HomeMy WebLinkAbout026-1109-30-000 n� o 0 C 0 3 - V
o
3 fD � I 3 (DD ICI 0 CD'13 0
i i d I t
3 ( 3
3 -
0 z 0 v z ° Cl) o v o 10 I � P. Q
C1 g� O O N C3 () •
o a rn° 3 0 CD
m ZA p CD z m w m (D 3
o
a m a N A
O CO 0 `
O\ CD w N A O N v v O '', dpOj O\ 1 LJ
00 O C (� a N n Q O 'p
3 o Ro o �_ F p -
to N G7 N N - 4 O O C !r
O d CD N d N
(D co z D C CD D a y
o rn �� =z o N a � u ° °� � N a
_a Q7 V QJ O
C ? C _ _ O C
O t 0 0 C+ N
O N
C i T � ' "
OZ CD `° N co J `J° (D
C) r to
coo coo N 00 oo 3 C N
0 0 0 CD 1 0 0 0 3
0 6 C N N n O C N N� a N CD
CD C o v a N Q o v o
`
7 (D I N CD ? N
CD
.. <
3 —
(D
I I �
•O• A <
-4 C 4
A o z - o w l z co o j
o O w O a D
N) m _ a h
CD CD C M. m a , + `l
S a CD 5 o CD
m c a m a
CD
CD c6 CD c6
lD
CL n A Z
li G) ..
z -I
00
co v m o
a M a (D zt z
3 3 A
°o $ cn
M c o
N 3
fD CD A
W < CJ d
CD 0
7 _ CD
w
(n CD 0D. o CD m
0.
a -
m o' —
� m c -� v c
N CD
CO 0
'NO N CD N
CD N
CD
CD
'O r A
(D 'C
3
N
O r
O i ti
I O N
Cb
a 0 ° o
(D (D o
0 0 0 0
O ( C) C �., a
0 CL CD CL
I
Ig
<<�g� NE 1 4 -SE 1 :4
51 D '( 228.00' 228.00'
y
P� 1 3 7 6 30 631 32
9 0
SE 4 01' ._
3Q� o
�Q 629✓ 6 A
-
,�� °� 28 ° o � du3 4 �3
° o. 2 7 s
♦ �`� ` "' S 148 o
.55 i 9) F �� '`
-- 7sq� �,�26 X026 ° R �� `1 226.4 Z
25 ,0»03 ?625 ��. 5�� °'� , 35 36„ �p���/�78
4 175.23' ° � ° `' i ` 247.27' o 87
�
♦' ' .� 2 4 's. X1 6
S °
- �� 174TH AVE
-, 4.73 90.00' 87.�Or 8 vD0 6
= -9 60
912 6 0 B
216, ; % 621 A �k� �'b 609 � 608 607 606 611 610 60 A 6 0
''
J O 190.26' 95.00' 90.00' 87.50' 94.00'
22
-- - 00 O
X , — 87.50'
� 13
�
C A SHEET
N% 620 87.50' 105.00' 105.0 105.DQ 105.Q� 105.90' S
" 206.40' I bb II I
rN I— - 19 1 g a 3 3
° i 20 619 618 617 616 615 614 613 612
O, . 00' l3o-�t.e
_ — °' 241.00' 150.00' 105105.00' 105.00 10 .0 22 — —
. - b
0
c i
N
N
• - -a � �r � - - vrr• .• • avaLaL LWl V�4 •
o. AP ESS TOWNSHIP i EC. �_ T�j N, R W
�r l ( "', ST. CROIX COUNTY, WISCONSIN. ..
'BDIVISION LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
?TIC TANKS MFGR. �'
TANK( S) .� �--� t en� �- E�.�nU.r CONCRETE STEEL .. . .
NO. of rings on cover Depth / DRY WELL
.,NCHES NO. of width length area
no. of line width _ L� L length 3 !S area (
depth to top of pipe
3REGATE
.K RATE AREA REQUIRED / _ AREA'AS BUILT
;claimer: The inspection of this system by St. Croix County does not imply complete %
- pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:item operation. However, if failure is noted the County will mane every effort to
ermine cause of failure.
:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
_ 'INSPECTOR
DATED ( '� " PLUMBER ON JOB
LICENSE NUMBER
f
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itaty Pehmit -t I;
State Septic
L.
NAME ezt Town.ahip St. Croix County
Location% 04 , /4, Section
SEPTIC TANK
Size (i Z gattons. Number as Compantment.6
Distance Fnom: Wet it. 12% on great ztope it
Buitding it. Wettand.6
Highwaten it.
