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HomeMy WebLinkAbout020-1491-00-000 (2)Wisconsiri Department of Commerce Safety and Buildings Division ' PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: ❑City ❑Village Town of: Girl Scout Camp of St. Croix Valley, Town of Hudson CST BM Elev.> I Insp. BM Elev.: BM Descrip11tion: �D � � 0'c% � CS � �Q�n��nSC" '' C SI— QwL� l TANK INFORMATION county: St. Croix Sanitary Permit No.: 353118 ate Plan ID No.: �,311.�! �'Trtxit�tr� iA� reel Tax No.: 020-1016-60-000 � ELEVATION DATA�,�,r QI� �= � 3 •�z� ` `� � � � TYPE MANUFACTURER CAPACITY Septic 3 51 5 -'� a� �.+�� l� , Dosing � � 2S6 Aeration Holding ; TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Airintake ROAD Septic >zao ` �z�` C�, �� NA Dosing �' `' C� � NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH. Lift Lristion ISiYeadm TDH Ft Forcemain Length v� Dia. � `r Dist. To Well SOIL ABSORPTION SYSTEM � (� �' TRENCH width , / Length SETBACK INFORMATION SYSTEM TO I P/ L I BLDG pe ut stem: (-'onJ. >2� � ncnes WELL }Zoo STATION S HI FS ELEV. Benchmar � cF DO (D �, e � /�. D Alt. BM Bidg. Sewer St/ Ht Inlet � •�`F y }. zG St/ Ht Outlet �•`l8 q�, �Z � Dt Inlet �0 `�S i 3.2z. � Dt Bottom (� • 2-`f � � ��, � Header /Man. Dist. Pipe "�`f S ys'd� 9�, i Bot. System See. Final Grade (Q;o qS,o ' St cover � �� y9 � o , LAKE / STR No. Of Pits LEACHING CHAMBER OR UNIT Inside Dia Manufacturer: Y O�, odel Nymbei Liquid Depth DISTRIBUTION SYSTE Header / a�fo'd �h stribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake Length oh Dia. Length — 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 Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: ��f/l�f/dd Inspection #2: •-l---L-� Location: 965 Alexander Road, Hudson, WI (NEl/4, NEl/4, Section 13 T2f9.N�-R19W) - 13.29.19.73 - �I<� F d ., I n y3,4s' -- Plan revision required? [C�� Yes ❑ No ds. D�- e r� oth�eQr�side for addi Tonal information. l latit_ _ _" �� r'�'—�e�.-�c� � Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ®�isconsin Department of Commerce SANITARY.PERMI ��P--�IJCATION In accord with Copftr�8 .0 ;�iNis!Ad��¢o `�.1 �.. �._� ,�` Safety and Buildings Division 201 •W. Washington Avenue P O Box 7302 Madison, WI 53707-7302 • Attach complete plans (to the county copy only) f r tka�`syste, ppaper''�otl' ss county than 8 v2 x 11 inches in size. f�' � • „See reverse side for instructions for completing this applic�{ion R�c��� E t�� State Sanitary Permit Number �, r t..._._ �` _ v �/�� Personal information you provide may be used for secondary pur a�e� �,�,� ��,�° � --- - r� '� 1. ❑Check if revision to previous applicJa on , State Plan LD. Number [Privacy Law, s. 15.04 (1) (m)1- t �� ,4��`C \C+C' •-.�s .--.�,� C� ��� ;-,... � I. APPLICATION INFORMATION -PLEASE PRINTALL IN 0i�rt1AAT10N�� �',S �� . Property Owner Name '. '`� `� � ;`•�:__ _P o'perty' ocation -- � �/4='` . � m��- r, �, I, 1/4, S / 3 T � , N, R � E (or� i- Pro erty Owner's Mailing Address "" •- tot NuYitber Block Number � City, State Zip Code . Phone Number Subdivision Name or CSM Number ` �'(�� �_ �� © 2) �/� �� "�J � r II. T PE F ILDING: (check one) ❑State Owned � pity l '�--( � Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms ,®. � Iowan OF o Cam" /l/ III. UILDING USE: (If building type is public, check all that apply) Parcel Tax Numbers) . 