HomeMy WebLinkAbout038-1137-10-100
ti N O 3
O f c 4r 0
y
ft Lo~
a 0 3 ~1
~ ~ Ili, ~ ~ c •
y fD
o N (n o m` w °w ~C •
3 0 0
CD co 00 0 °o
z n :z CO) A
ID Ca 5- a=)r
N _o
N N N '
O
o A7
3 N CD O
j O O C
• ' O
CD
fn D a W
CO CD N 03 a w
m c w
CL
O w C) C)
8
rn ~ 5
O (P -N Cl) .O. N
o A rn m M
C O O O•
~1 C 0
0 CD
:3 CD
R p y c'~o O a N
!~ryi
90
At- ;s
C7 m N
(D A Q
cu o n
z r- > > O
a
H z R N !~1 •
czz,
1 l~~ii1
d 4:1 Z-
j cn
~ r N l
~ A Z O
Q w (n ~ co
z W T j*, W
t_n n a z
rn o
o Cn H m
co o m
3
o n
3 n C
w 3 = ~
• w a T
m Z
N O a
~ N
3
O
A
=r
n
? `
A
a A
N
w
O N
O
O
V
A
qt,
It,
H3 0 ~ H
O
o a
CD
o 0 n
}
1
l ` ST. CROI X COUNTY
WI SC O N S I N
ZONING OFFICE
r ~<l
rn 796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
Q U A R T E R L Y P U M P I N G R E P O R T
S T. C R 0 I X C O U N T Y
NAME:
I~JRETURN COMPLETED FORM TO:
o
ADDRESS:
>7,
ST. CROIX COUNTY ZONING OFFICE
P. 0. BOX 98
2 MOND, WI 54015
LLL"~`~ 15-796-2239 or 715-425-8363
TOWNSHIP : _ _ 2 c
PLEASE PROVIDE THE FOLLOWING INFORMATION ACCOMPANIED
BY RECEIPTS FROM YOUR PUMPER-.;-)
NAME OF PUMPER: f to wGr3 ~~ti, is ~.ti
LOCATION OF DISPOSAL SITE:
NUMBER OF PERSONS LIVING IN RESIDENCE:
USE: (I!"-;v2 - , YEAR ROUND _ SEASONAL (CHECK ONE''
OCTOBER NOVEMBER DECEMBER
DATE VOL. PUMPED DATE VOL. PUMPED DATE VOL. PUMPED
THIS REPORT MUST BE RETURNED NO LATER THAN JANUARY 31, 1986.
OWNERS SIGNATURE
mj:12-83
STATEMENT
POWERS SANITATION
Route 1, Box 22, New Richmond, WI 54017
Phone: 246-4525
SEPTIC TANK AND DRY WELL CLEANIF
Date
G
To
7 ~ ,~~cJl ~
1~,
Date of Service
❑Septic Tank Cleaning
I] Dry Well Cleaning
❑ Portable Toilets
,1~dther
Rebilling charge" c~J
BALANCE DUE $
$.5o rebMing charge per month NRN 11-85
ST. CROI X COUNTY
WI S C 0 N S I N
ZONING OFFICE
Isla 796-2239 (HAMMOND)
- 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
U A R T E R L Y P U M P I N G R E P O R T
ST. C R 0 1 X COUNTS/
RETURN COMPLETED FORM TO:
NAMES
ADDRESS • ~=1 I L i.~--'~~-~-~=~~' ~l fs ST. CROIX COUNTY ZONING OFFICE
P.O. BOX 98
HAMMOND, WI 54015
715-796-2239 on. 715-425-8363
TOWNSHIP' PLEASE PROVIDE THE FOLLOWING INFORMATION ACCOMPANIED
BY RECEIPTS FROM YOUR PU P
s~1 ~(~14JTi r\
NAME OF PUMPER:
LOCATION OF DISPOSAL SITE: t't
NUMBER OF PERSONS LIVING IN RESIDENCE:
USE: YEAR ROUND/ SEASONAL (CHECK ONE)
JULY AUGUST SEPTEMBER
DATE VOL. PUMPED DATE VOL. PUMPED DATE VOL. PUMPED
THIS REPORT _ T BE^RETURNE7~ NIO LATER THAN OCTOBER 15, 1985.
