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Home My WebLink About032-1072-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420420 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: City Village X Township Parcel Tax No: Teasley, Anthony Somerset Township 032- 1072 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: /00. o /00, o /gym 4 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic n k Benc mar V � I 3 2y 103. /00 o Dosing Alt. BM A-- t 0 .Si Y . Y 4.t lru) -� 5. 3P // • ro Aeration Bldg. S6Wer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD D n Septic too ' �, ff f Dt to .� Dosing S Header /Man. Aeration Dist. Pipe Holding Bot. System PUMP /SIPHON INFORMATION Final Grade :2 `E Manufacturer D nd St Cove // p 62 - Z. o0 • v Model Number TDH Lift Friction Loss System Head TDH t Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM /2 7� BED/TRENCH WidthI Lengt i , o. Of Trenches PIT DIMENSI NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS - SETBACK SYSTEM TO P/L BLDG IWE LL LAKE /STREAM LEACHING Man urgr: INFORMATION Type f System: CHAMBER OR tad f Type v,v / � % \ UNIT Model Number: / i / DISTRIBUTION SYSTEM 'W ) (J(J J Header /Manifol Distribution / x Hole Size x Hole Spacing Ven it Intake pipes) n �j�y� sv� i Length Dia h Length / Dia h j y r p ci g / > ( w SOIL COVER x Pressure Systemms 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 W No Yes [1 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: _/Q/ i7 / Inspection #2: Location: 667 200th Avenue Somerset, t WI 54025 (NW 1/4 NE 1/4 26 T31 R1 9W) NA Lot �` Parcel No: 26.31.19.3528 1.) Alt BM Description = &443� 2.) Bldg sewer length = 5,!I - amount of cover = •'��' Plan revision Required? i! Yes (o /- Use other side for additional information. �(l — - -- SBD -6710 (R.3/97) Date Insepctor's S' nature Cert. No. 1 Safety and Buildings Division County C 201 W. Washington Ave., P.O. Box 7162 �1 - 6 Madison, WI 53707 - 7162 Site ,s�Ons,n ,�,t �, • n Department of Commerce 9 -9 �-D L ��(� Y �OU' /7� Sanitary Permit Application Sanitary Permit Number (� 1 In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision 41 may be used for secondary purposes Privacy Law, 05.04(1)(m I. Application Information - Please Print All Information State Plan I.D. Number P rty Owner's Name arccl Number — ; - '032 0 - a2o Property Location party owner's Address . 3 o Tf �� -A E u ; S T N. R City, State Zip Code PhofiCNumber t Number Block Number Subdivision Name CSM Number So 5 a 0 Aell - II. Type of Building (check all that apply) ❑City 1 or 2 Family Dwelling - Number of Bedrooms �Sh� Fi�(6` []village ❑ Public/Commercial - Describe Use ownship ❑ State Owned gl B `a d / r/S Lac Nearest Road /n/ �,2 Tai �►/GsLlt 3/ 2./ / 3'� /08.3 O T . A4l M. Type of Permit: (Check onl on ' e A (numbering scheme for interns! use). Complete line B if applicable) A For County use 1 ❑ New 2 )Q Replacement Syste 3 ❑ Replacement of 6 ❑ Addition to Sy stem Tank Only Exist= System B . ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 Non - Pressurized In-Ground 210 Mound 47 ❑ Sand Filter 50 U Constructed Wetland 22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line Yc 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispe rsaUTYeatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed f Rate(Gals./Days /Sq.Ft.) (Min./Inch) ✓ Elevation 5D ✓ N3 53= I VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic ions Gallons of Tanks w/. Concrete Constructed Glass ew Existing ii Tanks I Tanks Septic or Holding Tank posing Chamber VII. Responsibility Statement I, the undersigned, assume responsibility installation of the POWTS shown on the attached plans. Plumber's Name (Print) is Signature MP N Business Phone Number r f Plumber's Address (Street, City, State, Zip Code) C6 - f VIII ount /De artment Use Onl Sanitary Permit Fee (includes Groundwater fIssued I ing Ag Signature Stamps) Approved C1 Disapproved Surcharge Fee) El owner Given Initial Adverse l 4 Determination O � EK. Condi ions of Approval/Reasons for Disapproval �' j 33 _ r � comp) (to the C only) for th em on not less then 81/2 x 11 in es In .Qv ,��2C+%ri�a'.ttivt�vt. Ly►�w* • �'3. 3 —! ,be YJit� . SBD -6398 (R. 05101) � Ae— Mare NC ' F XiSriv� � -_ - - -- - - - -- - -mss: - , -_ - - -- — -__ . _ - -- 0 i —TAcT pj7.- B71 fl.)