12i. � .1S .'1'i. 1 ❑Apartment /Condo — -- D 2 ❑Assembly Hall 6 ❑Medical Facility/ Nursing Home 10 ❑ Outdoor•Recreational Facility 3 ❑Campground 7 ❑Merchandise: Sales/Repairs 11 ❑Restaurant/Bar/Dining 4 ❑Church /School 8 ❑Mobile Home Park 12 ❑Service Station /Car Wash 5 ❑Hotel /Motel 9 ❑Office /Factory 13 ❑'Other: specify IV. TYPE OF PERMIT: (Check only one box on IineA. Check box on line B; if applicable) ,qj 1. I/� New 2. ❑Replacement 3. ❑Replacement of 4_ ❑Reconnection of 5. ❑ Repair of an j`-' System System Tank Only Existing System Existing System ----------------------------------------------------------------------------------------------- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) 3 �C�gf�jt�/yj , f3G,��r-s' -- �E � Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑Seepage Bed 21 ❑Mound 30 ❑Specify Type 41 ❑Holding Tank_ 12�Seepage Trench 22 ❑ In -Ground Pressure 42 � Pit Privy 13 Seepage Pit •Z,X ,S�C��.,��~ 43 ❑Vault Privy 14 ❑System -In -Fill � �{/ Z 1 `�r'�.1� ,w a VI. ABSORPTION SYS EM INFORMATION: /�LLD�/ 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading. Rate 5,: Pert. Rate 6. SysterrtE(ev. 7. Final Grade equired (sq. ft.) Proposed (sq. ft.) {Gals/day/sq. ft.) Min./inch) �/ 9„$'. rJ / �- Elevation " �O S' � •� �� 2 .D °•feet Gr1Pml�1J� Feet .S; . . VII. TANK Capacity � INFORMATION In gallons TOtal Gallons # Of Tanks , Manufacturer s Name Prefab. Concrete Site con- steel 9 ass Plastic EAxppr. New Existin strutted Tanks Tanks ,� Septic Tank or Holding Tank .. �"' ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /S�iphrerrEtfOTTTt7er � .— ^ ❑ ❑ � ❑ ❑ ❑ VIII. RESPONSIBILITY ATEMENT w/ ��j"�G .tLTF'ILS I, the undersigned, assume responsibility for ins allation of onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumq�r's Signature: Sta iV�R/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zi Code): IX. OUNTY / DE ARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issu'in gent Signature (No Stamps) Approved ❑Owner Given Initial Surcharge Fee) � �- �� ° �� � ��" `�� Adverse Determination ..,�:1 G' X. CONDITI APPROV}�AL /REASONS FOR DISAPPROVAL: ( � /ONS•`OF _ �{� � `J •,�1 'T'i� G?�" G2 ��-Itic�Q i"l LY� �J t Y• ��� _ "ice r LJ� (.l (� �' i � 1 ___ _ _ _ _ ._ .._ _. DISTRIBUTION: Original to County. One coov To: Safetv & BuilUinos Division. Owner. Plumber a000 q 00 co 00 co 0 Lo �av N N 7 � ..p z t v, v. 2 cso � L� �£ _TI i s N*isconsin Department of Commerce August 04, 1999 CUST ID No.267341 WEGERER SOIL TESTING &DESIGN 421 N MAIN ST PO BOX 74 RIVER FALLS WI 54022 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 08/04/2001 Safety and Buildings 2226 ROSE ST LA CROSSE WI 54603-1905 TDD #: (608) 264-8777 www.commerce.state.wi. us Tommy G. Thompson, Governor i Brenda J. Blanchard, Secretary ATTIC• POWTS INSPECTOR ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 SITE: Site ID: 178033 St. Croix County, Town of Hudson