Loading...
HomeMy WebLinkAbout032-2119-40-000 Wisconsin Departmentdf Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ` INSPECTION REPORT Sanitary Permit No: 463304 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: Hartman Homes I Somerset, Town of 032 - 2119 -40 -000 CST BM Elev: Insp. BM Elev: BM Description. Section /Town /Range /Map No. / O d- Q 0j 1 D 26.31.19.1086 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Benchrpafk M 7 /0 � /OD v osing N Alt Y t q �`U17 G �-a" w r-- 1 I • � Aeration Bld�wer � 3 - 3 V oo Y!; - 7 Holding y SUHt Inlet SUHt Oyllet— TANK SETBACK INFORMATION SU Zr 1 • �o�o TANK TO P/L WEL BLD Vent to Air Intake ROAD Dt Inle s Sep '7 , Dt Bottom � •�! Dosing 14 w j I Header /Ma 3 �• ra a Aeration u Dist. P' e L Holding B ot. Svst�na . Final Grade ZZ PUMP /SIPHON INFORMATION S• �( `�7 Manufacturer n y� Demand t Cover I2• GPM Model Number TDH Lift Fric 'o o System H T DH Forcem n L 1 0la. a Dist. o 7 II SOIL ABSORPTION SYSTEM q (0 BED /TRENCH Width Length No. Of Trench e PIT D IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '31 2 SETBACK SYSTEM TO JP/Lt, JBLDG WEL LAKE /STREA LEACHING Manutaetgre�: INFORMATION T e S stem: CHAMBER O M Yp Y � 7 / UNI Model Number. r DI IBUTION SYSTEM ' Bader/ anifo`d Distribution / ? x Hole S x Hole SpaSjng Vent to Air Intake (� Pipe / Pipe(s) - ! 2 C1 1 Length Dia Length Dia Spacing J ' ! SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only C d- Depth Over Depth Over j yx Depth of j xx Seeded /Sodded xx Mulched Bed /Trench Center • Q Bed/Trench Edges Topsoil ' Yes ] No Yes No D COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /�/� Inspection #2: Location: 1975 62nd Street Somerset, WI 54025 (NW 1/4 NW 1/4 26 31N R19 ) Pinecliff Lot 24 Parcel No: 26. 31.19.1086, 1.) Alt BM Description = Vg, eT "`O — C �C� cf _ 1 �-• 2.) Bldg r length - amount of cover = Plan revis information. Yes _ - I -- - - - - -- -- - - - - -- -- - _ __ -_ Req _�_ — VI Use other side for additional No ` Date Insepctoes! &g at Cert No SBD -6710 (R.3/97) Safety and Buildings DJyi ��+' Qn County 20. Washington Ave., >1�Bplic 7162 �consin 1 W "7jyy;(�� 1* Madison, WI 53707 — Sanitary Permit Number to be filled in by Co.) p De artment of Commerce (608) 266 - 3151 q& 3301- Sanitary Permit App ' n S tate Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, persona info t may be used for secondary purposes Privacy w, sF� Project Address (if different than mailing address) I. Application Information — Please Print A I Information , Property er's Name Parcel # Lot Blo OFFICE S� Pfo perty Owner's Mailij Address Property Location c %a, %, _ City, State Zip Code Phone Number Section T R o op�J (ci e N, II. Type of Building (check all that apply) v �f s , 1 or 2 Family Dwelling — Number of Bedrooms 4 all C I Subdivision Name CSM-PlnmbeF -- ❑ Public /Commercial — Describe Use ❑ State Owned — Describe Use ❑City ❑Vi ge_2�rownship of Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) ©3 2— _ 2I p _ 5 A* New System ❑ Replacement System ❑ Treatment/Holding Tank 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 apply) c 2 - S X 2. Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound 1 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 Steaching Chamber ri Lin!Z ❑ Gravel -less Pipe ❑ Other (explain) V. Dis ersaVrreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation y> f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons ofUni Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber ' VII. Responsibility Statement- I, the undersigned, assume rpoonsibility for installation of the POWTS shown on the attached plans. Plumb 's ame Plumber's Si at MP/MPRS Number Business Phone Number P umber's ddress (Street, City, tate, Zip. Code VI II. County/Department U se Onl Approved ❑ tr ed Sanitary Permit Fee (includes Groundwater Date Issued Issrr' g Agent Signature o Stamps) Surcharge Fee) Given for Denial ��"` IX. Conditions o pprov SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size SBD -6398 (R. 01 /03) �c IL ) h, NS co p - VU" CA i a KY, A TM ir �` �, v \ v 0 Ta AL Il k y Av i � I Wisconsin Department of Commerce SOIL AND SITE-E-VALUATION 3 Division of Safety and Buiidings Page of Bureau of Integrated Services in accordance with a. ILHR 83.09, Wi&. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches n.size. Plan 'rto include, but not limited to: vertical and horizontal reference point (8M), direction and' percent slope, scale or dimensions, north arrow, and location anc(< distance Aq { igarest road. Perc I I.D. # b t ST r RaX APPLICANT INFORMATION - Please print all info�tlon. COI;�ITv aev ed by Date Personal information you provide may be used for secondary purposes (Privacy; Law; s. 1 (ICE l / Pr erty Owner [ ` Pr ti n L r C /,' ��/l?/S /lir dvt 1 / /ylf/ 1/4,S T� j ,N,R�� E (or) Property Owner's Mailing Address Lot # Block# Sub Name or CSM# Ci State Zip Code Phone Number Near st Road ?OM&) 1 601 S (7/1) z �7 s�� ER ❑Village Town 24 il ® New Construction Use: ® Residential / Number of bedrooms r Addition to existing building ❑ Replacement L /� ❑ Public or commercial - Describe: -7 u Code derived daily flow U�v gpd Recommended design loading rate P / bed, gpd /ft • y trench, gpd /ft Absorption area required u' "`- bed, ft trench, ft Maximum design loading rate ®� bed, gpd /fit m trench, gpd /ft Recommended infiltration surface elevation(s) �0 �S ft (as referred to site plan benchmark) Additional design /site cons(derations i e d uflti4,f A/ Parent material � }� !7 g g Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U EX S ❑ U Zs ❑ U ®S ❑ U Ns ❑ U EIS 21 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 -�a /09 3 2 S Au -4 f� Cal ccu Em _5 Ground -7 , - 7, SA Yy /Y/� G��✓ /10SM �L C� O is tt. 2 J)b 7sy�'% 1 1 1 - / �7Z Depth to limiting , fat l�In. Remarks: Boring # 0 l0Y� w 2m .7 22 /p, 2 SL 14f6 X1*1/ c c-, -2 p, 3 22 -U 75M % lSdGr Znoe M I- C w I -P ,-7 , C� Ground I 111 5�j� m S Z_ s 7 ,a elev. 101,A ft Depth to limiting 3 factor 1 } '7111 in. Remarks: CST Name (Please Print) Sign re Telephone No. 7 Address Date J 2 CS /Z / V PROPERTY OWNER ! in e G l r I7 lCt /f . 4 $P 11_ DESCRIPTION REPORT Page of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 i - X9 1 W,12 Z s 11Ps6k / &A- cw 2 m 2 20 /D It �V NA SZ ms4e fi�411', c 4&1 z M + s �6 Ground 3 20 -26 7-Me / *4 S`► 61- lmsAe ynG c u Iv-P e7 0 � Z6 7sY� 5 Oms 1))z Depth to limiting �(p, 0& factor > 6 in. Remarks: Boring # �— v -// A L S l m sdk - 2p, . g y 11 -3 7syk % d(, ' Sb* Ali Ce, 2M -7 Ground elev. Depth to limiting Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tren Boring # �-`�` ��'f` �� L S pifkr Apf/ C ' S z 1- 16 /0Ye ', SL Ground 2-/Q 7, SA '4 ✓E / dtNs L — �� er� elev, ft. Depth to limiting ) fa i t in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 7 _ _ s ' 3 0 � 3 o . ; ' f N t �J l So n� -.f ed - l,4� Jr 1 13 etrrkc r s i t , f 1 - I , i : • i . r 4 r t : 1 t ! I •_ -_ _;_ : f _i_ ±- - ; T i S E PINE CLIFF FIRST ADDITION 7CATE0 01 PART OF THE NVI/4 W THE NVI/4, IN PART tr TIE SVI/4 W THE NV1/4 010 IN PART W THE 3EI/4 W THE NVS 14 r SECTIOI 24 T2K R19V, TOVN w SOtomr, ST. CROiII COUNTY. VISCONSM 60T. S Am i PLAT ! of SERENITY � L-- m i �P.1 , LOT 1 _ WTH - `- - -� -- - SEC OUP _ _ sDD 5555 c )337.•r wORT u NE Gr THE W LOO TM_ A1! Et!Slg sn 3oert sccnoN s< ---- -- - - S89 "E 508.31' - •-� I - - - -- - � f to ■«+Me ?