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HomeMy WebLinkAbout036-1044-60-000 o 3 m m a m 3 - w, _ o S z C) n O v m < N W =7 N CD Q O = U a m a n o h o N ' (W O O V? C N Q 3 N O W W :E cs) O c N (D n CD O @ O W a O N y O O p r+e O N C A C o 0 ro N m ~ ~ N W \ j v Z (O O Z O V V y 0 C ~ N z 0C 0 0• O v < 0 a v v v v o m to cn S?o 3 'm m o o N m O y V N - Q ~ M ~ _0 O N Z CO O Z Cn Z y ro o (D =5 O m • a' ro CD O CD ro iw L Q c CD -i cn 9 i z m o N o A ' O A Z O a ~ n; G7 is a Cp - m w co Z CL 3 A O Z o m N ~ A CD a O CD o T> 3 7 N 1- N N O N (D Co G D 4 T a - co C C O CD N a O 47 7 F S O O O p X ~ W X V A O_ (D (D N a ! (p N 7 O C) O J J O N `7 a (D vp N c~ O w o CD ro C) CD- Wisconsin Department of Health and Social Services Flb. f,467 10/69 Division of Health PE3-UT APPLICA"PION for PRIV 1'TE DUIESTIC SEWAGE SYSTEMS A. OWNER OF PROPERTY A, TYPE OR USE BLACK INK Name Address (Street, City, Zip Code) County B. LOCATION OF PROPERTY _W_P'RE SYSTEM[ WILL BE COTISTR'JCTED, ALTERED OR EXTENDED Check One: dr -7 CITY VILLAGE ~ LEGAL DESCRIPTION: TOWNSHIP bp _)d 0 /Y C. IS LOCAL PERMIT REQUIPED FOR THIS TURK? YES NO PFW1IT NL`KBER D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete Poured in Place Steel Other NUNf3ER OF TANKS TO BE LQSTALLED: E. TYPE OF OCCUPAN)"Y Check One: One or Two Family Residence Commercial Industrial Other (Specify) Number of Persons to be Accommodated Number of Bedrooms t F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES NO Disi-washer YES NO Automatic Potato Peeler YES NO Other (Specify) G. EFFLUENT DISPOSAL SYSTE:11 NEW EXTENSION ADDITION REPLACEMENT -7 Tile Size No.Lin.Feet F C Trench 4fidth_ Depth S( Number of Lines Seepage Beds Length C Width 3 Depth Tile Size _ No. Lines Seepage Pits Inside diameter Tr Liquid Depth I P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Droo in Water Level Inches inutes Number Inches Thickness in Inches Since Hole in Hole `Inte-vat Second to i Next to Last ro Fall 1st Wetted Overnight in Minutes Last Period Last Period Period "One Inch Example P- 0 361- .2p Soil 3" Cl-.,,, 26111 25 es or no i 30 112 1/2 112 60 i 41 f) P ;CORD DAT4 FRUM i!?NIML'M OF 3 TES? HOL ES ompute size of absorption are,. in accord with H 62.20 Wis. Acninistr tive Code. S 0_1 L B 0 R I N G S- Mininv_m 36" Haley Proposed Absorption System Boring Total Depth Depth to Ground Water Depth to Bedrock umber Inches Observed Est. mated Observed £stim-,ted Character of Soil with Thickness 1n Inches xample - 0 72" 72"~- Blao'tJGTop Sofl 12"; Clad Is,,; Sand 1811, Gravel 24'r 7.9 -3 RECORD Da.TA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDE is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by suparnrision in accord with the procedures and method specified in Chapter H 62.20 (3), WisconsLr Administrative Code, and that the data recorded and location of test holes are oorrect to the best of my knowledg~© and belief. J t /7 NAME C /=ra~S-•• f-~ C/ / TITLE (Type or Print) REGISTRATION NO. or MASTER PLUP4BEk LICENSE No. ADDRESS A-1 /"~~~1 DATE SIGNATURE!Yj'2./ i MASTER PLU1,13ER MAKING APPLICATION n C a~ mp PLC.' J/ o Signatures License Numbers MP RSW (To bb Comp eted by Issuing Agent) Date of Application 7//c~ Fee Paid $ / l J' Permit Issued (dat Permit Number Agent (name) For: Torn, Village, City, County, etc. (Specify) Notes 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 $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 DEPAWIENT USE ONLY DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) see Corres. FEE RECEIVED VALID. NO. 3 S b PEFMi T NO. (Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) C OVAiiEN TS : SCIAJ 2, s' `~~o 3 Parcel 036-1044-60-000 06/27/2007 02:38 PM PAGE 1 OF 1 Alt. Parcel 19.31.17.280B 036 - TOWN OF STANTON 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 - GRAY, WILLIAM & PATRICIA WILLIAM & PATRICIA GRAY 2054 150TH ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description ' 2054 150TH ST SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 3.160 Plat: N/A-NOT AVAILABLE SEC 19 T31N R17W 3.16A IN SE NE COM E1/4 Block/Condo Bldg: COR SEC 19 TH W 438.8' TH N 307.9', ELY TO E LN, TH S 319' TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 19-31 N-1 7W Notes: Parcel History: Date Doc # Vol/Page Type 11/01/2004 778565 2686/310 QC 07/23/1997 710/68 07/23/1997 568/637 07/23/1987 428320 785/637 WD 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/16/2007 Description Class, Acres Land Improve Total State Reason RESIDENTIAL G1 3.160 24,000 120,100 144,100 NO Totals for 2007: General Properly 3.160 24,000 120,100 144,100 Woodland 0.000 0 0 Totals for 2006: General Properly 3.160 20,000 120,100 140,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 208 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00