Loading...
HomeMy WebLinkAbout028-1035-40-000 ST. CItOIX COUNTY ZONING DEp t As BUILT ARTMEN ' SANITARY REPORT Owner f Caa Stat ST CRc1x Y e L COUNTY Legal Descripti j Lot Block Subdivision/CSM #�7/ dLL�—, Sec. , 21L , TAN - 1,ZW, Town of �' `�� � �` • ` - r SEPTIC TANK _ PIN # DOSE CHAMBER _HOLDING TANK INFO Tank manufacturer i� RMATION: Pip manufacturer n Size ST/PC oe� Model Setback from: House_ Well P/L Alarm location • (HOLDING TANKS ONLY) Setbacks: Service road Meter location Vent to fresh air intake Alarm location Water Line SOIL ABSORPTION SYSTEM; Type of system: Setback from: House Width_ 2 2S Well Length ,� 2 � ©n-e► Number of Trenches k 75 -. _ P /L Vent to fresh air intake EL EVATIONS: �'`� Description of benchmark Descri ption of alternate benchmark Elevation /2 _ v Elevation Building Sewer j ST/HT Inlet S" ST Outlet �-- PC Bottom PC Inlet •- - Header/Manifold Distribution Lines Top of ST/PC Manhole Cover 9 ( ) a Bottom of System () %00 Final Grade Date of installation • / �/ Permit number L-2' Plumber's signatur State plan number Q �- tcense number Inspector Date $ /2Z)/ T9 ('omplete plot plan •r 'isconsin Departm ent ofcommerce PRIVATE SEWAGE SYSTEM Vae, ROIX afety and Buildings Division INSPECTION REPORT - JENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy L s (1)(m)j• .: Emi 'olcleOs l$me. l ifti - Q � RR KK tc� CST BM Elev.: Insp. BM Elev.: BM Description: A 9800284 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. �DUU Benchm go 3.8 (o3. I o 0 Septic b Dosing W7 �6 S� B�xt I a Bldg. Sewer jol. 36 j [' �' Aeration Holding Inlet TANK SETBACK INFORMATION St Ht Outlet ventto take ROAD Dt Inlet TANKTO P/L WELL BLDG. Airin Septic 1 l ^/�- NA Dt Bottom Dosing ' ` A-114 � ! Z ( NA Header / Man. log/ 0 2• �3 l ��' Z Aeration Dist. Pipe o. Bot. System 1 c3 3• � Holding 7•( �Ov PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand .\A46.4 lv.r .3 c 6b c f�o.7 Model Number W �C��JI`d� �.-' PM -#I W40V Cj'.D O /UU TDH Lift I Lriction� .-� System2 TDH?lj•cjfFt Forcemain Length 1 , L5b' Dia. n Dist. To Well SOIL ABSORPTION SYSTEM No. Of Trenches PIT No. Of Pits Inside Dia. L uid Depth BED Width ` Length7 DIMEN I N DIM N I N J LEACHING SETBACK SYSTEM TO Manufactur P / L BLDG WELL LAKE /STREAM CHAMBER Mode Num er: INFORMATION Type O ' 5f �a! OR UNIT SystemweurtG DISTRIBUTION SYSTEM x Hole - S p acing Vent To Air Intake Distribution Pipes) �, x Hole Size^ /0' 9 Header /Mani old ,I � ?� Length ( Dia. Length � Dia. � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over xx Depth Of xx Seeded / Sodded xulched Depth Over p ° Yes ❑ No Yes E01 No Bed/ Trench Center 1 a� Bed /Trench Edges 1, Topsoil (� COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RUSH IVER 26.28.17,SE,NW 151 COUNTY ROAD Y l73g l u4tz` 5 Plan revision eq fired? E] Yes 0 No G ( 1 Use other side for additional information. �� Date Inspector's Si nature Cert. No. SBD -6710 (R.3/97) • safety and Buildings Division A sconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave. P.O. Box 7969 In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969 )epartment of Commerce Attach complete plans (to the county