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HomeMy WebLinkAbout026-1135-09-000 a 09� Safety and Buildings Division N v isicons i n 201 W. Washington Ave., P.O. Box 7162 /� Madison, WI 53 707 - 7162 Si Address � g Department of Commerce Sanitary Permit Number Sa)�utary Permit Apphcatio 5v • °D �6 3 a z. In accord with Comm 83.21, Wis. Adm. Code, personal information y , Yd'Check if Revision may be used for secondary purposes Privacy Law, s15. 1 m I. Application Information - Please Print All Information State Plan I.D. Number Z J� A Property Owner's Name Parcel Number /�:). G e4!`nA-A, 9/dp5 Rp rcf Property Owner's Mailing Address t �p peaty Location p3q to-O. A T6 � 1r 5iSe14;S Z TA N, City, State Zip Code pPhone um f 0z t Number Block Num. C , / COO ubdivision Name CSM Number _ _3 OFF 1CC H. Type of Building (check all that apply) ❑City ❑ 1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ownship 1G,/ -O"4AI S ❑ State Owned Nearest Road 306ia.H,•lae*s v+.' 3 frete��- � X 13` D/"? M. Type of Permit: (Check only one box on tine A (ntmtbering scheme for internal use). Complete line B if applicable) A- 1 VN,, 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use stem I Tank Only stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV' Typd of Permit: (Check all that apply)(ntimbering scheme is for internal use) k--5 44 VNon - Pressurized In Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand 3r / 22 ❑ Pressurized in- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Msve rsaUTreatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals.lDays/Sq.Ft.) (Min./Inch) q , / O Elevation �fS7� 9 M °13 q9 3 0� q�f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 006 v x Dosing Chamber VII. Responsibility Statement- I, the undersigned, a responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) y Plumber's SjOfia I MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, e) t /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is eat Signature (No Stamps) Surcharge Fee ) 0 p ❑ Owner Given Initial Adverse Determination IX. Conditions of Approval/Reasons for Disapproval Sa/►A�'�t Attach complete plans (to the County only) for the system on paper not leas than Sla x 11 inches in size SBD -6398 (R. 05101) PLOT PLAN PROJECT P.C. C011ov a Builders Inc. A DRESS P.O. Box 489 Somerset Wi 54025 NW 1/4 SE 1 /4s 24 /T 30 / 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 7/24/02 BEDROOM 3 CONVENTIONAL XXX IN-GROU64 CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE 630 DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION ARE 1212 # of chambe s 39 IL BENCHMARK V.R.P. Top of 1.5" pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE (DWELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 92.9/92.8 a- 292' Property Line Vent ALo Standard Infiltrator Plans Designed Using Leaching Chamber Conventional Powts with 31.1 ft2 of Area Manual Version 2.0 " 2' -3' X 94' Cells p Grade at System El evation with >3 S Cells 34 " en s 20' 70' ro 3 Huffcutt Combo Tank B edroom 3% B_7 B 2 H ouse Slope 20 40' B- .� 20, 5 5' o :a 35' o B -3 B -5 Vents 45' .M.#1 B.M. #2 L 'L, 292' Property Line 15' 15' wisconsh Department of comawce SOIL EVALUATION REPORT Page a in accordance with Comm 85. wit. Adm. Code couur Attach complete As plan an paw not less then 8112 x 11 inches in size. Plan moust but not limited to vertical and horil reference Pont (BM), direction and Panel LD. percentslope, scale or dimensions. norm crow. and IocaGon and distance to nearest road Please prinf atl information. Oats %� ,�7, h �� PwwW WAwnwbe you Pruvids maybe used for sew dory Purposes tRiraey Low. s. 15.04 (t) irnl)• PMPWWOwner PrcperNl- Govt. t of JA 5^ 1N 22 T,3 O N R E( t W • C ep vim. l p� ti� L RoperlyOwneesMallingAddress (� Lot # Bbdc # Subd. Name or CSMN �./�iv State zip c o de Phone Number 1] CRY 0 T Nearest Road I ff ( ?