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Wisconsin Department of Health and Social Serviced
Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, C Y. Zip Code)
Si A` I~ LX %A,~c r3 t,. ix A. c
3' k tz ~ -
B. LOCATION OF PROPERTY WF!'_RE SYSTEM WILL BE CONSTRUCTED ALTERED )R EXTENDED COUNTY
U
Check One: CITY PILLAGE LEGAL DESCRIPTION `/-/A
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO G' ~r PERMIT NUMBER
D. SEPTIC TANK CAPACITY jc:.+ Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALSt Prefab Concrete Y_ Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: z
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence X Commercial Industrial Other
Specify)
Number of Persons to be Accommodated 2Number of Bedrooms I'
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES X NO
Dishwasher YES X NO Automatic Potato Peeler YES .n NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: .br•;' r-~n .c n ti Address: ris x i> - ; S License Number:
MP
Signature of Appliosnti 7 'f-- r MP RSW
Address
H. ( be C pleted by Issuing Agent;
Date of Application ,,..,~0 7 C Fee Paid
Permit Issued (date) Permit Number
Agent (Name) For: "t / 0"
Town, Village, City, County, etc.
(Specify)
Note: 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 $1.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Heai,th.
Do not write in space below - FOR DEPART]KENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTIMR SIDE
. s+ SZPTIC TANK PERMIT N0. ,1
R Z P 0 R T O N S 0 1 L P Z R C 0 L A T I 0 N T Z S T
AND SOIL BORINGS
TO
f
DIVISION OF HEALTH - PLLMBM SZCTI *
P.O.Box 309, Madison, Wis. 53701 `
Pursuant to H 62.20, Wis. Administrative Code
P Z R C 0 L A T 1 0 N T Z S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches utes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
let Wetted Overntzht in Minutes Last Period Last Period Period Orr Inch
Example
P - 0 361+ To Soil 10" Cla 261 25 Yes or No 30 1 2 1 2 1/2
r 711r'S. 4' ;i4> j c 3. 1 _ j !
y
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S 0.1 B 0 R I N G S- Minimum 361t Below reposed Abso tion S stem
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Zxaaple
B - 0 72" Black TO Soil 12f1 C1 1811 Sand 181+. Gravel 241'
L✓ 6 ,
06
d r,~~..:i ~i. 71.
REC<7W DATA FROM MINIMUM OF 3 BORE HOLES
PE OF OCCUPANCY:
RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons
ROOD WASTE GRINDERS Yes No Dishwashers Yes No X Automatic Clothes Washers Yes No
r
FFLUENT DISPOSAL SYSTEM; NEW EXTENSION ADDITION REPLACLIUNT
Tile Size L~ No.Lin.Feet Trenoh Width Je Depth A2 Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Diameter . =i _ Liquid Depth
ids-<• G'.i - n n y - w ~c''.t ~
I, the undersigned, hereby certify that the percolation tests reported on this fa:•m were made by me or under my super-
vision in accord with the proce,ures and method specified in Chapter H :2.20 (131„ Wisconsin Administrative Co", and
that the'data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE ti-, + n s
Type or Print
REGISTRATION NO. or MASTER PWMBER LICE.1tSE NO.
ADDRESS l? c` .4 1~ v / C S~.t/
DATE
-L ' f- i C1 ~1 • SIGNATURE' , . -1
Parcel 034-1041-30-000 06/19r2007 02:32 PM
PAGE 1 OF 1
Alt. Parcel 18.29.15.274 034 - TOWN OF SPRINGFIELD
ST. CROIX COUNTY, WISCONSIN
Current X
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 - STENE, JERRY & MARIAN
JERRY & MARIAN STENE
2755 CTY RD E
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 2755 CTY RD E
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 18 T29N R1 5W NW NE 40A Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
18-29N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/15/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 25,400 135,900 161,300 NO
AGRICULTURAL G4 30.000 5,300 0 5,300 NO
UNDEVELOPED G5 8.000 9,300 0 9,300 NO
Totals for 2007:
General Property 40.000 40,000 135,900 175,9000
Woodland 0.000 0
Totals for 2006:
General Property 40.000 22,850 111,300 134,1500
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 115
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00