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LEGEND Y CL
Aluminum County Section Monumbn•t Found �� �> Bearings are referenced to the
■ 3/4" Rebar Found West line of the SW} of Section
••••••••••••• 100' Roadway Setback Line 13, assumed to bear N00 0 10 1 43 11 E
0 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per linear foot
N D O O
U.J. LAi T ��, LA �
West line of the SW} O (D
N00 10' 43 "E '''' a
N00 "E 670.00' N00 °10'43 "E En r
0 0
335.11' 334.89' 1301.29 N N a
68 '
.-t ; 6.50 x.
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w N00 ° 10'43 "E 670.00' `° c M IF" " ( (D
N I I� 335.11' 334.89' I o I's H.
"
IFri co 1 66.00' 269.11' -0 66.00' 268.89 ( D
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I <� S00 ° 0705 "W 47.65' W W ct
ITS ° — 335.11 — 312.54' ti °'„ a
- b 66.00' 269 6 6.00' 246 .54' "$' jk
c 335.11' 334.90'
o a w 5 — 19 ' 31 "W 670. 01'
M East line of, the S W} of the SWI
T I ., w
R . ®]I►D
ST. CROIX COUNTY ZONING DEPAIEIVT�
AS BUILT SANITARY REPORT,`..;
R &cEI0
Owner rm
Address eb i. ;TY;� ^9�,;
City /Stat
Legal Description: .
Lot Block Subdivision/CSM #
'/4 SraL '/. L, Sec. ,L - L, T y4_N- .W, Town of PIN #
�q r2 — .Sb
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer J Size ST/PC/ / Setback from: House,- Well
Pump anufacturer. P/L
P _ y � Model
Alarm location
~
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: so Width _ Length �, Number of Trenches
Setback from: House Well z PAL f / °n Vent to fresh air intake T/o
ELEVATIONS
Description of benchmark 5' ' Elevation �g
- Z - , . Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet c s -g ST Outlet- PC Inlet Zp
PC Bottom 2 Header/Manifold ��,, L_ Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade () () ( )
Date of installation ermit number State plan number
Plumber's signatur License number . �y2_3 Date
Inspector
Complete plot plan �+
4
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 07799
P ersonal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
KILL WILLIAM �O1 SEa Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 65 Y — ` 2072 - 50 - 100
TANK INFORMATION ELEVATION DATA A9800187
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ZGbl Benchma � Rb
Dosing fI 1/. om +,r as 2.0 10Z -$Y
Aeration r - 7-( o - � j
Holding et 1.37 qgp 5_7
TANK SETBACK INFORMATION utlet
TANK TO P/ L WELL BLDG. Air I to ROAD t
irntake t•2
Septic /ay ZO` IQI0, NA tttom /j.G1�
Dosi �' ) �z� j ' 3' NA # der / Man. / Z . 6Z /Di l i
Aeration Ni ,t. Pipe /o3,q 2 .^ /D/ •3
Holding ot. System ?,Z9 E is
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer �� Di / , C)b 100 4-0
Model Number - �'1•
TDH I Liftk•3�- Friction 1 Syste tL TDH, S/:yrtt,,, G;47 `rV
Forcemain Length� Dia. 2 / ! Dist. To Wel A - / 24-
h1 4 o ,4
ABSORPTION SYSTEM
�IBEJYI TRENCH width /�� Length �2 No. Ot i �_ DIMENSIONS No. Of Pit
1 N (�
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of 1 y CHAMBER Mod Number
System: 50 A5 n1�L- OR UNIT
DISTRIBUTION SYSTEM
Header / apifold _I_ Distribution Pips, .l x Hole Size x Hole Spacing Vent To Air Intake
' cam' � 3 � / ,, N
Length Dia Length 0 Dia. � Spacing /�
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over it xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center g Bed/ Trench Edges Topsoil tE� Yes ❑ No Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.4kvv S . 3,j * Zb S( a
LOCATION: SOMERSET 13.30.20,SW,SW 1520 23RD STREET LOT`6
( 'I 67r4�1/1 - t, y�.stf
Plan revision required? ❑ Yes 0,
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector' ignature Cert ND.
