HomeMy WebLinkAbout032-2160-80-000 Wisconsin Departm9nt of Commerce Count
Safety and BuildingODivision PRIVATE SEWAGE SYSTEM St. Croix
INSPECTION REPORT Sanitary Permit No:
• 430647 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Pla 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 Somerset Township 032 - 2160 -80 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
co .0` OO.O 1 12.31.19.1386
TANK INFORMATION ' ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic nchmark /
Dosing A t. B 12 I
Aeration Bldg. e e / r
.o 0.50
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 1 ( v -- Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. Syste �� .t
C1. C1 �
PUMP /SIPHON INFORMATION Final Grade (,4) b .zo
Manufacturer Demand St Cover
GPM
Model Numb g1µ�� A
TDH Lift ric ' n Loss System Head TD Ft
Forcemain Lpfgth Dia. Dist. to well
SOIL ORPTION SYSTEM 11 e44
ENCH Width f Length ( No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIME S /O
0.. G.
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufact rer: �1`
INFORMATION CHAMBER OR TOE
Type Of System: � � UNIT
' ♦' Model Number. l'IO I t 4
DISTRIBUTION SYSTEM
Header /Manifeld Distribution x Hole Size x Hole Spacing Vent to Air Intake
11 Pipes) i
Lengt Dia Length Di Spacing 1/ ,20 +
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
jtd Yes L j No Yes o
CO EN ENT$: (Inclu a code discrepencies, ers s ser �� I�tsp�tion PRerJW4otM181 �
# Inspection #2:
Location: 2231h Str Sdfne�ef WI 025 ( 1/2 SW 1/4 12 T31N R19W) Wild Tu a Parcel No. 3 6
1.) Alt BM Description = nP a 't U+'�Qr : / b� �a — /d D'•
2.) Bldg sewer length
- amount of cover = > 42 ~ �+j
I� n rerequired? ? 1 Yes No
U o r� sid fforr additionaj Inf ma ion. ] -6710 54.Xc � R �� C?n Se 1 `s e 1 • J �- -t�� Cert . No
�,:.Qb a�..`N�. S s�•�t • Q
Safety and Buildings Division County i '
201 W. Washington Ave., P.O. Box 7082 v ' x
Madison, WI 53707 — 7082 Sanitary Permit N ber (to be fined in by Co.)
i sconstrn (608) 261 -6546 i a_-
Department of Commerce state Plan I.D. Number
Sanitary Permit Application
in accord with Comm $3.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Lam, s I5.04(1)(m) Project Address (if different t mailing address)
I. Application Information — Please Print All Information 2Z 3 (
Parcel # \ t # SttRFir
Property Owner's Nacle
co i�, lZ�jtXIBW o
P roperty Location perty O's Mailing Address J� �.�•
� r _ � ! /. Section
C' ,State Zip Code Phone Nu=mber
e - � E o n
21 L /� r � T N; R ot�
II. T of Building (check all that apply) Subdivision Name M Num
r2 Family Dwelling — Number of Bedrooms /
❑ Public/Commercial - Describe Use - v
❑City ❑village sh
❑ State Owned — Describe Use
IIL Xo�f Per mit: (Check only one boz on line A. Complete line B if applicable) 2 — 2 o `� System El Replacement System ❑ Treatment Bolding Tank Replacement
Only ❑Other Modification to Existing System
B. ❑ Permit Renewal it Revision ❑ Change of
1 0 Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner 3 l :�— �� , I ^
IV. T e of POWTS System: Check aU that a 1 13 / m
MK- -pressurizedin-Ground ❑ Mound > 24 in. of suitable soil 13 Mound < 24 in. of suitable soil 13 At-Grade [3 Single Pass Sand Filter
/ Constructed Wetland ❑ Pressurized 1n and ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit C3 Recirculating Sand Filter
Recirculating Synthetic Media Filter hing Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) /
V. Dis ersalfrreatment Area ormation: S sue Elevation
Deli ow (gpd) Design Application Rate(gpdsf) Dispersal Ar Required (sf) Dis rsal Area Proposed (s�
Tank Info Capacity in Total Number Manufacturer Pre fab Site Steil Fiber Plastic
VL Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
septic or Holding Tank +Q
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigne ume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plu=mber's re MP/MPRS mber Business Phone Nu er
s� z� o� ��� =-Z J/ 4
Pltunba Address {Street, CITY, State, Z1pJ1
����
VIII. Coun /D epartment Use Onl
Approved 11 Disapproved Sanitary Permit Fee (i Dudes Groundwater Date Issued Issuing ent Lure (No ?)Amps)
Surcharge Fee) 2Z
❑ Owner Given Reason for Denial JJ
IX. Conditions of ApprovaMeasons for Disapproval n
SYSTEM OWNER: E t/ 1 S I by� '. Net< sumac �.
