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HomeMy WebLinkAbout030-2054-20-000 nyp' 3d 0 C r� CD R o cn 0 3 Z ° mo o -"4 W . m a m o a m� m o y 0° o CA W C � y. 7 O A O 7 to O O N C, C71 O •'"3 CT � a f 3 N W O O r m v> f D m a? m n m m a cn 7 N W S CD 3 CL L CT !� C w CO oo ° 3 Q Z O O O = �r ° 0 w < OIQ c'n 0 n cn Co) o — Nv ( v,' °o o :3 m t'D :: m CD = D1 N °O N C M N _ o A � ° D D o N O ° N C CL C) o CD !V • 4� tNil ;L7 C W (D o (D 1 N N v Az (A -I N W V m WW -4 a Z g a 0 :► Z N H N � A O a CD 3 co Q fD ° 1 Q C _ <. o a t CD o I ' I I� A N N Nt I ° o A 0 b o= Al H °o CD �' b I � r ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT r Owner Address City /Stat 2 -5 7 IC Legal Description: Lot ,?d 3 Block =--? Subdivision/CSM # '/, Ste"_ '/. A(AL, Sec. 2-L, TAN -F,,,�W, Town of PIN # SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer L Size ST/PC P/L / L D � Setback from: House �.� Wel Pump manufacturer Model Alarm location GS (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: .r� %�s.,A), &I) Width Length 1,:,;2 _ Number of Trenches Setback from: House Well s ' PAL .,mss Vent to fresh air intake T� ELEVATIONS Description of benchmark ,3, , , ! 5 Elevation z" ,a Description of alternate benchmark fir Elevation Building Sewer 9'7 o4 ST/HT Inlet r ST Outlet PC Inlet 9,�, PC Bottom �_ Header/Manifold _ Qo? 7, Top of ST/PC Manhole Cover P Distribution Lines ( ) _ 9 7 y O ---fie � � ( ) Bottom of System ( ) 22 O ( ) Final Grade Date of installation / /9 ermit number _��S% State plan number 00 4g Plumber's signatur �� License number `lam_ Date // / �P 9� Inspector al p Complete plot plan or J C71 Cn �. o- } O j• � 4+I D P iW 1 520 .' y519 1 0 �. 51801 517 • Y B o� iwj 4 ; i� ow °' \ 5166 I�1� _ 1 I n r O Clt 528e �� cn d ('I w 516 A !y < 77 0 0 CA j ulm l J y Wes: ' STATE HWY. + x z D J 0 �c71:; Tt CD .. �'1 X .. 471 � + t71'`t�� � `�c ���71. a ,y A : 4�. = '.•567 B '�cN _ 0 01 6 - 1 f 4 I 567A K. r 566 ro s' r< ai x z 4,pu 565 564 o w w w= p c 4 *\ 17.50 4 a £ x.11 r,xcix•r. A E �;Y: �'� haw �.: ;�h � I p qtr r 10) � �t a '*' �''f�',- �::ifo�`3'-.;'•u�r r,,, sy" �. t.#ka a. � 417.6 ' Wisconsin''-DepartmentofCommerc PRIVATE SEWAGE SYSTEM V ROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)]. .: I� 5 g ity Permit Holder's am8: 111] O SON, Town of: HN 054 -20 - 00 0 CST BM Elev.: Insp. BM Elev.: BM Description: Cs•IZ q'{o•12. o �",�` A9800292 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ptic Bench ark & S S W osing 6j 'ee'oS 4� 1 . (0& ( ©( lofo t?D Bldg. Sewer Aeration -- Holding '``�" r Inlet TANK SETBACK INFORMATION St bid Outlet (o •�`' �✓�` � vent to ROAD Dt Inlet 11 D' 5 /l TANK TO P/ L WELL BLDG. Air Intake t �� ,, // �8' ��� NA Dt Bottom L5 Z9 S ptic ` !�� ' Header / Man. Dosin Z 32- �1.