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514223
CERTIFIED SURVEY MAP
LOCATED IN THE NE I/4 OF THE SW I/4, THE NWI/4 OF THE SE I/4, THESE 1/4 OF THE NW 1/4 AND THE SW I/4 OF
THE NE 1/4, ALL IN SECTION 9, T 28 N, R 19W, TOWN OF TROY, ST. CRO IX COUNTY, W ISCONSIN.
*ALSO IN THE,NW OF THESW ANDTHE SW OFTHENW.
PREPARED FOR:
MYRTLE HANSON
NOTE: BEARINGS ARE REFERENCED TO THE
'n N -S QUARTER LINE(RECORD NI 14 CORNER SEC. 9
U � BEARING). (COUNTY MON. FOUND)
W
N
UNPLATTED LANDS
rn�
o '
° •• 1557.68
6' 116 11*0–
610039 y'E N87 07 52 E 331 95' E'NCE
1
\ \\ N GA *9g E'W QUARTER LINE —
a
33•°'?. LOT i
i
:\ \o \4 BUILDING
-'✓ ySET ACK LINE r
30.50 ACRES
o\ \� (1,328,595 SQ.FT.)
30.25 AC. EXC. R- 0 - W
jp1 \•� (1,317,719 SO. FT.)
CO
�- .\... .•40.49 1291.91' GJ
\ S89 °07�29� 1332.40' m O N•
C.S.M. - VOL. 6 - \ ~ M �•
Ct Z•
a Q•
PG. 1593 -.. \ c0 a J•
Cn
N
MONUMENTED LINE 2
OF SMALL TRACTS Ch
� W '
ROVED \ s
\ SMALL a W'
mm
TRACTS o 4.•
:J. CRODOGIOUNTY
\ 3
rlarehensive ti`lant* o ;
If±
Zoning and CTS \, \ o
z
1¢ not recorded � 33'
vAthin 30 days of
approval date \ ......
•ID 331 11,02 "w FENCE .3(
vat shag be '••• S89
� S @9 ° 0702 " W
314 vcAd 131.28 3
N �
UNPLATTED
A¢. C VOL. 3 N.o . . . .
0 = SET 1 " 24 IRON PIPE WEIGHING PG 660
1.13 CBS. PER LINEAR FOOT. - -•• -. z LANDS
SI 14 CORNER SEC. 9
(COUNTY MON. FOUND)
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner
Address ST c;acbk
City /State CckATY
'a \� ZONAGCFFICE
Legal Description:
Lot_ Block Subdivision/CSM # 6
%. A L , Sec. , TAN -R /' ° / W, Town of PIN # tjyo : ! zz
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: �
Tank manufacturer Size&C /� Setback from: House- Well — P/L
Pump manufacturer <— Model '—
Alarm location --
(HOLDING TANKS ONLY)
Setbacks: Service road `� Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
e�
Type of system: Width / $� Length 3 (o Number of Trenches
Setback from: House Well --- PAL c2,,�? Vent to fresh air intake /K8
ELEVATIONS
Description of benchmark / /I/E C0.,1— - P Elevation
Description of alternate benchmark f A 1. M —` rQ . 0-f–A6 - JA = " \on Elevation ro
Building Sewer Kbl S /HT Inlet 7 / J ST Outlet- 9 �- g PC Inlet
PC Bottom Header/Manifold W op of ST/PC Manhole Cover
Lines
Bottom of System
Final Grade
Date of installation 7 Qg F ermit number ,S'• State plan number
Plumber's signat e J& License number Date
Inspector It rig
Cf
Complete plot plan sr
• Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
SafetV� and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. 315849
M old� I_ _ e: ❑Skv Village Town of: State Plan ID No.:
CSTBBMElev.MM LL Insp. BM Elev.: BM escription: jj�'jj�( Parcel Tax No.:
j� Tcs c�� r 040- 1225 -10 -000
TANK INFORMATION ELE ATION DATA A9800237
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
0M Benchm lip S•
Dosi ng Au. 5 q. le) V
Aeration Bldg. Sewer 7
Holding (2)IBC Inlet G ,5" O
TANK SETBACK INFORMATION NS 6 t/ Outlet ( .g
TANK TO P/ L WELL BLDG. q Intake ROAD Dt Inlet
e 6 NA Dt Bottom
Dosing Header/ Man. '
Aeration NA Dist. Pipe 3 r Yn
Holding Bot. System � A -A. "C-W
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer De and 1 5 .---
Model N er plVl
TDH Li Friction Syste TDH Ft
H
Forcemain Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
ENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 6 `--- DIMENSION
SETBACK
SYSTEM TO P/L I BLDG I WELL LAKE /STREAM LEACHING 1 ufacturer:
INFORMATION Type O i 1 ,4 /14-% -- T CH Mod umb�
S ste I L./
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s= f' 1 r x Hole Size x Hole Spacing Vent To Air Intake
� � �Y r
Length Dia- Length _s1 L Dia- Spacing
A � t 1p qk :5 2-7 2-Of
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 soi ❑ Yes ❑ No es
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 9.. G8.19,SE,NW 524 BRIANA LANE — GLOVER HILLS LOT 1
X12. dt ti t -�. WAew -' " k! {- 8At - p , W 10)4
Q) 7A6Zj -�� l fit ik� ,)I �:' a+. f �>G uJ 44�e 8aoj �s
�t1 `C� v�.��- ; k�s {� Cleat t� .1 ws (��► '7181 X
F�laf
Plan revision required? ❑ Yes No
Use other side for additional info r a ion. - 7 q I ff
SBD -6710 (R.3/97) Date Inspect Signature
V i sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION Po �Wa shington n Ave.
