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Home My WebLink About028-1031-50-000 0 U1 O g v 0 r„ 2 0 m • m CD w \ K N N rr CD m ::T 0, rn a CO (D :a ° O W < J C ` ^t \ 1 w U C~ CD n 0 0 C cD - CO O ID I W O J C p ri7 7 f%1 N ~ O N ~ " _ by C) 1> z a cn n Q G co O O 3 w w D (D O ? (D o m m n r a N o c g c o o o o c -I Up 3 N N N O CD 4 D o v c:> N O N N N O d N < N C 7 3 J N - d N C2 ~ Z .•r Z cn z D CD O _CD :p v O o !J N ~ O CD to h • N ~ lV ti -u CO C N CD d T cn Z m 10 U o a C I_. I° cn N co 'O CT O fD 00 Q Z 3 A O O Z 3 j Z C A W D f1 ~ C O C -n fl% C 2 Q 0 CG U V S ,A V ,A O w tv O O A_ C V, CID 7G tv ss O 0 O 1 V E ' Wisconsin Department of. Health and Social Services F Pib. J67 3/70 Division of Health 7 SEPTIC TANK PERMIT APPLICATION TYPE or USE BLACK INK -S3 ~~h e Sr~✓ ~/E A. OWNER OF PROPERTY Name y Address (Street, City, Zip code) k Be LOCATION OF PROPERTY WY'RE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY Check Ones CITY VILLAGE LEGAL DESCRIPTION TOWNSHIP E S ' c~ r 1 ` I L ~V C, C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? _ x YES NO PERMIT NUMBER D. SEPTIC. TANK CAPACITY ? Gallons NEW INSTALLATION /r REPLACEMENT ADDITION MATERIALS: Prefab Concrete I/ \ Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check Ones One or Two Family Residence Commercial Industrial Other Specify) Number of Persona to be Accommodated ~ Number of Bedrooms F. APPLIANCES, ETC: Food Waste Grinder YES A NO Automatic Clothes Washer YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) r G. MASTER PLUMBER MAKING INSTJi TION JJ I Named ` ~7 to ~_1 Address: License Numbers MA Signature of Applicant: MP RSW / Address: &411 H. (To be Completed by Issuing Agent) Date of Application Fee Paid Permit Issued (date)- Permit Number Agent (Name); ; { !tF i( r' . ( c ` t For: 14 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 forward application, the fee of 41.00 for each septic tank and the third copy of the permit (canary) to the Division of Health. Cheeks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT, USE ONLY I. DATE RECE1VFL - ~JI ACCEPTED BY RETURNED FEE RECEIVED (Initials) /-(Date) See orre VALID. No. S) ! PERMIT NO. I es or No REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE SEPTIP TANK r'ERMIT NO. R Z P O R T O N S O I L k Z R C 0+ A'TON T E S T A N D S O I L B O R I N G S w TO DIVISION OF HEALTH - PLLtMING S=TI6'4 P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Adninistrative Code P Z R C 0 L A T I 0 N T E 5 i Teat Depth Character of Soil Hours Water Test Time Drop in Water Level Inches hinutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Netted Overni t in Minutes Last Period Last Period Period O Example ns, Inch P - 0 3611 To Soil 10" Clay 2611 25 Yes or No 30 1 2 1/2 1/2 60 RECORD DATA FROM MINIMUM 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- Minimum 3611 Below reposed Abso tion a stem Boring Total Depth Depth to Ground Water De th to Bedrock Number Inches Cbservcd Eatir<,ated t)'aeerved Estimated Character of Soil with Thickness in Inches Exmaple B - 0 72'• 7211 Black To Soil 12l• Ci 18" Sand 18"; Gravel 24'1 RECORD DATA FROM MINIMUM OF 3 BORE HOLES YPE OF OCCUPANCY: , RESIDENCE: Number of Bedrooms OTHER: (Specify) Number of Persons ROOD WASTE GRINDERS Yes No Dishwashers Yes No Automatic Clothes Washers Yes V~ No EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION S REPLA~CLKENT Tile Size V No.Lin.Feet W) Trench Width 5 Depth Number of Lines Seepage Bed: Length Width Depth Tile Size No. Lines Seepage Pits Inside Diameter _Z,__ Liquid Depth 1, the undersigned, hereby eartify that the percolation tests reported on this fora were made by me or under my super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative.Code, and that the data,£eoorded and location cX tast holes are correct to the best of my knowledge and belief. NAME C/ ✓1 0 / N~ . TITLE Type or Print REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ADDRESS DATE SIGNATURE Parcel 028-1031-50-000 05/03/2007 11:24 AM PAGE 1 OF 1 Alt. Parcel 25.28.17.1958 028 - TOWN OF RUSH RIVER 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 CHARLES E KAMM O - KAMM, CHARLES E 2065 18TH AVE BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 2065 18TH AVE SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE SEC 25 T28N R17W E 295 FT OF N 295 FT OF Block/Condo Bldg: SW NE Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) -}-o 25-28N-17W Notes: Parcel History: Date Doc # Vol/Page „~?X Type 07/23/1997 828/169 •Wz 07/23/1997 07/23/1997 470/59 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/30/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 30,000 131,300 161,300 NO Totals for 2007: General Property 2.000 30,000 131,300 161,300 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 30,000 131,300 161,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 106 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 028-1031-40-000 05/03/2007 11:24 AM PAGE 1 OF 1 Alt. Parcel 25.28.17.195A 028 - TOWN OF RUSH RIVER 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 - LANGER, CHARLES J CHARLES J LANGER 2017 18TH AVE BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 38.000 Plat: N/A-NOT AVAILABLE SEC 25 T28N R17W SW NE EXC E 295 FT OF N Block/Condo Bldg: 295 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) /Aj 25-28N-17W Notes: ` Parcel History: 61& 7 - ~ Date Doc # Vol/Page Type 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/13/2007 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 38.000 7,000 0 7,000 NO 00 Totals for 2007: General Property 38.000 7,000 0 7,000 Woodland 0.000 0 0 Totals for 2006: General Property 38.000 6,600 0 6,600 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 Parcel 008-1085-60-000 05/03/2007 11:20 AM PAGE 1 OF 1 Alt. Parcel 30.28.16.453A 008 - TOWN OF EAU GALLE 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 - BENTLEY, CHARLES W CHARLES W BENTLEY 183 HWY 63 BALDWIN WI 54002 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 183 HWY 63 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 30.725 Plat: N/A-NOT AVAILABLE SEC 30 T28N R16W 30.725A NW NW LOT 2 & 3 Block/Condo Bldg: OF CSM 5/1212 _ Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 30-28N-16W7 Uv Notes: Parcel History: Date Doc # Vol/Page Type 04/12/2005 792008 2782/121 EZ-U 07/23/1997 807/283 07/23/1997 654/110 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 08/04/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 22,500 187,500 210,000 NO AGRICULTURAL G4 11.000 1,400 0 1,400 NO UNDEVELOPED G5 1.500 100 0 100 NO AGRICULTURAL FOREST G5M 16.220 10,800 0 10,800 NO Totals for 2007: General Property 30.720 34,800 187,500 222,300 Woodland 0.000 0 0 Totals for 2006: General Property 30.720 34,800 187,500 222,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 513 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00