HomeMy WebLinkAbout040-1235-90-000 ST. CROIX COUNTY ZONING DEPARTMENT ;.,-,
AS BUILT SANITARY REPORT
Owner doze a Yek KQ Y S cl N t "fin
Property Address i / t -
City /State
,;E
Legal Description:
Lot — _zl� Block Subdivision/CSM # ►,
t /4 SG) t / 4, Sec. .,2—, T AF N -RLW, Town of . 7'r-7:o v/ PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer �T1, ���fes�`�j --� Size ST/PC / QLav les Setback from: House ?,5 - ' Well ad- P/L 3�
Pump manufacturer Model .�
Alarm location tYQ A . (HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: a4k,4 Width 3� Length �� Number of Trenches
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmark off" - e-- Elevation
Building Sewer J ST/HT Inlet 3� �f ST Outlet PC Inlet
PC Bottom fd. `o Header/Manifold C /f Top of ST/PC Manhole Cover ?- r
Distribution Lines ( ) `1'5"' () ( )
Bottom of System(
Final Grade () () ( )
Date of installation 9 1l 19'r Permit number State plan number
Plumber's signatur License number 9¢� Date - 7 / / 19d"
Inspector d�'� /�
Complete plot plan �
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitard6l"9e2:
Personal information you provice may be used for secondary purposes [Privacy Lag, s.15.04 (1)(m)).
Permit Holder's Name: EY Village El Town of: State Plan ID No.:
LARSEN, HOWARD 'rtc
CST BMElev.: Insp.BM BM escript1 n: C Parcel T _1235 -90 -000
TANK INFORMATION V U ELEVA ION DATA A9800171
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
. ,
S tic t �Jw DoD r Benchm p 3 03 7 1 oa
Dosi I� -Sb I
/lt D l03 • / c9�
Aeration Bldg. Se e 1 � , '
Holding S Inlet loj. I-C&
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septi fi �,� NA Dt Bottom
NA Header / Man. p 3- &l fig.
Aeration NA Dist. Pipe 3 CH
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand -�, ( D�j — vnk Id
Model Number o0 - GPM 10(.$ 316 � � 3
TDH Lift( .a Friction( cl System TDH
oss 1 li o . g3 ! ro
Forcemain Length 010 Dia. '' Dist. To Well
S IL ABSORPTION SYSTEM
BE / TRENCH Width 1 Length No. Of Trenches PIT No. Of Pits Dia. Liquid Depth
M I N � DIMENSION
SYSTEM TO P / L I BLDG WELL LAKE / STREAM :1E HING Manu acturer:
SETBACK BER INFORMATION Type O Mo el Nu er:
Systerfr � R U
DISTRIBUTION SYSTEM
Header/M@nj fold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. 1 Spacing __q� 1I N
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 C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) .-7`r = ' 76 / Ce4
LOCATION: HUDSON 3.28.19,SE,SW 529 GILBERT ROAD — COUNTRYWOOD LOT 48
� &� ur ��
Pla vision eq 18 g l es N
Use other side for additional infor a ion. XWt-_5�ej I
SBD -6710 (R.3/97) Date nspector's Signature rt No.
*I scons i n SANITARY PERMIT APPLICATION of E wWaasnngtonAve si °°
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce 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
3o -7 7$9-
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
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
�Q 1 14 1/4, S _q Tgg , N, R fJ• E (orw
Property Owner's Mai ing Address Lot Number Block Number
Yr
City, State *Zip Coe Phone Number Subdivision Name or CSM Number
P 4 t .2 ( ^) W IV
11. TYPE OF B IL I G: ((check one) ❑ State Owned ❑ !t� Nearest Roa j�
0 ❑ Vil age r
Public N or 2 Family Dwelling J
- No. of bedrooms Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo � � ®- / 2.3 ?6
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 ❑ 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. /inch) Elevation
yam® J S 7 - 'y 9Y !� Feet . S1J Feet
VII. TANK in Capacit llon Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name concrete con Steel glass Plastic App
New Existing structed
Tanks Tanks
e tic Tank pC V' 640 l - El 1:1 11 1:1 11 V.
