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HomeMy WebLinkAbout030-1009-40-300 0 10 E 7 \ T T 2 m � CDA co 0 0 o ° e - . 1 R S S �, a / /\/ a\ k o k , E J @ § o \_ \ / ( k \� --I k \ to § ©e �k 0 - � E 7 @ > F f ; a © / / § $ \ CD ~` CL o ` 0 k § ` § E / co £ n § E r � co « 2 : � � 2 z o o o 2 - ® z § � G: < z § / g : (n (A Co) % > E ` 3 v § o v % 2 $ \ g z w � f \ g > , 0 ? I � \ / c o CD N � u \ q E i 0 \ � _2 z m g / � / $ < 0 w , § § 2 ° f z - / z % 7 %ƒ\ 0 � A \ % ƒ _ k � / � \ m / . � CL \ $ � k ! \ 0 % w < 4 \ f c % � 8/ ' R7 . � ST. CROIX COUNTY ZONING DEPART l AS BUILT SANITARY REPORT "' -. Owner / d , C Address City /State ��!s��J IQgB c�n Legal Description: \. INGc) FcE A` •. j' Lot - 7 Block Subdivision/CSM # '/, -LY-J/, AXJ Sec. , `LaN -RAW, Town of . G t s' d2 PIN # OZO - 106 -(/0 ? i SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer *lzo e ;; yy Size ST/PC /dva / dO�J Setback from: House Pump manufacturer 1,u�/ _ .� Well 5�4 P/L Model � ao �// Alarm location (HOLDING TANKS TANKS ONLY) Setbacks: Service road Vent to fresh air intake ater Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: If 4) Width _._e Setback from: House _ <d'�- Welln --�— Number of Trenches 2 - PR- Vent to fresh air intake fd ELEVATIONS Description of benchmark P_ Description of alternate benchmark Elevation Elevation Building Sewer (F ! �D ST/HT Inlet r-5 5�,T ST Outlet PC Inlet PC Bottom Header/Manifold 73 Top of ST/PC Manhole Cover '5 d Distribution Lines Bottom of System( Final Grade Date of installation L/-el Permit number ./ S f State plan number Plumber's signature �.,;�� License number . LSD Date It / Inspector Complete plot plan or Wiscopsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar5Mt6 "d_: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. arm il Alder' (pe: �Lty [J&a Litt'' p Town of: State Plan ID No.: EllCCev.: 11'vUPM1 Insp. BM BM Description: B Description: 11 CST IIJJttLL BIVI U J V V Parcel Tax�Dlo_:1009- 40-'300 � �/ l � - 76 6 Z 1 rlc k ��6 / U lJ TANK INFORMATION ELEVATION DATA A9800346 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �)� A, `, !' /,.} Dosing �: � fv1 8161M 2- 55 hz. a e� Aeration Bldg. Sewer g r � Holding St/ 0 Inlet 5 0, 355 TANK SETBACK INFORMATION St /W Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic o 50 I 28 -t NA Dt Bottom fT 3 Dosing r* -, '' �Z' NA Header /Man. - 7.0 'N. T3 Aeration NA Dist. Pipe n .� - 7.b 6 Holding Bot. System 7,73 7.78 g5,6Zelt'3 PUMP/ SIPHON INFORMATION D Final Grade 7B. Manufacturer <� a Demand f Model Number Pa C/ 2 4 GPM TDH Liftp_.j I Friction System TDH Ft Loss P ead Forcemain Length Y Dia. '' Dist. To Well SOILABSORPTION SYSTEM °r BED RE Width S > Length / No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM NS DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAC Manufacturer: SETBACK CH MBER INFORMATION TYpe�'11✓`Gtr /�' � /�� OR _� Model N er: / DISTRIBUTION SYSTEM Header /Manifold r/ Distribution Pipe / I x Hole Size x Hole Spacing Vent To Air Intake Length 12 — Dia. IL Length _ Dia � Spacing t0 ��'v( �jC_ Z'] Z ZC� 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 Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 3.29.19,NW,NW 1187 61ST STREET — LOT 3 f ��. ?j� - '✓L66 Plan revision r'equired7 Yes o Use other side for additional inform—St—lo—in. (a - l 1 SBD 6710 (R.3/97) Date Inspector's ignature / ert No. Safety and Buildings Division + 201 E. Washington Ave. Vi scons i n SANITARY PERMIT APPLICATION P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. '5'7 Yo • See reverse side for instructions for completing this application State Sanitary Permit Number you provide may be used b other government a nc ro rams �o S�jCo The information Y P Y Y 9 9 P ❑Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. / / (7 2.