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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer a� r P , t Y ,
Mailing Address
Property Addres r l Gk'
(Verificati;on required from Planning Zoning Department for new construction.
g g P )
City /State Parcel Identification Number 6 2v - / ��Y.(' - !�eU - 6 , j v
LEGAL DESCRIPTION
Property Location S� '/4 , 4t„i '/4 , Sec. T N R W, Town of 1-16ID S61j
Subdivision Plat: V `�/ ifiy�/� , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # 7�O S Y (before 2007)Volume -276 Z Page # a/o
Spec house i yes :bxo� Lot lines identifiable es l no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, jourileyman plumber, restricted plumber or a licensed pumper verifying that ( I ) 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 Planning &
Zoning Department within 30 days of, the three year expiration date.
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.
Number o ' bedrooms_ V � W'_ 6 /� /�
SIGNAT RE OF PLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deeO.
(REV. 08/05)
i
ST. CROIX COUNTY ZONING DEPARTMENI,-�"7__r`- ,,
AS BUILT SANITARY REPORT
Owner d MAW,-,
r ,.
Property Addre s 8"G-7
City /State �L •ts>d /c� ; < 3�0 / C v c v
Legal Description:
Lot Block Subdivision/CSM #
.s% '/4 XV u) ' /4, Sec. y, Tgj N -R& W, Town of i-,lg_ Q s'o,� PIN # _ � � C �Grl�1
SEP T IC TANK DOS CHAMBER HOLDING TANK INFORMATION
N -- E --
Tank manufacturer 1);7, -d e i e s Size ST/PC ! o Setback from: House .9,4 Well P/L
Pump manufacturer o v i ,/S' Model /i
Alarm location ,moo
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: r v Width ! �' Length _ 5 Number of Trenches l
Setback from: House - 7 ' Well X1 P/L -3Q' Vent to fresh air intake
ELEVATIONS
Description of benchmark 1 rf 0 1 S -' �� ��/ ,�' `1 Elevation 1 ,
Description of alternate benchmark Elevation
91
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines () () ( )
Bottom of System O O ( )
�< S
Final Grade O O ( )
Date of installation. Permit number �d ? 7�� Z-e> State plan number -
Plumber's signature ��.�� - License number .7'A Date
Inspector <JZ-
Complete plot plan �
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
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INDICA E NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermi IX
3389 8
Personal information you provice may be used for secondary purposes [Privacy LaV s.15.04 (1)(m)].
Perroit}{ftjkNarrLQ� RY El Cit 9 Vil16 Town of: State Plan ID No.:
CST BM Elev.. MA Insp. BM Elev.: BM Description: U SU1V Parcel Tax No.:
020 - 1045 -90 -000
1 CNo
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAP 2- STATION BS HI / FS ELEV. ZZ
eptic as ' 7Be r 0 •Y l elb
Dosing Aeration Bldg. Sewer , Holding StInlet 12-0
TANK SETBACK INFORMATION St/ Outlet ( TO
/
TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet � 2 .�j C' /. 0 03 /
_ ir
Septic $O / ��� 2, "? ` Dt Bottom /5-.
Dosing T-0 NA Header /Man. (1-0
Aeration A Dist. Pipe 6.7L1
Holding Bot. System - 7
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number C� YO GPM
TDH I Li � Friction System TDH� t
H
Forcemain Length ? ' 1 Dia. Dist.ToWell
SOIL ABSORPTION SYSTEM 2 fo L
ED BENCH Width u Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid De h
EN I N Zy 2 j DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma urer:
CHAMBER
INFORMATION Sy tcro 1 . � 7,p! f CIO OR UNIT el Number:
DISTRIBUTION SYSTEM
Header / Manifold y I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length A 1 Dia. Length 3 f 1 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 xx Mulched
Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 19.29.19.177S,SE,NW 867 TAMARACK LANE
WA
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Plan revision recI lred? es No Use other side for addltlo rmatlon. SBD -6710 (R.3/97) Date Inspector's Sign ure " — ! PetN,.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Visconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 Box Washington
Department of Commerce n accord with ILHR 83.05, Wis. Adm. Code
Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. >
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 3%-9 28'
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
IPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 000 ""
Property Owner Name Property Location
1/4 1 W 1/4, S Q T,2 , N, R E (or) /,
P operty ner's Mailing Address Lot Number Block Number
�4.tZ
City, State Zip Code Phone Number Subdivision Name or CSM Number
L
T YPE F BUILDING: (check one) ❑ State Owned 0 C it y Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms K Town OF AW lOA) ac e
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 101, Zq • 1 q. 778
1 ❑ Apartment/ Condo w o " oft6
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2 gi Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
------ System ..... System - __ Tank Only ________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound ( �Q ❑ Specify Type 41 [] Holding Tank
12 C] Seepage Trench 22 [] In-Ground Pressure X J6 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION: W ( 4'S:$z)
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 15. Perc. Rate 6. System Elev. 7. Final Grade
�, Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) er4- Elevation
$ w Capacity
f r � /V Feet 9I yS Feet
VII. TANK in allo s Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
eptic an r�k _ a go - d �i!v41 1:1 El E] 1:1 ❑
Lift Pump Tank ip tuber /� 0 Qd J/ ❑ 1 1110 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatur (No Stamps) M /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
G
IX COUNTY/ DEPARTMENT US ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Z /Z ) e Issued Issuing ent Signature (No Stamps)
+.