OWNERS SIGNATURE
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER A/LTOWNSHIPS COY / Y'-I Ir; r~ SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
,''UBDIVISION LOT LOT SIZE
~ PLAN VIEW
~istances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a
s
o-
\C
3
IINDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
A
s-y
Elevation of vertical reference point: Proposed slope at site: S,(
SEPTIC TANK: Manufacturer: Liquid Capacity:
4
Number of rings used: Tank manhocover elevation:
Tank Inlet Elevation: ,Tc Outlet,Elevation:
xi
Number of feet from nearest Road: Front,O Side,0 Rear, O feet
From nearest property line : Front,0 Side,0 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to sentic tank)
•
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon 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: FrO T)t, Si<{c', 0
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property lane: Front, O Side, O Rear, O Ft
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
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
Manufacturer: Capacity: C' ~in'n
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, Rear, O Ft. j;
Number of feet from well:
nJ
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector
Dated: Plumber on job:
~1L
License Number: '
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O~BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
❑CONVENTIONAL ALTERNATIVE State Plan l.D Number
lf assigned)
(
CJ Holding Tank El In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE-
Jehovah'.6 Witne/sse/s Kingdom H R. R. 2, New Richmond 6 95 A
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. IT, ELEV.: CST REF. IT ELEV
SW SE, Section 33, T31N-R18W, Town o~ StaA Ptcai)Lie j,- /J,I)
Narne of Plumber. MP/MPRSW No.'. County. Sanitary Permit Number.
,Cat Powe 6 1563 St. cuix 54984
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TAN LET ELEV.. TANK OUTL ELEV.. WARNING LABEL LOCKING COVER
~OO K I / 4 7~ PROVIDED. PROVIDED
Inc J, YES ENO YES ENO
BEDDING. C~ VENT DIA.. VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILD NG VENT TO F ESH
,L
ALARM
FEET l~ FROM LINE
0,9 YES ENO NEAREST ~~7/ I/•///
XYES ❑ NO
DOSING CHAMBER:
KING
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON ME13 UREN WARNID DLABEL PROVIDED OVER LOC J DYES ENO DYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. ER OF PROPERTY WELL BUILDING I VENT TO FRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FROM
PUMP ON AND OFF) DYES ENO EST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IF 7Ta DIAMETER MATERIAL AND MARKING
=FORCE
or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF IDISTR PIPE SPACING COVER INSIDE CIA API TS DQTID
TRENCHES MATERIAL PIT
DIMENSIONS
GRAVFI_ DEPTH FILL DEPTH DISTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BF LOW PIPES ABOVE C OVER ELEV E. AIR INLET.
. INLL i ELEV . END LIN
PIPES FEET FROM
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 ENO
PERMANENT MARKERS. OBSERVATION WELLS
SOIL COVER TexruRE
DYES ENO DYES ONO
DEPTH OVER TRENCH.'BED DEPTH OVER TRENCH,BED DEP~TOP L S ODDED SEEDED MULCHED
CENTER EDGES.
DYES ENO DYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH ABOVE COVER
LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR. DISTR. PIPE DISrR IBUTION PIPE MATERIAL & MARKING.
ELEV. ELEV. CIA. ELEV.. PIPES. DA..
ELEVATION AND
DISTRIBUI ION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. PLANS.
DYES ENO DYES ENO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING.
COMMENTS: FEET FROM LINE
DYES ENO DYES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side. TITLE
sIGNAT E
DILHR SBD 6710 IR. 01/82)
ST. CROI X COUNTY
W I S C O N S I N
r
ZONING OFFICE
796-2239 (HAMMOND)
- - 425-8363 (RIVER FALLS)
~ HAMMOND, W 1 54015
August 8, 1984
State of Wisconsin DILHR
Bureau of Plumbing
P. 0. Box 7969
Madison, Wisconsin
Dear Sir:
An onsite inspection done on the Jehovah's Witnesses Kingdoms Hall property
located at R. R. 2, New Richmond, Town of Star Prairie, revealed that the
soils are not suitable for any type of system other than a holding tank.
As this is a replacement system, we are recommending the use of a holding
tank.
Should you have any questions regarding this subject, please feel free to
contact this office.
Sincerely,
Thomas C. Nelson
Assistant Zoning Administrator
TCN:mj
i
- v
N i
~ m
m N? W? C C 3 0
p cn w 0 CD X cD A 0 CD ~
N 0 CD 3 -v (a M wr ~
~o?~ v3amm°oA
C) n O N C p
olm. oa00 a'~m0)N~
n O N a N
OD
co 'P'' 0 ? n O M O =r Co
o 3 a o co w
0 CD M= coo~iOOg
S O
W O p C- c cn
3-ftc oc3oao
~Zo c' a
m
ocs cl'
rn O ~o
O w - co n
7•~CD ~ - (D C
< (D r N (O Q 1i
(D ca r D c CD O
n 0 O
C C W 0_ a 0 O
114 = <D tG 7 S Ai N C N
=r CO)
SMD VOl O O CD M 0 =r =r CD
CD a
3 % cn N
a CD 0
0 co
CD CD -4 Cl)
(A 0 =r 0
Q N CD ~ N 0 acc
C It1
?moo vai'CD cD
m 3CS oa ~cn-•
. m j CO) CD CO) ' Cl) N = -1
~lS o o. w CD c co
CO) -ft 0 CO) 0 CD
O c c co co CA
~i ~a cCD a0c ID G)
3 f= m
0 a c a 0 o
* =r co
Q ~ N 0. p: m ~ 3 oyi g
CD 0
~cno ~coa 007o
s
ao::..a cc -4 M C
3 09'a S cSw.~O M
3 3
a CD p t 3
- °o
,w iw - O a O <
CA CD
O O
. 's..:` Is"
j
ii APPROVAL Safety and Buildis s
=77 PLN Bureau of Plumbing
P.O Box 7969
❑ General Plumbing Plans Madison, WI 537;,7
Private Sewage Plans Telephone: (608)266-3815
OFFICE USE ONLY
Plan Identification No.
