HomeMy WebLinkAbout034-1059-50-000 Ou nty an P ermit App ca 10 ST. CROIX COUNTY WISCONSIN
In accord with Chapert 12 St. Croix County Sanitary n e �LANNING & ZONING DEPARTMENT
Personal information you provide may be used for seco A ROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(i)(m)) 1101 Carmichael Road
Hudson, WI 5401 &7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
0
Application Information - Please Print all Information Location:
Property Owner Name
��� o 12009 1/4 114, Sec
N, R IS E (or W
Property Owner's Mailing Address Block Number
S1 . 4 1.{uljC iiUUN f Y Lot Number
V PLANNING & ZONING OFFICE
City, State Zip Code Phone Numer Subdivision Name or CSM Number
S D 7 71
1 Type of ui ing: (check one amity [] Village Town of
J M 1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use):
❑ State -owned Nearest Ro
1. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
Parcel Tax Nu r(s)
A) 1.0 Repair [ *'Reconnection ❑Non- plumbing ❑Rejuvenation
Sanitation
B) Perm' IV Date Is
State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
❑ Non - pressurized In- ground ❑ Mound 2 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter
❑ Drip Line
❑ Pressurized In- ground )4 Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating
Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min./inch) Elevation
1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con - Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
o r , ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ 1 ❑
II. Responsibility Statement
1, the undersigned, assume responsibility for repair /recd enction/r 'uvenationrnstallation of non plumbing for the POWTS shown on the attached plans. A
icense is not required for terralift repair o staliatio of non- lu ing sanitatio tem.
Plumber's Name 'nt) umber's nature t p MP/MPRS N Business Phone Number
T
Plumber's Address (Street, City, Sta Code) ✓
111. County Use Onl
ed Sanitary Permit Fee D to Is ued Issui Agent Si atu o st s)
K Approved Owner 'tial Adverse Z Z 5 • iac�
D mation 771
X. konditions of Approval/Reasons for Disapproval:
As per Pl��e-� ,, V;2/ ot,`S�'.1�, 2 hat&' �. rka ► °11�, 13 be.,' Ma�
e.vs Dial -`ol,. .'A- s r q/Z oq
ACt^ F�C'
Rev: 8/05
s
Form- S T C 104
AS BUILT SANITARY SYSTEM REPORT
OWNER X49 C"a?.2 P/2,M TOWNSHIP c d& SEC. T
� N -R W
ADDRESS L? ST. CROIX COUNTY, WISCONSIN
SUBDIVISION /� /tk. LOT N i LOPS SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
0
T_
r �
i
i
i
C i
E r
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference oint used
p G Esc :sue ,r,' C?r
:onir9 iDate -
This contract is made between the
lolding Tank Owner(s) Name(s) and Pumper's Name
I /
Ve acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
L
The owner agrees to file a copy of'this contract with the local governmental unit hereinafter called the "munici alit
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and p Y which has
with the County of
!. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
t. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit nilmber issued for the holding tank;
e. The dates on which the holding tank was serviced;
I. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
I. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
)wner(s) Name(s) (Pri I Owner's Signatures)
�ae£,e ��'IW 1 ,�- '
I Subscribed and sworn to before me on this date:
I ,
'Um er me n I
� u °� -p � Pumper's Signatu e
Notary Public
� My commis 'on expires:
'umper's Regi anon Number
a /
;BD -7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
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Document Number Document Title 903633
BETH PABST
