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Wisoonsir•. Deu~rtb.cnt of Health P- -J,
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Pl-., 67 3/70 Davisira o^ Health
SEPTIC TANK PERMIT APPLICATIOPd
• TYPE or USE BLACK INK
A. C".Ie,R 0? PROa3kTY
Nana _ _ .e. Address City, Zip CWT,,)
B. LOCATION OF PROPERTY W:T'.Rb' SYSTEM WILL BE CONSTRL'CTF.D, ALTEKEI OR EXT2;DED COUNTY
Oheck One:
CITY X VILLAGE LEGAL DESCRIPTION ,
MMSHIP
C. IS LOCAL PERTiIT REQUIRED FOR THIS WORK? YES NO
PERMIT NUN.Br.^
D. SE?TIC TANK CAPACITY /,I Gallons NEW INSTALLATION REPLACEMENT ~ ADDITION
MMTERIALS: Prxfab Concrete k. Poured in Place Steel Other
NUMBER OF TANKS TO BE
NSTALiEDt
E. TYPE OF OCCUPANCY
Cheek Ones One or Two Family Residence Commercial Industrial Oth r~~,~
"(Sp;;;;ify)
Number of Persons to be Acconmodated r Number of Bedrooms
r
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Diska.,asher YES V NO Automatio Potato Peeler YES v NO
Other (Specify)
G. MA5TER PIZIMBER .KING INSTALLATION
Name: F Address= Licerso 2u ber:
M2
Signature of Applicant: {
MP RS'.f
Address: , ~H• To be'Completed by Issuing Agent)
Date of Application Fee Paid
Permit Issued (date) Permit Number
Agent (Nara) For
Towri, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of t`„ °'ove queatio:s are answered and the
f fee paid. Agents will fo:rard application, the fee of ;1,011 for each septic tar< and the third copy
of the permit (canary' to the Division of Health. Checks an' money orders should ba irade payable to
i the Division of Health.
Do riot write in sr?-ca belaw - FOR DEPART::ENT USE ONLY
I. DATE RECEIVE, ACCE TED BY REPURti D I
(Initials) i (Date) See Corr,
FEE RECEIVED VALID. No. PERMIT NO. i Ll- r.^( 1
~~Ya s or N o)
R:,;iEa1D BY APPROVED
(Initials) DATE
Yes or No
COMPLETE O":4R SIDE
i
SEPTIC I,, F PUI1T N0.
• R E P O R T O N S O I L P Y R C O L A T T 0 27 T E S T
A N D S O I L B 0 R I N G S
TO
DIVISION Or HEALTH. - PLUA ING S : TILL
P.O.Box 309, Madison, Wis. 53701 \r
Pursuant to H 62.20, Wis. Administrative Code
P E R C O L A T I O N T E S T
Teat Dept?tCnaraet~r of Soil Hours Water Test ;'irla DQ it tst' Level 1-ohms mutes
Nxx=ber Inches Thiolmess in Ir-ohos Since Hole in Hole Lnte:°val Se pond to Nox'. to Last To Fall
lst Wetted 0•torni ht in Mtnutea Vi-st °ariod i.,,~ t Period~Periood Cn-= Inch
E=-'plo
P - 0 36i1 To Soil 10°' Ca.a 26°° 25 Yos orNo 30 _ 1+~ 60N'
44
36
RECO_Rik DATA FROM MEEN M TM 07 3 TF:ST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Ad'.ainistrativo Cods.
S 0 I L B 0 R I 11 G S- ;iini ,-,m 3611 Below pro osed Absorpti~on S,yat.