<9 q , / _ , 2- Y ) hl ` Gallons Per Day
C-) C)
PRIORITY PLAN REVIEW ONLY
Plan Review
Petition For Modification
L$
Project Name , , I Project Location - Street No. or Legal Description
~i oLla~~S' W+ N( !3~ W
I iIU-
County
El city 111 Village Town of: r
The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is
based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval
is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the
city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of
plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be
made.
❑ FOR GENERAL PLUMBING PLANS:
This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan
approval must be obtained.
FOR PRIVATE SEWAGE PLANS: Qte This approval will expire two years from approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary
permit expires.
Comments:
By:
James Sargent
Bureau Director
If Questions Plans Approved By: Date Ap roved:
Contact ♦ ~ /
cc: OWS ❑ DPS ❑ H&R & Rec. San. Section
County ❑ Local PI ❑ Facilities Need Analysis Section
❑ UW-SSWMP ❑ Plumber ❑ Department of Agricultu
DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
- j
I~Z /T--,/ N f R~ t (or) W 14" ~111)i
COUNTY: OW ER'S/BUYER'S NAME: MAILING ADDRES
USE DATES OBSERVATIONS MADE
=,/NO, DRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 7PER OLATION TESTS:
❑Residence j 1 ❑New IJRe lace /
p n ; )
R ATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) I
DS U ~S DU DS ~ U DS x U ClS ❑U , ~ .
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 1
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_
P-
P-,
P- I
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. i
SYSTEM ELEVATION
X ~-L[..1TI~~~/-+-Q~ dY/ I _ -Y I I 1 ~ 1 j ~ I -
-r i j I ( ~ ~ ~ I ~ ! I I + X71
- - I _
75
- 1 - - - -5t--
I
i
- I 1.Z
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): y=ice v TESTS WERE COMPLETED ON:
ADDRESS: ? 1 9,, 4 - CERTIFICATION NUMBER: PHONE NUMBER (optional):
CSTTU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
Dli. 11P SE>D-6395 (R 02182) OVER -
ST. C R 0 1 X COUNTY
; f X12 r WI SC0 N S I N
ZONING OFFICE
796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
August 8, 1984
State of Wisconsin DILHR
Bureau of Plumbing
P. 0. Box 7969
Madison, Wisconsin
Dear Sir:
An onsite inspection done on the Jehovah's Witnesses Kingdom Hall property
located at R. R. 2, New Richmond, Town of Star Prairie, revealed that the
soils are not suitable for any type of system other than a holding tank.
As this is a replacement system, we are recommending the use of a holding
tank.
Should you have any questions regarding this subject, please feel free to
contact this office. 1
Sincerely,
i '
Thomas C. Nelson
Assistant Zoning Administrator
TCN:mj
Ll G 2 119 8 4
ST. CROI X COUNTY
WI SC0 N S I N
~ ~r'~ XcyTrT.
►....f, j 796-2239
I fit, Poe tI N G O F F f3ox 227 06 - Kw K
11 =F`I1 i Hammond, WI 54015
O W N E R
P U M P E R
A G R E E M E N T
PLEASE BE ADVISED, That un.t.it you are again noti6~ ed, I wilt
06 c
coKt)Lact with Of.c_e c o ne .i n , (pumper), 6o& the punpos e 06 kemov4..ng aLL wae.te 6nom the
Aan..i-tan.y eyatem to be Located on the pnopen.ty and 6u.tuaehomes .64'-te
1h~1r►~
located in St. Cn.o.cx County, Wi,econain, Townah.ip 06 ST,
3~ T.~/ N.-Kld
being n the G~ ~ 0 6 the o j sec. W.
(On mope 6u.tty deacn.ibed as 6ottowa: )
i!✓✓
Dated Lh.ie day o6 19
f
(OWNER)
State o6 W.ia co na.in )
ee ,
County 06 St. Cno.ix)
Peheonnattyappeaned be6one me h.i.e / day o6 19
the above named to me mown .to -~~he
peh.eon who execute ^the onegoAng Ln4txum.ent and actz ow.Cedged the name.