copy only) for the system, on paper not less County St. Croix than 8 112 x 11 inches in size. State Sanitary Permit Number See reverse side for instructions for completing this application S�p� Check if revision to ►► previous application information you provide may be used by other government agency pro�am y e 8025 State Plan I.D. Number acy Law, S. 15.04 (1) (m)]. t G y �I / • 4PPLI ATION INFORMATI N - PLEASE PRINT ALL INF RMPr pert Nocation T 28 , N, R 17 E/ yW )erty Owner Name S E 1/4 NW 1/4,5 26 X0yy1i`y0y j/ Kory Kerr Lot Number Block / N A umber perty Owner's Mailing Address 1 1620 5th Ave . A t. D Q r, State Zip Code Phone Number Subdivision Name or CSM Numbe Baldwin WI 54002 ( 715 )684 -4974 581965 C,5tA1 i . �O? y Neare Road TYPE F BUILDING: (check one) ❑ State Owned o v )age Public 1 or 2 Family Dwelling - No_ of bedrooms To wn OF Rus River Par Count Y . BUILDING USE (If building type is public, check all that apply) A 9 — 1035 + Z/O _ a �g, ter. a14� ❑ Apartment / Condo ❑ 10 Outdoor Recreational Facility [] Assembly Hall 6 C] Medical Facility/ Nursing Home 11 ❑ Restaurant/ Bar/ Dining I ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 12 ❑ Service Station/ Car Wash l ❑ Church /School 8 ❑ Mobile Home Park 13 ❑ Other: specify ❑ Hotel/ Motel 9 ❑ office/ Factory /. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an New 2. ❑ Replacement 3. ❑ p Existin _S stem _____ Exlstingsystem A) 1. ® Tank Only -- ---- - - -- sem System -- �------------- - - - - -- 9 - - ------- y - S t ------------- y--- ------------- - - - - -- Date Issued B) [] A Sanitary Permit was previously issued. Permit Number F. TYPE OF SYSTEM: (Check only one) Experimental Other Non - Pressurized Distribution Pressurized Distribution P 41 Holding Tank � Mound 30 E] Specify Type ❑ 11 ❑ Seepage Bed 21 42 ❑ Pit Privy 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 43 ❑ Vault Privy 13 ❑ Seepage Pit 14 ❑ System -In -Fill A. ABSORPTION SYSTEM INFORMATION: 5. Elevation 1. Gallons Per Day 2. Absorp. Area 3. A (Ar a .) a (Ga d ing R a ft) (M � r /inchee 6. System Elev. 7. Final Grade 450 Required (sq. ft.) Proposed q .5 N/A 100.6 Feet 102.95 Feet 375 Pl Capacity Site Fiber- Exper. VII. TANK in gallons Total # of Prefab. Plastic Manufacturers Name Con- Steel lass INFORMATION New Existin Gallons Tanks concrete structed g Tanks Tanks (� [� ❑ El Septic Tank or Holding Tank 1000 1000 1 Midwestern PRECAS © ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 650 650 1 Midwestern Precas VIII. RESPONSIBILITY STATEMENT _ I, the undersigned, assume responsibility for installation of the onsite sewage! ystem shown on uh th attached s p N umber: Plum S ignature: S mp) MP/MPRSW No.: Plumber's Name: (Print) 0292 715/772 -3278 Bennie Helgeson Plumber's Address (Street, City, State, Zip Cod 54767 W1229 770th Avenue, Spring alley IX. C UNTY /DEPARTMENT USE ONLY ( includes Groundwater ate ssue Issuing Agent tune N ) ❑ Disapproved Sa i ary Permit Fee Surcharge Fee) Approved []Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: DISTRIBUTION: Original to County, One copy ro: Safety a B j&,, Dirm0jL oww, Pk nb0r coatazan (R. t tl961 