� New Qarsbuclion utw dential / Number of bedrooms Code derived design flow rate �� 0 GPD R4tplaoameneplacement // es Pt�ic - Describe: Flood Plain elevation if applicable . ,dCr Iq tt General commonts OW naootrwttertda r IS. Boring # j _ . pit Grouts surface R Deptl� b Rmitsrg tabor m. Sol Depth Domiowtoow Redotc Desaip M Texture Structure Consistence Boundary Roots GPOW in. Mursell Qu. Sz Cart. Color Gr. Sz. Sh. •EtFtl1 •Eflfl2 E Beft p eain ❑ Pit Cxotmd surface elev. R Depth b STAV factor in. Soft Application Rate Horizon Depth Don*wtCdw Redox Description Texture Struct" Gorsistence Boundary Roots GPDW in. Mursell flu. Sz. Can. Color Gr. Sz Sh. •Eff#1 I *EM • Effluent #1= BCC k 30 nV& and TSS >30 150 mq0L EMuen #2 = BCC 1 30 nV& and TSS 130 moll- Address Date Evaluation Conducted Telephone pkrnber �I race Ut SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIF ICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADE WEATHERPROOF Z: 25 1 FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W1 PADLOCK 5 FINISHED GRADE WARNING LABEL 6 -- 0.x•• MIN. all a 18" IN. flfE pd�fivwiwa :; t D t8'WM• INLET WATER TIGHT SEALS GAS- ; '� T TIGHT: PROVED FILTER ---�- A SEAL , JOiNT5 WITH APPROVED —1--- ALM APPROVED PIPE PIPE 3 B ONTO SOLID �' ON 3 OL SO C SOIL i PUMP OFF ELEV . +— OFF D 3 APPROVED BEDDING UNDER TANK C RETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: NUMBER DOSES PER DAY: TANK SIZES SEPTIC GAL, DOSE VOLUME INCLUDING D0:"r GAL. F LOWBAC K : G AL. ALARM MANUFACTUR3 �� CAPACITIES: A =p INCHES = rL�GAL. '�— MODEL NUMBED. B = 2 INCHES = 120--GAL. SWITCH TYPE: PUMP MANUFACTURER: C = INCHES =�-�- -GAL. MODEL NUMBER: S _ D = C7 INCHES = ZC2__C-AL SWITCH TYPE: S REQUIRED DISCHARGE RPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VER'T'ICAL DIFFERENCE PUMP OFF AND DISTRIBUTION PIPE ` FEET + NIMUM NETWORK SUPPLY P�SSURE . . - FEET + ��j FEET FORCEMAIN JO FT /100 FT. FRICTION FACTOR FEET TOT AL DYNAMIC HEARD INTERNAL DIMENSIONS OF P P TANK: LENGTH / ' `� ID�k1 b 91: TER LIQUID SIGNED: LICENSE NUMBER' � �UATE: 1/88 l HEAD/CAPACITY CURVE EFFLUENT and DEWATERING WARNING: Model 18514185 should not be subjected to less than 30 feet TDH. TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE sus 43 t t 4004 K rt :� J ........ .. G&U� Gat - W Gd. .-- i6 CA tes 6 71 1 wb J 144 4S 140-- 4­ 71 s. j3 34 71 ' 1 42 13 » R11 u fi 3 T f , n, 36 V" .4ll.. n arc ffl 9w a 133 '5U. tie 3 0 X 121 to 40 ss� U s:e to 30 e MI. �44 � =1 _jTj 46 4 6 SU R 7.7 '. , .-R-1 40 'Z' �55 �?N� R. M N." to -- 21 33 51 K a 38 125­ is :ftoj .43 ism �w 120-- W A 7 7. 11141 w set 191 twx WIF 32 3"? 34 11cr VOW. 2,x z r sir tsr 32— 105 Lod' Ily n 2r 2r 4r 100 1 A 30 95--_ 28-- 90—NS— 186 26 — 41 165 80 - 4 5 24-- Ils" 7 5 5 22-- 70— 20— 65 65 0 1 6j' 18— 163. \1 89. 4163 4189__ r 55 16- N __ 50— 14 — -w_ 12 40 — 140. 188 .4140 41 35 10 __ 30 185. 137,139 4185 — 20 6— N 15 10. 