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Parcel 040-1053-50-000 06/01/2007 04:26 PM
PAGE 1 OF 1
Alt. Parcel 13.28.19.199A 040 - TOWN OF TROY
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 - SENN, GARY M & CAROL
GARY M & CAROL SENN
370 CTY RD U
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 370 CTY RD U
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 6.200 Plat: N/A-NOT AVAILABLE
SEC 13 T28N R19W THAT PT OF SE NW LYING Block/Condo Bldg:
WLY OF HWY "U" EXC S 945.5 FT
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
13-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 876/266
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.200 78,000 232,100 310,100 NO
Totals for 2007:
General Property 6.200 78,000 232,100 310,100
Woodland 0.000 0 0
Totals for 2006:
General Property 6.200 78,000 232,100 310,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 132
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Pb. 67 Wisconsin Department of Health and Social Services
3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. € 1rFR OF PROPERTY
Name Address (Street, city, zip coda)
i _
B. LOCATIC°! OF PRO?ERTY WI RE SY'STEM WILL BE CONSTRUCTED ALTERED OR EXTENTIED
Check Ona; - COUN'T'Y
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP
FC, IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO
PERMIT NUYb
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEtIZN'P ADDITION
MATERIALS: Prefab Concrete poured in Place Steel Other
NUMBER OF TANKS PO BE INSTALLED:
One: One or Two Fa.7ily Residence Commercial Industrial Other
of Persons to be Accommodated (Specify)
Number of Bedrooms
FG.MA.STIR OCCUPANCY
CsS, ETC: Food Waste Grinder YES NO Automatic Clothos Washer
Dis?-~rasher YES NO
YES NO Automatio Potato Peeler YES NO
Other (Specify)
PU 2 9ER 2U4{L*1G INSTALLATION
Address=
License Numbers
MP
Si&natura of Applicznt:
MP RSW
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number
Agent (Name) / - ~
i
For;
Town, Village, City, County, etc.
Note: The application cannot be considered for filing until all of the above questionsparefa.nswered 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) tj the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
rI. DATE RECEIVED C~ - l - - Q ACC
~ EPTED BY RETURNED
i (Initials) / (Date) See Corr
es.)
FEE RECEIVED c/ VALID. No. n -7 PERMIT NO.
Yes or No
REVIEWED BY APPROVED DATE
(Initials)
Yes or No
COMPLETE OTHER SIDE
1
+ SEPTIC TANK PERMIT NO.
• 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 S 0 1 L B O R I N G S
TO
DIYISIGN OY HEALTH - PLU IBIi4'v SBCTI6?D
P.O.Box 309, 2-rai3on, Wis. 53701
Pursuant to H 62.20, Wis. Adminlstrativl: Code
P B R C 0 L A T I 0 H T E S T
Test Depth C•naraoter of Soil Hours Water Test Time Dr o2 Water Level Inohes utes
Number Inches Thickness in Inches Since Hole in Halo Interval Second to Next to Last To Fail
p 1st Wetted Ovei'ni in MJ-11 t03 Last Period Last Period Period On, Inch
Example
P - 0 3611 To Soil 1014. Clay 2611 25 Yes or No 30 1 2 1 2 1 2 60
L 3 4~ 1. 5~ ~
RECORD DATA FROM MINIPrUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. A&.Ainiztretive Code.
S 01 L B O R I N G S- Mini== 3611 Bel" reposed Abso tion S stc~3
Boring Total Depth h to Ground Matnr Dapth Zo Bedrock
Number Inches Observed gn-timated Observed Estiizated Character of Soil with Thio mess in Inches
Lxaaple
B - 0 7211 7211 Black Too Soil 121';_ Clay 1811; Sand 18"; Gravel 2411
k u
i,
RZ,:ORD DATA FRCr`i MINLMU`? OF 3 BORE HOLES
YPE OF OCCUPANCY: 7 V
RESIDD+Cz: Number of Bedroass OTHER: (Specify) Nur.ber of Persons
D WASTE GRINDER: Yes No Dis!afashers Yes No Automatic Clothes Washer: Yes No
FFUJENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC +i_N`T
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth t
Is the undersigned, hereby certify that the percolation tests reported on this form 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 Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME r, TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS i
DA i E ! t SIGNATURE
i
I