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Home My WebLink About032-1065-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety and Building Division t INSPECTION REPORT Sanitary Permit No: 420522 0 r 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: Turner, Jo ce Somerset Township 032 - 1065 - 10-000 CST BM Elev: Insp. BM Elev: BM Description: b, o 1 1 0DO u j6m ni�/- � TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark /ODD /D• /Z 11 b 4 /�a o Dosing Y Alt. BM Aeration Bldg. Sewer - 4 41111 6 vi Holding St/Ht Inlet 6o- TZ 1 TANK SETBACK INFORMATION St/Ht Outlet 6 2 /Q 3. TANK TO P/L W BLDG. Vent to Air Intake ROAD Dt Inlet J. Septic �� / Dt Bottom Dosing 4V Header /Man. U7 , Z Aeration Di Pipe Grn A/S Holding Bot. System / m / PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover G •fo (v- Model Nu er T Lift iction Loss System Head TDH Ft Forcemain Length 1. SOIL ABSORPTION SYSTEM 1 fry / o� BEDITRENCH Width L Len$th iNo?'OrTrenchds PIT DI NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING a turer: , INFORMATION HAMB to 7yp Of System: / , UNIT � /_� Model Number: u � DISTRIBUTION SYSTEM Header /Mani d Distributiol, x Hole Size x Hole Spacing Vent to Air I ake + ` Pipe(s) V ` Length Length_ Dia l Sp"a g t / om` S �✓ / SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 3Cr Depth Over 1/ Depth Over xx Depth of xx Seeded /Sodded xx Mulched S Bed/7rench Center % BedlTrench Edges Topsoil --�� //-- 4 Yes U No [ I Yes j= I No COMMENTS: (Include cak Iscrepencies, persons present, etc.) Inspection #1:L/GY� 1 Inspection #2: / / Location: 739 210th Avenue Som „„er��set,pWI 54025 (NE 1/4 NW 1/4 24 T31N R119W)) NNA LLot �j 2 Parcel Noo:�2]4..y311�.,19.3238 1.) Alt BM Description =�T - ChV_C_ � ” `1 �0 '� Q `Cl �"'" - 33 (u1e' 2.) Bldg sewer length =r�I. 0 )2 ' / / amount of cover = — — — -- — - - - - — Plan revision Required? I�:.' Yes o � � Use other side for additional information. SBD -6710 (R.3/97) Date Insepc 's Signature Cert. No. J Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 N visconsin Madison, WI 53707 - 7162 Site Address , E - i De artment of Commerce T P Sanitary Permit Application ` P 4 f o Nu mb z Z Z In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 0 Check if Revision may be used for secondazy purposes Privacy Law, sl5. 1 m I. Application Information - Please Print All Information State Plan I.D. Number Property Owner's Name CFUk \ L. d a_ti arcel umber Property is Mailing Address L ?rope t-A Location 3 O Ll 7� r E %; S T N, R Pho r Num Lot limber Block Number City, Star Zip Code ��: Subdivision Name CSM Number II. Type of Binding (check all that apply) ❑City 1 or 2 Family Dwelling - Number of Bedrooms 3 OViBage ❑ Public/Commercial - Describe Use XTownsltip 5 01V - 0 State Owned Nearest Road 2 1 a T" M. Type of Permit: (Check onl one box on line A (numbering scheme for internal use). Complete line B if applicable) A. For 0 New "2!Rteplacement System 3 0 Replacement of 6 0 Addition to For County use Sy stem Tank Only stem I B. 0 Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) JO Z A ---100 44 K Non - Pressurized In- Ground 210 Mound 47 0 Sand Filter 50 0 Constructed Wetland 22 0 Pressurized In -Ground 410 Holding Tank 48 0 Single Pass 510 Drip Line 45 0 At -Grade 46 0 Aerobic Treatment Unit 49 0 Recirculating 30 0 Other V. t Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./ Days /S4.Ft.) (Min./Inch) Elevation �Q 6 q3 , r /4 / .3 0 , 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 ®® _ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) ber's Signature Numl Business Phone Number - V2VI 713 6 - 0, Plumber's Address (Street, City, State, Zip Code) 'L VIII. Coin /De artment Ne — O nly XApproved 0 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued IssuinY Agent Signature (No Stamps) Surcharge Fee) 0 Owner Given Initial Adverse Determination IX. Conditions of Approy"easons for Disapproval G M MIA S - fie. ,�u�aw►�i.,teQ . M atu SB246 98 (R. 05101) i Safety and Buildings Di vision Cry V isconsi n. 201 W. Washington Ave., P.O. Box 7162 T Madison, Wl 53707 - 7162 Site Address Department of Comme 9 Aq Tf Sanitary Permit Application tu'' Permit Number `f s � In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision way be used for secondary purposes Privacy Law, a15. 