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Home My WebLink About028-1038-90-100 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Address City /State .r�< Legal Description: Lot _� B l ock A/* Subdivision/CSM # f/p 2 . V4 L �4 �C S � ec. -2L T,�N -R1LW, Town of . , v'ivy.- _ PIN # SEPTIC TANK — DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer m c. P Size ST a - 7 L_____ S back from: House -ZL Well j �z P/L , -2R- Pump manufacture_ r Gb edu 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 3 Length 75 Number of Trenches Z Setback from: House 3° , Well �i' P/L �' Vent to fresh air intake 8,0 't ELEVATIONS Description of benchmark 6 � 1� Elevation o o Description of alternate benchmark Elevation Building Sewer ST/HT Inlet 9y zs ST Outlet- PC Inlet PC Bottom 90, o Header/Manifold 9rr, 97, Top of ST/PC Manhole Cover 8 G Z Distribution Lines ( ) () ( ) Bottom of System O 98.6 3 O 9� �� ` Ot b��s Final Grade O 16-Z , O O ( ) Date of installation / LI M Permit number 3l SB 3 State plan number Plumber's signature �,rw License number :L L62 z Date /a w/M Inspector gad Complete plot plan x Wisconsin Department i Div Commerce PRIVATE SEWAGE SYSTEM Count Safetyand Buildings Divi /' y ST. CROIX INSPECTION REPORT v GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar 1 Pegdn $ V.: Personal information you provice may be used for secondary purposes [Privacy s.15.04 (1)(m)]. Permit Holder's Name: ❑Uitv� Town of: State Plan ID No.: IELSEN, MALCOLM R $ CST BM E lev.: Insp. BM Elev.: BM Description: Parcel a o.: 10-0 &V ,. a,� �� b - 1o3s -90 -000 TANK INFORMATION L%^G ELEVATION DATA A9800225 TYPE MANUFACTURER STATION BS HI FS ELEV. Septic �--- �4� "a l0 Ben a I�g U0 Dosing Aeration Bldg. Sewer Holding �S /4 Inlet 1 t1, 1 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. A ir ir I to ntake ROAD Dt Inlet A Septic ��&� N NA Dt Bottom 1'7 Y �?•3 qo . Dosing rl N •r �� NA Header /Man. t x�OG /DO Aeration A Dist. Pipe 2r,3'r Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade ( �f ( , Manufacturer Dz! U s Demand Model Number �� GPM TDH Lift q,3 Friction System_ TDH Ft FHe Forcemain Length 1?5' Dia. rf Dist. To Well SOIL AB TION SYSTEM BED / Width , � Length No. Of T PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N 3 DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA G Manufacturer: INFORMATION Type O q CHA Syste / I �� OR UNIT er. DISTRIBUTION SYSTEM 30;" . &onkt4o Header/ Manifold Distribution Pipe(s)/ I� x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length ^Bra. 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: RUSH RIVER 27.28.17.239,SW,SE 119 185TH STREET Plan revision required? Yes ❑ No Use other side for additional information. E2 MCV-2 : F;7 S SBD -6710 (R.3/97) Date Inspector's Signa ure Cert. No %6consin SANITARY PERMIT APPLICATION 201 ahingtonAvenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81 x 11 inches in size. CX • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for seconda ry Purposes [Privacy Law, s. 15.04 (1) (m)]. ❑ Check it revision to previous application I. APPLI ATI N INF RMATI N PLEA E PRINT ALL INF RMATI N State Plan I.D. Number Prope y O ner Name P opert Location ''n /G'!C SQ7i /4 ,, 1/4,S -;Z T 2g , N, R I Sor)o Property Owner's M iling Address Lot Number Block Number 1 t P; sf Crty.state l Zip Code Phone Number Subdivision N me or CSM Number �[ �� o 15 ( ?Y3 ) � laf / Z a ZS I . E B ILDIN : (check one) [I State Owned o C ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 E] t o age - own OF Ct.Q' /(/�/� s S� III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo /038 — Qo 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 a Sys 2 E] Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an _____________________Y_ P _____ y _______ Tank Only__ ________ ____ Existing System ---- Existing System B) E] 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 XSeepage 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. 7. Final Grade y � D Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) �� 7 Elevation 7 3 r 2 � Feet Jot. Z. Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per. New Existin Gallons Tanks Concrete Con- steel glass Plastic A p p Tanks Tanks structed Septic Tank or Holding Tank 1 4 1 40 �'- /do0 f LcJ,a¢k S 9 1:1 1:1 E] 1:1 O Lift Pump Tank /Siphon Chamber El 11 El ❑ 1:1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe ' Name: (Print) Plumber's Signature: (No St IMPS) MP /MPRSW N o.: Business Phone Number: __ - +�!/ / c Plumber's ddress(Street, City, State, Zip Code): 7/5 — 772 Z IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL IREASCYNS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber 06/11/98 THU 09:25 FAX 715 684 2666 ST CROIX CO- UWEX /LWCD 16 001 em cum LAND & =10 Co noN DEP[ 1960 8th AMOK PA 6=95 BAWMK WI FAX FAX NO. 1 -715- 684 -2666 z - Date: From:E (S'� Number of pages including cover shee If complete and legible information is not received, please contact: Name: Telephone R: 1- 715 684 - 2894 - 06/11/98 THU 09:26 FAX 715 684 2666 ST CROIX CO-UWEX/LWCD 0002 TIMM EXCAVATING SHEET No. OF Route I Box 192 WILSON. WISCONSIN 54027 CALCULATED By- A�oe u PATE (715) 772-3214 (725) 386-5443 DAIM MPRS 03224 WI MPCA 0696 MM C HECKED BY L k . .......... Z 7Dr . ... ........ . . . . ..... . ......... ....... . ..... . . . I .......... .... ...... ..... . ........ ......... ......... ......... ....... ........... .......... . .. . ...... . _71 .. . .. . .. ............. . - 7 ...... . ..... . ....... ... ...... ... ....... ........... ..... ... I .......... ........... ............. - . . . .. . . .. ............. ....... ... j .......... .......... .. ..... ........ ._..... ...... ........... .......... .......... ... .. ........ .. ........ .. ........... fi .......... . ...... .......... .... ........ ..... . ............. -A ........... .......... ............ . .......... ... .. ..... .. .......... r .. .... ..... . .... . ... ...... .. ............. ....... .......... ....... ........... . ................... ......... . ... 71' .................. ........... i.-.;/ ... ......... i.l....".... j .......... . 11 ........... ...... ... .......... . . ...... .......... ........... I ........... ........ .. ------------ - 7 - & ... .......... . ..... . ...... .......... .... ........... ......... . . . ......... ........... ....... ......... . .......... -4 ..... . ..... ..... . .. . . ....... . ............. ........ ... .. Z . ...... .. .. .. .......... .......... . ....... ... .......... ..... ..... ..... ..... ........... --------------- ----- f ......... . T ........... ........... ------- .......... ............. I .......... .... . .......... ....... .......................... ...... - ------------------- r ...................... .......... ......... . . ...... .......... .................. .... . r .. ....... ..... ........ ...... . . ................. . .......... .................... ....... . .... ...................... ... . ..... ........... . ... ........ ..... ........ I . ............ ... .......... ...... ........... ........... ..... ..... . ....... ... .. ........ ........... . . ... ........ . ...... . .. . .. ..... .7- ... . ....... ......... .. .......... . -- - ---- - -------- .......... .......... ........ x 1 , .......... . ..1 14Ak7 ... .. ... . .......... . ................. .... -I ...... ... ------- ....... .. A . . ....... .......... ........ .. .......... lll-.� ....... ........... i A a "el ez . .. ......... zoo ]A 0141MOZ 0:) xxa is ovot owe sTL YVA TV! No rM VG/TT/90 EROSION. CONTROL PLAN CHECKLIST Joi e Q Check (./) appropriate boxes below, and complete the site diagram with necessary information. Site Characteristics North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways. ❑ Location of existing drainageways, streams, rivers, lakes, wetlands or wells. ❑ ❑ Location of storm sewer inlets. !9 Location of existing and proposed buildings and paved areas. The disturbed area on the lot. ❑ Approximate gradient and direction of slopes before grading operations. ❑ Approximate gradient and direction of slopes after final grading operations. ❑ Overland runoff (sheet flow) coming onto the site from adjacent areas. Erosion Control Practices 7 Location of temporary soil storage piles. Note: Soil storage piles should be placed behind a sediment fence, a 10 foot wide vegetative strip, or should be covered with a tarp or more than 25 feet from any downslope road or drainageway. Location of gravel access drive(s). Note: Gravel drive should have 2 to 3 inch aggregate