HomeMy WebLinkAbout026-1070-10-050
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Wisconsin Department of Health and Social Services
Fib. #67 10/69 Division of Health
PER{UT APPLICATION
for
PRIVATE DOMESTIC SEWAGE SYST:21Sj
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name 1 Address (Street, City, Zip Code)
County _
B. LOCATION OF PROPERTY WF'RE SYSTEM WILL BE CONSTRUCTED, ALTERED IR EXTENDED
Check One:
CITY VIU-kGE LEGAL DESCRIPTION:
TOWNSHIP C
I '
;.sit.-.E.-.~~`~.~~ /L-,i~ ~
Ij C. IS LOCAL PEFSIIT REQUIRED FOR THIS FORK? YES NO / PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION _ REPLACEMENT ADDITION
I!
i
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: /
Ee TYPE OF OCCUPANCY l
Check One: One or Two Family Residence Commercial Industrial Other
i Specify
j Number of Persons to be Accommodated Number of Bedrooms
I
F. APPLIANCES, ETCs Food Waste Grinder YES X NO Automatic Clothes Washer YES NO
Dishwasher YES ✓ NO Automatic Potato Peeler YES NO
Other (Specify) .~.-J-
1
i
G. EFFLUENT DISPOSAL SYSTEM NEW X EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet LC Trench Width 'S Depth ;Z, + Number of Lines _L^
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside diameter Liquid Depth
f
{ P E R C O L A T I O N T E S T
t _
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
f Number Inches Thickness in Inches Since Hole in Hole Interval Second to i Next to Last To Fall
13t Wetted Overnight in Minutes Last Period. Last Perio Period One Inch
Example
P- 0 3611 To Soil 1011, Clay 261, 25 es or no ' 30 1/2 1/2 112 60
x -T7~
RECORD DATA FROM TI21IMUM OF 3 TEST HOLES ~
i
i
ompute size of absorption are-% in accord with H 62.20 Wis. Adninistre;ive Code.
S O I L B O R I N G S- Minimum 36" Belau Proposed Absorption System,
oring Total Depth Depth to Ground Water Depth to Bedrock
umbsr Inches Cbserved Estimated Observed Estimated Character cf Soil with Thickness in Inches
Example
- 0 72" 7219 Black To Soil 1211, Clay 18'x• Sand 18"; Gravel 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDS
I, the undersii;ned, 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)s
Wisconsin Administrative Code, and that the data.recorded and location of test holes are correct to
the best f my knowledge` nd belief.
co o C-
NAME w ` / a.• l r `J TITLL`
(Type or Print)
5 1
REGISTRATION NO. or MASTER PLUI1BER LICENSE No.
ADDRES,S'f!"J,~- ) c'~-cz^"r
DATE L 1 ~ SIGNATU,-C-
MASTER PLUFE3r,R MAKING,A/P CATION
MP
Signatures- Z License Number:
MP RSW
(To beomplet d by Issuing Agent)
U
Date of Application Fee Paid
Permit Issued (date -fir y( Permit Number
Agent (name) z
Town, V1 lagg4ty, 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 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 DEPART:1ENT USE ONLY
DATE RECEIVED c. ACCEPTED BY } RETURNED
(Initials) / r (Date) See Corres.)
-
FEE RECEI VED VALID. NO. PERU T NO. z-/
(Yes or No)
REVIEWED BY APPROVED DATE _
(Initials) (Yes or No)
COMMENTS:
t
's
Wisconsin Department of Health and Social Services
Plb. >7 Division of Health
3/70
SEPTIC TANK PERMIT APPLICATION
,a
TYPE or USE BLACK INK
A. OWNER OF PROPERTY (qR `
Name Address (Street, City, Zip Code) 5 ,ZGLl
B• LOCATION OF PROPERTY WHERE: SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTP2ED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION / (CAD
TOWNSHIP I F 47' C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? v X YES NO 0 1 P IT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT DITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NLTBER OF TANKS TO BE INSTALLED: 1
E. TYPE OF OCCUPANCY
Cheek 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 YB:S NO
Dishwasher YES - NO Automatie% Potato Peeler YES~_ NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTA TION
Name: 4 ki '~J - Lam" Address License Number:
MP
Signature of Applicant: MP R ~X
Address:
r ;
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid $
Permit Issued (date)7 Permit Number
Agent (Name) For:/- 1~+,".✓ ~l!':
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of tape above questions are answered and the
fee paid. Agents will forward application, the fee of 41.00 for each septic taruc and the tnird 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
1. DATE RECEIVED 7~ n L-f 6 ACCEPTED BY RETURNED
/ (Initials) (Date) ~Se, orres,)
FEE RECEIVED VALID. No. b5+1 J PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
X SEPTIC TANK PERMIT NO.
R Z P 0 R T O N S O I L P I R C 0 L A T I 0 N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLU1BING SECTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P Z R C 0 L A T I 0 N T E S T '
Test Depth Character of Soil Hours Water Test Time Dro in or Level Inohes inutFa as
Number Inches Thickness in Inches Since Hole in Hole interval Second to Next to Last To 11
1st Wetted Overnight in Minutes Last Period Last Period Period One,Inch
Example
P - 0 369, To Soil 10" Cla 2611 25 Yes or No 30 1 2 112 1 2 60
kZ1
00
RECORD DATA FROM MIN It M OF 3 TEST HOLES
Compute size of absorption :sea in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 3611 Below Pro osed Absorption S stem
Boring Total Depth Depth to Ground Water De th to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thiokness in Inches
Ixample
B - 0 7210 7210 Black To Soil 12111_ Clay 18111 Sand 1811• Gravel 2411
RECORD DATA FROM MINLMIM OF 3 BORE HOLES
f
PE OF OCCUPANCY:
RESIDENCE: Number of Bedrooms - OTHER: (Speoify) Number of Persons
rOOD WASTE GRINDERs Yes No Dishwashers Yes No Automatic Clothes Washers Yes J No
?;raJLVT DISPOSAL SYSTEM: NEW s' EXTENSION ADDITION REPI.ACEifENP
Tile Size 'y No. Lin. Feet f' Trench Width ~ Depth 3 Number of Linea
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter 5 Liquid Depth
E
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me cr under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Codai and
tifat the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME ` , ' TITLE
Type or Print
or MASTER PLUMBER LICENSE NO.
REGISTRATION NO. >
ADDRESS G4 Z Z Y
DATE
- 7 - 24-J SIGNATURE
Parcel 026-1070-10-050 07/10/2007 05:03 PM
PAGE 1 OF 1
Alt. Parcel 24.30.18.360A 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 - LANGNESS, LELAND E
LELAND E LANGNESS
1493 CTY RD G
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description " 1495 CTY RD G
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 24 T30N R18W NE NE EXC PT TO CSM Block/Condo Bldg:
16/4252
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-30N-18W NE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
05/14/2002 678929 1890/192 EZ-U
02/24/2002 672127 16/4252 CSM
09/18/2000 630095 1543/451 WD
07/23/1997 903/02
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/22/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 27.850 4,100 0 4,100 NO
AGRICULTURAL FOREST G5M 6.000 5,800 0 5,800 NO
OTHER G7 2.000 6,000 63,700 69,700 NO
Totals for 2007:
General Property 35.850 15,900 63,700 79,600
Woodland 0.000 0 0
Totals for 2006:
General Property 35.850 15,900 63,700 79,600
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