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Home My WebLink About032-2110-20-000 n m 0> a m n = \ } (D 2 \ : ƒ _ < ƒ z E z \ CA) r- \ ƒ 8 8 j K = - @ k § ' / 2 / } w + f i \ \ 2 § r E 2 m G 9 \ j \ \ \ \ � \ \ § ° ` CL E E CD K ° \ ^ ® 4 / » 4 y ( ({ \ E « $ R e ) e \ ( a � Go \ » £ k ( CD / / } \ 2 \ / Z o z 0 0 0 =0 g %\ § / / / . . . \ G i po \ ) Cr 7 7 \ \ � ° e 2 { ID cn CD » { m m ,_ CL z z ® _ / 2 0 \ cn 0 0 CD \ � ' t j ] { \ jo w @ ° k \ z 2 o = o [ - � 0 \ § / « 0 ƒ \ z $ o E : z 2 z % \ i � < k � 2 ■ \ � k c 0 % ( 0 \ � > \ K � ) � \ / I § � / \ 2 � I � o < ( ) \ e 0 § \ \ \ / wsccvgnDepartmentofCommerce SOIL AND SITE EVALUATION Divsi6h of Safety and Buildings Page of . Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm., Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. # APPLICANT INFORMATION - Please print all information. R i Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). / Props er Property Location Govt. Lot 1/4 1/4,S T ,N ,R (orx9 Property er's Mailing Address Lot I Block Subd. Name or CSM# J , 611e 1142 - City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nea r t Road New Construction Use: ® Residential / Number of bedrooms _5 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/ff trench, gpd/ft Absorption area required l/ _ bed, ft 2 _j,::2 trench, 11 Maximum design loading rate bed, gpd/fi trench, gpd/ft Recommended infiltration surface elevation(s) �. 5 / f5 It (as referred to site plan benchmark) Additional design/site nsiderafi s 6 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 for system ® S ❑ U [Os ❑ U ® S El I ®S El I EIS ®U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f12 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. �ft• a'f . fo Depth to limiting factor Remarks: Boring # Ground / elev. Ud , Depth to limiting factor _�S Remarks: CST Name (P ase P 'nt) Signature / Telephone No. Address Date CST Number s J s 144- Arm ss�� 4 02 Asa I d cl o � � N a .-•I " J m b 00 � �O CA J iy wl Q an \ no � rl rl g ay m + Nq N S A M O > � yC) V o p a� en ^ c 00 CA a �w 0� M � Q M on GO M p e} Q m m n O M ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address City /State Legal Description: Lot Block Subdivision/CSM # > P,1 - Ali ' /a ,AL_ t/a, Sec. <, TAN -R_4�'W, Town of ,z, Ems. / PIN # `= SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/PC Z;?,2 / , m Setback from: House IX Well R_ P2 r 0 Pump manufacturer Model (,1i 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 Length Number of Trenches Setback from: House ) Yg Well j e-�/ PAL, Vent to fresh air intake ELEVATIONS Description of benchmark a �' Elevation f2 Description of alternate benchmark f Elevation 1e; /, 7/ Building Sewer //t3. ST/HT Inlet & - ST Outlet eZ - PC Inlet W.,-, PC Bottom 9,s Header/Manifold Top of ST/PC Manhole Cover �/ 0,-T -1'9 Distribution Lines Bottom of System Final Grade O ,i��R/ O ( ) Date of installation / / P rmit nu ber State plan number Plumber's signature License number ,—ZZ-//,2. /Z Date Inspector :6- Complete plot plan r AA Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) sanitarr�if�.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. Permit Holder's Name: [ ] Town of: State Plan ID No.: UNDBERG, MIKE � sh� bkEi ❑ CST BM Elev.: Insp. BM Elev.: BM Des�cjri�ption: [� Parcel "�Q-:2017 -10 -000 1 1 (/ �. 