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Parcel #: 030 - 2149 -03 -000 07/16/2007 11:36 AM
PAGE 1 OF 1
Alt. Parcel #: 36.30.20.3028 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
03/31/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - JEROME, DARCY D
DARCY D JEROME
804 SPRUCE DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description 1246 25TH ST
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 3.004 Plat: 02 /011 -SEVEN OAKS 030/06 LOTS 1 -13
SEC 36 T30N R20W PT NE SW SEVEN OAKS Block/Condo Bldg: LOT 03
('06) LOT 3 (3.004AC)
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
36- 30N -20W NE SW
Notes: Parcel History:
Date Doc # Vol /Page Type
11/07/2006 838264 WD
07/18/2006 829908 WD
03/31/2006 821891 PLAT
10/12/2005 809192 2907/359 WD
more...
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/16/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 134,500 0 134,500 NO
Totals for 2007:
General Property 3.000 134,500 0 134,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
l
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
499155 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: O , City Village X Township Parcel Tax No: 1 ��r
Cory, Stan 6 !-fi ge St. Joseph, Town of 03 Y — 1
CST BM Elev: Insp. BM Elev: BM Descri tion: Section/Town /Range /Map No:
36.30.20.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMAT St/Ht Outlet
TANK TO P/L WELL G. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /M .
Aeration Dist. e
Holding . System
Final Grad
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head T Ft
Forcemain Length Dia. Dist. to Well 04
SOIL ABSORPTION SYSTEM If
BED /TRENCH Width Length N PIT DIMENSIONS N f Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/Z JBLDG IWELL LAKE /STREAM LEA NG Manufacturer:
INFORMATION CHAMB R
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distributio i x Hole Size I x Hole Spacing Vent to Air Intake
Pipes)
Length Dia Lang er/Manifold
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 Mulched
Bed/Trench Center Bed /Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1246 25th Street Unknown (NE 1/4 SW 1/4 36 T30N R20W) Seven Oaks Lot 3 Parcel No: 36.30.20.
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Require Yes No
d tional information.
Use other side ad --
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County
F as = 201 W. Washington Ave., P.O. Box 7162
i, Madison, WI 53707 - 7162 San' Permit Num y Co
I Department of Commerce
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide N-
i may be used for secondary purposes Privacy Law, s15.04(lXm) Project Address (if different than mailing address)
I. Application Information - PleaseY=t All Informationi
Property Own Name P cel # (p I of Block #
Ir
Property Owner's Mailing Ad S E P Q Property Location
� �)
City, S Zip a hone Num •[X� Y->'5- '�- %•, Section
(circle )
II. T T>�- N; &;c?L. or(
T ype of Building (check all that apply) � 6K �
5d I or2 Family Dwelling - Number ofBedrooms 3J�rtnv G Subdivision Name qcs"_ iwaber
❑ Public /Commercial - Describe Use sn MM k o �. l Lc --.
❑ State Owned - Descnbe Use ?, U S�' C�J�A L J ❑City ❑V' 1 Township of
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A- � New System ❑ Replacement System ❑ Treatment/Holdin Tank
g Replacement Only ❑Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System Check all that a pply)
Non Pressurized In Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At - Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Em G Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information: - 3
Design Flow (gpd), Design Soil Ap�ation Rate(gpdsf) sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
T�tt �s g
Septic or Holding Tank Oa ld e- 5Z5 J RL
_
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, asquine responsibility for installation of the POWTS shown on the attached plans.
Plumber's a (Print) Plumber's Sign e ' �MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
VIII. Conn /De artment Plea o
Approved ❑ 'sapp Sanitary Permit Fee (includes Groundwater D Issued Issui Agent Si tamps)
Surcharge Fee) c�
❑ iven en.fpr _.D enial 4 46c� . Oc /6 Zip
IX. Conditions of Approval/Reasons for Disapproval n
SYSTEM OWNER: 3� 1 <CQ(CL(P— 4t, 0—k �'� A&U
1. SOPW tank, of kwtt lifter and 1
I P W 0.0 oust aY 0& sankes / maintakwd / J L-J d �-- Co C am- ($' (c 3.5
as W► 1 110 1 19 PIM Provided by plumber.
2. All setback r44Uk*#*ft fMgdt be IIgNIWfNd
as per applicable code / oM wino.
Attach complete plant (to the County only ),for the system on paper not kss than 81/2 x 11 inches in sire
AJo f&,,� f7 6 A—
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RESe«ISRC POR DEIDWNNa PRaPm T30N R20W, TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN.
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OWNER: . \....