AY2: izz?,
o any .cc, .t. no -cx our y,
My Comm. (,ia penman.t) (Expi/Lea) 3
heneiribe6one ne6enned to as Pumper,
j oi At t 4ao agneemen-t• .to -t e extent that I have a con,tnac.t with
Owner ae above o.ta:ted.
y ( (PUMPER )
• 1.11..- {if
4 11984
a~ wiscons~n APPLICATION FOR SANITARY PERMIT
DILHR -COUNTY
(P L B 67 )
oEaaarmenr OF
E~ 1nousrav.LFkBOR&umanaeLanons UNIFORM SANITARY PERMIT #
r 2z -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 j MAILING ADDRESS
i
PROPERTY LOCATION CITY:
VILLAGE:
1/4~ 1/4, S T~~i . N, R (or) W TOWN OF: ( ' /
LOTNUMBER JBLOCKNUMBIER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE P~A~N~1. NUMBER
/ / oQ6s~l J rb~
TYPE OF BUILDING OR USE SERVED
❑ 1 or 2 Family Number of Bedrooms. Public (Specify): i
C >r `r
THIS PERMIT IS FOR A:
❑ New System p 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 C] 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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
1 Holding Tank capacity i
manufacturer: _
i
IF THIS IS AN ALTERNATIVE SYSTErJI 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,jSquare Feet): PROPOSED~Square Feet): 11 Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Si a ure: MP/MPRSW No.: Phone Number:
Plumber.'s Address: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: F;ee: Date:
k LJ Disapproved
~-~12c V ~ 2J 9~ ~ ~ ❑ Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
i G-V
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
t0LDI NG TANK CROSS-SECTION AND SPECIFICATIONS
Approved
Vent Cap Approved Locking
Weather Proof Manhole Cover
Junction Box
41, C.I • 12 Min
Veni Pipe
Final Grade 4" Min
i
/Approved Joint
~a 18" Min
Water Tight i
Seal
High Water
i
Alarm Switch
~a -1~
SPECIFICATIONS
Approved
TANK Manufacturer: iL ~ Joint w/
7 -11-ZC . I . Pipe
Tank Size bZj Gallons Extending
ALARM Manufacturer: 3' Onto
Solid Soil
Model Number:
Switch Type
NUMBER OF BEDROOMS:
-may f
OWNER'S NAME:
ADDRESS : X /
LEGAL DISCRIPTION:~_;_3~, ` 3t,Sec._' 1 ,T,_N, /
TOWNSHIP/MU*f- 1-PITY:
T~r ✓ i y.. k p ~~1~11~
COUNTY:
I =z Sc ~ t
SIGNED:
LICENSE NUAtRF.R: a ,
DATE: G~~G ~ 194
y r 5 F-~' r''J}.
~K
r
:
i
I ~ I
I
r
lv
1
,
j j i i j i
RECENED,
~ 984
I
i
I I I t I I I I I ~ _ -
' 'NOTE: As specified in H63.18 (4 A) Wisconsin Administrative
Code this document is to be recorded in the Tract-'Index, lo-
cated at the County Register of Deeds. At the time of Sani-
tary Permit Application, a copy of this aL~reement, with the
recording dates and number should be submitted to this office.
HOLDING TANK AGREEMENT
This Agreement is glade and entered into this day of
191 by and between the
J, 1=;
hereinafter called
and '~k A(7J,P
A5 L i :Sn hereinafter ca e t e
"Owner.
We hereby acknowledge that application has been made for a building
permit on the following described property, to wit:
or that continues use of the existing premises requires that a holding
tank be installed on the property for the purpose of proper containment
of sewage. We also acknowledge that said property cannot now be served
by a municipal sewer or septic tank - soil absorption system.
Therefore, as an inducement to the County of ( S?n to
issue a sanitary permit for the above described prem ses, we ere y agree
and bind ourselves as follows.
1. Owner agrees to conform to all applicable requirements of the
Plumping Code relating to holding tanks. Any time the Town or Municipality
of - 9- ) Q_-~X-~_, I~~, through its Plumbing Inspector or Health Offi-
cer, deems it necessary to pump out the subject holding tank, the Owner
shall have same pumped out in twenty-four (24) hours, or~t~~
will have said work done and charge same back to Owner and p ace same on
the tax bill as a special char e. The Owner further agrees that the Town
or Municipality of~*7s PtZ1 fZ1 may enter upon the property des-
cribed above at any reasonable time, to nspect, or pump and haul wastes
from the subject holding tank.
2. Owner agrees to pay all charges and costs incurred by the Town or
Municipality of "5~~ for inspection, pumping, hauling or
otherwise servicing and ma nta n ng a subject holding tank in such a man-
ner as to prevent or abate any nuisance or health hazard caused by such
holding tank. `~5T'*>+2 Pa2 tt~lf shall notify the Owner of any such
cost which shall-be pa by the Owner w thin thirty (30) days from the date
of notice and in the event that the Owner does not pay said cost within
thirty (30) days, Owner hereby specifically agrees that all of said costs
and charges may be placed on the tax rdll as a special assessment for the
abatement of nuisance, and said tax shall be collected as provided by
Wisconsin Statute.
r t;-C;EIVEC
DILHR-SBD-6123 (R.3/8111) [,IJG 2 ; ~ga4
t
Page 2 T -
3. Owner agrees to have a quarterly pumping report submitted to the
local government and the county which will state the Owner's name, location
o7 the property on which the holding tank is located, the pumper's name,
the dat~2s, volumes pumped and the disposal site. An annual pumping report
or the fourth quarter report including a summary of the pumping history of
the previous year shall be submitted to the Department of Industry, Labor
and Human Relations by the governmental unit responsible, per section 145.01
.(15). Wisconsin Statutes.
