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Wisconsin Department of Health and Social Services
Plb. 167 3/70 ' Division of teaitk
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
_ -5 U
VU
A. WM OF PROPERTY
Rase Address (street, city, zip cc")
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check COnes
ITY VILLAGE LEGAL DESCRIPTION 720 N " R 02 - ~61&1
__I,::-:oWNSHIP
r
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY L...~ Gallons NEW INSTALLATION l-' REPLACEMENT ADDITION
MATERIALSt Prefab Concrete L--~ Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLEDs
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence ~Com+ereial Industrial Other
Specify
Number of Persons to be Accommodated 7_ Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer 4--fl;S NO
Dishwasher YES NO Automatic Potato Peeler; YXS
Other (Specify)
G. MASTTR PLUMBER MAKING INSTALLATION
i Name: ZeJ~ Addresss License Humbert
MP
Signature of Applicant: MP RSW
Addresss 'i 2-
H. (To be Completed by Issuing Agent)
Date of Application - ~1/ Fee Paid
Permit Issued (date) '-7/- /a 2_ ~J Permit Number ~1 %C)
-
Agent (Name)~.~ Fort
Town, Village, City, Country-, 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.OG for each septio tanx and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - OR DEPARTMENT USE ONLY
I. DATE RECEIVED C3 =.L _ Ll_ ACCEPTED'BY RETURNED
(Initials) (Date) See Cres.
FEE RECEIVED ✓ VALID. No. PERMIT NO. 17
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPISTR OTHRR STnr
r
SEPTIC TAN[ PERMIT Nos
REPORT ON SOIL PERCOLATION ?EST-,,
A N D S O I L B 0 R I N 0 S
a %
?0
r ' DIVISION OF HEALTH - PLLMDG SECTAN i ;
P.O.Box 309, Madison, Wis. 53701.;*L t
' pursuant to 8 62.20, Xis. Administrative Code J
w
P E R C O L A T I O N T E S?
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches minutes
Number Inches Thickness in Inches Since Kole in Hole Interval Second to Next to Lest To Fall
lot Wetted Overnight in Minutes Last Period Last Period Period Ow Inch
Example
P - 0 36" ?o Soil 10" Clay 2600 25 Yes or No 30 I L2 1/2 1/2 60
It V
10 q0
2
RECORD DATA FROM MINIltUM OF 3 TEST HOLES
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- Minimum 36" Below Pro posed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 72" 72" Black To Soil 12" Clay 18" Sand 18» Gravel 24~
) /i O21-
A
V0 0"
RECORD DATA FROM MINIMUM OF '3 BORE HOLES
PE OF OCCUPANCYt 3
RESIDENCES Number of--Bedrooms OTHERs (Specify) Number of Persons
rOOD WASTE GRINDERS Yes ~'No Dishwashert Yes No L~Automatic Clothes Washers Yes A----No
o
FFWENT DISPOSAL SYSTEMS NEW f~--- EXTENSION ADDITION REPLkCEKENT
Tile Size..L~ No.Lin.Feet, - Trench Width Depth Number of Lines
Seepage Bed: Length Wi~dtth-4gf Depth -2 Tile Size ;4, No. Lines
Seepage Pits Inside Diameter "Liquid Depth
I, the undersigned, hereby certify that the percolation tests reported on this form were made by as 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 ✓ c 4, TITLE
~ (Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO. O /
ADDRESS
DATE SIGNATURE)
- i
Parcel 032-2078-10-000 04/30/2007 05:07 PM
PAGE 1 OF 1
Alt. Parcel 14.30.20.794C 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 STUDER, RONALD C & CAROL
RONALD C & CAROL STUDER
1507 ANDERSEN SCOUT CAMP TRL
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 1507 ANDERSEN SCOUT CAMP TRL
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 14 T30N R20W 2A N330' OF S 495' OF W Block/Condo Bldg:
264' OF SW SE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
14-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
07,123/1997 437/380
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 2.000 32,000 111,300 143,300 NO
Totals for 2007:
General Property 2.000 32,000 111,300 143,300
Woodland 0.000 0 0
Totals for 2006:
General Property 2.000 32,000 111,300 143,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 216
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 000 0.00 0.00