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2. Saint Croix County Health and Human Services - Public Health
   1752 Dorset Lane
   New Richmond, WI 54701
   Phone: 715-246-8361
   Fax: 715-246-8367
4. This application must be submitted to above address at least 30 days prior to the event.
8. Name of the Event*
9. Address of the Event*
11. Starting Date and Time of the Event *
    Starting Date and Time of the Event

    Starting Date and Time of the Event
12. Ending Date and Time of the Event
    Ending Date and Time of the Event

    Ending Date and Time of the Event
14. Name of Legal Licensee*
15. Mailing Address of the Legal Licensee*
17. Name of Organizer of the Event/Personal Contact
18. Phone Number of Organizer of the Event*
20. Estimated Number of People Attending the Entire Event*
21. Estimated number of people attending the event that will be camping in the special event camping area*
23. Area of Land, number of acres, of the Special Event Campground*
24. Total Number of Special Event Camping Sites you are applying for:*
26. Number of Dependent Sites*
    These are sites with tents or a type of camping unit that does not have it's own bathroom inside.
27. Number of Independent Sites*
    These are campers that have their own bathrooms.
29. Formula for calculating the maximum number of sites and maximum number of people camping:
    The maximum number of sites per acre for special event camping is 50. The maximum number of people per site is 6. Therefore the formula is as follows: Number of Acres in special event camping area X 50 sites per acre = maximum number of sites in the special event camping area. The maximum number of sites in special event camping area X 6 persons per site = Total number of campers
33. Wastewater: Number of toilets to be provided: (Use this table to determine how many toilets you will need)
    
35. How many of each of the following will you be providing? Note: Portable toilets do not have to be sex designated and urinals are not required. The chart above is the minimum number of toilets required. Generally events do exceed these numbers.
37. Number of Portable Toilets to be Provided
38. Number of Female Flush or Privy Toilets
39. Number of Male Flush or Privy Toilets
41. Name of Licensed Disposer Servicing the Portable Toilets or Independent Units
42. Address of Licensed Disposer Servicing the Portable Toilets or Independent Units
43. Phone Number of Licensed Disposer Servicing the Portable Toilets or Independent Units
47. Potable Water Source

    1. Municipal
    2. Private Well
49. For private wells, it is required that the water be tested for coliform bacteria. Unless your results are already on file with our department , please email results to environmentalhealth@sccwi.gov
51. Please describe the water disturbution method within the special event camping area:
55. Solid Waste / Garbage Removal Service Name
56. Solid Waste / Garbage Removal Service Address
57. Solid Waste / Garbage Removal Service Phone Number
61. Fees: Based on Sites (Make check payable to the Sant Croix County Public Health)
    $235.50 for 1-25 sites
    $289 for 26-50 sites
    $338.50 for 51-100 sites
    $385.50 for 100-199 sites
    $435 for 200 or more sites
    
63. Email a scaled site drawing of your intended campground. This drawing must include the following: well location, toilet facilities, solid waste containers, dependant campsites, and independent campsites.
65. I certify that I am familiar with Chapter ATCP 79.
    Chapter ATCP 79 is located on the Licensing and Inspections page.
    Campgrounds, Wisconsin Administrative Code and the above-described establishment will be operated and maintained in accordance with all applicable regulations.
67. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
69. Electronic Signature*
71. Submittal
    Check the "I'm not a robot" and then hit submit below. If you would like to receive an email copy of this submittal enter an email address below. An inspector will review your submittal and contact you. Thanks from St. Croix County Public Health!
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field