11/ C�i TANK INFORMATION ELEVATION DATA A9800586 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Ben ark ?1 j Do Dosing 4 IL S C6 D • 7 / Aeration — Bldg. Sewer j 03. -b Holding wkriniet 7 a7 TANK SETBACK INFORMATION Sy Ht Outlet 74,4- 10 ; 7 Airi ROAD Dt Inlet to TANKTO P/L WELL BLDG. Airintake 10-43 � 2 p�- . eR t 1 O0I 1 0 JJ1 j � NA Dt Bottom t 9S Dosing '� 6 S9 NA Header /Man. ,(� pal. Aeration NA Dist. Pipe Z' l [ Holding Bot. System !o •2, J03.c�� PUMP / SIPHON INFORMATION Y% Final Grade Z�� /O(p.� F. 0 Manufacturer b Demand 6.6T E Model Number ` GPM TDH Lift�� Lrictio ��, System TDIJ (.d0 Ft Head Forcemain Length Dia. a'r Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dim Liquid Depth DIMENSIONS ��– DIMENSION SETBACK SYSTEM TO P/ L BLDG I WELL LAKE /STREAM LEACHING Manufacturer INFORMATION Ty p CHAMBER Mod Number: Sy a d0 )5 4 1 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia - Length -M Dia. Spacing G T(M Z Z 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: SOMERSET 5.30.1 1779 46TH STREET LOT 12 �j �Ct�' �C��Ci•c.., r. lo t4J A tM,� POW Plan revis oh required? ❑ Yes No Use other side for additional informn. SBD -6710 (R.3/97) Date Inspector' ignature 4NNo. Safety and Buildings Division 141sconsin SANITARY PERMIT APPLICATION 20 1.W. O Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State San PPerrmmit N umber Personal information you provide may be used for secondary purposes ❑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 Prope ner Na a Property Location 1/4 1/4, S T , N, R E (or Property Owne ' Mailing drill Lot Number Block Number 7 � ' j City, tate Zip Code Phone Number Subdivision me or CSM u er y IJ ( ) II. TYPE F BUILDING: (check one) ❑ State Owned ity I NearestR ad Public 1 or 2 Family Dwelling - No. of bedrooms C Town OF 'L Ill BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 03 _ OC 1 0 ^ a o _00 1 171 Apartment/ Condo 5 / 9 . / O 3 Q 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. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ...... Syrstem S ________ ystem T _____________ ank Only Eti S 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 JXSeepage 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 eet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per- INFORMATION New Existing Tanks Manufacturers Name Concrete Con- steel glass Plastic A p p structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber / ❑ 1 ❑ I ❑ ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, thejlndersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plu e ' Na : ( int) Plumber' re: MP /MPRSW No.: Business Phone Number: P mber'sAddr ss treet,='� ipCode IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa tary Permit Fee (Includes Groundwater ate slue Issuing Agen S' n�e(,NoWf; A roved surcharge Fee) / pp E] Owner Given Initial Q �� / !� Adverse Determination 7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 3g� I la � 1So' � t � 3 U i Ad PAGE of PUMP CHAMBER CXO55 SECTIO AN S PECIFICATIO KS___ VENT C r VENT PIPE WEATHERPROOF /APPROVED LOCKING _ I JUWCTIO)J BOX `- M�WHOLE COVER WITn ? 