2-- 43 95 161 4161 0— 4 1 150 16 U.S. GALLONS 10 201 D 01 50 66 1 70 80 1 90 100 jjA ?0 120 1 � LITERS 80 iio 240 320 400 480 560 640 0 FLOW PER MINUTE OM22 Note For Head Capacity on Model 112, industrial column-explosion pr000f pump, see FMO219. J f a < V L ;s M 4 L; S. t No i " w"WI tr Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety and Building Divis;*,n INSPECTION REPORT Sanitary Permit No: 420302 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: • City Village X Township Parcel Tax No: P.C. Collova Builders, Inc. I Richmond Township 026- 1135 -09 -000 CST BM Elev: Insp. BM Elev: T Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark d / Dosing k 36 Alt. B� 4 7 2 Aeration Bldg. Sewer . - -. -- `f. X 102 - ys Holding St/Ht Inlet /0 ,7 g/ 3 St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet , 67 LN Septic Dt Bottom Dosing / Hea er /Man. S� 2 4V b. o 9 ` Aeration Dist. Pi j Z s S Holding Bot. System PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number !S- TDH Lift , t FrictiT LQs System Head TDH I Ft Forcemain Len( Dia. Dist. to Well. SOIL ABSORPTION SYSTEM BED /TRENCH Width Lengt No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 41 DIMENSIONS d� SETBACK SYSTEM TO P/L E BLDG WELL LAKE /STREAM LEACHING anufa�turer. INFORMATION CHAMBER OR I7 Type f System: � f e � UNIT Model Number: S , _ _/ DISTRIBUTION SYSTEM Header /Manifpld Distributio x Hole Size x Hole Spacing Vent to Air Intake G I P L ipe's) j(,Pj (V, S 1 1 ----- i Length Di a e ngth Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center + Bed/Trench Edges T � ELM] Yes Eff] No Fm� Yes [] No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / Inspection #2: Location: 1425 144th Street New Richmond, WI 54017 (NW 1/4 SE 114 24 T30N R18W) Evergreen O eriioff, of 9 '- Parcel No: 24.30.18.939 1.) Alt BM Description � 2.) Bldg sewer length = S`Zj ' p • r -amount of cover [� t/1 S 2d 'G c. z o►• �1Gx y.R� bK g /3(�lbZ Plan revision Required? ,VY F w , No 4 to �— �.— -- — ^ � � L/ 7�TILf4 �-Z � e� T h (AT IFS 9 3�� I 6 Use other side for additional information. ___ _� SBD -6710 (R.3/97) Date lnsepctor's Si nature Cert. No. r n Ssfety and ihv>san �' �Sl�4ItSI/f 201 W. W Ave., P.O. Box 7162 Mahon, Wl g x7 - 7162 She Address ne artmetdt of cotrdme�ce f-� K..,v %-- Di 9do IA( AS- / �{�{ Sanitary Permit Application''' 4Number Z , In accord willt Comm 83.21. Wis. Adm. Code, pasoml information you provide ❑ Cbedc if Bunn may be used fe¢ Law, s15 L App lemon - Plesse Print All hdattmation Safe Phi I.D. Number Property Owner's Pa"°H v - ,5 -fl cc — Peopacay owner's IdaiRgg Audios Paopeaty Location _ C fJ �J aid !i; TI N Ci y. Soot zip Code Phone N Block Number 9 If JUL 2 visionxanae C5M Meow 3 2002 � II. Pw of Building (the* aill dud appa) orx Number dro ( T7' 0(s�y DWORM - NumbafBeoms ZONING OFFICE 0 - DeacrAe Use 9".V- 0 soft Owned , k W- 2- � 3 NeaieatRaaad 13L TypK of , Rftmik (OW& a* boat on fide A (m nbft selfeme for hternal use). Complete fine B if applicable) A ' 2 Repiaaaxaieat Sysfacn 3 0 Rgdwcmm of 6 0 Addition to Fo^ Casaty use lank Ody B. 0 ('heck if Sansocy Permit Ps'Crioaly isamd Pr:it�t Nuanber - Date Issued IV. of Paaoit: (Check all dug a epply)(sumberlug she is for Internal um) Paew ariaed In43muod 210 Mound 47 0 Sand Pilfer 50 0 Conmucaed Wedaod 22 0 Pnousized h G ound 410 FIoldioa Took 48 0 Sim& Pass 510 Drip Lim 45 0 Ai -Glade 46 0 Aerobic Treatment U®c 49 0 Reeds 30 0 O1bar V. Area Manual Od: Daigu Plow WO Dispeesd Area Dqpcnd Area soil APPS Faiwhtion Rafe System Bie"don Find Glade R,pired Ian > -) OAHM/lach) Elevation VL Tank info opaaey in TOW Number Manaf lc mu Prebb She SICd Fiber Plastic Galbms Gailoos of Tastrs tsoaecefe Consorucad (am New Tasioc Sep& - T=k -— �i VII. RgqmmRdfty S ate -1, the respa far lostW htlan *(d POWPS dwwn an the plans. Phunbex's (Prit>Q Phi �aty � s Addrrss City. Shoe. ) l vM use Only )irAoroved 0 Permit Fee (includes