HomeMy WebLinkAbout038-1036-20-000 (2)
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Wisconsin Department of Health and Social Services
?lb.;#b7 370 Division of Health `
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK 3G v 3 -~U ~OZSz~
A. OWNER OF PROPERTY
Name ~j Address (Street,.City, Zip Code)
B. LOCATION OF PROPERTY W"ERE SYSTEM WILL BE CONSTRUCTED ALTEREf OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
f TOWNSHIP °
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? r~ YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete l Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Cheek Ones One or Two Family Residence T Commercial Industrial Other
~ Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YESNO
Dishwasher YES -z NO Automatic Potato Peeler YESNO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION /
Name: Address: '-7-" G C ~Lioense Number:
Signature of Applicant: MP RSW
r
Address:
H. (To a Completed by Issuing Agent)
Date of Application' ~ Fee Paid
Permit Issued (date)" Permit Number
For:~
Agent (Name) " . 7~~111
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above quesriors are answered and the
fee paid. Agents will forward application, the fee of 41.GU for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks am money orders sinould be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED 1,521 `7 ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED f VALID. No. PERMIT NO. 111
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
s SEPTIC TANK PERMIT NO,
R Z P 0 R T O N S O I L P Z R C 0 L A T I 0 N T Z S T
ti A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTIN
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P Z R C 0 L A T I 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 Sinee Hole in Hole Interval Second to Next to Last LI Fall
1st Wetted Overnight in Minutes Last Period Last Period Period , Inch
Example
P -j 0 36" To Soil 10" Clay 26" 25 Yes or No 30 1 2 1L2 1/2 60
" RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36" Below Pro osed Abso tion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 72" 72" Black To Soil 12" C1 18" Sand 18l, Gravel 24"
RECORD DATA FROM MINEMUM OF 3 BORE HOLES
PE OF OCCUPANCY:
RESIDENCEs Number of Bedrooms OTHER: (Specify) Number of Persons ~.f
FOOD WASTE GRINDERS Yes No Dishwashert Yes No _ Automatic Clothes Washert Yes No m
FFWENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length_ Width Depth Tile Size No. Lines
Seepage Pitt Inside Diameter Liquid Depth
I, the undersigned, hereby cert'ty that the percolation tests reported on this form were made by me or under m•• super-,
vision in accord with the proceduras and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location or test holes are correct to the best of my knowledge and belief.
Nary TITLE
Type or Print
REGISTRATION NO. for MASTER PLUMBER LI "U SE NO.
ADDRESS
-7
DATE SIGNATURE ~~Er , : I l > >
v -
Parcel 038-1036-20-000 06/19/2007 11:50 AM
PAGE 1 OF 1
Alt. Parcel 8.31.18.158D 038 - TOWN OF STAR PRAIRIE
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 - SCHUMACHER, VIRGINIA L
VIRGINIA L SCHUMACHER C - ZIMNEY, CONSTANCE M
CONSTANCE M ZIMNEY,ET AL C - FOURRE, MARY ELIZABETH
1791 STANFORD AVE C - FOURRE, MARGARET A
ST PAUL MN 55105-2043 C - FOURRE, MARK W
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8050 SQUAW LAKE RHAB & MANAGE
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 8 T31 N R1 8W N 150FT OF S 975 FT OF Block/Condo Bldg:
SE SE
t~-j Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
Notes: Parcel History:
Date Doc # Vol/Page Type
12/07/2006 840201 QC
08/10/1987 428950 787/563 PR
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 116,900 35,500 152,400 NO
Totals for 2007:
General Property 0.000 116,900 35,500 152,400
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 116,900 35,500 152,400
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