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Wisconsin Department of Health and Social Services
Plb. #67. 10/69 Division of Health
PEFtUT APPLICATION
for r
PRIVATE DOMESTIC SEWAGE SYSTEMS ~C
' 0 32-lost, ooo /
i
' A. OWNER OF PROPERTY r
~ 1CJjZ TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED' County
Cheok One: ~ I Sr C
CITY VILLAGE LEGAL DE5CRIPTICN;
TOW14SHIP l L-,
C. IS LOCAL PERUT PEOUIRED FOR THIS WORK? YES NO S PERMIT NUMBER
D. SEPTIC TANK CAPACITY r~*r Gallonu NEW IN STALLATION REPLACEMENT ADDITION
MATERIALS; Prefab Concrete Poured in Place Steel Other
NUDU ER 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 Accommodated C` Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES _X NO Automatic Clothes Washer 2~ YES NO
Dishwasher YES . NO Automatic Pot%to Peeler YES NO
Other (Specify)
•
G. EFFLUE11T DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines_
Seepage Beds Length Width Depth Tile Size No. Lines
f Seepage Pits Inside diameter ___7. Liquid Depth S
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 i.n inches Since Hole in Hole Inter.,al Second to Next to Last "o Fall
Example 1st Wetted Overni hg t , in Mi mtes Last Period I Last Peri Period tine Inch
P- 0 3691 To Soil 10" Clay 261, 25 es or no ' 30 112 1/2 1/2 60
i~
RECORD DATA FROM MINIMUi-f OF 3 TEST HOLES
ompute aize of absorption area in accord with H 62.20 Wis. Administrative Code.
r
S O I L B O R I N G S- Minimum 36" Below Proposed Absorption System
G oring Total Depth Depth to Ground Hater Depth to Bedrock
umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
xample
- 0 7211 7210 Black To Soil 12"• Clay 18'x• Sand 1811• Gravel 2411
1
-7- 1
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
E'
COMPLETE OTHER SIDE
r
• S I' the undersigned, hereby certify that the percolation tests reported on
this or under by supervision in accord with the procedures and method specified inChaform pteraH 62.20 (3),
Wisconsin Administrative Code, and thrt the data recorded and location of test holes are correct to
the best of my knowledge and belief.
NAME
TITLE
REGISTRATION NO. or MASTER PLUI 3ER LICENSE No. 7:5 ADDRESS 'ev
DATE SIGNATURE
7MASTERR Mt:R MAKING APPLICATION
gnature:~_ MP
License Number:
MP RSW
7
(To,be Co pleted by Issuing Agent)
-N- Date of Application - j J G Fee Paid $ rj_.\
Permit Issued (da e)~, Permit Number
Agent (name) For:
Town, Village, City, County, etc.
Notes The application cannot be considered for fill (Specify)
ng 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 write in space below - FOR DEPART:'IENT USE ONLY
DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. NO. U 3 a L 7 t~L
PERMIT NO.
(Yes or No)
REVIEWED BY APPROVED
(Initials) DATE
(Yea or No)
COMMENTS:
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91
14,E°" _-t Sip 2 5
1
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Tom"
ST. CROIX COUNTY
r
z,s~k WISCONSIN
EMERGENCY GOVERNMENT OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
j'
(715) 386-4680
October 10, 1989
Tom Martell
P.O. Box 198 A
Somerset, WI 54025
Dear Mr. Martell:
C
An onsit "fig--fin o die sep~i-c-s em on your property
locat South of Somerset on County Rd. I was conducted on
Octob 19. At the time of t e insepction, the sanitary
system appeared to be functioning properly for the existing
use. The inspection of this sewage disposal system was based
upon a surface inspection of said system, and did not involve
any excavating or chemical analysis. Accordingly, there is
the possibility of hidden defects in the system not discoverable
by this inspection. This does not in any way warrant or guar-
antee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped
once every three years. Therefore, the prolonged life of this
system is totally dependent upon proper maintenance of this
system.
Should you have any questions regarding this subject, please
feel free to contact this office.
Sincerely,
Thomas C. Nelson
Zoning Administrator
cj
Parcel 032-1056-40-000 12/23/2009 10:28 AM
PAGE 1 OF 1
Alt. Parcel 21.31.19.280B 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - MARTELL, THOMAS W
THOMAS W MARTELL
439 208TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 439 208TH AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 14.000 Plat: N/A-NOT AVAILABLE
SEC 21 T31N R1 9W THAT PT SE SW LYING S & Block/Condo Bldg:
E OF TN RD
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 1030/321 TI
07/23/1997 923/500
2009 SUMMARY Bill Fair Market Value: Assessed with:
543 Use Value Assessment
Valuations: Last Changed: 11/03/2008
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 48,000 112,200 160,200 NO
AGRICULTURAL G4 5.000 500 0 500 NO
UNDEVELOPED G5 6.000 12,000 0 12,000 NO
Totals for 2009:
General Property 14.000 60,500 112,200 172,700
Woodland 0.000 0 0
Totals for 2008:
General Property 14.000 60,500 112,200 172,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 203
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00