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N d a L: a Y r`F~1 +9 E c U a) c 3 r A 0 a O in V A-90 0111 • Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division NE SE ' 2 7 , 2 9 , l (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION g 0th Ave 149252 Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.: Dale >Ieyers Baldwin CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: y 27-29-16-412A TANK INFORMATION ELEVATION DAT 2 TYPE MANUFACTURER CAPACITY STATION HI FS ELEV. Septic Benchmark Z. 3 /235' e)b .GD ~ l Zl Dosi n /,Z • 3 1 08 Aeration Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ Outlet v dtY -2. 27 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic i NA Dt Bottom Dosing - NA Header Aeration NA Dist. Pipe /z.~i3 99.9' Holding i Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model-WL mber GPM TDH Lift Lriction Syst~ TDH Ft Forcemain Length Dia. HH Dist. well SOIL ABSORPTION SYSTEM BED / TRENCH Width _ e I LengthNo. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Type O Cvq t CHAMBER Mode Number: System: ~_r211 S OR UNIT DISTRIBUTION SYSTEM Header /mod Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length i Dia. Length 12 Dia. __5L Spacing l~ 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 Edges c: Topsoil E] Yes No ❑ Yes E] No Bed /Trench Center 6 COMMENTS: (Include code discrepancies, persons present, etc.) C,Q Plan revision required? ❑ Yes Imo Use other side for additional information. c~ SBD-6710(R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNT DILHR . ..e..,..,...~...e. I - 0 - C~~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. h 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 Pq lw, 14 e. G e S N- F/14 s-.F S 9, T0,~ , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER NEAREST SAD 11. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE El Public 1 or 2 Fam. Dwelling-# of bedrooms ~ PAR LT ARX NUM ER( ) III. BUILDING USE: (If building type is public, check all that apply) r A 14, 41114 1 ❑ Apt/Condo ( 2 ❑ Assembly Hall 60 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. ew 2. ❑ Replacement 3. El Replacement of 4. El 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 El s age Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 L~I'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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 3 I D U r U 3 M 99.6 ?P. G Feet 1 G 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 Holdin Tank D uV bd F-I Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu is Signatur (No Stamps) ffAPRSW No.: Business Phone Number: toe Etc, n G G 4( 4. `/s' G~~-~~GG Plumber's Address (Stree , ity, State, Zip Co : 15,11 W I.vt 116 4. w6OC , 114_ h/t S ,~-llp Z IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Hilary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No s) -ism Approved El 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. A sanitary permit is valid for two (2) years. r 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 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. 11. 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; close 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) a APPLICATION FOR SANITARY PERMIT STC-100 This application form Is to be completed In full and signed by the ovnet(s) of the property being developed. Any inadequacies will only result In delays of the patmit Issuance. -should this development be intended lot tesale by thrts should retained the completed tr when r# e property Is mold and submitted to this offi appropriate deed recording. Owner of property O4 /e Ale-r--T? Location of property N_,:~ 1/4 S 1/4r Section - 2 W Township Walling address Address of site .Su- 8ubdivision name Lot number IV - Previous owner of property Total also of parcel . r Date parcel vas created , Are all corners and lot lines ldentlflable? _,,,_Yes 0 Is this property being developed for resale ('spec house)? ,Yes -_>to Yoldwe -and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINGt A WARRANTY DINO which Includes a DOCUMENT NUMBER, VOLUNR AND PADS NVMBZR, and the 8EAL OF THE REGISTER OF DEEDS. In addition, a certlfled survey, It available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Ceitlfled Survey Nap, the Certified Survey Nap shall also be required. T PROPERTY OWNER CERTIFICATION I(Ye) 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. j and that I (we) ptesently own the proposed alto for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, lot the construction of sold system, and the same has been duly recorded in the office of he County Register of eeds, as Document No. f gnature o wner Signature of Co-Owner (11 Applicable) Dale of Signature Date of Signature - cn a r STC - 105 t" a • H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z c7 a OWNER/BUYER Qq H ROUTE/BOX NUMBER - 2 S U "yc- Fire Number CITY/STATE ;_t ZIP PROPERTY LOCATION: N~ SE~ 14, Section, T ~ N, R~W, St. Croix County, Town of Subdivision Lot number • I I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to H three year expiration. ° E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- "d ment 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 St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. r Q ` y D 0 v o o c c F rte j n 1/~ N NM. ~ d) .C rt 3 3 0 to O j Z N 7 O'*ii ~p N D r m 0 01.3 o m N v° rl N c rn c 3 N to - 0 ~j 3 3 m v o N ? G fC I X 3 ? 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