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Parcel 038-1089-10-120 12/08/2006 12:22 PM
PAGE 1 OF 1
Alt. Parcel M 21.31.18.3631-20 038 - 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 - OSWALD, DANIEL F
DANIEL F OSWALD
2054 CTY RD C
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2054 CTY RD C
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 2.480 Plat: 3320-CSM 12/3320
SEC 21 T31 N R1 8W PT S 1/2 OF THE NW 1/4 Block/Condo Bldg: LOT 4
FORMERLY LOT 1 CSM 8/2218 NKA LOT 4 CSM
12/3320 Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/17/2003 746798 2457/446 WD
09/30/2002 692194 LC
878/395
07/23/1997 5
ov1
2006 SUMMARY Bill M Fair Market Value: Assessed with: /SGjU
175403 229,800
Valuations: Last Changed: 10/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.480 35,400 167,700 203,100 NO
Totals for 2006:
General Property 2.480 35,400 167,700 203,100
Woodland 0.000 0 0
Totals for 2005:
General Property 2.480 35,400 167,700 203,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 124
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Health and Social Services
Pltp. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. 0:?.ER OF PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WH"RE SYSTEM WILL BE CONSTRIr TED ALTERED OR EXTENDED COUNTY
Chock One;
CITY VILLAGE LEGAL DESCRIPTION
Y TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? f YES { NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY ! Gallons NEW INSTALLATION REPLACEMENT i ADDITION
MATERIALS; Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial other
/ (Specify)
Number of persons to be Accommodated ~J Number of Bedrooms
F. APPLIANf.ES# ETC: Food Waste Grinder YES ~ NO Automatic Clothes Washer YES ~ NO
Dishwasher YES NO Automatio Potato Peeler YES i NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: Addresss i1-11 - /i1•': i. A License Numbers
MP
Signature of Applicant: MP RSW
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number •
Agent (Name) For, . ~r
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 for;,.-ard application, the fee of $1.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks anc. money orders should be ode payable to
the Division of Health.
Do net write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY ✓ ~I L~ RETURNIM
See res.)
(Initials) (Date) ( Cc
FEE RECEIVED VALID. No. PERMIT NO.
Yes or No
REVIEWED BY APPROVED DATE
(Initials) (Yes or No
COMPLETE OTHER SIDE
1
SEPTIC TANK PERMIT NO.
t
R S P 0 R T O N S 0 1 L P E R C O L A T I O N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLU43M SECTI6N
P.O.Box 309, Madison, Wis. 53701
Pursuant to It 62.20, Wis. Adainistrut ivs, Coda
P S R C 0 L A T 1 0 N T E S T
Test Depth Character of Soil Hours Water Test Tine Drop In Water Level Inches inFal
Number Inches Thi.e?ixess in Inohes Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni. t in Minutos Last Period Last Period Period lo n& Inch
Example
p - 0 36^ To Soil 10" Clay 2611 25 Yes or No 30 1 2 1/2 l Z2 60
RECORD DATA FROM MINIMUM OF 3 TEST BOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S 0 1 L B 0 R I N G -S- Minimum 36" Belon Pro osed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thioiness in Inches
Example
B - 0 72" 72" Black To Soii 12" C1 18111 Sand 1811• Gravel 2411
L
RECORD DATA FROM MIN P4UM OF 3 BORE HOLES
YPE OF OCCUPANCY:
RESIDENCES Number of Bedrooms OTHER: (Specify) Number of Persons
FOOD WASTE GR L*7DER: Yea No y Dishwasher: Yes No Lutomatic Clothes i;'asher: Yes No y
FFUJENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC&M.ENT
Tile Size ..._-r No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width s Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
e
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 prooeaares and method specified in Chapter H 62.20 (13), Wisconsin Administrative Coda, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO. / t
ADDRESS
DATE ( / SIGNATURE' /