MAUREEN K
MAUREEN K BROICH
1210 172ND AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1210 172ND AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.260 Plat: 2021-GREEN ACRES ADD
SEC 3 T30N R18W LOT 6 GREEN ACRES ADD Block/Condo Bldg: LOT 06
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/17/2003 744080 2438/500 QC
1230/374 WD
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.260 30,600 108,300 138,900 NO
Totals for 2006:
General Property 1.260 30,600 108,300 138,900
Woodland 0.000 0 0
Totals for 2005:
General Property 1.260 30,600 108,300 138,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 128
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Health and Sooial Services
Plb. #67 Division of Health
PER-UT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYSTEMS i
A. OWNER OF PROPEFTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
County
B. LOCATION OF PROPERTY WHT'RE SYSTEM WILL BE CONSTRUCTED, ALTER:"D '1R UTF34DED
Check One: t:,) "t c-'/ S
CITY VILLAGE ION: -t~
T WNSHIP Lz, 9: l / c T-~~
C. IS LOCAL PER"iIT REQUIRED F0. ? YES NO
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT T ADDITION
MATERIALS: Prefab Concrete` ; Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other
specify
Number of Persons to be Accommodated
F. APPLIANCES, ETCS Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES - NO
Other (Specify)
G. EFFLUE4T DISPOSAL SYSTEM NEW I EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
/ Seepage Beds Length Width Depth Tile Size No. Lines
l/ Seepage Pit: Inside diameter Liquid Depth
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 Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to I Next to Last To Fall
1st Wetted Overnight in Minutes Last Periodl Last Perij Period C..e inch
Example
P- 0 36" To Soil 1011, Clay 26" 25 es or no 30 1/2 1/2 1/2 60
r
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
umpute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 36" Below Proposed Absorption System
_
oring Total Depth Depth to Ground Water Depth to Bedrock
unbar Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xnmple
- 0 72" 72" "z? Black To Soil 12"• Clay 18"• Sand 18"• Gravel 24"
j
21ACORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
r NAME Or, t it h ) ll~ vas TITLE YY
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No. _
ADDRESS
DATE 1 r 1 i I U `
SIGNATUf+ r~-L•<~
MASTER PLUMBER MAKING APPLICATION)
Signatures ! t L. s r MP
License Numbers
MP RSW j v 7
(To be Completed by Issuing Agent)
Date of Application
Fee Paid
Permit Issued (date)
I Permit Number ` J/_
Agent (name)
For:
l Town, Village, City, County, 'etc.
Notes The application cannot be considered for fil (Specify)
and the fee paid. Agents will forward application,ithelfeefofh$10.00eandeCopy ( are answered
Permit (yellow oopy) to the Division of Health. Checks and money orders should be madehe
payable to the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
DATY RECEIVED ACCEPTED BY JQ RETURNED
(Initials)
/ (Date) See Corres, r
FEZ RECEIVED ✓ VALID. NO. Z2
Yes or No) PERMIT N0. _ Lf~ L'~~
REVIEWED BY APPROVED
(Initials) DATE
Yea or No)
COMMENTS:
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