1 m I. Application Information - Please Print AB Information State Phu I.D. Number Property Owner's Name /�,., , k \ L arcel r r Property is Mailing Address `) 5 20 zt Location 7-32 7W 'A, S T N, R City, State Zip Code Pia Numb�{ Loth r Block Number CL Subdivision Name CSM Number 1 S O Y- 9 II. Type of Building (check all that apply) R ❑City 1 or 2 Family Dwelling - Number of Bedrooms OVillage ❑ Public/Commercial - Describe Use O - ❑ State Owned Nearest Road 2 III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B U applicable) A For County use 1 2 J4 Replacement System 3 ❑Replacement of 6 ❑Addition to Tank Only Existing Systern 13. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) pie ?= . 44 0 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 0 Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Hall Grade Required Proposed R WGals./Days/Sq.F0 (Min./Inch) Elevation so kA f . 3 0 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 O _ E Dig Chamber VII. Regmnsib Statement- I, the undersigned, assume responsibility for installation of the POWTS Shown on the attached plans. Plumber's Name (Print) is Signature Numbe Business Phone Number z -5 �s Plumber's Address (Street, City. State, Zip Code) L - VIII. Cam /De ent se Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse .� Determination IL Conditions of Approval/Reasons for Disapproval des-4 Z61 A� in abe SZZ98 (R. 05101) _ -------- y " ?lic uenrr 1NSIOK;ION PioC - _ - ,5CA t_ - -- - -- 0 � -- - - -- - - — -- s ysz.F -4 ? 9 -.. 8io lino -A h , as _ � R � 1 _ 10 dr souTH 4oi L/N ,73? �1�_rH IUE___:__ _ _._ . ___ _ - .586 01446 y IIIELV 7 _- 0 2 2/ 75// UC ANT !A(S/�K/ �p iY A/p,C- �jO Quo ' 10 — � : - r ti A Z a j qpq S'ourM LoT ciN - 7�3 5"8� : TAZ - -- -- �'Ql.`2�R.��T __ __- __ _- _ _ _ _ __ _ _ _ __ - - _ __- - - -- - - -- ___ - -- __ __ _ __ __ . __ __ __ _- __ _ __ f 1142 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt Attach complete site plan on paper not less than BY x 11 inches in size. Plan must County St. Croix 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. Please print all in formation . __. viewed By Date Personal information you provide may be used or seco"_puq)4w (Ppracy t„pi, s. 15.04 (1) (m)). A\?� Property Owner P4erty Location Tuner, Joyce a Go . Lot NE 19 NW 1/4 S 24 T 31 N R 19 W Property Owner's Mailing Address Lot Block # Subd. Name or CSM# 739 210th Ave City State Zip ode Phone Number _ City Village ✓ Town Nearest Road Somerset WI 1 54025 1 715 - 247 -5299 Somerset 210Th Ave. New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD of Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system with a 0.7gpd/sgft rating. Possible system elevation for replacement area is 99.30'. Slope is 6 %. 1 Boring # Boring ✓ Pit Ground Surface eiev. 103.22 ft. Depth to limiting factor >101 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 *Eff#2 1 0 -17 1Oyr3/3 none sl 2msbk mfr gw 2f .5 .9 2 17 -36 1Oyr3/4 none scl 2msbk mfr gw 2f .4 .6 3 36-54 10yr5/6 none Is 1 msbk mvfr gw --- -- .7 1.2 4 54 -93 10yr5 /4 none grms Osg ml gw - -- ,7 1.2 5 93 -101 10yr5/6 none ms Osg ml - - -- - - - - -- .7 1.2 �.o'f 83•a`� Boring Boring onng ✓ Pit Ground Surface elev. 103.32 ft. Depth to Limiting factor >100 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef1#2 1 0-8 1Oyr3/3 none I 2msbk mfr gw 2f .5 .8 2 8 -12 1Oyr3/4 none sl 2msbk mfr gvv - - -- .5 .9 3 12 -50 10yr5/6 none ms Osg mi gw .7 1.2 4 50 -65 1Oyr5/4 none grms Osg ml gw - -_ .7 1.2 5 65 -100 1Oyr5/6 none ms Osg ml - - -- - - - - -- .7 1.2 B •2.� � L * Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD 130 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt s ._� 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 9/19/02 715 - 247 -2941 L Property Owner Turner, Joyce Parcel ID # Page 2 of 3 3 ] F Boring # Boring ✓ Pit Ground Surface elev. 104.12 ft. Depth to limiting factor >96 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -11 10yr3/3 none I 2mgr mfr cs 2f .5 .8 2 11 -20 1Oyr4 /3 none sl 2msbk mfr gw - - - - -- .5 .9 3 20-49 10yr4/6 none Is 1 msbk mvfr gw - - -- .7 1.2 4 49 -96 10yr5/6 none grms Osg ml - -- - - - -- .7 1.2 93. Boring # Boring F Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 _— _ _ _ 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 GP 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 —d f--.f nl.. A —f.m th..4— rtmonf of (./1R_7(.!._'2I S1 — T PV 4nR-7f.A_9777 I 4 e 112 aa / / �1 f Vo tti gVA AL. t Ck ' �s r h s` _ I I , n n 737 1V -' t —,5,fc aY73 11V y F STATE BAR OF WISCONSIN FORM 3 - 1998 622942 Y,ATHLEEN H. WALSH Document Number QUIT CLAIM DEED REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD John R, Pfluger, a single person, quit- claims to Joyce L. Pfluger, a single person, the following described real estate in St. Croix County, State of 05-12 -2000 1:50 PM Wisconsin: QUIT CLAIM DEED EXEMPT I 8M CERT COPY FEE: COPY FEE: TRANSFER FEE: RECORDING FEE: 10.00 PAGES- 1 Recording Area Name and Return Address Judith A. Remington REMINGTON LAW OFFICES P. O. Box 177 New Richmond, WI 54017 PIN: 032- 1065.10 -000 , '; �& This is not homestead property. The West 417.0 feet of the North 312.75 feet of the East Half of the Northeast Quarter of the Northwest Quarter (E1 /2 of NE1 /4 of NW1 /4) of Section 24, Township 31 North, Range 19 West, Town of Somerset. This deed is given pursuant to judgment of divorce in St. Croix County as Case No 98 FA 282 and is given ( t! / between husband and wife for no consideration. ykC7 6 3'0 ^` day of Ma 2000. Lj5(O Dated this �. y y, JOHN R. PFLUG AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated this ! day of ST. CROIX COUNTY ) Personally came before me this (fit day of May, 2000, the Y TITLE: MEMBER STATE BAR OF WISCONSIN a bove named John R. Pfluger to me known to lit the persons) who executed the foregoing instrument and acknowledge the (!f hot authorized by ' 706.06, Wis. Slats.) same. du n _ THIS INSTRUMENT WAS DRAFTED BY Judith A. Remington Judy K. annex REMINGTON LAW OFFICES Notary Public, State of Wisconsin. P.O. Box 177 My Commission is permancrlt. New Richmond, WI 54017 (If not, state expiration date: C G - l J G ) Telephone: (715) 246.3422 JUDY K. TANNER (Signatures may be authenticated or acknowledged. Both are not NOtaty R7DMe -State of WftM* necessary.) •Natnes of persons signing in any capacity should be typed or printed below their signatures. QUIT CLAIM DRED STATE BAR OF WISCOMIN FORM No. J - 1998 Informittlon Prefeesionals Company Fond dU Lae, Wisconsin 800. 855.2021 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner 6 ve _ _ Septic Tank Capacity 000 g al ❑ NA Permit # Septic Tank Manufacturer EEXS ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer DLL ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A00 ❑ NA Number of Public Facility Units )9 NA Pump Tank Capacity a l 91 NA Estimated flow (average) 0 gal/day Pump Tank Manufacturer QD NA Design flow (peak), (Estimated x 1.5) ' 7S_ al /da Pump Manufacturer 14 NA Soil Application Rate 01 2 gal/day/ft'- Pump Model 5D NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit $1 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand MOD,) 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD <_30 mg /L A In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ 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 every: IR ea�( (Maximum 3 years) ❑ NA 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: ❑ month(s) (Maximum 3 years) ❑ NA ® year(s) Clean effluent filter At least once every: ea�(s(s) ❑ NA Y ❑ month(s) ® NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) M NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once eve ❑ month(s) ❑ NA every: ❑ year(s) 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. t , Page of ' START UP AND OPERATION 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 INSTALLER POWTS MAINTAINER Name 5 cHm17 - r aL, 5 1 ' aNs t Name C /C Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Q djA I E - 12 S CAPIC67 Name r, mix /X DU T Phone Phone ! j _ 116RO This document was drafted in compliance with chapter Comm 83.22(2)lb)0)ld) &(f) and 83.54002) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ClO liC L / aA x[672 Mailing Address 73 1 le T , 4 UE LSD p%'f= 'a� T Property Address f �C /O T '' AC�� SB/`7E� s � S y� 5 (Verification required from Planning Department for new construction) . City/State c701'/E12 S 6 T /,��/ ` , Parcel Identification Number 0 ,3 1- /D6 SJ /0 x-000 LEGAL DESCRIPTION cation r/4 r/4 Sec. 3 / N- R. Town of Son Rs� 7 . Property Lo � , �� .�.� T " Subdivision ,ly,4 , Lot # Certified Survey Map # . Volume , Page # Warranty Deed # . f .� iZ , Volume 1 :5 - 14) , Page # i Spec house ❑ yes ('no Lot lines identifiable 21yes ❑ no 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 lumber, restricted lumber or a licensed umper verifying that (1) the on -site wastewater disposal system master plumber, joumeymanp p P 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 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. 0 121 9 0 1 &- CtA-141A- r /d /&/OZ GN TORE OF APPLICANT DATE OWNER CERTIFICATION are true to the best of m (our) knowledge. I (we) am (are) the owner(s) of I (we) certify that all statements on this form e Y ( the property descr above, by virtue of a warranty deed recorded in Register of Deeds Office. /0 /1Z l02 N TURF 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