HomeMy WebLinkAbout004-1043-90-000 ST. CROIX COUNTY "ZONING DEI'ARTME'"
AS BUILT SANITARY REPORT
Ow e r
Address a7,-,k3
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City /State ft
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Legal Description: , c
Lot Block Subdivision/CSM # yp /9�rPp
Y, St1 V. `) Sec. Z5—, T Z8 N -R 15 W, Town of (f�-d2y PIN # O 4 -AP V3- 9m -OD
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: A? /5"
Tank manufacturer Size ST/PC /vao 1 7Sa Setback from: House Sri ' Well B 7 ' P/L
Pump manufacturer go, I1 Model 0, 5
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: ryes -� Width 6" ° Length Number of Trenches �
Setback from: House -2? e. ' Well 9.y pIL Vent to fresh air intake 12
ELEVATIONS
Description of benchmark _ > -',ye' f' i c Elevation
Description of alternate benchmark Elevation
Building Sewer /6) ST/HT Inlet _ /vd'. 18 ST Outlet • /O,V y3 PC Inlet
PC Bottom _ 8 58 Header/Manifold /O -", 5 V Top of OT PC Manhole Cover 11Z- 02
Distribution Lines ( ) /o 6, 5�/ ( ) ( )
Bottom of System ( ) fU�, d 2 O ( )
Final Grade ( ) ( ) ( )
Date of installation ! 1 9 l1�f� Permit number 3159 5.5' State plan number //Z 36s'
Plumber's signature w... License number Date I /
e
Inspector
p complete plot plan
i
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
Y aT
•
X 50 5
INDICATE NORTH ARROW
V111 Department of Commerce PRIVATE SEWAGE SYSTEM Count y=
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 315935
.
Permit Holder's Name: ❑ Cit p Village Town of: State Plan ID No.:
WRIGHT, MICHAEL db
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
3 %'` 040- 1043 -90 -000
TANK INFORMATION ELEVATION DATA A9800323
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic W lieS e Bench ar .
113.1
Dosing v " J 1 7M N 2� f5 �3 Alit It3. f /
Aeration Bldg. Sewer 1, 4 4 -as'
Holding N Inlet 11`� l +61
TANK SETBACK INFORMATION 0 Outlet 1( �' t
I
TANKTO P/L WELL BLDG. Air to ROAD Dt Inlet
irntake 1 it i1 )z
eptic� �r NA Dt Bottom t ( 1
14G'6
Dosing N NA Header / Man. J C 3422
Aeration NA Dist. Pipe 1113•iL. -7 f ,.S-f-> ft ,5_4
Holding Bot. System (I a - 81
PUMP/ SIPHON INFORMATION w�a>< Final Grade
Manufacturer Demand /-1 .0;), G f2 1214
Model Number VD GPM L C t44.
L FcemLaiin H Lrictiorr> �, Syste TDH 77 Fi Length Dia. �'� Dist. To Well
SOIL ABSORPTION SYSTEM
BED / ENC Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN S 7T 1 DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHIN cturer.
INFORMATION Type O l CHAMBE Model N ber:
SysterWou n.e r LOO (�� iw( OR UNIT
DISTRIBUTION SYSTEM
Header/ i r Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake
Length t Dia - Z Length y Dia. _ ) _ V 7 - Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over ri Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
r.
Bed /Trench Center O 125 Bed / Trench Edges Z ` Topsoil r Yes ❑ No Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) r, ,
q� Z Il 1 U 1� D2
LOCATION: CADY 19.28.15,SW,N 2723 27TH AVENUE
Ho -Ko�t'
cn
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspec 's Signature Cert. No-
P
. Safety and Buildings Division
SANITARY ITARY PERMIT APPLICATION 2 01 W. Washington Avenue
�Vrsconsrn In accord with ILHR 83.05, Wis. Adm. Code Box 7302
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. Y'
• See reverse side for instructions for completing this application State Sanitary Permit Number
y ou p rovide may be used for secondary Personal information
y p y purposes ❑Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Propert Lo ation
/'� i�(�i..Jt/I 1/4 fh,� 1/4, S ` T ZB N, R
Property Owner's Mailing Add% ss Lot Number x Block Num er
.1 ?9 3 v2 7 /�u-e A/ 14' A
City, St Zip Code Phone Numb } r Subdivisio N ame or CSM Number
J�/ a–)z -I VI 2 ( ) N 4 A ofne
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
❑ Village �7 7 "-# Public 1 or 2 Family Dwelling - No. of bedrooms __ Town of
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers)
1 ❑ Apartment/ Condo 0#6 - 1043 ' �p
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 tine B, if applicable)
A) 1 New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System -- ------------- Tank Only -------------- Existing System ________ Exl -- S -rstem
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 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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. 1 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
39 -7 3 3 2— /05 Feet /v s Feet
Capacit
VII. TANK in gall Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App
New Exist � � strutted
Tanks Tanks i
Septic Tank or Holding Tank 1400 ❑ ❑ ❑ ❑ ❑
Lift Pump ank /S Chamber 7-4o �-- 513 e Col El 11 ❑ 1 : 1 P P
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb Name: (Print) _ Plumbe 's Signature: (No mps) Business Phone Number:
Plumber' Addr (Street City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved nrtary Permit Fee (includes Groundwater D ate I ss ue UZ (No Stamps)
�
Approved Owner Given Initial Surcharge Fee)
%�� ,
Adverse Deter mination /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD 6398 (R.11/97) 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.