? � r /f�DusE- 11Y, 1� 1- r I i WALL - NEuf / 000 ✓4 /D - - - - '�_dr �_fALT 3 - 1�?T1`[__$/9rvlr_' -Qr ee I j VAcr� - �'cz�c - _ __ 'r -_ _ _ -- - _ _ __ ___._ _ - _ _ - -- -- __ _ _ _ -- __ _ _ __ __ __ __ __ _._ -- --AN VIEW ��If�N� � InS�c- CTionr Pr�1Gs 3 `x bad Feer two A r- F M5e/1S T R Enrc 14JIV 31 y� BEN r yapvc_ veNr x 11vVcci✓aff T/1 EivcN CROSS 520TSGr: Original GrIW 96 Wiles. ?Get he nc 12 irches ri n. a inches min . Manufacturer I Q Name �---- inches Height of leacItung chamber prod,.. cCE came: "f ...�r1`�us� = � QCt 0 - -In situ Soil-0 92 L. L:. `l.e'r. 2set "ode N umber : Treatment and -- --0 --- !)iepersa. Zone ,Ls requixecr by Table 83.44 -3, Wis. Aden. Ccde m, • r 70 3rt'6 SE CNH ',Z:60 ZACZ /67;'60 Page - 3 o�� cr..hN t *iEw �iiV�NT � Inrs�c -t rider P��cs . 3 `�C b2,1 r r CO A, F-FuseR V &-wC � MIN 3 / yAf vEl� r 'X 4$,3/ .F Ecr a�'o �ifFUS�Ks CROSS S:'CTIOT_e Original Glade I In. IneY:ea'71 12 inches min. 0 inches bIanu acturar's Name Inches Height of leaching chamber Yrodac� vamp : ��p..��1�? � p / 0.. -Ir. s s oil - -4 l;odei Ifumber: Treatment and» --O —D-Japersal Zone As requires: by Table 83 -44-3, Wis. Ado. Ccde Av v v =EN!ng QNV h13J' at £f5 L809 1:60 ZfiCZ /fL;'ED l 1134 SOIL EVALUATION REPORT Page 1 of 3 ` Wisconsin Department of Commerce Tom Schmitt Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. coo slope, scale or dimemsions, north arrow, and location and distance to nearest road. (..o D _ /O �� D, Please print all information. 9— Z �� evie ed Date ,�- B Personal information you provide may be used (IJapll, s. t5. (1) (m)). ZG 6 r Property Owner Pro rty Location Govt. of NW 1/4 NE 1/4 S 26 T 31 N R 19 W Teasley, Anthony or CSM# Property Owner's Mailing Address "- " Lot Block # Subd. Name 20 Acre Parcel 667 200th Ave. City State Zip C e Ptrd f 14rR City Village ✓ Town Nearest Road Somerset I WI 5402 Somerset 200Th Ave New Construction Use: y Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ✓Replacement Public or commercial - Describe: Flood plain elevation, if applicable na Parent material Outwash General comments and recommendations: Area is suitable for a conventional system with a 0.7 gpd/ sgft rating. Possible system elevation Is 91.88'. System is on a 7% slope. Boring # Boring EE be >99 in. Soil Application Rate Pit Ground Surface elev. 96.88 ft. Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Consistence Boundary Roots GP Structure r Eff#2 in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 * 1 0 -8 10yr3/3 none sit 2mgr mfr cs 2f 5 8 2 8 -21 10yr3/4 none sicl 2fsbk mfr gw 1f .4 .6 3 21 -38 1Oyr4/4 none sl 2msbk mfr 9w 4 38 -50 10yr4/6 none sl 2msbk ml gw - - - - -- .7 1.2 5 50 -99 1Oyr5/6 none ms Osg ml - - -- ---- -- .7 1.2 ❑ 2 Boring # Boring > 101 in. Soil Application Rate le Pit Ground Surface elev. 96.88 ft. Depth to limiting factor G PD Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 Eff#z in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 1 0 -9 1Oyr3/3 none sil 2mgr mfr cs 2f 5 8 2 9 -28 1Oyr4/4 none scl 2fsb k mfr gw 1 f .4 . 3 28 -53 7.5yr4/4 none sl 2msbk mfr 9w — .5 .9 4 53 -101 1Oyr5/4 none ms Osg ml - - -- - - - - -- .7 1.2 1pb y *Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L " Effluent #2 = BOD < 30 mg /L and TSS - 30 mg /L Signature- CST Number CST Name (Please Print) g 227429 Thomas J. Schmitt Date Evaluation Conducted Telephone Number Address Tom Schmitt 7/30/02 715 -549 -6651 586 Valley View Trail, Somerset, WI 54025 i . Teasle . Anthon age 2 of 3 F3 I Property Owner Y, Y Parcel ID # Boring # Boring Pit Ground Surface elev. 95.07 ft. Depth to limiting factor > 105 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAIL in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr5/3 none SO 2mgr mfr cs 2f .5 .8 2 8 -18 10yr4/3 none sil 2msbk mfr gw if .5 .8 3 18 -32 7.5yr4/6 none sl 2msbk mfr gw - - - - -- .5 .9 4 32 -54 10yr5/4 none Is 1 msbk mvfr gw - - -- - .7 1.2 5 54105 10yr5/4 none ms Osg ml - -- - ---- . 1.2 F41 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 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 Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD L30 mg /L and TSS -i mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or icr —Try AnQ_ '),<n_R77'7 r -- C6 /V fS� ;y8� OL Y ea S-e ' i qT i O$ o andA cs r ?, "9 SN p. c 2O 4C W 4 a ce.` STC1291 a sersrrrr 'ssr�arrsax+a-•r•+ -n-++ m• _r. .+ _ -. _t -*v: a. m*.y�ra:•ra mar .- ram::. irr. r . - •z- .sa-sr- s- e+*+sas:aas*r -r• T.