Fillable City, State Zip Code Phone Number Subdivision Name (St. Croix County Wisconsin)

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City, State Zip Code Phone Number Subdivision Name (St. Croix County Wisconsin)

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U.S.A. forms for St. Croix County Wisconsin

BROWSE ST. CROIX COUNTY WISCONSIN (WI) FORMS

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County Sanitary Permit Application
ST. CROIX COUNTY WISCONSIN
In accord with Chapter 12 St. Croix County Sanitary Ordinance
COMMUNITY DEVELOPMENT DEPARTMENT
Personal information you provide may be used for secondary purposes
ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)]
1101 Carmichael Road
Hudson, WI 54016-7710
(715)386-4680 Fax (715)245-4250
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit #
Check if revision to previous application
I. Application Information - Please Print all Information
Location:
Property Owner Name
1/4
1/4, Sec
T N, R E (or) W
Property Owner's Mailing Address
Lot Number
Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
II Type of Building: (check one)
City
Village
Town of
1 or 2 Family Dwelling - No. of Bedrooms:
Public/Commercial (describe use):
State-owned
Nearest Road
II. Type of Permit: (Check only one box online A. Check box online B if applicable)
Parcel Tax Number(s)
A)
1. Repair
2. Reconnection
3. Non-plumbing
4. Rejuvenation
Sanitation
B)
State Sanitary Permit was previously issued
Permit Number Date Issued
IV. Type of POWT System: (Check all that apply)
Non-pressurized In-ground
Mound ≥ 24 in. suitable soil
Mound ≤ 24 in. suitable soil
Mound A+0
Sand Filter
Constructed Wetland Peat Filter
Drip Line
Pressurized In-ground
Holding Tank
Single Pass
Other
At-grade
Aerobic Treatment Unit
Recirculating
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd)
2. Dispersal Area
Required
3. Dispersal Area
Proposed
4. Soil Application Rate
(Gals. /day/sq.ft.)
5. Percolation Rate
(Min./inch)
6. System Elevation
7. Final Grade
Elevation
VI. Tank Information
Capacity in Gallons
Total
Gallons
# of
Tanks
Manufacturer
Prefab
Concrete
Site Con-
structed
Steel
Fiber-
glass
Plastic
New
Tanks
Existing
Tanks
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnection/rejuvenation/installation 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.
Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
VIII. County Use Only
Approved
Disapproved
Sanitary Permit Fee
Date Issued Issuing Agent Signature (No stamps)
Owner Given Initial Adverse
Determination
IX. Conditions of Approval/Reasons for Disapproval:
Rev: 3/21
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City, State Zip Code Phone Number Subdivision Name (St. Croix County Wisconsin)

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Completed 26 March 2021

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