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CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 00 FEET OF SYSTEM C@OAR, L F N Q. I I 83 Cer~~wfi 51 A, h 18. 31' Slap ~ (00 A OAb INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK ALTERNATE BM: SePtlC 7Aa 10 e USW S ou House SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: O'tQ~S Liquid Capacity: 00 Opt Setback from: Well House Other Pump: Manufacturer Model# SizeJ~' Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM - Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet; ST outlet. PC inlet PC bottom rte' Pump Off Header/Manifold Bottom of system Existing Grade Final grade A II DATE OF INSTALLATION: d 5 PLUMBER ON JOB:, UIV~`~ LICENSE NUMBER: 3 Va Y i INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and HumanRelations INSPECTION REPORT ST. CROIX Safety and Buildings Divisio on GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI BOUMEESTER, THOMAS/ELIZABETH X CST BM Elev.: Insp. BM Elev.: BM Description: 0 L- Parcel Tax No.: TANK INFORMATION ELEVATION DATA ~s TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i:J 5 Get 7 Benchmark Dosing Aeration Bldg. Sewer H g St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se Ic Dt Bottom Dosing A Header/ Man. Aeration NA Dist. Pipe Ho 'ng Bot. System PUMP/ SIPHON INFORMATION Final Gra e nufacturer and Model Number Gp TDH Lift F Ion Ft F aln Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid DIMENSTIDN DIMEN IONS SETBACK SYSTEM TO P / L BLDG WELL LAKE LEACHIN r ' INFORMATION Type O CHAMBER -Wdel Number: System: OR UWT D T TION SYSTEM Header/Manifold Pi e(s) x Hole x Hole Spacing Vent r Intake Length Dia. Length ta. S acing SOIL COVER x Pressure Systems Onl xx Mound e S stems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded Bed /Trench Center Bed /T dges IT opsoil _1 Yes No ❑ Yes ❑ No nclude code discrepancies, persons present, etc.) LOCATION: Star Prairie.3.31.18W, Gov't Lot 5, County Road H Plan revision required? ❑ Yes Use other side for additional information. L~z- [(-/-v k I SBD-6710(R 05/91) Date Inspector's Signature Cert. No. ~ 1 ADDITIONAL COMMENTS AND SKETCH - SANITARY PERMIT NUMBER: t SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code ~S-~ I'OlX STATE ~IY6F,j+j~,Xl`/{y(IT# -Attach complete plans (to the county copy only) for the system, on paper not less than IT 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER ~ PROPERTY LOCATION A 4- 2cc C°. +2e15t~°~ ,/4 - ,/4, S 3 N, R If E (o) PROPERTY OWNER'S MAILING ADDRESS LOT # p V Pte` N M BLOCK # CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER i~ Miel~-4.3iVe? 11. TYPE OF BUILDING: (Check one) ❑ State Owned 13 VI AGE NEA BEST ROAD J /7 ❑ Public ❑ 1 or 2 Fam. Dwelling- # of bedrooms - PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 ❑ Hol 12 ❑ Seepage Trench 22 ❑ In-Ground rivy 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 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE PROPOSED s/da /sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed 9 Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Ky",7,4zi~~J MP/MPRSW No.: Business Phone Number: jo-me l~, oum~e;~~er L) , 3 X16 36, -q0 Plumber's Address (Street, City, State, Zip ode). IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater Date ssu suing Agent Signature (No mps) Approved El Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i 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 6399) to be r submitted to the county prior to instal la.i n. 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: 1. 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 arid/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) 0,~fQ r- Qo~~'eeaf~~. A loco aAx T Grl i . s~©1 T /-A46-4341 --fi~5~ - - - Di -Sill Alf ;Ko v Q o i Y 7 1 ` A) 16 ~ C1 1 STC - 106 1 1 PRIVY INSTALLATION AGREEMENT St. Croix County, Wisconsin PRIVY INSTALLATION AGREE M ENT - COPY TO BE ATTACHED TO THE SANITARY PERMIT APPLICATION. Property Owner(s): Reserved For Recording Data ~h~mas~r~ l I L, :~4, c , Mailing Address: s9-7 /7o'fh u e~ N e-w t IT: S J T-3 N R It E o r W City, Village. Township Of: Parcel Tax Number: - v Legal Description: 1. No plumbing will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permit to install such a system has been issued. 3. A privy vault/ pit shall maintain minimum setbacks as specified in Table 1. Table 1 Well Building Lake / Stream Additional County Setbacks Open Pit 50 Ft 25 Ft Min. 75 Ft ~~a~ q'veha 5 t n~ Sealed Vault 25 Ft 25 Ft Min. 75 Ft ~ u r el 0 ~u 4 Privies for public buildings shall comply with ILHR 52.63, Wis Adm. Code. 5. Privies used for one- and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and other vermin. Doors should be self-closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall comply the intent with ILHR 83.20, Wis. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. 7 The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 113, Wis. Adm. Code 8 This agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the register of deeds in a manner which allows its existence to be determined by reference to the property where the privy is installed. I Pnnte Owner s Names hp Yet q g 21>u meubscribed and sworn to before me on this date: Ow r s nature'. y~ Notary Pu he C~-~/~~~ ~OCz~2se My commission expires on: NOTE: This document was drafted by the State Department of Industry, Labor and Human Relations, Bureau of Building Water Systems. JOAN RITTER Will PubMtate of W bl S T C - 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. ri.21 of ~JO~-,ate M property ~ . /.z4 e4- aca ri-~~~s~e~ Location of ro ert PQ r't o~ "MC)71 LCT P P Y_ _1/4 1/4, Section, T_aJ_N_R /.9 W `fo";nship JS - r'alrie trailing address 7o'fJ7 yd!- rr, ~ H c~ i z/ D/~ Address of site p~~}, Sores d~ (1 ,cq~4in ~4~ ('~IUo qtr Subdivision name of Lot no. Other homes on property? es Y ____XNo Previous owner of property Con T a- C ~1 Total size of parcel C'" Date parcel was created Q h e ? 1 ~(v Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No volume B~ and Page Number S of Deeds. as recorded with the Register INCLUDE WITH THIS APPLICATION THE FOLLOWING: _ WARRANTY DEED which includes a DOCUMENT NUMBER, & THE SEAL OF THE REGISTER OF DEEDS. ~ In dditon AGa certified survey, if available, would be helpful so as to avoid delays of the reviewing references to a certified Survey Map, If hCertifedd SurveytMap shall also be required. PROPERTY OWNER CERTIFICATION :(we) certify that all statements on this form are true to the !jest of my (our) knowledge that I a t`ie property described (we) m (are) the owner (s of in th ) i -'arrant s information form, b de v y ed in recorded in th Y ue of a i:eeds as the office of the County Register Document No. o _S f 9 3 ~7 of the and that I (we) presently proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, the construction of said system, and the same has been duly recorded in the office of county Y Re o. gister of deeds as Document Signature of ap licant-u~m~~p►~ Co-applicant v 19 Date of signature Date of Signature