� • �� Aeration NA Dist. Pipe Bot. System • 0 a` Holding PUMP / SIPHON INFORMATION Final Grade G Manufacturer Uu Demand PM Model Number v3j l� a23'AG 1�-Z S b �4 ' TDH Lift�,3c, Friction 3� Syste D �1 Ft H Forcemain I Length 6Le Dia. Z�� Dist. To Well L ABSORPTION SYSTEM No. Of Pits Inside Dia. Liquid epth B TREN Width Length ,p� No. Of Trenches IT I N IM I N of LEA NG Manu SYSTEM TO P / L BLDG WELL LAKE/STREAM SETBACK CHAMB Mo el Num INFORMATION Type O Vv j O r 5' — ORUNIT System:M 1 / � DISTRIBUTION SYSTEM S Hole S e x Hole S acing Vent To Air Intake Header /Mani old �7 r � Distribution Pipe(s) 3�r/J Length_ Dia. 2 Length _R Dia. d Spacing l� , J SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over xx Depth Of x dxx Mulched No ❑ Yes F1 No Bed /Trench Center Bed /Trench Edges ta- Topsoil COMMENTS (Include code discrepancies, persons present, etc.)� LOCATION: ST. JOSEPH 27.30.20.535,SE,NW 1352 HWY 35 0 1 k w lD k . 5e_Nt&-r e— Plan revision required? ❑ Yes 0 No Gjtq � gN, Use other side for additional information. 6� L ins I pector' ignature Date SBD -6710 (R.3/97) Vicon - SANITARY PERMIT APPLICATION 20 Safety 1 E. Wahn Avel In accord with ILHR 83.05, Wis. Adm. Code P.O. Box I 53707 -7969 Department of Commerce Madison, W W • 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. • See reverse side for instructions for completing this application State sanitary Permit Number 3 /s�os 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 RMATION Propel O r Nam Property Location – 1/4 1/4, S T , N, R (or Property Owner's iling Address Lot Number Block Number �3 City, to Zip Code Phone Number Subdivisi n me or CSM Num r ( ) II. TYPE BUILDING: (check one) ❑ State Owned ❑ it� Neares R ad ❑ Vil age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a7 34 " ao" 53 1 E] Apartment/ Condo 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 ❑ New 2. Ig Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an - - __ - _System ........ 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 ❑ Seepage Bed 21 §' Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ 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 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /'nch) Elevation Feet Feet VII. TANK Capacity Site INFORMATION G / ons anks Manufacturer's Name Co�c e e con- steel Fiber- lass Plastic ApPr in gallons New Existin structed Tank Tanks Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber — ❑ Vill. RESPONSIBILITY STATEMENT I, the yndersigned, assume responsibility for in allation o e onsite sewage system shown on the attached plans. Plum r' I am ! 7(P Plumbe s na N to ps MP /MPRSW No.: Business Phone Number: k Plumber's Address (Stre t, Cit , State, Zi IX. COUNTY / DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater F;;te ss ue Issuing A nt Sig t re (N tam Surcharge Fee) Aproved []Owner Given Initial �� " Adverse Dete ation X. CONDITI OF P AL/REASON S OR DISAPPROVA .01c�� SOD-63918 111 11/96) DISTRIBUTION: Original to County, one copy To: ety 6 Buildings Diirision, Ownw, Mumber i�� Safety and Buildings 15837 USH 63 HAYWARD WI 54843 -8107 ■ sco /'� 1 SI n Tommy G. Thompson, Governor Department of Commerce William J. Mccoshen, secretary May 21, 1998 CUST ID No.224263 KIM A O'CONNELL 504 3RD AVE OSCEOLA WI 54020 RE: CONDITIONAL APPROVAL Transaction ID No. 80978 APPROVAL EXPIRES: 05/21/2000 SITE: Site ID: 7316 ST CROIX County, Town of SAINT JOSEPH;, SAINT JOSEPH SE1/4, NW1 /4, S27, T30N, R20W TODD & MARY BETH JOHNSON FOR: Description: REPLACEMENT MOUND Object Type: POWT System Regulated Object ID No.: 20584 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(10), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan approval is for a 300gpd mound. P.0.1 The following conditions shall be met during construction or installation and prior to occupancy or use: Cpndij • Correspondence Note: dEPARTMENI • Bury sewer per Comm. 82.30(11)(c). a lstON "AF • Abandon existing system per Comm. 83.03(2). • Install dose pump per manufacturer recommendation (Re: "D" dimension — 4 inches). _ A copy of the approved plans, specifications and this letter shall be on -site during construction and open to SEE CORRI inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. When making an inquiry or submitting additional information, please refer to Transaction ID No. in the regarding line. Sincerely, DATE RECEIVED 05/19/1998 FEE REQUIRED $ 180.00 TOM BRAUN, PLAN REVIEWER FEE RECEIVED $ 180.00 Integrated Services BALANCE DUE $ 0.00 (715)634-3026, M - F 7:45 AM TO 4:30 PM TBRAUN @COMMERCE. STATE. WI.US RESIDENTIAL MOUND DESIGN INDEX AND TITLE SHEET project TODD JOHNSON Owner TODD JOHNSON Address 1352 STATE HW '35 HOULTON WI 54082 Legal Description SE/NW-27 T30N -R20W I.T.S. �ondly Township ST. JOSEPH County ST. CROIX OVED Subdivision Name Lot No. I Ct1MMEICI S= 41c � — Parcel ID Number 030- 2053 - 95000 - 030-2054 -20000 Plan ID Number 80978 ,PONDENCE INDEX SHF-ET PAGE ONE MOUND CALCULATIONS PAGE TWO MOUND DRAWINGS PAGE THREE PRES. DIST. CALLS. & LATERALS PAGE F OUR PUMP TANK DRAWINGS PAGE SIX PUMP CURVE PLOT PLAN PAGE SEVEN Desig KIM A ONNELL License Numbe -� Phone No. 715- 755 -3145 Signature Date 5 -16-98 Notice: TamperkM with this file by UadhorMW persons is protdblted. Deliberate modlfication wNi result in dlsdplinary adlon under s. 146.10, V" Stets. RECEIVED Page 1 of 7 MAY 19 1998 SAFETY a BLIAS. DIV. i RESIDENTIAL MOUND DESIGN Eight Bedroom Maximum Complete information in red framed boxes as necessary . (y or n) n Itheern over creviced bedrock? Slope Number of bedrooms Wastewater flow rate pd 1135.5 Lpd Depth to limiting factor 83.8 cm In situ soil infiltration rate (code) 0.5 g 20.4 L/m Contour line below the upsio a of absorption cell 91.1 ft 27.77 m Use standard fill depths? x OR Designer speed depth in cm Place X in bout to use standard depths (1$ A A+4 lhclusNe) OR specify design Mi depth. Center or end manifold a (c a e) Estimated hole space 4 ft Not a final �u�• Lateral O eft Minimum dose >= 10 times void volume Use a o lateral spacing for trenches. Pump tank elevation 81 ft Outside bottom of tank Number of laterals 2 Force main diameter 2 in Force main length 3b ft Force main actual dia. 1 2.067 in SYSTEM SOLUTIONS Inch - pounds Metric Cell media "x" one only. Estimated daily flow ®gpd 1136 Lpd