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LOCATION: STAR PRARIE 16.31.18.292A SE, SE CO. RD. CC
Wisconssn Department of Industry, PRIVATE SEWAGE tYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. RO
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 175634
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
COOK, DAVID U STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
038-1067-90-000
TANK INFORMATION ELEVATION DATA A9200293
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System mead TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type Of CHAMBER Moe Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code CouN
. _ . e..... a. ~„a.
STATE SANI PERMI
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. c if vi pre sous applicatlon
-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
'/as' s T3/ , N, R E (or) (0
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME O CSM NUMBER
Al W
11. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State Owned 0 VILLAGE : _
❑ Public 1 or 2 Fam. Dwelling~#of bedrooms 'PARCEL TAX NUM
III. BUILDING USE: (If building type is public, check all that apply) 0-38 _ 1616 7 _ 90
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
40 Church/School 80 Mobile Home Park 12 ❑ Service station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 M Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
120 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 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
DO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min. nch) ELEVATION
MW AW . 7 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
Septic Tank or Holding Tank - -
Lift Pump Tank/Si hon Chamber. Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installs on of the onsite sewage system shown on the attached plans.
Plumber s Name (Print): Plumb 's !net to MP/MPRSW No.: Business Phone Number:
/ -
Plum is ddr Street, City, State, Zip Code).,
G" IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
A v Daterminlgl2n
066
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (formerly Pib-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 ovinership 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 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 ,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.
Vlll. Responsibility statement. Installing plumber is to fill in narne, 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 thar 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 rather treatment tanks, building sewers; wells; water mains1water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absc-Ption systems; rep^acement system
areas; and the location of the building served; B) horizontal and vertical elevation references 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.
GROUNDWATf'R SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The roonies collected through there surcharges are user!:; for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R. 1 1!88)
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 04 v a
Location of propertyf,,- 1/4 _,5,ff-1/4, Section T_,JL_N-R_Z.S_W
.Township S -1~y L , r , -f
Hailing address _ b 6 f y Cc,
Address of site
Subdivision name Lot no.
other homes on property? yes No
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? No
Is this property being developed for (spec house)? Yes •,4-No
Volume-2ZLhnd Page Number .5JG as recorded, with the Register
of Deeds. .
INCLUDE WITH THIS APPLICATION THE rOLLOWING:
A WARIUVI1'Y DEED which includes a DOCUMENT NUIiDER, VOLUME AND PAGE
,
NUMBER & THE SEAL or- THE IUrGI57L , ;
It 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 ny (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 i the office of the county Register of
Deeds as Document No. , 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
Signature of ap~la.cant Co-applicant
i
Hate of signature Date of signature
1 iYf' y 3
g}
♦ F~~~19- ~ ~w ~n~f,'r ER
~ ♦ is
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.y
I , A BE SURE THIS SCRIP ION cOV R PROP TY
1 {
I
OWNER/BUYER 02 v
ROUTE/BOX 'NUMBER
ARE NO. 2/0 6
CITY/STATE S0 !'►1 rf f ZIP St/U S
PROPERTY LOCATION: ~1/9 ,S 1/91 Section , T N R W
Town of v4e i Y I I , 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.Crotx,,County Zoning Office within
30 days of the three year expiration date.
C.
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 9th Street
Hudson, WI 59016
(715) 386-4680
Sign, Date, and Return to above address
W t(*t,n0eoa•lr fetof'rovit/y, )Ulf Ut)Lhlf llVle n.r Vrel
rl,a~,W And mumfn RtlaUOns V foe .
(Attach Soil Profile Location Map - To Scale • On A Stparate, Signed Sheet) rladlton, S1: c'
Page L :r
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Additional Remarks: RECOMMENDED SYSTEM-TYPE:
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