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020-1159-68-000
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CROIX COUNTY, WISCONSIN H' I�ef W15 SUBDIVISION / " /y t StQ/'1 fo LOT d LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Y r y � y f ► .k W E $ i i ! A4 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used -[dlo ° f o le'G p d Elevation of vertical reference point: 6 6� Proposed slope at site: �O SEPTIC TANK: Manufacturer: f �' r Liquid Capacity: Number of rings used: %L- Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: r Number of feet from nearest Road: Front Rear, O feet I � From nearest property line Front, Side, Rear, 7 feet O Number of feet from: well g , building: 0 A (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Y" Manufacturer: Liquid Capacity: Pump Mo del: Pump/Siphon hon 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,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed. Trench: Width: Z Lenth: Number of Lines: Area Built: Fill depth to top of pipe: 01 Number of feet from nearest property line: Front, OSide, O Rear,0 Pt . � ` Number of feet from well: l Ll 7 Number of feet from building: f (Include distances on plot plan). SEEPAGE PIT N 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 141 ,4 Manufacturer: 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 feet from building: i Number of feet from nearest road: Alarm Manufacturer: Inspector: o�cri` Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS "& HUMAN RELATIONS P.O..O.BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING SE4iNE4,Sec. 16 ,T29-R19 ❑CONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number Town of Hudson Lot 20 El Holding Tank ❑ In-Ground Pressure ❑Mound Itf assigned) 564 Minnie Rd. NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE: �f- � Thomas J. Stanck 783 Larson Lane �I �j/, d BENCH MARK(Pe(manent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No.. Cnunly Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 112841 T SEPTIC TANK/HOLDING TANK: MANUFACTURER: IDOID PACITY. TANK INLET ELL V.. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER �y PR��OVyyIDED: PROVIDED. ��-� / �Vo?•ZS & YES ❑NO DYES NO BEDDING: VENT DIA.: VENT MATt HIGH WATER NUMBER OF / PROPERTY WELL- BUILDING. VENT TO FRESH ALARM FEET FRO C LINE— �}/? /O JAIR INLET DYES NO f DYES O NEAREST J /y �. DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACI I PUMP MODEL jPtjMP,SIPHON MANUF ACTUHEH WARNING LABEL LOCKING COVER PROVIDED PROVIDED: ❑YES ONO ❑YES NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER Of r.P"(IPEHTV WELL BUILDING]VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM' LINE AIR INLET. PUMP ON AND OFF) EYES ONO NEAREST'► SOIL ABSORPTION SYSTEM.Check thesoil moistureat the depth of plowing FORCE FN(,TH IIIIAMITEH 111ATIRIA1 A.NO MAHKING or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BFw D/TRENCH - WIDTH LENG7N NO OF UISTH PIPE SPACING COVE" ,INSIDE DIA PITS LIQUID THENC�IiES MljiEF IAL: PIT 2 �C/ G ,f, DEPTH. GRAVEL DE H -- FILL DEPTH UISTH PIPE DISTH PIPE DISTR,PIPE MATERIAL NO DISTVi NUMBER OF `PROPERTY WELL BUILDING: VENT TO FRESH BE LOW PIPES ABOVE COVER EIEV INLFI ELEV ENU PIPE; - LINE ^ 9 ql T_ G '' 2 59 y7 99 .3�l�?7-2� a °"" l7 S MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE III HMANI NT MAHKEHS OBSERVATION WELLS 1:1 YES ONO OYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED IlEPi11 OE TOPSOIL S(1DUF D " UFD MULCHED CENTER EDGES ❑YES. ❑NO DYES ONO OYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH T TRENCHES LARAL SPACI NG GHAVEL DEPTH BELOW PIPE- FILL DEPTH ABOVE COVER DIMENSIONS I,MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL IPID DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV. ELEV DIA ELEV ES DIA DISTRIBUTION INFORMATION "HOLE SIZE HOLE SPACING DRILLED COHHECT L COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES El NO 1:1 YES NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. PROPERTY WELL. BUILDING: NUMBER OF, FEET FII)M . L\ OYES El OYES ❑NO INEfi 1 30 0 6)j— Sketch System on lain-in county file for audit. Reverse Side. SIGNAT TITLE: /y DILHR SBD 6710 (R.01/82) -.