Safety and Buildings 2226 ROSE ST ' IA CROSSE WI 54603 -1905 Isc0n 'si Tommy Thompson, Governor William I J. McCoshen, Secretary Department of Commerce May 29, 1998 ,gT7TV: POWTS INSPECTOR CUST ID No.26809 HELGESON EXCAVATION INC W1229 770TH AVE SPRING VALLEY WI 54767 RE: CONDITIONAL APPROVAL Transaction ID No. 80541 APPROVAL EXPIRES: 05/29/2000 SITE: Site ID: 8025 St Croix County, Town of Rush River SETA, NWI /4, S26, T28N, R17W KORY KERR FOR: D Mound Object Type: POWT System Regulated Object ID No.: 19873 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVE The following conditions shall be met during construction or installation and prior to occupancy or use: • A Sanitary Permit must be obtained from the couty Code this project is located in accordance with the requirements of Sec. 145.135 and 145.19 Ins Wis. Adm. ection of the private sewage system installation is required. Arrangements for inspection shall be made with • In s p the designated county official in accordance with the provisions of Sec. 145.20(d), Wis• Stats. this letter shall be on-site during construction and open to A co of the approved plans, specifications and may i PY c ude local in pectors. All permits inspection by authorized representatives of the Department, which may required by the state or the local municipality shall be obtained prior to commencement of co nstruction /installation/ope this correspondence may be made to me at the telephone number listed T ID address Inquiries concerning ui or submitting additional information, p on this letterhead. When making an inquiry No. in the regarding line. Sincerely, E 1/1998 80.00 80.00 GERARD M SWIM , POWTS PLAN REVIEWER 0.00 Integrated Services (608)785-9348, MON - FRI, 7:15 AM - 4:00 PM JSWIM @COMMERCE.STA i INDEX SHEET PROPERTY OWNER: KORY KEEP, Rs cs/ vs p 1620 5TH AVE. APT D MAY 2 1 1 998 BALDWIN WI 54002 SAFETY & B PROJECT NAME: KORY KERB BIV, 80541 PROJECT LOCATION: SE 1/4, NW 1/4, S 26, T 28, N, R, 17 W MUNICIPALITY: RUSH RIVER TOWNSHIP COUNTY: ST. CROIX CONTENTS Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Detail Page 4: Pump Chamber Cross Section & Specifications Page 5: Pump Specifications Signe Name: Bennie Helgeson - Address: W1229 770Th Avenue Spring Valley, WI 54767 Date: May 19, 1998 p +� W.onally Credential number: 220292 Ca dltl N 0 �D gF �® MM�RCE S moval OFa ID O �► 0o O NpE NGE ST--E G0RRE DY\ 'roP o � �o NtSk P UC, P AP¢ Co. h4ou�� Eltu, r 7e 99. (o TO 1 31op� � 100.E Top a-f Av c c we Ce PuL �lC/ �oS-e Co t�bo Self F �C QobTteX , I JIV �OC4�o r. c� , xc -c Page Of Cross Section Of A Mound Using A Trench For The Absorption Area Elcv l02, d5 i M G��i F — o Sol Medium Sand Fill J1 E 0 3 g 91,E Plowed Layer Trench Of h" - 2h" Aggregate, D 1, Ft. 6" Below Pipe. Covered.With Ft. Straw, Marsh Hay Or Synthetic Fabric E Ft. H Ft. F A Trench For The Absorption Area �-s-- Plan View Of Mound Using Distribution Pipe Observation Pipe PermanentMarker �`�rc. - - ---------- - - - - -- - - - • K J✓�o.