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dEPARTME' r OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&1,MAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX)69 BUREAU OF PLUMBING
MADISC'•WI 53707
Swj,,tU%,S17,T29N-R19W CONVENTIONAL El ALTERNATIVE State Plan I.D.Number:
(It assigned)
Tout o4 Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound
TA) 1311 oo Road
r,—IAE OF PERMIT HOLDER: _7ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
I Dona.2d Maktin 967 Tuut Mook Road, HudSon,Wl 54016
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV..
Name of Plumber MP/MPRSW No.: County: Sanitary Permit Number:
Gatcy Zappa 3300 St. ctoix 112752
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
OYES FIND ❑YES ONO
BEDDING. VENT DIA.: IVENTMATE.-. HIGH WATER NUMBER OF ROAD PROPERTY WELL. BUILDING. VENT TO FRESH
ALARM FEET FROM LINE: AIR INLET
DYES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY JPUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
[:]YES ❑NO ❑YES NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY JWFLL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ❑NO 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: LENGTH NO.OF DISTR.PIPE SPACING COVER INSIDE DIA =P ITS LIQUID
BED/TRENCH TRENCHES MATERIAL' PIT DEPTR
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF WELL. BUILDING VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV INLET 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 OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ❑NO
SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WE LLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES ❑NO ❑YES [:1 NO El YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING GR,kVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD IN11 MA NIFOLD DISTR.PIPE MANIFLD MATERIAL DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL.&MAHKIN(,
ELEV.. ELEV.. CIA.. ELEV.. PIPES DIA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES E:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
DYES NO ❑YES 1:1 NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE 1
DILHR SBD 6710(R.01/82) Zoning Adinini6 tcu.ton
-- SANITARY PERMIT APPLICATION COUNTY
• (�t 13ILHR In accord with ILHR 83.05,Wis.Adm.Code T
STATE SANITARY PERMIT##
/1a ysa
—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
lk/ % ,V/, /a, S T , N, R E(or W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
VILLAGE : D o
1;ive 09 TOWN 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. r 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 Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ Seepage Bed b. ❑Seepage Trench c. ❑ Se7AREA
2. PERCOLATION RATE '3. ABSORPTION AREA 4. ABSORPTIO5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Sq
Feet ❑Private ❑Joint ❑ 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 Holdin Tank tl a !J N ❑
Lift Pump Tank/Siphon Chamber 1-1 1 101
❑
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) W/MPRSW No.: Business Phone Number:
/11�0/L v Zl.� 0 4opi-0
umbe s Address eet,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 ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee 4
Adverse Determination 2�- r
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
i
h
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:
:;J
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
11. 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;
Vlll. 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 axtB[
included the creation of surcharges (fees) for a number of regulated practices which Wisco
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ree"SUYB !...
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.
a
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations 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 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 gnp�A�-��, 9 c7,Jc A-
Location of Uj_1/4 A-)Lj /4, Section /7 , T_jc N-R�GW
Township k_h'Son1
Mailing address 116007- e600K .
Ll-j 1,3
Address of site 167 /�JT 3/'moo K
Subdivision name J
Lot number _ /l, A
Previous owner of property LU11c-12� f Z &k.KE_
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes X_No
Is this property being developed for resale (spec house)? Yes 5C No
Volume 6,60and Page Number .331 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.
-------------------------------------------------------------------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of -my. (our)
knowledge; that 1% (we) 'aik (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 It, (We)
presently own .the proposed site for the sewage disposal sys em (or I (we) have
obtained an easement, to run with the above described property, for the
c struction of said system, and the same has been duly recorded in the Office
of a County Rlstep.,of Deeds, as Document No. � v
Signature of 0"wner Sig tune of Co-Owner (If Applicable)
g / -- (il
Date of Siq atur Date of Signature
LuVerne J. Burke a_ nd Joan c� Gt�T�:I'S OFFICE
THIS INDENTURE, Made by .$T 0,101X CO.
R. Burke, husband and wife ► WQ.
Recd, for Record 1t 8th
day of March AD. 1983
grantor S of St . Croix County, Wisconsin, hereby conveys and warrants Qf 9:40 A
to Donald E . Martin and June M Martin husband ► k
and wife as joint tenants
by►h► W DOW$
grantee S RETURN TO
301 $dCtiK K"X for the sum of
One Dollar ($1 .00) and other good and valuable
consideration
the following tract of land in t • Croix County,State of Wisconsin;
Part of Southwest Quarter of Northwest Quarter (SWJ of NWJ) of Section
Seventeen (17) , Township Twenty-nine (29) North, Range Nineteen (19) West
described as follows: Commencing at theSouthwest (SW) corner of said
Southwest Quarter of Northwest Quarter (SWJ of NWJ) ; thence East 392.0
feet; thence N 780 .0 feet to the point of beginning; thence North 61002'
East 200 .0 feet ; thence North 28058' West 227.6 feet to the bank of the
Willow River; thence South 50056' West on a meander line 203.0 feet;
thence South 28058' East 192 .0 feet to the point of beginning and also
all land between said meander line and the centerline of the Willow River
Together with an easement for access road over a strip of land 30 feet
wide lying immediately South of and adjacent to the above described parcel
and extending South 61002' West to the existing Town Road.
EXr�l
IN WITNESS WHEREOF, the said grantor S ha Ve hereunto set their hand S and sealer this 12th
day of November A. D., 19 68.
SIGNED AND SEALED IN PRESENCF OF (SEAT,) r
- f LuVerne J. Burke
(SEAL)
Ardell W. Skow J Joan R. Burke
r ; (SEAL)
Susan Gary (SEAL)
II
STATE OF WISCONSIN,
ST. CROIX r ss.
ounty.
!' 12th
Personally came before me, this day of November , A. D., 19-E8.
theabovenamed LuVerne J. Burke and Joan R. Burke, husband and wife
P
i
j to me known to be the person S who executed the foregoing instrument and acknowledged the same.
Pub?±c . ]j
Not I �" ��'� i �� i
Axad W S'-co,,,r Ardell W . Skow
.State t MO
1 1 Y tYARY.Zia
SEAS
This instrument drafted by Notary Public St • CrO1X County,Wis.
ARDELL W. SKOj'i _ My Commission(R*i4 (Is) permanent
to ue reco[d_8
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER _fQAJE Al • Ab+e-7'in�
ROUTE/BOX NUMBER g(, -/ he_c(j-r _=i2bk �i�= ,FIRE NO.
CITY/STATE LL_6 S-o..i (/l) 1. ZIP
PROPERTY LOCATION: <d.,J114 AJL 1 1/4, Section T_Z,7_N, R
Town of 1CJJ� S_n'I St. Croix County,
Subdivision Lot No. A.)JA _
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 N ural Resources Certification
form must be completed and returned to the St.0 o'x County Zon gO? ce wit in
30 days of the three year expiration date.
SIGNED
DATE / /O
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
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