4. We guarantee that the holding tank contents will be disposed of at
a site meeting the requirements of chapter NR 113, Wisconsin Administrative
Code.
5. This agreement will remain in affect only until the sanitary permit
issuing agent ins`~TcGC3L"Ty County certifies that the subject pro-
perty is served by either a pu c sewer or a septic tank - soil absorption
system that complies with ch. H 63, Wis. Adm. Code. In addition, this Agree-
ment may be cancelled by executing and recording said certification with re-
ference to this Agreement, in the Tract Index indicated above.
6. This agreement shall be binding upon the indicated governmental
unit and the Owner or heirs and assignees and shall run with the deed.
W TNESS our hands and seals this 4~ day of , c cn a 7
19~
TOWN OR MUNICIPALITY OF ~./l~~t~c✓..x~ ~C
N RS
l / .
by
STATE OF WISCONSIN
Personally came befo a me his- , day
19 -the above named
to me known to be the persons 'who-executed the o ego ng nstrument an
acknowledged the same.
I: 1.
. ~ ~~:aRji ('•.d~l~~' ~ft~Jl Rill
THIS INSTRUMENT R PUBLIC
DRAFTED BY:
My commission expires: o°~E'
P1 b. 0 -63
1/78
j PROJECT DETAIL DATA SHEET
NAME OF BUSINESS LEGAL DESCRIPTION 7-~~; Al&iI,
OWNER MAILING ADDRESS
_ ~rLj •Yr ~~c,,,~ ZIP .~~7
ARCHITECT, ENGINEER, ADDRESS PLUMBER OR DESIGNER
TELEPHONE NUMBER
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building 7( New building Addition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . . Seating capacity
( ) Bar . . . . . Seating capacity # of meals served
( ) Bowling alley . . . . . Number of lanes ( ) With bar
( ) Campground and camping resorts . . . Number of sewered sites
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons
( ) Catchbasin ( ) Day and night Number of persons
Number
( Church . . . . . . . . . . . . . . . No kitchen Number of persons~Qp
( ) Dance hall ( ) With kitchen Number of persons
Number of persons
( ) Dining hall . . . . . . . . . . . . Number of meals served daily
( ) Dog kennels . . . . . . . . . . . . Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity
Car-service Number of car spaces
( ) Dump station Number-of-dump-stations
( ) Employees ( total of all shifts) Number of employees
( ) Hotel ( ) Motel Cottages . . . . Number of units with 2 persons-per unit
Number of units with 4 persons per unit
( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff
Number of office personnel
Number of patients
( ) Mobile home parks . . . . . . Number of sites
( ) Nursing homes . . . . . . . Number of beds
( ) Parks . . . . . . . . . . . . . Number of ersons
( ) Restaurant p ( ) Toilets ( ) Showers
Seating capacity j
84 0 F; 7,28 ( ) Dishwasher and/or disposal? I
( ) 24-Hour service I
( ) Retail store . . . . . . . . . . . . Total number of customers
( ) Schools . . . . . . . . . . . . . . Number of classrooms __UT ( ) Self service laundry . . . . . . .
. Total number of machines Meals ( ) Showers nF-CEiVELD
Service station . . . . . . Number of cars served daily
( ) Swimming pool bathhouse Number of persons
( ) OTHER (Specify) . . . . . . 2 1984
COMPLETE OTHER SIDE _
2. Indicate whether the following facilities are present.
• i
Floor drain yes no X Number of drains'
Food waste grinder yes no
Dishwasher yes no X '
Automatic clothes washer yes no Y Number of clothes washers 1( j
3. Septic tank capacity - I
Holding tank capacity :3o
Septic or holding tank manufacturer
4. SEEPAGE TRENCHES: total square feet width of trenches
i
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet width -
length of bed depth
SEEPAGE PITS: total squat-,e feet outside diameter
i
depth below inlet
total depth from top to bottom of pit
Signature of son completing form: FOR DEPARTMENTAL USE ONLY--
Address
3 4
IJT Zip /
Telephone Number 7/C--
Date
E-
PLUMBING
Conjitionaffy
a low$
yy
4Y~i"7i i~pp 1
~ N 3i to d
GF-E CC
i
~ PLAN APPROVAL Safety and Buildings Division
Bureau of Plumbing
D I L H R
mP„o.o., P.O Box 7%9
❑ General Plumbing Plans Madison, WI 53707
❑ Private Sewage Plans Telephone: (608)266-3815
6
n OFFICE USE ONLY
Plan Identification No.
rQ C2, v 4`"-- - O l+~V Gallons Per Day
PRIORITY PLAN REVIEW ONLY
Plan Review
Petition For Modification
Project Name Project Location - Street No. or Legal Description
❑ City ❑ Village ❑ Town of:
The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is
based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval
is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the
city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of
plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be
made.