�� W \ Trench Of 3 1" - 2 Aggregat I I 9, 7 Ft. K I /3 Ft. W q � Ft. L Ft. Q 1� F t. J 11�=� i y License Date: S - Number: Signed: Page_ .._- LU bution Pipe Detail For Lateral Network Distri PVC Force Main End Cap Holes Located On Bottom / A e Equally Spaced Ala BA H pyC Distribution Pipe X y Y1 p * Last Hole Should Be Next from En Ca fold end of bed First hole to be ,z Inch Hole Diameter _� P ) Inch(es) Lateral Diameter Inches o? Inches Force Main Diameter y _ Y / $ — Inches � Of Holes /Pipe Invert Elevation Of Laterals Page Of CHAMBER 4 CI Vent Pipe with ' COMBINATION SEPTIC TANK /PUMP- Approved Cap, +25' ( N o Scale) Manhole Cover. From Buildings Appr Lock Attached /�. With Warning Approved _ -----� Weatherproof Vent Cap 12" Minimum Label Junction Box .Warning , -�-- _ 464Minimum 6 Mi nimum Final Grade --% + ' Quick 6" Maximum Disco 4" C.I. - -- Insp. Pipe I 18" Minimum 1/4" Weep ' Hole D Baffles I . t I A Approved Joint Alarm 6 B Approved Joint w /C.I. Pipe On w /C.I. Pipe �i Extending 3 , Extending 3' I C O , Onto Solid Sol Onto Solid Soil W, S Off D Conc. Block 3" of Beddi nq Under Tank -� $SPer Day - )Gallons crate circuits Number of Doses: o Doses: Pump and ( Gallons Alarm Are On separ Per Day / .•...+ _ 8 Note Volume of Backflow:•• Gallons �s Total Dose Volume:.-.*,*** w Z'..•�. a ons � � 6 Tank Manufacturer: inches or 3 gallons Tank Size - Septic /Pu Gallons Capacities* A /7 B � — in ches or 3�Gallons + C Alarm Manufacturer inches 0r Model Number: o Gallons � Switch Type: + D to inches o a llons Pump Manufacturer: Total ..... "Tinches or Model Number: W �-�- ate: Feet tion Minimum Discharge Pipe D ifference Between Pump Off and Distribu Feet Vertical D 1 Pressure:•••••••• " ............... Minimum Required e i x u Man I Friction 'total Feet: + off- ee t Feet of Forc l Dynamic Head: ee nch Diameter Force Main th 3 8 Internal Tank Dimensions: Length_+ Width 55�� : Liquid Dep _-- Date____-- - License Number__- Signature "�.................No NEON MOEN No ��..............ME ........... MEN No on-IN 0 NOON Won . \. 0 No ■...ice. \■ ii . C�t��a� \.iii.i►l.i ► \ \..� ON No M MODEL 3885 ON WOMEN MEN SIZE3/4 Its .�..: ., ,' l 'i' aY..� t':gJf .tiLl, �... � . ,.3r��.jfl,iFr't t;Sq,,l�rC, ,_..� ..,, ,d'.. o •^ c' �iiE iiiiiiiiiiii .... .. .�i� .. C ............. :..... ........• �::::::::: . .,.........ME mom mom :. •...... ► \..NONE M.......... ............. .'.OMEN ........ . ......... �O!M���l iisiiiiiii mmom MOON N a Eiiii�iiiiiiiiiii ONE No �_Ommmmmmm ON ■ ........................■ Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page —\ -of 3 Labor and Human Relations p;vaabn of safety & Buikbngs in accord with ILHR 83.05, Wis. Adm. Code COUNTY sue- • c,� tix Attach complete site plan on paper not less than 81/2 x asRze. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point ) %slope, scale or dimensioned, north arrow, and location and dist �st road. \\ Rg\;IEWED BY D TE APPLICANT INFORMATION - PLEASE P g Ill ALL 1 ION 1 Cl EPROPERTY OWNER: 01\ 1}�1`z � � P Qf RTYLOCATION �;,� "O �� St~ t/4 •Nit /4,S Z L T Zt N,R 11. E (a0W Cq T-# BLOCK # SUBD. NAME OR CSM # OWNER':S MAILING ADDRESS OU( ll RV e , • - COUNTY C. 3)" 1 , ZIP CODE N FFICE (]CITY []VILLAGE MOWN NEAREST ROAD � Lbw ► rv, Iry I 5 � � o Z t'� ' �E 4 °t y; -, : ; ,� �Sl � 1 V c,UV,.