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Home My WebLink About040-1235-10-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner dpi sc Address V, 1 ;d �p -- City /State mar d s � ,t/ � , ' Legal Description: , Lot Gf Block Subdivision/CSM # Gou A J 7 L r '/, , Sec. ,�, T?EN -RZW, Town of Try PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INF � OItMATION: 3 z8. /g, //7� Tank manufacturer �� , w �5-71 Size ST/PCl /GSo Setback from: House Pump manufacturer �c� �,� Model .�� Well Alarm location �- �e l� (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Meter location Water Line Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width Setback from: House ;2 Q " Well � Len gth 2,5 ,- Number of Trenches = P2 S ' Vent to fresh air intake G ;� ELEVATIONS: Description of benchmark Description of alternate benchmark ��wa�� r,� y ,�� Elevation Elevation v �•i� o Building Fd ST/HT Inlet 1 77. !:�; :L ST Outlet PC Inlet PC Bottom -?- Pte' Header/Manifold Top of ST/PC Manhole Cover /D.?• i2 Distribution Lines ( ) % p 7 , () ( ) Bottom of System () y' -- 7 ( ) ( ) Final Grade Date of installation / / Permit number 5 lea 1 State plan number Plumber's signature 4 License number ?,g> Date Inspector Complcte plot plan Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division INSPECTION REPORT Q= Cyri x GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit N Personal information you provice may be used for secondary purposes [Privacy Law, S. 15.04 (1)(m)]. 32 Perm' H Ider's Name: [I City [] Village Jq Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: I%yo Iv i ran Oft) 1235— I6-002> TANK INFORMATION EL NATION DATA Aq TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ptic Benc�hm Dosing ��? i. om -D /0 Aeration Bldg. Sewer 9$. Holding St/ Inlet TANK SETBACK INFORMATION St /M Outlet TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet ir S pti 11— X3 NA Dt Bottom 1P.,34 , g�( osin A Header /Man. `pd,-7 Aeration NA Dist. Pipe 5 � - ( o [ Holding Bot. System �9 °7 PUMP/ SIPHON INFORMATION (p a Final Grade r a.$ l o 3 - 3 Manufacturer° V Demand S+ y4uv h 3r Ib 03.�3- Model Number I (� GPM TDH Lift (07 Friction .$ System TDH /0; ,17t oss Forcemain Length I da Dia. H n Dist. To Well SOIL ABSORPTION SYSTEM BED / R N Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME N 7 I DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACH G Manufacturer: SETBACK INFORMATION yy Sy Pe a16 �Q r 0(' o OR UNIT CHAMBER Moe um be r: DISTRIBUTION SYSTEM Header / Mani old r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length L Dia. Length Dia. � Spacing � (� �C[c�°T 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 El E] No ❑ Yes E] No COMMENTS (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. 18 sconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes 3z(1 [Privacy Law, s. anon tion o (m)]. ❑ Check if revision to previous plication State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION �+ Property Owner Name Property Location c s 1 /4Sw 1/4, 5 3 T ,?� , N, R f E (or)g Property Owner's Mailing Address Lot Number Block Number .Wc 9-/% sr o y0 City, State Zip Code Phone Number Subdivision Name or CSM Number 4 / ( > oo II. TYPE F BUILDING: (check one) ❑ State Owned 0 it� Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms ❑ VII age Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ 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. RNew 2. ❑ Replacement 3 ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an ______System System _____________ Tank Only Existing System Existing System ______________ xistiny ________ 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 [j'Seepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy 13 ❑ Seepage Pit C X 7 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. /inch) ?o0 Elevation g o 7 Q6 16� ZIA Feet Fee VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Fiber- plastic Exper. New Existing Gallons Tanks Concrete structed Steel glass App. Tanks Tanks cSTe4- Septic Tank or olding an ,0 ado � � ® El E] ❑ ❑ ❑ lift Pump Tan /Siphon Chamber s"� l ® ❑ ❑ ❑ ❑ 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 (U0 Stamps) PRSW No.: Business Phone Number: 144 11'4 ,4 , 1. 