DISPOSAL SYSTEM
Distance Fnom wett 12% on greaten stope it.
Building ix. wettandA F t.
Highwaten it.
FIELD DIMENSIONS:
Width o6 tnench it. Depth of )Lock below tite - _in.
Length o6 each Zine y it. Depth of rock oven tiZe in.
Number . o f tines Depth o b Cite b eZow grade Z tin.
Totat .length of tines 90 it. Stope of trench in pen 100 it.
t
Distance between tines 6 S t. Depth to bednack
Totat abzoabtion an ea jt2 Depth to gnoundwaten jt.
Requited area 6t2
PIT DIMENSIONS:
Number of pits / GnaveZ anaund pitzs yu no
Outside diameters 6 Depth below inlet it.
2
Tatar ab�5anbt� an z
Anew nequ_.n �t rn
INSPECTED BV TITL
APPROVED L�U , DATE 197.
REJECTED ,DATE 197
1
a� 4
v
v .
H 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
.1 i DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
` MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TES
LOCATION: We- %,�' /4, Section 4 , T ,„ , Rig K(or)&!, To i or M""ten9W+€y ,�%A6010AW
Lot No. , Block No. County a'
n f4G Subdivision Name
Owner's Name: ,[ �&j-
Mailing Address: —��:� 4C.J.rxWO
TYPE OF OCCUPANCY: Residence — No. of Bedrooms --� Other
EFFLUENT DISPOSAL SYSTEM: NEW /� ADDITION REPLACEMENT�j •gyp
DATES OBSERVATIONS MADE: SOIL BORINGS 9= lJ_ PERCOLATION TESTS I ` /�'�1)- --
SOIL MAP SHEET SOIL TYPE C
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM— INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P— r
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- •. _,
B_ .r _
i
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of sujt*e areas. Indicate number of square feet of absorption area
needed for building type and occupancy. 445 ` Indite ? e
or distances. Give horizontal and vertical reference points. Indicate slope. /
o
n
O
P N
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and belief.
Name (print) Certification No. -
a
Address
Name of installer if known
d
CST Signature - -
COPY A —LOCAL AUTHORITY
v -
State and County State Permit #
PLB67 Permit Application County Perm
for Private Domestic Sewage Systems County `
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: .# / 4"_ %, Section T3UN, R A (or) -W Lot# —City_
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family Duplex No. of Bedrooms No. of Person
D. TYPE OF APPLIANCES: Dishwasher _ YES NO Food Waste Grinder _ YES_X_NO # of Bathrooms_.
Automatic Washer _YES NO Other (specify)
E. SEPTIC TANK CAPACITY AWO — Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition _ Replacement _ Prefab Concrete
* Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) /a 2)J_,/_3) _Total Absorb Are sq. ft.
New Addition Replacement __ *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length I Width Z Depth Tile Depth _.21(# No. of Lines ?
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope '--+
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Ce ified Soil Tester, _
NAME ; C.S.T. # - 5 _�% and other information
obtained from (owner /builder)l.
Plumber's Signature M / PRS '3 Phone
ss t
Plumber's Addre
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Do Not Write in Space Below - FOR DEPARTMENT USE ONLY O o
Date of Application — 7 Fees _Paid: State 1d eld o i type Date
Permit Issue&Bejo rd (date) — — Issuing Agent Na
Inspection Ye No Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, DISON, W.I 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76
Plb. 1 WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES
Division of Health
Section of Plumbing & Fire Protection Systems
INSPECTION REPORT
Name of Premises
,Street City Cou�ty
Master Plumber Address
3ourne Plumber Address {1'
Owner Y I&II- ' ir - t, .;�,e.f Address ,�
LIST PARAGRAPH VIOLATED. CHECK BOX LOCATED IN FRONT OF W.A.C. YIOIAIED.