2S' FROM DOOR, I WMw1NG LAIN WINDOW OA FRESH IL�MIU. I AIR IMTAKE GRADE I y.. MIlJ. le' Mlu. COQDUIT -- - - - - - - - - Id'MIIJ. PROVIDE I - - - -- IAILET AIRT'IGl1T SEAL I I � i I A I I A PPROYED JOIU? APPROVED JOIWT � I II w/ PIPE EXTENDPWb 3' I I ALARM EXTEWDIWG 3' OWTO SOLID SDiL I II ONTO SOLID SOIL B I I I Oti C (. CLIE FT. PUMP -` - -J b OFF D COkJCKETE DLOCK RISER EXIT PERMUTED OWLy IF TAUV, MAULIFACTURCR HAS SUCH APPROVAL 3" f 15CCGbING 't"r%NK SEPTIC E SPEGIFICATIOFJS 005E T A W_Kj MAWLIFACTURER: 1�� (JU-^ ECR OF DOSES: ___ PER DAm TAMK SIZE: / G DOSE VOLUMC ALARM MAIJUFACTURCiL: S._1 e J�_v�� iV�c? _ IMC:LUDIKIG OACKFLOW: — , S GALLON. MODEL WUMDEK: � �� CAPACITIES: A= IWCNE5 DR GALLOWS SWITCH TYPE: / j 6 = ,2. IMCHES OR _�d GALLOMS: PUMP MAIJUFACTURCR: h C ,A2 IMCHES OR CALLOUS 3 MODEL MUMBER: ,'� E D ; ii.0 D - _2— INGHES OR GALLOU SWITCH T`JPE: �+ h� - ��i1ir:'/ MOTE' PUMP AUD ALARM ARE TO BE. INSTALLED OW 5EPARATE CIRCUITS MIIJIMUM DISCHARGE RATE GPM VERTICAL DIFFEREN OETWEELI PUMP OFF AWO DISTRIbUTIOW PIPE.. �� FEET + MIWIMUM METWORK SUPPLY PRESSURE . . . . . . . . . . FLET + FE ET OF FORCE MAIIJ X. /on r FACTOR.. • S , i FEET TOTAL 09WAMIC. HEAD = JJ - FEET IIITERWAL DIMEWSIO f, OF 7 LE14GTH _ IWIDTH jLIQUID DEPTH �IGUEO: LICEMSE NUMBER: veriormance Curves Pumps METERS FEET . � Y0DEL 90 25 3885 - SIZE 1/4" - Solids E I SH F 70 __T 20 60 Wf 7ti 0 .0 WE074 E05H E03 40 W W 10- 30 w W M (�W (w E 0 �X -- - - -- - -� � - -1 -- — 20 0 0 10 20 30 40 50 60 70 60 90 1cc 110 120 GPM L L 30 mllh CAPACITY 'CIOULDS) PUMPS. INC. L AAA:,A ;A-�� t.LW YCi. MITER$ FEET 120 M 0 D E 35 - HI N SIZE 1 /4" Solids 110 -WE15HH-� 100 30 - 25 — 70 20 - I 0 -- _ -- 1 5 - 50 'WE05 i4 40 10- 30 F_F_ tt 20 r— r 10 0- 0 0 10 20 90 40 50 60 70 c L-0 1W 110 120 GPM 0 10 ml/h CAPACIT e "6 oquias Pump•, Inc. Eftw*ve luy. t w' C36111 Safety and Buildings Division ��■�r■r. SANITARY PERMIT APPLICATION 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 81/2 x 11 inches in size. S C.pur • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs 3 0 74-2-6 (Privacy Law, s. 15.04 ❑ Check it revision to previous application (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION 0= — 16) Property Owned N L arpe Property Location 1 L NA W N 1/4 N 1/4, S C' T 3d , N, R 19 E (or) W Prop Owner's M i g Add Lot Number) Block Number C Zip Co Phone Number Subdivision Nam or CSM um r Ooh S 1 OF BUILDING: (check one) ❑ State Owned it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms s@ Town of Sz U ve i�Y RSA. III BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Y A 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. ❑ Replacement 3. ❑ Replacement of 4 E] Reconnectionof 5- ❑ Repair of an - ___ ___ystem ________ 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 12ff*eepage Trench - S�1vplJat Npe nS 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 Re d ui re ( q. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation 5 3 SSFeet ri 7 � Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Fiber- plastic Exper. New Existin Gallons Tanks Concrete Steel glass App. structed Tanks Tanks Septic Tank or Holding Tank a 0 tW e e S ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATE - MENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb Name: (Print) Plumber's Signature:: (N Stamps MP /MPRSW No.: Business Phone Number: 1 � J 1 Q� Yr. t,t S { Yl D �•.J v 711 Plumber's Address (Street, City, State, Zip Code): J IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (i ncludes Groundwater L Issuing ent Si A roved Surcharge fee) pp ❑ Owner Given Initial ,e` et �/ ) � ! � Adverse Determination ll 8 JC/ X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: safety & Buildings Division, Owner, Plumber P I O J EC T . N A M E LAN A 6 R --AM E . • -P L IO ._�_... C .4. ' l_ IC E NS = /;L. P . L 0 �I' M A I' ,.., _ . t • � ��PfZLC, h.., . Alt 9M • .t• pl, laoo �p� � r Jlc FRESH AIR. INLETS AND OBSERVATION PIPE C110"S SE CTION Approved Vent Can • Minimum 12" Above �RbpP Final cra ne__ 1 8 0 _ 4" Cast Iron Above Pipe Vent Pipe To final Gracie! VQh&in Department of Industry SOIL AND SITE EVALUATION REPORT Page _ of 3 Libor and Human Relations Division of Safety s BWd'irgs in accord with ILHR 83.05, Wis. Adm. Code C OUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St. Croix 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. 