VIE. 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.
Vlll. Responsibility statement. Installing plumber isto 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.
Michael Wright - Mound
Transaction # 112305
Location: SW 1/4, NE 1/4, Sec. 19, T 28 N, R 15 W
Town: Cady
County: St. Croix
Date: July 8, 1998
Owner: Michael Wright
Address: RR 2, Box 119 D
New Richmond, WI 54017
Plumber: Roger Timm
Signature:
License # MPRS 26524
Attachments: 6748 -Plan Review Application
SBD 8330
page 1: cover
2: calculations
3: plot plan
4: system cross section
5: plan view, lateral detail
6: pump tank exit detail
7: pump curve
page 1 of 7
0 AY
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Safety and Buildings
2226 ROSE ST
LA CROSSE WI 54603 -1905
I�consin Tommy G. Thompson, Governor
Department of Commerce William J. McCoshen, Secretary
July 08, 1998
CUST ID No.226524 ATTN: POWTS INSPECTOR
ROGER L TIMM
3128 20TH AVE
WILSON WI 54027
RE: CONDITIONAL APPROVAL Identification Numbers
APPROVAL EXPIRES: 07/08/2000
Transaction ID No. 112305
Site ID No. 13448
SITE: Phase refer to both identification mimbers,
Site ID: 13448 above, in all correspondence wit ei agency.
St Croix County, Town of Cady
SW1 /4, NEIA, S19, T28N, RI 5W
Michael Wright
FOR:
Description: Mound
Object Type: POWT System Regulated Object ID No.: 28208
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Adm. Code.
0 Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely,
� /� \ � / / J� � DATE RECEIVED 07/06/1998
,�ttv FEE REQUIRED $ 180.00
RARD M SWIM , POWTS PLAN REVIEWER FEE RECEIVED $ 180.00
Integrated Services BALANCE DUE S 0.00
(608)785-9348, MON - FRI, 7:15 AM - 4:00 PM
JSWIM @COMMERCE.STATE. WLUS
System Calculations
one family residence 3 bedrooms
Loading rate �' �' gallons /sq ft per day
Depth to ground water �� in
Depth to bedrock in
Cross slope %
Force main length 2 ft of 2 in
Manifold /header length ft of in
Drainback gallons
Lateral length @ °'� ft of 1 - in
Lateral elevation 1 � ft (bottom of pipe)
Lateral hole size in @ (' ° ' O in ( S '" ft ) spacing
l� �
holes /lateral, holes total
Lateral volume 6 Of gallons
Total lateral discharge rate gpm @ ft head
i
Elevation difference ft
Friction loss C ' N 6 11' " ft @ $ gpm
Total dynamic head ft
Pump /si�bon 10 gpm @ � ft of head
Manufacturer G' °"`� °"' , Model #
Dose volume gallons
a
Lift /son tank '��'' , gallons
Septic tank ' , gallons
Measurement pump on & off S '� in
Height alarm from tank bottom 3. g in
Reserve capacity 4 } gallons
talcs page of
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VEWT CAP
4 "C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKIAIG
JUIJCTIOM BOX AWHOLE COVER
25' FROM DOOR, a -A/ w A 04% *4 �
WIWDOW OR FRESH �� I LgQfst_
AIR IIJTAKE I
GRADE
COMMIT � --
� ��`
- - I
Lt d
PROVIDE - - - --
AIRTIGHT SEAL
� C, -p%4 (;LBS1:Ry%7 Z3.2 ( III APPROVED JOIIJTS
I III W /C.I. PIPE
ALARM EXTEUDIMC. 3'
CNJTO SOLID SOIL
I 1
o w
l� PUMP
� OFF
BLOCK
a�•w�. 4 4, e-�
II i I I f I I I I I
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MODEL DVP03 MODEL 3071
Vertical Sum • • P0
GOU LDS
i
Pump Spe0ffcatim METE Ri FEET
//3 HP to
UP to 40 GPM MODEL: 3871
Dischargge size 1 NPT • 30
Solids: 'Y•" maximum • -
Motor 7
Single phase: 115V ,
Materials of Construction S
Brass/thermoplastic +S EPOS
Features and Benefits
� 3 to
*Top suction eliminates EPa
impeller clogging. 3 S
• Corrosion resistant +
construction. • 10 zo 30 40 5 •
• Float actuated switch. 0 Y . 6 • 10 13 aft
CAPACITY
METERSET
7 DvPO3 Pump Specifications Features and Benefits
MODEL 6
'/Y and 1 /z HP • EPO4 impeller- semi -open design
Up to 60 GPM with pump out vanes to protect
t• Maximum head to 32' mechanical seal.