St. Croix County RE D EEDS
Co. ST CO
RECEIVED FOR RECORD
Occupancy Affidavit for a single POWTS 09/14/2009 08:25AN
servicing Two Dwellings via PIMS ZONING AFFIDAVIT
J EXEMPT I
ko pe REC FEE: 11.00
ame — (Owner) Typed or printed PAGES: 1
being duly sworn, states, under oath, that:
1. He /she is the owner /co -owner of the following parcel of land
located in St, Croix County, Wisconsin, recorded in Volume 6$0
Page Y24D Document Number 3505 2$_ St, Croix County Register
of Deeds Office: Re cordinz Area
A parcel of land located in the NE ;/4 of the Nt,> t / 4 of Section Z7 Name and Return Address r j,tyc
T 21 N -- R 15 W, Town of So r:.,tilr:el� 3oq -7 o U e_
St, Croix County, Wisconsin, being duly d scr ed as follows 01N 150
(include lot number and subdivision/CSM or detailed legal t b /6-5 _ 0 — CCQ
description): ;a- }i gl fi 6� At 4,w QK < tkr CE 1h --F XU rT Pamel Identificati nNumber(PIN)
.b r 5&*s oe , 1 wc,�l.� ° Se�ev+ (Z f - M-041 n�+, � 2`�� /Vor4A, ti
As owner of the above described property, I acknowledge tgiat a Priva�bn -site Wastewater Treatment
System ( POWTS) serving the primary residence is sized for (o bedroom(s) with a design wastewater flow
of gZO gallons /day. (DWF calculation based on 150 gpd /bedroom @ 2 persons/bedroom). Two dwellings
will be connected to the POWTS via Private Interceptor Main Sewer (PIMS) in compliance with Comm
82.30(12). A maximum of !Z occupants are permitted. There are currently a total of occupants in
these residences, therefore the POWTS can be considered code - compliant at this time. However, I
understand that if the number of occupants exceeds the maximum for POWTS design, the system will be
undersized to accommodate any increased wastewater flows and/or contaminant loads and may be subject to
premature failure. I also acknowledge that I will disclose this information to any parties interested in
purchasing this pro e rtty in the future.
Dated this — day of �, � •
* *
* *
AUTHENTICATION ACKNOWLEDGMENT
tur s� STATE OF WISCONSIN )
(-- )ss.
St. Cr ix County. }
authenticat d this day of Personally came before me this, day of
`� the above named
*
TITLE: MEMBER STATE BAR OF WISCONSIN tQ =a
(If not, to be the person(s) who executed the
instrument and acknowledge the sa?. N
authorized by § 706.06, Wis. Stats.) 0 1 A R y
THIS INSTRUMENT WAS DRAFTED BY
�..; ti� 'T�_ci.�.n:c,�b� U'a X la�,.t� * • . � ���1�' OF W1�'4`�
Not Public, State of 3Uconsin
(Signatures may be authenticated or acknowledged, My Commission is permanent. If not, state expiration
Both are not necessary.) date:
Date: t AU (An Z ` 40
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE"
This information must be completed by submitter.• document title. nWg & retu ad and PZ (lf required). Other information such as the granting
clauses, legal description, etc. maybe placed on this first page of the document or maybe placed on additional pages of the document. Nqjr; Use of this
cover pp16f#s one page to your document and $2.00 to them ino a Wisconsin Statutes, 59.317.
Pam Quinn
Subject: Bowman /Prinsen - holding tank reconnection
Location: 3047 $Otte. Sec. 27 springfield
Start: Wed 10/21/2009 9:00 AM
End: Wed 10/21/2009 10:00 AM
Recurrence: (none)
C�`
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Sa and Building Division
INSPECTION REPORT Sanitary Permit No:
146
GENERAL INFORMATION (ATTACH TO PERMIT) state Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Prinsen, Robert I Springfield, Town of 034 - 1059 -50 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No:
27.29.15.411
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Bt Bottom
Dosing Header /Man.