Boring Total Depth De2~h to Ground Water D'3 th to Eodroo,
Number Inehos Gbservod Estinatod Cbserved Estir- ted CMracta.r of Soil with TMc',ne3s in Inchon
B - 0 72" 7211 Black Toe Soil il'Clay 19"Sand 1811- 3ravel 241j
RECOPM DATA FROM MINI , C? 3 BO?v HOL.,
YPE OF OCCUPANCY:
»S CE Nu=ber of Bedrooms OTHFRs S eeif Number of Persons
D WASTE GRLNDERs Yes No ~ Disriasher: Yes No ~ Auta.::atic Clothes Washer: Yes No ---=~e-
Fr^LUE.NT DISPOSAL SYST%,°i: Nrrl EXTENSION ADDITION REPLA.Gai E-''T 2-
Tile Size No.Lin.Feet Trench Width Depth Number of Linea
Seepage Bed: Length Widths'70 Depth ~/,i Tile Size No. Lines .J
Seepage Pits Inside D"eter Liquid Depth
I, the undersigned, hereby certi y that the percolation tests raoorted c.; this fo::a Raro mada by me or under m. super-
vision in accord with the procedures and method specified ir. Chapter H 62.20 (13), Wisconsin Adainistr3.tive Code, and
that the data recorded and location o test hole3 are correct to the best of/my kno-ried3a and balitf.
`'j f~ j
NAME TITLS
/
(Type o~ Print) ~i
REGISTRATION NO. or MASTER PITZ1334 LICENSF, NO.
ADDRESS Lf!,l;;~ .1r /rte' ~iDATF. SIGNATURE_~j f
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Parcel 182-1020-50-000 03/20/2007 10:51 AM
PAGE 1 OF 1
Alt. Parcel 311801-43-60-02-06-010 182 - VILLAGE 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 - BETHANY LUTHERAN CHURCH
BETHANY LUTHERAN CHURCH C - PO BOX 40
PO BOX 40
415 BRIDGE ST
STAR PRAIRIE WI 54026
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 1 PT OF LOT 6, 7 & 8 COM SE COR LOT Block/Condo Bldg:
6 BLK 2 S & M ADD TH N 151', TH W 19',
TH S 97', TH W IT, TH S 54', TH E 32' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TO POB VIL STAR PRAIRIE ASSESSED WITH 01-31 N-18W
96B & 98B FKA PARCEL 188
Notes: Parcel History:
Date Doc # Vol/Page Type
01/21/1999 596260 1398/01 WD
07/23/1997 1164/541 OC
2007 SUMMARY Bill Fair Market Value: Assessed with:
0 182-1011-10-000
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 182-1010-60-000 03/20/2007 10:52 AM
PAGE 1 OF 1
Alt. Parcel 311801-43-60-02-01-000 182 - VILLAGE 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-BETHANY LUTHERAN CHURCH, CHURCH PARSONAGE
CHURCH PARSONAGE BETHANY LUTHERAN CHURCH
415 BRIDGE ST
STAR PRAIRIE WI 54026
Districts: SC = School SP = Special Property Address(es): = Primary
Type Dist # Description ' 119 FIRST ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
LOT 1 &2 BLK 2 S & M ADD VIL STAR Block/Condo Bldg:
PARIRIE FKA PARCEL 90, 91 CHURCH
PARSONAGE Tract(s): (Sec-Twn-Rng 401/4 1601/4)
01-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
I
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/15/1985
Description Class Acres Land Improve Total State Reason
OTHER X4 0.001 0 0 0 NO
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
P:.. #43 SEPTIC TANK PERMIT NO.