� ,S?� S/ i lS 7 State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propert Owner Name Property Location �/1 /4W4,j 1 3 T _2 ,N, E(or) Property Owner's Mailing Address Lot Number T�ber r! a r,J 3 City, State Zip Code Phone Number Subdivision Name or CSM Number /O CZ Q kyd'd 1( 7 9 II. TYPE F BUILDING: (check one) E] State Owned E] C it y Nearest Road sy ❑ village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) 1 ❑ Apartment/ Condo ®3 d-loa 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 line B, if applicable) A) 1. [Z New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ______System ________ System Only System _ __ Existing System B) M Sanitary Permit was previously issued. Permit Number �7(pC1(p Date Issued 7 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 [K Seepage Trench 22 ❑ In- Ground Pressure f I 42 E] Pit Privy 13 ❑Seepage Pit �" )( - 7S 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. AB SORPTI ON 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 (s q. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation �co 7 0 4 73 4D Feet 9 7, /Q Feet Capaclt VII. TANK in gallons Total # of Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturers Name concrete Con steel glass Plastic App Tanks Tanks New Existin structed Septic Tank r Holding Tank �Q C x .,� ❑ ❑ ❑ ❑ ❑ Lift Pump Tau Chamber X ❑ I ❑ I ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number: Idl A" ' ,s 7 ( C /,.4 / Plumber's Address (Street, City, State, Zip Code): .Sc a Z'7` Gc/ ' 6 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fe (Includes Groundwater ate sue ssuing Ag t S' re�pl Stamps) Approved ❑Owner Given Initial '1 �urchargeFee) I q Ad verse Determination O ac X. CONDITIONS OF APPROVAL / REASONS F DISAPPROVAL: SBD4M (8.11/96) DISTRIBUTION: Original to County, One copy To: safety 6 su"n"s Division, Owner, Number o J i I ' n No d '< r z, P A r, t I)-- G a PUMP CHAMBER CIROS5 SEC IOW AUG SPECIFICA VEUT CAP 4`C.I. VENT PIPE WEATHERPROOF _APPROVED LOCKIKIG > ?_5' FROM DOOR, JLJJCTIOU BOX fAAMHOLE COVER - WINDOW OR FRESH 12 "Mill. AIR IAITAKE I GRADE I `__ IB'MIW. COIJOLIIT 11� INLET PROVIDE AIRTIGHT SEAL *� A I II \* � I � b ( II c *APPROVED i i Ow JOINTS WITH ELEV FT. APPROVED PIPE - -� 3' ONTO PUMP �, OFF D SOLID SOIL ` CONCRETE 5LOCK RISER EXIT PERMITTED OWLy IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC f SPECIFICATIOUS DOSE TANKS MANUFACTURER: ,t2cdcy 7esr.� IJLIMBER OF DOSES: PER DA-`! TAWK SIZE:- GALLOIJS DOSE VOLUME ALARM MANUFACTURER: e UEi n,- IMCLUDING 6ACKFLOW: Zal- ^ W' G M ODEL AIUMBEK: - 421, CAPACITIES: A = h% IWCA1S OR ,ADO GALLOWS SWITCH TyP �I PY B = _— It,ICNES OR 3 `r GALLOWS PUMP MANUFACTURER: e «!