- SANITARY PERMIT ' C�IIL' R TRANSFER/RENEWAL -COUNTY UNIFORM PERMIT (PLB 67-� - �- y, PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D.NUMBER: PRgqOPERT'Y LOCATION: CITY: .l 1� �4 '/4,S ��,T Z N,R I�+� or VILLAGE: I I TOWN OF: ``� K.1 S 0 'l LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: 4 U D ,; r� �`'� PO 7 " PHONE NUMBER: ADDRESS: -F A .5 PHONE NUMBER: ADrJIFSS: I the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER'S SIG TURE: -ee� PREVIOUS PLUMBER'S NAME (CIF/CHANGED)@ G V: 'S PL BER DDRE S: 8 n ;/ /; 1 /1 '7 PRE`IOUS PL MB�R'�AD;RESS: �vGt' `5 MP/MPRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER:r PHONE NUMBER: UMBER: MF �' �3y ( 71�, � g7 3,� 3 3 7 ( �I ► 7 �� 33 �� SIG) URE OF ISSUING AG NT: DATE APPROVED: DISTRIBUTION: Original-County Copy-Bureau of Plumbing DILHR-SBD-6399 (R.5/82) Copy-Owner COPY-Plumber LILHR SANITARY PERMIT APPLICATION COUN In accord with ILHR 83.05,Wis.Adm.Code ! ,�f e4 STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / I a / 8%x 11 inches in size. check if evis on previous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PROPERTY OWNER _ PROPERTY LOCATION h,t lr 5% t/a Ale %,S TZ , N, R 1 E(or PROPERTY OWNERR's MAILING ADDRESS/ LOT# BLOCK# 7 -v L— 7 r �' � Leh CITY,STATE tI `1 Zr 1 f 1PHONENUMBER 2 �C Y SUBDIVISI NNE METR�CSiu)t *UMBER � / d � ;,o II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ��/ State Owned ILLAGE l`4-46, J2 9❑ Pubiic LJ 1 or 2 Fam.Dwelling--#of bedrooms 3 PAR EL TAX NU/'f ER( ) III. BUILDING USE: (If building type is public,check all that apply) C// 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. R New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System System Tank Only > �t Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit# 11 °�g ( Date Issued--10 "t V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 I IJ-'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 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 � t IF 2 3 f g, Feet L y 1 . Feet VII. TANK CAPACITY Site in gallons 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 Lift Pump Tank/Siphon Chamber EE VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumb is Signature:(No mps) MP/MPRSW No.: Business Phone Number: 7 ;M,X,c�� /i/ PI u ber's Address(Street Cl ,State,Zip Co e): IX. COUNTY/DEPARTMENT USE ONL .-'' ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Agent Signature(No Stamps) proved ❑ Owner Given Initial 9.0 Surcharge Fee) Adverse Determination 130 laaw — � X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROV : 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 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: 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. Vill. 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 maim/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) " 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 / ��`►� S .� Sa Location of property 1/4 1/4, Section E , T ` N-R j q W Township {� Mailing address _ 4 Address of site Subdivision name Lot number Previous owner of property T-h e `'` e 14 Tim q aw Total size of parcel 04 CUA&S� Date parcel was created Are all corners and lot lines identifiable? Yes N Is this property being developed for resale (spec house)? y Yes No Volume and Page Number /7 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 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. ---------------------------------------------------------7--------------------- 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. ; 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 M thCounty Register of Deeds, as Document No. ) . Signature Yof wner Signature of Co-Owner (If Applicable) 10)_ y Date of Signature Date of Signature -�i' w3^fir�'' �" Y �,+«1►.w'p.�4 �'t � .r:i •pM••Y+�' '"��� �� �l•1��(1Mw ��L.v�jG�' +•A��••�1�R , ♦�,•a.• tW1 IMfY.x�M{I•, 4.••!f►s1�•NM�A � �w^ cI IIN a4 pt CXIMY ��.�+a.ieF.iir4•-wa-.,»w t '�� X g* r� ... I•` wisp -....