REPORT ON SOIL PS RC0LATI0N TEST
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTION
P.O.Box 309, Madison, Wis. 53701
Pursuan to H 62.20, Wis. Administrative, od
NAME PROPERTY RESS
LOCATION (Cheok e) City Village , Town,;` t / County
City or Township
WATER SUPPLY FROM: Publio Utility, Cooperative ~ Private Well 1
SEWAGE DISPOSAL INSTALLED BYt Address y -!t~`~ Date
SEPTIC TANK SIZE Material Peroolation & Soil Borings Test Date
EFFLUENT DISP.t Tile Size No. Lin. Ft. Trenoh Width Depth of Tile
Seepage Beds Lengthy Width Depth of Tile
Seepage Pitt Outside Diameter Liquid Depth
TYPE OF OOCUPANCYt
RESIDENCE: Number of Bedrooms OTHERS (speoify)~~' Number of Persons
FOOD WASTE GRINDER: Yes _ No
Dishwashers Yea No Automatio Clothes Washers Yes No
4L 4-
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 In-ohes Minutes
Number Inohes Thiokness in Inohes Since Hole in Hole Interval Seoond to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One Inoh
Example
P- 0 361, To Soil 1011, Clay 261, 25 es or no 30 1/2 1 2 112 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in aooord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 36N'Below Proposes d Absorption System
Test Total Depth Depth to Ground Water Depth to Redrook
Number Inohes Observed Estimated Observed Estimated Character of Soil with Thlokow in Inches
Example
B- 0 72" 72" Bla Vo Soil 12411 Clay 18E Sand 18n Gravel 2411
j,
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
I, the undersigned, hereby oertify that the percolation tests reported on this form were made by me or under my super-
vision in aooord with the prooedures and method speoified in Chapter H 62.20 (13), Wisoonsin Administrative Code, and
that the data reoorded and location of test holes are oorreot to the best of my knowledge and belief.
NAME
TITLE
Type or Print)
J- REGISTRATION NO. or MASTER PLUMBER LICENSE NO. I ADDRESS
DATE SIGNATURE
•ls93 uollelooaad
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•alea uollelooaad 043 a3einoleo of pasn aq lle4s
doap lanai ua3eM leUi3 ayl •pasn aq pln04s lena0lui !sal aa3ao4s a salnuiw ual
ue43 ssal u! Aeme sdaas lanea6 943 anoge aalem jo sayoul xis 043 aaa4m saseo ul
•lanea6 043 anoge sayou! xis 09/10 Sou luiod a of Auessaoau u04m 0104 043 6uliildau
1an04 auo jo polaad a aol slena93ui 93nulw ual le lanai aa3eM ul doap 043 aanseaw
lulod aouaaapa paxil a woaj pue lanea6 043 a9AO sayoul xis ueyl aaow IOU lulod
e of a104 043 03 aa3eM ppe ssal ao salnulw u93 u! Aeme sdaas (q) £ uolloaS ui
pallloads se J8nea6 943 aano aa3eM jo sayou! Z1 10 6ui111j puooas 043 dl (o)
•lsal uoilelooaad a43 aleinoleo of pasn aq lle4s poped alnuiw ual lsel a41 ul
s.inooo le43 !anal aa3eM ui doap a41 •an04 auo uol una 3sal 043 pue salnulw ual
se uaNel aq ile4s sluawaanseaw uaaMlaq ienaalu! 0w'3 943 pol.ied 6u!llams 1los 043
aalle salnuiw 0£ ue41 ssal u! Aeme sdaas ua3eM 10 sayou1 xis lsalJ ayl uayM (q)
•alea uollelooaad 043 alelnoleo of pasn aq
lleys lenaalu! alnuiw 0£ lsei ay3 ul sanooo ley! Jana[ aa3eM ul doap 041 •doap lanai
ualem paanseaw 3se[ a43 10 sliwll 943 04 ldaoxa spoiaad luawa.inseew £ lsel 943
6uianp apew aq 30u Heys JanaJ ua3eM 043 10 3uawlsnfpy •40ul ue jo 91/1 ue43 aaow