Discharge size 1'/:" NPT • EPOS impeller - enclosed design
3 10 Solids: 1 /4 ' maximum for improved performance.
;0 3 • Motor • Rugged glass - filled thermoplastic
+ All motors feature ball casing and base design provides
0 o bearing construction. superior strength and corrosion
a s t0 is 3• 3s 30 3• ro U-9-01`0 Single
u s 4 e e � � Single p hase: 115V .Cast iron motor housing for
cAPACm Materials of Construction efficient heat transfer, strength,
Cast iron and durability.
Thermoplastic • Corrosion resistant threaded
Stainless steel stainless steel shaft.
• Available for automatic and
manual operation.
• CSA listed models available.
All Models are designed for continuous ration and feature stainless steel hardware. o
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Lahr and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
s-r. GR.c»
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
1 `C!A Q E L `^ Z G WT 3v`� GOVT. LOT S w 1/4 NW 1 /4,S 1 ° 1 T ,N,R 5 E (0 W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE [TOWN NEAREST ROAD
'iv` - R RCN Y)W k) S Flo n ( '2"48- 3 Z 1 C D Rah %.over RA .
New Construction Use [ fCJ Residential / Number of bedrooms Z [ J Addition to existing building
j ] Replacement [ J Public or commercial describe
Code derived daily flow 3z� 0 gpd Recommended design loading rate bed, gpd/ft D ' trench, gpd/ft
Absorption area required Z so bed, ft2 2-5 13 trench, ft Maximum design loading rate o- S bed, gpd/ft2 0. 6 trench, gpd/ft2
Recommended infiltration surface elevation(s) \Q S• O ft (as referred to site plan benchmark)
Additional design/ site considerations w l," S' Y- 5%7j' `TQ1FW clf - M 1N ym I' o F - SA Fr L L
Parent material s 1 u+ <M Flood plain elevation, if applicable N A - ft
S = Suitable for System CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem 11 ❑ U ❑ S ICU ❑ S S RU (� S � U [I S RU 11 S kru
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Baxldary Roots Bed Trench
`.<;.:. }:�•:.< 1 0_ l p 1 b `12 313 — S t� Z `F S bk t� � - F�. a, S - o. S o• b
:
y /y — 5 l z `Fo >K �� a S _ o , s o. 6
Ground 316 — S 1 z `F seh Y,,J' ,
elev. + Slip VA.
\O ft. 4 36 - lb `1 2 3)(o to�tQ S!Z sl QW N
Depth to S y6 -6) 10`12 Y LL kn U ' 1, — — -
limiting
factory gITS 30"e 1�1.kt I►.� �L - v <�4% P SW k_
Remarks:
Boring #
s a s
) 0 %1(t S/ / y - S I, 0-S - o • S ' c� 6
3 t t- 3y Lv Li Q Y /Y — s z s�k � fir. c s — o. S o. 6
Ground `F L S yR u/6 0 ll
elev. �/ 3Y -6 Lo L i Lira Y/y Ln�� 2 sli St Q v n�v� _ -
l0 \•8 ft.
Depth to
limiting S 1� To 12 R"r'3l 1 S
factor
>v
Remarks:
T Name: — Please Print Phone: +, \
Arthur L. We erer 715- 25`- -•-:';
Address: Soil Testing & Design Service -P.O. Box 74 River_ Falls,AF . ... 5 22
Signature: L /�� %� 0'3 - l7 -93 Date: CST Number:
165 8- M00576
PROPERTY OWNER w"ZAG14T SOIL DESCRIPTION REPORT Page Of 3
PARCEL J.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
.8:..,..,.,,,... b
Ground 3 3�=1Z LO `2IZ /S/ �VS `1R 5) Z St, . O� err U'f� _ -
elev.
1 bk.0 ft.