NE1/4, NE1/4, S133 T29N, R19W Facility: St. Croix Valley Girl Scout Camp - Bathroom Facilities FOR: Description: Dosed Non -pressurized In -ground System Object Type: POWT System Regulated Object ID No.: 483570 Transaction ID No. 239170 Site ID No. 178033 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145,19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the the Zabel filter is required. Access to the filters for cleaning must be provided per Comm 84 product approval conditions. • The leaching chambers must be installed in accordance with the manufacturer's printed instructions, the plan approval and Cornm 83, Wis. Adm. Code system sizing criteria. If there is a conflict between the manufacturer's instructions and the plan approval, the plan approval and code requirements will take precedence. • This approval does not include plans for the general plumbing systems or sewer piping leading to the septic/holding tank that may be required for this project. See section Comm 82.20,Wis. Adm. Code, to determine if plan submittal and approval is required. A copy of the approved plans, specifications and this letter shall be on -site during constructiori'and open to inspection by authorized representatives of the Department, which may include local inspectors.. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/op eration. WEGERER SOIL TESTING & DESIGN Page 2 8/4/99 4 Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, POWTS Plan Reviewer -Integrated Services (608)785-9348 , Mon" Fri, 7:15 AM - 4:00 PM j swim@commerce.state.wi.us DATE RECEIVED 07/27/1999 FEE REQUIRED $ 240.00 FEE RECEIVED $ 240.00 BALANCE DUE $ 0,00 W>SIVIARTcode ;7633' DOSED CONVENTIONAL SOIL ABSORPTION SYSTEM FOR 3 �r'iiwowt 8vt�p��vGs__ Page \ of �1 LOCATED IN :THE NE1/4 OF THE NE 1/4 OF SECTION �� Z TOSdN OF , T `� N, R �9 td, �u�So�1 , STr Q�~, 0 LK COUNTY, WISCONSIN INDEX PAGE 1 of 7 TITLE SHEET PAGE 2 of 7 PROJECT DATA PAGE 3 of 7 PLOT PLAN PAGE 4 of 7 PLAN VIEt CROSS SECTION PAGE 5 of 7 LEACH CHAMBER DETAIL PAGE 6 of 7 PUMP CHAMBER PAGE 7 of 7 PUMP PERFORMANCE CURVE , a PREPARED FOR tv . S TCZci- a�;., >,�'9'+• �';,�'�� � �'� - - ... \-1 � o S. Cam. U QUIZ-T y:, v,1��TJD .i .A4.% r WEGE�cER SOIL TIE=ST = NC-� AND ' �ES.2 (3" SaF=ty T C1= F.D. BOX 74 421 N. RAI}t ST RIVET FF1.lS. YI 54022 1 I5-i �r01 b5 m ARTHUR L WEGERER S RP EusWoRrH, e ~••.n PROJECT DATA Page z- of -7 This system will serve 3 bathroom buildings at the St.Croix Valley Girl Scout Camp. The anticipated use is a maximum of °40 persons per day per bathroom with 1 floor drain in each building. System sizing is based on 5 gpd/person (outdoor sports facility) which appears to be the most logical sizing criterea. AidTICIPATED tdASTETdATER gpd 1 floor drain at 50 gpd =------------ 50 gpd Total per building = 250 gpd Total effluent from 3 buildings = 750 gpd SEPTIC TANK' 250 + 750 = 1000 gal. minimum capacity req'd. A 1000 gal Wieser Concrete septic tank with a Zabel Filter will be installed at each building. Effluent from the 3"buildings will flow by gravity to a 1250 gal Tdieser Concrete pump tank which will then dose the proposed trenches. 