„!s C =_ �IWCHES ORGALLOlIS MODEL KIUM6ER: � D- 1/1- /_011IHES OR 1 GALLOMS SWITCH TYPE: _ eH NOTE: PUMP AMD ALARM ARE TO DE MIKIIMUM DISCHARGE RATE - A il/ 6PM INSTALLED ON 5EPARATE CIRCUITS I VERTICAL DIFFERENCE OETWEEAI PUMP OFF AUD DISTRIBUTION PIPE.. _L_L_ FEET + MINIMUM METWORK SUPPLY PRESSUR'r,E:. , FEET + - � FEET OF FORCE MAIIJ X �_ /ooFLFRtCTION FACTOR.AZY FEET TOTAL 091JAMiC. HEAD FEET INTERKIAL DIMEIJSIONt OF TAUK: LEKIGTH ;WIDTH iLIQUID DEPTH i Goulds�� Submersible Effluent Pump a J C� 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas- • Homes components. Available for automatic and tic cover with integral handle • Farms Motor and float switch attachment • Heavy duty sump • EPO4 Single phase: 0.4 HP, manual operation. Automatic points. • Water transfer 115 or 230 V, 60 Hz, 1550 models include Mechanical RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty • Dewatering automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 built in overload with construction. • Solids handling capability: automatic reset. IN EPO4 Impeller Thermo - 3 /e' maximum. • Power cord: 10 foot plastic Semi -open design AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO with pump out vanes for • Total heads: up to 24 feet. with three prong grounding mechanical seal protection. SP• Canadian Standards Association • Discharge size: l'h` NPT. plug. Optional 20 foot ■ EP05 Impeller. Thermo- ` plastic enclosed design for • Mechanical seal: carbon- length, 16/3 SJTW with p (CSA listed model numbers g rotary/ceramic- stationary, three prong grounding plug improved performance. end in "F" or "AC ".) BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 i • Capable of running —T -- -- — - 4 -- - dry without damage to 9 - 30 components. Pump: EP05 - - - -- — -- - - -- • Solids handling capability: 0 25 Y4 maximum. Q 7 I I LU • Capacities: up to 60 GPM. = U 6 20 • Total heads: up to 31 feet. • Discharge size: 1 NPT. a — - -- - ! — • Mechanical seal: carbon- } s �— -- - -- rotary/ceramic - stationary, � 15 i BUNA -N elastomers. 4 - -- ' p — EP05 • Temperature: s 10 ; 104 °F (4M) continuous 140°F (60°C) intermittent 2 - 5 i 1 0 00 10 20 '30 40 50 GPM 0 2 4 6 8 10 12 m'Vh CAPACrTY A 1995 Goukk Ptr I- i Wisconsin Department of commerce SOIL AND SITE EVALUATION Division of safety and Buildings Page of 3 Bureau of Integrated services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and :57 CVo r X percent slope, scale or dimensions, north avow, and location and distance to nearest road. Parcel I.D. # 3 © -l009 -�� —2 APPLICANT INFORMATION - Please print all information. Revie Da Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). v Property Owner Property Location n ow u Govt. Lot 1/ • T ; Zc� ,N,R / 9 E (or4 Property Owner's Mailing Address Lot # Block# Subd. Nam or CS a /­ a.0 e a) 1- 1 1 /o 0 City State Zip Code Phone Number ❑ City ❑Vill Z) Town Nearest Road do u e-v S.5"3oY ) C New Construction Use: Residential / Number of bedrooms ddWon to existing building Replacement (pow ❑ Public or commercial - Describe: Code derived daily flow - 75C> Recommended design loading rate gi bed, gpdHt trench, gpd/ft Absorption area required j G 4'3 S gy bed, ft SG.� trench, ft 2 Maximum design loading rate 9 9 _Z bed, gpd/ft - _F trench, 9Pd/ft Recommended infiltration surface elevation(s) q-?• A 0 AL T 5"Y /d ft (as referred to site plan benchmark) Additional design/site considerations Parent material � ,. 