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HomeMy WebLinkAbout026-1064-20-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner r-tj 0 W , Address " City /State Legal Description: Lot Block --- Subdivision/CSM # '/. AIt %, VUJ, Sec. .2L, T 3aN -RAW, Town of e M Q1& PIN # © Z d r SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer (.cJ t` Size ST/PC Setback from: House 3 Well � P/L aa0 G Z4- Pump manufacturer Model 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: Width l Length Number of Trenches / Setback from: House � t5 Well _ P/L to fresh air intake _ yS t- ELEVATIONS Description of benchmark (� `a ti 5 �= � ^^� -� Elevation l cm Description of alternate benchmark Elevation Building Sewer — ST/HT Inlet 9 ST Outlet � PC Inlet PC Bottom -- Header/Manifold 93. Top of ST/PC Manhole Cover Distribution Lines () °l3 L () ( ) Bottom of System () 9 oZ rs () ( ) Final Grade Date of installation ermit number-_ State plan number �b ° L01 Plumber's sign tprq License number Date I / Inspector Complete plot plan * r , 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. I PLAN W prw�w o �o I i INDICATE NORTH ARROW I I i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM � Safety and Buildings Division Count y INSPECTION REPORT 57, bee ;x GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 3 Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. a7 657 Permi older's Name: [I City ❑ Village A Town of: State Plan ID No.: 14 �11cQ�/ays 6-710 C / M. �-- CST BM Elev.: Insp. BM Eiev.: B Des ription• Parcel Tax No.: 00 too ' o s% ' OK o G oar - ©b -- TANK INFORMATION ELEVATION DATA W 9SqOC>yl0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e W e f Benchm J�/ l0� Dosing /y5D Aeration Bldg. Sower Holding #t Inlet &2 :5 Gft� TANK SETBACK INFORMATION l�s Hq Outlet 7.17' TANK TO P/ L WELL BLDG. Air In 1 k ROAD Dt Inlet Septic It> 4- Z064 r � NA Dt Bottom Dosing NA Header /Man. -7,73� Aeration NA Dist. Pipe 7gro g 3 i Holding Bot. System 81'6 ` 2, C/9 PUMP/ SIPHON INFORMATION Final Grade e l . ZY P.C, Manufacturer emancl Mo um er GPM TDH Lift Friction Ft Force Dia. Dist. To well SOIL ABSORPTION SYSTEM TRENCH width Length / No. Of Trenches PIT its Inside Dia. Liquid Depth - OffoYE LYSIONS — DIME N I N SETBACK SYSTEM TO P / L BLDG I WELL LAKE/STREAM LEACHING INFORMATION Type O • f .�`� HAMBER el Number: Syste LvV OR DISTRIBUTION SYSTEM Header / Ma fold f! Distribution Pipe(s) �� ` x Hole Size x Hole Spacing Vent To Air Int� ke Length _� Dia. ' Length Dia. � Spacing �,'rp�( 2 -72q 7 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over /� [ B ed h Over xx ee e u c ed Bed /Trench Center 3 � Trench es ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 113 cr C I 7 Pfan revlslon e ❑ Yes X) No / Use other side for additional information. j moo+ l SBD -6710 (R.3/97) Date Inspector's Signature rt. No SANITARY PERMIT APPLICATION S afety of Building WaeS Division Bureau of Building Water Systems 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. n s c • See reverse side for instructions for completing this application State Sanitar Permit Num o� o The information you provide may be used by other government agency programs �� �' ❑ Check it revision to previou application 1 (Privacy Law, s. 15.04 (1) (m)]. 113 State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 01 o ) l�S Pro erty Owner Name Property Location E1 / 4 N iJ /4, S T , N, R 1) W Pro i r ty Owner's Mailing d ss tt lr Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number au II. TYPE OF BUILDING: (check one) E] State Owned [] cit Nearest Roa E] Vll age ` 1 Public 1 or 2 Family Dwelling - No. of bedrooms town of cL III. UILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 [ Apartment/ Condo a /. 30, 1 g. v pl l q C) � (0 i) c)(0 4 _C; �� 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 Mf Outdoor Recreational Facility 3 E] 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. El Replacement 3. [] Replacement of 4. E] Reconnection of 5, [] Repair of an - ___)_` ________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 Xseepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure r 42 ❑ Pit Privy 13 ❑ Seepage Pit /'2 >< 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) p� Elevation Soo , f N 6 _I oZ 1.,5 Feet Feet Cap acit y VII. TANK in a llo S Total # Of Prefab. Site Fiber- Plastic Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete . Con- Steel glass App. New Exist in strutted Tanks Tanks Septic Tank op Wel ing- +aik— ) J b L u PS r7s El ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: t) Plu is �jgnatu: (NS amps) [WtV/MPRSW No.: Business Phone Number: . `5 & 71 S S1 -S Plumber's Address (Street, City, State, Zip Code): 1 7 ` -f V\ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate l Issuin /L gent;Signa re (No Stamps) A roved Surcharge Fee) [B App roved ❑Owner Given Initial l � �� 1 / J X Adverse Deter mination /' X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: S60-639 8 (F, S/94) _ DISTRIBUTION: Origins! io Cminty, One copy To: Safety & Ruildimp. Divreion, Owner, Plumber f - SAFETY AND BUILDINGS DIVISION 2226 Rose Street NVisconsin La Crosse, WI 54603 Department of Commerce Tommy G. Thompson, Governor 18- Feb -98 William J. McCoshen, Secretary POWERS EXCAVATING PINE MEADOWS GOLF, INC CAL POWERS 1969 185TH AVE NEW RICHMON WI 54017 PINE MEADOWS GOLF, INC. Plan ID 9820165 NE, NW,21,30,18W Municipality of Richmond Inspector: Leroy G. Jansky County of St Croix (715) 726 -2544 Private Sewage plans including the following element(s): CONVENTIONAL 500 GPD The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to the conditions listed on the following page(s). 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. All permits required by the state or local municipality shall be obtained prior to commencement of construction /installation /operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincerely, O erard Z MS POWTS Plan Reviewer (608) 785 -9348 s SAFETY AND BUILDINGS DIVISION 2226 Rose Street LaCrosse, WI 54603 s M sconst n Tommy G. Thompson, Governor Department of Commerce William J. McCoshen, Secretary Page 2 gg 20165 - 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. Stats, prior to installation. - 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. SBD- 5524 -E (R.07/96) File Ref: PRIVATE SEWAGE SYSTEM Department of Commerce • Safety and Buildings Division REVIEW APPLICATION Bureau of Integrated Services Hayward Office LaCrosse Office Madison Office Shawano Office Waukesha Office 209 W. 1st St. 2226 Rose Street 201 E. Washington Ave. 1340 E. Green Bay St. 401 Pilot Court, Ste. C Rt 8, Box 8072 La Crosse, WI 54603 P.O. Box 7969 Suite 300 Waukesha, W153188 Hayward, WI 54843 - Phone (608) 785 -9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548 -8606 Phone(715)634 -4804 Fax (608) 785 -9330 Phone(608)266 -3151 Phone(715)524 -3626 Fax (414) 548 -8614 Fax (715) 634 -5150 Fax (608) 267 -9566 Fax (715) 524 -3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill In all applicable data and submit this form together with fees and plansMformation. Your submittal must be received at least two working days prior to the appointment at the office where your review was scheduled. Please call any of the listed offices If you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form Is on the reverse side for your reference. ®� Personal infortnation you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. 1. APPOINTMENT INFORMATION - If you have scheduled an appointment, fill in the information requested below to save time: Appointment Date Reviewer Name Plan Identification Number a - I (K -9 1� i r14.1 �0 ir, P �4 I T� a0l(g5 2. PROJECT INFORMATION If this review is a revision o extension to your existing p lan identification number, provide that number here: Proied Name County C9 0 1 5 - V1,C, [ ❑ Village Town of: ro�X Project Location C Location GOVT. LOT N 114AI J 11/4,S,41 4,S ,4� T 3 N,R 1k Apr) W 841% m 0'%'- 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type r (include new and existing tanks) o �D A ❑ At -Grade Up To 1,500 gallon septic tank .. ............................... ::$110.00...................... H ❑ Holding Tank 1,501 - 2,500 gallon septic tank .... ............................... ..$120.00...................... M ❑ Mound 2,501 - 5,000 gallon septic tank.... .... .......................... ..$160.00...................... N 19 N on-Pressurized In- Ground (Conventional) 5,001- 9,000 gallon septic tank..�f�.,.. GEIY.E.�. ..$200.00 ...................... P /❑ Pressurized In- Ground 9,001 - 15,000 gallon septic tank TEB ... F7 ... $300.00 ...................... O ❑ Other. Over 15,000 gallon septic tank ..................... 1� ..$500.00...................... Up To 1,000 gallon dose ; ... U � 70.00 ...................... Building Type (check one): 1,001 - 2,000 gallon dose chamber . ..............................t 80.00...................... D 0 Dwelling, 1 or 2 Family 2,001 - 4,000 gallon dose chamber ............................. ..