Aeration Dis
Holding . System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHAMBER OR
YP Y UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes E] No 11 Yes 0 No
I
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 3047 80th Avenue Wilson, WI 54027 (NE 1/4 NW 1/4 27 T29N R15W) 40 acres Lotcle. j / No: 27.29.15.411
1.) Alt BM Description = ,A%
2.) Bldg sewer length = � G ' &"d " G �� "-
- amount of cover =
'back 41� _Zkmt S � e�x��
Plan revision Required? Yes ❑ No 'v.v
Use other side for additional information. M�=
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
County Sanitary ermlt pllca to ST. CROIX COUNTY WISCONSIN
In accord with Chapert 12 St. Croix County Sanitary n� A DLANNING & ZONING DEPARTMENT
` Personal information you provide may be used for seco purposes . CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
fol Hudson, WI 54016-7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
1. Application Information • Please Print all Information Location:
roperty Owner Name
,, t C q 1/4 1 /4, Sec
&wf 29 N SLP 01 ZOOS N, R E (orfA
Property Owner's Mailing Address U' OUN i N' Lot
Si GkVIX Numb er Block Number
3 047 Alf) v pLp,Np11NG & ZONING OFFICt
City, State Zip Code Phone Numer Subdivision Name or CSM Number
t 5 0 . VM
I Type of ui d ng: (Check one) ity []Village ^Town of
1 or 2 Family Dwelling - No. of Bedrooms: `
❑ Public/Commercial (describe use): L
❑ State -owned Nearest Ro
I. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
Parcel Tax Nu r(s)
A) 1r [ .X'Reconnection ❑Non- plumbing . ❑Rejuvenation
Sanitation
B) Perini Wr Y X , , g Date Is
, t
State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
❑ Non - pressurized In- ground ❑ Mound t 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In- ground )4 Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating
. Di sal/Treetment A rea Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min. /inch) Elevation
1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
ec r .w r ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
II. Responsibility Statement
1, the undersigned, assume responsibility for repair /recd enction /r 'uvenationlnstallation of non - plumbing for the POWTS shown on the attached plans. A
icense is not required for terralift repair o ' stallatio of non- lu ing sanitatio stem.
Plumber's Name (print) umber's ' nature t p MP/MPRS N Business Phone Number
Plumber's Address (Street, City, Sta Code)
III. County Use Onl
ed Sanitary Permit Fee D to Is ued Issui Agent Si atu o s s)
X Approved ial Adverse Z Z
D
X. nditions of Approval /Reasons for Disapproval:
I As I per P i�, �- �.� 9/z�o� o rr 5 �'.1 2 16' �e, A46U sQ &JL
A� G��.. ;� i,�ke.k �lo�..�� �r`at>✓r �a /�,ale� >�.
O� Ip tc. o... $ It (y�— 'l' .a� e. �✓� 7ow �- �+�F.(�C o ,n, � fi
— ow-_ 6 a lltr 26 'l �of` rc, dw; Zr.d1
Rev: 8/05
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER I�9 '�2•l"� �1I 'hJ TOWNSHIP -�?d&'AJ6 SEC.4a T N -R W
ADDRESS A f- __ ST. CROIX COUNTY, WISCONSIN
t S
1 : 3 �
SUBDIVISION /� /tk LOT N A LOTS SIZE 4U/
PLAN VIEW
1HR 8 3
an dimensions to meet Distances d requirements of I q
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i s
1
1 �
lea'
f 9
� 1
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point _! y, _ = Proposed slope at site: -1�:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: / /� Tank manhole cover elevation:
Tank Inlet Elevation: ` Tank Outlet Elevation:
Number of feet from nea s Road.: Front,O Side
,O Rear, O feet
From nearest-pr pertyine Front,OSide,ORear,O feet
Number of feet fro : well , building:
P
Include this information of the above lot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
PUMP CHAMBER
Manufacturer:_ Liquid Capacity:
Pump Model: /` Pump /Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: " Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 It
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depths Bottom of seepage pit elevation:
Area Built:
Has either a drop box Q or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: �, :.'ts' ti f C's Pacity:
Number of rings used: Elevation of bottom of tank:
a
Elevation of inlet:
Number of feet from nearest property line: Front, O Side,�Rear, 0 Ft.
Number of feet from well:
Number of fer!t from building: -
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
,.
Dated: Plumber on job:
License Number:
3/84:mj
. 844 PA5E 675
>cumerft No. This space reserved for recording data
HOLDING TANK AGREEMENT
;ireemeintDate g REGISTER'S OFFICE
This a is made between the
— — —
>unty or Local Governmental Unit Holding — Tan k s) — Owne r — — — — — — — s) T. CROIx CO. WI
TDON OF .SI /E /V j t J Recd for Record
'alled Municipality below) I �I� I Sh at `� 3 1989
11:30 A. iM
'e acknowledge that application is being made for the installation of (a) holding ro /� .���w
ink(s) on the following property, (Provide legal land description:)
v (.�l tM^;.iC.
i of Deeds'"'
. _
_..__ Return To
that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
swage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
h. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats.
s an inducement to the County of Sr- l_.. �� to issue a sanitary permit for the above described property,
e agree to the following:
Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty 0 days, the owners specifically agrees Y ( I ees that all of
Y P Y 9 the costs and charges may be laced on the tax roll special assess -
9 as a s
Y P P
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county.