x Aggregate and pipe Chamber and pipe Absorption cell Design load rate & area 1.2 gpdfie 250.0 ft 23.23 m Linear load rate 7.1 gpolft 88.0 Lpd/m Design width (A) 6 ft 1.83 m Cell length (B) ffidin ft 12.80 m Depth of cell (F) 25.1 cm Sand filter Upslope fill depth (D) 12.0 in 30.5 cm Downslope fill depth (E) 16.3 in 41.4 cm Basal area required (gpd/infiltration rate) 600 f 55.74 m Supporting components Topsoil depth 6.0 in 15.2 cm Subsoil depth at center 12.0 in 30. cm Subsoil depth at cell wall 6.0 in 15.2 2 cm End slope toe length (K) 10.5 ft 3.20 m Upslope toe length (J) 7.2 ft 2.19 m Downslope toe length (1) 11.6 ft 3.54 m Total mound length (L) 63.0 ft 1N.2 0 m Total mound width (W) 24.8 ft 6 m Project: TODD JOHNSON Page 2 of � Plan I.D. 80978 MOUND PLAN VIEW observation pipes (typical) J 24.8 ft A A= 6.0 ft 1.83 m W= 7.56 m — B= 42 ft 12.8 m B JK J= 7.2 ft 2.19m I I = 11.6 ft 3.54 m K=Fl ft 3.20m = 63.0 ft 19.2 m' typ. obs. pipe A X B refers to absorption cell width and length (anchored securely) J = upslope width I K = end slope dimension Lu 61 mm) T MOUND CROSS SECTION m D = 12.0 in 30.5 cm topsoil G H subsoil cap E = 16.3 in 41.4 cm lateral invert 1 92.6 ft F = 9.9 in 25.1 cm 28.22 m� - - see note F G = 12.0 in 30.4 cm elev. H = 18.0 in 45.6 cm D E ASTM C33 Sys. 92.1 ft Sand Fill elev. F28.07 1m 91.1 ft contour 6% 27.77 m slope Nate: gbsorpRlon cell media wUl D = upslope fill depth plowed layer ©onsist of aggregate and pipe E = downslope fill depth or leaching chambers and pipe F = absorption cell depth as specified �x Aggregate G = subsoil + topsoil depth at cell wall at rw t• Chamber H = subsoil + topsoil depth at cell center Designer notes: If agg regate is used, it is covered with code compliant mat erial. Project: TODD JOHNSON Page 3 of 7 Plan I.D. ### PRESSURE DISTRIBUTION CALCULATIONS Absorption cell Inch-pounds Metric Width (A) 1 6 in 1.83 m Length (B) 42.0 ft 12.8 m Lateral specifications Number laterals 2 Holes/tateral 10 holes Lateral length 39.0 ft 11.9 m Perforation dia. 0.25 in 6.4 mm Lat. dis. rate 11.65 gpm 0.7 Us Sys. dis. rate 23.30 gpm 1.5 Us Hole spacing 52 in 132.1 cm Lateral diameter Pipe diameter ter D"Un °° D"gn c11O1e Designer must Place X In red '7(" one choice X bau[ of chosen from the options X x diameter. provided X X Manifold diameter Pipe diameter Dlo" opli" Oman chow* Designer must 1 inr25 mm -- Place X in red 0 )( w one choice 1 1 /4inr32 mm X lox of chosen from the o ptions 1 Jon/40 mm X diameter provided 2inW mm X X 3in175 mm X 4rt/'100 mm X Distribution system contains 2 lateral(s). LATERAL DIAGRAM - END CONNECTION Place correct lateral dagram by clicking in one of the drawings at right and dragging the diagram into this area. Last hole drilled next to end cap Cap stet dente over p � rF"Oroe IEX--'>I Holes drikd on the bottom of dw lateral s * sP � IMOWdOn Ilia tQe or cxoss to marrfaW at 441 POkV- LateralsC�� Table 94. P j � 40 permanent end marker (per Inch-pounds Metric Lateral length (P) 39.0 ft 11.89 m Lateral spacing (S) 3 ft 