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Wisconsin Departtrent of Health and Social Services
Plb #67 Division of Health
` PER-tIT APPLICATION
V
for
✓ PRIVATE DCUESTIC SEWAGE SYSTE:11S
3
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Ccde) /
County
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BF. CONSTRUCTED ALTERED OR EXTENDED
Check One: X1 s
i CITY VILLAGE LEGAL DESG RIPTION: !
TOWNSHIP u J1
St,) fi" L; L -7-
C. C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? A YES NO
D. SEPTIC TANK CAPACITY 1-2 -f` Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence f Commercial Industrial Other
Specify
Number of Persons to be Accormodated
F. APi'LIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer X; YES NO
Dishwasher YES ~X NO Automatic Potato Peeler YES NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length _ Width Depth Ti-le Size No. Lines
/Seepage Pit: Inside diameter Liquid Depth
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Internal Second to Next to Last To Fall
1st Wetted Overnight in Mirmtes Last Period Last Period. Period One Inch
Example
P- 0 36" To Soil 10" Cla 26" 25 es or no 30 1 2 1/2 1/2 60
Z i 'J^1 1 v -2 ~V E CJ W
4.
Z' I?
RECORD DATA FROM MINIrIUMI OF 3 TEST HOLES
ompute eize of absorption area in acoord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below Pro osed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
umber Inches Cbserved Estimated Observed Estimated Character of Soil with Thickness in Inches
xample
0 72" 72" Blaok To Soil 12"^ Clay 18"• Sand 18"• Gravel 24"
c" c
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and looation.of test holes are oorreot to
the best of my knowledge and-belief.
NAME TITLE
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICE14SE No.
/ - ' -1 /
ADDRESS t.' / t ~ • e-_
/
DATE > S IGNATU F9
MASTER 'PLUMBER MAKING APPLICATION
MP
/
Signatures . - I* ?7. License Numbers
MP RSW S l
(To be Completed by Issuing Agent)
Date of Application / 3 - ~ Fee Paid
Permit Issued (date) - Permit Number
Agent (name) ~'jid~ 42.= For:
Town, Village, City o ty etc.
(Specify)
Notes 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 $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
Do not writs in space below - FOR DEPARTMENT USE ONLY
y_
DATY RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) (see c orres,
FEE RSCEIVSD VALID. NO. PERMIT NO. iw J
Yes or No)
REVIEWED BY APPROVED ` DATE
(Initials) Yes or No)
COMMENTS:
I
a '
Parcel 032-1054-80-000 04/30/2007 04:03 PM
PAGE 1 OF 1
Alt. Parcel 21.31.19.272B 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 - VEDRA, PAUL D & CONSTANCE A
PAUL D & CONSTANCE A VEDRA
472 208TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 472 208TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE
SEC 21 T31N R19W 10A N1/2 OF S1/2 SE NE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-31 N-1 9W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1203/468 QC
07/23/1997 788/82
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 10.000 83,000 164,800 247,800 NO
Totals for 2007:
General Property 10.000 83,000 164,800 247,800
Woodland 0.000 0 0
Totals for 2006:
General Property 10.000 83,000 164,800 247,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 211
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00