❑ FOR GENERAL PLUMBING PLANS:
This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan
approval must be obtained.
❑ FOR PRIVATE SEWAGE PLANS:
This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary
permit expires.
Comments:
By:
James Sargent
Bureau Director
If Questions Plans Approved By: Date Approved:
Contact
cc: ❑ OWS ❑ DPS ❑ H&R & Rec. San. Section
❑ County ❑ Local PI ❑ Facilities Need Analysis Section
❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture
DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other
1
NOTE: As spedified in H63.18 (4 A) `Wisconsin Administrative
Code this document is to be recor4 ed in l the.ATr,ac t Index, lo-
cated at the CQunty Register of Deeds. At the time of Sani-
tary Perinit Apl3lication, a copy of this at;reemenL, with the
recording dates and number should be submitted to thisb~&:UiclCPS OFFICE
YDL 69,5p GE 79 ,T• CRC!IX CO., WIS.
l'--c U for Record this 23
HOLDING TANK AGREEMENT v:,y ®f August A 0.
3:15 P , M.
This Agreement is made and entered into this ~1-- ay o er *tw 04 R®
~tj6uS"t 19~'- by and between the
hereinafter called
an a W w t"W SS here nafter called the
"Owner r-
We hereby acknowledge that application has been made for a building
permit on the following described property, to wit:
or that continued use of the existing premises requires that a holding
tank be installed on the property for the purpose of proper containment
of sewage. We also acknowledge that said property cannot now be served
by a municipal sewer or septic tank - soil absorption system.
Therefore, as an inducement to the County of to
issue a sanitary Permit for the above described premises, we hereby agree
and bind ourselves as follows.
1. Owner agrees to conform to all applicable requirements of the
Plu ing Code relating to holding tanks. Any time the Town or Municipality
of V"V z. , through its Plumbing Inspector or Health Offi-
cer, eems t necessary to pump out the subject holding tank, the Owner
shall have same pumped out in twenty-four (24) hours, or-=-,cj9_ QY_%Q1~_
will have said work done and charge same back to Owner and place same on
the tax bill as a special charge. The Owner further agrees that the Town
or Municipality of S~ PPUi k Ql may enter upon the property des-
cribed above at any reasonable timenspect, or pump and haul wastes
from the subject holding tank.
2. •Owner'agrees to pay all charges and costs incurred by the Town or
Municipality of S TV-gl 1~ for inspection, pumping, hauling or
,otherwlse_servicing and~ma nta n ng the subject holding tank in such a man-
ner.,as to- prevent or abate an nuisance or health hazard caused by such
holding tank.°( P4ZA tiles shall notify the Owner of any such
cost which dial be pa by t fie Owner wTthin thirty (30) days from the date
of .notice and :in the event that the Owner does not pay said cost within
thirty (30)_days, Owner hereby specifically agrees that all of said costs
and chargeji`may be placed on the tax roll as a special assessment for the
abatement,of nuisance, and said tax shall be collected as provided by
Wisconsin Statute.
DILHR-SBD-6123 (R.3/81)
s. Vtll J!5 PAGE
Page 2 _
3. Owner agrees to have a quarterly pumping report submitted to the
local government and the county-*which wi-1.1 state the Owner's name, location
or the property on which the holding tank is located, the pumper's name,
the dates, volumes pumped and the disposal site. An annual pumping report
or the fourth quarter report including a summary of the pumping history of
the previous year shall be submitted to the Department of Industry, Labor
and Human Relations by the governmental unit responsible, per section 145.01
•(15), Wisconsin Statutes.
4. We guarantee that the holding tank contents will be disposed of at
J a site meeting the requirements of chapter NR 113, Wisconsin Administrative
Code.
5. This agreement will remain in affect only until the sanitary permit
issuing agent in S County certifies that the subject pro-
perty is served by either a public sewer or a septic tank soil absorption
system that complies with ch. H 63, Wis. Adm. Code. In addition, this Agree-
ment may be cancelled by executing and recording said certification with re-
ference to this Agreement, in the Tract Index indicated above.
6. This agreement shall be binding upon the indicated governmental
unit and the Owner or heirs and assignees and shall run with the deed.
W TNESS our hands and seals this day of - ~,rc .
19
TOWN OR MUNICIPALITY OF
S
l
'SrC CC
by
STATE OF WISCONSIN '
Personally came before me this,,=! day f
19A -the above named
to me known to be the persons w o execute the o ego ng nstrument an
acknowledged the same. 51,1
0~ .....yam` i,s !.I Via?+.Ll4,~
THIS INSTRUMENT C v'=
d tr L q ,~4
DRAFTED BY:
My conmission~'bx~'~
I AV
atate of Wisconsin
County of St. Croix
I hereby certify that this instrument is a full,
trae and owed copy of the document on file
and of record in my office and has been
compared by me.