0.91 m Manifold length 3 ft 0.91 m Hole diameter 0.25 in 6.35 mm Lateral diameter 1.5 in 40 mm Number of holes per pipe 10 Invert elevation of laterals 92.6 ft 28.13 m project; TODD JOHNSON Page 4 of 7 Plan I.D. 80978 i Total dynamic head System head = 3.25 ft 0.99 m Vertical lift= 10.70 ft 3.26 m Are laterals the highest point in the Friction loss = 0.34 ft 0.10 m system? Yes 'w here. Total dynamic head = 14.29 4.36 m if no, what is the highest elevation —_ Dose Volume downstream of pump? Lateral void volume = 8.2 gal 31.0 L Force main drain Minimum dose = 82.0 gal 310.4 L back to tank? (Y one) Drain hack = 6.1 gal 23.1 L Yes Dose volume = 88.1 gal 333.5 L No Typical Pump Chamber Layout In combinations with state approved treatment tank Tank construction as per Comm 83.20(3) WAC. approved manhole cover weather proof F1 wNvaming label and padlock grade levels junction box —� grade levels quick disconect W alternate 4„ vert �� electric as par NEC 300 and �— outlet Comm 16.2B WAC location 18" (46 cm) min. approved wall of pump outlet chamber or combination joint tank A 1/4" weep Grade levels alams on hole as pump tank maN+de = 4" mim above fbtahed Wade pump on B y pump tank man. -100 mm min above Meshed Wade C I vert - 12" min. above finished Wade pump 81.9 ft vent - 3W mm min. above OnWwd Wade off elev. 25.0 m D 3 " (75 mm) of bedding under tank and anchor tank as necessary 81.0 ft Pump tank elevation 24.7 J m bottom of tank Tank specifications: WEEKS Pump tank = 19. gad /in Pump tank volume = 800 gal Capacities: Inches Gallons A= 27.4 521.5 Pump manufacturer: GOULDS B = 2 38.1 Pump model number IVYE0311 L C = 4.6 88.1 D = 8 152.3 Project: TODD JOHNSON Plan I.D. 80978 Page 5 of 7 -- " ■ ■ ■ ■ ■ ■ MEN ■ ON �:■■ 1 :: :4■■ ■ ■ ■ MEN ■ ■E � �m ■ ■ ■ ■ ■■ ■■ ■NE �,!�� MEN �■ ■NNE■ ■■■■■ �'N ■ ■��, ■ ■ ■■ ME ■ IN min mom MEN MEMO "..q■� ■1.. ■ ■��. ■ MEMO IN � ■■ ■■. mom 00. ram MMI MENM"mMaanqg me IN I MMMMMMw MIN mMmMuWMMMMMMM1 ME U. MIN ► �� ■ ■■ ■O 11 :: MON SIZE 1 /4" Solids, No 0 '►1 ■ ■ ■ MEN ■ ■■ ■ NONE MENOMMIN IN "NOON ■, ■ ■E■■ ■ME■� IMMEMME ■E■iE■� , Comm■■■■■ ■■ ■■■■ ' ■ ■ ■ ■ ■ ■ ■ ■■■ ■ ■_� 111m ■■■■■■ ■►:1 ■ ■ ■ ■ ■■ ■ ■■■■■■■11 ■■ ■ ■ ■ ■ ■ ■ ■f /� ■ ■ ■ ■ ■� ■� ■■ ■■■ ME win, ■�■ ► \ ■ ■ ■ ■ ■■ N ENE E ■►� ■ ■ ■�..rNi� ■■ ME ' ONE MMMMM►■M■■■r■ ■�'i■■ ' iOME■NN■r■•�■E■■ ■ ■■ 'ii ■.....■..■... ON E■■■ ■ ■■ ►��� ' ' iiEi I I I ! I !; I I ' X I I I I I I _ I 1 I I i t a � ' � I I I i I I I I I I , � 1 -,;, i, 7M Al o' l F` Wisconsin Department of Incistrj(r' F ;' f AND SITE EVALUATION Pag of 3 Labor and Human Relationsx acE > ,� Division of Safety and Buildings-` /" in 66 e ance with s. ILHR 83.09, Wis. R a ss County Attach complete site plan 'ajar not is i .1 /�' 11 i e in size. Plan must S "J' : C O 1'}L include, but not limited to: ibobl A a�# c, &mireferenc (BM), direction and Lo .810 c.810 3 percent slope, scale or dime W,t�rtEi loc d distance to nearest road. parcel I. # poa .