( )H62.01 ( )H62.09 ( )H62.17
( )H62.02 ( )H62.10 ( )H62.18 INSPECTION -- CHECK APPROPRIATE BOX
( )H62.03 ( )H62.11 ( )H62.19 ( ) BUILDING SEWER ( ) WATER DISTP.IBUTION (vy"SEWAGE DISPOSAL
( )H62.04 ( )H62.12 ( )H62.20 ( ) WATER SERVICE ( ) DRAIN WASTE & VENT
( )H62.05 ( )H62.13 ( )H62.21 ( ) BUILDING DRAIN O FIXTURES, FINISH INSPECTION
{ )H62.06 ( )H62.14 ( )H62.22 Approximate number of fixtures,, -
( )H62.07 ( )H62.15 ( )H62.23
( )H62.08 ( )H62.16 ( )H62.24 TYPE OF BLDG. (- f PRIVATE ( ) PUBLIC OCCUPANCY s✓ ~'
BRIEF, FACTUAL COMMENTS:
�` Qom' ',:.. -C k..�'•._u..-- .{,.} -. S.j..,._..._ , r,..:?� �::s.a �,_.k+ r n> .::,�.:.,. .._� - _..;r
r
i
I
( ) SEE ATTACHED
DISCUSSED WITH PLUMBER (Yes ( ) No SIGNATURE (Voluntary)',
DATE OF INSPECTION
SIGNATURE 0V DIST ICT PLUMBING SUPERVI§M
I'
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Coun %T . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaJ141000.:
Personal information you provice may be used for secondary purposes [Privacy k w, s.15.04 (1) (m)].
Permit Holder's Name: rLCjthR ge Town of: State Plan ID No.:
ANGER, DAVID & GALE 1j
CST BM Elev.: Insp. BM Elev.: BM Description: ParceUrd'9. -30 -000
TANK INFORMATION ELEVATION DATA A9800493
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Air to
i ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Di;77 Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER mo Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length 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:�2ICHMOND 4.30.18.611,SW,SE 1176 CARROLL STREET — LOT 12
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and
ofBui din Water SANITARY PERMIT APPLICATION
Bureau of Bui ld i ng Water 5 stems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 '
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. J?' 6j'
• See reverse side for instructions for completing this application State Sanitary ermitt Numbe
0
The information you provide may be used by other government agency programs E] Check if revision to previous a�piication
(Privacy Law, s. 15.04 (1) (m)]. Sot~
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope Owner Name Property Location
h W 1/4 S 1/4 S T 3 /E; 0 , N, R � E (or)
Property Owner's Mailing Address L Number Block Number
ri' �/ Z
City, State Zip Code Phone Number Subdivision Name or CSM Number
W01-f e n U�� syo) (7i5 >zy� `` 7 l" Ik v.
. TYPE OF BUILDING: (check one) ❑ State Owned C it y Nearest Roa
ill
Public or 2 Family Dwelling V age
- No. of bedrooms Town OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /Condo 1 .1 30• /49. 1691 (J G__ 116q
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
S ❑ 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) 7 rrq 4 4—
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. 'Repair of an
System System Tank Only______________ Existing System Exls_t gSystem
- _____ ________ _ _____ ____ ___
B) El Sanitary Permit was previously issued. Permit Number Date ed
r V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distri Pressurized Distribution Experimental Other
11 l
Seepage Bed 40 J E] [] 21 Mound 30 Specify Type 41 [1'11olding Tank
12 ❑ Seepage Trenc 1 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill _
V 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) Elevation
Feet 9 Feet
VII. TANK Capacity in gallo Total # Of Prefab. Site
g Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Co Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic o ding an a ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberl I I I ❑ I ❑ I ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instaNat+en of the onsite sewage system shown on the attached plans.
P Name: (Print) Plumb r'sSi ature: (No Stamps) MP /MPRSW No.: Business Phone Number:
. Address (Street, TZity, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit lee (Inclucie5Groundwater ate Issue Issuing ent Signature (No Stamps)
A pproved ❑ Owner Given Initial Surcharge fee)
Adverse Determination �� ® ,
X. CO DI rIONS OF APPROVAL / REASONS FOR
' r D
SHD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, Plumber
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
N N N N N an M ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
_�- — Hudson, WI 54016 -7710
(715) 386 -4680
AFFIDAVIT OF SYSTEM REJUVENATION
Property Owner: ' �' p '
0
Address: i 171e Coj (0 ' 1T
Day time phone: 7_u6
Parcel
Legal Description of property: t ;, Sec., T N.
R.L2_A. , Tn. of
St. Croix County, RI
i
As owner of the above described property, I acknowledge that the
septic system serving this residence (is /is not) undersized by
current code standards. I understand that the issuance of a
sanitary permit to allow the attempted rejuvenation of the septic
system does not imply that the system meets current code sizing
requirements, nor does it imply that the proposed procedure will be
successful. I also acknowledge that I will make this information
available to any future parties interested in purchasing this
property.