1 Septic tank, effluent filter and G
dispersal cell must all be serviced 1 maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Attack Complete plan (to the County only) for the system all paper sot less than 81/2 z 11 Inches In size
SBD -6398 (R 08102)
Soil Test and System PLOT PLAN
PROJECT P.C. Collova Bldrs. In ADDRESS P.O. Box 489 Somerset Wi 54025
E 1/2 SW 1/4S 12 / 19 W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 1 8104 BEDROOM 3
CONVENTIONAL )00( IN- OUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
IL BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION Ia0' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 98.5 4' below grade @ B -1
Alt. BM Top of Power Box @ 100.3' B.M. Alt.
70 B.M.
Pr operty Line Vents B- 35' 35' S, lft---1
2 -3' X 69' Cells with
Vents >3' Spacing
7 �a
25'
2% Slope B -3_ Slight depression,
30' sands were found at 6'
o below grade
9
o
N a
B o Plans Designed Using 3
Hous Conventional Powts
Manual Version 2.0 o
Replacement a
area is original
soil test =
P n Vent
,rte
J, r
>6„ Standard Biodiffuser
of Cover Leaching Chamber
with 31.1 ft2 of Area
6' Long 11 1$
IF 34" Grade at System Elevation P
489' Property Line
' Soil Test and System PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc. ADDRESS P.O. Box 489 Somerset Wi 54025
E 1/2 iSW 1/4S 12 / 19 W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 1/8/04 BEDROOM 3
CONVENTIONAL XXX IN- OUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 of chambers 22
BENCHMARK V.R.P. Top of Steel Fence Post ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE (D WELL - H.R.P. Same as Benchmark
SYSTEM ELEVATION 98.5 4' below grade Ca) B -1
Alt. BM Top of Power Box @ 100.3' B.M. Alt.
70' B.M.
Property Line *
Vents B- 35' 35' S B-1
70' 2 -3' X 69' Cells with
Vents >3' Spacing
25' -
.5 T 2% Slope
B -3 Slight depression,
' 30' sands were found at 6'
0 below grade
�0 0
N Pro 3
Bedroom Plans Designed Using 3
House Conventional Powts
Manual Version 2.0
Replacement
area is original
soil test !
r�
t�
Vent
>6„ Standard Biodiffuser
of Cover Leaching Chamber
with 31.1 ft2 of Area
1 1 6' Long 11 "
34" Grade at System Elevation
489' Property Line
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 'J
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I. .
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information tRevi ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Locati
/ . Govt. Lot /4 S�o� T N R E ( r) W
Property Ovtger s Mailing Address Lo # Block # Subd. Name CSM#
City State Zip Code Phone Number ❑ Cp� ❑Village Pftown 66rest Road
New Construction Us Residential /Number of bedrooms Code derived design flow rate J LJ GPD
❑ Replacement , ❑Public or comm al - escribe: __—
Parent material Q`� 1 (,c���J :� -r` Flood Plain elevation if applicable
General an recommendaations�y.—'�zt ,a / � �/1�C! l�> • J
- t c 1
Boring # El ri ng
it Ground surface elev. �� ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I - Eff#2
Al L
®Boring # Boring /�� .
Pit Ground surface elev ` �ft. Depth to limiting factor tn.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
h.
s ✓1�' - Z
o Q�
Ef fluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L Efflue = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Sig CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date ifLation Con cted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 -- 715 - 246 -4516
i
Property Owner_ Parcel ID# Page of
a Boring # ❑Boring /
Pit Ground surface elev. - o -e ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 I •Eff#2
C
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Kplication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDtff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - Eff#2
Effluent #1 = BOD_ > 30 1220 mg/L and TSS >30 < 150 mgA. ' Ef fluent #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.W00)
County
Safety and Buildings Division s,
rA 201 W. Washington Av itarY ermit Number (to be Stied in by Co.)
