HomeMy WebLinkAbout030-2082-50-000 ST. CROIX COUNTY ZONING DEPARTMEN
J i�C
AS BUILT SANITARY REPORT
Owner & U L ff %1 L 1 Al ftd[ E
Property Address 13 7 9 PINE f//jg�UJ T4 �--
City /State o u t- Ta a /,0,- .S yo f2 1999
Legal Description: ``'� zoNHYGO Fck
Lot A -15" Block - A(A Subdivision/CSM #
jfW 1 /4 dIE '/4, Sec. ,LS , TJILN -RAW, Town of Si: j ,r��_ pftO
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC ouse Well P/L
Pump manufacturer odel
A a ion
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to Water Line
Meter location
Al
SOIL ABSORPTION SYSTEM
Type of system: TaP n-C# Width 3 Length 75' Number of Trenches
Setback from: House ;7- 7 Well Ida P/L 4 f a , Vent to fresh air intake /OD'`
ELEVATIONS
Description of benchmark C'ow 9,4, LoT Elevation AV,0
Description of alternate benchmark & r o ftreA roar-- SLAB Elevation 4v 1 = 1
Building Sewer NA ST/HT Inlet IVA ST Outlet 5, PC Inlet - ' AM
PC Bottom Header/Manifold 7 y. ZG Top of ST/PC Manhole Cover
Distribution Lines 10 (2) 23, `j / ( )
Bottom of System !0 (2) 4 2 . y 7 ( )
Final Grade 0 (2) 27.
( )
Date of installation F 1141 Permit number ,3YyS8 7 State plan number
Plumber's signature License number _12, f 7 q / Date 2//.7/
Inspector 6:!. -
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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2- 3`X'75` in/G«r/1�roR TLE
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c''XrSrinrG- /000 GL S� ;r,
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: ST . IX
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)). 344587
Per am City Villa e Town of: State Plan ID No.:
`r*IVL1jP, P'AUL El J PH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
16 7 ILI O 030- 2082 -50 -000
TANK INFORMATION - ? ELEVATI N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 2, ( oac) Benchmark Z -�U f6Z,7d /06
osi n 44 5n
Aeration Bldg. Sewer '
Holding St/ Ht Inlet
TANK SETBACK INFORMATION 0' Ht Outlet
TANK TO P/ L WELL BLDG. Air I ntake ROAD D et
ir
Septic - 7� r f NA m
Header /Man. �•� 9y
Aeration N Dist. Pipe T
z '1
Holdi g Bot. System
Te R
P-rx jAJ2 4 .5T
PUMP / SIPHON INFORMATION Final Grade y •03 .6
Man cturer mand 3
Model Number GPM
TDH Lift L oss I System TDH Ft
ead
F main Length Dia. To well
SOIL ABS RPTION SYSTEM Z ��
BED / 3O E14M Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME 3 Z 1 DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma tur r:
SETBACK CHAMBER J.
INFORMATION Type O [[�� / ' q M del Num er:
System: .� 70 / Zi(/ <d r OR UNIT
DISTRIBUTION SYSTEM
Header/ Id rr Distribution Pipe(s) j x Hole Size x Hole Spacing Vent To Air Intake
Length - f = � Dia. Length � 1 Dia. �� Spacing If A111 7 � V(
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: ST. JOSEPH 25.30.20.702,NW,NE 1379 PINEVIEW TRAIL
3 IO R 1-1
s / � le* - I S Ae,4?1 vk teGr ✓dr 11 eje�u� 3(g. s ✓
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Plan revision required? ❑ Yes ❑ No -
Use other side for additional information. i � 1 2 , 11 1 f V i?T6
SBD 6710 (R.3/97) Date nspector's S a ure Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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V iscons i n SANITARY PERMIT APPLICATION 2 01 E. Washn
P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
10
• Attach complete plans (to the county copy only) forth p� less County
than 8 112 x 11 inches in size_ A.
• See reverse side for instructions for completing thi State Sanitary Permit Number
icat���Q
The information you provide maybe used by governm y�ograms r' ❑ Check if rew on to previous application
[Privacy Law, s. 15.04 (1) (m)] 6 / —t ,J` /f iC ( 1999 �
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRI T ALL INS TI01 --
Property Owner Name rt�jfLd2 tion
PAUL JC i 41 L ZoNI O 1 /4,; � 1 T 31 0 , N, R 0 E( W
Property wner's Mail' n Address ; - il�b�r Block Number
Ci State Zip Code Phone Number Subdivision Name or CSM Number
( ) ,
11. TYPE OF BUILDING: (check one) ❑ State Owned E] ity Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms _.3 ❑ Town OF 1A U
111. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s).:
1 ❑ Apartment/ Condo 6 - 3 0 '
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 online B, if applicable)
A) 1. ❑ New 2. A Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
_ System____,___ System____ _________TankOnly _____________ Existing System _________ExlstingSystem
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 30 []Specify Type 41 ❑ Holding Tank
12 NSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit l � 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) qcy,/ p " Elevation
5 - 6 u , . S ✓F e ' Feet
Ca acit
VII. TANK in allo s Total # of Prefab. _ Site Fiber- E
INFORMATION g Gallons Tanks Manufacturer's Name App concrete co " steel glass Plastic xper.