stone laid at least 7 feet wide and 6 inches thick. Drives should extend from the roadway 50 feet or to the house foundation (whichever is less). - Location of sediment controls (filter fabric fence, straw bale fence or 10 -foot wide vegetative strips) that will pre- vent eroded soil from leaving the site. ❑ )I Location of sediment barriers around on -site storm sewer inlets. ❑ ❑ Location of diversions. Note: Although not specifically required by code, it is recommended that concentrated flow (drainageways) be diverted (re- directed) around disturbed areas. Overland runoff (sheet flow) from adjacent areas greater than 10, 000 sq.. ft. should also be diverted around disturbed areas. ❑ Location of practices that will be applied to control erosion on steep slopes (greater than 12% grade). Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions, and re- vegetation by sodding or by seeding with use of erosion control mats. ❑ Location of practices that will control erosion in areas of concentrated runoff flow. Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod, and rock rip -rap. When used, a given in- channel barrier should not receive drainage from more than two acres of unpaved area, or one acre of paved area. In- channel practices should not be installed in perennial streams (streams with year -round flow.) ❑ A Location of other planned practices not already noted. a Indicate management strategy by checking ( ✓) the appropriate box: Mahagement Strategies K ❑ Temporary stabilization of disturbed areas. Note: /t is recommended that disturbed areas and soil piles left inactive for extended periods of time be stabilized by seeding (between April 1st and September 15th), or by other cover, such as tarping or mulching. Permanent stabilization of site by re- vegetation or other means as soon as possible (lawn establishment). Indicate re- vegetation method: Seed N Sod ❑ Other El Expected date of permanent re- vegetation: 1' Re- vegetation responsibility of: Builder ❑ Owner /BuyerA Is temporary seeding or mulching planned if site is not seeded by Sept. 15 or sodded by Nov. 15? Yes-, No ❑ ❑1 Use of downspout and /or sump pump outlet extensions. Note: It is recommended that flow from downspouts and sump pump outlets be routed through plastic drainage pipe to stable areas such as established sod or pavement. ❑ X Trapping sediment during dewatering operations. Note: Sediment -laden discharge water from pumping operations should be ponded behind a sediment barrier until most of the sediment settles out. Proper disposal of building material waste so that pollutants and debris are not carried off -site by wind or water. IK Maintenance of erosion control practices. • Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to half the barrier's height. • Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing straw bales will be replaced (typical bale life is three months). • All sediment that moves off -site due to construction activity will be cleaned up before the end of the same workday. • All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday. • Gravel access drives will be maintained throughout construction. • All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized. For more assistance on plan preparation, refer to Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code, the DNR Wisconsin Construction Site Best Management Handbook, and UW— Extension publication Erosion Control for Home Builders. The Wisconsin Uniform Dwelling Code and the Wisconsin Construction Site Best Management Handbook are available through State of Wisconsin Document Sales, 608/266 -3558. Erosion Control for Home Builders (GWQ001) can be ordered through Cooperative Extension Publications, 608/262 -3346 or the Department of Industry, Labor and Human Relations, 608/267 -9360. • � TIMM EXCAVATING �� // Route 1 Box 192 SHEET NO. OF L WILSON, WISCONSIN 54027 CALCULATED BY — DATE 7 w (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE Ni .. .... .........; .... . ............................... .....:..........s....... .... .... .... .... '.... 4 1414 °... N... .;.. ....... .,. .. 1 / ... - .` .. .. ..... . 0 .. ..... ..... ...... . ... ....., i fy � �. ........ ....... i .... u ... N. ... ............... J ♦' ..... ..