Madison, WI 53 07 - -V 30 b
VIS�109*00 State sin (608) 261 6
P LD. Number
De srtment of Commerce c atio n JAN 2 004 _
Sanitary Permit Appli
nsl information you rovide psn�ect A dress (if different than mailing a
m ddress
Cowan )
in accord with 83.21, W is. A.dm sa LAW, s15.04(1)(m) ST. CROIX CO N r )�
may be used for secondary purp CE `T'\
ease
I. Application Information — Pl Print All Information 4 22-?
�t
Parcel # Lot # Block #
Property O s N me // f�
me 110va/ (!J proper Locati
Property
z
Siwepr's Mailin g Address Section
City, State
Zip C e Phone Number
? ird one)
of— .5 y / 1` ; R E
of Bttlldia (check all that apply) Od S Su ri ° am* CS
II. Type S S • i /�
or 2 Family Dwelling — Number of Bedrooms
❑ PublidComtnerc Describe Use t 6 G S Ciry ❑villa tP
❑ State Owned — Z o 06��
III. Type of Permit: (Cheek ly one box on tine A. Complete Ilse B if applicable) - 21 �O o "' � �O ' � 3
A. S tern ❑ Rep nt System ❑ Ttsattn
ent/Holdiag Teak Rep
lacemmt ❑ Other Modifmrion to Existing System
ow Ys
List previous Permit Number and Date Isauod
H. ❑ p Transfer o►
❑ Permit Renewal ❑ Permit Rey, ❑ Change of n ew
Before Expiration
Plumber Owner �
IV. a of POWTS S tem: Check all that 1 e Sin an Filter 0
on _Pressurized In Ground ❑ Mound 2 :24 in. o 'table soil ❑ Mound < 24 in. of table liter
❑ Ho Tank Peat Filter ❑ erobic ant Unit ❑ Recjrcu ari
d Cl eas d
ttrizod la roun ✓ .S
Constrtteted Weclan O
❑ Gravel
n
Chamber Dri Line
Racirculatio Synthetic Meths Filter hies
atment Arso st)
ntormatiaa: Diszursal Area
V. Dis ers&Vrre e
Design. Soil Application RstaWdsf) Dis i Area Aequir (
7 ,-1—ZD flow (gpd) gn � ufacturer Pre Site Plastic
VI. Tank Info Capacity in Total Number Concre Construct ass
Gallons Gallons of Units
New Existing
Tanks Tanks
Septic at Holding Tack
Aer°btc?marment Unit
Dosing Cbamber
VII. Responsibili Statement- I, the waders ae lime respons 1[ for installs Nfm K TS shovra an
the B e iness Phone Number
Le M z v
Pl m
s Name (Print) t Plumber'
Plumb���?Strxt, C4 S z ip
VIII. Coun/D� a Use Onl
Sani ermit F (includes Groundwater Date Issued is win Agmt Signature (No Stamps)
Approved ❑ Disapproved Surch a Fee) �?50
❑ Owner Given Reason for Denial
roval/Reasons for Dlsapprova Q OAAk
IX.ConditlonsofApp 3> �° I, `�^'�^ac'e"``
SYSTEM OWNER: anfl�S , I
1 Septic tank, effluent Biter and
dispersal cell must all be serviced / m Ingg
as per management plan provided by JUMber. OAA
2. All setback requirements must be ma' tained
as p erapplicable code /ordinances.
Ash eampkte puss (te the Causty Daly) for the system sa paper n ot kss than 9112 1 11 Inches in size
SBD -6398 (R. 08102)
PLOT PLAN
PROJECT P.C. Collova Bldrs. Inc. DDRESS P.O. Box 489 Somerset Wi 54025
E 1/2 SW 1/4S 12 /T 31 19 W TOWN Somerset COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 1/8/04 BEDROOM 3
CONVENTIONAL XXX IN -GROUN ESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22
BENCHMARK V.R.P. Top of 1.5" Pige
(: - g,,,� 1 ASSUME ELEVATION 100° Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P Same as Benchmark
SYSTEM ELEVATION 97.0/96.0 5' below qrade
Alt. BM op of 1.5" Pipe @ 9 9.6'
Vent
Plans Designed Using
A6'Long Standard Biodiffuser Conventional Powts
Leaching Chamber Manual Version 2.0
with 3 1. 1 ft2 of Area
34
Grad e at System Elevation
' Pro 3
p Bedroom
0 House
N 20'
3
o
T
0 '
3
Alt. Vents
B
5' B -1 70' B -2
10%
70, Slope
1 489' Property Line
150'
vwisoorsinn Deparnnent of Coevnerce SOIL EVALUATION REPORT Page of
Division of Safety and Buld'ungs
in aocordarroe with Comm 85, Wis. Adm. Code
Attach complete site Man on Paper not less then 8112 x 11 inks in`size. Plan trust � Cr 0
include. but not Nmited to vertical and horizontal reference point MR, dh+sction and Parcel l.D.