2 trenches, each 3' wide by 93.75' long with High Capacity Sidewinder leach chambers are proposed. 750 gpd :- .8 = 937.5 sq.ft. absorption area required. 2 X 5 X 93.75 = 937.5 sq.ft. provided. This system will serve 3 bathroom buildings at the St.Croix Valley Girl Scout Camp. The anticipated use is a maximum of °40 persons per day per bathroom with 1 floor drain in each building. System sizing is based on 5 gpd/person (outdoor sports facility) which appears to be the most logical sizing criterea. AidTICIPATED tdASTETdATER gpd 1 floor drain at 50 gpd =------------ 50 gpd Total per building = 250 gpd Total effluent from 3 buildings = 750 gpd SEPTIC TANK' 250 + 750 = 1000 gal. minimum capacity req'd. A 1000 gal Wieser Concrete septic tank with a Zabel Filter will be installed at each building. Effluent from the 3"buildings will flow by gravity to a 1250 gal Tdieser Concrete pump tank which will then dose the proposed trenches. 2 trenches, each 3' wide by 93.75' long with High Capacity Sidewinder leach chambers are proposed. 750 gpd :- .8 = 937.5 sq.ft. absorption area required. 2 X 5 X 93.75 = 937.5 sq.ft. provided. e - PL. P� Y\1y..) ` \04k) -.. r3 u-r �m Sc4c�l4, 6' 3' CL3�7S- �tN�St� G �u'c'DE e Z'�Pvc Fn�, P �'�-� E sc �� e EF C� �r �'� e � N LL a 03 . s w YYo i• � �� �� N F� �d NN 1 2� n' X y k L �� Y� n �� ,G K d L r� �T �^ s� N N G' M T' C L z a c z t s 9 LL 3 ,t' r aA b r W d �, a c J m '� �� P to D (n � � q � o� x � m_ � 9 � �. m• m c� v � N C ci N m }� O 7 W 4 V y � � O y�o e x 0. d a� �� o 4` c c � m C7 � o� @ A y (Ji N b N 'i z O r_� W � � m, �� � � _ @ � �. r � x Z m '� �. Q � ...i � � X � � � �' � � � Ul X CAD , W --i � ca �i 4 cn �-- Invert 11 "--�� C7 Q a m `1�Cola VENT PIPE 10FROM DOOR, WINDOW OR FRESH AIR INTAKE 18"14IA1. Ih1LET APPROVED JOINT PUMP CHAMBER CROSS SECTION AND SPECIFICATIOMS ' PAGE 6 OF % C C� VENT CAP WEATHER PROOF JuuCTION Box GRADE COIJDUIT APPROVED LOCKING MANHOLE COVER WITH WARNING LABEL I- I MIN. am _ ib'Mime moms mw%w Room Room? Affism RON* mods 1' PROVIDE I AIRTIGHT SEAL I Tank construction shall comply with ILHR 83.15 and ILHR 83.20 PUMP —� �i?1.ca � CONCRETE 6LOCK III APPRoYED JoIWTS II IJ ALARM OFF 3" APF'QaYED RISER EXIT PERMITiEO ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL• gCDplµ� SPECIFICATIOUS DOSE TAWKRunningS MANUFACTURCR. ~� `- `-�`-� JUMBER OF DOSES: 3 ' 3ROMPER, DAB TANK SIZE: \ZSO GALLONS DOSE VOLUME r ALARM 1h "UFACTURCR: S �� L- LnW S`iSi"�r-±� INCLUDING 6AGKf<L0W: 6�, GALLONS MODEL 1JUMBER:wwwwo CAPACITIES: A=.19 INCHESOR 12"L'4 GALLOWS SWITCH TZJP>E: �"1E1ZCcaC�° 6 = Z INCHES OR LLOWS PUMP MANUFACTURER: l I�IWCHES OR GALLOWS MODEL NUMBER: Room 3�Z1 k!Fy4 D= INCHES OR GALLOWS SWITCH TYPE* � 0�u�� NOTE: PUMP AND ALARM ARE TO 6C g MINIMUM DISCHARGE RATE L4 66 t) GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEN PUMP OFF A1JD,.DI5TRIBUT{6N PIPE., gZ FEET + MI►.11htUM NETWORK SUPPLY PRESSURE , FEET -F L0 FEET OF FORCE MAIN X ' I FY0 fTFKICTI0W FACTOR.. FEET —_ TOTAL DyNAMIG HEAP -FEET - DIAMETER 1 , INTERNAL DIMERWSION�i OF TANK: LENGTH ;WIDTH 1 LIQUID DEPTH L`_, lZ BOTTOM AREA 231 'GAL/INCH 4 . AS PER MANUFACTURER = '2b•Vi' GAL/INCH 4,0 APPLICATIONS Specifically designed for the following uses: • Effluent systems •Homes • Farms • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS Pump: EP04 • Solids handling capability: 3/4" maximum. --� •Capacities: up to 55 GPM. .