� .... / ......... � ` \�`.�. fi � ......... ,... -. :. ........ t ... IRt �. ... D_1s� r� ell... ..... ....._.. . _. .._ ...,... ... .. f _.......... _. ,...,,.. / ...A�.�i.,. ..IQ. ......... ................... . y i PRODUCT 205-1 �• Inc, Groton, Mass. 01471. To Order PHONE TOLL FREE 1-000-225 -6380 TIMM EXCAVATING a SHEET NO. Z OF Route 1 Box 192 WILSON WISCONSIN 54027 CALCULATED BY r DATE (715) 772.3214 (715) 386.5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE i Fj t 101 [Al -4-4- ' ... .... _ .. i 3� bJ ..... ........ PRODUCT 2054 ®Inc., Groton, Mass, 01471 , To Order PHONE TOLL FREE 1- 800.22 -am Mimi" A sconsin Deii e N age 1 of 3 Uivisiori of Safety and Buildings In r with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less tharti 8t4 x 11 iir laze. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.# 028 - 1038 -90 -0000 APPLICANT INFORMATION - Please aCkformation. R2! B . Date Personal information you provide may be used for a-a purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner ,;; / ".. , property Location Nielson Malcolm rx .! Gpvt Lot SW 14 SE 1/4 S 27 T 28 N,R 17 W Properly Owner's Mailing Address " L # Block # Subd. Name or CSdIA# 101 185th St. x ' CSM Pending For N 1/2 Above 40 City State 74-09de PFton City Village ®Town Nearest Road Hammond WI '54015 =3748 Rush River 185Th St. ® New Construction Use: ® 'Regidantial / Number of t@ grams 3 ❑Addition to existing building Replacement Pub I cpm" ' de Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpolfF .6 trench, gpd/ft= Absorption area required 900 bed, f? 750 trench, RE Maximum design loading rate .5 bed, gpd/ftz .6 trench, gpolft' Recommended infiltration surface elevation(s) 98.7 ft (as referred to site plan benchmark) Additional design / site consideration s' nstall 2 - 3' x 72' Sidewinder, Hi- capacity "turtle - shell" trenches Parent material fluvial outwash Flood plain elevation, if applicable NA ft S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ®S ❑ U ® S El ® S C] U ® S ❑ U ❑ S ®U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft' Boring# Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Trench .................. 1 0 -10 10YR 3/2 - sl 2 m cr mvfr cs If/m .5 .6 2 1 -22 l OYR 4/6 - A 2 m sbk mvfr cs l m .5 .6 Ground 3 22 -80 IOYR 4/4 - mcos 0 sg ml - if .7 .8 elev - 102.1 ft Depth to limiting factor > 80" Remarks: occasional inclusions 10YR 4/6 s in horizon 3 ................. ..,2..... 1 0 -10 10YR 3/2 - sl 2 m cr mvfr gs If/m .5 .6 2 10 -28 7.5YR 4/4 - sl 2 m sbk mvfr cs If .5 .6 Ground 3 28 -60 IOYR 4/6 - mcos 0 sg ml cs Ira .7 .8 elev — 100.8 ft 4 60 -80 7.5YR 4/4 - lmcos 0 sg m1 - - .7 .8 Depth to limiting factor > 80" Remarks: size for 0.6 loading rate due to moderate sl structure observed at depth in B4 CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -665 -2681 Address P.O. Box 57, Knapp, WI 54749 Date CST Number Ref # 2/14/98 222774 232 ', � M 1.'a.p1ti.. ��! ��`SO,.. � 1��er �� s�,� 02.8- �01�•to -d000 1 KI'L- S- L- •• -1� w li -`o N I 1�AY o Z o 4 6K 4p I aQ�►V��i- �•� T ��, r�.� 1 9 S 4A.- «fie �o .+a a S s►s�C S 1•�� eo . p J�v ?(` 1 UL Z r Cc, �-++ > moo' a. 44v- r 1 �i 0 Wisconsin Department of Comm SIT C EV L A O r Page 1 of 3 • t7ivisiori of Safety and Buildings mm 83.05, Wis. Adm. Code Attach complete site plan on paper not less rn nce n Plan must County include, but not limited to: vertical and horizontal refereB direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. St. Croix Parcel I. D.# APPLICANT INFORMATION - Please print-all information. 028 - 1038 -90 -0000 Personal information you provide may be used for §�`oP d`�ryi purposes (Privacy Law, s. 15.04 (1) (m)). R I y Data 3 Go 9� Property Owner Property Location Nielson Malcolm f C-1 Govt. Lot SW 14 SE 1/4 S 27 T 28 N,R 17 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 101 185th St. �- I ' `' CSM Pending For N 1/2 Above 40 City State Code �on�y u ;r 0 City ❑ Village ®Town Nearest Road Hammond WI 5015 7( -3748 ' ' Rush River 185Th St. New Construction l'feential / Ntim �r , ms 3 ❑Addition to existing building Replacement Use. ❑ k- arcomrr a - i l' ` be Code Derived daily flow 450 gp� Recommended design loading rate 5 bed, gpolft' 6 trench, gpolft' Absorption area required 900 bed, ff 750 trench, V Maximum design