Approved ❑ Surcharge Fee)
Owner Given Initial ��
Adve Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------=-----------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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PUN',P CHAMBER CROSS SECTIOIJ AMC, SPECIF IcA r10�jS
I
VE IJT CAP
`"C.I. VENT PIPE
WEATHERPROOF APPROVED LOCKIAIG
Z5� FROM DOOR,
JUIJCTIOAI BOX MAMHOLE COVEF,
WIMDOW OR FRESH 12 "MID.
AIR IMTAKE
I
GRADE
I 18" MI M.
COIJDUIT --
18 "MINI. ---- - - - - --
\ 11l
ID LET PROVIDE
AIRTIGHT SEAL
_T
I I \*
* A
I
I I
I I i f ALARM
15 II
i I
c *APPROVED i aD
JOINTS WITH I I
ELEV. F r. APPROVED PIPE
3' ONTO PUMP OFF
D SOLID SOIL
COMCRETE BLOCK
RISER EXIT PERM11TED OWLy IF TAUK MAWUFACTURE:R HAS SUCH APPROVAL
SEPTIC E SPECIFICATIOUS
DOSE
TAWKS MADUFACTURER: /WYuJ ' ,/
NUMBER OF DOSES: PER DAy
TAIUK SIZE: _ d?2!)lh GALLOWS DOSE VOLUME
ALARM MAWUFACTUFMR: A -v a In IKICLUDIUG BACKFLOW: fSY GALLON'
MODEL NUMBER: IN y CAPACITIES: A= -Wlf
IMCHES OR 5i3.� GALLOAI.
SWITCH TYPE: IVeYc- '/ ,
B =— � _IAICHES OR 7/ GAlL01J.
PUMP MADUFACTUREK: °4 C = 15 IUCHES OR 1- GALLOU!
MODEL DUMBER: _ D= IMCHES OR _zya'u
SWITCH TYPE: fAlGr/'c MOTE: PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE °/� GPM INSTALLED OU SEPARATE CIRCUITS
VERTICAL DIFFERENCE DETWEEU PUMP OFF ADO DISTRIBUTIOU PIPE.. FEET
+ MIUIMUM NETWORK SUPPLY PRESSURE FEET
+ FEET OF FORCE MAID Y ' -Z F /IUOFLFRICTI 0 W FACTOR._ ��o FEET
TOTAL Dy1JAMIC HEAD FEET
I
i
IMTERUAL DIMEIJSIOWS OF TANK: LEAIGTH ;WIDTH -;LIQUID DEPTH ,r1 /•9e� d I ��
4
SIGIJED: LICEOSE ► JUMBER:
DATE: 6 9
! _T
:. Goulds N: (, or— t;
Submersible
- Effluent Pump
3871 EPO4
EP05
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
• Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas-
• Homes components. Available for automatic and tic cover with integral handle
• Farms Motor manual operation. Automatic and float switch attachment
• EPO4 Single
or 230 n le phase: 0.4 HP , models include Mechanical points.
•Heavy duty sump 11 V 60 Hz, 1550
• Water transfer Float Switch assembled and ■ Power Cable: Severe duty
• Dewatering RPM, built in overloa with rated oil and water resistant.
automatic reset. preset at the factory.
• EP05 Single phase: 05 HP, ■Bearings: Upper and lower
.