7 1 s Va,/ Plumber's Address (Street, City, State, Zip Code): .tom Gl t ll IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) A roved Surcharge Fee) PP ❑Owner Given Initial j �`�1 ov /�� Adverse Determination / V X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 1✓ Z67`' Y I i I r i ® ,mac 11 �7r: �a c✓U Y C � I � L . , �� P i e , (DO PUMP CHAMBER CROSS SECT 101,1 AMC, SPECIF ICt r10�J5 VE KJT CAP `I C.I. VENT PIPE WEATHERPROOF APFROVED LOCKIAJC. 25� FROM DOOR, JUIJCTIOM BOX MANHOLE COVEF, WINDOW OR FRESH 12 "MIL1. AIR INTAKE I GRADE 18" /MI Id. CONDUIT 18 "MIN. \ ---- - - - - -- \ 11l IMLET PROVIDE I - - -_— AIRTIGHT SEAL i I I \* * - A i I I I. I I I I I ALARM Is I I I I I *APPROVED I I ON JOINTS WITH I I ELEV. FT. APPROVED PIPE 3' ONTO PUMP OFF D SOLID SOIL COAICRETE 9LOCK RISER EXIT PERMITTED OQLy IF TAMK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPEC,IFICAT10US DOSE TAIJKS MAUUFACTURER: &;&e<7`�v /J IJUMBER OF DOSES: PER DA-4 TAWK SIZE L/14G��'SD GALLOMS DOSE VOLUME ALARM MAWLIFACTURER: eUtls�.LZ IMCLUDIMG B ACKFLOW: joZ� GALLONS MODEL IJUMBEK: _0Ly CAPACITIES: A= 'S UICRES OR 34s GALLOWS SWITCH TYPE: A1 P.Y c B = IIJCHES OR - GALLOUS PUMP MAAJUFACTURER: ?;,L��B C = IUCHES ORI CALLOUS MODEL IJUMDER: O� D =— Z_IAICHES OR L=—_ GALLOWS SWITCH TYPE: NOTE: PUMP AMD ALARM ARE TO DE MIAIIMUM DISCHARGE RATE y� GPM INSTALLED OM SEPARATE CIRCUITS VERTICAL DIFFEREUCE 15ETWECU PUMP OFF AMD DISTRIBUTIOM PIPE.. I_ FEET + MIIJIMUM METWORK SUPPLY PRESSUR , , , , . , , FEET + FEET OF FORCE MAIM X 3 'a 7 F /0o►LFRICTIOM FACTOR.. FEET TOTAL DyIMAMIC. HEAD =�_ FEET IMTERKIAL, DIMEIJSIOIJS OF TAIJK: LENGTH ;WIDTH ;LIQUID DEPTH SIGUED: � "�•Cl�� LICEAISE AIUMBER DATE: /•s" Wisconsin Department of Commerce SOIL AND SITE EVALUATION Divisiori of Safety and Buildings Page / of Bureau of Integrated Services in accordance with s. ILHR_$3 09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size parr must 1 i bounty include, but not limited to: vertical and horizontal reference point (BlpfAe "ction and, s�'cyra X percent slope, scale or dimensions, north arrow, and location and fist>e to n Pardel I.D. # i t APPLICANT INFORMATION - Please print all info n oon ? s` tClf evie ed by Date Personal information you provide may be used for secondary purposes (Priv cy L w, s. 15.04tt) CrQL-ix f Property Owner r jl)�Lionovt. Lot '1!4 1 /4,S 3 T4 7 ,N,R '� E (or Property Owner's Mailing Address o 9' ; B16ckf,j Subd. Name or CSM# City State Ziip Code Phone Number ❑ City ❑ Village 21 Town Nearest Road QQ - G(c- /e F I ( , d ul BY G� New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement L� ❑ Public or commercial - Describe: Code derived daily flow 7J�CJ god Recommended design loading rate bed, gpd /ft 1 trench, gpd /ft Absorption area required A bed, ft 2 trench, ft Maximum design loading rate - bed, gpd /f1 _ trench, gpd /ft Recommended infiltration surface elevation(s) �'y ft (as referred to site plan benchmark) Additional design /site considerations Parent material Ci4.4C a a Gf S'/ 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 ®S ❑ U ® S ❑ U 2 S ❑ U ❑ S 10 U ❑ S 2 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 3 H5r elev. — �p ft• pia 2 s R y --'-- S Depth to limiting factor 14 in. s Remarks: Boring # is -sa ,� j mu 6 1rr FA� 1 Ground YC 7 , elev. / de ft. Depth to limiting factor / Remarks: CST Name (Please Print) Signature Telephone No. x Address Date � CST Number 1,d r 7 Ll��+ 6� 6' I 2? T /' 7 Q /n� ✓o Jl raS t �e � � %!