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Wisconsin Department of Health and Social Services
-:ebr.` #67 3/70 Division of Health
..ww SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK I
,,,,o.: _
A. OWNER OF PROPERTY
ss (Street, CL , if Fode)
Name Addre
1\ A
/ Y(
RR)
~ I
B. LOCATION OF PROPERTY W '.ERE SYSTEM WILL BE CONSTRUCTED ALTEREL OR EXTENDED COUNTY f•.~.
Check One:
CITY VILLAGE LEGAL DESCRIPTION, t) i~ I(
Tr T SHIP f i
C. IS LOCAL PERMIT REQUIRED FOR THIS WORKT YES NO PERMIT NUMBEF.
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION R$PLAC NT ADDITION
MATERIALS: Prefab Conarete Poured in Place- Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
-Check One: One or Two Family Residence Commercial Industrial Other
Specify)
Number of Persons to be Accommodated S Number of Bedrooms
F. AFPLIANCES, ETC: Food Waste Grinder YES __Z\NO Automatic Clothes Washer _ y YES NO
Dishwasher YES l-,~NO Automatic Potato Peeler 'YES NO
Other (Specify) _
G. MASTER PLUMBER MAKING INS~TALLA ION
Name: Address t - i 1 License Number:
Signature of Applicant: MP RSW 4~7-
r
Address: d1r/ ~i"~ v
g. To be.Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (dater_ Permit Number
Agent (Naas)
Town, Village, City,"County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will. forward application, the fee of $1.00 "or each septic tank and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below FOR DEPARTMENT USE ONLY
1 I~ ACCEPTED BY RFTURNED
'L DATE RECEIVED
(Initials) (Date) Se4n^ .r: e
FEE RECEIVED VALID. No. 0 ~ PERMIT NO. G Z
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT No.
R= P O R T O N S O I L P I R C O L A T I D N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECT16H
P.O.Box 309, Madison, Wis. 53701
PurwoiA to H 62.20, Wis. Administrativs, Code
P E R C O L A T I O N T Z S T
Test Depth Character of Soil Hours Water Test Time Drop in hater Level ohes Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To imii
1st Wetted Overnight in Minutes Last Period Last Period Period One, Inch
Example
P - 0 361, To Soil 10„ Cla 26" 25 Yes or No 30 1/2 I L2 1/2 60
76 Xv"
el
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S 0 I L B 0'R I N G S e Minimum 3611 Balox *posed Abs2rp-tion System
Boring Total Depth Depth to round Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Sail with Thlcnness in Inches
Example
B - 0 72'0 7211 Bzaok Top Soil 12"; C' 18° Sand 1811 Grave. 24'3
22-
/'/j/ -3 _
RECORD DATA FROM MLNLMUM OF 3 BORE HOLES
PE OF OCCUPANCYt
RESIDENCE: Number of Bedrooma~ OTIERs (Specify) Number of Persons
D WASTE GRINDER# Yes No ~ Dishxashers Yes No ~1:utomatic Clotheb Washers Yssl- No
FFUIENT DISPOSAL SYSTEM; NEW EXTENSION ADDITION REPLACEwT
Tile Size / No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width L0 Depth 7! Tile Size No. Lines Z_
Seepage Pits Inside iameter -r Liquid Depth
Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the pr dures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the rda,Lre ad and ca ion of test holes are correct to the best of my knowledge and belief.
NAME o (i ,:2 r TITLE
Type or Print
REGISTRATION NO. or MASTER PLUMBER LICENSE N0. l
f
ADDRESS
DATE SIGNATURE
Parcel 038-1094-70-000 12/06/2006 04:13 PM
PAGE 1 OF 1
Alt. Parcel 23.31.18.393 038 - TOWN OF STAR PRAIRIE
Current _X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - JONES, MARY A
MARY A JONES
1247 CTY RD C & CC
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1247 CTY RD C/CC
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 38.690 lat: N/A-NOT AVAILABLE
SEC 23 T31 N R1 8W NE NW EXC PT TO HWY Block/Condo Bldg:
DESC 993/476 EZ-UT-1226/273
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
23-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 993/476 WD
1245/512 TI
2006 SUMMARY Bill Fair Market Value: Assessed with:
175465 399,100
Valuations: Last Changed: 10/18/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 35,000 223,400 258,400 NO
UNDEVELOPED G5 35.690 94,300 0 94,300 NO
Totals for 2006:
General Property 38.690 129,300 223,400 352,700
Woodland 0.000 0 0
Totals for 2005:
General Property 38.690 129,300 223,400 352,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 126
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
MADISON,+WI 53707 BUREAU OF PLUMBING
MCONVENTIONAL ❑ALTERNATIVE State Plan LD. Number:
(ll assigned)
O Holding Tank O In-Ground Pressure O Mound
RECONNECTION
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Mike Jones Rt. 2, New Richmond, WI 54017
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
NE NW, Section 23, T31N-R18W, Town of Star Prairie
Name of Plumber: JMPIMPRSW No.. County Sanitary Permit Number:
Gary Steel 3254 St. Croix 79170
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED
OYES ONO OYES ONO
BEDDING: VENT DIA.: VENT MATt 11116H WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: IV ENT TO FRESH
ALARM FEET FROM LINE. AIR INLET:
OYES ONO OYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP; SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
OYES ONO OYES ONO DYES ONO
GALLONS PER CYCLE: PUMP ANO CONTROLS OPERATIONAL - NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES ONO NEAREST-_ -
SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing 1,11AMITEH 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:
BED/TRENCH WIDTH LENGTH INO01 WITH PIPE SPACING, COVEH NSIOE DIA =PITS LIQUID
THE NCHES MATEHIAL PIT DEPTH
DIMENSIONS
UHA LL DEPTH FILL DEPTH UH. PIPE DISTH PIPE DISTR. PIPE MATERIAL NO UISTH NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER [E~SEI
V. INLE T ELEV END PIPES - LINE AIR INLET.
FEET FROM
NEARESTs
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.