$100.00...................... P JIM Public Building 4,001 - 8,000 gallon dose chamber ............................. ..$120.00...................... S ❑ State -Owned Building 8,001 - 12,000 gallon dose chamber ............................. ..$140.00...................... Over 12,000 gallon dose chamber ............................. ..$160.00...................... Up To 5,000 gallon holding tank .... ..............................$ 60.00...................... Code Derived Daily Flow 'S gpd 5,001 - 10,000 gallon holding tank ............................... ....$100.00.................... Over 10,000 gallon holding tank ............................... ...$150.00..................... ❑ Check If Replacing Existing System Experimental System (additional one time fee) ....... .........$300.00............... .. Rev isions to Approved Plan . .......... ..............................$ 60.00............. Petitions for Variance: Setback ................. ..................$100.00...... ❑ Petition for Variance Site Evaluation ............. ............$225.00............ Plumbing ......... .........................$225.0 .................. Revision ..... ..............................$ 75.00.... .............. ❑ Groundwater Monitoring Groundwater Monitoring - Per Site .... ..............................$ 60 other than a proposed subdivision) ❑ Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring .......... ;V ..................... S total :.................. Priority Review: Enter same amou t a ubtotal :................. MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION otal Fee: ......... 5. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Co y Name Contact Person No. & Street Address or P.O. Box City, own or V' age, State Zip Code Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and do chambers. Y Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. OVER -- - -� SBD -6748 (R. 07/96) PI b'. # 60 1/78 PROJECT DETAIL DATA SHEET NAME OF BUSINESS M Q_C&&0Cz _ S LEGAL DESCRIPTION OWNER �, T r ,,� , S2 It e MAILING ADDRESS AN wrz I P d/ 7 ARCHITECT, ENGINEER, u��. Ppc,.�. �� ADDRESS Z94 C l ✓lrr!�AN*_ PLUMBER OR DESIGNER - ZIP s y 0 > TELEPHONE NUMBER 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building` New building Addition (,) Apartments and condominiums . . . . Number',of bedrooms ( Ass'embly'hal'1 .'. . . . . . . . . Seating capacity ( Bar . . . . . . . . . . . . . . . . Seating capacity 1tL # of meals served ( ) Bowling alley . . . . . . . . . . . Number of lanes ( ) With bar ( ) Campground and camping resorts . . . Number of sewered sites Number o;9 unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . . Number ( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons ( ) With kitchen Number of persons ( ) Dance 'hall . . . . . . . . . . . . . Number of persons ( ) Dining hall . . . . . . . . . . . . Number of meals served daily ( ) Dog kennels . . . . . . . . . . . Number of enclosures ( ) Drive -in restaurant . . . . . . . . Inside seating capacity Car- service -- Number of car spaces ( ) Dump station . . . . . . . . . . . . Number of dump stations Employees ( total of all shifts) Number of employees Hotel ( ) Motel ( ) Cottages . . . . Number of units-.with 2 persons per unit Number of unite with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . . Number of sites ( ) Nursing homes . . . . . . . . Number of beds ( ) Parks . . . . . . . . . . . . . Number of persons ( ) Toilets ( ) Showers ( ) Restaurant . . . . . . . . . . . . . Seating capacity ( ) Dishwasher and /or disposal? ( ) 24 -Hour service Retail store . . . . . . . . . . . . Total number of customers ( ) Schools . . . . . . . . . . . . . . Number of classrooms _TT Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . . . . . . . Number of cars served daily ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . . (Specify) . . . . . . . p;� s. rt- 60 COMPLETE OTHER SIDE 2. Indicate whether the following facilities are present. Floor drain yes no Number of drains Food waste grinder yes no Dishwasher yes no Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity Holding tank capacity. • uz- Septic or ma,puf4 turer 4. SEEPAGE TRENCHES:- 'total square feet width of trenches • length of trenches depth number of trenches i SEEPAGE BEDS: total square feet 7/.5 width /7 length of bed O depth $ Ra3K ue�► o � /.t n SEEPAGE PITS: total square feet outside diameter depth below inlet total depth from top to bottom of pit Signature of pers i completing form: FOR DEPARTMENTAL USE ONLY Address tj? -Z i p S U t Telephone Number 715 - -V,4 " Date I i Pht )A r* .7 cAJ -- = o'o = to 504 - _ = _, to 90 :! UAJ �0 PI d W t sad ' ' 7saf/l &u 715A c6 n d l - Ifoom A DPIARTMENTI pF t��MER� 6;0 - EE NDE�E p p �T - - r • � �� � �� c i s ' » �� �'�` � . . PAGE _ OF — CrvSS S zc�lon p 2 . for Iill A" 1111016 And Ob►arrallon p ID , J.A + �APD+oritl Vanl Cap 12' Abor• Cfodo 20oro plpp V Cost Iron Troa• V+nt P 1po Or SCo.uln MIA af apolo DIUrIbOn°a Tao Pip• 0 0 0 aolo Oip• ° Porloroh0 P1pa 6'alov ° "�Coapiln1 Twminolina At 008104% 01 Sy /foul SOIL FILL, DISTRIB.U7lOr.l PIPE 2~OFAGGRCOME �.