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wisoonsin Department of Health and Sooi^1 Sarvices
Plb. X57 3/70 Division of Health
SEPTIC TANK PEPMIT APPLICATION
-WO
TY, u or USE BLACK N. is A. GAINER OF - PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WhIAF SYSTTw4 WILL BE CONSTRUCTED ALTERED JR EXTENDED COU+iY
Check One: _ 't) 1U ~N f(1 5 ~Lr•~ ,O c'
CITY VILLAGE LEGAT.. DFSCRIPTION
_ TOWNSHIP
- C< IS LOCAL PERPiIT REQUIRED FOR, THIS WORK? YES NO PERMIT NUMBED ~
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACE-SNT ADDITION
MATERIALSt Prefab Concrete Poured in Place Steel' Other
NUiBER OF TANKS TO BE Ii STALLLU:
E. '.YPE OF OCCUPANCY
Check Gnat One or Two Family Residence Commercial Industrial other
(Specify)
Number of Persons to be Acccrx:odated Number of Eedroems
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clotl,as Washer YES NO '
Disbm Sher YES NO Aut,-,matio potato Pester T YES NO
Other (Specify)
G. YKASTI.'R PLUMBER MJt KING INSTALLATION
Name Address: f - License Nxnber:
. , r
r ti t
Signature of Applicant: MP RS'~i
Address:
H. (To be leted by Issuing Agent)
Date of Application /pE0C0 7 Fee Paid
Permit Issued (date /UPermit Number
:.,gent (Name) 1 , a 1 /f~•~_ For? > - a L1 1.,i i
Town, Village, City,~County, etc.
(Specify)
tote: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. kdents will forward application, the fee of $I.OO 'or each septic tarx and the third cony
of the permit (canary) to the Division of Health. Checks and money orders should be wade payable to
the Division of Hearth.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) $e`~,~~~
FEE RECEIVED VALID. No.
es or No
REVIEWED BY APPROVED DATI
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R Z P O R T O N S O I L P Z R C O L A? I O N ? E S T
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLU-3I tG SECTI(~Y
P.O.Box s0, Wis. 53701
Purvaant to H 62.20, Wis. A&iinistrativs Coda
P Z R C 0 L A T I 0 N T Z S T
Test Depth Charactsr of Sail noi:rs Water Tea: T1mj Drop in kac Level Ina;^.29 Snut
I:,;: bor i Inches Thiokness in Lrohes Since Hole in Hole Interval Second to Last ;To Fail
I let Wetted Overnight in Minutes Last Period L"t PeriodlPer.od 10ns, Inc;?
P - 0 611 ?o Soil 1017 Clay 2611 25 Yes or No 30 1 2 1 2 I 1 2 6f:
~i~• %i I' ;',-1,C y; Y :J. f .y' 7. ~ .ice ~ ~
/'r ,:,'~_•,-1A 1.1 27' 3 LI •i•1' 7 1- -
RFCORD.DATA FROM ML`7L`:}_i1 07 3 TEST N.OL:: s
Compute size of absorption area in accord with H 62.20 Wis. Admiriatra.tiva Code.
S O I L B O R I N G S- tlini = 3611 Bplcn Prcrosed Absorption Sy:.t a
Boring Total Depth Depth to Ground :;ate: Depth to Bsdror,%
Number Inches Cbserved T.etimated Observed Esti -iad Character of Soil with Thio'.cness in Inches
Example
B - 0 72'1 7211 TTBla,,zTc- So! L214; Clay 18", Sand 1817, Gravel 2411
~ ,ry~C C.','J ,"Y~ `/i✓1~~" ,d ~ •1r'/~ 1'? 1 ..T/r •t: .Y. GJ„ .f i'•n. , .1J
•~"L'' ~ ~.fJ t i)s.>, =J'' .c. :Thy a- .i.lr I) .
j J,
R CORTD DATA FROM 141NPI_T,7_ OF 3 ?OR HOT-rS
PE OF OCCUPANCY:
RESIDENCE: Number of Bedrocras _ OTHER: (Specify) Number of Persons
D WASTE GRINDERs Yea Nc y DishnT Sher: Yes No m Luto:~tic Clothes Wash!r: Yes No m
FFUIENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAx`"
Depth ; Number of Lines
Tile Size No.Lin.Feet Trench Width L,
Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Disseter Liquid Depth
I, the undersigised, hereby earthy that the percolation tests reported on this form were made by me or under m- super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Coas, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME C to . r - -I , / d f - TITLE
Aj /I
Type or Print,,-
REGISTRATION NO. V y or MASTER P14MER LICENSE NO.
ADDRESS ~r ! '7( J ✓ C3 it Z . . , ix t is S Ye- a
DATE SIGNATURE f 1`;- r
Parcel 034-1009-30-000 06/19/2007 02:14 PM
PAGE 1OF1
Alt. Parcel 05.29.15.66B 034 - TOWN OF SPRINGFIELD
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 - JESKE, RONNIE A
RONNIE A JESKE
2857 CTY RD DD
GLENWOOD CITY WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 2857 CTY RD DD
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 1.380 Plat: N/A-NOT AVAILABLE
SEC 5 T29N R15W PT NW NE LOT 1 CSM Block/Condo Bldg:
4/1045; EXC NSP
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
05-29N-15W NW NE
Notes: Parcel History:
Date Doc # Vol/Page Type
03/07/2001 639981 1598/25 OC
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/15/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.380 17,550 154,250 171,800 NO
Totals for 2007:
General Property 1.380 17,550 154,250 171,800
Woodland 0.000 0 0
Totals for 2006:
General Property 1.380 8,900 141,300 150,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 308
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 034-1009-20-050 06/19/2007 02:12
PAGE 1 OF 1
F 1
Alt. Parcel 05.29.15.66A-20 034 - TOWN OF SPRINGFIELD
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 - FICKLING, BRIAN IM & BRIDGET L
BRIAN M & BRIDGET L FICKLING
1178 290TH ST
GLENWOOD CITY WI 54013
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 3.060 Plat: 4528-CSM 17-4528 034-03
SEC 5 T29N R15W PT NW NE CSM 17-4528 LOT Block/Condo Bldg: -OT 01
1 (3.06 AC)
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
05-29N-15W NW NE
Notes: Parcel History:
Date Doc # Vol/Page Type
05/29/2003 723499 17/4528 CSM
12/30/1998 594717 1391/420 WD
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/15/2007
Description Class Acres Land Improve Total State Reason
PRODUCTIVE FORST LANDS G6 3.060 10,700 0 10,700 NO
Totals for 2007:
General Property 3.060 10,700 0 10,700
Woodland 0.000 0 0
Totals for 2006:
General Property 3.060 5,500 0 5,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
SPRINGFIELD T 29 N-R. 15 W 37
11 DD SEE PAGE 49 11
X
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WILSON ELEVATOR CO.
PHONE: WILSON 772-4764 KOOIMAN MOTOR SPORTS
VALLEY ELEVATOR Suzuki Snowmobiles
PHONE: 778-5734
Feeds- Seeds PHONE: 684-1615
and Blackhawk Fertilizer
~ BALDWIN, WIS. 54002