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Plb. #07 3/70 Division of Health -
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY ;
Name Address (Street City, Zip Code) _
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY ,
Check One:
CITY VILLAGE LEGAL DESCRIPTION
7-
TOWNSHIP~ f~ ✓C~ ~C : f/~ a /1 ✓
i
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TWX CAPACITYZ C'c ` Gallons NEW INSTALLATION REPLACZMNT ADDITION
MATERIALS: Prefab Concrete. Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLEDs
E. TYPE OF OCCUPANCY
-Check One: One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES A NO Automatic Clothes Washer --1~6S NO
Dishwasher YES NO Automatio Potato Peeler YES NO
Other (Specify)
G. MASTER PLUIjBER MAKING INSTALLA EON
Name: /L---L-- ;-K-7- Address: C i License Number:
MP
Signature of Applicant=- MP RSW / S b
Address: ' L - / -%y
H. (To Competed by Issuing Agent) /111 Date of Application (1 Fee Paid "0
Permit Issued (date) Permit Number
Agent (Name) :f it k~ 'J'l For: " .
Town, Village, City, ounty, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will ro mard application, the fee of 41.00 for each septic tarot and the third copy
of the permit (canary) to the Division of Health. Checks and money ordars should be made payable to
the Division of Heaat_:.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED VALID. No. PERMIT NO. L l
es or Y.o - T 7
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO,
F R Z P 0 R T O N S O I L P E R C O L A T I O N T E S T
A N D S 0 1 L B 0 R I N G 8 .
TO
C `
DIVISION OF HEALTH - PLUMBING. SECT16N '
P.O.Box 309, Madison, Wis. 53701 ^
Pursuant to H 62.20, Wis. Administrative Code
P Z R C 0 L A T 1 0 N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
lst Wetted OverniaMt in Minutes Last Period Last Period Period One, Inch
Example
P - 0 361' To Soil 10" Cla 261* 25 Yes or No 30 1/2 1/2 1/2 60
2 7Z
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 36" Below Pro osed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Esticated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 72" 72" Black To Soil 12" C1 18" Sand 18"-, Gravel 24"
RECORD DATA FROM MLVL`IUM OF 3 BORE HOLES
YPE OF OCCUPANCY:
RESIDENCES Number of Bedrooms OTHERs (Specify) Number of Persons
FOOD WASTE GR LNDERs Yes No ~Lr- Dishwasher: Yes No~ Automatic Clothes Washer: Yes/ No
EFFLUENT DISPOSAL SYSTEM: NEW -Y EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet D Trench Width Depth Number of Lines
Seepage Beds Length Width Depth Tile Size Me. Lines
' Seepage Pits Inside Diameter Liquid Depth ..2__
Is the undersigned, hereby cert'fy that the percolation tests reported n this fora were made by me or under -:U, super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the ,ta recorded and loe on of test holes `are correct to the best of my Icnowledge and belief.
NAME i I / Y` TITLE
Type or Print L~
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE ~7 ! SIGNATURE
Parcel 036-1095-20-000 01/1112007 01:18 PM
PAGE 1 OF 1
Alt. Parcel 36.31.17.574 036 - TOWN OF STANTON
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 - POWERS, CALVIN W JR & PHYLLIS A
CALVIN W JR & PHYLLIS A POWERS
1969 185TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1969 185TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 36 T31 N R1 7W 40A NW SE Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
36-31N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
2006 SUMMARY Bill Fair Market Value: Assessed with:
167058 Use Value Assessment
Valuations: Last Changed: 05/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 17,000 129,900 146,900 NO
AGRICULTURAL G4 38.000 5,700 0 5,700 NO
Totals for 2006:
General Property 40.000 22,700 129,900 152,600
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 22,700 129,900 152,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
y TOWNSHIP ,,~~1r i' SEC. j~T-RAW
OWNER 2Li a a
ADDRESS ST. CROIX COUNTY, WISCONSIN.
LA/
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
_ EVERY-THING WITHIN 100 FEET OF SYSTEM
l
1 IT
JL Y
I di a Le o thj Arrow
SC LE: 1 i
{ ('~J
~~,~~f f~por"
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: ZZ,, er r Slope at site: „
SEPTIC TANK: Manufacturer: AJOI Liquid Capacity: Number of rings on cover : Tancmanhole cover elevation -
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal.. pump set or a cycle gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: Number 0 pits ---met iameter
feet liquid depth seepage pit in eft pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines_ width_ le,igth "tile depth]
SEEPAGE 'FRENCH: idth length_ _
PERCOI_,ATION RATE ` AREA REQUIRED AREA AS B _ r -
INSPEC'
DA`T'ED.-"_' / P ER ON
LICENSE NUMBER
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit /~/4- _
State Septic :w6s -
NAME___-_0__.l-__ 0&V r TOWNSIIIP , St. Croix County
k0CATtON_*4j S -_Section%XLot ~l Subdivision
E:PT IC TANK
Size 4,0 gallons Number of compartments-__
ULstance from: Well Building 12% slope
Highwater
PUMPING CHAMBER
Size gallons Pump Manufacturer' _Model Number_
IIOLD LNC TANK
Size gallons Number of Compartments-
Pumper Alarm System_ _
U [ stance from: Well _ Building- 12% slope
Highwater-
ABSORPTION SITE
Bed Trench
i)istance from: Well C' Building~~ 12% slope
Highwater
ABSORPTION SITE DIMENSIONS
Width of trench / 2- ft Required area K5 5 _ ft.
Length of each line ft Depth of rock below the Ln.
Number of lines 2 Depth of 'rock over
in.
'T'otal length of lines _1 l ft Depth of tile below grade-35,
Distance between lines G- it Slope of trench in. per 100 ft.
Total absortption area 6,- 2 - ft Type of Cover: _
I'L'I' DIMENSIONS
Number of pits Gravel around pits-- yes_ no
outside diameter ft Depth below inlet -ft
Total absorpon.-are _ f t
Area requ...re ft
INSP ' 'ED BY 1'ITL.F.
APPROVEDf DA.T,P:- - 198
REAECTED DATE 198
RI?AS0N 100R REJECTION
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mail' g Address:
i
Property Location: C ty, Villa or -township: County:
%S36- iT N/ / (or) W e
an I.D. Number: i
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: t(177anecl)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required. t
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER I
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
CDC
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER i
MANUFACTURER: 7 7,
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): 1-D New Replacement ❑ Experimental Seepage Bed E:1 Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench 6
~ i
i
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public i
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. I
Name of Plumber: Signature: MP/MPRSW No.: Phone Number:
t_ (71, )
Plu er's Address: ° Name of Designer:
}
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: 1 Fee: Date: APPROVED Sanitary Permit Number: Y
7 , 3 ❑ DISAPPROVED
Z16 J
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior
staliation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03181)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDIjSTRY, C DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
A) '/f . /T=a/ N/R ~ (or) W
'COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I R DESCRI TONS: ER LA ION TESTS:
~Residence ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
M s []U ❑ s ❑u ❑ s 11U ❑ s [A ❑ s ❑u _snl,yt-rl.C
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
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.)
f
B ? 23 - I :X7- 21 S
B } 4
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERT D2 PERI D PERINCH
i r
P-
P f ! 7 L
P-
P-
P-
P-
PLAN VIEW: 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 slop.
SYSTEM ELEVATION/
r
J:7¢ntic
.
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:t1
3 r,{. X/Uc~ i
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative 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:
i 0 f ? ~6- _
ADD ESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
4:3 AL - 1 ,5:j
CST SIGNATU E:
r o
I
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 IN. 03/81) '