2t!4'_ 4 /%ti - Flood plain elevation, if applicable �^ ft S = Suitable for system Conventional Mound In -Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system (J S❑ U ®S ❑ U 23 S ❑ U El s ❑ U ❑ S a U CIS O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 6 -8 Z 0 R4 2 j -�_- 'o Y s"< Ground .3 7 . �t elev. Depth to limiting factor Remarks: Boring # a 7 2 4'e y2 l s r Mll/l? ::5 6J Y Ground �/ $' /( 7 elev. 9L�ft. s a & — CAS c eJ Depth to limiting factor EL — in. Remarks: CST Name (Please Print) Signature Telephone No. �� a Scl7a X , gli�21 Address Date CST Number l 1410 .227���� h � 1 0,2 S r4� 7" S ; re Ylr ay h 4 e fv d e C 7 71e,&,- d •7 b�sail SANITARY PERMIT APPLICATION 20 1 fety and Buildings E. WashngtonA Division . ,- NVisc©nsin P.O. Box 7969 Department of Commerce acco with ILHR 83.05, WIS. Ad m. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less county than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number 71�,6:P The information you provide may be used by other government agency programs ❑ 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 Property Location '.) /a V W Zia, S 2 T �Z Cl , N, R /9 E (or ) Property Owner's Mailing Address Lot Number Block Number /—a V Zd City, State Zip Code Phone Number Subdivision Name or CSM Nu er �T3 I1. TYPE LDING: (check one) ❑ State Owned ❑ it Nearest Road Public 1 or2 Family Dwelling- No. of bedrooms x Tow OF O III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) - 3 � EQ � �'- Y� � 1 E] Apartment/ Condo 090- 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 online A. Check box on line B, if applicable) A) 1. 14 New 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System ________ System_ _ ___________Tank Only______________ Existing System ________ Exlsttnq5ystem 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 ja 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 S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min_/inch) Elevation r'o Q0 '7 9y1 q Feet Feet Capacit VII. TANK in gallo s Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer Name Concrete con- Steel glass Plastic App New Exist in structed Tanks Tanks Septic Tank ortfvfdrny7btrk- 1 LS'��v,�! ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1:1 11 11 El 11 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur : (No Stamps) &WMPRSW No.: Business Phone Number: leer 2 713 - 3 Plumber's Address (Street City, State, Zip Code): Id 7 o �- sa d 6 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Approved =58 Issue Issui ent Si nature (No Stamps) F1 0o Su Owner Given Initial rcharge Fee) J u Adverse Determination i X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD (8.11/96) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plumber .�L d N a T 5 INt�d vj "4 fh P( - I' 75 s ,� Yf o Po4�Ol vJG�� �� X1 uA oVa+ A Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of L o&r and Human Relations Division of §p Building & Buildi - in actor , Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 1 inches in size. st include, but not limited to vertical and horizontal reference posit ), diredon ar% of scale or PARCEL I.D. # dimensioned, north arrow, and location and dist 'e ' o neare*'�. a&,'-I,_' APPLICANT INFORMATION- PLEASE PRJI4y4(jNFO4fiWAtJO REVIEWED BY DATE PROPER OWNER: - r PROPERTY LOCATION C3QVT.'