Groundwater Dame Issued Issues Agent Sigmnne {No SUMP) a 0 Owner Ohim Imtiad Adverse ®— A*g+ • Lmlennioation I% Canditious of Ap fns for Disapproval t�s - eat s •ka ale" e syskv— Olt Adam >� � +� � �7, iar ak.,.um.o p.per aksr a� sic x u � ta.t.e PLOT P AN PROJECC P:C. Collov a Builders Inc. D Ess P.O. Box 489 Somerset Wi 54025 NW 1/4 SE 1/4S 24 /T 30 N W TO Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 7/24/02 BEDROOM 3 CONVENTIONAL XXX IN- GROUND MSSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1212 # or chambers 39 BENCHMARK V.R.P. Top of 1.5" pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE (DWELL - H.R.P. Same as Benchmark SYSTEM ELEVATION 92.9/92.8 292' Property Line Vent >6 „ Standard Infiltrator Plans Designed Using of Cover Leaching Chamber Conventional Powts with 31.1 ft2 of Area Manual Version 2.0 12" 3' -3' X80' Cells 6 Long 3 4" Grade at System Elevation with >3 Spacing Vents 20' 35' T B -2 Pro 3 Bedroom 3% House Slope 40' B -6 0 5' 5' 0 B -4 35' o 45' B -3 B -5 - Vents 45' B.M. #1 B.M. #2 292' Property Line 15' 15' i PLOtDESS N PROJEC P.C. Collov a Builders Inc. P.O. Box 489 Somerset Wi 54025 NW 1 / 4 SE 1 / 4 s 24 /T 30 N W TO Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE7 BEDROOM 3 CONVENTIONAL XXX IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1212 # of chambers 39 BENCHMARK V.R.P. Top of 1.5" pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE (DWELL *H. R. P. Same as Benchmark SYSTEM ELEVATION 92.9/92.8 292' Property Line Vent >6 „ Standard Infiltrator Plans Designed Using of Cover Leaching Chamber Conventional Powts with 31.1 ft2 of Area Manual Version 2.0 12" 3' -3' X80' Cells 6 Long with >3 Spacing Grade at System Elevation 3 4" Vents 20' T 35' B -2 Pro 3 - Bedroom 3% House Slope 40 B -6 0 5' 5' a °. B -4 35' o 45' B -3 B -5 Vents 45' B.M. #1 B.M. #2 L J!k 292' Property Line 15' 15' Wi sconsin Department of Commerce SOIL AND SITE EVALUATION Df,dsion of Safety and`Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all ' o 1 - ! �� e wed by Date Personal information you provide may be used for secondary pu see vacy La s. 15.04 (1k (m }) ,_ • 047 Property Owner Propefty-Lication C6tr� Govt. Lot 1/45�J114,S �� T 36 ,N,R E (or) Property Owners Mailing Address It �_� i y Black# Su Name or CSM# ]� een b vef >> City State Zip Code Ph6ee "illumber 'OF t� ❑ Village � Town Nearest Road udSon i wi i 5LA41u nvl , �)' l � , �h mo o , -Lao CYU-e1 0,-- (New Construction Use: [`esidentiai 1 Number of bedrooms - L � Addition to existing building ❑ Replacement El Public or commercial - Describe: Code derived daily flow & ��) , o gpd ^1 Recommended design loading rate . S bed, gpd/ft trench, gpd/ft Absorption area required IZod bed, ft CJCI v trench, ft Maximum design loading rate bed, gpd/fi gpd/ft Recommended infiltration surface elevations) 9 (as referred to site plan benchmark) Additional design/site considerations ✓ t—f F 3-6; ,n Parent material _�> ) �Ci- S ' / Flood plain elevation, if applicable �/ `T ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S El WS ❑ U 0 ❑ U ❑ U ❑ S AP U ❑ S SOIL DESCRIPTION REPORT 0 Boring Horizon Depth Dominant Color Mottles Structure GPD/ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o—(5 LO r I Z y mfr c S I �+� �- to • s' Ground �(e Q }' L S c S elev. Depth to limiting a ± o , qd factor Remarks: Boring # • r lovrf& Sal r� c v 5 a F: Ground elev. r C a IS ft. Q Depth to limiting fa or in. Remarks: CST Name (Please Print) Signet u Telephone No. Adam Schu moke z Address Date CST Number ZSJ PROPERTY OWNER SOIL DESCRIPTION REPORT Page —L of v PARCEL I.D.