PIRIUS DEVELOPMENT CO. LLC. :\ ` �. >.�; nw -N2e DRAINAGE
1 �u
400 SOUTH 2ND ST.
HUDSON, VA 54016 '� / y / 1 11 ` EASEMENT'!" u
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NAI sconsin, SOIL EVALUATION REPORT #1756
Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3
Division of Safety and Bulldin� ' O Steel's Soil Service, Inc.
Attach complete site plan on paper no t�+.uYdy sin size. Plan must County St. Croix
include, but not limited to: vertical and oriz irection and
percent slope, scale or dimensions, n rth arrow, en ng
ant dista ce to nearest road. Parcel I.D
Please pri t all i1tr ti Revie d By Date
Personal information you provide may be ed for secondai p_Grp� Q($rivacy aw, s. 15.04 (1) (m)). Z v Q Jr
Property Owner ST. CROIX COUNTY Property Location
Pirius, Terry ZONING OFFICE Govt. Lot na NE1 /4 SW /4, S36, T30N, R20W
Property Owner's Mailing Address Lot # Block # Subd. Name or CS
400 South 2nd ST. na Seven Oaks
City State Zip Code Phone Number City ❑ Village ® Town Nearest Road
Hudson WI 1 54016 1 715 - 386 -0252 St.Joseph I 125Th St
® New Construction Use: ® Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
❑ Replacement ❑ Public or commercial - Describe na
Parent material Knolls of pitted outwash plains Flood plain elevation, if applicable na ft.
General comments C onventional system system elevation 94.30 Trenches spaced and depth to code 3. 00ft below ow grade
and recommendations:
F-1-1 Boring # F Boring
® pit Ground surface elev. 97.30 ft. Depth to limiting factor 110 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2
1 0 -9 10yr3 /2 none sit 2msbk dfr cs if .6 .8
2 9 -25 10yr4/4 none Sid 2msbk dfr cs if .4 .6
3 25 -110 7.5yr4/4 none cos osg ml na na .7 1.6
IV
I
,t
tt t t
Fil Boring # ❑ Boring 30
® Pit Ground surface elev. Q? ' ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
1 0 -9 10yr3/2 none sit 2msbk dfr cs if .6 .8
2 9 -25 10yr4 /4 none sicl 2msbk dfr cs if .4 .6
3 25 -110 7.5yr4/4 none cos osg ml na na .7 1.6
1
if
►� t t
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD <30 mg /L and TSS < mg /L
CST Name (Please int) Si t CST Number
David J. Steel —� 248956
Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number
994 200th St. Baldwin, WI 54002 7/27/2005 715- 760 -0347
SBD -8330 (R.07 /00)
Property Owner Pirius, Terry Parcel ID # pending Page 2 of 3
�� 3 ❑ Boring 3
❑ Boring #
® pit Ground surface elev. 94.80 ft. Depth to lime ng factor 110 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -15 10yr3 /2 none sil 2msbk dfr cs if .6 .8
2 15 -24 10yr4/4 none scl 2msbk dfr cs na .4 .6
3 24 -130 7.5yr4/4 none cos osg ml na na .7 1.6
I
'
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F]Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff #1 *Eff#2
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 <150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777.
SBD.8330 (R.07 /00) Steers SOII SENice, Inc.
�
STEEL'S SOIL SERVICE INC. 3of3
David J. Steel Terry Pirius 994 200" St.
CST - POWTSM NE1 /4,SW1 /4,S36,T30N,R20W Baldwin, WI 54002
Lic. #248956 To of St. Joesph St. Croix Co. Direct 715- 760 -0347
Lot, 3 Fax 715- 684 -3449
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use.
The location of this test may or may not be as shown, as permanent lot lines were not established at the
time the soil test was conducted.
Legend N
1" = 40'
♦ = Benchmark Ele. 100.00 ft
Top of 3/4" pvc pipe
C�� / � • =Alt Benchmark Ele. 99.40 ft
❑ Top of 3/4" pvc pipe
Borings
Boring Elevations
B1= 97.30 ft
B2 = 97.30 ft
B3 = 94.80 ft
B4 = 0.00 ft
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WEmrowmBC Fm 9Emwwwc PaOPFA T30N, R20W, TOWN OF ST. JOSEPH, ST. CRODC COUNTY, WISCONSIN.