�•M �Q New Construction Use M Residential / Number o 3 [ ]Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow l-L S0 gpd Recommended design loading rate - bed, gpd/ft ' 3 trench, gpd/ft Absorption area required 3� S bed, ft2 3�S trench, ft Maximum design loading rate • S bed, gpd/ft trench, gpolft Recommended infiltration surface elevation(s) 1D O • � ft (as referred to site plan benchmark) Additional design / site considerations "% Lv / s I x 't S I I_Zk - Kj Ct f . y" I" . ti" of S ft b Fr C Q Parent material st LT. oU Gvr" , rrL- _n LL Flood plain elevation, if applicable ►y J . ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem S ®U 0S ❑ U [IS O U ❑ S ®•U ❑ S ®U ❑ S O U SOIL DESCRIPTION REPORT De th Dominant Color Mottles Structure GPD /ft Boring # Horizon P Texture Consistence Botndary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I I Bed ITmnch � o_t0 tO`1 -313 S1,) ZwtSb vn'Fr `�'S � •S •� Z ►o_ZZ 1�yR 3l b Gr sal Zm sb� m'f1� ew _ , s .� •y Ground 3 2Z -3� � •5 `ttZ3ly - S � l CS�k lnlv'Flr cw - • S elev. V I 6k '1 fL y 3y_v s Depth to limiting factor Remarks: Boring # vn E 8 - tiotitz y/3 ss 1 Z�s�1� wt`�� �S •S •b 3 iU ZL uy,Z - t l6 - 6>+si I Z-m s bk w►'�t- �w — •5 , L Ground - . �{ . S elev. 1- SK1Z31 4g-% ft. S 36 -�1$ � • $ `1Q Y,l Zls `? lZ 3 /b S � Oby� V►? l)fL - 13 ,y Depth to limiting factor b, F71 Remarks: T Name - .- Please Print Phone: 715-425-0165 Arthur L. We erer g rer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022 Signature: Date: 3 L .. `3 CST Number: 00 5 7 6 z"i ri 4 ;; — 7 Lr PLOT PLAN Pa 3 of 3 SCALE 1 "= 40 ' fjruRr� W r UN tr - - t4, %�4� 5' FT 01 13 u LJp . 'L1, Rol 8 0 4 BOT. OF 'T�Ui l o e• o ►J 6`l1t16N CTL 1pp � I ! RS' DIA. 1a�C P1Pra' tL °tg 5 V6 zg. — 9. rD' �a1 I �Z��H'�61F, 3 l V` 0 ►� I i PUC PIPE W /�FI I ZS __ tn,49 ° - `� a ►voT CUM PR O�Z v I C�ovS� 41 W ` 0 e emml LO C" , sv Z S • l,1►J�T O� SLS� /y - Ivw /ryt 3l . Z` ( 715 ) 425- - 1'.400576 CST Signature Date Signed Telephone No. CST # Wmwrr�in Department of Industry SOIL AND SITE EVALUATION REPORT Page -L of 3 Labor and Human Relabons Division of safety & Buildings in accord with ILHR 83.05, WIS. Adm. Code COUNTY ST • C�11.x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BIM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. EWED, 8Y 0 9 F 7 APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION c� 8 PROPERTYOWNER: GLUUY- WQXLr6E 1 PROPERTY LOCATION �;,-� �V�te1Z : ACC�l1ZY C�Z, Reff E � S 114 't i"/4,S Z6 T Zip ,N,R \7. E (o PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # S ` - A 7 �" — - �R.oPc�s e� a S►'9 GTY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD Y a �� I" LAvl S�LooZ (111s) C 4 Ru%NA �1V cu vn.r{ �Q New Construction Use rXI Residential / Number of bedrooms 3 [ ] Addition lo existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow LI. SO gpd Recommended design loading rate _ gpcW ' 3 trench, 9fdjft Absorption area required 3- ' S bed, 112 3�S trench, 1`1 Maximum design loading rate • S bed, gpd/ft trench, 9VW Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design/ site considerations w / S xx S ` -E'`� e� h''h