New Existing structed
Tanks Tanks
e ti nk loeo 42 d K ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibilit y for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) PI b is Signature: (N S tam M RSW Business Phone Number:
Dowaf-& 7
7 16'-,5'9 -6 s
Plumber's Ac dress (Street, City, State, Zip Code):
0
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuin n i na re (No Stamps)
A roved surcharge Fee)
pp ❑Owner Given Initial 7
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -63M (R.11196) 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.
if r i for tank replacement, reconnection, or r
on lin A. Complete line B per s o to e air.
IV. Type of permit. Check only one e p p p
V. Type of system. Check appropriate box depending on system type.
h 7.
VI. Absorption system information. Provide all information requested for numbers 1 through � q 9
p Y
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 1/2 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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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOP 11'I'MI ZATT(1N OF AN RXT r.T1N(. PE "I'1(' TANK
This is to certify that I have inspected the septic tank presently
serving the & at- 6 /A/ residence located at:
. AW 1/4, 1(jF 1/4, Sec. , T_N, R Town of
'5L r�BSEa/f Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: �QQQ
Construction: Prefab Concrete Steel Other
Manufacurer (if known):
Agez6f Tank (if known
0 jzMAa iN ��l'�frr TT
(S gnature) (Name) Please Print
p S . � LU /
(Tit e) (Licen e Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name �Giir �' Signature P/ PR 11 �7y1
5/88
l
,r. w " rbnent of lndusvy, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Relations
o�sarsty a Buildings in accord with II-HR 83.05, Wis. Adm. Code [PARCEL NTY
S Cr oix
Attach complete site plan on paper not less 1'� � i dkos In size• Plan must include, but I.D. 0
not Ornited to vertical and horizontal refer e�.p` !At (BM),'ditectloil' 9�e of slope, scale or 0 -2085- ' com nsioned, north arrow, and location nd distanc to r crest
d. ,;� IEWE BY TE
1 1,1 0ji4A'f�bN �9 $
4PPUCANT INFORMATION -PL X131: PRIN r�� UU
pql +gq;Y OWNFR ' PROPERTY LOCATION
` ~ � 1 � r1nV1 lrrl 1II4 1f rJl? 'a
1 /A,R T (1 •N.n 7( 1 7E
I pull 111 V 1 111 76Z /I� q�' 101 M 1111"* 0 t1111111 tJAMI INllt!1MM
pROIERIY oWNEtl�.a MAILING AU /yr 25 na Woodland Hills
1379 Pine View Trl. CITY VILLAGE ®TOWN NEAREST ROAD
:CITY STATE ONE�� ❑ ❑ Hudson, WI . 5401 "�)" St . Jose h
j New Construction use [
Residential / Number of bedrooms 3 [ ) Addition to existing building
k) Replacement [ ) Public or commercial describe 2
Code derived daily flow 450 gpd
Recommended design loading rate .5 bed, gpd /ft .6 trench, gpdt
�Absorpdon area required 900 bed, ft 750 trench, ft Maximum design loading rate . 5 bed, gpd /tt . Fz- trench, 9Pddt
it (as referred to site plan benchmark)
Recommended infiltration surface elevation(s) 94.10 & 92 55
Additional design / site considerations recommend use o f fl
Flood plain elevation, it applicable na
Parent material
S Suitable for System CONVENTIONAL MOUND IN GROUNQ PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
S
U. uitw ble for system C" ❑ U ®S ❑ u ®S ❑ u [ s ❑ u �] S ❑ u ❑ S fl U
SOIL DESCRIPTION REPORT
G ft
PD /
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Bed Ttenctt
Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
1 0 -11 10yr3 /3 none scl lcsbk mfr CIS lm .2 .3
1 sici lmsbk mfr gw lm •2 •3
2 11 -2 10yr4 /4 none
Grod 7.5yr4/6 none
fs Osg mvfr na na .5 .6
3 28 -9
etev. S L � s C'�s � rat � C✓a lV�
98.1 ft. 0 // /. Q 1 /4 oril L'
• f - /1 e
ng .� 11er�'�y 1 C S 7 d .2 7 q,) 9
factor /
Remarks:
Bang fr
n # lc . 2 i . 3
1 0 -18 10yr3 /3 none scl lcsbk gw
sicl 2msbk mfr gw lm .4 .5
` 2 2 18 -40 10yr4/4 none
I� 3 40 -84 7.5 r4/6 none fs sOg mvfr na na .5 .6
Ground y
elev. ,Ste II1 0 / —
9 10 ft.