- { I. OtON PIK i UM LATUw I1t1 1 tt: N1.3r 1 1 1 _ ;� 1 1 21 1 b I IZ I , - -- - 13uliis ACRES 1 3r , 33' i ( 19 AC) va_ �ti Pa 3o3s I � rn ( � 1 � k I 22 ----------------------------- 3.ou ACRES - ---- -- ------------ I Iwa O WN ER i m SCE NOTES :A ► t 13L130 so. FT. �, MICHAEL J. N RTNE ODA , �� , PINE CLITr PA PLAT OF PINE CLIFF I rO r - \/ (2.•3 AC) C/O HARTMAN HOMES INC. - ....- ....- .... -....- ► y 1 . 103 MAIN STREET I , SOMERSET, vt 5 1 1 19.7•./- L wou 1 n ----- - - - - -- 1 LEGEND I I 23 4,I 1MONLI ENT trOANTOr s[cT1oN CORNER 3011 ACNE$ R r. / 13L1.1 $o, FT. ;f * • 1• IN " PIPE rp" 0.01 AV 2' K 3r IRON PIK SET WEIGHING O 143 LIS. MEN LINEAR rOOT H • r IRON OVE rOUND ® NOTE ALL OTHER LOT CORNERS w wwwv 37 MONUN[NTED WITH P s 14• 1e.r•11- PER IRO L PI PE V IMy 7N LDS KR LINEAR TOOT ■1 ' ��, - N .... • • • • . • • .. • IOC RCIAVVAY SETBACK LINE Ir VIDE UTILITY EASEMENT i. J: 17I PROPOSED DRIVE 3. RES ( - ► -a- trunwo rcwcuHE (2.3t AC) •I \RV= D7D) HIGH VATCR LINE ELEVATION - USGS II 1 ( r, tgTE A WATER or T to ALTER T HE C APACITY / •T , T' y n is tK Slow VAT[R RETENTION AREA \ ) R i IS ►RPIDITEB 1 ` n MOTE t THE STORM ARE RETENTION WI ON AREA ` 26 3.t61 ACRES 1301 Ac) NET WUILDARIC AREA PER ACRE 14LO33 S0. rt. soHERSCT oa9nwNcE 11.2 ACRE MI w1MIHlM) 25 (31% Ac) \ ` 3293 ACRES 143AOt SO. FT. \ , r .•• . WED K) '••.,, •••••••••••••.. NOITH LINE Or THE SC )1C or T "V114 S8 •05'38" E 470.00' r low PIPE • '\, to.••.n USG � DATUM 1"9 � ` a \ r '' 1'` r[MCCLINE 13 0.6'• /- / saTM OrTHE LOT CONER 583'00' " 50.00''\ , 27 ` �'� .� •T ��• 3M ACRES 1 CA 1.153. So. n. (2.N AC) I ' O `� l O� (A/ .% Li LOT 8 \ \ j; 1 , 3.044 ACRES PLAT OF PINE CLIFF i \ 13L 6o3 So. rt. / .` _....- ....- ....- .... -.. i LOT 9 1 (1.77 AV .• •� 1 LOT 7 `� \ - -- -- 1 '^ ``% ``` U \ n i i EASTERLY NITS Or SU0.W DIN AREA �----__ -_ -- _--• -)-- 1- j ' PC* TO SOMERSET OR OR 1 RN SOMERSET • ?' (TOP SLOP[) 4AT M INSTALLATION VOULD 1 ) ) )31739 ACRES T. G A iry L OT LINE OR STREET LINE. 1 l\ (1.36 AC) VWLATION or SECTION IX3 SET rORTw ARE FOR THE SE U Or THE WNW TO SERVE THE AMA 0 STATE. COWTY. Awe T LOT I0 T• LOT SIM ACCESS TO PARCEL ETC.). 1 C4 •' 40 CONTACT TIE ST. CRO01 COUNTY i ,' 1 • T .~ • r 1 j 3.oa ACRES a 131913 So. FF. N (1.13 AC) •O fi I WEANING CHORD LENGTH ARC LENGTH TANGENTS 1 105-4 HsM 23r•••Iry 21317'""[ 1-47-V I" IV 11w S33••••4ry S66 1It.5••V Dow WAV S06 213 � ` - 1 110.43• III-3r SI3 S01-3V34 , LOT it » 5•v $17.71• 3310 N94VI.47 N3P01• 7 134.4Y 1.2.17' w31ro1•x•v N10•eI'37••c %' ' 1 n•1L3"v O'Ot.Sw D0• 53s.r "RAW N1o•OI.3r•E Sq•eo•OO•v Is5 IK.7r mom 27 NI9.31'.ry %' \ �6•Ir•V 173161• 17UV MS*3Y4rY N49'54*54•Y i - ``'• \ �•'IYV I91 -W I04.30• "40`31`34 N9r35•x 'v 1 7 - 46•v 1541' 13.36' 00110 Sol .00ro0'v POWTS OWNER'S MANUAL & MANAGEMENT PLAN. / o 2 FILE INFORMATI N SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al D Ni Permit # �3� Septic Tank Manufacturer ,F S ❑ N. DESIGN PARAMETERS Effluent Filter Manufacturer ❑ Nf - Number of Bedrooms O NA Effluent Filter Modal _ © O NA Number of Public Facility Units _ Pump Tank Capacity al ZI NA Estimated flow (average) gal/day Pump Tank Manufacturer �N;' Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer N Soil Application Rate Pump Model Standard Influent /Effluent Quality Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg /L 0 Sand /Gravel Filter E3 Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 6150 mg /L O Disinfection O Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) N!' Biochemical Oxygen Demand (BOD 530 mg /L in- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L 0 NA ❑ At -Grade © Mound Focal Coliform (geometric mean) S10' cfu /100,111 ❑ Drip -Lieu Q Other; ^ Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ Nt, R, Other: ❑ NA Other: E3 NA Other. Cl NA I "values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency ) Inspect condition of tank ❑ month(s (Maximum 3 years) ❑ NA s) At least once every: 8� asrlsl „ Pump out contents of tank(s) When combined sludge and scum equals one -third .