�-- � •Total heads: up to 24 feet. • Discharge size:l'/2' NPT. • Mechanical seal: carbon- rotary/ceram ic-stationary, BUNA-N elastomers. • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to - components. Pump: EP05 • Solids handling capability: 3/a'"maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. + Discharge size:l'h°NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: 104°F (40°C) continuous 140°F (60°C) intermittent. ;: , �. • Fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 60 Hz,1550 RPM, built in overload with automatic reset. • EP05 Single phase: 0.5 HP, 115 V, 60 Hz,1550 RPM, built in overload with automatic reset. • Power cord:l0 foot standard length,l6/3 SJTO with three prong grounding plug. -Optional 20 foot length,l6/3 SJTW with three prong grounding plug (standard on EP05). METERSIFEET 10 !- 0 a _' U a Z r 0 H 0 9 30 s 25 s 20 5 15 4 3 10 2 5 1 0' CGl!IdS �UiJ17'l ��'�]�J� � ���j� �n� �'��mp lT^,, ��i • '1� • '1 • Fully submerged in high grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation. Automatic models include Mechanical Float Switch assembled and preset at the factory. FEATURES ■ EP04 Impeller: Thermo- plastic Semi -open design with pump out vanes for mechanical seal protection. ■ EP05 Impeller: Thermo- plastic enclosed design for improved performance. ■ Casing and Base: Rugged thermoplastic design provides superior strength and corrosion resistance. ■ Motor Housing: Cast iron for efficient heat transfer, strength, and durability. ■ Motor Cover: Thermoplas- tic cover with integral handle and float switch attachment points. ■ Power Cable: Severe duty rated oil and water resistant. ■Bearings: Upper and lower heavy duty ball bearing construction. AGENCY LISTING SP� CanatlianStandardsAssociation (CSA listed model numbers end in "F" or "AC".) I j � i I ( � i i ..I --��t--5 GPM I �I I i � I .-.�.:_�2.5Ff _ I I I ! i � ( � I � � j �— I ! � I i� i ' � � EP05 — f .... I q . �} i � EP04 I � � ! .8 j i i 10 20 30 40 50 GPM G: 2 4 e 8 CAPACITY 10 12 m�/h w;scon'sin Di .partment of Commerce SOIL ANI��iT_E EVALUATION g / of bAsion of Safety and Buildings Page Bureau of Inte rated Services - in accordan' its _ ,' IIR' 83�09, Wis. Adm. Code g ���-- . Attach complete site plan on paper not less than 8 1/2 x 1 )rincfjes in si P st �� County include, but not limited to: vertical and horizontal reference point (BM),��Hd percent slope,ascale or dimensionh, north arrow, and locdtbh `and distance to nearest roadk_•1` Parcel I.D. # APPLICANT INFORMATION - Please print.atLrir ormati#NTY � Re wed by Date / r� Personal information you provide may be used for secondary purpos s (Ptacyi�t,®(m)r�, Property Owner Pfo{� T L 6ation C �t. 6: E/L� S"CGGr " mJ Qvt, I /- 1/4y� 1/4,S �3 T� N,R E (or Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 00 City State Zip Code Phone Number ❑ City ❑ village Town Nearest Road - f(itG n/ (6/L) zz 7 ��3 fft(d © ,INew Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate • 7 bed, gpd/ft2 • & trench, gpd/ftz Absorption area required bed, ftz pptrench, ft2 Maximum design loading rate . 