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AS BUILT SANITARY SYSTEM REPORT
a 01" 2J
OWNER Vk Lx S ° TOWNSHIP
SECTION 1,3 T~?/ N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
zA o Ave V 2 ;
SUBDIVISION LOT LOT SIZE U
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
,i
d
r
r
INDIC E NORTH ARROW
BENCHMARK: Elevation and description: F C40.4 /u e A
Alternate benchmark / C~ ry 0
SEPTIC TANK: Manufacturer: A7 f f C~ Liquid Cap.
I-j
Rings used:'L Manhole cover elev:2.0/~inal grade elev: -~=v J -3
Tank inlet elev.: ?i' 2Tank outlet elev.: 3
, Side, Rear Ft.
No. of feet from nearest 11 b
From nearest prop. line:Front_jlg Side3 Rear!-)it.
No. of feet from: Well ~C' . Building: 7 j
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
T .t
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: Length k 6 Number of Lines:--&;2_Area Built d
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: 7 C
No. feet from nearest prop. line:FrontL Side3~s, Rear"`t.
No. feet from well:) v No. feet from building-
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE
5
PLUMBER ON JOB
LICENSE NUMBER:
6/90:cj
i►G?iri~'iartr+"t~bInIRIE,13.3~d~`EWAGEY~EMIOTH AVE County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
186554
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
STAR PRAIRIE
ev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
038-1169-30-000
A9300010 S/a0j93 :J/
An.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
SepticL, 0(9 _ d Benchmark . O-7 --t, X00
Dosing u..k.~"1;~ 1 6
Aeration Bldg. Sewer (p 1,3
Holding St/Ht Inlet 7 3 '13,7
TANK SETBACK INFORMATION St/ Ht Outlet q 3.
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic a3 7SO j y l r ~1 NA Dt Bottom
Dosing NA Header/Man. ~t,0 gt 7
Aeration NA Dist. Pipe ,j 5
Holding Bot. System io -1 90.0
PUMP/ SIPHON INFORMATION Final Grade q i•`>
Manufacturer _ Demand t1~
„r
Model Number / GPM
TDH Lift Lrictio Systtem TDH Ft
Forcemain Length 4 1 Did. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Leng h No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
Mode Number:
INFORMATION Type CHAMBER
. / 7 /l 7 OR UNIT
w
System: u;
DISTRIBUTION SYSTEM
Header/Manifold ' I Distribution Pipe(s) t x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. ` LengthDia. 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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE,13.31.18,SW,SW, LOT 3, 210TH AVE.
-7 _a~ - -
V,; C4
Plan revision required? ❑ Yes ❑ No q~ f
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
IL HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNTY
~TMa
` STATE SA I A PERMI ~
-Attach complete plans (to the county copy only) for the system, on paper not less than
8%x 11 inches in size. ❑ C~ revision to eviousapplication
-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 9 p
• 6 +n v '/a S T31, N, R If (or) W
PROPERTY O NER'S MAILING ADDRESS LO BLOCK #
19 C iy
CITY,ATE / ZIP COD PHONE NUMBER „ l SUBDIVISION NAME OR C~SyM NUMB/ER
ep~" S/0G ~'fe~LC~ r s
III. TYPE OF BUILDING: Check one CITY = NEAREST ROAD ~J
( ) El State Owned ❑ VILLAGE ~/0 Tai 1~ U -
❑ Public 9~ or 2 Fam. Dwelling of bedrooms 3 PARCEL TNUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) l1`
1 ❑ Apt/Condo C~
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TY PE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 -W Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System- In-FillYv
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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) _ELEVATION
7.W G Z 5~ ~ / qv Feet Y / d Feet
CAPACITY
VII. TANK Site
INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank ( U d __X+ Fj Fj El Ej 1 [71 _1 Ej
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans.
Plumber's (P 'nt : Plumber's Signatu (No mps) /MPRSW No.: Business Phone Number:
11140 Na 7 t7W O. /(I kv'~ 7/J J - 3J
Plumber's Ad ress (Street, City, State, Zip Code):
U
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved 3apry Permit Fee (Includes Groundwater Date Issued ent S nature (N to )
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. 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. t pt sanitary permit is valid for two (2) years.
2. Your ganf&4permit may be renewed before the expiration date, and at the ti ne 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
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by id licensed
pumper whenever necessary, usually every 2V3 years.
6. If you have questions concerning your onsite sewage system, contact your local code admirirstrator 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.
H. 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 jail 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; yells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption sy:,tems; 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 1Worm; and F) all sizing informal ion.
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 groundwate r, ground-
water contamination investigations and"establishmenfof standards:"
SBD-6398 (R.11/88)
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.