Depth to A � A
ling G S r"�' ,71.? 7 S/d
- 77 rrt S'c z _ /� G� �.�t- , � � , ,s/— S,
4// Remarks: G s �9 -. c' -0
CST Name
: -- Please Print G L. Steel
Phone: 715- 246 -6200
Address: 1554 200th. New Riichmo d WI 54017 CST Numbet- m02298
Hare:
Signature: OQ
PROPERTYbWNER Paul Kivlin SOIL DESCRIPTION REPORT Pk
PA&A IA: # 030 - 2082 -50
' Depth Dominant Color Mottles Texture Structure Consistence Bour,3y Roots G 11
Boring # Horizon In. Munsell tau. Sz. Cont. Color Gr. Sz. Sh. 1. Bed
3 1 0 - 18 10yr3 /3 none sicl 2msbk mfr gw Ic .4
2 18-37 10yr4 /4 none scil 2csbk mfr gw lm .4 .5
I�IIIHIN)
1 It till 1 - 1 'iY l .1 /1'. � �..� �. f r, I ln. l mull I In 11 1 t . 6
Neu.
Q(Z. 3 1t• �
Dep th to
Imitlng
. lector
+88
Remarks:
Boring #
Onwnd -- - -1 - - -- --
elev.
ft.
IMtlr
lector
ii Remarks:
I Boring #
LJ
I
i
. Ground
slat►.
ft. — —
Depth to — —
limiting
factor
I
Remarks:
Boring #
Li
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b
Ground
j elev.
Depth n.
I —
Remarks: -- -
can enn�re'f nernm
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STEEL'S SOIL SERVICE
va � ry L. Steel 1554 200th Ave.
,'bSTM2298 Paul Rivlin New Richmond, WI 54017
MPRSW -3254 NWkNEk S25- T30N -R20W (715) 246 -6200
town of St. Joseph
1 1 oh #29 - Wcndl and Fli 1 1 s
N
1 =40'
EM.= concrete base of clothesline pole C el. 100'
Alt. &4. =NW corner of concrete slab @ el. 101.10'
b
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�y Gary L. Steel
5 -22 -98
. 137 9
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Wisc onsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
tabor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper nrdistance 22z 11 i in size. Plan must include, but St. Croix
not limited to vertical and horizontal rBM) dtrecti'oW And % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and locatitorest {o¢�i. ;'� 030- 2085 -50'
APPLICA NT INFORMATION -PL '�!] ORM31��bN REVIEWS BY �P
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PROPERTY OWNER: ` 4 PROPERTY LOCATION
Paul Kivlin y. `, * GOVT. LOT NW 1/4 NE 1i4,S25 T 30 ,N,R 20 - (or) W
PROPERTY OWNERS MAILING ADDRE � LOT # BLOCK # SUBD. NAME OR CSM #
1379 Pine View T . 1 i, VG 25 na Woodland Hills
CITY, STATE ZIP DE "; PHONE NUM EJCITY ❑VILLAGE ®TOWN NEAREST ROAD
Hudson, WI. 54016 ` ' / St. Jose h Pineview Trl.
(] New Construction Use [ xJ Residential / Number of bedrooms 3 [ ] Addition to existing building
jc] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd /ft .6 trench, gpd /ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate .5 bed, gpd /ft .6 trench, gpd/ft
Recommended infiltration surface elevation(s) 94.10 & 92.55 It (as referred to site plan benchmark)
Additional design / site considerations recommend use of infiltrators
Parent material outwash Flood plain elevation, if applicable nA It
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 06 El CA ❑ U IRS ❑ U E2 ❑ U AD S ❑ U EIS E7 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0 - 11 10yr3 /3 none scl lcsbk mfr cs lm .2 .3
2 11 -28 10yr4/4 none sicl lmsbk mfr gw lm .2 .3
Ground
3 28-90 7.5y r4/6 r4 6 none fs Os g
mvfr na na .5 .6
elev.
98.1 ft.
Depth to
limiting
factor '
+90"
Remarks:
Boring #
1 0 -18 10yr3 /3 none scl lcsbk mfr gw lc .2 .3
2« 2 18 -40 10yr4 /4 none sicl 2msbk mfr gw lm .4 .5
3 40 -84 7.5yr4/6 none fs sOg mvfr na na .5 1 1 .6
Ground
elev.