�G I h h I a Jai e4r, 7e, • w ,8l 3T I c rA v / Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary320230 Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. JOHNSEN, N RANDALL 10 CST village Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: vYY Parcel T 64 - 1235-10 -000 TANK INFORMATION ELEVATION DATA 9800416 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. wer Holding St/ Ht At TANK SETBACK INFORMATION St/ Ht Out et TANK TO P/ L WELL BLDG. Air I I to ntake RO D t Inlet Air Septic NA Dt ott m Dosing NA Header / Man. Aeration NA ist. Pipe F Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Deman Model Number M TDH I Lift Friction Syst DH Ft Loss Forcemain Length Dia. H Dist. o W I SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION TypeO Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Di ribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. 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: (I clude code discrepancies, persons present, etc.) LOCATION: TR 3.28.19,NE,SW 547 GILBERT RD — COUNTRYWOOD LOT 40 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No Safety and Buildings Division Vi scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 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 81/2 x 11 inches in size. e • X • See reverse side for instructions for completing this application State Sa Permit Number Personal information y ou p rovide may be used for secondary r n to previous application �� Y p Y ry purposes ❑ Check it revisio [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop rty Owner Name Property Location ZT -OAL 7V 1/4 W 1/4, S j T .2f, N, R E (or) Property Owner's Mailing Address Lot Number O Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE F BUILDING: (check one) ❑ State Owned We It� Nearest Road d Public 1 or 2 Family Dwelling - No. of bedrooms _� Town OF ►� cJG a' A Jr- 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 6 — it .1 :r - 1 , 0 — ado 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 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank 12 §d 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 1 1 1 5 ..� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 7S6 ?SQ 9G e 6:2 Feet /Gib. ° ZFeet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con Fiber- plastic Exper New Existin Gallons Tanks Concrete strutted Steel glass App. Tanks Tanks y Septic Tank or Holding Tank 4ve / �y ❑ ❑ ❑ ❑ ❑ _L Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/ PRSW No.: Business Phone Number: Plumber's Address (Street, City, State Zi Code): /o ; S 44 - IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) �Ap Surcharge Fee) ❑Owner Given Initial Adverse Determination �l X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber e — A a s�•7� • we- /� Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Pa e 1 of 3 Labor and Human Relations g rdiroision of Safety & Buildings r -> in accord with ILHR 83.05, Wis. Adm. COCO Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must i but 3e• Croix l i not limited to vertical and horizontal reference point (BM), direction and % of slope, s ,leer RAFICEL I."- dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION I EV1D B DATE PROPERTY OWNER: PROPER _t ATION Richard Stout GOVT. LO*." q :1/4 F 1/A S 3 f_? g AR 19 -E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # B SUBD. NAME2!1 # 1353 Awatuk CITY, STATE ZIP CODE PHONE NUMBER [ []VILLAGE NEAREST ROAD Hudson, WI. 54016 (715) 549 -6731 Troy Tower Rd. [ flew Construction Use [xJ Residential / Number of bedrooms 4 [ ] Addition to existing building ( ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd /ft •6 trench, gpd/ft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd /ft .6 trench, gpd /ft Recommended infiltration surface elevation(s) 96.52 ft (as referred to site plan benchmark) Additional design / site considerations alt area =el . 95.06 system brought to code with extra rock Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S El ®S ❑U ®S ❑U 191 0 :]S ❑U I El ®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 1 0 -30 10 r2 2 none .6 2 30 -48 10 r4/4 none sicl lfsbk mfr Cfw if .2 .3 Ground 3 48 -60 10 r4/6 none sl 2csbk mfr 9W na .5 .6 elev. 99 ft. 4 1 60-96 7.5 r4/6 none fs osg mfr na na .5 .6 Depth to limiting factor +96" Remarks: Boring # 1 0 -24 10 r2/2 none 1 2msbk mfr gw if .5.6 2 <` ...:.::< 2 24 -36 10 r4/4 none sicl lfsbk mfr gw if .2 .3 Ground 3 36 -50 7.5yr4/4 none sl 2mgr mvfr gw na 5 .6 elev. 4 50 -90 7.5yr4/6 none s losg ml na na .7 .8 100 ft. Depth to limiting factor +90" Remarks: CST Name: — Please Print Phone: Gary L. Steel 715 - 246 -6200 A ddress: 155 0th. Ave., New Richmond, WI. 54017 m02298 Signature: 4 -23 -96 Date: CST Number: �% , � STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Richard Stout NEgSW4 S3- T28N_R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246 -6200 lot #40- Country Wood N 1 =40' BM.= top of 1 steel pipe @ el. 100' � t ti Gary L. Steel 4 -23 -96 DR/28/98 WED 07:40 FAX 715 388 4888 ST CRI CO ZONING IM002 ST CXtQIIi COUNTY SEPTIC TANK MAINTENANCE AGpEEMENT AND OWNERSHIP CERTIFICATION FORM Own Bayer Maili ;Address :�s Prop` y Address (Vam ication required from Planning Department for new construction} City/; rte I 1. Paxcel Identification Number - LEG. aj DESCRIPTION Prope 1 Location % S Q y, SM 3 r 2 N- �V4T, Ton of lb Subdi aion Lot # L� va, Certi d Survey Map # Volume . Page # Warr t y Deed # _= �� . Volume 3) (o Page # Spec' use 4 yes ❑ no Lot lines identifiable ❑ yes ❑ no SYST U MAIlV'1'EaANC +' ruproper use and maintenance of your septic system could result in its preroaturs failure to handle wastes. Propermaint w== consist f pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the systmu can 'Aff the function of the septic tank as a treatment stage in the waste disposal system, 're property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master' rte, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the oa -Nitc wastewaterdisposal system is in pr ;r' operating condition and/or (2) after inspeetian and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1/we, tt 1J1&n4ned have read the above requirements and agree to maintain the private sewage disposal system with the standards set ford rrrein, as set by the Department of Como Me and the Departmntof Natural Resources, State of Wisconsin. Ccrtiticatiou stating • t your septic systeaxn has been m2iatainal must be completed and retuned to the St Croix County Zoning Office within 30 s of a ar expiration date. GNA ri APPL DATE QWNWN.. t cz & SON (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (am) the owner(s) of ZA l ty seribeove, by virtne of a warranty deed recorded m Register of Deeds Office, ' 1�tB tJF 1 I DATE swssss ny info rmation #hat 181t1iS- represeatedmay result in the sanitary permit being revolted by the Zoning Department. rwwwww w* Ineli , with this application: a stamped warranty deed from the Register of Deeds offi'ice a copy of the ccrdfiod survey reap if rofor= is made in the warranty deed 07- �7 r 98 MON 07:16 FAX JEFF METZGER 004 y , LANE 713 -xZ' x a y = ? x i ti a g oryi /9 # e 4c w � o� N 8 43 AT �;6�5/t0' d 66£tt Tb :6C� 52! -50' $66T N05Qr" Ai oN Y [ra l wfJ' d