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Wisconsin DepArtmont of Health and Social so-ricer
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
'TYPE or ME BLACK INK
A. 0MIER OF PROPERTY
Name Address (Street, City, Zip Cosa)
B. LOCATION OF PROPERTY W' FB SYST'"'M WILL BE CONS_ tRUC_ T_ED, ALTFRE' OR EXTENDED COU;t'n'
Check One:
CIT
Y VIDE LEGAL DESCRIPTION
MMS HIP
V
C. IS LOCAL PERIMIT REQUIRED FOR THIS WORK? ~ YES NO PEFMIT Y ~B € t
D. SEPTIC TANK CAPACITY lDi0r Gallons NEW INSTALLATIO"I REPL•kC=:'. NT ADDIT11314
MATaRIALS: Prefab Concrete Poured in Place Steel Other
NIMER OF TA 'Y.S TO BE NSTALL D; L t
E. TYPE OF OCCUPANCY
-Cheek One: One or Two Family Residence Commercial Industrial Other _
Spe.ify)~
Number of Persons to be Accomiadated Number of Bedrooms ~2
F. APPLIANCES, ETC: Food Waste Grin der YES A NO Automatic Clothes Wa>her L YFS NO
Dishwasher YYS NO At+- ti1 pot_to Pp.°le YFS- NO
Other (Specify)
G. NuASTLR PLUMER FLAKING INSTALLATION
~0 e_.~ L LAG rLl Ad9r~s ! / v, License Nu ,,ber:
j L S L?~1 L~ ~i 4~~ .If
rn
Sig; tune of Appiicant: % ' 'rat`- MP R514 _
Address:
i} `J / rZr_ Y~
H. (To be Cooplo-ted by Issuing Agent)
Fee Paid
Pate of Application
12
Permit Issued (datelo0or ~fCf~ t Permit Number
t~ .
Agent (Name) Lc/~ 1;✓. 1~ Ci /~4.L For
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all cf the above questions are answered and the
f fee paid. Agents will forward application, the fee of ;I.OG for each septic taro and the third copy
of the permit (canary to the Division of Health. Checks ano money orders snould be made payable to
the Division of Health.
Do not write in space below - FOR DEPART21ENT USE ONLY
is
I. DATE RECEIVED G ACCEPTED BY v RETMNED
(Initials) (Date) (See Corres
i
FEE RECEIVED ✓ VALID. No. / PERMIT NO.
Yes or NOT-
REVIEWED BY APPROVED DATI
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PF MIT NO.
R Z P 0 R T O N S O I L P Y R C 0 L A T I 0 N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLU-01N3 SaCTItiN
P.O.Box 303, Msdison, Wis. 53701
?u,wuant to H 62.20, Wis. Adninirtrativa Code
P E R C O L A T I O N T S S T
Teat D%V Character of Soil HotL~s Water Test Time Droo in rater Lcvel Lsohes li7lutes
Nis`;tibar Inches Thia:ma33 in Inohos Since Hole in Hole Interval Second to Naxt to *',s Po Fall
IIIII) 1st Wetted OterTif??1t in Minutes Last Ps-ia'1
Example ~ ~ ~ wv I
P - 0 361, Too Soil 10", Cla• 2611 25 Yes or Na 30 1 2 1 2 112 i - 6O
L
RECORD DATA FROM MINIPAJH OF 3 TEST `O
Compute size of absorption ex-.a in accord with H 62.20 Wis. Adainiztrativa Cod-
S O I L B O R I N G S 1"fin',,un 36" $ x Pro3osed Ahs;r~aaic~n ~y~t•,.~
Boring Total Depth Doh to o and D,th to ➢ droc=;
Number Inch,-Is ~Gbserved Estiat.ed+ Case.raed Esti atal Charact s' o:' Soil with Thic ra,33s Ln I?ches
Example
B - 0 7e'~~M^C 72" Blac: op bc1.~12"; C' * Sand 18';; C ravoi 2111
"J RgZGRJ DATA FR0;1 MINI:ILJ1I O_,' 3 BO?-- H0L7:15
TYPE OF OCCUPANCY: i
RESIOrs'IC£a Number of Bedrocas OTHER: (Specify) Number of PEP30n9 ,:OD W STE GRINDERS Yes No Dis?oasher: Yes No A Automatic Clothes
bfashsv: Yes ~r No
FFUJENP DISPOSAL SYSTEM: N:•f EXTENSION ADDITION RF.PLA.C:1"iENT
Tile Size No.Lin..Feet Trench Width Depth Number of Lines
Seepage Bad: Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Diamater ~7® Liquid Depth
I, the undersigned, hereby eert'"y that the percolation tests reported in this fora were made by me or under r9-• 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 t j(l TITLE Csi~r'
Type or Print)
REGISTRATION NO. or MAE TER PUMER LIC;-N'JSE NO
ADDRESS J
DATE ~Q Z2 1) SIGNANR%
r
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06 k
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Parcel 040-1115-10-000 06/04/2007 12:34 PM
PAGE 1 OF 1
Alt. Parcel 30.28.19.472E 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 - CRAIG, DANIEL & LISA MICKELSON
DANIEL & LISA MICKELSON CRAIG
143 SKYLINE DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 143 SKYLINE DR
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 30 T28N R1 9W PT NE SW LOT 1 OF CSM Block/Condo Bldg:
IN VOL I PAGE 289 ORD INCLUDES P473G
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/31/2002 685504 1937/56 WD
07/23/1997 573/355
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/23/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.044 50,800 197,300 248,100 NO
Totals for 2007:
General Property 2.044 50,800 197,300 248,100
Woodland 0.000 0 0
Totals for 2006:
General Property 2.044 50,800 197,300 248,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 211
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00