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Wisconsin Department of Health snii Social Services
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
rM or USE BLACK 11; *K
A. OW TFR OF PROPERTY ~ ?
Vase Address (Stre',t, City, Zip Code)
1~0 13 T 0/"5/,t/
B. LOCATION OF ? 2OPERTY WF'Y t% SYSTT='b WYLT, Ai CONSTR',rTU, ALTERED OR EXTENDED COUNTYrL
Chec% One:
CITY VILLAGE: LEGAL DESCRIPTIO':
1.L.. TOWNSHIP,-- ) 0,176. j ' e- T ~J LCJ /°/j aJ W a w
(.~J
C. IS LOCAL PERMIT REQUIYED FOR THIS WORK? YES NO 7ERM1T ?,UMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITIGN
MATERIALS: Prefr~.h Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:t
E. TYPE 0? OCCUPANCY
Chs,.+'- Ones One or T, o Family Residence Comex c.ial Industrial. _ Other
Specify
Number of Persons to be Accommodated Nm.ber of Bedrooms
F. APPLIANCES, ETC: .".7d Waste Grinder YLS , NO Automatic e`«sE;as Was},er YES NO
L:shwasher _.k yes NO Automatic f tato Peeler YLS'~. N NO
Other (Specify). _
G. FI STTE.R PLU: _ MAKIT6 ai 1'ALLA , z ON
Na ' rf~(~ /~7` Address: Lioense Numbers
MP
Signature of Applicant: f ' / MP RSW
Ader- ass 7-z ~7 `
H. (.r be Completed by Issuing Agent)
Date of Applliaf-on Fee Paid
Permit Issued (date)` Permit Number
Fort (Name) t
J Town, Villare, City, county, etc.
(Specify)
Note; The application cannot be considered for filing until all of the above ques;,ions are answered and the
fee paid. Agents will forward application, the fee of $1.OU for each septic tents and the third copy
of the -_>r:iit (canary) to the Division of Health. Checks and money orders should be made pLyable to
the Div,~,i of Heaath.
Do not trrite in space below - FOr, ;,FPARTY,ENT USE ONLY
I. DATE RECEIVE"u L ` .7 -7 - ACCEPTED BY 1 ! RETUR kl; -T
(Initials) (Data) See C r r
FEE RECEIVED ~i VALID. No. PERMIT NO.
es or No
REVIEI,TLD BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
Al qq~
A12- 3/ /1&
---7-- SEPTIC TANK PSIL`1IT NO.
DTs ~ ~ ~ ~ ~
V~ Gk a~SPjy~ R E P O R T O N S O I L P Z R C O L A T I O N T 9 S T
AND SOIL BORINGS
TO
~ 71)
DIVISION OF HEALTH - PLUMBING SXCTIt% .77CEI,,
P.O.Box 309, Madison, Wis. 53701 RAY 14
Purse nt to H 62.20, Wis. Administr=tive Cods
r"Ilslofl
G'r . f _ 6
PSRC 0LATI ON T I S T EA, r;;
Ta..t kepi Lharaoter of .:'41 F'aurs 11ater "r ±et Time Drop in kster Lintel Inches Minutes
Number in! %,As Thickness in Inches Since Hole in Hole Interval Second to Next t0 Last To Fall
1.3t Wetted Overni in ?'.3zu t,s Lay Period Lsst Period Period One, Inch
Example
P - 0 3511 To Soil 10" Cla 2611 25 Yes or No 30 1 2 1/2 1/2 /60
J 61 V0
RECORD h: ATic FROM MI's !Ml M OF 3 TEST HOLES
Compu'.a size of absorption area in aooord with H 62.20 Wis. Adainistratlve Code.
S O I L B 0 R T N G S Mint am 3611 Below Proo:>°ed Abso tion S str3
Aorir.g El IT L; to Gro .1 4 or Depth ~n .ia roc:*
Number ! fnm sc8 _ I C "rod atimatN;,+ O-r,,ertr_ Estimated Cr:."acter of Soil xt,h Thiol.oe!,a in Inches
LyAmple
B - 0 y 7?'rte+f^'~7?n y µY~ Yy Bla .`op Soil 12"z Clay 18111 Send) 'Grav,,l 2411
, . (
f°
RU;ORD DATA FROM MIN li',ORE HOLES
YPE OF OCCUPANCYs
RESIDENCES Niziber of Bed~,ooms OTHER: (Spey: ify) Number of Persons
D WASTE GRIND''.Ri Yes 3 No Dishwashc:.rs Yes Al No m Automatic Clothes Washers Yes / f No
EFFLUENT DISPOSAL SYS.215 NEW i EXTENSION ADDITION REPLACEMENT
Tile S1ze`~ No.Lin.Feet Trench Width Depth _ Number of Lines
Seepa-go Beds Length J6 Width c-,J D Depth Tile Size r!1 No. Lines
Seepa a Pits Insida Di~arc.m ¢er Liquid Depth
Ia the under i7ned, hereby certify that the poroolation torts reporttd on hiss form were made by we or under my super-
vlsion in with the; procedures and mothod specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data r^corde3 and locatio-, of test holes are correct to the best of my knowledge and belief.
NAME ~l C l t G% TITLE /,'r L~ t
Type or Pr'_nt0
REGISTRATION NO. or MASTER PLUMBER LIC'<;dSi: NO. ADDRESS
DATE SIGNATURE- -
Parcel 032-2082-40-000 05/03/2007 09:07 AM
PAGE 1 OF 1
Alt. Parcel 14.30.20.818 032 - 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 - VAN TASSEL, JAMES B & MARY A
JAMES B & MARY A VAN TASSEL
1512 TWIN SPRINGS RD
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1512 TWIN SPRINGS RD
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 2566-TWIN SPRINGS
LOT 22 TWIN SPRINGS ADD TOWN SOMERSET Block/Condo Bldg: LOT 22
ASM'T INC 032-2082-50 (8.19 5 . Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
14-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
02/02/1999 596893 1400/316 OC
07/23/1997 753/32
07/23/1997 701/163
07/23/1997 652/172
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 40,000 194,400 234,400 NO
Totals for 2007:
General Property 0.000 40,000 194,400 234,400
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 40,000 194,400 234,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 114
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00