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County Sanitary Permit Application ST ROIX COUNTY WISCONSIN
q in accord with Chapert 12 St Croix County Sanitary Ordinan G & ZONING DEPARTMENT
~ 20 5 Personal information you provide may be used for secondary purposes T. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(i)(m)) 1101 Carmichael Road
?'97. CROIX COU N Hudson, wt 54016 710
(715)386-4680 Fax (715)3B6-4686
Attach complete plans for the system on paper not less than B-1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
Z
L. Application information - Please Print all Information Location:
Property Owner Name 130 I 2
X13` ~ls»/f ~3< l rk~rC. yJ 1/4 1/4, Sec Z 7
Natvev Z Il . Qn Z`f N, R E or
Property Owner Mailing Address ~rtvrh of Number Block Number
G
City, State Zip Code Phone Numer Subdivision Name or CSM Number
h f0h 11'a ~w P
11 Type of Building: (check one) amity ❑ Village own of
X 1 or 2 Family Dwelling - No. of Bedrooms: T
❑ Public/Commercial (describe use): SD~e/NGt ~~ELIJ
❑ State-owned Nearest Road
It. Type of Permit: (Check only one box on line A. Check box on line B K applicable) 3(a*I'`
_FAIV Parcel Tax Number(s)
A) 1.0 Repair 12- ❑ Reconnection 3-Non-plumbing 4. ❑ Rejuvenation 03i-/05* Z -'qu--0crap
Sanitation a 3,3 9 _ iS 363
B) Permit Number Date Issued
❑ State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
❑ Non-pressurized In-ground ❑ Mound ? 24 in. suitable soil ❑ Mounds 24 in. suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland • ❑ Peat Fier ❑ Drip Line ki{
❑ Pressurized In-ground ❑ Single Pass ' Other - ps,* y
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
Dispersal/Treatment Area information:
1. Design Row (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals./day/sq.ft.) (Minfnch) Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnencbon/rejuvenationrnstailation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
L
Plumber's Name (print) Plumber's Signature no stamps): MP/MPRS No. Business Phone Number
Plumbe s Address (Street, City, State, ZIP Code
w 24 5 ~tG Rs ~gd~
Vlll. County Use Only
Disapproved Sanitary Permit Fee Date issued Issuing Agent Signature (No stamps)
Approved Owner Given Initial Adverse
Determination Z Z
X. Conditions of Approval/Reasons for Disapproval:
/JU~v~ was-ler vrc-l~~ 1~ coktveyed v(~z
N`z'u~,5f ~v ~,aQ, r/d~1 0~ Ll~~ssih• Co~ ~~lS, ~l~ n~~j,v~ S~s~a~S, w~,s ✓~cv~+r~ts~
74 OU6144d 11JA 6-b. .0-
92.3 Permits and Applications July 1, 2005
3) If a POWTS serves more than one structure under different ownership, a
document must be recorded identifying all parties that have ownership rights and -
are responsible for the operation and maintenance.
4) If a POWTS is owned by a parry other than the owner of the parcel on which it is
installed, a document must be recorded identifying the owner of the system, the
structures to be served by the system, and the party responsible for operation and
maintenance.
5) If the design wastewater flow of a POWTS for a dwelling is not based upon the
number of bedrooms within the dwelling, a deed restriction limiting occupancy to
that used in the design must be recorded.
3. COUNTY SANITARY PERMIT
a. Applications for County Sanitary Permits shall be submitted, to the Planning and Zoning
Department for review and approval of the following:
1) The installation, construction or modification of a pries.
a) Setbacks for privies shall be located according to the following minimum
horizontal distances: / W ~C
is 25 feet from dwellings.
ii. 25 feet from lot lines.
iii. 25 feet from any 20% or greater slope.
iv. 75 feet from the OHVWM of a lake, stream, or river.
b) Privies shall be constructed in conformance with Comm 91, and the following
requirements:
i. All privy structure openings shall be screened and all doors shall be self-
closing.
ii. A vent shall be provided for the vault and extend not less than one foot
above the roof
c) Prior to the issuance of a sanitary perms the property owner must sign a
maintenance agreement on forms furnished by the Planning and Zoning
Department ensuring proper maintenance of said pries.
d) Pit privies require a Soil and Site Evaluation Report in accordance with
Comm 85 to establish compliance with § § Comm 83.44 (4)(b) and Comm
91.12(1)(b)l.
2) The installation of a non-plumbing sanitation system.
a) Non-plumbing sanitation systems shall be constructed and maintained in
conformance with Comm 91.
b) A service contract shall be submitted with the County Sanitary application.
3) Chemical or Physical Restoration for POWTS.