- .. . ............. ... ... .... yy tows !1 TA*m- o 5 offeeK, 4 13AI -� v*k- T* e 'f" j *p= rpr e 7. E t n 5c Al 4,Opt fill 4 t4 P z 7 JJ- 1 ' R �= I 1 In A I e 41% lbR. Zk. 1 OL e DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUI VISI GS INDUSTRY, ( `�'A� SOIL 1. it Dt'VISION LABOR AND 115 PERCOLATION TESTS 1 P.O. BOX 3707 HUMAN RELATIONS ) MADISON,WI 53707 (H63.090)&. Chapter 145.045) LOCATION: ) SECTION: TOIGlNSHIP/MU itC;IPALITY: LOT NO.:BLK. O.: SU¢DIVISION NAME ✓-/ ,E�9s r / -� /T /R/' E fors �> say✓ v�' COU TY: ZOWNER'S BUYER'S NAME: IMAILINU ADDRESS: f USE DArES OBSERVATIONS MADE __ —T -----. ----- ---- ---- --- - - —--.,---- NO.BEUI3MS.: CUMM AL DESCRIPTION: PROFILE- ESCRIi-'TIONS: �ER��LATiON 11Z]Residenc�e_ ZNew ❑Replace I _,� I / Y7 l RATING:S=Site suitable for system U_=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ES�u o s ❑u os au �a s [Z u [--IS au �,,,��,fn�,�� If Percolation Tests are NOT requir�d DES RATE; If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 7 BORING ZOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH I# ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B / B-2 '? n 7 �/.4.Z/! l7iJS.I o 1Z J B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER tfJE+tf$ AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P P- ��' ? P- _. P S jjsz c, P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what arf 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 ar d l e 0 it of land slope. _ ? `�! SYSTEM ELEVATIONS l / / y !-�r. . C'f Mz tN x 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 th isconsin Iministrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief_ TESTS WERE COMPLETED ON: �S: CEH f I I ICATIUIV UMBER: PHONE NUM&F- S;l I ATL 3F:� [ t ,rte. TOWN OF HUDSON PERMIT FOR ACCESS DRIVEWAY IN TOWN OF HUDSON A,1 Permit Number 7., Nanle and Address of Applicant /., Highway County JXV TOWN OF HUDSON 'gyp ,of Driveways Number of Driveways Proposed Land Use Completion Date Location of Driveways IL L+ side of the highway_`'`L'k miles of Quadrant L— Section Township lf,641 North Range h Required Drainage Structure If No Drainage Structure, State Why s v � G Description of Proposed Work (include specaa--restrictions, intersection clearances, other details and reference to any sketches which may be attached.) / Cj .2 Z. U t Any driveways shall be constructed In accordance with all requirements printed on the reverse side, and any special conditions stated herein, The maintenance of the driveways shall be the responsibility of the applicant. Issuance of this permit shall not be construed as a waiver of the applicant's obligation to comply with any more restrictive requirements Imposed by local ordinances, CzA'11S �,Y Signature of Applicant ate Approved by Town Chalrmav Date DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR a-WUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION MADISON,P.O.ISO 7969 N,WI 53707 BUREAU OF PLUMBING SP4,NE'4jS16,T29N-R19W ,CONVENTIONAL ❑ALTERNATIVE FState—Plan l.D.Number. El T (lf assigned) T'awn a� HucGsan g Tank ❑ In-Ground Pressure ❑Mound Lot 20 Nonth.2ine Station NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE. t TheoAdatce TAe taw 709 Michaetsan Wat, Hudson, wI 54016 BENCH MARK(Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV. Name of 11.1-7' MP/MPNSW No. County Sarntary Perm t Number. Hw J. Neehv-i,Ue 3258 St. Ct oix 112841 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO ❑YES ❑NO BEDDING VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING VENT TO FRESH ALARM FEET FROM LINE: AIR INLET. DYES 0 N [--]YES 1-1 NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID(1APACITV PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO DYES ONO I ❑YES ONO 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) C_�YES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LE NGTII JNO1 O IDISTR PIPE SPACING COVER JINSIDE CIA -PITS LIQUID BED/TRENCH THFNCHES MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DE PTN FILL DEPTH UISTII PIPE DISTR PIPE: DISTR.PIPE MATERIAL. NO DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPFS ABOVE COVER F.I.EV INLF L ELEV END