� 7 o . - 030- -0S3 - tS LOT 3 13/e 3 — p 105 5/- 2- 0 c2 v APPLICANT INFORMATION - } all information. Re wed by Date Personal information you provide may be ysed'for,secondary purposes (Privacy Law, s. 15.04 (1) (m)). S (� Ptoperly Owner Property Location - r0DD ? Y Si � - HAIJO r.3 Govt. Lot S� 1/4 /v�t S 7 T 0 ,N,R 2 E (orJ W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# . 13 S Z City State Zip Code Phone Number D r Nearest Road f f bt1GTo�✓ ��. (7 /j )Sgq'�O /6 ❑ ity �L Vi El Town $T r ❑New Construction Use: residential /Number of bedrooms 2 Addition to existing building [] Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate s bed, gpd/ft ' trench, gpd /ft Absorption area required �'S� bed, ft2 2- trench, ft Maximum design loading rate - S bed, gpd/ft • 4O trench, gpd /0 Recommended infiltration surface elevation(s) .S� �1 3 ft (as referred to site plan benchmark) Additional design/site considerations 'S'Q'L IL'O T F 5 1 w� Parent material 'T lh;? /0/fMy s . olm, Flood plain elevation, if applicable N ft S = Suitable for system Conventiio�na/l Moouu In-Ground Pressure AT Grade System FillHolding Tank U = Unsuitable for system El S LJ U u S ❑ U F1 S Liu ❑ S Ly"U ❑ S ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench / 0 -lo /o YR3 /3 — Z 5_ 2- - 45 /oY,0 � Ground 3 ' Z 10Ye / L S 7 7/e C ' S:' ql % S io Yoe l �S .e 4+1 �.° C'� - . S S 3 • y iaXe 4S 51c 2fsk 9* 7ci' a .S Depth to C U�SL /* -�/ — • 3 limiting !rp y ) • !Q y/ factor �0 in. V/Q $ / e_ S 5.5' Remarks: u 7'!, f� yy G Boring # GS / A e /)AU-FR z — Ground /a Yk / Im fie Q S — ' • S q elev. /a y C 2 ee ors • 3 2 • z 1 ft . . s yR ylq Depth to limiting factor 3�in. Remarks: V I - s�'�'�' �4 T CST Name (Please Print) Signature Telephone No. lPoa��r 2t�be�r -�,r 7is• 3 -klgs Address A Date ^ d, CST Number Z 13�Y»Pi�f z& Q s zy T TOM fiX .2 So 4+ o r 8 M o ellEt). 1 b �b S� 0 � zL \ LAJ i P14 MNi o gle \ r N& s ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM w n Mailing Address U C J To a - a Property Address SArY\ C — `` (Verification required from Planning Department for new construction) City /State H S__�C�a Parcel Identification Number L • - V � `�? -30, LE GAL DESCRIPTION Property Location 5 (A) '/4, '/4, Sec. R - 7 , T 3O N -R W, Town of 1 701 Subdivision lJt L�� � 944 Lot # Q �oc Certified Survey Map # , Volume , Page # Warranty Deed # q 0_3 9 5 - , Volume ~? °� , Page # S 0 Spec house ❑ yes X 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, 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. 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. p SIGNATURE OF AP CANT 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 ,��' � � � � �p � � � �' O �' (C` �, . „ l • �� • t� � iii . • f ' � � y � � � � � � � � � 0 �` l 1 � ��.� H C , � � �� A �+ �, y �; G � � � y r � � �i` •� r � � ��e � 4 , �1 CH � � �`' �. A � (� � �e � to cl kk Zi Po Nx a' C1 y` 14 , INS s • 1 � c 1 c �• �i n fv q r i74. ff. ^ z s t � ev ' � � � • � �� STREET. ... �, .� '20+x, e o �C � w z✓f8�u. fr zir�. fY. �., ,� w � o v SrRrEr, ,:.: 20. -tor, d /art 3 d r.T.tdr, �' . rdr. 7h. -rZr. 20: tdu,