Atiast Aug. 23.19 84
James O'Connell
James O' Con A Regbkw of Deeds
Deputy
. H
y
S T C - 105 r
y
H
'
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County
0
y
OWNER/BUYER_..n
ROUTE/BOX NUMBEN-416 lJLa~j Fire Number_ _
r
CITY/STATE. `LIP
PROPERTY LOCATION: Section T 3J _N, R_ / W
Town of ..5 T_ A 9t ~ ~ St . Croiy, County,
Subdivision Lot number
b >
Improper use dnd 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 umber. 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 maw 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
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County,Z 'ng Office within 30 days
of the three year expiration d'ate../
SICNE
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.
APPLICATION FOR SANITARY PI~1~NfI""
S T C - 1.00
This app] i_cation form is to he ('0mj)1(0(1(i iri Iiili and signed by the owner(s) of the
property being developed. Any inadequacies w_i11 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 '4, Section j 3 T ~ N - R W
Township " rk ~i
Mailing Address
Subdivision Name
i
Lot Number
Previous Owner of Property ~seV
Total. Size of Parcel
Date Parcel was Created
Are a_ll corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH. THIS APPLICATION ONE OF THE FOLLOWiNC:
1. Warranty Deed
2. Land Contract
i. Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
PROPt=RTV OWNER CERTIFICATION
I (We.) eenti{y that aXI statements on thus Bohm ahe hue to th.e b"t oA my (ouh)
knowk.edge; that 1 (we) am (au) the ownett(b) o{ the, pnopvr~ty d"nibed in this
UtAonmation {onm, by vi tue of a wa4Aanty deed necohded in ,the. 0{(jice oo .the
County Regi.6teA o{ Deeds as Document No. 07- ; and that I (we)
pne,5e.ntfy own the pnopo6ed Aite. {,on -the. sewage oba, bybtem (on I (we) have
obtained an eabement, to nun witdl the above, deselu_be.d pr_opehty, {fort the.
*conA_t,quc,tionr 0{ d 5y, -tem, and thetame had been duty uconded in the OAS )i"ee
y R g.l,te.no~ Dee.ds, a~ Docu_ment No.
1. t -
C OWNER SIGNATURE. OF CO-OWNER (IF APPLICABLE)
DA` F, SIGNI?D DA` F SICNI,;D
n N O 0 cn O 3-0 n C7 r..
0 O m f c d 0 f.
c °1 c ° 3
m _ •
(D c .r
'0 (D
m l
3 3 m _
3 3.
I (rn O (Ji (D 2 2 i(T. CD J O
CD W W •
00 0 p N N N m v 7 We
O
tr D
Q O ZS CD I(p p r
j O
7 N N i-s N N N p p O•
(D CD O .7
C CD N
N z D a N V
CD D d O N d W
N m O OD O
C O O N CO j
Op Qp
N O N N O_
(A _ CO O 3
z co co D Oz m
° 0 c
co (D N N a
ID OWA
z CD
0 0 0 Z7 O O O Z? s
° c n c(n 3 rn cn cn cn o (D
0 3 v v q fl. eQ
CD ID fD N d 0- (D fp N
T v
w m m - 0
0 4,
7 v (D
N N
z z o rn zD co °z d
O D D Q O a~
CD (D ~1 s
cb O (G C
CD Nn
i- N IN -O C _
f r_' C (D N.
Imo. O
(C
O
3 (D O
~7 CD
p O
O z
) 7
(n -1 W
W W N W
CD N z
Q
3 1 3 a
0 0
0 0 cn co
3 m
(3n N z
D p
°
O O
p~
O (D
_
S =r O O- (D _O O 2
(D n 3 G C p a
(D T. 3 O. G W CD
O O
° T 3
Q N 3 O V'
z a O (D Z a
O co ° O_ O
7 N N (D CD n N
v 0 m
~ (D 3 ~
O
C 3 7 R
~ d F v
N S 0
W N O
7
CL CD
m ° x
O :r ?
O i (P
~a° zT
J N (D
O Q
N O.
T N O w
7 0 ZZ,
N
p O
O ~ n v
CD (D 6p O
fa Q <A O
O * p t
O O O CD
p G O Q - H
RLPCR.T CF IiJS '"CTICN---INDIVUAL SEDkTAGE-DISPOSAL SYSTa1
PRIi 2`t TZEAT%IENT consists of Septic Tank% Cther (Describe)
SEPTIC TANK: Distance from: Well,-)( t., Lot Line ft. Building/
High watermark ft. 12% or greater slope ft. Wetland ft.
Cistern ft. No. compartments`. Liquid capacity/gal.