4) Repairs to an existing POWTS.
5) The reconnection to an exi.stbag POWTS, including:
a) The disconnection of a structure from an existing POWTS and connection of
another structure (new or different) to the same system.
b) Construction of a structure to be connected 0 an existing POWTS; and
c) Reconstruction of a structure to be connected to an existing POWTS.
b. The following is required when applying for an application for a County Sanitary
Permit for reconnection:`
1) A completed County Sanitary Permit application signed by a licensed plumber.
12-8 St. Croix County Sanitary Ordinance
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Land Use
ST. CROIW4 ' 6C. . Ue ;~1 T Y Planning & Land In formation
~ Resource Management
Community Development Department
September 25t', 2015
DSPS - Industry Services
PO Box 7162
Madison, WI 53707-7162
RE: Waiver request by Harvey L. Mast for exemption from Wis. Stat. § 145, POWTS standards
Site: 801 310' St.. Wilson, WI, Parcel 034-1052-40-000, Sec. 23 T29N R15W, Town of
Springfield
To Whom It May Concern,
St. Croix County Community Development Department has received a request for a waiver to
plumbing standards, and is recommending denial of the request.
Per Wis. Stat. §101.648(6), St. Croix County does not believe that the applicant(s) are entitled to
receive a waiver to Wis. Stat. §145.20 & Wis. Stat. §145.245, relating to the required POWTS for the
1-2 family dwelling at the above mentioned property.
Furthermore, the St. Croix County Community Development Department feels the applicant(s)
request does not meet Wis. Stat. §101.648(5)(b), as it will create an undue risk of harm to public
health and safety by discharging untreated domestic wastewater to the ground surface, seasonally
saturated soils, and/or surface or ground water. St. Croix County believes that waiving Wis. Stat. §145
plumbing standards will create a direct conduit for pathogens or diseases to be transmitted to the
general public, which could lead to illnesses or fatalities and the degradation of natural resources.
Please feel free to contact me with any questions or concerns. I am available Monday-Friday from
8:00-5:00 at my office number (715) 386-4680.
Respectfully,
Craig Dantoin
Land Use Technician
Cc: Town of Springfield
File
Ecc: Todd Dolan, UDC
Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, Wl 54016 Fax 715.386.4686
www.sccwi. us/cdd www.facebook.com/Stcro/*Xcountywi cdd@co.saint-Croix. wi. us
t ART, p.A
STATE OF WISCONSIN Mail to:
"~Of
j $ P Department of Safety and Professional Services PO Box 8935
WI O Box 8935
1400 E Washington Ave. Madison
Madison WI 53703
Email: dsps@wisconsin.gov
Web: http://dSpS.WLgOV Sacr Governor ScottrEI tary Dave Ross
Phone: 608-266-2112
NOV a 9 701
November 5, 2015 ST. CROIX COUNTY Notice of Waiver #1004
:;OMMI UNITY DrVELOPMENT
Craig Dantoin
Land Use Technician
Community Development Department
St. Croix County
1101 Carmichael Rd.
Hudson, WI 54016
RE: Notice of Waiver
Dear Mr. Dantoin,
We have received your Recommendation of Denial of the Waiver Based on Religious Beliefs (form 1000IS)
for Harvey Mast for the future dwelling to be located at 8013 10ffi St. Wilson, WI in the County of St. Croix.
We have reviewed your rationale for recommending denial and disagree with your conclusions. We therefore
issue this notice of waiver. Wis. Stat. sec. 101.648(6) provides in part as follows: "Upon receipt of the notice,
the political subdivision shall waive the applicant's requirement to comply with the dwelling construction
standards specified in the waiver."
Regarding the smoke detection and CO detection requirements, the political subdivision has not demonstrated
that their absence constitutes an unreasonable risk to public safety. Therefore these requests for waiver are
approved.
Regarding the plumbing and electrical requirements, the political subdivision has not demonstrated that the
absence of code-complying plumbing and electrical wiring will constitute an unreasonable risk to public
safety. Therefore these requests for waivers are approved. p
Note that this waiver is for the State Uniform Dwelling Code requirements specifically mentioned on me
waiver form and granting this waiver does not alter the need for a building permit and inspections for
compliance with those code requirements that have not been waived above. Additionally, requirements to
obtain other State and local permits and inspections (well, sanitary, privy, zoning, etc.) may also apply.
Sincerely,
Lenny Kanter
UDC Engineering Consultant
Bureau of Technical Services
Division of Industry Services
WI Department of Safety and Professional Services
(608)261-6541
RobertKanter@wisconsin.gov
cc: Harvey Mast, 801 310"' St. Wilson, WI 54027 P