- � ��APPROVED .S�NrIETIC COVCR MATFRIAt- olt I OF OR MARSN HAy ELEV, O F -- g FU T , AGGREGATE 1 D!S't'RIeUTI +JIJ PIPE TO BE AT LEAST •�� AAIU AT LEASTLO IWCHES BUT 1,10 MORE THAI) 42�uCIgES BC`OORIGI�.IgL GRADE W FINAL GRADE i MA7cU1UM DEPrvi OF E)<cAVATIo;j FK OKIitN 69w wtt_t. BE 9 1UN1MUFq 0cfyjl of EACAvAT1oN H.Olf1 l60Jgtr GRAPE WILL BE .flD — 1►J INCNC S SIC>'1JED: i LICEtJSC UUIA BE11: DATE :_,_" 9Q 110 _ - 1Nisc0sinVepartment of Industry SOIL AND SITE EVALUATION REPORT Pag of c3 Labor and Human Relations g Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 51 r ' 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. (o f O (o —�C APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY_QWNER: PROPERTY LOCATION G - rn (Al.) e57r I- n I p5o j GOVT. LOT 1/4 N Q 1/4,S al T 3 0 N,R 9 jPr) W PROPERTY OWNER':S MAILI DDRESS L T # BLOCK # SUBD. NAME RR CSM # w '� CITY, STA ZIP CODE PHONE NUMBER ❑CITY []VILLAGE IXTOWN NEAREST ROAD o� c �l �ia.gb a3 &/ n� G� IF New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building Replacement [ Public or commercial describe C ) u,.b WoLa 2 Code derived daily flow X50 gpd Recommended design loading rate _gy bed, gpd /ft g trench, gpd/ft Absorption area required gals bed, ft 106 3 trench, ft Maximum design loading rate _gy bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) 9 5 It (as referred to site plan benchmark) Additional design / site considerations Parent material A X ©L.L* LZCk Flood plain elevation, if applicable IVA ft S = Suitable for system C NVENTIONAL MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDIN TT NK U= Unsuitable fors stem S❑ U S❑ U 09 S❑ U 0 S VW ❑ S U [IS M SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendri Noun Q jl - .) , q fD SJI W A. si� m 5 h k Lo '2 Ground 3 o?y ':36 /p 4+5 +G elev. 91 ft. t yy /a R s 6 s o M S Depth to limiting factor n I Remarks: Boring # .................. I � g s 6 7 7 LJ o a � Ground '� 4 3 C r elev. 3 ? S S o yn ? i ft. Depth to limiting i bw factor r ~ter Remarks: .. j v CST Name: — Please Print a O f c �►^S - [� N Phone: �I Address: _5*01 f Signature: Date: r. C 3 I PROPERTYOWNER C, �'� Y`(11� W SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BaXclaty Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench - o — 1 i fs �r 3 y :tt ;fii Ground 3 ola 4 1 /OM 0 rn S /l?/ #' . - 2 elev. Depth to limiting factor�� Remarks: Boring # �::��,��... ��:� a 9 - a3 e s b 5. � a �, slk �► f� w a 4. ::: \••.?:ice Ground el � a.ft. Depth to limiting factor i Remarks: Boring # :.;t. >::: Ground eleft. £ - Depth to limiting factor Remarks: Boring # ; ' Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) j - - - I i 1 I I tl' i C r I ; , TJ lei G ON I • 1 -� I : l _ - " .. t y 7 I r X I I : I 1 I I 1 -( I f I > I t - -- - - - - -- - -- Y I i I I I{ T T ' , t - _ - -- r - -- 1 -- -- !- - - -- -- -- } -- -- - -- - - 1 I I A ' I I I i I I I I j I ' I , ; I i ' I i _- -- r_._ -I -- - I i -1 A L L i- I , I I ! I I I I I i I r i i I , I I { 1 j I 1 ' I a I ' i I I : I 1 - I I I i I I I II I i I i t I I f I I I l I I t .. 1 T 1 A 1 . -�. r L !_l I T J I I I I i I I I -_ I I I I I ' I -- - '- - - , h ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer W Mailing Address - y �� i LL i S r 7 1139 Property Address W (Ver required om Planning Department for new construction) City /State N ,2 t ,..� 1S & C � hn o AA G arcel Identification Number 0 Q J 0 to — Q LEGAL DESCRIPTION Property Location ' /4, 1l W ' / Sec. T -R W, Town of Subdivision N,l )4 , Lot # Certified Survey Map # Volume . Page # Warranty Deed # _.S �7 -I:; ) , Volume a c 1 . Page # 4 . Spec house ❑ yes Off 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, journeymanpl*nber, 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 been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNA OF APPLickNT 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. _ r SIGNATLJRE,JF APPLICANY 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