%) of tank volume ❑ NA 1 months) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 0 year(s) I ❑ month(s) . ❑ N!, Clean effluent filter At least once every: years) _) ❑ month(s)Nh Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) ! Nl,. Flush laterals and pressure test At least once every: ❑ ear(s) Other: la month(s) D NA At least once every: O earls) Other: C7 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calls 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. GMW (4/0 ., .; of Page C;2 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(&) in one large dose, overloading the cell(#) 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'oporoting 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;; moat- 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 Pealed, • 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, REBCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLO POWTS MAINTAINER F Name Name Phone S - Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone 5 � 'his aocument was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code, ST. CROIX COUNTY S)tliMC TANK MAINTAINANClc AGREEM1cM AND OWNERSHEr CERTMCATR FORM OwnerBuyer I ►1 �i K,o �ax Mxiting Addressi 0 /E� Property Address (Vadficadan revuM& aexPlanniQgDegaetmmtfarnewoanattu�i. city/State �nl (��- Parcel Identification Number LEGAL DESCRIP'T'ION Property Location AJA /.,Nk) V. Soc.94 T31 N. It N Town of "� Prjr Subdivision �✓�L�, (i Lot# o� Certified Survey Map# , Voliane Page warranty Deed# , Volume Page Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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 frmction of the septic tank as a treatment stare 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, joumeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on- site wastewater disposal system is in proper operating condition and/or (Z) after inspection and pumping (ifnecessary), 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 th Department of Commerce and use the Department of Natural Resources, State of Wisconsin Certification stating that vow septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 10 days of the three year expiration date. sic N.ATuRE DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge I (.we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds ice. SIGNATURE OF APPLICANT DATE 919. " Any mfa m um that is m wepresnsed may rack is the eaoaary perms being revokedby the Zoning Departmm"' 00 include wah this applicam a armed wnrmsy died from the Rapdar of Deeds cEme a copy of the owafted o vy map if r>lbrmw awade in the watfrazy deed 9 - d 6t3Eir —LIZ (S i L l -p{veew 182ud e99:11 SD LZ UeC Jan 27 05 11:59a Rngel Maack (715)247 -4388 p.7 Cl fJ i i VT � M t � S 1 1 w I 1 i ► gov -- ---- --------- --- ---- ------ I KVI. 6 Wft tell •CK! its �Orts • • o 13LIn t0 rf. PLAT Or PINE CLIFF ro_ �� rt.As .c► e 1 I � I j 23 tr 3 011 ACIL k �. / NLI•e so rr � � 13.41 AC) w c r v �.n• � �•• trl.z•r l oose• , 1 1 �• A7 � n 1 ` 26 3r61 .c+lcs 14?m to TV. �4 25 , f34M K► 3.113 ACRES 143 ME so. rt. till AD r PVT j� ` f uses y It" 683'00`0 f ,�s s o. 00t LOT 0 1 / %` \ ' PLAT OF PINE CLIFF 1 \ I LOT 9 LOT 7 , 1 ' � I , S ' d BBE-lr-L*p2 (S TL ) -joeeW 192ud eBS : T I SO LZ UeC