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tO NTY PERSONNEL AUTHORIZATION Rule being petitioned
ite inspection ) �.?1 2 L1 l�
indicate the information recorded on this request form is accurate and correct
e best of my knowledge and belief.
VERIFICATION BY OWNER—PETITION IS VALID ONLY IF NOTARIZED.
FOR INFORMATION CONTACT THE DEPARTMENT AT(608)266-3815
being duly sworn,says he is petitioner herein,thus he has read
the foregoing petition and that the same is true,as he verily believes.
Subscribed and sworn to me this day of 19 ,
County,Wisconsin. Signature of owner,
Notary Public
My commission expires:
OFFICE USE ONLY
DEPARTMENT ACTION
SITE EVALUATIONS SET-BACK OR EXPERIMENTAL
Date Received Amount Paid Receipt No. Date Received Amount Paid Receipt No.
Department Action Department Action
ADMINISTRATOR Date BUREAU DIRECTOR OR DESIGN Date
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1--- --- ---- ---- - ----- ------------- -- ------ -- - - - - - - - -
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D,FPARTMENTOF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
NGIi, S16,T29N-R15W )0 CONVENTIONAL ❑ALTERNATIVE State Plan I.D Number:
Town o4 SpAing4ietd ❑Holding Tank ❑In-Ground Pressure El Mound 21 (if
County Road E
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: IN ECTION DATE:
ViUman Farms Inc. Route 1 Gtenwood City, W1 54013 �7-
BENCH MARK(Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: FTFILE P7.ELEV..
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Date E. HuAon
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.'. WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED
1:1 YES ONO I DYES ❑NO
BEDDING. VENT DIA.'. VENT MATIL. JHIGH WATER NUMBER OF ROAD: PROPERTY WELL'. BUILDING. VENT TO FRESH
ALARM FEET FROM LINE AIR INLET
DYES ❑NO ❑YES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER REDOING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED.
DYES ONO ❑YES ❑NO OYES ❑NO
GALLONS PER CYCLE: PUMP Al D CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL 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 JDIAMETLH MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING COVER JlNSIDE DIA -PITS LIOUIU
BED/TRENCH / TRENCHES MATERIAL; PIT DEPT,+
DIMENSIONS
GRAVEL DEPTH FILL DEPTH JUISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPER TV WELL BUILDING VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END. PIPES FEET FROM LINE Al.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-
meets the criteria for medium sand. TIONS MEASURED.
DYES ❑NO
SOIL COVER ITEXTURE PERMANENT MARKERS OfiSE RVATION WE LLS
❑YES ❑NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES 1:1 NO DYES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH- LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. 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.. DIA. ELEV.. PIPES DIA..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL V n I L CORRESPONDS TO APPROVED
1:1 YES NO ES ONO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. F PROPERTY WELL: BUILDING.
rN EET F M LINE
O L I
DYES 1:1 NO ❑YE — D_ 1q6 E ARES
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Sketch System on Retain in county file for audit.
Reverse Side. ----
SIGNATURE. TITLE.
DI LHR SBD 6710(R.01/82) Zoning Admini6ttc(ton
SANITARY PERMIT APPLICATION COUNTY
(�MILHR In accord with ILHR 83.05,Wis.Adm. Code 3Y%_ C/'D/X
STATE SANITARY PERMIT##
y �v
—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 ONO
PROPERTY OWNER PROPERTY LOCATION l
, �� Q/? G?✓ S /�'� . '/a )'/4, S T 29, N, R (or)W
PROPERTY OWNER'S MAILING ADDRESS LOT 72 �ER BLOCK NUMBER SUBDIVISION NAyI
T
CITY STATE / ZIP CODE PHONE NUMBER 0 CITY / NEAREST ROAD,LAKE OR LAN MARK
CJc')C)Q✓ /. J /� 77Z` lf/ O VILLAGE:
II. TYPE OF BUILDING OR USE SERVED: • O a 14— —
Number of Bedrooms if 1 or 2 Family OR Public(Specify): /)X
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. ❑ New b.p 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.AConventional 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 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): /
/ 9�'� 7 Z1 S 9Y'� Feet ❑Private Joint ❑Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Exper.
