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Plb. f{67 10/69 Wisconsin Department of Health and Social Services
• Division of Health
PERMIT APPLICATION
for
PRIVATE DU~ESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY TYPE OR USE BLACK INK 7
Name ✓ ry Address (Street, City, Zip Code)
County
B. LOCATION OF PROPERTY WH'RE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED
c
Check One: 3 2--3 SJ d~ w q yc
CITY VILLAGE LEGAL DESCRIPTION: S C l~~
17C,- TOWNSHIP X a
C. IS LOCAL PERMIT REQUIRED FOR THIS FORK? `1 YES NO 7 PERMIT NUMBER
D. SEPT16 TANK CAPACITY ~ ~i t_) Gallons \ NEW INSTALLATION Nle > REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place` - 5tA'eZJ~/ Other
NUMBER OF TANKS TO BE I'ISTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence X Commercial Industrial Other
Specify
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES ~t NO Automatic Potato Peeler YES NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width Depth Tale Size No. Lines
/ Seepage Pits Inside diameter 'w7' 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 ,inutes
Number ,Inches i Thickness in Inches Since Hole in Hole `Interval Second to Next to Last To Fall
1st Wetted Overni ht in Minutes Last Periodl Last Period Period ane inch
Example
P- 0 36" To Soil 0" Clay 26"I 25 es or no 30 1/2 1/2 1/2 60
.y iLDc 'r ~r, Sh~~V r s < ~r T~
RyCO;RD DATA FROM M11411 UM OF 3 TEST HOLES
I
Compute size of absorption are in accord with H 62.20 Wis. Administr tive Code.
S O I L B O R I N G S- Minimum 36" Below Pro osad Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock
umber InchRS Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xample
0 72" 72" Black To Soil 12"• Cls 1811• Sand 1811• Gravel 2411
(f 1~ IL/ rr 7
271- r v s 7
Z .2 X fl"2 r.
RECORL) 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.
NAME A V CPA . TITLE A
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No.
ADDRESS
DATE 7o SIGNATUt
MAS'T'ER PLi1M3ER MAKING APPLICATION
i MP
Signature: License Numbers
MP RSW
(To be omple ed by Issuing Agent) /j
Date of Application / Fee Paid $1.,
Permit Issued (dat Permit Number /"2.2 -S
' Agent (name) Forz
Town, Village, City, County, eto.
(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 DEPARTMENT USE ONLY
DATE RECEIVED ~Q ZT - O ACCEPTED BY RETURNED
(Initials) (Date) See Corrres 7
FEE RECEIVED ✓ VALID. NO. PERMIT NO.
(Yes or 140)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS :
i
1
f
31111
~g 3z3
Parcel 026-1093-50-000 07/11/2007 10:20 AM
PAGE 1 OF 1
Alt. Parcel 32.30.18.491 B 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 - MURRAY, BETH,& PATRICK LAUGHNAN
BETH,& PATRICK LAUGHNAN MURRAY
1272 110TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 1272 110TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE
SEC 32 T30N R18W 10A N 330' OF SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
32-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 842/22
07/23/1997 776/415
07/23/1997 717/630
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 10.000 58,500 102,400 160,900 NO
Totals for 2007:
General Property 10.000 58,500 102,400 160,900
Woodland 0.000 0 0
Totals for 2006:
General Property 10.000 58,500 102,400 160,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 125
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00