EFFLUENT D"SPCS.L SY`'T"M consists of Tile field. Seepage pit (s).
Seepage Pit or Tle Fields Distance from: Well , ft. Building ft.
Lot Lint, ft. Cistern ft. High Watermark of water course ft.
Slope 127 or greater ft. Wetland ft.
Total length of the linesF'ft. Number of lin s Length of each
line ft. Distance betwlines t; ft. Width of trench n.
Total effective absorption area of trench bottom6'~" Sr. ft.
Depth of filter material below tile in. Depth of filter material
over tile in. Cover over filter material
Depth of the below finished grade; in. Slope of trench bottom :..in.
per 100 ft. Depth of bedrock - ft. Depth to ground water ft.
4 Number of Pits Outside diameter ft. Depth below inlet ft.
Lining material Gravel around pit: Yes.
Vo. Total sbsorption area so. ft.
Square feet of seepage trench bottom area required
Square feet of seepage pit area required
Inspected by: L;"1-0'e (
Title: i
- /7 r; r
Approved Date ,19
Rejected Date ,19
l_ < • _ C ounty, Town of
Cwnery~w (Al "44-~
Sanitary Irmit No. ' / Pronerty Addr=ess _
Septic Tank Permit No. ry J _Subdivision ' t110 A
NAME: ,
COUNTYs_
SEPTIC TANK PERMIT NUMBERt
REPORT ON SOIL PERCOLATION TEST
AND SOIL BORINGS
TO
DIVISION OF HEALTH - PLUMBING SECTION f r
P.O.BOX 309, Madison, Wis. 53701 f.
Pursuant to H 62.20, Wis. Administravive Code
P E R C O L A T I O N T E S T
TEST DEPTH CHARACTER OF SOIL HOURS WATER TEST TIME DROP IN WATER LEVEL INCHES MINUTES
NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO EXT TO LAST TO FALL
13t WETTED OVERNIGHT IN MINUTES LAST PERIOD LAST PERIOD PERIOD ONE INCH
EXAMPLE
P - 0 36" TOP SOIL 1011, CLAY 26" 25 YES OR NO 30 60
1
2
3
RECORD DATA FROM M111TMUM OF 3 TEST HOLES
COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62.20 WIS., ADMINISTRATION CODE.
S O I L "B 0 R I N G S- MINIMUM 36" BELOW PROPOSED ABSORPTION SYSTEM
BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES
EXAMPLE
B- 0 7201 n BLACK 0 SOIL u CLAY 81 S-AND 18". GRAVEL 2411
1
2
3
RECORD ATk 0
TYPE OF OCCUPANCY:
RESIDENCE: NUM3ER OF BEDROOMS OTHER: (SPECIFY) NUMBER OF PERSONS
FOOD WASTE GRINDER: YES NO DISHWASHER: YES NO AUTOMATIC CLOTHES WASHER: YES NO
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION: REPLACEMENT
TILE SIZE NO. LIN. FEET TRENCH WIDTH DEPTH NUMBER OF LINES
SEEPAGE BED: LENGTH WIDTH DEPTH TILE SIZE NO. LINES
SEEPAGE PITS INSIDE DIAMETER LIQUID DEPTH
I, 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 procedures and method specified in Chapter H 62.20 (3 Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my Inicwledge arid-belief.
NAME TITLE -
TYPE or PRINT)
REGISTRATION NO. OR MASTER PLUMBER LICENSE NO,
ADDRESS
DATE SIGNATURE„
DO NOT WRITE IN SPACE BELOW - FOR DEPARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY
RETURNED
FEE RECEIVED VALID NO. PERMIT NO.
REVIEWED BY APPROVED DATE
INITIALS YES OR NO
'Plb #67 7/71
Wisconsin Department of Health and Social Services
Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE OR USE BLACK INK - PLEASE PRINT
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check Ones
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP (Block, Lot, Sea,) ' -
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES No _ PERMIT NUMBER
D. SEPTIC TANK CAPACITY GALLONS NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: PREFAB CONCRETE POURED IN PLACE STEEL OTHER
NUMBER OF TANKS TO BE INSTALLED:
E.. TYPE OF OCCUPANCY
Check Ones One or Two Family Residence Commercial Industrial Other (Specify)
Number of persons to be Accommodated Number of Bedrooms
F. APPLICANCES, ETCs Food Waste Grinder YES NO Automatic Clother Washer YES 110
Dishrmsher YES NO Automatic Potato Peeler YES NO
OTHER (specify) YES NO
G, MASTER PLUMBER MAKING INSTALLATION
Names Address:
SIGNATURE OF APPLICANT;'
License Numbers MP
ADDRESS: MP RSW
H. (TO BE COMPLETED BY ISSUING AGENT)
Date of Application Fee Paid
Permit Issued (date) Permit Number
Agent (name) For:
town, village, city, .county, eta. (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 for 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.
COMPLETE OTHER SIDE