SPECIFICATIONS FEATURES heavy duty ball bearing
115 V, 60 Hz, 1550 RPM, construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller Thermo-
• Solids handling capability: automatic reset. plastic Semi -open design
'A' maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
• Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association
• Total heads: up to 24 feet. with three prong grounding 0 EP05 Impeller. Thermo- `
• Discharge size: l' /z' NPT. plug. Optional 20 foot (CSA listed model numbers
• Mechanical sea(: carbon- length, 1613 SJTW with plastic enclosed design for end in "F' or "AC ".)
rotary/ceramic- stationary, three prong grounding plug improved performance.
BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104 °F (40 °C) continuous superior strength and
140 °F (60 °C) intermittent. corrosion resistance.
• Fasteners: 300 series Mt -=TIERS FEET
stainless steel. 10 1
• Capable of running
dry without damage to s 30
components.
Pump: EP05 8
• Solids handling capability: c 25
maximum. W
• Capacities: up to 60 GPM. X s 20
• Total heads: up to 31 feet.
• Discharge size: 116' NPT. z 5 • Mechanical seal:
carbon-0 15
rotary/ceramic - stationary, _j 4 i
BUNA -N elastomers. o
• Temperature: 3 10
104 °F (40°C) continuous , !
i
140 °F (60 °C) intermittent. 2
5
1 i
J 0- 0 0 10 20 30 40 50 GPM
L_
0 2 4 6 8 10 12 ml/h
CAPACITY
®1995 Goulds Pumps, Inc_
r
Wisconsin Qepartment of Commerce SOIL AND SITE EVALUATION
Division•of. Safety and Buildings Page l of _
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and -5-v2, yp 4 X
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. R Ned by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). y
Property Owner Property Location l �
Govt. Lot 114lj 114,S /!�! T Qel ,N,R E (orX9
Property ner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number
❑ City ❑Village ®Town Nearest Road
A/A el- g o'd 14d, , 1 1 (71 )J'f6 - F3�f3 # a d Aj A ma v fi v e-
❑ New Construction Use: ❑ Residential / Number of bedrooms l y Addition to existing building
X Replacement ❑ Public or commercial - Describe:
Code derived daily flow 06 gpd Recommended design loading rate e 7 bed, gpd/ft - OF trench, gpd /ft
Absorption area required 57 bed, ft 7 S 6 trench, ft Maximum design loading rate 7 bed, gpd/ft � gp
trench, d /ft
Recommended infiltration surface elevation(s) ys + ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material ,1A C'`_ / el i,2t �41a 9 io� Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank
U = Unsuitable for system I R] S❑ U ® S ❑ U Xs ❑ U Rl S ❑ U EIS ®U ❑ S [24 U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GP.D /ft
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
/ o -iA /e R 4
a a a 6 J &VOce c S A 7 r
Ground S COS — c
�lev.
Depth to
limiting
factor
Remarks:
Boring #
1, 5 .1 ma y pr= c -7 .7
a a2 r / -(aZ ei' S 5
( 7.
Ground 2
elev.
Depth to
limiting /
factor
/,") _in. Remarks:
CST Name (Please Print) Signature Telephone No.
a
Address Date CST Number
PROPERTY OWNER AMR T,'Al SOIL DESCRIPTION REPORT
Page
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1-5
Ground R4 , e G a s' RS CGS Q 5 — — 7
e l , ev.. _,,,
Depth to
limiting I
factor .
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
...........................
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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DOCUMENT NO. STATa - BAR OF WISCONSIN —FORM 3
QUIT CiAlIM DEED
3 1 ► ThlS SPACE RESERVED FOa RECORDING OATH
VOL 61-0
REGISTERS OFFICE
_ ST. CROIX CO., WIS.
M chew J. Martin Roc'l for Recor4 tNs__ 213t
quitclaims to Mary C. Martin doy of Apcll A,(3. 14
- -- — at 8: 0 A M.
the following described real estate in St. Crofx _County,
State of Wisconsin: n To
Doar, Drill, Norman,
Bakke, Bell & Skow
New Richmond, WI 54017
Tax Key No.