pereerk slope, scale ordimensiens. north avow. and location distance to nearest road.
Please print all inf ma Data
p 4mond b rou acv& m" be toed for sec«w.rr (Primay LAW. s.15.01 rn tmrr Pbnl . 1 2lA
Property d Lorton i
l . L . C. lf/ c✓ Gott lot ; / 114 S /9T 3 N R /2 E ( W
Property Oar's Malmg Address _ Lot # # Snbd CStu#1
qt Stye lip Code Phone Nunbw ❑ C V ❑ vilage own oftarest Row
i fads (z 1 9 'o ��
New Conshufion Use: R / Nunber of bedrooms Code derived design flow rate
O moamimt O Public - Des«be: - - - --
Parent I �i /-� Flood Plain elevation it applimMe n.
General comrnenls s �1.��� 5 � 1
and
l G ca,�
o f �
1 Pn Ground surface elev. _ it. Depth b factor J� — Soil Application Rals
Hmim Depm Dontinarrt Redox Description Tax%" Sbuctue Consistence Boundary Roots
GPW—
lin. Murnsel Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 '011112
—� ice/ C � � -
soft 0 sofft in.
Pit Ground surface elev. � ' ft. Depth to tirn" factor ® J9 Sal Applicatim Rate
HoFb n Depth Dominant Color Redox DesaipGon Texture Struct" Consistence Boundary Roots GPDW
In. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. •Etf#1 'Etf#2
IS
76a) r
St . �Z9`4•ED
. Etflnrent = Bpp > 30 < 220 610L and TSS mgll • Erom t #2 = WD < 30 nV& and TSS <— 30 mglL
CST Number
C ph SO IwFe
Date Evaluation Conducted Telephone Nksnber
Address
J
7 �� -'' S�
f -
Property owner Parcel ID # Page d
E Boring # ❑ Bormg
JO Pit Ground surface elev. it. Depth to WnW+g tactor in Sod Rate
Horizon Depth Dominant Redox Description Texture Structure
Consisten Boundary Roots GPDAf
In. Mussed Qu. Sz. Cont. Color Gr. Sz Sh. 'EfW1
Z
a + 9� �
=Y10
Borkg # ❑ SorkV
❑ Pit Ground surface elev. fL Depth to Inv" factor i^• Sad Application Rabe
Horizon Depth Dominant Color Redox Description Texture Structure Corusistence Boundary Roots GPM
io. Munsell Qtr. Sz. Cora Color Gr. Sz. Sh. 'Eff#1 'Efd2
❑ Borktg # ❑)9
❑ Pit Ground surfaos elev. tt. Depth to Nmfing factor in.
Sod Application Rye
Horizon Depth Dominard Color Redox Description. Textre Struchxe Consistence Boundary Roots GPD fF
in. Moused Qu. Sz. Cont Color Gr. Sz Sh. 'EfW1 *011t2
Effluent #1 = BOD > 30 mglL and TSS >30 150 mg& ' Etlluert #2 = BOD < 30 mg& and TSS < 30 mglL
The Department of Commerce is an equal opportunity service provider and employe r. if y our need assistance to acces s services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
seo43w(R.W)
I
Soil Test Plot Plan
Project Name P.C. Collova Bldrs. Inc Shaun
Address P.O. Box 489
Somerset Wi 54025 #226900
Lot 1 8 Subdivision Wild Turkey Retreat Date 9/ 6/02
E' 1/2 S W 1/4S 12 T 31 N /1319 W Township Somerset
E] Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top 1.5" Pipe
System Elevation 95.5/94.7 *HRPSame as Benchmark
Alt. BM Top of 1.5" Pipe @ 99.6'
Please Note: Tested area
may not be suitable for
desired building area.