OYES NO
SOIL COVER TEXTURE PERMANE NT MAHKFHS OHSEHVATTON WELLS
OYES ONO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVFHTRENCH BEU UE PTH OF TOPSOIL SODUFU JF,E OFD MULCHED
CENTER EDGES
OYES. ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATERAL SPACING (TRAVEL DEPTH HELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATEHIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV. DIA ELEV. PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION ROLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATEHIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES ONO OYES NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBEROF PROPERTY WELL: BUILDING:
FEET FROM LINE:
OYES ONO OYES ONO F NEAREST-
Sketch System on Retain in county file for audit.
Reverse Side.
TIT LEDILHR SBD 6710 (R. 01/82) S
wtsconsln APPLICATION FOR SANITARY PERMIT d
(~I DILHR " COUNTY
- OEGRRTmEr1TOF (PLB 67) UNIFORM SANITARY PERMIT #
- InOUSTRV,LRBOR6NUTRn RELRTtOnS 79170 mommmomm -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in
size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION CITY:
4C/4NkI/4, S A 3 TN, R/ 954o r) W V N OF j7`1 i
LOT NUMBER BLOCK NUMBER JSUBDIV1$1 N NAME NEAREST OLD, AKE OR LANDMARK STATE P AN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED K 1 or 2 Family Number of Bedrooms: _3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity ✓
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
❑ Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for instal lati of the private sewage system shown on the attached plans.
Nam Plumber (Print):
Signature: PRSW No.: Phone Number:
A Cf
Plumber's Aclbress: ~ ~ . Name of Designer:
9 1
COUNTY/ DEPARTMENT USE ONLY
Sig ure of Issuing Ag Fee: Date:
❑ Disapproved
✓ / /fir.~J G / ❑ Owner Given Initial
Approved Adverse Determination
Reason Tor Di p r al:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
L
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
APPLICATION FOR SANITARY PERMIT
ST C- 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
Location of Property 14, Section , T,-D_N-R~ W
Township
Mailing Address
Address of Site
G L
Subdivision Name L) Vs
Lot Number
Previous Owner of Property
Total Size of Parcel}
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number Z 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) centi.sy that all.btatements on this 6otm cute tAue to the b"t o6 my (out)
knowledge; that I (we) am (a&e) the owneh (.s) o6 the pto pen ty des ch it ed in th i s
injortmation botm, by vi4tue o6 a waAAanty deed tecotded in the 0j6ice of the
County Regi.sten ob Deeds" Document No. 3d3cf" ; and that I (we) pnesentty
own the ptopo.sed site jot the .sewage d"poza sya em (ot I (we) have obtained an
easement, to nun with the above d"cAibed ptopexty, 4ot the eonstnucti,on o6 .said
system, and the same has been duty tecotded in the 046ice o6 the County Reg.usten o6
Deeds, as Document No.
SIGNATURE OF OWNER SIGNAT OF CO' WNER (IF APPLICABLE)
3 o r~ ~
DATE SIGNED DATE SIGNED
z
H
a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT
St'. Croix County z
d
EWNERA;BUYER S
ROUTE/BOX NUMBER Fire Number
CITY/STATE l ZIP-7
PROPERTY LOCATION: -14, ~14, Section , T N, R W,
Town of 64 -A.#- PA 4,& 1, , St. Croix County,
Subdivision Lot number'
' I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. Ho
• E
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- u
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.
SICNED_ j ge c ~ ~Q
DATE g6
St. Croix County Zoning Office
P. 0. Box 98•
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IND'JSl-LAY, c DIVISION BOX HMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 7969
(H63.09(1) & Chapter 145.045)
LOCATION:,1 SECTION: u pp TOZ17 HIP/ ITY: LOT N BLK. NO.: SUBDIVISI N NAME:
A) 15 , Iltl4 2.3 /T 1 N/11)Ior1W 6
COU T OWNER'S/BU ER'S ME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIA DESCRIPTION: IPROFILEDESCRIPTIONS: 1PERCOLATIONTESTS:
Residence ❑New ❑Replace I Z / /
l fp
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MO NQD: 'I IN-GROUND-PRESSURE: ISYSTEM-1 N- HOLDING TANK: RECOMMENDED SY TEM:(optional)
J ~S JAI I ~J U
~U
If Percolation Tests are NOT required DESIGN RATS: If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
S//77 441 PROFILE DESCRIPTIONS Z~~
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL W H THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER N. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
C) Aj 72A1 I, _S,A 40, 4 - k
B-
B-
B-
B-
B
PERCOLATION TESTS
TEST DEPTH. WATE IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P-
P-
P-
P-_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borin and he dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their cati n on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
_
,
I= _ q ew _
4
I,
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1, - _ . _ E _ i.._..,,,._i., d--- s,..., £ Y-1 _ .....e......_ Imo„. ,._e_e'i,~......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 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 r 'S
TESTS WERE COMPLETED ON:
ADD CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIG T E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
: TRI?CTIfJ lS FOR COMPLETING FORM 115 - BD - 6395
To a and ,c, orate soil test, your report must include:
1. "
2 ~.ast whethe a i :siclence or commercial project;
3. ar rer of' or commercial a pl. nnetl;
4. ! lac ern;
A SITE IS 1 V, P --DING TA 1I< nNLY IF ALL
J !T BASED
6. I [ i here for writir nd comp ti plot elan;
7. crating y( r wing to sc ferred, A
si, )wn, rmanent;
9. ;r as lata, per7" to;t exernp_
e;
{ V r":e box;
WITH THE
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