98 ft.
Depth to
limiting f� /g
factor
+84"
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. j ka,. New Richmo d WI 54017
Signature: Date: 5 -22 -98 CST Number: m02298
PROPERTYOWNER Paul Kivlin SOIL DESCRIPTION REPORT Page 2 — of3
PARCEL I.D. # 030 - 2082 -50
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
` 1 0 -18 10yr3 /3 none sicl 2msbk mfr gw lc .4 .5
} 3
2 18 -37 10yr4 /4 none scil 2csbk mfr gw lm .4 .5
Ground 3 37 -88 7.5yr4/6 none fs Osg mvfr na na .5 .6
elev.
9 6.3 ft.
Depth to
limiting
factor `f s
+88"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
f
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Paul Kivlin New Richmond, WI 54017
MPRSW -3254 NW4NE4 S25- T30N -R20W (715) 246 -6200
town of St. Joseph
lot #25- Woodland Hills
N
1 " =40'
BM.= concrete base of clothesline pole C el. 100'
Alt. BM. =NW corner of concrete slab @ el. 101.10'
4� 6 A5
's VI
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fl
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�y Gary L. Steel
5 -22 -98
i
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer PAUL 6 1 UCIA(
M1011ii n....... ►.n . 1371....
Property Address 5ArT'e
(Verification required from Planning Department for new construction)
City /State 1-113 "g_ o At /.yi' Parcel Identification Number d' 3B --- ZQ 8�'-5'jQ
LEGAL DESCRIPTION
Property Location " ` /a, `/4, Sec. T d N -R 4 QW, Town of S ?. &gW IJ
Subdivision t&64 Q l A nclj A - LGS. , Lot #
Certified Survey Map # 3_ , Volume _ , Page # 1 0
Warranty Deed # 9/ 7 , Volume So , Page # L111z
Spec house ❑ yes ®no Lot lines identifiable 0 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 wastewaterdisposal 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.
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 three year expiration date.
2 / /q
SIGNATURE OF AP LICANT 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.
7 a 5// 9
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis-re presented 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
4 r
ooc !rnFNT NO WARRANTY DEED ,•.: E et.,.�,> Ev ,<q
STATE BAR OF WISCONSIN FORM 2 -1982
491677 ►,,� 98:1.PI 4 REG I$TER'S OFFICE
Brad A. James and Susan E. James,
$T. CWIX CO., WI
husban ' and wife, Ree for Record
NOVI 7M2
:j 10:30 A
conveys and warrants to Paul T. K1Vlln af,d ?hs'tl °.' y•... - a C y ""''K/�/f.
Culbert, as }pint nants and not as
in - common..
the following described real estate in St. .Croix County, -
a
State of Wisconsin:
'_ Tax Parcel No: ... ...........
j
Lot 25, Woodland Hills in the Town 4
li of St. Joseph, St. Croy County,
Wisconsin.
i
This .- ___ls_.. _. homestead property.
i (is) (is not)
Exception to warranties:
!1
Subject to easements, reservations arnl rFa--rictions of record.
Dated this day of NC : eTtiber
(SFAL) (SEAL)
•
BR&D JAMES.
(SEAL.) (SEAL) =1
SUSAN E. JAMES • �.
ij
AUTHENTICATION ACKNOWLEDGMENT
jl Signatur_(s) ------- .......
STATE OF WISCONSIN
111 ... .. -- --- ---
----•- Wit. Croix . - ss
County.
-------- -- - - -- -- - --- -- • ` I
authenticated this _. - - -- -day of --- .------ . . ..... ...... 19 ------ Personally carne before me this ._ ------- ... _.day of
-f.
No 19.y�... the above named
• ------ ...•--- -- ------ ---- -- - - -
Brad A,. E SusaiZ- E.-- Js- mes --------
._
•
TITLE: MEMBER STATE BAR OF WISCONSIN ..... _ -_ -_- - -_ -_. _ _ . - - --
{ (If not, -- -•-- ----- . -. - - - -........... - ... ' - -- - --------- --- ... .. -- --------- -
f
authorized by § 706.06, Wis. Stated r +" �h kn)wn to be the person s ... -. who ho er.,-uted the
t ,
zyroistg instrument and acknowled¢e file same.
THIS INSTRUMENT WAS DRAFTED BY . o
�j STEPHEN J. DUNTAP
` Hudson, Wisconsin r '• °r Public St. Cir _- _ Count, R is.
i ouin on is perman
issient.(If r statt r <piration
(Sigt.atures may be authenticated or f: know .,. o3`y,� s 1'
i are not necessary.)
........ -----
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