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INSPECTION REPORT uD Penmxn
GENERAL INFORMATION (ATTACH TO PERMIT) Po oxnSAN-2020-277
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Legal Description 3 ,/4 CF tIR sqA. Szo. (ccc*t where nptA4
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$FP 082020 ST. CROIX COUNTY ZONING OFFICE
CERTIFICATIONSTATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to cony that I have inspected the existing topic and/or doer tad
Inwardly striving the following routines
(Smees pddreee) e�0/6Cry CA&aVc,,i YSm? located
at: 5ci M, Section �' , Town--6C_N, manage 15 W,
Town of 6/ ..».rl . SL Cmix Cmmty W'Ycmem.
Upon inspection, l earl that I have fount the Ynlr(O, b fie butOf my
knowledge, will custr m to the re4uirersan OfSPS. 384 25, and it hd ry)
appear(s) to be functioning propmly.
Most recent date of inspection Or service 113 �Ak 5 0
Did Flow back occur fmm absorption system? Ya rr No X
(rpm, skip next loss)
Approximate volume or length Of time. _ gallom_ minutes
Took Capacity.
Construction. Prefab Concrete S Stcel_Otha
Manufacroer(if knowa): t
Age ofTank(if knovi S - R-1,143
Permit number(ifkmvm) SL go4Sqq
�OS1 1 Z,✓r Xc S"n rd'b
(Licensed Plumber Signature) (Print Name)
(title) (License Nmnber)MP/MPRS
Si-,ZpIJ
(Date)
Form to be completed by licensed plumber (Dept of Safety and Profasi(sl
Service Chapter 305 and s 145M. Wisconsin Statute) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev 22012
ROBS
401Ave Pull BID
2J00 2CM Ave /POSSs
Fica Lake. Vill 56868 US
rous120&D1919A
ossplumOmpinc`'Agmad com
Blum
James Drury
Drury Construction
Progaui a r 1 0OD •000
Imperial of wink septic System Oerarmms that the system is
sell In compliance with no sign of failure.
The new structure will meet the seNacks for the system q�
Make checks payable to Ross Plumbmg, Inc \\O
For any questions about payment please call 714W\l
thank you
AnymmakwhiSSIANSSINpromply os we lion nwrmemo.m ukhe.ent Soacts nay amoum
nmsmseameuems ys u. uenq m In amp uonprores
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OW NERSFUT CERTIFICATION FORM
a�iRnrer T. IA , ^ f c-/'
Matimg Address Z SS C (,nn '�'L cr— Property Address
(vm5ca/e+nn ayaued PWmvg&Zoning Depatmmt for new cooswceov) v-c
OtylSdste l Ildevcif¢auov Number Q//o��0�%5-�-0-�OU
LEGAL DESCRIP�TIIO�N /
Property Location N/4,Slf(it, Sect , T�N R PS W, Tovm of l�2/(LH>nd
Subdtvisiov Plat �� K Lott
Cerut Survey Map M r , Volume , Page N
Warranty Deed M CI J � � a/ (before 2007)Volmme Page a
Spec house O Yes Oto Lm Imes odmvfiable esoao
SYSTEM MAINTENANCE MU OWNER CERTIFICATION
Impmpv,N.a.nem.mtevme of Yrw eWrc vysmm Nvuld temltwne prtm.twer dvawbmme w.etee Pvpv
wad pumping out the scPuc unk ever Wre Yemmsomv, Soxdeq bYahceosM PvmW 3vbV YoopW mro
Ma rys� cm me s Ne (turn mf�Lc 52(l) o4 vs a treemml sugem ode wane Stormy
s Om Owner mem�cmoce
responsibilities are specified w §SPS 3g3 4(I) and m Chapter ID St Cora Corry Smitary Ordmmce
The property owns Wife; to submit to St Crou Comp Pluvmg & ammg Department a wvficsbon form, signed by me
caner mod by a diasso plumber, lotaeymm plumber, meammed plumbs Or a hrmsed pmnper vent mg short (1) the ov-sae
mdommad rynm to mproper: ogtamg condom mYor (3) am, mspxmet and pumpbNg (if boundary), the sest ink 1s
leWestminster
s food I (WI of sludge.
Owe, the mderstgned have read the above requvemats and dome b marmot the pin Vote sevnge doemal rytem wood the
rtummdn aouM,mom. m set by Ne Depmnncat of Sehty Mtl Pmons, mal Swmes and be Depattmmt ofNmet Resources,
Shim of Woommsr C icamn morm that your septic system has both m tuned must be completed atom removed b the St Croix
County Plmavg&Pastures Deparmmt weer 3d days of me duet year exp von date
Owe carom, Ns W summers w this dome me some to me tin of myrour kmo.vledge. Owe mNare Ne owa(s) tilde
povpmr dambN sedum, by vvm, of a warto dy dad rewNN he Regsim ofpxds Office
Number of bedrooms _
avm 'ZI/Y,.E
SIGNATURE OF APPLICANTS) DATE
•'!uy Wotmavor that is misrtprtsmfee may book come smty part berg riveted by she Planmvg is bmvg Department •"
Include shut Ease application a recorded wertmry det Gom me Register of Deeds Office and a copy ofNe ccntfiW survey mm if
refermsz to made m Ne wananry deed
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D g i PROPOSED PROJECT FOR: REBEKAH 6 DEREK WINK
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PROPOSED PROJECT FOR REBEKAM & DEREK WINK
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N� OTPROPOSED PROJECT FOR REEKAN ® DEREK WINK y L ==-
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INSPECTION REPORT
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GENERAL INFORMATNNI (ATTACMTOPERMrt)
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