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Wisoonsin Department of Health and Sooial Services
Plb. f67 ' 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
3012 YY -71101-70
TYPE or USE BLACK INK VA,-Pl4a, / 63 /r-,t-
A. fMNER OF PROPERTY wb q7~ y 55/, 7 y
Name Address (Street, City, Zip Codes) 5G 91.2 y 7
7Ya - ,26 -2-
j
B. LOCATION OF PROPERTY W1U.RE SYSTEM WILL BE CONSTRUCTED ALTERED 0R EXT -DED L .C/OUNTY.•=
Check One: y / !/2 J SL~ W Nt ~C~L
_ CITY VILLAGE LEGAL DESCRIPTIO.t V
~.:TOVNSH1P
C. IS LOCAL PERMMIT REQUIRED FOR THIS 'CORK? t YFS NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY I--17 Gallons NEW INSTALLATION REPLACE"ENT ADDITION
PiATERIALS: Prefab Concrete / - Poured in Place Steel Other
DUMBER OF TANKS TO BE IT:'STALL'.D:
E. TYPE OF OCCUPANCY
Check Ones One or Two Family Residence Commercial Industrial Other
Specify)
Number of Persons to be Accommodated - Number of Bedrooms
i
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer G 'YES NO
Distroasher YES NO Automatio Potato Peeler YES ~.--NO
Othe: (Specify)
G. MASTER PLL13ER NAYITG INSTALLATION
Namo: Address: Lioenss Numbers
Signature of Applicants MP RSN~ ' i
S - - -?--r--
1 ~
Address:
H. (To be Completed by Issuin; Agent)
Date of Application Fee Paid
r--
Permit Issued (date)-'' Permit Number
Agent (Name) 1_ Fors
Tow:i, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered r-.nd the
fee paid. A-gents will forc+ard application, the fee of 41.00 for each sep,.is tanx and the third dopy
of the perud t (canary) :o the Division of Health. Checks and ..oney orders should be mdc pa rablo to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVEDI ACCEPTED BY RETURNED
L (Initials) P (Date) Se Ccrres.)
FEE RECEIVED ✓ VALID. No. PERMIT NO.
es or-N-0)
REYIE:*£0 BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PEIMIT NO.
R K P O 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 Or HIYALTH - PLUMBING. SFCTI6N
P.O.Bor. 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Adasinistrativo Cod*
P 8 R C 0 L A T I 0 N T T S T
Teat Boyth Ctwa^aoter of Soil Hours Water Teat Tirsa Drp in Water Level 7nnhas inutes
Number Inches Th.Se.n,:ss in Inohos Since Hole in Holo Irtcrval Second to Necb to Last To Fall
1st Wetted OverniA-xt in Minutes Last Period Lnst Period Period One Inch
E=mpla
P - 0 361' To Soil 1010C/la 2611 25 Yee or No 30 1 2 1 2 1/2 60
RECORD DATA FROM NINLUi OF 3 TEST HOLt.S
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G_S - Mintr_av_m 3611 _Beloav Preposed Absorption S stow
Boring Total Depth De th to Ground Yatcr lle th to Bedrock
Number Inohea Goservod 93timated Observed Estir:hed Character of Soil with Thickness in Inches
E=nple
B - 0 7210 7211 Black Top Soil 12l'3 C1 18"• Sand 18"• Gravel 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOJXS
TYPE OF OCCUPANCY: ~ Z
RESIDENCE: Number of Bodrooms OTHER: (Specify) Number of Persons ~
OD WASTE. GRL'tDERs Yea No Dishwashers Yes No .Y kutomatic Clothes Washer: Yes i' No
EFFLUENT DISPOSAL SYSTEM: NEW ' EXTENSION ADDITION REPLACEs`M
Tile Size No.Lin.Fset Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth •r Tile Size No. Liner
Seepage Pits Inside DiZa-ter Liquid Depth
I, the undersia}ied, hereby oerti y that the percolation tests reported L.1 this fora were za.de by me or under m, super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13)2 Wisconsin Administrative Code, and
that the data recorded and location of test holes are oorre.t to the best of my knowledge and belief.
NA2~ 4"), i rl
TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE 1 7 SIGNATURE
r
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S` ~ ~ - ys / z~ a ✓-lw~,,~a~
~3 2 ~ ~
Parcel 032-2027-40-025 04/30/2007 11:48 AM
PAGE 1 OF 1
Alt. Parcel 7.30.19.569B-10 032 - TOWN OF SOMERSET
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
05/24/2004 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - STARK, MYRA M
MYRA M STARK
1673 38TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 1673 38TH ST
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 16.350 Plat: N/A-NOT AVAILABLE
SEC 7 T30N R19W 20A N1/2 SE NE EXC TO Block/Condo Bldg:
HWY PROJ 1559-08-21 & EXC AS DESC
2579-30 Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-30N-19W SE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
05/24/2004 763574 2579/30 WD
04/19/1999 601530 1419/623 QC
07/23/1997 780/202
07/23/1997 569/297
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/09/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 48,000 66,300 114,300 NO
PRODUCTIVE FORST LANDS G6 13.350 53,400 0 53,400 NO
Totals for 2007:
General Property 16.350 101,400 66,300 167,700
Woodland 0.000 0 0
Totals for 2006:
General Property 16.350 101,400 66,300 167,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 11/17/2006 Batch 06-20
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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