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Parcel 040-1115-60-000 06/04/2007 04:06
PAGE 1 OF 1
F 1
Alt. Parcel 30.28.19.473C 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 - GUSTAFSON, GERALD W
GERALD W GUSTAFSON
306 GLENMONT RD
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ` 306 GLENMONT RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 5.090 Plat: N/A-NOT AVAILABLE
SEC 30 T28N R19W 5.09 AC W 168 FT OF E Block/Condo Bldg:
840 FT OF NW SW EZ-UT-1508/431
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1198/492 WD
07/23/1997 724/105
07/23/1997 465/558
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.090 71,500 160,500 232,000 NO
Totals for 2007:
General Property 5.090 71,500 160,500 232,000
Woodland 0.000 0 0
Totals for 2006:
General Property 5.090 71,500 160,500 232,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 315
I
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
Plb. #67 10/69 Division of Health
PERMIT APPLICATION
for
PRIVATE DaIESTIC SEWAGE SYSTEMS
7 f el/
l
A. OdNER OF PROPERTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
County
B. LOCATIO14 OF PROPERTY WH- RE SYSTEM WILL BE CONSTRUCTED, ALTER D R EXTENDED
gheok One:
CITY VTll.SGE LEGAL DESCRIPTION:
/
TOWNSHIP {l
~7 z t f?- , ~,-i ~ ='/Y rC fir. rl~_ ?
C. IS LOCAL PERMIT REQUIRED FOR THIS W rcx? YES NO PFIVIT NLTMER
D. SEPTIC T'ANK CAPACITY Gallons NEW INSTALLATION REPLACEMTFNT ADDITION
MATERIALS: Prefab Concrete F/ Poured in Place Steel Other
NUMER 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 ' Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES --'-~N 0 Automatic Clothes Washer ,11__Y~ES NO
Dishwasher YES NO Automatic Potato Peeler YES /NO
Other (Specify) _
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Prench Width Depth Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
C
Seepage Pits Inside diameter Liquid Depth ter" fOF
' /.Ssn V
PE RC 0LATI ON TES T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches `P1.*rItres
Number Inches Thickness in Inches Since Hole in Hole ~IntarvaI Second to I Next to last <To Fall
rin Miautes Last Period Last Perio Period One Inch
1st Wetted
fxuvple OverighT
P- 0 3611 To Soil 1011Clay 2611 25 es or no ! 30 1/2 112 1/2 60
Fr .
RECORD DATA FROM INInNI OF 3 TEST HOLES
Compute aize of absorption are-. in acoord with H 62.20 Wis. Administra ive Code.
S O I L B 0 R I N G S- Minimum 3611 Belau Proposed Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock
giber InchRS Cbserved EstiTa.ted Observed Estimated Character of Soil with Thickness in inches I
xample
- 0 7211 7211 Black To Soil 12"• Cla 1811• Sand 1811, • Gravel 2411
i
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
i _
NAME / r~ f/, / ~0 ~fJ TITLE
(Type or Prim/t)
REGISTRATION or MASTER PLUM ER LICENSE No.
ADDRESS .Jy~
DATE e / Ca SIGNATURE
MASTER'PLUK-3E:R MAKING APPLICATION
MP
Signatures License Number:
MP RSW
(To be Completed by Issuing Agent)
Date of Application Fee Paid $ G',
,y
Permit Issued (date) C Permit Number.
Agent (name) / U_, For:
Tocm, 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 DEPARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY RETURNED
(Initials) _ (Date) (See Corres.
FEE RECEIVED VALID. NO. ~ - ` PERMIT NO.
(Yes or No)
~f
REVIE:4ED BY l ~ APPROVED DATE
(Initials) (Yes or No)
CGMMNTS.
. `
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