PIPES FEET FROM LINE. AIR INLET. _� _ NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER ITFXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES NO DEPTH OVER TRENCH BED DEPTH OVER THENCH.HED DEPTH OF TOPSOIL JSODDF D SEEDED MULCHED CENTER EDGES ❑YES ❑NO DYES ONO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO OF LATERAL SPACING JGRAVELDIPTHBELOWPIPI FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV, ELEV CIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING; DRILLED CORRECTLY COVER MATERIAL VERTICAL LIE T CORRESPONDS TO APPROVED PLANS ❑YES ❑NO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING FEET FROM LINE: ❑YES ❑NO DYES 1:1 NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. GNATURE: TITLE SI DILHR SBD 6710(R.01/82) Zoning Admi.vi i,6tnatan SANITARY PERMIT APPLICATION COUNTY .( DILHR�„ In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY 7 MI# -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 9%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES C+NO PROPERTY OWNER PROPERTY LOCATION mofo a t/a '/a, S T� , N, R E(or W PROPERTY OWNER'S MAILING ADDRE S LOT NUMBER BLOC N BER DIVISION NAME 7n9 / �C�a�/so LC/ IP SU fX le a& CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK O/ U LLAGE: • A1— o` II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. l_J New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE�O�F SYSTEM: (Check only one in#1 and only one in#2) 1. a. L�J Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPT!9X SYSTEM INFORMATION: (Check one) 1. a. See a e Bed b. ❑Seepage Trench c. ❑See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROOPOS,ED'(Square Fee): Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New rxisting Gallons Tanks lConcretel tructed glass App. T ks Tanks Septic Tank or Holding Tank MOO Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: I=iy" 21jokDA 'XS- 7 9 3 Plumber's Atl re (Street,City,State,Zip Code): Name of Designer: Vlll. SOIL TEST INFORMATION Certified So'I Tester(CST) ame CST# /�LQr, C� CST's ADDRESS(Street,City,State,Zi ode) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S anitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial 1c^J1 /�y� =e Fee Adverse Determination l4 -W �i X. C MMENTS/RE SONS FOR DISAPPROV L• . SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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 musrbe approved by the permit issuing authority. A new permit may be,needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. 'Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. !f you have questions concerning your privat sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: !. Property owner's narne and mailing address. Provide the legal description where the syste -i is to be . installed; II. Type of building or use served: If public Is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; Vi. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. Thi:a change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater included the creation of surcharges (fees) for a number of regulated practices which Wisco*in`5 a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that burden Ire85u re is used in your building is returned tc the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. 0 The monies (,ollectec? through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural R%sources. These funds are used for monitoring ground- t water, groundwater contamination in•restigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owners) 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. ------------------------------------------------------------------------------- 1 Owner of property T F oil(9►Z r-� , y ��0� {f I Ari L T RF_ PTo \V1/ Location of property S W 1/9 _1/9, Section //o_ , T�N-R_Z2 nW Township c Z... Mailing address 70� �lr ,lcl/ CU Address of site 1 AJAJj 1-4 AiL Subdivision name„f ,grw L nr- Lot numberL i Previous owner of property T.atP HA,us d- 4,oa .Sr1°IP/y."S Total size of parcel Date parcel was createdL� Are all corners and lot lines identifiable? _Yes No 1 Ls this property