This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall sg0� +'>ttki� to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existg &of ttre agreement
to be determined by reference to the property where the holding tank is installed.
Nner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn to,06fab me on4his date.'
Poia oe
unicipal Official Name (Print) I Municipal Official Signature Notary Public
I My commission expires:
r�3Q F 4 PRIAV FLUB I
unicipal Official Title (Print) I /0 - 1 - `l
CL-ER K
313-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
HOLDING TANK SERVICING CONTRACT
i
;oniract Date
This contract is made between the
lolding Tank Owner(s) Name(s) and I Pumper's Name C 's
befel
Ve acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality ", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of l— 901 Y
!. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
t. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
1. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
)wner(s) Name(s) (Pri I Owner's Signature(s))
�aa�� J b'D�lh I x �t7.�, e �1,�','t.va„/
Subscribed and sworn to before me on this date:
ZL_A-
)umAe , dame n � Pumper's Signatu a Notary Public
(� I My coAsexpires:
'umper's Registration �Number
'-1 /
'BD -7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
• t
HOLDING TANK CROSS- SECTION
Approved Weather Proof
Vent Cap Junction Box N
Approved Locking Manhole Cover
4�� C•I• �— With Warning Label Attached
Vent Pipe T And Padlock
Minimum 12
Final Grade
4" Minimum
Approved Joint _ - ,
18" Minimum
dater Tight—'' �
Seal Hig S W l ater \ \F '
A.l a rno Swi tc� 1
SPECIFICATIONS
TANK New Existing Approved Joint
Manu of cturer: _ w/ CA e
. Pi
/'I7 �Dd.SES r �2c' �'�T P
Blind C.I. Tank Size: cf ads al ons Extending 3'
Plug ALARM Manufacturer: S LckC�7 Onto Solid Soi;
Model Number: , j is ,
Switch Type 146
NUMBER OF BEDROOMS
GALLONS PER DAY C0(}
3" of Bedding Under Tank
Owner's Name: �S
Address:
Legal Discription: _, " ^0 ,j G
Township/Municipalit
�
County:
Y
ONSITE SEWAGE SYSTEM
PLUMBER /DESIGNER A W
v�. E
Signature:,��
License u r v k �
Date: r �
DEPARTMEN i fir, IP D U F'Y - OMI AND H):NMAN RELATIONS
iVi__.jON, OF SAFETY AND BUILDINGS �
SEE COkRLSiN)idDENCE
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SANITARY PERMIT APPLICATION
R In accord with ILHR 83.05, Wis. Adm. Code COUN
_ � 1 &0
STATE ANITAR PERMIT
- Attach complete plans (to the county copy only) for the system, on paper not less than ❑ �a o
8%z x 11 inches in size. C eck if revision to pre ous application
—See reverse side for instructions for completing this application. STATE PLA I.D. NUM4ER
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. Yin p�
PROPERTY OWNER P LOC
Q� /Z //d szG � , /t/ 5 ' Y. tW' /a, S,,P ;' T- N, R /J' E (orifV
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
4- �-
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
f CS�1 fS S"`�O.•z S'
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ V LL AGE NEA EST ROAD
c:2
❑ Public �1 or 2 Fam. Dwelling - # of bedrooms PAR EL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) 4 1/
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining
4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash
5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 �5 Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY . 2. ABSORP. AREA 3. ABSORP. AREA 1 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
��tr11�1 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION
60 Feet Feet
VII. TANK CAPACITY Site
in allons Total 's Name Prefab. Con- Steel Fiber- Plastic p
INFORMATION New istin Gallons T nkk Manufacturer A
s Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank 0411 /e
Lift Pump Tank/Siphon Chamber El I El El F 11 = o - 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name (Print): Plumber' Signa re: (No S ps) P / No.: Business Phone Number:
�.� CJ 2 �6' ZS2-&
Plumb 's Address (Street, City, State, Zip Co
2 0- a _ 2 5 �
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved anit ry Permit Fee (Includes Groundwater a e Issu Iss Agent Signature No Stamps) 9 74 Approved
El Given Initial Surcharge Fee)
Adverse Determin tion / � — VA
. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
SBD -6398 (formerly PIb -67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
1
4
DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.Cq. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707
State Plan I.D. Number:
iQ , NW ► 2 7 , 2 9 , 15 ❑ CONeNI t ❑ALTERATIVE (Ii assigned)
n�r in g field n H RRTcbHen olding Tank In- Ground Pressure El Mound
NAME OF PERMIT HOLDER: ADDRESS OF R: INSPECTION DATE:
Robert Prinsen Route 1 Wilson WI 8 -10 -89 P
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number:
Lyle rI ers 1 6219 St. Croix 128609
SEPTIC TANK /HOLDING TANK:
MANUFACI "UR.ER LIQU / CAPACITY: V TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
y �j fj PROVIDED: PROVIDED
(� G✓ v! i / CJ r L b dl r YES ❑ NO DYES ❑ NO
BEDDING: VENT DIA.• VENT MATL.: HIGH WATER NUMBER OF I ROAD: PROPERTY WELL: BUILDING: I VENT TO FRESH
YES ❑ NO C
ALAR YES ❑ NO NEARES�� LINES /�
DOSING CHAMBER:
MANUFACTURER: I BEDDING: LIQUID CAPACITY: P PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCK COVER
PROVIDED: , PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST --- ► � I j
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY NG: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: WELL: BUILDI 1 7 LET:
NEAREST -'�
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED PTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES: DE
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. I DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV: ELEV: DIA.: ELEV: PIPES: DiA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS' PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERT' WELL: BUILDING:
FEET FROM
❑ YES ❑ NO ❑ YES ❑ NO NEAREST —►
Sketch System on
Retain in county file for audit.
Reverse Side. TITLE:
SBD -6710 (R. 06/88) Zoning Administrator
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Parcel #: 034 - 1059 -50 -000 08112/2005 04:26 PM
PAGE 1 OF 1
Alt. Parcel #: 27.29.15.411 034 - TOWN OF SPRINGFIELD
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
ROBERT PRINSEN O - PRINSEN, ROBERT
3047 80TH AVE
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 3047 80TH AVE
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE
SEC 27 T29N R1 5W 40A NE NW Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
27- 29N -15W
Notes: Parcel History:
Date Doc # Vol /Page Type
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/26/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.000 4,250 0 4,250 NO
UNDEVELOPED G5 1.000 50 0 50 NO
OTHER G7 2.000 9,550 49,800 59,350 NO
Totals for 2005:
General Property 40.000 13,850 49,800 63,650
Woodland 0.000 0 0
Totals for 2004:
General Property 40.000 13,850 49,800 63,650
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 138
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
r
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER "I'LL" P/b rlJ 'XJ TOWNSHIP li(IG
SEC., 7 T N -R�W
ADDRESS 12 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT N Xq LOT SIZE oCJ /l
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
i
i
1
3
:
y :..... ?
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used '' %�'�. `., x /, V(0/
Elevation of vertical reference point: . Proposed slope at site:
SEPTIC TANK: ManufacturerN j Liquid Capacity:
1 /
Number of rings used: T �/ Tank manhole cover elevation:
I
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from neaj, st Road: Front,Q Side 0 Rear, O feet
From nearest pr perty ne Front,O Side, fee Rear, O t
Number of feet fro : well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: t / Liquid Capacity:
Pump Model: Pump /Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft:
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Lenith: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,O Pt.
