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HomeMy WebLinkAbout038-1062-20-000 0 vn o K m 0 w Q 3 o m 3 - ~ sa t ~ 3 - - Q (Cfi Z 2 U O CO (n (n O •1 N• o w m J a v cD o o Cn (D CO 2 (D Q O m W ° co rn C 2 w rr v, FD. N N 'S \ 7 J N O om CD n m o ~+u cr F o tws rc) to to m c o N C ~ `.S t!i O O y CD Z D ° o co o ~ a rn c _ c CD o o "ft"A q N D Z o m r 4 1 L7 c -4 cn 0 o Z a s 0 0 0 ~ Z O O O ~ ~ Z 0 o p Qr~ F), f N N N C z w c 0- -0 v _q a (D O N O y ro w N ~ ~N N ~ ~ O N !D W Ca- 7 J N Z co z Q C D D D w ~ o CD m • T N N rn F c (D CL a Z ro O = l0 A Z CD N c _ c' c `p z o u CD- O s c' cn w W ~ ~ Z ~ 3 A ~7 O - _ 0 Y C J Z N A N N N p A cn a C W (ND G (D o. -O O T1 N C C CD Z O o a to 3 in ii o ~ o m °7 O N ? ro W ` O N ~ ~ c (D N 0 f O ,r 7 O N O O cn C { Ic ~ O ro Wisconsin Department of Heq.lth e-d Social Services Plb. #67 3/70 Division of Health ' SEPTIC TANK PERMIT APPLICATION ' TYPE or ILE BLACK INK A. 04NER OF - PROPERTY G CJV (•(J o 6 a~l~ ' Na*e Address (Street, City, Zip Coda) B. LOCATION OF PROPERTY W:CRE SYSTM WILL BE CONSTRUCTED, ALTERS OR EXTENDED COUNTY.~~ Check One: CITY VILLAGE LEGAL DESCRIPTION TUhT;S HLP/ / C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUr L D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACLITh'T ADDITION MATERIALS: Prefab Concrete •y Poured in Place Steel Other NUMBER OF TANKS PO BE INSTALLED: E. TYPE OF OCCUPANCY Cheek One: One or Two Family Residence Comercial Industrial Other (Specify) Number of Persons to be Accommodated - Number of Bedrooms F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dish7rasher YES T' NO Automatic Potato Peeler YES NO Other (Specify) G. MASTER PLU TER MAKING INSTALLATION Nacre: Address: License Number: Signature of Applicants / / i /,1 .1 • _ / MP RSW, r / Address: H. o be Completed by Issuing Agent) Date of Application Fee Paid Permit Issued (date) Permit Number ! ~'J Agent (Name) Fors 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 applicaticn, the fee of $1.OU for each septic taruc 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 Health. Do not write in space below - FOR DEPARTM NT USE ONLY I. DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See orres.) FEE RECEIVED c/ VALID. No. PERMIT N0./ % (Yes or Nor- REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE DIAL TESTING LABORATORY, INC. Street, P.O. Box 526 '4'j (.`Visconsin 54730 3121 k ' 5227 "ROIX COUNTY r,Er shit: sir JRTHOUSE PATF PFCEIVEDI 0N. WI 5401, THOMAS C, NELSON tie - CATIOty: 1096 C 0C W-0 ~ Aue,- , TE COLLECTED: ME COLLECTED 4 2 S 30p!s` SOURCE OF SAMPLE: ;LATE ANAL YZEn r 0- 1~ ME At+ c ~ ~IFOF-°°. s`iERPRETATIONS BacierioEo i,_= 8 ppm e iG ppm exceeds the recommenJed na 'skater 5fiG3~ir ~FCF~ tco 4119- t9 OF.,NDEPENOEHT WI Approved Lab No. i. p` `9P Z6 A { Means "LESS THAN" L. , r wd..~r PROFESSIONAL LABORATORY SERVICES SINCE 1952 s f ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 1 ,Yhe St. Croix County Zoning office offers the service of septic tl` and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with corm to the above address. Testing will be done as soon as possible after fee and form are received. / WATER TESTING----------------------------FEE: $ 35.00 V (For nitrates and coliform bacteria) WATER TESTING FEE: $127.00 (For VOC'S) SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if system is properly functioning at time of inspection) Property owner's name Imo- 24 - S (a?~ - u C S~e~-~r Pra i v Property owner's address loc° to Ce7u.v~ Legal Description 1/4 of the 1/4 of Section, T--:~]N-R Town of _Lot Number Subdivision Name Lo 1 CSWI S 132'1 ivA- Sw/SCE -4 SC1SC bL 1 to-3(-t~ ~Ll~ FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house?,-\cbIf so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing'of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. r~ Firm or individual requesting services: _~S~ Telephone Number__ 3~(0-S - S L\ ` Y REPORT TO BE SENT TO: Closing date Signature t. ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET a HUDSON, WI 54016 (715) 386-4680 Aug. 19, 1992 Doreen White First National Bank of Hudson 307 2nd St. Hudson, WI 54016 Dear Ms. White: An inspection of the septic system on the property of Curtis & Diane Bulman located at 1096 County Rd. CC, Star Prairie, WI was conducted on Aug. 18, 1992. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this sewage disposal system was based upon a surface inspection of said system, and did riot involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Sijncerely, Mary J. Jenkins Assistant Zoning Administrator cj Parcel 038-1062-20-000 10/20/2009 12:39 PM PAGE 1 OF 1 Alt. Parcel 15.31.18.270E 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - MIELKE, JOHN C & MARY JANE JOHN C & MARY JANE MIELKE 1096 210TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1096 210TH AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 1.180 Plat: N/A-NOT AVAILABLE SEC 15 T31 N R18W 1.18AC SW SW & IN SEC Block/Condo Bldg: 15 & IN SE SE SEC 16 LOT 1 OF CSM 5/1327 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 967/152 07/23/1997 957/152 07/23/1997 676/498 2009 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.180 40,700 76,600 117,300 NO Totals for 2009: General Property 1.180 40,700 76,600 117,300 Woodland 0.000 0 0 Totals for 2008: General Property 1.180 40,700 76,600 117,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 SrKIC TANK ?ERMI`1" NO. . 5 R E P O R T O N S O I L P E R C O L A T I O N T E S T A N D 5 0 I L B O R I N G S TO DIVISION OF HEALTH - PLLPCaING S CTI(`N P.O.Box 309, M-dison, Wis. 53701 Pursu=t to H 62.20, Wis. Ad--ainistrutivn Co e» P E R C O L A T I O N T E S T Test Depth Cr~ractor of Soil Hours Water Test Time Drop in katar Level Inohas 9inutes Number Inches Thickness in Irohos Sinco Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Ovea'ai. t in Minuton Last Period Last Period Period Inch Example P - 0 36n To Soil 101' Clay 2611 25 Yes or No 30 1 2 1/2 1 2 60 71 RECORD DATA FROM MIND„ OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Coda. S O I L B O R I N G S- Mini=_~n 361' Belc,T -reposed Absorption Sx3tv-2 Boring Total Depth Depth to round hater Depth to Bodroc'.t Number Inches Observed Estifiatad Observed Esti t-cd Character of Soil with Thio'~ness in Inches Ex$aple B - 0 72" 72" Black To Soii 12" Clay 16"; Sand 1811, Gravel 24" j RECORD DATA FROM MINriL,`i OF 3 BORE HOL.E;i YPE OF OCCUPANCYs RESIDRNCEs Number of Bedrooms OTHER: (Specify) Number of Persons FOOD WASTE GRI1NDERs Yes No Diskmashers Yes No Automatic Clothes Washers Yes No FFUJENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC&MENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Bed: Length Width Depth Tile Size No. Lines cA Seepage ?its Inside Diameter `lz:_ Liquid Depth I, the undersigned, hereby certify that the percolation tests reported on this fora were made by me or under My super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Co", and that the data recorded and location of test holes are oorrect to the best of my knowledge and belief. NAME k' TITLE Type or Print REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ADDRESS DATE j / ! SIGNATURE GT , ~,~i 2~` ) c Parcel 038-1062-20-000 06i18/2007 10:10 AM PAGE 1 OF 1 Alt. Parcel 15.31.18.270E 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 - MIELKE, JOHN C & MARY JANE JOHN C & MARY JANE MIELKE 1096 210TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description 1096 210TH AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 1.180 Plat: N/A-NOT AVAILABLE SEC 15 T31 N R18W 1.18AC SW SW & IN SEC Block/Condo Bldg: 15 & IN SE SE SEC 16 LOT 1 OF CSM 5/1327 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 967/152 07/23/1997 957/152 07/23/1997 676/498 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 1.180 40,700 76,600 117,300 NO Totals for 2007: General Property 1.180 40,700 76,600 117,300 Woodland 0.000 0 0 Totals for 2006: General Property 1.180 40,700 76,600 117,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 5 I A K t-' t-~A I K I t I. .31 N:- K. 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