SANITARY PERMIT APPLICATION S afety Washington Buildings ADbision
Vi sconsin 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. ,
• See reverse side for instructions for completing this application State Sanitary Perrn Num
The information you provide may be used by other government agency programs ❑ Check if revision n o previoLfs ap lication
[Privacy Law, s. 15.04 (1) (m)]. 3 0� State Plan I.D. Number
I. APPLICATION INFORMATION PLEASE PRINT ALL INFORMATION
Pro e y ner Na Property Location
1/4_ 1/4, S T , N, )(or
Property Owner's ai ling Andress Lot mbQr ti� Block Number
�O 1J v
City, State Zip Code Phone Number Subdivision Name or CSIt9
II. TYPE OF BUILDING* (check one) ❑ State Owned it� Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms E Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo /9. �o. °�?io r 7790 0&�2 --, �, V - Sll �Bd
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
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 IZMound 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
7 Feet Feet
VII Capacit
TANK in g all o ns Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existin structed
Tanks Tanks
i tng Tank ' El ❑ 13 ❑ 11 ft ' um i am er ® 111 ❑ 1 ❑ ❑
.RESPONSIBILITY STATEMENT
I, thf undersigned, assume responsibility fo nstallation of th onsite sewage system shown on the attached plans.
P Nam : (Pr Plu r s Sign �St MP /MPRSW No.: Business Phone Number:
P u ber's Ar re reet, Pty, Sta e, Z ode):
IX. COUNTY/ 13FPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Iss, ing Ag t Si ature (No Stamps)
eA roved surcharge ree>
pp ❑Owner Given Initial �
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR ISAPPROVAL:
SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
Safety and Buildings
15837 USH 63
HAYWARD WI 54843 -8107
Visconsin Tommy G. Thompson, Governor
Department of Commerce William J. McCoshen, Secretary
May 13, 1998
CUST ID No.224263
KIM A O'CONNELL
504 3RD AVE
OSCEOLA WI 54020
RE: CONDITIONAL APPROVAL Transaction ID No. 80148
APPROVAL EXPIRES: 05/13/2000
SITE:
Site ID: 8016
ST CROIX County, Town of SOMERSET
SWIM, SWIM, S13, T30N, R20W
WILLIAM KILL
FOR:
Description: NEW MOUND
Object Type: POWT System Regulated Object ID No.: 19848
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.
all code requirements
This plan approval is for a 450gpd mound.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This plan action is subject to designer comments on the plan
• Correspondence Note:
• Per Comm. 83.23(3)(b)2, the area 25 feet below the downslope edge of the soil absorption system must remain P 1
undisturbed. Condi
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to APPF
inspection by authorized representatives of the Department, which may include local inspectors. All permits DEPAPJMEN1
required by the state or the local municipality shall be obtained prior to commencement of DIVIS10 F SAf
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address SEE CORK)
on this letterhead. When making an inquiry or submitting additional information, please refer to Transaction ID
No. in the regarding line.
Sincerely,
DATE RECEIVED 05/08/1998
d,4.1 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 WILLIAM KILL
Owner WILLIAM KILL
Address 384169AVE
SOMERSET WI 54025
Legal Description SW /SW 13- T30N -R20W
Township SOMERSET County ST. CROIX
Subdivision Name CSM Lot No. 6
Parcel ID Number 032- 2072 - 50-100
Plan ID Number 80148
N.T.S.
INDEX SHEET PAGE ONE tivnally
MOUND PAGE TWO )
MOUND DRAWINGS PAGE THREE a0VE D
PRES. DIST. CALCS. & LATERALS PAGE FOUR OF COMMERCE
PUMP TANK DRAWINGS PAGE FIVE D 6UILWNG4
PUMP CURVE PAGE SIX
PLOT PLAN PAGE SEVEN _SPONDENCE
Designer KIM A O N E License Number
Signature Phone No. 715 - 755 -3145
Date 5 -4-98
Notice: Tampering with this file by unauthorized persons is prohibited.