Number of feet from well:
i
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer:/), 'c. f Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, Rear, OFt. �;
Number of feet from well:
Number of fe:r,t from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: �/ �Qf Plumber on job: ' 11
License Number:
I
3/84:mj
x '
DEPARTMCNT OF INDUSTRY INSPECTION REPORT FOR SAFETY &BUILDING
LABOR & HUMAN RELATIONS DIVISION
P BOX 79M ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707
State Plan I.D. Number:
i ► NW ► 2 7 ► 2 9 , 15 El CONV elL El ALTERATIVE (If assigned)
WRb�gnniringfieldn Holding Tank In- Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF R: INSPECTION DATE:
Robert Prinsen Route 1 Wilson WI 8 -10 -89 P
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber MP /MPRSW No.: County: Sanitary Permit Number:
Lyle Myers 6219 St. Croix 128609
SEPTIC TANK /HOLDING TANK:
MANUFACT LIQUID APACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
� URER /f� �e�o PROVIDED: PROVIDED:
/'� a l ❑ NO I CKYES ❑ NO
BEDDING: VENT DIA. VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
/� / ALARM: FEET FROM LIN AK T'
YES ❑ NO 1. r YES [j NO NEAREST ���
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: P PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO I ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ) ❑ YES ❑ NO NEAREST---*
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST —♦
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
[::]YES ❑ NO [DYES ❑ NO
DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO E] YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND
ELEV.: ELEV: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY I WELL: BUILDING:
COMMENTS FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST —
Sketch System on Retain in county file for audit.
TITLE:
Reverse Side. Zoning Administrator
SBD -6710 (R. 06/88) Th OLL1,aZi y n
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couN
_ R o 1
STATE A
–Attach complete plans (to the county copy only) for the system, on paper not less than � � Rx PERMIT
8% x 11 inches in size. ❑dec if revision to pre ous application
–See reverse side for instructions for completing this application. STATE PL A I.D. NUM R
I. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. g of
PROPERTY OWNER PR
PERTY LOC * TION
"S A) '/a ti��' j /a, S:� � T N, R ��`�� E (OnfV
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #�
�/
CITY, STATE ZIP , CODE PHONE NU MBER SUBDIVISION NAME OR CSM NUMBER
(
II. TYPE OF BUILDING (Check one)
S tate Owned VILLAGE : NEA EST ROAD
�,'6
❑ Public �91 or 2 Fam. Dwelling –#f: of bedrooms PARCE TAX NUMBER(S
III. BUILDING USE: (If building type is public, check all that apply) 411/
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining
4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash
5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION
60 I I Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exp
INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glaze Plastic App
Tanks Tanks structed
Septic Tank or Holdin n
Tank Fj
Lift Pump Tank/Siphon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name (Print): Plumber' Signs re: (No to ps) 4 k4POPRSW No.: Business Phone Number:
Plumb 's Addre�eet, City, State, Zip Co
22- z — _s 2 - S
IX. COUNTY /DEPARTMENT USE ONLY
❑ Disapproved snit ry Permit Fee (Includes Groundwater Date I ssued tss Agent Signature No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adv rse D ter inatio.
. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD (1399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266 -3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in #1 -7.
VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% X 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD -6398 (R.11/88)
689
t
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r
77 to
GIN-
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2
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HOLDING TANK CROSS- SECTION 2
Approved Weather Proof
Vent Cap
Junction Box ,r
Approved Locking Manhole Cover
4 C.I. With Warning Label Attached
Vent Pipe T^ And Padlock
Minimum 12"
Final Grade
4" Minimum
- 7 f Approved Joint t _
18" Minimum
4ater Tight- M '
t
Seal High Water '
A13rto Sw i tch � ,,,
SPECIFICATIONS 1 '' - _ _ - - + ��
TANK New Y Existing Approved Joint
Manu of cturer. F r w/ C.I Pipe
Blind C.I. Tank Size: c , ao&, G allons Extending 3'
Plug Onto Solid Soil
ALARM Manufacturer: S', kr-c -r-"
Model Number: .4&j is I -
Switch Type ,rte'
NUMBER OF BEDROOMS i
GALLONS PER DAY ca
3" of Bedding Under Tank
Owner's Name:
Address: rs d L s syd,�7
Legal Di scri pti on: ,l
Township/Municipal
1 t
County: �7--
SY STEM
PLUMBER /DESIGNER 4
Signature:
MA
License u r i0 `
Date:
', N!' jj.., A.N RELATIONS
D idGS �
i v i ... ,.;:! U.