A tract of lanel in the Southeast Quarter of the Northwest Quarter
(SE'!t of NUN), section Nineteen (19) , Township Twenty -nine (29) North,
Range Nineteen (19) West, described as follows: Commencing at the North
west corner of the Southeast Quarter of the Northwest Quarter (SEh of NW10
of said Section Nineteen (19), thence South 87 41' East 150.2 feet; thence
South 7 East 201.7 feet to the POINT OF BEGINNING of the tract to be
described; thence South 38 East 229.5 feet; thence Southwesterly 125
feet to the Easterly right of way line of a proposed town road; thence
Northwesterly 230 feet along the Easterly right of way of said proposed
town road; thence Northeasterly 126.5 feet to the POINT OF BEGINNING.
FEE
This lS homestead property.
(is) (bq;O *
9 Dated this t day of April I9 8 .
l
_ (SEAL) J"/�VAC (SEAL)
`Micheal J. M rtin
(SEAL) (SEAL)
; AUTHENTICATION ACKNOWLEDGMENT
j Signatures authenticated this-----day of STATE OF WISCONSIN
' 19_ �ss.
St e O ro i County.
Personally came before me, this day of
• ��.__,_. _ A pri1 ___L 198 0 the above named
TITLE: MEMBER STATE BAR OF WISCONSIN Micheal J • Martin
(If not, —
authorized by § 706.06, Wis. Stats.)
This instrument was drafted by
Gary L. Bakke tv.-RRe.krAl t'.jo be the person.— who executed the fore-
.• �
g ping 1'nstrukeirq and acknowledged the same.
Bell & Skow rx
New Richaard _5_4411_
Signatures in y Le autne ; cated or acknowledged, Bath ,.. aryPuhlie'' �� �f _ County, Wis.
are not necessary.} tAy,4 s:. n is permanent. (If not, state expiration
date: _, 1r;
t ir)n, St, Croix Cokmty, Wis. R
QMT. CLAN 7Er.V- STATE: SA,2 OF k?SCCrN >jN. FOwy
I
` ' h ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Mailing Address _ r�� T �.�, � l;� ,� �lS� �i //
Property Address S'a /.� z -e_
(Yercficatioa rcquirrd from Pluming Department for new coastructioa) n
City/State _ S �e�� CJ ( r Parcel Identification Number _ Q,�w /d"/ S — 9,0 -- o o d
LEGAL DESCRXPUON
Property Location S %, '�JA) y, Sec. T AR W Town k
_ ZN Subdivision Lot
Ce 7 ified Survey Map # Volume — . Page #
Warranty Deed —�17 Volume 4"' 4� . Page #
Spec house ❑ yes 01 no Lot lines identifiable ❑ yes ❑- no
SYSTEM-AFAR
MNANCE
��' DP ��� cof y� r KPti+ esysGcmooald�cltmitspc�atatic�a�iuctoLandlewastcs .Propermaimbcaa�c consists of pumping out the septic tank cvMy &= yc= err zoom if vended a[ ]incased
' Whit
can. :ffed�ie farLCtica of the � - you put-into the sj►stcm -
septicfiaalcas -i tccatmr,�tst:ge is tie �astcsysbcai, . - - - -
VIC ScPatY owner agr= to sabmi St: Quiz Z Dement i cer f estion form. signed by tin owner and by a
P yataapl c odplamberacsl' ieea9edgampervrnfS+ iag�at( t) tbeoa -sitaivastewaterdisoSalsystem-
is proper operating condition aadlor(2) after inspection tad pmapmg (if necessary), the optic• tank -is less d= M W of dodge.
. LSM. & C gnedhm -mad &c above tvgu¢=cats and agroe to maintain the pci at o mwne disposal system wig 6u standards
set fart, herein„ u act by t,5c Departna t of Gl=m=e and the DTaztment of ISairaxl Resoarncs State of Wrscansia.. Qcrtr'ficatioa
- that your uP� � has b� maiataincd mast be oompl�eLed and rctamed to the St. taioix.
days of the throe ' date.. County Zoning Office within 30
7/ `1
SIGNA APPLICANT DATE
OWNER• CERTMCATTON
I (we) eatify that all stag on this form are true to the best of my (our) knowledge, I (we) am (arc) the owncr(s) of
Property above, by virtue of a warranty deed recorded in Rc&w of Deeds Office.
� AP r.ICArrr
DATE
«ss «ss 'Am infotmatioa drat is mis ma s sssss
-rcgmxcatod y t+�u1t is the sanitary pccmit bang revoked by the Zoning Depactmeat.
ss Include with this application: a tramped wactaaty dood fiom the Register of Deeds of floc
a Copy of the certified twcy map if reference is made in the warranty deed