032-2017-10 APPLICANT INFORMATION– PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Mike Lundberg GOVT. LOT 1/4 1/4,S 5 T 30 ,N 19 k(or) W NR PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 2040 Oriole Ave. N. 12 Cedar Valley Estates CITY, STATE ZIP CODE PHONE NUMBER E]CITY []VILLAGE MOWN NEAREST ROAD Stillwater, Mn. 55082 (61 180th. ave. W New Construction Use k ] Residential / Number of bedrooms 3 [ ] Addition to existing building ( I Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate -7 ed, gpd/ft gpdtft Absorption area required 643 bed ft _ 5fi3— trench, ft Maximum design loading rate __7 bed, gpd/ft —_ trench, gpd/11 Recommended infiltration surface elevation(s) 10 ft (as referred to site plan benchmark) Additional design /site considerations ;%j :t _ area system el__ 104551 & 181.55 Parent material pitted glacial -drift Flood plain elevation, 0 applicable It S = Suitable for s ystem CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U- Unsuitable fors tem E ks O U I) S❑ U 0 S O U RI S❑ U ji S❑ U 0S @ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Chu. Sz. Cont Color Gr. Sz. Sh. Bed Trench r `z. 1 0 -8 1 r3 3 none Sl 2msbk mfr aw 2f .5 .6 2 8 -16 7.5 r4/4 none is 0sq mvfr 9w if .7 .8 Ground 3 16 -78 7.5 r4 6 none ms osq mvfr na na .7 .8 elev. 10625 Depth to limiting factor +7R Remarks: Boring # x< 1 0 -8 10 r/43 none Sl 2 r mvfr w if .5 .6 2 2 B -17 1 r4 4 none sl 2m r mfr qw if .5 1 .6 Ground 3 17 -28 7.5 r4 6 none is oscl mvfr Qw na 1 .7 .8 elev. 4 1 28-7A - 7.5 4 105,5• Depth to \ limiting factor 74,� `�' , J �! p; 1997 ti Remarks: s GDUNTv E CST Name -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. Avd New Ric on 54017 Signature: t Date: 5 -27 - 9 7 CST Number: mO2298 f t STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Mike Lundberg MPRSW 3254 NE4NEk S5- T30N -R19w New Richmond, W154017 town of Somerset (715) 246-6200 lot #14 -Cedar Valley Estates 12 N 1 "=40' BK.= nail in tree @ el. 100' Alt. BM.= top of #13 - #14 lot survey stake C el. 88.75' '� /v 20 o L o w 40 0x �'2a Gary L. Steel 5 -27 -97 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L 6-pa Mailing Address o� Q", �/ _ kp _ A2 �.5fI 1Q p Property Address I _] - 1 S �+� ,�f ��" (Verification required from Planning Department for new construction) City/State T fd Parcel Identification Number _IQ - d6 /'T -/6 LEGAL DESCRIPTION Property Location %,, Ali ' /,, Sec. , T 3�) N -R-/'? W, Town of S01nfP6e 4 . Subdivision (tea dar l J a lleq �S , Lot # 102 Certified Survey Map # Volume _!!� 53 , Page # 70 Warranty Deed # � D r� Volume ' "' , Page # 6 3LS 7 Spec house )4 yes ❑ no Lot lines identifiable Vyes ❑ 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 Xear expirat' n date. X � / l3cx A O 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 esc ' d above, by virtue of a warranty deed recorded in Register of Deeds Office. / V/ S' A O APPL 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