`LOT 1 ,v 114& 1/4,S T N,R K(o& PROPERTY OWNER' AILI DRESS N CO'# BLOCK # S UBD. NAME OR CSM # CITY, S ATE ZIP CODE (HONE N _ ❑CITY QVIL GE MOWN NEAREST ROAD [)!J New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow - " gpd Recommended design loading rate 7 bed, gpd /0 gpd /ft Absorption area required � bed, ft2 _S--Z,? tre ch, ft Maximum design loading rate 7 _ bed, gpd /ft - trench, gpd/ft Recommended infiltration surface elevation(s) q ft (as referred to site plan benchmark) Additional design / site considerations Parent material ' _ Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 14 S O U I 0 S ❑ U 0 S LI U ❑ S O U ❑ S ZU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots // in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .................. ?Y a GJ S Ground s� s elev RZ ft. — s Depth to limiting factor Remarks: Boring # 1 1/1 A,1 Z. Ground 3 elev. 1 2id ft. Depth to AI J ' ° _ limiting factor Remarks: CST Name: — Please Print , Phone: A ddress: Signature: Date: C CST Number . /` r � � ��olz �9 cs� 'sue A_ I� � ,w ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer cstin. ' / to r y1RlV Mailing Address 0 139 s" 3 Property Address Zzrt (Verification required from Planning Department for new construction) City /State Parcel Identification Number Dab - /1�P�' -30a LEGAL DESCRIPTION Property Location W &u '/4, /V 0) ' /4, Sec. \, Tl_N -R Town of a se Subdivision , Lot #. Certified Survey Map # 2 7 ffl'7S , Volume /0 , Page # - Warranty Deed # 5 306 , Volume /la 1 , Page # 1x'73 Spec house ❑ yes 19"'n Lot lines identifiable Oyes ❑ 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 licensedpumper verifying that (1) the on -site wastewaterdisposal 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 day�,athe three year e�tion 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 (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 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 0 Z m m S � cn r rr 0 ! "�i��� LANDS ulZ rt O WEST LINE OF THE NWI /4 SECTION 3 Z ; p I j D O O p, S00001 w., S00 ° 01'40 "W wm 0 qm X 1J S00 W 599. 62 83.00' °m n N M $ m f 1879.53' 509.11' 90.51' M O 'Z7 ^ i a - -�I Z W on 0) Z 3r— zm w � E y� O ?�Q w _ 1 U1 a : 1 OD z D 0,S 0 C'0, - (1� ?-h L N (A D - �W L I N DO Z O c m u, f i to P. tt M , M O ti y z N ►�' rn ®, S00 "01'4rJ' W n y n ts \ in N 11- I C -ROAD —DEDICATED 0 � N00 ° 01'40 "E E p 191.50' �u'o F`. N _ yl - rt In 1 y co s ��:. rn� � m Irn (D c--) I ov °o m o w r _ o� N, ch z m I —� v W o 0 p� v I U N % f J° Ci , V L r c rn �� / — ('•r'1 1 ni 1 H vs c �6� pa �,. a, I r N00 "E 4 6.54'' 00 0 - __j n c 0) 010 tC7 z g N -� 0 m i r,0 (0 w U I - < Z 0 c to W A . �. Nom y 01 m z o c 0 4% m .� W La ? N v Ul r H S 0 0 C3 O N00 40 759.24' m m x -I or En UNPLA V LANDS z r� C 3 � fi — — -- — - -- rn� zc z G Ca cn m m cn "—� 0 t CD SHEET 1 of 2 SHEETS m (n Z" 1 1 y %-N, I A I c* D i_a "��J� mz 00 WEST LINE OF THE NWI /4 SECTION 3 ZZ Soo 0 01'40 "w O r rr S 00°01'40 "'M ww .. S00 01 40 W 599.62' 83 .00' ou : M 509. II' Z 90,5 1' 1879.53' `on En Z zo 00 rn *-4 to o f � _.I N 00 00 O w` w T1 N N N a '. r •° N �a p o r z 0 O O a) : u, S00�01'41) W (n .. � N r IJI C) Lo -ROAD DEDICATED - --T0 4N U) IS NOO ° 01'40" E —I © 191.50' o �S'F\, N a° I V K I QI / —. c r - - NOO ° 01'40 "E 429 4'' 0000 rn < 0) a) o N � .. co Ln U ED w v rn -0 -o � 0 0 N 01 o O m _p � `� w