INFORMATION New sting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank 1101049 Qw 12 0 ❑ ❑
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:
a ..moo ? ',- . �. � ���9 7 s' 01fV 3.?70
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
�d Ma ' c�oi7' C,� : S DD�'J IVVe
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST## � /�
.5 ale �. �� s0
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S�Aitary Permit Fee Groundwater ate Is I g Agent Signature(No Sta s)
�pproved ❑ Owner Given Initial `�1D ( �Q S�rchargeFee
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
i
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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 revisigns 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;
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;
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 liter
included the creation of surcharges (fees) for a number of regulated practices which Wisco ttt'S
°
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that
buried re8sttre
is used in your building is returned to the groundwater through your soil absorption e
system or the disposal site used by your holding tank pumper.
0
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- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
r
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.
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Owner of property � J��/� ¢!fir/ �/�! .
Location of property — 1/4 /4, Section , T G 7 N-R W
Township f e
Mailing address
Address of site C Q1"4�
Subdivision name
Lot number - x�
Previous owner of property r `///I2?(712
Total size of parcel -I
Date parcel was created
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for resale (spec house)? Yes ��N0
Volume 7 and Page Number /�T 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 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. �(0 007 ; 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
of the ounty Regi er of Deeds, as D ument No. ) .
e
4
Signature of Owner Signat of Co-Owne �(If Applicable)
Date of Signature Date of Signature
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER f, � Fire Number
CITY/STATE ��r°�1l��C�O���./�[ `I.I P .540%-
PROPERTY LOCATION: 34, )14, Section �� T ;26;? N , R �� W,
Town of rim St . Croix County ,
Subdivision Lot number
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
three year expiration .
0
I/WE, the undersigned , have read the above requirements and agree
to mahntain . the private sewage disposal system in accordance with x
H
the standards set forth , herein , as set by the Wisconsin Depart- b
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
i
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 .
4
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&,BUILDINGS
INDI�STRY,• DIVISION
LABOR AND P.O. BOX 7969
MADISON,WI 53707
PERCOLATION TESTS (115)
,HUMAN RELATIONS
'? (H63.09(1)& Chapter 145.045)
TOWNSHIP/MUNICIPALITY LOT NO.:BLK.NO.: SUBDIVISION NAME:
'/a /a la /T29H/R/51(or W S'
COUNTY: OWNER'S BUYER'S NAME: AILING ADDRESS: �� J
USE DATES-OBSERvATt6NS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑New Replace I I?_ 23 _ ff
-3 A44
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND:�� IN-GROUND-PRESSURE: SDEM-IN-FILLHO�LDING TANK:RECOMMENDED SYSTEM:(optio a/� /
S UU S S U S JO U S U S°4
=i DESIGN RATE: QS
q If Percolation Tests are NOT require If any portion of the tested area is in the /p
under s.H63.09(5)(b►,indicate: Floodplain,indicate Floodplain elevation:
,s
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PROFILE DESCRIPTIONS
BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH}}, ELEVATION OBSERVED ES T.F-IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
d /
D ,
B-3 G D 9 �� e G /o - /o ,/3 �- s ,
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER LUG4.4E9� AFTERSWELLING INTERVAL-MIN. PERT D 1 PERT D 2 PER INCH
P_
P e
P- i
P-_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION -0'7 '
< P'L WOO I
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- - - -
. ... __-_..
I,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 Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
_Dal ,
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
o
CST GNATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
1
DILHR•SBD*6395 (R.02/82) OVER --
I
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and,accurate soil test,your report must include:
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1. Complete legal description;
2. The use section must clearly indicate whether this is-a residence ix commercial project;.,
3. MAXIMUM number of bedrooms or commercial use planned;
4.' Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately.locating your test locations. Drawing to scale is preferred..A
separate sheet may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
9. Complete all appropriate boxes as to dates, names,addresses, flood plain data percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain,elevation)does riot apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THEW
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob -- Cobble (3- 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater
cs "- Coarse Sand Perc, - Percolation Rate
med s - Medium Sand W - Well
fs Fine Sand Bldg Building
Is - Loamy Sand > - Greater Than
*sl - Sandy Loam < - Less Than
*I - Loam Bn - Brown
*sil - Silt Loam BI - Black
si Sift Gy - Gray
*cl - Clay Loam Y --- Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles -
sc - Sandy Clay w; - with
sic - Silty Clay f f f - few, fine,faint
*c - Clay cc -- common,coarse
pt -- Peat rnm - Many, medium
in - Muck d - distinct
p - prominent
HVVL - High water level,
r " Six general soil textures surface water
for liquid waste disposal BM - Bench Mark
VRP -- Vertical Reference Point
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TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit: issuance. A complete set of plans for the private
sewage system and a permit application must, be SLA)rPittOd to the appropriate local authority in order to
obtain a permit. The sanitary permit nurs be obtained and posted prior to the start of any construction.
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