Deliberate modification will result in disciplinary action under s. 146.10, Ms. Slats.
SBD- 10462 -E (R.04/97) Page 1 of 7
80148m"-,"v
RESIDENTIAL MOUND DESIGN
Eight Bedroom Maximum
Complete information in red framed boxes as necessary.
(y or n) r n Is the stem over creviced bedrock?
Slope 7 %
Number of bedrooms 3
Wastewater flow rate 450 gpd 1703.3 Lpd
Depth to limiting factor 28 in 71.1 cm
In situ soil infiltration rate (code) 0.5 g 20.4 um
Contour line below the upslope edge of absorption cell 99.55 ft 30.34 m
Use standard fill depths? OR Designer speed depth I in cm
Place X In box to use standard depths (14 24, A44 inclusive) OR specify design till depth.
Center or end manifold 1(c ore) Estimated hole space 4 ft Not a final calculation.
Lateral spacing 3 ft Minimum dose >= 10 times void volume
Use a li lateral spacing for trenches. Pump tank elevation 90 ft Outside bottom drank.
Number of laterals Force main diameter 2 in
Force main length F:eqoft Force main actual dia. 1 2.067 in
SYSTEM SOLUTIONS Inch- pounds Metric Cell media "x" one only.
Estimated daily flow ®gpd F-1-7-03-1 Lpd x Aggregate and pipe
Chamber and pipe
Absorption cell
Design load rate & area 1.2 gpwe 375.0 ft 34.84 m
Linear load rate 7.1 gpd/ft 88.0 Lpd/m
Design width (A) 6 ft 1.83 m
Cell length (B) 63.0 ft 1920 . m
Depth of cell (F) 9.9 in 25.1 cm
Sand filter
Upslope fill depth (D) 12.0 in 30.5 cm
Downslope fill depth (E) 17.0 in 43.2 cm
Basal area required (gpolnfiltration rate) 900 ft 83.61 m
Supporting components
Topsoil depth 6.0 in 15.2 cm
Subsoil depth at center 12.0 in 30.4 cm
Subsoil depth at cell wall 6.0 in 15.2 cm
End slope toe length (K) 10.6 ft 3.23 m
Upslope toe length (J) 7.0 ft 2.13 m
Downslope toe length (1) 12.3 ft K7.71 m
Total mound length (L) 84.2 ft m
Total mound width (W) 25.3 ft m
Project: WILLIAM KILL
Plan 1. D. 80148 Page 2 of 7
MOUND PLAN VIEW
observation pipes (typical)
E W= 25.3 ft A A= 6.0 ft 1.83 m
7.71 m — �= B = 63 ft 19.2 m
B K J= 7.Oft 2.13m
I = 12.3 ft 3.75m
K= L122ft, 3.23m
84.2 ft
25.7 m typ. obs. pipe
A X B refers to absorption cell width and length (anchored securely)
J = upslope width
I = dowrislope width
K = end slope dimension G' (150 mm)
i
MOUND CROSS SECTION 11 l - subsoil cap D = 12.0 in 30.5 cm
lateral topsoil G H E = 17.0 in 43.2 cm
invert 101.1 ft--- I F = 9.9 in 25.1 cm
elev. 130.82 m see not G = 12.0 in 30.4 cm
H= 18.Oin 45.6 cm
Sys. 100.6 ft
D E Sand Fill
elev. 30.66 m 99.61 contour 7%
130.36 I m slope
/ tote: Absorption cell media will
D = upslope fill depth plowed layer consist 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 right. Chamber
H = subsoil + topsoil depth at cell center
Designer notes:
If aggregate is used, it is covered with code compliant material.