Depth to
limiting
factor
3%
Remarks:
Boring # ,rr
;��`*�v"•��`.'�i � � -$ �l� `i. R 3 l 3 — S l � Z T 3 b1Z 1�n v �' t,. C g - O• S �' ( O
{
y Z 8 - 3S t o �Q yi - s 1 J Z�s �k ►�-� es o, s `�• 6
3 3S_�13 l t 4lz t/ /y 10 2 s/Z 5 t 1 o w, L» v tt.
Ground
elev.
\ <o ft.
Depth to
limiting
factor , �
3S
I
Remarks:
Boring #
N - S
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
€�4v
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
` PLOT PLAN Pa 3 of 3
T
SCALE 1 "= 30
° L SO
v
Z.1 O T)t rN e,
�O
by ea
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a a k10T CAS �? RCT i //
a 3 ��
t�t,lol-
Ll..LOl1.0� ON� Q.y c
1�1oCe: ` w o o D L�
a3 - 16 S
715 ) 425 -nj 6 5 M00576
CST Signature Date Signed Telephone No. CST #
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ✓'� /�
Mailing Address
Property Address 703 d ` A a"M
v
(Verification required from Planning Department for new construction)
City/State &' yai L Parcel Identification Number
LEGAL DESCRIPTION
Property Location $� LJ 1/4, i� %4, Sec. l' , T -R /S W, Town of
Subdivision � /tires , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # (���� , Volume Page # 3�
Spec house ❑ yes (3'51 no Lot lines identifiable ® 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.
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 ren maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the expiratio e.
IGNATURE OF APPLIC DATE
OWNER CERTIFICATION
I (we) certify that all state nts on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property sc A ed above, b 1 ' e of a warranty deed recorded in Register of Deeds Office.
SI NATURE OF APPLI ANT 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
` ` ' t �,`. ? ..' �'` r��"., ��'. xt' �; Gs.g'*`- 5i�'tr'�r•- .'�4�'.�;'��` +ib a # s"i'�.; a ";.i','b...'Ik ;,'"�..�" +�':r.�: 0�'.`r�`:'�' 1�°'�s�"+'fi.,•±:B- i > 51�F :f 'b•+.:�a°
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tIN i S ineaRed iaaI in . - - --- .. _OIX - --
E Stam of Wiaeo"Wo:
Tai Fared Nos .....»._ .. « «.. ».
SWkNW% except flowage rights to the Village of
Spri Valley recorded In Vol. 411, page 309,
See. 19-T28g -B25it
f �
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This deed Is given in complete fulfillment of that certain
land contract between the parties dated June 1, 1988 and recorded
June 2, 1988 in Vol. 812, page 453 as Doc. No. 437975. ,
This ......... Is-- : ........ .. bonx*.ja property.
> zuception to Warraatlase
Existing highwayq, easements and rights of va of record.
Dated this ... « :...._ dsy of w.-_ -AVAPUM- 7
•--.. -• • .....
(SEAL)
.... .._.... ............ (SEAL) t
• .........:........ ------------- --- « - -------------------- • _11chard.A... • chard..........._......
(SSAL) i a�c+.t lf.. - - -- - -- -- ---(SEAL)
• Lorraine...PuTm toad .....................
AQTHBNTIOATIOX AO=NOW LEDGMZNT
ZrATZ OF WISCONSIN
« .................. _....««««_..._ «__... - St. Croix County.
antboistiesUd :'erwnally cWo b4re me this . « --- -.day Of
L 19.93. -- tbo abo" ned
............ . ............ «. «...... «« _.... ...... - =ich .. ncli n=
ad
and --- . «........
a.... «.
--- « ------ ««... «.._ « ........ ......------------ �?F�#�n�.�unshacd, -- hlxsbu�nd_............
TrMZ: YZKBZiR STATZ BAR OF WISCONSIN .....«._..-----«.__........«---
............... . ............. «-
a d try 0'►ae -9a. Wla. Stela.) 1e „ the perm . «s....... executed tM
THIS INSTRUM[NT WAa DWAPTW WY '•
.........
Attorney David J. Estreen
_. . ... . .... . ... ............
• . .. .. J G
�L�n�,...ft.r d--- a 8A2] «1iL :pnbli) .,.. ...... t�, is
..........
(Sisnatntes may be outhmUmbed or adcnowledSsa- Brt! nt (( ms. stste r+ 3 Iratioo
I *WSM r at sewer dsabe is aq maeft A►wN M br.W - Pri a.s ea.,. "Eir aiswwW��!
�� • ' • Is Wisconsin ! eye+ swig Co . Inc
wAIIEANlT DR" RATE m = e, a E4ast:vll$iN Mifwauwet. Ww -onsin
sv�sae lYin - -IT" ° 3 ate' ix