7 bed,'gpd/ft2 . i' trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plah benchmark) Additional design/site considerationssG, Parent material Flood plain elevation, if applicable 1a_D/V S = Suitable for system �'"' "-"-� U = Unsuitable for system [/]�S ❑ U �S ❑ U Boring # Depth to limiting fa t zin. Ground Pressure AT -Grade System in Fill Holding Tank �S ❑ U VTS ❑ U ❑ S ON ❑ S �U c nn n�croiorinni RFP(1RT vMottles `v _.. Horizon Depth Dominant Color Texture Structure Consistence Boundary Roots GP rft2 Bed in. Munsell Qu. Sz. Cont. Colorst Gr. Sz. Sh. ,Trench 41 89 7. � Depth to limiting factor > n. Remarks: CST Name (Please Print) Address Ramarkc• -- Se s� v R . s y Signature Telephone No. CAST Number -� // P d PROQERTY OWNER 6!J;" Jcectr Chr�fOIL DESCRIPTION REPORT PARcriL I.D.# D=2D0r Ile /4 Page 2 of _3 Boring if �-� 7 Ground elev. �ft. Depth to limiting factor /0D in. Boring # t 93.r Ground elev. �^ S" ft. Depth to limiting factor Boring # Depth to limiting factor /Z7 in. Ground elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. Bed ,Trench �G -- z n24— 3 I1r FX ; G . s-- ---- c s 02 07 Remarks: 2- --02 ..3I VFAGs / c L- J.r -- --- - f? t '-- ' 17 Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fie in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ALI UFL49;. 3 .--- S S M L crJ 7 ' . �-s� .._ -- s - .s Remarks: k Remarks: SBD-8330 ai�VE EOGER'i''if AL. U�l181NG Licensed Pork Tester' & Piiimber Foggeerty Hei is Rand ROBERTS, yYISC�NSIN 54023 Phone 749-3656 8hf �f57"c, F ivd.o r ot TFtif` �t�El�, � = Sit-T�R/9-T,�D Ffoe��v,l w�.zvV • SSY m �fid7r. - jJo,Cty� 7 .ems LOC147rb 40co lu S e-olg� /,F iwpTjr*Dn/ �FNf .4� Lkensed* ark Test RUF3E Rhone 749-3656 V� j. y ps S7 Yo X = JQre -yraG ®= 2 J1 7a rLo9�, y �izi = sv-Tc�R,�-r�1 �k, wlfisv �-y d0wAl ec�Lof%z�:% L� �T ►�, r / c r � r P i r` t �y J 0 ` 7k der cr�.kp w q i. I;ENf C) r h Owner/Buyer Mailing Address Property Address ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM S{� (Verification required from Planning Department for new City/State G�DS�t/, tea. Parcel Identification Number. P%.20 -- /y2 tv a12_ LEGAL DESCRIPTION Subdivision Certified Survey Map # �- Volume ''---�--� ,Page # rF f Warranty Deed # �1= �`j Z , Volume—` , Page # Lot # Spec house ❑yes ❑ no C'�/h��' %��'� Lot lines identifiable pJ yes D no C> % SYSTEM. MAINTENANCE Improper use, and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, jqumeyman plumber, 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 tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. A zo SIGNATURE OF -APPLICANT DATE ****** Any information that is mis-represented 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 map if reference is made in the warranty deed Mbl?J 'NbZl `£I '��S a0 4/I �P1 aHl �0 3(d"1 1.5V� m SONd7 Od11 b'7dNn ,OS'L6l l W O � I in to o rn NM10 Z N t. 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