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Wisconsin Department of Health and Social Services
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. -OWNER OF PROPERTY
Name Address (street, city, Zip Code)
}
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CCNSTRUCTED ALTERED OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP r l r-
V
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK?. YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEIENT ADDITION
Steel Other
MATERIALS: Prefab Concrete Poured ace a
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 Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher YES NO Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: d Address= License Numbert
Signature of Applicant: MP RSW
~
i
Address
H. To be/Completed by Issuing Agent)
Date of Application 711 ! Fee Paid
Permit Issued (datey Permit Number
For:
Agent (Name)
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 $1.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Cheoks and money orders should be made payable to
the Division of Health. /
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY / RETURNED
(Initials) a (Date) See C9~res~
FEE RECEIVED VALID. No. 6 c' ~ PERMIT NO.
es or Nos-
REYIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT N0. L
R X P O R T O N S O I L P L R C 0 L A T I 0 N T E S T
A N D S 0 I L. B O R I N G S
TO
DIVISION OF HEALTH - PLUPIBM SECTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P E R C O L A T I O N T T S T
Test 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 Watted Overni. in Minutes Last Period Last Period Period One, Inch
Example
P - 0 3611 Too Soil 10" Clay 2611 25 Yes or No 30 1 2 1L2 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 0 I L B O R I N G S- Minianm 3611 Belcw Pro osed Abso tion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Cbservad Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 7211 7211 Black To Soil 12'1 Clay 1811 Sand 18"• Gravel 2411
7 l
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCY:
RESIDENCEi Number of Bedrooms ' OTHFRs (Specify) Number of Persons
FOOD WASTE GRINDER: Yes No i' Dishxasher: Yes No J Automatic Clothes Washer: Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
L Tile Size No. Lin. Feat _ Trench Width Depth Number of Lines _
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Diameter c- Liquid Depth
a
ti\ Is the undersigned, hereby certify that the percolation tests reported on this form 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 recorded and Location of test holes are correct to the best of my knowledge and belief.
NAME "i ! L~~ 1 • TITLE
Type or Print
REGISTRATION NO. or MASTER ?LUMBER LICENSE NO. ~
ADDRESS
.1
DATE _ 1 `I SIGNATURE
Parcel 032-2024-30-000 04/25/2007 04:36 PM
PAGE 1 OF 1
Alt. Parcel 6.30.19.565B 032 - TOWN OF SOMERSET
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 - STATE OF WISCONSIN, D O T
D O T STATE OF WISCONSIN C - LAND FOR NEW HIGHWAY
LAND FOR NEW HIGHWAY
718 W CLAIREMONT AVE
EAU CLAIRE WI 54701
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 393 CTY RD V V
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 12.000 Plat: N/A-NOT AVAILABLE
SEC 6 T30N R19W THAT PT OF SE SE LYING Block/Condo Bldg:
ELY &SLY OF HWY 35 WI DOT LAND FOR NEW
HWY Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/07/1998 588565 1363/387 WD
07/23/1997 464/262
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 02/09/1999
Description Class Acres Land Improve Total State Reason
STATE X2 12.000 0 0 0 NO
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
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