Signature
Date:
5/97
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the (�; r residence located at: 4, 1/4,
Sec. �, T�p N, R W, Town of St. Croix
County, Wisconsin. 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: /�
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
(Sig a ure) (Name) Please Pri t
(Title) (License 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
c(!'rtify 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 baff e)
Name Signature
MP /MPRS 6
Wisconsin Department of Indus", SOIL AND SITE EVALUATION REPORT Page__L_of_;;L
` Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis.
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. PI in lude, but I S+ ' r t
not limited to vertical and horizontal reference point (BM), direction and % e scae�'+ EL I.D. #
dimensioned, north arrow, and location and distance to nearest road.' <`.'' —
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATIy�° R E ED BY DATE
^� nJ
PROPERTY OWNER: OPER Lp
1 )-a G r O QV X T . LOT g y T 3 D ,N,R / g E (or)gl
PROPERTY OWNER':S MAILING ADDRESS B S E OR CSM # Vo, )I G.i t.J
CITY, STATE ZIP CODE PHONE NUMBER ❑CI WN NEAREST ROAD
Ghw. rat 0 w:r syo) (�►s1 a -a� ?� v e-
[ ] New Construction Use [ ] Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate _ bed, gpd/ft gpd/ft
Absorption area required ( 3 bed, ft (ol• ft Maximum design loading rate J Z bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) ° � �J . o� ft (as referred to site plan benchmark)
Additional design / site considerations
Parent materi N -m y N, e- o Nain elevation, if applicable ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem S ❑U 0S ❑U OS ❑U ®S ❑U ❑S ®U ❑S 9U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Mx Uy Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmr&
I 0 L4 5; L_ s dk mF C� w F .5
Ground 3 li -as Dim YN 5; c. 1. sirs Y, MF"r F , .5
q
elev.
g • ft. L t a 5.3 `f qlq L vl m 15 b K Mfr jF j St I t.
Depth to S 3 0 - 7 , 5 H w►
limiting
factor �o D - Q K y
Remarks: 1 97
Boring #
Ground V
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name: — Please Print Phone: s
A ddress-, a o t r� J �- r` f` Gl' S q0 a`
Signature Date: CST Number:
O'Qjr�� L, , T —a$- q t., q 1 1 1
PROPERTY OWNER SOIL DESCRIPTION REPORT Page , * Of
PARCEL I.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
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Egg
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
i�
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
'r ! -
1
j I
I I
:
i � I
-
I I
I
j
I I I i I
- - -- - -- -T- - - - -
Al
I
i
i
I
T o 0 o f d -
- ��, ►.�_�t.� .�� ` ice .— ,
t
I I v tr
I
:
I
I
i
I I j
I � ,
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer o1Z� �ati 4c
Mailing Address _ 0 -- )(-
�c„ Cur, ► �� �, �,
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number(-
LEGAL DESCRIPTION
Property Location v t.> %., S ,, S �/ • T 3d N R _ LLW, Town of k
Subdivision 1 v.�r.� Lot # 17/
Certified Sarvey Map # Volume . Page #
Warranty Deed # I t 1 Volume pag # *o
Spec house ❑ yes Wno
-Lot Imes identifiable. - yes ❑. no
SYSTEM - AMTENANCE
consists apuropiag IniPmPuuse andmai atcna=ofyourscpticrfdcmcouldres*k its Vfailmtolharl wastd0kopermamtenanoe
can affect oa tmk every throe � y or sooner; if noeded by a incased pampa What you put into due system
septic tm* - a treatment stage is do waft. isposal system,
11 = PrOPedY owner agrees to sabmit to St. Croix Zoning Department a motion fom:k signed by the -owner. and by a
rphmibe4joumcy=,Lphmobe4resWceedphmibaora licenscdpumpervaifyiag that (1) the oa-site disposal system
PmPer q=atwg wadi ion aadlor(2) after &&room and pumping C¢ Y), due septic.tm* -is less drag IS dull of sludge.
U'RA, the uOdcmigned have _read the above
set f z�izrmeats and ague to maintain tine private sewage disposal system with tha standards
ordu, herein. - as set by the Department of Commcroe and tine Department of Natural
stating that your septic has been mainxained must be completed and to the .qty Zoning Office 30
days throe year iration date.
SIGNATURE OF APPLI
DATE
OWNER- CERZTRICAITQN
I (we) certify that all stat=cnb on this form are true to the best of my (our) knowledge. I (we) am (are) the owna(s) of
M described a vt. by virtue of a warranty deod recorded in Register of Deeds Office.
E OF APPI;I
DATE
« « « « ««
Any nformation
Y that is aais
-rcPresauod may result is 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