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Parcel 042-1041-10-000 01/18/2007 12:40 PM
PAGE 1 OF 1
Alt. Parcel 15.29.18.236C 042 - TOWN OF WARREN
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 - CAVE, WM S & MARGARET A
WM S & MARGARET A CAVE
1234 HWY 12 ✓ A V ~
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1234 HWY 12
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 15.000 Plat: N/A-NOT AVAILABLE
SEC 15 T29N R1 8W W 3/8 OF SE SW Block/Condo Bldg:
EZ-U-1556/315
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1215/549 QC
2006 SUMMARY Bill M Fair Market Value: Assessed with:
149283 Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 37,500 Q1 49,4W) 186,900 NO
COMMERCIAL G2 2.000 8,000 T6,200' 54,200 NO
AGRICULTURAL G4 11.000 1,300 __.-,---0 1,300 NO
Totals for 2006:
General Property 15.000 46,800 195,600 242,400
Woodland 0.000 0 0
Totals for 2005:
General Property 15.000 46,800 195,600 242,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 302
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
I
Wisconoin Departrent of Health rnd Sooial Sorvieos
Plb, #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. (1-4TER OF PROPERTY 4 12- 3 Y(A I v
Name Address (Str t, City, Zip Code)
B, LOCATION OF PROPERTY WITAE SYST12I WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check One: j~
CITY VILLAGE
IPTION
TOWNSHIP LEGAL DESCR
/ -47
~i
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NU`MBZR
D. SEPTIC TANK CAPACITY _ Gallons NEW INSTALLATION REPLACEMENT ADDITION
?1ATERIALS: Prefab Concrete Poured in Place Steel ' Other
NUMBER OF TANKS TO BE INSTALLED: ~f
E. TYPE OF OCCUPANCY
Cheek One= One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANLES, ETC: Food Wasto Grinder YES it NO Automatic Clothos Washer==.YES NO
Dishwasher YES NO Automatic Potato Peelor YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
c r
i
k 1 ii
Name: i 1 ! C t t" Address: x f t License Number:
s MP
a ~ r 4
Signature of Applicant::' MP RSW , F
Address:
H. (To be Completed by Issuing Agent)
Date of Application i7 Fee Paid #
Permit Issued (date) - Permit Number
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 for-Kard application, the fee of $1.00 for each septic tanK and the t:,ird copy
of the permit (canary) to the Division of Health. Checks and money orders should be msde payable to
the Division of Health.
Do not write in space below - FOR-DEPARTMENT USE ONLY
1. DATE RECEIVED - ACCEPTED BY RETURNED _
(Initials) y (Date) See Corres.)
FEE RECEIVED VALID. No. PE.RklIT NO.
Yes or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE 017hER SIDE
l
SEPTIC TANK PEFu`!IT NO.
R E P O R T O H S O I L P 3 R C 0 L A T I 0 N T E S T
A N D S O I L B 0 R I N G S
TO
~tl^~
DIYISICII 07 HEALTH - PLLiIB.U:G SEC°TIt-
P.O.Box 309, r.dison, Wis. 53701
Pursuant to It 62.20, Wis. Adninistrative Code
t As►or;
~..t r 6
EA.
P E R C O L A T I O N T E 5?
Test Depth C'naraotar oP Soil Hours Water Test Ti:oo Drop in dater Level Inohcs Minutes
Number Inehaa TIVtolmess in Inchos Sinco Holo in Hole Interval Second to Next to Last To Fall
Ist Netted OvenliAht in Minutca Last Poriod Lust PoriodlPcriod G:x Inch
Example
P - 0 3611 To Soil 1041 C1^.y 2611 25 Yes or No 30 112 1 2 1 2 60
/ 3%
r
RECORD DATA FRCM MINIP1UM 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=am 3611 Bel" Pro used Abso tion SYSte,n
Borinj Total Dopth Depth o Gxou l{at or Da th to Bedroc.;
Number Inohos Cbservod EZtinatod Caserved Estimated Character of Soil with Thio!sness in Inehss
P.xamplo
B - 0 721f 7211 Black To Soil 1211; Clary 18111 Sand 1811• Gravol 2411
RECORD DATA FROM MINIMUM OF 3 BORE HOL•.':i
YPE OF OCCUPANCY:
RESIDENCES Number of BodroonA - OTHER: (Spooify) Number of Persons
D WASTE GRINDE43 Yes No Distrsasher: Yes No Automatic Clothes Washers Yes No
t_
FFLUE`7T DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth ry Number of Lines a
Seepage Bed: Length Width _ Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I
r
~I, the undersigned, hereby certify that the peroolation tests raported 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 Adainistrative Code, 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. ti MASTER PL03ER LICENSE NO. ?
ADDRESS
DATE y SIGNATURE