-.v. aase�aw�� DOCUMENT NO. sTA.TE BAR OF WISCONSIN -FORM 1 . n WARRANTY OEEO THIS S/ACE aFStaylo i0A A(COntNNO DATA '1' ^ . I REGISTER'S OFFICE THIS DEED, made between _A & L, [nc.. d `if nw sat a ST. CROIX CO., WI Corporation Recd for Record Grantor !)I ( 9 - r ` 1 988 an d Anthuny H TaaslNy :rna ❑' A at 1:45 PM _ husband and wife. as surv ivorship mart tY— MM Grantee, V � �Rg,stcr Oceds W i t n e s s e t h, That the said Grantor, for a valuable consideration _ _ •.. RETURN TO conveys to Grantee the following described :eal estate in St. Croix County, State of Wisconsin: The E 1/2 of the YW 1/4 of the NE 1/4 of Section 26, Township 31 North, Range 19 West. Town of Somerset,_ St. Croix County, Wisconsin. Tax K a 0 i t This i not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Easement for Town Road over the Northerly 33 feet. and will warrant and defend ti,e same. Dated this 24th day of August _ 19 :n J on =",I (SEAL) A & L Inc. a Minnesota cor orati (SEAL) �-•� � .� --fit ---- x by� %yn s (SEAL) Ralph D. Afton, its president _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this— day of STATE OF WISCONSIN 1 . ss. St. Croix County. Personally came before me, this 24th day of Augus 1988 the above named TITLE: MEMBER STATE BAR OF WISCONSIN R alph D Alton (If not, authorized by 4706.06, Wis. Slats.) This instrument was drafted by A & L, Inc. to me known to be the person._ who executed the fore - going instrument and acknowledged the same.__ _ St illwater. Mn 5 50$2- ---- (Signatures may be authenticated or acknowledged. Both `__ Michae K. l_isvol are not necessary.) Notary Public St._t ^r County, Wis. My Commission is permanent. (If not, stale expiration date June 1_ +_ - -- - - -• 19 90 •) *Names of persons signing in any aparity roust be typed or printer] below their slgnahlr.t. I - - - - ...r•R - '-- �s —tis n�krcrn t�v no.. vn ... t_t � - -' -- - - -- POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of Z FILE INFORMATION SYSTEM SPECIFICATIONS Owner — Septic Tank Capacity 1 gal ❑ NA Permit # a a (�� Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS / Effluent Filter Manufacturer ZA ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A - ❑ NA Number of Public Facility Units A NA Pump Tank Capacity a l 04 NA Estimated flow (average) S gal/day Pump Tank Manufacturer O( NA Design flow (peak), (Estimated x 1.5) al /da Pump Manufacturer 0"NA Soil Application Rate 7 gal/day/ft' Pump Model 1K NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 04 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) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD :530 mg /L O.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: 3 ❑ year(s (s) (Maximum 3 years) ❑ NA year(s Pump out contents of tank(s) When combined sludge and scum equals one - third (Y of tank volume ❑ NA monthi Inspect dispersal cell(s) At least once every: 3 5t year(s)(s) (Maximum 3 years) ❑ NA ❑ month(s) ❑ NA Clean effluent filter A z NE At least once every: ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month [I yeaarr((s) s) l O(NA ' ❑ month(s) J,NA Flush laterals and pressure test At least once every: ❑ year(s) ❑ month(s) Other: At least once every: ❑ year(s) [I NA 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 I— of START UP AND OPERAT104Y 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 Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name //0/ t — Name C �� Phone Phone ,7 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(11, l21 & (31, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer /ONE T EA 0 Mailing Address G 7 oD 7-* i9Ok Property Address 6 62 0 4 .Ile 7-// 'Alit= (Verification required from Planning Department for new construction) /Via City/State g S� T ll1i ,�yo2s Pazcel Identification Number 31-46 7� =Y LEGAL DESCRIPTION Property Location -)LLL %., _9—G' V4, Sec. T-3JN -R--/,'P-W, Town of Ie Q M 6 Z , S.t T . Subdivision _ 1 ' dcA& & C & , Lot # IYA Certified Survey Map # . Volume . Page # Warranty Deed # x/ C& I , Volume tP,2 / , Page # 0 Spec house ❑ yes 1no Lot lines identifiable IR'yes ❑ 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 master plumber, journeyman 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. 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 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 & 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 9 lal0 S GNA APPLIC 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