,
�6_e. . i w #�SYi..•.�.6`
i
(
HOLDING TANK SERVICING CONTRACT
Cont'raci Date -
This contract is made between the
Holding Tank Owner(s) Name(s)
and I Pumper's Name !�+ C _ S C �� i�L IC /lC
P�
& / A &
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
1. The owner agrees to file a copy orthis contract with the local governmental unit hereinafter called the "municipality ", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
I. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Pri I Owner's Signature(s)
�oPiWS.�� I �
Subscribed and sworn to before me on this date:
9 Z1
Pu �ame�Ppint� � I Pumper's Signatu a Notary Public
��((,� ��C[ �5(( My commis 'on expires:
a /
Pumper's Regi t atwn Number
SBD -7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
. 844 PAGE 575
Documertt No. This space reserved for recording data
HOLDING TANK AGREEMENT
Agreeme Date g REGISTER'S OFFICE
This a is made between the
—
---- — — — — — — — — — — — —
(County or Local Governmental Unit I Holding Tank(s) Owners) ST. CROIXCO ., WI
Recd for Record
- A t j N OF SP0Jw9- F!E /D I JUN v 41989
Called Municipality below) I R 6 15, ✓ ( G ? F g0 jt j , 5 41j at 11:30 A . M
We acknowledge that application is being made for the installation of (a) holding ro
tank(s) on the following property, (Provide legal land description:) V
Register of
d 941-11
Return To
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats.
As an inducement to the County of s c y8 Ix to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall s tagreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existlgnc of the agreement
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn td d me on „this date: 1X_P JQ�11
b j 9 ;; X7 1
Municipal Official Name (Print) I Municipal Official Signature Notary Public
I gj My commission expires:
Municipal Official Title (Print) I I o ” 1,3 — y/
C _ E R K ix
SBD -6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
'DEPARTMENT OF RE PORT ON SOIL BORINGS AN D SAFETY & BUILDINGS
QU
INSTRY; _ __e __ _ ___ DIVISION
LABOR AND PERCOLATION TESTS (115 MADIS N BOX 969
HUMAN RELATIONS
(1LHR 83.0911) &Chapter 145)
LOCATION: SECTION: TOW PH hINOFIELD P /MUNICIPALITY: LOT N O.: O.: BLK. N SUBDIVISION NAME:
E'14 /T',qN /RISE (.49 J
COUNTY: O NER'S BUYER'S NAME: MAILING ADDRESS:
S o o R �/ W
USE DATES OBSERVATIONS MADE
��yy{{
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
X Residence ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CON . M S . Ju IN G � P RE: SYSTEM -IH
ILL � ING TANK: RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: Floodp ind Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B" ! 0- 6 1 0 1 ,51L , 6- �G: s jt wl,-ic cl or
B- PR O *° S �° - S °° /si/ I S - /, �'G si/ wl e -iC oT
B-3 J > o o ztloxl e 6 ,yam s
B- y/ 9 9, S z tl f 7 4,5 A3
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 P R D PER INCH
P-
P-
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
E
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PB
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o
I • '�N
• ••
NQc�S.E �
F •
ja
3
3 •
t
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NA (print): TESTS WERE COMPLETE N:
A RVS: CERTIFICATION NUMBER: IPHONE NUMBER (optional):
C 36 a
C NATURE:
'ION: Original and one copy to Local Authority, Property Owner and Soil Tester.
4
I '
)-6395 (R. 10/83) — OVER — a -
Aik ___ —
' .