Len lou op s6uipeaa anlssooons oml ji san04 .inol ue41 ssal ul paleuiwaa3 aq stew
!sal 841 •Ajdwa ~laeau sawooaq 9104 043 uayM Janea6 a43 anoge sayoul xis a9AO 30u
luiod a of aa3eM 441m s0104 043 6ullllJau `sanoy .inol jo polaad a aol salnulw 0£
30 slenaaluJ le 3ulod aouau0jaa paxlj a woaj pa.inseaw aq lle4s Janal aa3eM ul doap
043 pue Janea6 044 anoge sayoui xis uey3 avow IOU jo yldap a of p03sn(pe aq lle4s
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:luawa.inseaw alea uollelooaad
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salnuiw u94 ul Aeme sdaas aa3eM jo sayou! Zl 10 6ullll3 puooas ay3 11 •aanpoooad
943 3eada.i ssal ao salnuiw u03 ui Aeme sdaas aalem sly! 11 'lanea6 ayl JOAO aalem
40 sayoul Z[ anod Allnjaaeo Aelo ou ao alllll 6uiuleluoo silos Apues ul (q)
•molaq (q) pue (e) ~ suoiloaS ul
pallloads se paaoo,id tie4s !sal uollelooaad ay3 pol.iad 6ulllams a43 jade Alalelpawwl
•aeaA 943 jo suoseas 3s913aM 843 6ulanp lsix9 lllm ley1 suolllpuoo ayl 43eoadde
llim 31 3ey4 os san04 of uey3 aaow ao sanoy 9l uey3 ssal 30u [lams of pamolle
aq !let's 1los 941 •panowaa aq lou Heys sanoy .inoj aa3je aloy 043 ul 6ululewau
ua3eM •sanoy anol aseo[ le ,}o po ped a aol Janea6 944 JOAO sayoul Z[ jo yldap
e of aa3eM 431m p91111 st alo4 3sal ay3 os `uoydls ollewolne ue se 4ons aa3em jo
aionaasaa snldans a 6uiAlddns Aq ao Aaessaoau 11 6u!1113aa `laneu6 ay3 aano sayou! Zl
10 43dap wnwlulw a of aalem aealo 431m pal[l3 Allnjaueo aq lleys alo4 ay3 (e)
:llos jo 6ul[lams pue uolleanaeS
•s9104 944 ui Janea6 a0 pues asaew jo so4oul oml 0oeld
pue sanoy ay3 3o wo33oq 943 wouj lelaalew asooi 943 anow0b •11os ieanleu a43 asodx0
of luawnulsul palulod duet's a 441m s0104 943 jo wol3oq pue saps ay3 ua46noa
:0104 jo uol3euedaud (Z)
(•seaae pa[lij Aimau ul s3sal jo uolleuap!suoo Jeioads aol y3le9H 10 uo[sinia
943 loeluoo) -plaid a6euleap ao ald a6edeas pasodoad ay3 40 4ldap ay3 of pue 3o
e9ae ay3 ui `aalaweip ul sayoul Z1 03 h `s0104 le:,j3a0n aaa44 !seal le aaoq ao 610
:aloy 4o adAl (1)
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Plb 60
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NAME OF BUSINESS /,1~AC //f r7 /
LOCATION
street or highway city or township county
LEGAL DESCRIPTION L/
WNER
Mailing address
ZIP t1 v~ G~
ARCHITECT OR ENGINEER Address
ZIP
PLUMBER i%',~ Address L -i.t ,~l f t G i~ F~
ZIP
1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed=
Existing building Ius\ New building Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant . . . . Car spaces
( ) Restaurant . • . . . . • . . . Seating capacity 10 sq. ft./person)
( ) Dining hall . . . • . . . . Per meal served Toilet waste Yes No
( ) Motel ( ) Hotel ( ) Cottages . . . Number of units: 2 persons unit 4 persons unit
TOTAL NUMBER OF UNITS
Churches . . . . Number of persons Kitchen Yes _ No
Bar or cocktail lounge . . . . Seating capacity (10 sq, ft./person)
( ) Nursing or rest home . . . . . Number of beds
( ) Mobile home perk . . . . . . . Number of units - dependent (camper tre.iler)
- nondependent (mobile home)
( ) Retail store • . . . . • Number of employees Number of customers (10 sq. ft./person)
( ) Service station . Number of oars servedTdai7y)
( ) School . . . . . . . . . Number of classrooms Meals served Yes No