Project: WILLIAM KILL
Plan I. D. ### Page 3 of 7
PRESSURE DISTRIBUTION CALCULATIONS
Absorption cell Inch- ounds Metric
Width (A) 6 -- � ft 1 1.83 Im
Length (B) 63.0 ft 19.2 m
Lateral specifications
Number laterals 2
Holes/lateral 16 holes
Lateral length 60.0 ft 18.3 m
Perforation dia. 0.25 in 6.4 mm
Lat. dis. rate 18.64 gpm 1.2 Us
Sys. dis. rate 37.28 gpm 2.4 Us
Hole spacing 48 in 121.9 cm
Lateral diameter Pipe diameter Design optiorn Design choice
Designer must 1 in25 mm Place X in red
0 )C" one choice 1 1 /4inr32 mm box of chosen
from the options 1 12in/40 mm X x diameter.
provided. 2inW mm X
3inf75 mm X
Manifold diameter Pipe diameter Design options Design choice
Designer must 1 in25 mm
"V one choice 1 1 /4n/32 mm Place X in red
from the op t ions 40 ions 1 1mn mm X box of chosen
provided. 2in50 mm X x diameter
3in175 mm I X
4inn00 mm I X
Distribution system contains 2 lateral(s).
LATERAL DIAGRAM - END CONNECTION
Place correct lateral degram by c6ckfng in one of the drawings at right and dragging the diagram into this area.
L aterals centered over Last hole drilled next to end cap en cap
P
All laterals are identical k- X —�I Holes drilled on the bottom of the lateral
e"a! spate S
41 n
•
Force maim coronation via tee or cross to manifold at any point. Laterals & force main of PVC Sch 40
. ■ permanent end marker (per COMM Table 84.30 -5)
Inch-pounds Metric
Lateral length (P) 60.0 ft 18.29 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 16
Invert elevation of laterals 101.1 ft F 30771 m
Project: WILLIAM KILL
Plan I.D. 80148 Page 4 of 7
Total dynamic head
System head = 3.25 ft 0.99 m
Vertical lift = 10.20 ft 3.11 m Are laterals the highest pant in the
Friction loss = 1.39 ft 0.42 m system? Yes' X here. � J
Total dynamic head = 14.84 I 4.52 m If no, what is the highest elevation
Dose Volume downstream of pump?
Lateral void volume = 12.7 gal 48.1 L Force main drain
Minimum dose = 127.0 gal 480.7 L back to tank? r'x' one)
Drain back = 10.5 gal 39.7 L x Yes
Dose volume = 137.5 gal 520.5 L No
Typical Pump Chamber Layout
In combination with state approved treatment tank. Tank construction as per Comm 83.20(3) WAC.
approved manhole cover
weather proof wNvaming label and padlock
grade levels junction box BIO 7— grade levels
quick disconect
` alternate
4' vent Pipe electric as per NEC 300 and outlet
Comm 16.28 WAC location 18" (46 cm) min.
wall of pump approved
chamber or outlet
combination / joint
tank A 1/4" weep Grade levels
alarm on u, hole as pump tank swift ie - 4' min. above Mehed grade
pump on B necessary pump tank men. -100 mm min above firished grade
vat m 12' min. above firished Weds
pump 90.9 ft vert a 300 mm min. above fWshed wade
off elev. 27.7 m
D
3 " 75 mm) of bedding under tank and anchor tank as necessary 90.0 ft Pump tank elevation
27.4 m bottom of tank
Tank specifications: WEEKS
Pump tank = 19.04 gal /in
Pump tank volume = 800 gal Capacities: Inches Gallons
A= 24.8 472.1
Pump manufacturer: IGOULDS B = 2 38.1
Pump model number: 1WE0311L C = 7.2 137.5
D = 8 152.3
Project: WILLIAM KILL
Plan I.D. 80148 Page 5 of 7
venormance
Curves P
METIERS FEET
MODEL 3885
25 SIZE 3 /4 " Solids
WF1SH
70
20 'E10H - - _
60
WE07H
15
W E05H 1 -- -
40
10 WE03M - - - - -
20 WE03L
5
10
0 L 0
0 10 20 30 40 50 60 70 60 90 100 110 120 GPM
i
0 10 20 30 m
CAPACITY
!'UGOULDS PUMPS. INC.