# k a f Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench b-► Ip Z I -16 i0 4 Z IL r c5 Ground 3 c-:s ' Q elev. (� Depth to limiting f t r L in. Remarks: Boring # Ow y _ 3 91 I r g1w Ground elev. 9 ?.75 ft. Depth to 7 S limiting f��sst,or Y in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Boring # Ground elev. 9 0.75 ft Depth to limiting factor in. Remarks: Boring # Ground elev. J ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) PAGE-3-OF 3 NAME e n ( (()U C., LOT# LEGAL DESCRIPTIONS r_ - '/4.svt /4,SP4 Tap ,N,R I 9'E (or) SCALE: 1 "= LO© BM I ELEVATION BM I DESCRIPTION 40p y (Z " �/c P,'p -c ✓f� Y�► BM 2 ELEVATION � D - U v Z c BM 2 DESCRIPTION -W o-� ���ps SYSTEM ELEVATION ALTERNATE ELEVATION J CONTOUR ELEVATION ,,jtZ T 3i g2 P /J �►ai � a SIGNATURE ��' DATE :4 I� I Y11 Y I D YI . . 11 s r- • r k 117 ■ ■ I�.. .: MOMOM err■ �r � � ���� oi�� I' ��iO� ■ Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan 1. If system fails, determine cause of failure, use alternate area and install new system or install system at a lower elevation. 2. Replace an other failing components as needed. P Y 9 p Plumber: Shaun Bird 715 - 246 -4516 i St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 i ST CROIX COUNTY ` SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSIiIP CERTIFICATION FORM Owner/Buyer P. I I oVA A I D S - -T-AJ Mailing Address V • (.� Property Address (Verification required from Planning Dcpartmcnt for new construction) City /State N.PM) q1 J )OVI UY O 1 '� Parccl Identification Number e)30 - 1/3C" -04— c t3 c f) LEGAL DESCRIPTION Property Location '/" ; %, Sec. I . T -R W, Town of IC� t Subdivision © C, Lot /i . Certified Surrey 1)1,ip 4 Volume Paee 1r Warrauty Deed # �� y Volume L Q Pa Q (r Spec House [I yes ❑ no Lot lines ldcntitiauic ! ycs ',:] no SYS'T'EM NfAINTENANCE Improper use and maintcaancc of your septic system could result in its premature failure to liandlc wastes. Propc. niaintenancc consists of pumping out the septic tank every three years or sooner, if nccdcd by a liccascd pumper. What you put into the systc:n can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner arrccs to submit to St. Croix Zoning Dcpartmcnt a certification form, signed by the owner and by a master plumber, journeyman piunibcr, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tack is less than 1/3 full of sludge. Uwe, the undersigned have read the above requiremcuts and agree to maintain the private sewage disposal system with the standards sct forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Slate of Wisconsin. Certification stating tha ur septic; system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 d of the thr yc % X n date. NATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) larowlcdge. I (we) atn (are) the ownci(s) of rty described ve, by virtue of a warranty decd recorded in Register of Deeds Office. SIGNATURE• OF APPLICANT DATE •fM•�i 4 Any information that is nris- rcrresenteri may result in the sanitary permit being revoked by the Zoning Department. '• Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey snap if reference is made in the warranty deed FROM P C COLLOVA BURS, INC PHONE NO. : 715 549 5911 Jul. 21 2001 01:54PM P1 02/03/00 TUE 11:33 FAI 718 364 4687 MASTER OF DEEDS Q001 ��,:151'242 �fl L CYA7 '&taMWiiIvE76►1Sblipc4j..19�! l Dasuwtflomct WAMARTY ])KID Fa t Ub DMA, MLU b9ma2 Snv =n S r mx ZYIr. l�rlLtar. and P Ca41DVa tictNOStia. Ire., r Nfksaaota CarOa,oiiw ! 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