� INSTRUCTIONS FOR COMPLETING FORM 115 ' S6D - 6395 ' ~
�
To beucomi)ecm ar id mrooemSoUteoc
� 1 Cnmp\*,* |ega|desoription;
2 TMe use section must clearly indimsevvhotho/ this i«a residence u,00mm*rniui pm/o#;
3, MAX IMUMnumbe/of bedrooms o/ commercial usop\annod,
� 4� b this u new wrmp!mcemcnto\stom;
5, Complete the suitability rating boxes, AS|TE \SSU)TABLE FOR A HOLDING TANK ONLY IF ALL
�
OTHER SYSTEMS ARE RULED OUT BASED 0N SOIL COND|T|OWS�
| '
8, PLEASE LJSm the abbleviations shown herel for writing profile descriptions ancl completing the plot plan
� 7. MAKE A LEGIBLE diagram accurately locating your tom locations, Drawing to scale is preferred. A
oepam� sheet may beused ifdesi/ed;
8, Make sure your hpnchma.kand vertical elevation ref mnce point amc|eady shmwn, and are permanent-
3. Complete all appropriate boxes as to dates, names, oddmses.flood p(aindata, poruo(ationtest oxvmp'
� if appropriate;
� 10, if the information (such ax flood plain, elevation) does not app/y,cdacv N,/\. in the anprop/iotebox;
� 11 Sign the fo'n and piaoo you! current address and Your conificmionnumber�
� 72� Make legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE
�
LOCAL AUTHORITY WITHIN 3U DAYS DFCOMPLETION.
�
ABBREVIATIONS FOR CERTIFIED SOIL l[ES
Soil Separates and Textures Other Symbols
5 — Slone (Over 10~} BR — Bedrock
rob — Cobble (3 lO") SS — Sandstone
Or — Gravel (under 3") LS — Lim*slonu
Sand HGVV — H|8hGvouod��ator
o — CoanoSand Pem — Peno<adnnRotc
mod s — Medium Sand VV — Well
� N — Fine Sand Bldg — Building
|o — Loamy3and > — GmmerThmn
� ^x/ — 8andyLoum < — Less Than
°| — Loom 8n — Brown
Si|c Loam G! — Black
Gy — 8ray
~d — 0ay Lnnm Y — Y�
vJ — ��ndy Clay Loam R — Red
oio� — �U,v C|av Loam mot — &;o�|mx
oc —
Sandy Clay w/ — with
sic — Si|ty Clay f f — few fine faint
- — C lay *: — Common umre
pc — Pe �,l, mm — 1"Viany, nmdium
in — Muck d — distinct
u—pmnimm�
HVVL — High water |evoL
° S|xg*nooa| soil tvxlxrro ourlomywm�or
fur ummedispOe| BM — Bench K8ark
VRP — Ve,doo< Rofa,en:w Point
�
�
�
�
TO THE OWNER: �
�
This soil test report is the first step in securing a sanitary permit, The county orthe Department mayrequest |
�
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private �
� xmvago system and a permit application must be submitted to the appropriate local authority in order to
obtain o permit, The sanitary cw/mk mum be obtained and posted prior to the uartnfany oonnt,u�--tinn.
�
`
�
----- -----------
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER /BUYER /) b b rt n S e, -1
ROUTE /BOX NUMBER e6X J FIRE NO.
CITY /STATE So Y) M S ZIP
PROPERTY LOCATION: A,r1 /4 /4, Section, TZ R_�W,
Town of sb 1 ', h 9 �� �1- , St. Croix County,
Subdivision , Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the , requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I /WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE n,,,, 2S
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386 -4680
Sign, Date, and Return to above address
01 M
4;
oa"Moto of record a"
Ni
cartan Land Contrin ut"I"W
jecor Uotember 8,
De"s for St. CmIx
Vk-
$ 17
........ .......
wt h6r
A: 4,4
40 10
V r
Ax
j, 41
1`
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner /contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property 1 o
Location of property Mr- 1/4 N.10_ 1/4, Section , TrV) R_
Township -73 �'j .n9 T
Mailing address
Address of site
Subdivision name
Lot number
Previous owner of property
Total size of parcel FQY ran
Date parcel was created
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for resale (spec house)? Yes X No
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER Ott DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (ate) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. 390 S cZ•g ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the Count Register of Deeds, as Document No. ).
Signature of Owner Signature of Co -Owner (If Applicable)
Date of Signature Date of Signature
;.
. .. _ _