being developed for resale (spec house)? es No Volume '77? nd Page Number la5V 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 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. ------------------------------------------------------------------------------- 1 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 warrant deed recorded in the Office of the County Register of Deeds as Document No. ; and that I (We) ��{R9g 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 County Register of De , Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) �G Date of Signature Date of Signature I A A 3 ' / D 0 7 � v _ �l11 , i ..� .,..,s,y,��..t.• ..,�.,., n1o. WANIAMY Wn L s nM asseme o aar& a'I'ATi BAY OF 1R3CON8IN >rOE>f[ !—� Orl1C! -- --- - o., w� Doaaid Stephens and Lori S rtephens, husband and aurvivoir.. . a 1�3 ................shi....._-ro... r� -A&........ ...... .....�? �? ...................."A warrants to TeQdOre H Tre . .................... .... Ptow and�kow ......___...••.xiusk;uld..-diidW1-f. �..a viyrshpr �1• 1 ►G v. .... ....................................................... >�h 1 .....................................................••••..........._•••....... .._ . ........_.......... ........ __ -- ----- 1 ��r .... ......................... ................................................-.._..__._ .. ttartIMt TO 1 the fellewing described real . ..... ............... estate iA .._S.t iltaRe of Wiseeasia: ••••Croix.......................County, 1 �o Tas Pared No:..... —. 1 Lots Nineteen (19) and Tw � of Hudson. enty (20) of Northline Station II in the Town T 1 �� 1 z 1 to 1�1 °O CO ►�, This ...1a.-not.......... homestead property. (T i (is) (is not) ls>teeption to warranties: O Dated this ..........18th............................... day of ......... . ....... . May. ........ ....... .. . 87 ......... 11..._. .. .......(SEAL) Is1• .Donald Stephens .....(SEAL) �I • ..Lori Stephens ..................................(SEAL) .(SEAL) ±± ADTHRUTICATION ACKNOWLXDGK RNT ', afsaatute(s) .......................................................... STATE OF WISCONSIN ............................................................. . . • •-•, St. Croix authenticated this ........ ...................................... Personally came before me this ....18th...day of klay._........-. 19--8 7 -•---.-.•..._.. ---•-•. •._... the above name) AQA?"'d- teP.11`eDs..and_-Lorr•Step wAp -OF_-•----•-------------------- TITLE: YEYBEB ST ATE BA1t WISCONSIN (If sot,..........._..-_... _ 0 1 ......................................••... autherised by 768.06. Wis Stats.) .....................................--................... to me known to be the -I .�'' ......... person _ , wf4 e: ted the TM'S.INSTRUMENT WAS oRArTEO my forego* instrument and ack W �khl.• ed `. Reinstra, Van Dyk & Needham, S.C. Attorney 1--> Nt__ �h{n9nd. Wisconsin 54017-0127 Tan .....L. Glaser .? f�; �> •� - ` \ N (SiSnatmres may -- Croix �• . ._...- . Notary pub11C .......`St•...... i r O sre not necessary.) authenticated or acknowledged• Both my Commission is permanent.(If not, g o [�-- y •v 1k \ o date: o .3-31-91 - O ~deNnf i•ahY 4pacltY should be tYped or printed below their signatures. ....� SWIM aTAT= W 0V w1eCONS,, yl S mast No. a.. Ira: Sft& No. 13M / C-3 N S�( _ / C CV 0 0 2s,00 I \w \ \ \ F 280 / �i'� ►� w « , O N 9002> 1 ' 0Q � '2\9. 90 0 27'37 1 444. _ - 663•p0 O 1 -1 ��' , - 225•p0 N wti' _ - s9° �- C� R G �� 438•�� �� � O I 33 , O w CD to _ I O O ',Q 1 1D p `� QQ Cb 1 \� N y r o�� 438• ° N 1 �-� o n m 3g'W w o O° w = I \v o < 1 ° \° 70 1 cr 90 1 I 0. I -A \ 34\56 1 m, -1 O N \ ! mi 0 438.00 Z n I 0 1 1 0 1 so 2\36 6 /4;.010, I t O °- 1 O 1� �+y O O 0. N / 3 O N 0 1 / O (T ��\ 0 4'56.