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100 SUTH 2ND ST. .� DWAGfi
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899108 //
KATHLEEN H. MALSH
REGISTER OF DEEDS
ST. CROIX Co., MI
STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD
Document Number WARRANTY DEED 07/18/2006 10 :00AN
WARRANTY DEED
THIS DEED, made between Pirius Development Company, LLC, EXEMPT #
Grantor, and Stanley H. Cory, a single person, and Linda K. Jerlow, a REC FEE: 11.00
single person, as joint tenants, Grantee. TRANS FEE: 450.00
Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE:
the following described real estate in St. Croix County, State of Wisconsin: CC FEE:
PAGES: 1
Lot 3, Seven Oaks, St. Croix County, Wisconsin.
Metro Legal Services
EDMET 501256 A
594486 �N D 419030
Recording Area
Name and Return
Edina Realt e, I WN T0:
400S. t. - Suit 0 LFGAL SF.gVI % INC.
Exceptions to warranties: H on, WI 54016 WTI M FVERt11F, 150
Easements, restrictions and rights -of -way of record, if any. 1256 MINNEAPOLIS, MN 55401 -2217
030- 2070 -95- 000...
Parcel Identification Number (PIN)
This is not homestead property.
Dated this 2nd day of June, 2006.
Pirius Devell nt Company,. C \
B
* Te E. irius, ember
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN }
ST. CROIX COUNTY. ) ss.
authenticated this 2nd day of June, 2006
Personally came before me this June 2 ,2006 the above
* named Terry E. Pirius, Member, Pirius Development
Company, LLC to me
TITLE: MEMBER STATE BAR OF WISCONSIN kno cu
(If not; I
he foregoing i strtunen and a�
authorized by § 706.06, Wis. Stats.)
NOTARY PUBLSIN
THIS INSTRUMENT WAS DRAFTED BY *Pamela J. Goulet
Notary Public, State of Wisconsin
Peterson, Fram & Bergman - Steven H. Bruns MY commission is permanent. (If not, state expiration date:
50 East Fifth Street, St. Paul, MN 55101 1C? f U jaodl )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
*Names of persons signing in any capacity must be typed or printed below their signature
WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2 -2000
1 of 1
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION f - 7 SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity ga l ❑ NA
Permit # Septic Tank Manufacturer 1 ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer _ ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units J2(NA Pump Tank Capacity al JVNA
Estimated flow (average) g al/day - Pump Tank Manufacturer aNA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer ANA
Soil Application Rate al /da /ft2 Pump Model _,9 NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit J91 NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD : 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ' O l in-Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :_30 mg /L JE NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once ever onth(s) (Maximum 3 ears) ❑ NA
y' -3 ear(s) y
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: .3 ❑ onth(s) (Maximum 3 years) ❑ NA
ear(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
Oyear(s)
❑ month(s)
Inspect pump, pump controls & alarm At least once every: ❑ year(s) )ANA
Flush laterals and pressure test At least once every: ❑ month(s) ,0 NA
❑ year(s)
=er: ❑ month(s) At least once every: ❑ year(s) CIA
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION Page ,-V- of ,,.,2— .
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALL R POWTS MAINTAINER
Name Z I V64, Name
Phone _ Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
I
09/26/2000 10:40 7152473038 BELISLE EXCAVATING I
ST CROIX COUNTY
S[iPTIC 'I - ANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ¢
Mailing Address ,/O
7 v
Property Add
ress
(Verification required from Planning Department for new construction)
City /State . AC 14 — /W/ Parcel Identification Number
Lf,, GAI, S
T 0 N.R Zb W, Town of -2 — 1y>5
Property Location '
� /., � ' /., Sec, ,� ---
Subdivision 5 Of,{cS Lot q
Certined Survey Map # , Volume , Page #
Warranty Deed M , Volume , Page #
Spec house 0 ycs no Lot lines identifiable ( - yes ❑ no
SYSTEM MAINTENANCE,
improper use and maintenance of yout 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 pmperty owner agrees to submit to St. Croix Zoning Department a ceniftcation form, signed by the owner and by a
niasi r plumber, journeyman plumber, testrictz d plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating conduion and/or (2) afirr:nspeciton and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I /we, the undersigned have read the above requirements and agree to maintain the private scwagt: disposal system with the standards
set forth, herein, ac set by the Dcpanment of Cummetce and the Department of Natural Resources, State of Wisconsin. Cen,fcatton
stating that your septic system hac been myint-cle t thus, he completed and retumcd to the St Croix County Zoning Office within 10
d s of the three year expiration date.
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on thts form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
th ropcny described abovc, by ��tnuc of a %�arraniy deed recorded in Register of Deeds Office.
\ ,7 1 0 6��
SIGNATURE OF APPLICANT DATE
••fir•• •ee.**
Any information that is nits- nprescntcd may result m 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