Lift Pump Tank " r - 6 14 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
[,the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: o Stamps) MP PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Surcharge Fee) Ete
Iss nt Si nature (No Stamps)
X Approved E] Owner Given Initial Z� u I)o
Adverse Determination v �! �bj c;
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-&W IRA 1/96) D1578NPJTWU: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber -
M � Safety and Buildings
2226 ROSE ST
LA CROSSE WI 54603 -1905
' VIA ,
Tommy G. Thompson, Governor
Department of Commerce William J. McCoshen, Secretary
May 05, 1998
CUST ID No.267341 A7TN.• POWTS INSPECTOR
WEGERER SOIL TESTING & DESIGN
421 N MAIN ST
PO BOX 74
RIVER FALLS WI 54022
RE: CONDITIONAL APPROVAL Transaction ID No. 76868
APPROVAL EXPIRES: 05/05/2000
SITE:
Site ID: 6409
St. Croix County, Town of Troy
SETA, SW1/4, S3, T28N, R19W
RICHARD LACASSE = sr Ro
FOR. Z
N
Description: MOUND N /�y pFF� ..
Object Type: POWT System Regulated Object ID No.: 15605 F es,
The submittal described above has been reviewed for conformance with applicable Wisconsin Administr
Codes. The submittal has been CONDITIONALLY APPROVED
The following conditions shall be met during construction or installation and prior to occupancy or use:
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Adm. Code.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
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,
64� DATE RECEIVED 05/01/1998
FEE REQUIRED $ 180.00
GERARD M SWIM, POWTS PLAN REVIEWER FEE RECEIVED $ 180.00
Integrated Services BALANCE DUE $ 0.00
(608)785-9348, MON - FRI, 7:15 AM - 4:00 PM
JS WIM @COMMERCE. STATE. WI.US
Page of 6
MOUND SYSTEM
A 3 BEDROOM `'' " 76
LOCATED IN THE 1/4 OF THE SW 1/4 OF SECTION 3 ,T N, R 19 W,
TOWN OF T Zug ,
Sr. C.t?!J IX — COU NTY, WISCONSIN-
INDEX
PAGE 1 `of 6 TITLE SHEET s ' 9 FQ r
PAGE 2 of 6 PLOT PLAN ��'k ! l998
PAGE 3 of 6 PLAN VIEW -CROSS SECTION : lU
PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT Gs
.PAGE 5 of 6 PUMPING CHAMBER
PAGE 6 of 6 PUMP PERFORMANCE CURVE
PREPARED FOR
W T,S'
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o � �iti na ll y
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o oN, w 1 s Qt o 1(� �MMER
1 tAEVO Of uoto '
pEPAR SY 1►N
D1V1S
SEE co
NDEN
PREPARED BY
WEGEFREFz;t SO I L TEST I P4
AND. ���m�at�ae'�►i
V
F.O. BOX 74 421 K. KAIK ST. +'. • `�y,
RIM. FMS. NI 54022 ® � AP_ L.
® W_ RER
EILSrORTH,
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A
®® S I C r
3C, -
JOB NO. b
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Page Z of 6
Scale 1 "=
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NOTES
-1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install permanent markers at end of each lateral. (_Y_ required)
3. Install 4" observation pipes with approved caps. ( z required)
4. Septic tank to be l oon h, S u gallon capacity manufactured by
5. Bench Mark t_, r_u Oo• b' oN BUT' o!= 0 STWE.L. C 2 p ti
6. Divert surface water around systek to prevent ponding at the uphill side.
Page 3 Of lO
Approved Synthetic Covering
ts� c 33 Distribution Pipe
Medium Sand
H -- G
Topsoil F Elev. qO
°►.'
3 �. E D
b
y % Slope
Bed Of 2�— 2 %2 Force Main Plowed
Aggregate From Pump Layer
D \ . u Ft.
Cross Section Of A Mound System Using
E .32 Ft.
A Bed For The Absorption Area
F Ft.
G 1.o Ft.
A �_ Ft. H \.5 Ft.
Linear Loading Rate = 9 -1 GPD /LN FT B U1 Ft.
Design Loading Rate = O 4.GPD /SQ FT I Ft.
J S Ft.
K Ft.
Alter-Rate Position L 6q Ft.
of
Force Main W 3 Z Ft .
Observation Pipe-,
K
I -
-t
I• - - - -- ----- - - - - --
rA A
----------------- - - - -�� �e+�
Distribution Bed Of 2 2
Pipe Aggregate
I
Observation Pipe Permanent Markers
(Anchbr securely)
Plan View Of Mound Using A Bed For The Absorption Area
r Page _L)0f
Perforated Pipe Defoil
J 0
End view
Perforated
End Cop. E PVC Pipe
1.