loading rate .5 bed, gpd/ft° .6 trench, gpd/ft' Recommended infiltration surface elevation(s) 98'7 ft (as referred to site plan benchmark) Additional design / site consideration si r'stall 2 - 3' x 72' Sidewinder, Hi capacity "turtle shell" trenches Parent material fluvial outwash Flood plain elevation, if applicable NA ft S= Suitable for system Conventional Mound In-Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ®S ❑ U ® S ❑ U ® S ❑ U ®S ❑ U ❑ S ® U ❑ S ® U ' SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPDN Boring# Horizon in Munsell Qu. Sz. Copt Color Texture Sz Consistence Boundary Roots Trench ................. .................. 0 -10 10YR 3/2 - s1 2 m cr mv& cs 1 f/m .5 .6 1 -22 10YR 4/6 - sl 2 m sbk mvfr cs lm .5 .6 Ground 3 22 -80 10YR 4/4 - moos 0 sg m1 - If .7 .8 elev 102.1 It Depth to limiting factor > 80" Remarks: occasional inclusions 10YR 4/6 s in horizon 3 2 a 1 0 -10 10YR 3/2 - sl 2 in cr mvfr gs 1f/m .5 .6 " "•• 2 10 -28 7.5YR 4/4 - A 2 m sbk mvfr cs if .5 .6 Ground 3 28 -60 l OYR 4/6 moos 0 sg ml cs 1 m .7 .8 elev 100.8 it 4 60 -80 7.5YR 4/4 - lmcos 0 sg ml - - .7 • .8 Depth to limiting factor > 80" Remarks: size for 0.6 loading rate due to moderate al structure observed at depth in B4 CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -665 -2681 Address P.O. Box 57, Knapp, WI 54749 Date CST Number Ref# 2/14/98 222774 232 • �1 �ol�.. ��) 2.�YC .. — ��m� �� 6•a.� OL2 -10'i1 - 'to —n000 +,. c9 .S' ....r 1s � S .�X�. ►" ,. 4p � K'1 � - $ `'� - S lc - 2�• • 'Z � - 1 } w 1 1 SAY ( IL z-� 6K k -3' C102.2� lie �l 5 �.�•� (�' I � r �1 s+„ �••► 4 i s�G 4.y ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer /'" I61 GC-1, M Nth L SF AJ Mailing Address l U y / g J 1-11 5t �-l� N�Ni o�v (,J-� 5v-61 Property Address � `7 _ �g� rh �. .,�u."„»� �� l rfr, o /S N (Verification required from Planning Department for new construction) . City/State _ IdjkV'^l Gin wl Parcel Identification Number BLS —/d 38 - 4a LEGAL DESCRIPTION Property Location - 514 - ) %4, _ 5 E '/4, Sec. T_,,aN -R_Z7 W, Town of lew h j i xr Subdivision Lot # Certified Survey Map # 6 & 7 , Volume Page # 3' yozS Warranty Deed # _`� co- Sa . Volume , Page # Spec house ❑ yes W no Lot lines identifiable F yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 thy, owner and by a masterplumber , journeyman plumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewat:,-rdisposal 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. I/we, 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 stag 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. SIGNATURE 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 (ar4:) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. la / s8 SIGNATURE 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 l �. o� FlL'E� 3 MAR 2 4 1998 f� KpTHLEENH• 4 Roglster of Deis St. GroixCo�Wl 575678 � s CERTIFIED SURVEY MAP Malcolm and Barbara Nielsen Part of the Southwest 1/4 of the Southeast 1/4 of Section 27, Township 28 North, Range 17 West, Town of Rush River, St. Croix County, Wisconsin. NORTH 114 CORNER SEC. 27, T 28 N, R 17 W (BERNTSEN ALUM. MON.) i i � O 7 UNPLATTED LANDS *� 01 FENCE NORTH LINE SW I/4 - SE 114 SEC. 27 FEN EF ZI = - -- N 89 29 00 E 1305.96 -- 1272.96 1 � 0' ENCHMARK g O TOP I' IRON PIPE l OI ELEV.:100.00 ZI (ASSUMED) / Q� 33 33'I / � N tl (3 LLJ I LOT en K _ to E•II ( SETBACK LINE FROM W tnl 3 871, 257 SO. FT. OR 20.001 ACRES HIGH WATER MARK �y 3 e (INCLUDING R /W) J N N lip �2 849,216 SO. FT. OR 19.495 ACRES \ t g O W 2 W Ip O �`j (EXCLUDING R /W) �r.1y Q ( A o o I x �Q cn W LU 2 2 �m Note: An erosion control plan must \ I C.)� v. H be submitted to the St . Croix County Zoning z 00, IQ Office prior to construction on this parcel f A) Q ��33 33I �0 BEPPNCF(MgBARK / dl(�211 ATER E LEV. = 5 7 6 J Z, J� '� I EOEV �= I270.00� N ZI� i j� - - -S 89 2900" W 1303.00' - -- W UNPLATTED LANDS L EGEND 1 ` SOUTH 114 CORNER INDICATES I "x 24 "IRON P /PE SET SEC. 27,T28N,R17W O (BERNTSEN ALUM. NON.) (M /N. WT. —/./3 L85.1L /N. FT.) INDICATES SECTION CORNER MONUMENT IS (AS NOTED) OWNERS ADDRESS - /O/ 185th Street This Instrument Dratted by Mork W. Peavey Hammond, WI. 54015 ::1 - ,�� 1t1111/1/ ��yl , % q �� \ SC O NSA 'LAUREN d Dated: December 30, 1997 "' " "`' .`. _ : %n/ �AII o v oc