E YL °F s+rr'U F t- Parent material s ter► ou t1st Gv-r -I m- - n %-t Flood plain elevation, if applicable N Plt ft $ _ Suitable for system CoNVBJTIONAt MOUND IN- GROINID PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S ®U u S ❑ U EIS O U ❑ S OU ❑ S � U EIS O U SOIL DESCRIPTION REPORT, Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rertctt 0 -10 10`12 vn'� 0"S S A, Z lo_zZ lotitz � Grs�l Zmsbh ��'� cw _ •s ,L Ground 3 ZZ -39 S (z -3 /y — S l Csbk lrlv'F4� c'^' _ .�) • S 9 S ft. y 3y_y S s Ll V-- V/y �z.s�l� wh`�- _ r�� - Z Depth to limiting factor 3y" Remarks: Boring # - S . 1D `'t tZ 3/3 si l ?.m s bh m'�r• °�-S Z \-1 IL y/3 Si I Z`£ S�1t 1yl`�1- cS — •S '•b 3 lU ZL � u tZ 31 - G>^ si [ Zvrl s bk wl'�i- �, — • • L el� y Z c -3 6 — I . S 4g�ft S 36 -�[ $ � • $ �'J Q �� Z-l5 y (Z- 3/,� S � OYy► YY! V �L - .� � y Depth to limiting factor Remarks: CST Name- -Rease Pmt Arthur L. We erer Phone: 715 egerer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022 Sipna4re:/ 8 Dom; 3 V 3$ CST Number 0 5 7 6 PLOT PLAN Page 3 of 3. SCALE 1 "= 40 ' R,yutZ;� w r U•V N - - M \-se LQNsT S' PTLOM r, uD c�hJtnvlZ �1 . 94 0 4�" 1 Z -C� , qq•8' %Or. OF �t ct Ito g Z �DN 6'� 1t �6N,31y" LTl 1pn (? � CIA. 1,VC P1pw zB . 1 PVC 1��PE W /LR'T}I � ; { L'L49 ° - i Oo ►voT cQ�1PR X12 Y U 41 `0 i w�lL Z I � � � l- _ SovT�1 l_uT Lr;v� S- I,�►JtT O'F SLr / /y- ►`►w /cyr 3�.Z� (11 5 ) 4L-0165 CST Signature Date Signed Telephone No. CST # ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer KORY KERR Mailing Address 1620 5TH AVENUE, APT D, BALDWIN WI 54002 Property Address 6D. ed, WY (Verification required from Planninj Department for new construction) Grp) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location SE ' /a, NW ' /a, Sec. 26 , T 28 N -R 17 W, Town of RUSH RIVER Subdivision , Lot # Certified Survey Map # � (Df 9 (a.s , Volume zz, Page # Warranty Deed # 6 U C) , Volume 6 3 Page # Spec house ❑ yes 0 no Lot lines identifiable EY 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 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 APPLICANT 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 r perry described above, by virtue of a warranty deed recorded in Register of Deeds Office. ,� '�/ 2 /9' SIGNATURI OF APPLICANT 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 C\j LLti£ abed Z l ' IoA IM ° oa Mol0 Is Z N N 0 sPaga 10 jolsloay Of Z ° �� HS1VM'HN331H11AI ° 0 uj ? 8661 6 Z Nn 5 �w LL) z p� a31l� w `� W z Lj LO N p J�� - N Zj WO - O U. N 0) +N it w co co N w W Z Z Z SGNV' 03lld�dNn Z.+ o Z N00'1 5'57 "W Via° V) �S 0 0*15 57 E 324.0 ' s �0�5'S7" E —® 2273.44' W 2639.72' NORTH — SOUTI ' Din \ w0 Q yF.. OW Vq«. W. U i. (....: rte, W t-- r r J O a W A,r,_ .t' r W Z N U N O. I r , � � y , W M'°o ^ 1 Y '�I Q i � z ti Z I O 00 uj �- O D Of e 004 z U Lo Ld W a l d' O W 0 O) 0 0 r _Z i w W O C) I N J o N J p i zz c� _ z N w ti Ji N O� i u U N--i I Q z _ �i O �F ; o �o W ^ �W tli 0 ro 3: U w LLJ r Z �� �Q LLJW C) j Q Z Z J Q O O w 00L- 0� ow U LLJ C) 0- I - :2 Z v - CL �+ 168.97' 66.00 W z? N m z rG ,� O �Z xm 0 0., v S00 5 5 0 , E \Z J Q � + o ti0� � N W q �� Z o N �o Ld w V _ Z d fn I M z o