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Winoonsiu Department Of Health and S olal Serviacs
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or us BLACK INK _ ~6 3 S 0 12 ff
A. OWNER OF PROPERTY
Hume Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY W171' ;vw WILL BE CONSTRL7CTED. ALT&RE) OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION ~~c 2G{ip
TOWNSHIP,-) Sz-
C. IS LOCAL PERPiIT REQUIFED FOR THIS WORK? ~ YES NO PERMIT NUMBER
D. SEPTIC TlL;K CAPACI'T'Y Gallons NEW INSTALI.A',ION ~i REPLAC01ENT ADDITION
MATERIALS: Prefab Concrete _ Poured Sn Place Steel Other
NUMBER OF TANKS 70 B£ INSTALUIED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence / Commercial Industrial Other
Number of Persons to be Accor,-modated Specify)
Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES ~ NO Autovci is Cla-!.vy Washer YkS_ !0
Dishwashe:° YES _ NO Automatic Potato Pie ar YIS R"
Other (S; ecify)
G. MPZT1R PLOTB£R MAKLYG INSTALLATIC`T
Name: , jG_%rl~f'h1 ~ ~Yc?P Address: C~t~~i C'iil f t~ License Number:
Signature of Applioant MP RSN
s %~L rat ~Address:
H. (T be Completed by Issuing Agent)
Date of Application 4J J (J Fee Paid ; C✓
Permit Issued (date 2 Permit Number
Agent (Name) For
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be eor.sider4d for filing until all of the above questions are answered and the
fee paid. Agents will for-hard application, the fee of 31.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Cheeks and money oraers should be made payable to
the Division of Healt:i.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED y_ ACCEPTED BY ` RETURNED
(Initial) 4
(Date
See rras.
FEE RECEIVED VALID. No. r_~p 17 PERMIT NO.~
es or no 7-
REVIEWED BY APPROVED DATY
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO. J /
R E P 0 R? O N S O I L P: R C 0 L A I 0 N T E S T
A N D S O I L B O R I N G S
T5
DIYISIOY OF HEALTH - PUtMING SBCT16N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Ad:inistratile Code
P o r C O L A T I 0 N T E S T
Test ueptn Character of Soil Hours Water Te:: Time Drop in Water Level Inches utaNumber L.ohes Thioknos3 in Inches Sinea Hole in Hole Int;rval
Second to Next to Last ffT~-F-17
1st hatted Rvornight in ;5_.711 ln3t Peri^d L°-st Period Period ;Cn- lraeh
Example
P - 0 3611 Too Soil 1011. Clad 2,'.;, 25 y Yes or No 30 1/2 1/2 112 I 30
~ c7~ -{i.ti i
c~
~ ~ 4•~ GLOS.. ~ ~~V~ 41-~1+~ ~ _ / ~~.5
RECORD DATA FROM MINIMUM 07 3 TIST 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- Mince 3611 Balms Proooser Abao `ior Sy^`zm
BOIL-3 Total Doa th nth to Grote--a w;at3, Depth ZQ Badroc s ~
Number iInehaa Gbservad i - Observed Estimated Character of Sail wish Thio_vna;ss in I=•.-oh~3
Example
B - 0 I 7211 7211 Black To Soil 12", C1 ; 1911. Sand 1811: G~r"a'vul~2`411'
'
RECORD DATA FROM MINZML 4 C? 3 BO'RZ HOT;F`i
YPE OF OCCUPANCY:
RESIDENCE: Number of Bedro- s OTHER: (Specify) Number of Persons - -
FOOD WASTE GRINDER: Yes No ~ Dishmashers Yes No Avtor•atic Clothes Washer: Yes ~ No
FFLUENT DISPOSAL SYSTEM: NEd EXTENSION ADDITION REPLA.C"'VSz. ENT
Tile Size No, Lin. Feet ~ Trench Width Dept-'T 3 Number of Lines _L
Seepage Bed: Length Width Depth Tile Size No. Linos
Seepage Pits Inside Diaaetar Liquid Depth S
I, the undersigned, hereby certify that the perooiation tests reported on this form were made by me or under ndy super-
vision in accord with the procedures and method specified in Chapter H 62,20 (13), Wisconsin Ad*iristrative Code, and
that the data recorded
4 and location of test holes are correct to the best of my knowiedge and 'belief.
NAME C /Y PKl TITLE ll~ G~c
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE NO. C~ U5_
ADDRESS z le 4. ,7 1 r/
DATE azf /7/l r SIGNATURE /_oII 1
I
i
Parcel 032-2035-70-000 04/30/2007 02:16 PM
PAGE 1 OF 1
Alt. Parcel 9.30.19.612B 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 - HALL, CLIFFORD A JR & WF
CLIFFORD A JR & WF HALL
556 160TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description 556 160TH AVE
SC 5432 SOMERSET
SP 1700 WITC
I
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 9 T30N R19W 1A S 208' OF W 208' OF Block/Condo Bldg:
SW SE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
09-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 463/546
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 16,000 57,500 73,500 NO
Totals for 2007:
General Property 1.000 16,000 57,500 73,500
Woodland 0.000 0 0
Totals for 2006:
General Property 1.000 16,000 57,500 73,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 204
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00