()0 O S 2 00 �\ \ SOO?156,E 11 504-06 T 9.36 \ \ 66.00--a� tip - Z., `40 Y U, D ,J1 O 1 , \ .P O 00 D C2 N 0 N \� 00, gso 40 � 20, Sall w C� 82• N \ ° \ gso \ \ /0 \ o \ 20 S O 299 20' 01" X1,0 N / \ S9" � S N / o STC - 1705 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER 7D � Gl�,�S��f FIRE NO. CITY/STATEr u. �SD/1/ ll�, S ZIP '�Dlfa PROPERTY LOCATION: X1/9 1/9, Section AKo , T_tN, R ,4L4G) Town of d S d'4.) , St. Croix County, Subdivision NnR7'f/ J-jA).t o-q)�&d r, Lot No. OZ 0 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED V DATE St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, * DIVISION HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.09(1)& Chapter 145.045) LOCATI N: ,/ SECTIO% �/� (or OOWNS t IP/MU ACITY: LOT NO.:BLK. O.: SU DIVISION NAME: �/ 6 S COU TY: OWNER'S BUYER'S NAME: MAILING ADDRESS: 4Z— '74,_o USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMME IAL DESCRIPTION: PROFILE S R PTIONS: PERCOLATION TESTS: 4 Residence Z New ❑Replace 99 7 RATING:S=Site suitable for system U=Site unsuitable for system IIC ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ®$ ❑U ®$ ❑U DS ❑U ❑S Z U 0 ®Ui,�E��>,A�,�/ If Percolation Tests are NOT requir d DES RATE- If any portion of the tested area is in the under s,H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORINGI TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH NUMBER DEPTH M. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- > B- Alm,- > 8' _ B- g > / �3 B-S- 7 > L&/3 Z 1,edas B- Ar TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER-FNQIIF! AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 P PER INCH P- ! (v Aid 4-P- P-. P S P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what ar 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 a of land slope. SYSTEM ELEVATION �� 3j _ 3 i X_K_74 -------- ''Q 1 el iE E [ E i z 3 I 1 t - a z i t_J [( g€ € %_ L_ 1,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 isconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief_ NAME(pr' t): TESTS WERE COMPLETED ON: AD SS: CERTIFICATION UMBER: PHONE NUMBER(optional): CST S QAIATIA E: 6L,�9, DISTRIBUTION: Original and nne copy to Local Authority,Proper Ly Owner dnu Soil Tester. DiLHri-SSC�-5395 6 02/82': - OVEP — INSTRUCTIONS FOR COMPLeTI.NG FORD 115- SBD - 63911 To be a complete and accurate soil test,your report must include; 1. Complete legal description; 2. The use section most 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 relalacement 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; fi. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plotplan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desire(".]; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Ccarnplete all appacapriate poxes as to dates, names,addresses, flood plain data, percolation test exemp- tiora, if appropriate; 10. If the information (such as flood plain,elevation) does not apply, place N.A.in the app opi iate box; 11. Sign the form and place your current address and your certification number; 12, Dial€e legible copies and distrit)ute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols st -- Ston(3 (Ove'r 10") BR - Bedrock co ID - Cobble (3- 10") SS Sandston�e gr Gravel (sander 3"( LS Limestone s - Sanc1 HGVV - High Groundwater Ors cozftse Sand f erc, Percolation Rate, Mediwn `:]and vV - "'No 11 is _. I z ,a Saner k1'=.I]e`s - T?uildin!t t -- L.,TrziT4'tit Ijeitlfi __ {.ti c'iz?_E,'r Than -Si - Sandy Loam - Lass That" - l.etasn Bn - r! n OVII it Loarn B ... Black, Silt 3y Gray r[ - Clay Loam y Yeliow S awly C'.ay Loarci R _. Rv,:i Sic! - s>ity Clay Loa,; mot 4fUtrles sra 5(wov Salty La.y rff { m c f ., P __. p I E_9 j`i'i(a E?Iit HVVL 1-1i'i h, via t e'v,:,l, `„^c t;e;neral soil ie;xtur€:s surface, t, ,t;E- �r ' lirlu s{ „vast= disp'--al HM - Bench (dial! V[JP - Va 11 :l Rfr:aren „ Poirrt TO -rHE OWNER: �; soil test rc he rt is t(fe first stop in securing a sanitary faerrmt. The count`; r�Th7'D Depart ,as n", array rc-eguest vu,s icat.o,i of this -E,t ,est in the field print, to p s¢rait ;ss(.rmce. A cornplaa(e set (=f plant-, f=,r the private a pet"]"nit ar)plicana m mast be stibrn eft„l to 1ho approptiFin" local authovil.=,° in Girder l.o rho SArWaiv lie>rs-€'rat rnust be obta '.:d and ponied prim it) li .,tai t of any c'onz trrlctaom ' _, � �� . ��'Nl ry ��c-�i,trj G L �,.c �.z �"S /°�r.�►,,c.