Check system location
before excavating. Also,
survey was not completed
at time of test. Set backs
o from lot lines may
a change. b
N
O
H
102' B -3
35' �
101'
30'
Alt
B.
5' 15' B -1 B -2
10%
70' Slope 100'
489' Property Line
150'
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
C ncy Plan
ption #1 If system fails, determine cause of failure, use alternate area and install new
system in tested replacement area.
Op ' #2. Install system at a lower elevation, by removing chambers, removing biomat,
and install new system.
Opti 3. No adequate area is suitable for replacement area, and system elevation
cahnont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715- 246 -5148
Shaun Bird #226900
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer P. C. Collova Builders, Inc.
Mailing Address
P O Box 489 Somerset, WI 54025
c
Property Address V v
(Verification required from Planning Department for new construction)
City/State 6fyU-k6-* Parcel Identification Number 03Z- Z-Ibo /
LEGAL DESCRIPTION
Property Location %,, V -, Sec. �a , T 3 N -R 19 W, Town of Sbo'\'u .
Subdivision WA & � �Q � ' Lot it , c
Certified Survey Map # Volume Page #
Warranty Deed # _ Ce � (Q Volume Page #
Spec ho es ❑ no Lot lines identifiable *0 no
us�� ; l�y
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
masterplumber, }ourneymanplumber, 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.
I/we, 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
sta ' that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
yeaz expiration date.
• P. C. COLLOVA BUILDERS, INC. iD t f
SIGN OF APPLICANT (715) 247 -2742 DATE
P.O. Box 489 SOMERSET, WISCONSIN 54025
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of myiour) kilo' I (v am (are) the owner(s) of
t rty Tcri ve, by virtue of a warranty deed recorded in Register of Deeds O r
P. C. COLLOVA BUILDERS INC.
(715) 247 -2742
SIG A OF PL:ICANT P.O. Box 489 TE
SOMERSET, WISCONSIN 54025
* * * * ** Any information that is mis- represented may result in the sanitary permit being: revoked by the Zoning Department. * * * * **
r'
** 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
1
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FROM P C COLLOVR DLDRS, INC PHONE NO. : 715 247 2747 Oct. 28 2002 02:14PM P1
1u /LajUl Aw ll.ul rAA. riu ;2 "j Auer uvIaLUA ur IJZWr _._. Lwuus
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Tll1 DaA ends batwwM B uou Don Qr Q�Oh, �lilri� FOR M UP 10
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AWMENTIGATION ACXNUWLLJ)GMLNT
a3atueKs; !wo• ots" Q&M Cam Qit b4ivkhWS� STATE OF wl�roNSII� `
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(trams., asd srkmx- lsdle.d the awo.
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WAAAJIAIYY CCt9 "ATE MsOlMrM aNWN
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Nq . COINER OR RESIDENT SHALL DO ANYTHING WHICH WOULD INTERFERE WITH OR CHANGE THE
OPERATION OF THE APPROVED COMPREHENSIVE WATER DRAINAGE AND SOIL EROSION PLAN FOR
THIS PLAT. THIS INCLUDES BUT IS NOT LIMITED TO BUILDING UPON, OBSTRLWTING, ALTERING,
FILLING. OR EXCAVATING OR PLANTING IN ANY POND EASEMENTS, WATER DR NAGE DITCHES, WA
RUNWAYS, WATER CULVERTS, BERMS OR GRASS SEEDINGS. t
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GENERAL NOTICE STATEMENT:
EACH PARCEL SHOWN ON THIS MAP (PLAT) IS SUBJECT TO STATE, COU Y. AND TOWNSHIP LAW
RULES AND REGULATIONS (I.E. WETLANDS, MINIMUM LOT SIZE, ACCESS T PARCEL, ETC.) BEFORE
PURCHASING OR DEVELOPING ANY PARCEL OF LAND, CONTACT THE ST. ROIX COUNT ZING
OFFICE AND THE APPROPRIATE TOWN BOARD FOR ADVICE.
S 00 01f08 E
"< Z_ 2650.03'
/4 �JPLATTED LANDS 2617.03'
160.71' � ^ s3 _ _ 335.69' — _ _ _ 236_11'_ _ _ _209.7
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