Owner of property 61,4 y ou S* '/0 11,4 C*--, Jf
Location of propertyjw 1/4 Sw 1/4, Section T_2_LN-R/8 W
Township rdr ~r `r, ` e,
Mailing address
Address of site / I
Subdivision name n l~ e v ,cl `Fh a G10 Lot no.-.,5
Other homes on property? yes No
Previous owner of property - A"d N F
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?_ Yes 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 & THE SEAL OF THE REGISTER OF 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 (are) 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. X9/209 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
Signature f applicant Co-applicant
Date of Signature Date of Signature
a ~Va ens. n r.e
' I~ • N(' 'ES • jL' 19Jk PIPf '~F VA~ slung as 10
165 LBS.:N frua tASnce N. ah
OfN0 rf5 !11 r 71" IRON PIPE sr r, thne polr
h w •/A NE //r II w!/6Ntve / L BS /LN FT
II ~ TAat said pl si
O a Of vC7fS a i' a JLUMiNUM CAPPEV Sr 0010 CO, of •nr lands •ur
• r W COUNTY SURVFYt;R S MONO FOUND
• _ I _ j k 'z'rS~l • OENOrfS / IRON PIP! FOUNO II.-t•sdvD-11
2 t~OCNOre$ ACCESS PO//vr
L-j. That I have ful:
A Q O O UT/LlTY EASFNEN75 (NORTNlRh' STArFS POWER COMPANY/ St.tutas and tM
N /Sr CRO/.r rELfPMONE COMPANY/ and ae ppln9 the
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0 o RCVIS[D THIS II•
gIJNRR•S CRRTIrTI
As osssrs, we Met
..versa. dl.ldsd,
this plat is rew"I
.pproaal or abject:
RapertatK a[
Dtpartamt of
tbunsup or M
City of Nee Rl
st cro1N CIS
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In the pawatro of.
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ti 1 of the State of NI
QI w h~I the surveying, div
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wr ! It Lor 2 W LOT 3
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0 JAW-4444 I51.l7' seas
R J u Ny -mminslon expn
SN.~--rts~ - -s 210 !h_ Avenue
14
SW CORNER - - - - - - - - -/r- - _ _
SlC. /J, l!/N, B/Iw
SOUTH CORNER
UNPL A r rro LA 14/DS SEC 15, r5/N. R/Bw
A c R61A[CTipN
It'Sp•'YC: l0 .G.
M Owen, ws hereby restrict to 1 and Lot 7 to one (t) t,.,acn access point located (1) and (2) Wis. Slats.. NM IllIR .S c
on
the colon lot I1rw between tot I and tot 2, and restrict Int p ho ono (1) acceu mint h:fi~t.F.' Coati as taovideG oy Sec. 236-12(6h M& Slap
an designated on thin plat, in nowt no owner, poaaesaor, o , nor licenses, nor other
person shall news an riqht e1`
shown on the plat, other Vo of dlract the Ingress or egress with ilotA Avenue, as
by way of f the den esignated access points'. ~ 44-
Certified ed this.. :.1 day Of. -bLAv 7Ru A
'MIS /NS7B UNENr ONAFTlO BY CARL w NETFELD diouA A7~
Df•n+ftrnrnl of Agfhpullum. Tisch a Cmnumaf Ih010c"ot
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~+y A~v
ADDRESS: FIRE NO:
LOCATION: SGJ 1/4, 1/4, SEC. W,
TOWN OF: 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 to
help with the cost of the 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 system properly
maintained.
The property owner agrees to submit to the 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 from 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 DNR.
Certification form must be completed and returned to the St.
Croix County Zoning Officer within 30'days of the three year
expiration date.
SIGNED: L
I `
DATE:
77 09
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
LnEPAR`TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABORAND PERCOLATION TESTS (115) MADISOP.O. BOX N W153969
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT No.:BLK. NO.: SUBDIVISION NAME:
sue'/ sw'/a 13 /T 3/ N/R/gE (or) W
COUNTY: MAILING ADDRESS: 5!~ - 9~Z(oS
Ale, je 8 t. a 2
USE DATES OBSERVATIONS MADE
g Residence COMMERCIAL DESCRIPTION: PROFILE DES R PTIONS: PERCOLATION TESTS:
II~J Residence 3 _ New El Replace I O. a' / /S p f
RATING: S= Site suitable for system U= Site unsuitable for system 7
CO ENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LL HOLDING TANK: RECOMMENDED SYSTEM:1 tional)
LAVS [:1U MS ❑U ®S DU ❑S [ZU ❑S ZU -
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: / I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
o76 1-),5;, dO-35r",~ , 611 1,n. 5,
B p /I A
B- Z S~ 93• z 0-?"611 , - 4 It /517 S 9 - 3</ 4.-r.4 /,fin e>W- S.
1 -8b" J.
- 3 > 6-~~ c3f~~ //{~~-aco" 1511.3,";Pa4 B,44 26- (9 o- bn-M.S-",617 C
, 6h S-
BB- g°t 9a Sa p- 'j 5/
B- 8Co 9a I > 8 60
S b- S.
/1yL_P_x_ la
B-
_T_
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 PERIOD 3 PER INCH
P-1 a /D Z L
P- Z- 0 /d
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 8~0 9 ,
5 70
J_
i
7tlp
00
3
(Admi 1 2°
dersigned, 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
trativ and that tiie data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
s X99 Z-
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST GNATURE.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use suction must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Solt Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
's - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well .
is - Fine Sand Bldg - Building
Is- Loamy Sand - Greater Than
'sl - Loamy Sand - Less Than
'1 - Loam Bn - Brown
'sil - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic - Silty Clay fff - few, fine, faint
'c - Clay cc - common, coarse
pt - Peat mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
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