�.,L 0 7l S-- 749- 33,E 4 -65- r ,lam�y6 � I � �--�9� �• a i D- 3' 26- ?0/ DiLHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm. Code STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑NO PROPERTY OWNER PROPERTY LOCATION '/4 %, S T , N, R E (or�.W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER 7n CITY NEAREST ROAD,LAKE OR LANDMARK ❑ VILLAGE: Q TOWN OF: II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1,and only one in#2) 'I 1. a. ❑Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet El Private ❑Joint El Public CAPACITY VI. TANK in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Tank/Siphon Tank ❑❑ ❑❑ ❑❑ ❑❑ ❑❑ Lift Pump Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT j I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: If Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) ❑Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber J INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: r 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; ll. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; Vi. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DI!HR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. -------------------------------------------------------------------------------------------•----------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground,�ater included the creation of surcharges (fees) for a number of egulated practices which Wigcot�sirhs can effect groundwater. The surcharg,� took effect on July 1, 1984. All of the water that buried treasure is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. � Q The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural R=,-sources. These funos are used for monitoring ground- f water, groundwater contamination ir--estigations and establ snment c-i standards. aroundwate.1, it's worth protecting. SEM-6398(R 03/86) DiLHf SANITARY PERMIT APPLICATION COUNTY �a In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑NO PROPERTY OWNER PROPERTY LOCATION ..,� '/4. 1/4, S T , N, R E PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK ❑ VILLAGE: 171 TOWN OR II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. ❑ New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing system has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) 1. a. ❑Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ,.- - Feet ❑Private ❑Joint El Public VI. TANK CAPACITY Site in ga ons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ El ❑ VII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## CST's ADDRESS(Street,City,State,Zip Code) Phone Number: i IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) ❑Approved Surcharge Fee ❑ Owner Given Initial Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SB (formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber I INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION , TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I Property owner'_ name and mai!ing address. Provide the legal description where the system is to be installed: I!. Type of building or use served: If public is checked, indicate type of use (i e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; Ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 81,12 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; dosing or pumping chambers; 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. ------------------------.------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground':titer included 'he creation of surcharges (fees) for a number of regulated practices which Wiscori in`$ o can effect groundwater. The Surcharge took effect on July 1, 1984. All of the water that burl °d `ef aa�tlr� is used it yo.:r building is returned t> the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. w� The monies co!l stcc through these surcharges are credited to the groundwa`er fsnd adminis tered by the :department of Natural Resources. These funds are used for monitorirg ground- t water, groundwater contamination imestigatirms and establishment of standards. aroundwatt , _ it's worth protecting. SSD-6:98(8.03/86) 2�i al MJ Ala lot 7 IS-- 7-r9- 33.z.2, 46Aa� to �4 y 3� 5-3 i s2� �Df-Al i I- I XOA�a P��