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Wisoonsin Department of Health end Socir,? Sorvioeo
` Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
T1PE or USE B -.?.CK It!: OC 1 (o b 7 V, 1~e L1: 71f 3 30
A. CCT,NER OF PROP-P.TY 7
Nacre 'yd c' Address (Street, City, 'Lip Cod*)
0 CI 6Yw,~~ :rc
B. LOCATION OF PRO?ERTY WhERE SYSi'a.M WILL BE CONSTRLrITFD, ALTERED OR EXTENDED COUNTY r
Check One: GG~~ )
CITY VILLAGE LEGAL DESCRIPPION OY S6u_ 0 1 Zh d '
P41
C. IS LOCAL PERMIT REuUIRED FOR THIS WORK? YES NO Jl•5 PERMIT NUMBER
D. SEPTIC TANK CAPACITY ~CTZ3C~ Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Conorete A Poured in Place Steel Other
NUMBER OF TAP.KS TO BE .'NSTALLE.D: 1
E. TYPE OF OCCUPANCY
,Cheek One: One or Two Family Residence 4- Commercial _ Industrial Other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms _
F. APPLIANCES, ETC: Food Waste Grinder YES ~C NO Automatic Clotnes Washer YES NO
Dislxasher YES Y NO Automatio Potato Peeler YES NO
Other (Specify)
G. MASTER PLUNDER KAKING'I1' TA ATION
Name: _ 0-./V S, Address= Lioenso Number:
Signature of Applicant: MP RSW
Address:
H. (To be-Completed by Issuing Agent)
Date of Application j ~ Fee Paid $
~ t,
Permit Issued (date) / 7 3 /7 Permit Number
Agent (Name) Fo.:_
Town, Villag.-, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above i..cstions are answered and the
fee paid. Agents wil_ for.,,-ard appiic=.ticn, the fee of X1.00 or each septic tanx and the third cop;;
of the peranit (canary) to the Division of Health. Checks and money orders should be redo payable to
the Division of Health.
Do not write in space below - FOR DEPARTfiENT USE ONLY
i
I. DATE RECEIVED 3 ' ?O ACCEPTED BY RETURNED
(Initials) 5 (Date) -S_ee. Tires.)
FEE RECEIVED VALID. No. 6,!f PERMIT NO.
es or No
REVIEWED BY APPROVER _ DATE
(Initials) Yes or No
\ COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P T R C 0 L A T I 0 N T E S T
A N D S 0 I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLIIMuIYG SECTI63
P.O.Box 309, M-.tdison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
'.i
P E R C 0 L T I O N T E S T
Test. Depth Character of Soil Hours Water Twat Time D~ in Water Level Inches Minutes
Nwber Inchon 7hia1*nos3 in Inches Since Hole in Hole Interval Second to Nest to List To Fall
1st Wetted Ovoi°ni. ~t in Minutes Last period Last Period Period One. Inch
F•x~mple
P - 0 36" To Soil 10112 2611, 25 Yes or No 30 1 2 1L2 1 2 60
RECORD DATA FROM MINL% s OP 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrativo Code.
S O I L B O R I N G S- Minirwm 3691 Below Proposed Aboo tion 5 stem
Boring Total DepthDe2th to Ground Water De th~ to _Bedrock
Number Inches Observod Eatimatod Cnaerved EstScUStad Character of Soil with Thickness in Inches
Example
B - 0 72" 7211 Black Top Soil 12"; Clay 18113 Sand 1811, Gravel 211,
r
RF,I.;ORD DATA FROM MINIMUM 0? 3 BORE HAL S
TYPE OF OCCUPANCY:
RESIDENCEt Number of Bedrooms J ~ OTHER: (Specify) Number of Persons
FOOD WASTE GRINDER: Yes No Dis~-_,?asher: Yes No+ Automatic Clothes Washer: Yes No
-4-
EFFLUENT DISPOSAL SYSTEM: NEW X EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepags Bed: Length Width Depth Tile Size No. Lines
: ry Seepage Pit: Inside Diameter r Liquid Depth
I, the undersigned, hereby certify that the puroolation tests reported on this form were cads by me or under my super-
vision it accord with the procad,_ es and method spooified in Chapter H 6,_.20 (13), Wisconsin Administrative Cori,,, and
that the da reco -dad anndd location of test holes are correct to the best of my knowledge and belief.
NAIL TITL'.
* Type or Print)
REGISTRATION NO. or MASTER PLLQfDER LIC:21SE NO.
ADDRESS
DAiF. 7~~ / SIGNATURE
Parcel 032-1081-90-000 07/11/2007 02:56 PM
PAGE 1 OF 1
Alt. Parcel 28.31.19.393B 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 - MEYER, JAMES V
JAMES V MEYER
410 192ND AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description 410 192ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.700 Plat: N/A-NOT AVAILABLE
SEC 28 T31 N R1 9W 3.70A W230' OF E 950' Block/Condo Bldg:
OF S 700' OF NWSW
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
28-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1061/406 QC
07/23/1997 1061/405 WD
07/23/1997 1047/422 JD
07/23/1997 718/330
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 3.700 51,500 137,100 188,600 NO
Totals for 2007:
General Property 3.700 51,500 137,100 188,600
Woodland 0.000 0 0
Totals for 2006:
General Property 3.700 51,500 137,100 188,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 316
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00