Install permanent marker
at end of each lateral
Holes Located On Bottom,
Are Equally Spaced
Q S
P
PVC
Manifold Pipe
PVC Force Main
t
Distrn ution
Pipe
Lost Hole Should Be I
Next To End Cop
End Cap
P 2 -Z Ft
Distribution Pipe Layout
S _Y p Ft.
X Y l� Inches
Y qt Inches
Hole Diameter 1 1y Inch
Lateral Inch(es)
Manifold 7 Inches
Force Main " 2. Inches
# of holes /pipe
Invert Elevation of Laterals 9 a -S Ft.
fix\ Y1_1.(3Zx4= Zg
Place lst hole from center of manifold with succeeding holes
at intervals. Last hole to be next to the end cap.
Combination Sept;c;Tank and
- PUMP CHAMBER CROSS SECTION AMD SPECIFICATIONS ' PAGE S. OF to
VENT CAP WEATHER PROOF
JUWCTIOW BOX
M'C.I. VEIJT PIPC APPROVED LOCKING
� 10' FROM DOOR, P4AIJIiOLE COVER 1utTll
- 4I UDOW OR FRESH wARNlN6 LJNt3El.
AtRI UTAK E COY - 3DU I r
tj
6 M�X. t
�`— � �. IB Ml
--
IJ3•Mlti.
y „ t1�s ?tlor.� PIPC PROVIDE I — - --
INLET AIRTIGHT SEAL
I I I I \✓ .
�+aFFLCS
A I I I APPROVED JOIIJTi
APPROVED JOIAIT
. I III W /C.I. PIPEOKP'C
W /C.I. PIPE OR Tank construction ) it
shall comply with ALARM
P Y I 11
ILH11 133.15 and 33.20 B I I
I t Ow
C I I
L -g-3 FY PUMPS - -�
OFF
0
COUCKETE
BLOCK
1 3#' APPRw RISER EXIT PE E RMITTED 0MLJ IF TAW MANUFACTURR HAS SUCH APPROVAL B600tNG
SEPTIC f SPEC.IFICATIDKJS
DOSE yvt� L p��HT I UMBER OF DOSES: 3 ' PER D”
TAWKJ MA WLIFACTURCK.
TAWK :,IZIL: �bd� L 6S0 GALLOUS DOSE VOLUME r
ALARM MAIJUFACTURE.R:
INCLUDIiJG BAGKFLOW: GALLONS
MODEL NUMBER: ��, ��w CAPACITIES: A= INCHES OR 3 o�D GALLOLJS
SWITCH TZJPE: C k B = Z IIJCHES`OR =J__ G( LLOUS
PUMP MAWUFACTURrK' �UL✓� S C- IUCHES OR GALLONS
MODEL NUMBER: 3�1I �0y D = IIUCHESOK GALLONS
WI
SWITCH TYPE: C,U N OTE: PU M P AMD ALA ARC TO 5E
�"J
M DISCHARGE RATE Z8 " GPM INSTALLED OW SEPARATE CIRCUITS
VERTICAL DIFFEREWCE DETWEEU PUMP OFF AUO.DISTRIBUTIOU PIPE.. � FEET
+ MINIMUM NETWORK SUPPLY PRESSURE .. 2.S0 FCCT
6 cJ FT `.
+ F EET OF FORCE MA►N X �`�) /OFi.FRIG710N FACTOR.. FEET
TOTAL DtIUAMIC HEAD = � • Z FEET
Pump chamber DIAMETER 1 ,
1UTERWAL DVALIJSIOLI� OF TA1JK: LEM&TH ;WIDTH — ;LIQUID DEPTH 3 � _
BOTTOM AREA - 231= — GAL /INCH
AS PER MANUFACTURER GAL /INCH
Goulds or—
Submersible '
Effluent Pump
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.
dry without damage to heat transfer. ■Motor Cover: Thermo las
• Hom t systems components. tic cover with integral handle
Available for automatic and
Farms Motor: and float switch attachment
• EPO4 Single phase: 0.4 HP, manual operation. Automatic
• Heavy duty sump g p models include Mechanical points.
• Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty
• Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant.
automatic reset. ■ Bearings: Upper and lower
SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing
115 V, 60 Hz, 1550 RPM, construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo-
9 Solids handling capability: automatic reset. plastic Semi -open design AGENCY LISTING
3 /4" maximum. • Power cord: 10 foot with pump out vanes for
r- • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. R. Cawdian SWndards Asmdation
• Total heads: up to 24 feet. with three prong grounding
Discharge size: 1 NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- {CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F' or "AC ".)
rotary/ceramic- stationary, three prong grounding plug improved performance.
