Community Development Department – Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
email@example.com 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of your new or replacement sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email. If you would like to view your issued sanitary permit online, you can
do so by using the Property Files Scanned weblink.
Phone Number (required)
Email Address (required)
Parcel Identification Number
(found on the property tax bill)
Property Location _____ ¼ , _____ ¼ , Sec. _____, T _____N R_____W, Town of .
Subdivision Plat: , Lot # _____.
Certified Survey Map # , Volume , Page # .
Warranty Deed # (before 2006)Volume , Page # .
Number of bedrooms Spec house yes no Lot lines identifiable yes no
New Property Address
(Verification of new address required from Community Development Department for new construction.)
(Staff Initials) (Date)
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified
survey map if reference is made in the warranty deed.
NEW SYSTEM: LEGAL DESCRIPTION
Office Use Only