METERS FEET
120 MODEL 3885
35 110 wE15HH SIZE 3 /4 " Solids
100
30
�o
25
70
20
7 60
0
WE05H)
15
40
10
20
5
10
0 0
0 10 20 30 40 50 60 70 Fr 90 tG0 110 120 GPM
L-- ' -
0 10 20 30 M IA
CAPACITY
•IQ" Gould&Pump$.Inc. EI1 W" July. IpN
C�111�
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Wisconsin Department ti e
ons g Industry
Labor and Human Relations SOIL AND SITE EVALUATION REPORT Pa 1 of 3
—
Divisiqn of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 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. C? 3.2 - +o
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
John DeRosier GOVT. LOT SW 1/4 SW 1/4,S 13 T 30 N,R 2 x: k ( or) W
PROPERTY OWNER':S MAILING ADDRESS LOT BLOCK # SUBD. NAME OR CSM #
1472 23rd. St. " I na na
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN NEAREST ROAD
Houlton, WI. 54082 (715)549 -5877 Somerset I 23rd. st.
New Construction Usejrx] Residential / Number of bedrooms 3 ( ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate * bed, gpd /ft ' 6 trench, gpd/ft
Absorption area required 375 bed, ft2 375 trench, ft Maximum design loading rate • 5 bed, gpd /ft , 6 trench, gpd/ft
Recommended infiltration surface elevation(s) 100.55 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material glacial till Flood plain elevation, if applicable na ft
i
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U = Unsuitable fors stem I ❑ S E U CRS ❑ U EI S ®U ❑ S ® U EIS EP ❑ S ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 0 - 10yr3 /2 none sl 2msbk mfr gw 2c .5 .6
2 9 -16 10yr4/3 none sl 2msbk mfr gw 2m .5 .6
Ground 3 1 16-32 7.5yr4/4 none scl lfsbk mfr gw if .2 .3
elev. 4 32 -60 7.5yr4/6 no 1 2msbk mfr na na .5 .6
10 ft.
Depth to
limiting
factor .M
Remarks: cc�tJs�I' V
Boring # >r
1 0-9 1 non '._ 2msbk mfr ClW 2m .5 .6
2 2 9 -17 10yr4/3 none ' " sil 2msbk mfr gw 2f .5 .6
3 17 -29 7.5yr4/4 none sicl lmsbk mfr gw if .2 .3
Ground c p yr
elev. 4 29 -45 7.5yr4/4 7.5yr5/8 sicl lfgr mfr na na .2 .3
9
Depth to
limiting
factor
29"
Remarks:
CST Name: Please Print Phone:
Gary L. Steel 715 - 246 -6200
Address: 1554 00th. veo New Richmond, WI. 54017
Signature: Date: CST Number:
6 -1 -94 cstm 2298
w w .
STEEL'S SOIL SERVICE
Gary L. Steel John DeRosier 1554 200th Ave.
CSTM2298 Sw4 Sw4 S13- T30N -R20W New Richmond, WI 54017
MPRSW 3254 lot #2 (715) 246 -6200
f town of Somerset
N
1 =40'
BM =top of 1 1 'steel pipe at el. 100' w /marker
alt. BM.= RR spike in oak tree at el. 102.85
0 40
Oro
ate , do
yyl
3 - Z
C
o m
N
Gary L. Steel
6 -1 -94
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer C�.�- ��J,��,.� L- �► L��� rte,,,;
Mailing Address
Property Address A, N
(Verification required from Tanning Department for new construction)
City /State 'c S, y� parcel Identification Number
LE GAL DESCRIPTION
Property Location '/4, '/4, Sec. �:� , T N- K Ao• \ Town of
Subdivision , Lot #
Certified Survey Map # ':Sa \C� \'I , Volume \0 , Page # �
Warranty Deed # (�) i nn ' (77 , Volume \ Ci,`A , Page #
Spec house ❑ yes,® no Lot lines identifiable (9 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.
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
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.
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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
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