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
• Capable of running w ;
dry without damage to s 30
components.
Pum . EP05 1 —
P: $ _
• Solids handling capability: 0 25
3 /" maximum. w
• Capacities: up to 60 GPM. s 20 '
• Total heads: up to 31 feet.
• Discharge size:1 W NPT. z 5 '
• Mechanical seal: carbon- 0 15
rotary/ceramic- stationary, _ ' I
4
BUNA -N elastomers. 0
•Temperature: t U
104 °F (40 °C) continuous '
140 °F (60 °C) intermittent. 2
5
�j
OL 00 10 20 30 40 50 GPM
L j - L L
0 2 4 6 8 10 12 m °/h
CAPACITY
®1995 Goulds Pumps, Inc. Effective May, 1995
83871
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor.and Human Relations
Division of Safefy &Buildings in accord with ILHR 83.05, Wis. Adm. Code,,...- OU
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must in de;;but { ;St. ".,Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scii le or PARCEL LD. #,
dimensioned, north arrow, and location and distance to nearest road. pertdl g
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION RE E ED DAT
PROPERTY OWNER: PROPER LOCATION
Richard Stout GOVT. LOT 1/4 SW 1/4,S 3 T"2 N,R 19 Mor) W
PROPERTY OWNERS MAILING ADDRESS LOT # LOCK #,� SUBEJ.`fi}PrMEb,a ' I
1353 Awatukee Trl. 48 1 na.,. Coun `, d
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD
Hudson, WI. 54016 (715) 549 -6731 Troy Tower Rd.
[x] New Construction Use [ jj Residential / Number of bedrooms 3 [ ] Addition to existing building
(] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 4 bed, gpd /ft * 5 trench, gpd /ft
Absorption area required 375 bed, ft2 375 trench, ft Maximum design loading rate • 4 bed, gpd$ • - 5 trench, gpd/ft
Recommended infiltration surface elevation(s) 97.34 ft (as referred to site plan benchmark)
Additional design / site considerations system el. based oncontour line of 96.34'
Parent material pitted outwash plain 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 for s stem ❑ S ®U 5S 11 U El S IR U ®S ❑ U El :E] U ❑ S $7 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Ttertch
€< 1 0 - 10 10 r2 2 none 1 2msbk mfr if .5 .6
2 10 - 22 10 r4 4 none sicl 2msbk mfr gw if .4 .5
Ground 3 22 -36 7.5yr4/4 none sl 2msbk mvfr gw na .5 .6
elev.
96 ft. 4 36 -56 10 r3 6 2 7.5 r5 6 scl lfsbk mfr 9W na .2 .3
Depth to 5 56 -65 7.5yr4/4 none sl 2mgr mvfr na na .5 .6
limiting
factor
36"
Remarks:
Boring #
1 0 -12 10yr2 /2 none 1 2msbk mfr gw if .5 .6
2 U 12 -29 10 r5/4 none sicl 2msbk mfr gw if .4 .5
2
3 29 -68 7.5yr4/4 none lfs lcsbk mfr na na -5 .6
Ground
elev.
9
Depth to
limiting
factor
+68"
Remarks:
CST Name: — Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th Ave., New Richmond, WI. 54017 m02298
Signature: Date: CST Number: 4L2L 4 - -
STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
C SE SW4 S3- T28N -R19W New Richmond, WI 54017
MPRSW RSW -3 3254 town of Troy (715) 246 -6200
lot #48- Country Wood
r
N
1 " =40'
BM.= top o 1" steel pipe @ el. 100'
G� r
k
/b N
S®'
05.
Gary L. Steel
4 -25 -96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer t4o of o r,� Z I? A z•" L 4-P'e'-L ,
Mailing Address 1 y3 y0 //c L L
i
Property Address XS 2
(Verification required from Planning Department for new construction) YA
City/State �� Ltc�, 5 dry (AJ -L Parcel Identification Number .0 yd - 2 3S 90 - d d
LEGAL DESCRIPTION
Property Location , ' /., 6 (A-) ' /., Sec. T A 9 N -R 1 ' W, Town of _ `t r- o Y
Subdivision C 6 cA.vt, �/ wood xA A _ Lot # r n
Certified Survey Map # Volume , Page #
Warranty Deed # S S O V-�?8' Volume 1-2Q Z , Page # d,Z 7
Spec house ❑ yes Q Lot lines identifiable B ❑ 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.
A91
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 pr erty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
c� cvr� --
f 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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