Shovers provided Yes No
( ) Factory or office building Number of persons (total all shift-91-
Residence . . . . o . . . Number of bedrooms
( ) Apartments . . . . . . . . . . Number of bedrooms
( ) Other . . . . . . . . . . . Specify
2. Indicate whether or not the following facilities are connected: Food waste grinder . . . . . Yes No~
Dishwasher . . . . . . . . . Yes No
Automatic clothes washer . Yes No
3. Fill in the appropriate information for the following as indicated:
Septic tank capacity planned i- TOTAL Septic tank capacity required ~ t~Percolation test results - ATTACH PEBCQLA ION TEST REPORT SHEET
Seepage trench bottom area planned width linear feet depth
Seepage bed area planned Z~ width =I GI linear feet depth
Seepage pit planned outside diameter depth below inlet depth
Seepage trench bottom area required width linear feet depth
Seepage bed area required 6) width linear feet R?6 depth
Seepage pit required ouj ide diameter depth below inlet
Signature of person completing form: STATE DIVISION OF HEALTH, PLUMB SECTION
z.
P. 0. Box 309: Madison, Wiscons n 53701
(l
Address i 1/ 1.2 /1( . < / Approved: !-s -
ZIP
Dates '7 Dates
THIS APPROVAL IS BASED ON STATE PLUMBING
THIS APPROVAL SHALL BE VOID IF REVISE11 CODE REQUIREMENTS AND DOES NOT EX9,9PT THE
WITHOUT THE WRITTEN APPROVAL OF THE INSTALLATION FROM CITY, VILLAGE, TOWN-
DIVISION OF HEALTH. SHIP OR COUNTY REGULATIONS OR PEXIIT
(OVER) REQUIREMENTS.
INFORMATION REQUIRED FOR SUBMISSION OF PLANS
1. Legal description of property on which septic tank and effluent disposal system
is to be installed.
2. Percolation test data from a minimum of three test holes. Tests are to be conducted
in the area and to the depth of the proposed effluent absorption system. Where ground
water and/or bedrock conditions exist, the vertical depth from grade level to same shall
be indicated.
3. A detailed plan of the proposed installation specifying the location of the building
served, size and design of septic tank, effluent absorption system with location and
numerical identification of percolation test holes.
4. Indicate on plan lateral distances between septic tank effluent disposal system and
building, well and lot lines.
5. Include complete data on expected use of the building. See Section H 62.20.
J~
LAKE 0P 1? STREAM 50~
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P * I
SF PAGE 50' ~ 7s'
T R E N C H ~P
P# 2
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75' I
SO
SE`PAG~ BED z$' 100 251
J
#I~ `GAL WELL
I
WELL BLDG.
G-- 50 fI- - - - -
2~i 31 6' _ I o0o
I T P I Ga -P-5
P-4 3 V
GAL.
50~ 25~
5 0 /0 5
WELL SE E P G E I TS
P P
LOT LI NE
O-'-- P • Peroolation teat hole
SAMPLE PLAN DEPICTING SEEPAGE TRENCH, SEEPAGE BED AND SEEPAGE PIT
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THIS APPROVAL SHALL BE VOID IF REVISED
~,y ± t WITHOUT THE WRITTIN APPROVAL OF THE
DIVISION OF HEALTH.
Approved,
DATE JAN - 6 '
{t{ WIS. DEPT. OF PT-A[ R & 5r I AL SE ICES
THIS APPROVAL 18 BASED ON STATE PLUMB.
^.y/✓ .fa ING CUQE REQUIREMENTS AND NOES NO-,
1~-r Att i7 ! E i
ts / Ek'PI THE INSTILLATION FR.()M CITY,
TOWNSHIP OR COUNTY REGLLATIOAS
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