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Wieoonain D p^.rtmpnt of Health end Soci,l Setviccs
Plb. j~(67 1059 Division of Health
4
PZ,-,MIT APPLICATION
for
PRIVATE DG: ?STIC SE~IAGF SYS'1'EP!S
~ A. CWPii 2 OF P 10! a , " TYPE 0 SE BLACK INK
rte,,{ Adci e _ (Straet, City, Zip Code) Lff/~ 1 _ ` r~i f `t % / l _ 1• )C - _ _ _
County
B. LOCA7 ICI 0P PtOF - h l W'! " S =T Ii + B~, CCCt 1 rJt "PtD 1 R U OR EX F 7)w D.
CITi V1IT.,4+=E LEGAL DE3CRIP'TIO :
~ , . .1 1 / :
i' TOWNSHIP
w I
C. IS LOCAL. PEWIT Pr UIJIRED FOR THIS YES _ NO ~ _ PE XIT NUM. ER
D. SEPTIC' TAN: CAPACITY C Gallons Nr.! TiiS`i'A-LLATS'OtI REPLACE v:N': ADDITION
V w ` R Steel Other
MATEq!ALS: Prefab Concrete A e Poured in Pl~ce
Nu:°3F R OF TANKS TO BE Iwo ~ 1 ED:
E. TYPE' OF OCCUPAtJ"Y
Check One: One or Two Family Residence Commercial Industrial Other
Num.)er of Persons to be AccoLrodated *)-y Number of Bedrooms ,j-
F. AP,'LIANCES, ETCt Food Waste Grind_nr YES NO kutoratic Clothes hasher YES NO
Dis'm skier -YES NO Auto;atio Potato Peeler YES NO
Other (specify)
G. EFFLUFNT DISPOSAL SYSTF^i NEW EXTENSION ADDITION REPLACETIF.NT
Tile Size No.Lin.Feet French Width LX-r Depth _ Number of Lines
SeepaZe Bed: Len`th _ Width _ Depth Tile Size No. Lines r_.
Seepage Pitt Inside diameter Liquid Depth',--
P E R C O L A T I O N T E S T
Test Depth T-~ Character of Soil Hours _ Wator~~Test Tiefta Dro in Water Level Inches Ninut,
Number Inches ( Thickness in Inches Sinsa Hole in Hole !Interval Second to Next to Last To Fall
1st Wetted Overri^ht f in Minut_s La st Period I± Perio:: Period Jnloh
Examplo _ _ I
P- 0 36" To Soil 10" Cla 26"~-~ 25 ( es or no 30 1 2 1,L2 - 1/2 60
f .
RL.COPB 'DATA F'RCki iI.',UM OF 3 T ES'i HOLES
ompute size of absorption aria in accord with H 62.20 Wis. Administ.-five Codas.
S_0 I L B.0 R I N G S- Minimun 36" Below Proposed Absorptio.7, Sy : _
oring Total Depth Dash to Ground iJa..ter Depth to Bedrock ~i
umber InohPs 6s9erved Esti'.r. ted observed Estimated Character of Soil with Thickness in Inchn3
xsmple
- 0 72" 72" Black Too Snil 12"; Clay 12"; Sand Gra- el 24"
-77
l'
/f-----~~ RECG+tD DATA FP.OM F1IVI"JM 07 3 hC:iF:
COMPLETE OTHER SIDE
s I the ,u:dersiLmed, hereJ by -certify that the percolation tests reported on this form were by nn
or under by sunsrvision in accord with the procedure:; and rnrshod specified in Chapter H 62,20 (3),
WJ consin A&iinistrative Code, and that the dat,ai recor•d;d and location of test holes are correct tc
the 'nest of my knoNled~u and belief,
T i T LE~
(i'yno or Prim,)
,
~ RE=~ISTIu1'i'i0N N0.
_ D_* I'GS tR A; P;aEit LiC4,7:~ i~o f!•~~~ L(. lj ~ L,
MASTER PLOIVDd :St FLAKING APPLICATION
Lican e Nu.-:oer:
MP ~ N
(To be Completed by Issuing Agent)
Dato of Application u Fee Paid $ c
Parrnit Issued (date) c?^r C- Permit Number
Agent (namU) if'Z
For: _ t• _ (
Town, Village, City, County, etc.
(Specify)
Notes The application cannot be considered for filing until all of the above questions are anonered
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 write in space below FOR DEPARi^;L:NP USE ONLY
DATE RF.CEIVFD ACCEPTED 5Y
(Initials) (Date) Sae Ccrres.)
FE£ RECEIVED VALID. NO. a.
(Yes or No) PE.~ IT N0.) I _
r'EVIF:4ED 3Y A: PROVED DATE
(Initials)
(Yes or No)
COEME*NTS:
i
Parcel 032-1055-50-000 07/11/2007 10:57 AM
PAGE 1 OF 1
Alt. Parcel 21.31.19.273C 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 - METZDORFF, BERNARD H & MARJORIE
BERNARD H & MARJORIE METZDORFF
I
449 210TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 449 210TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 6.900 Plat: N/A-NOT AVAILABLE
SEC 21 T31N R19W 6.9A IN NE NW E 300" OF Block/Condo Bldg:
N1000'OFNENW
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 479/443
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 6.900 67,500 52,300 119,800 NO
Totals for 2007:
General Property 6.900 67,500 52,300 119,800
Woodland 0.000 0 0
Totals for 2006:
General Property 6.900 67,500 52,300 119,800
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