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 5 T C /"O
than 81/2 x 11 inches in size..
• See reverse side for instructions for completing this application State Sanitar Permit Nu b
315
The information you provide may be used by other government agency programs E] 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 RMATION
Pro ert Owner me Prope Location
Pa
E' 1 /4 4/ 1 /4, 5 9 T N, R/ c ) E (or) W
Property Owner's Ma ilinig 40dress Lot Number Block Number
,, cy /0 S 1 F 2
�ty,State Zip Code Phone Number Subdivi ion Name or CSM um er
Ii/A✓ /I JA/ </O 7. ( ) Vts !f S
11. TYPE B ILDING: (check one) ❑ State Owned -a it Ne rest Road
Public 1 or 2 Family Dwelling - No. of bedrooms `S E row OF / O �/"' /�zt. � L K '
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s �yV i z
1 ❑ Apartment/ Condo Gyu fZZJ 20
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. F 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 B 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 S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Dr/ Elevation
V 15 - 0 (, y J b y /6. Feet 00,,0 Feet
Capacity
VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glaze Plastic App
Tanks Tanks
Septic Tank or Holding Tank 1Oa(, /000 2 %tvTT {`1 ❑ 1:1 1:1 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu ber' igna e: (No S ps) MP /MPRSW No.: 1/j-.26 usiness Phone Number:
Er in kp -� 27 4,s S 66 3 7
Plumber's Address (Street, City, State, Zi Code):
3 L r/ti s i `rt f Lvi .5 Yvo
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved SanitarPermit a (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved []Owner Given Initial surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS f OR DISAPPROVAL:
SBD-6398 (R.11196) DISTRIBUTION: Original to County. One copy To: Safety E Buildnrgs Division, Owner, Pb Amber
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1W=onsin Department oflWusby, SOIL AND SITE EVALUATION REPORT Page O f 3
- ^ C - ")or and Human Relations
.•� "�
in ofSalety a, Buildings in accord with ILHR 83.05, Wis. Adm. Code
.� COUNTY
,Amplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. I
..ut limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: SA�Q B " R . G iZ1 S S 11k1 G tm PROPERTY LOCATION
1M . FO RD 6AVT-.keT S t 1/4 NW i /4,S 9 T Z ,N,R 1 E ( W)
PROPERTY OWNER':S MAILING ADDRESS NAME OR CSM 1t
y S o C' Uo vEZ 1�k A 1, — t_ov 1f1 vl,- S
CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE ®TOWN NEAREST ROAD
NND)'s S (I t)l ( ( 33 &— 13 1`1 � �( a2tl�tvi} LPt1Jg
(� New Construction Use N Residential/ Number of bedrooms U LJhJ'Jowr'j (J Addition to existing building
[ J Replacement [ ] Public or commercial describe
Code derived daily flow \- So gpd/gtbrcoowt Recommended design loading rate Q- bed, gpd /ft a • b trench, gpd /ft
Absorption area required — bed, ft — trench, ft Maximum design loading rate o bed, gpd /ft 0 - 8 trench, gpdM
Recommended infiltration surface elevation(s) 5t?1✓ ►-a oTi- 43Q P►f6Q 3 , ft (as referred to site plan benchmark)
Additional design / site considerations
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 fors stem 14 O U ® S ❑ U IN S O U 8 S D U lid S O U [IS ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I Bed rerldt
Vn iv . Cw 3vf o• S o-
n<�
: -
c.sbh _ p. q o. S
wt v `�h Cw
Ground 3 Zy q 1� `1 tt 31 L L
i w►�� cS
1ot ft y U -ql 10� P— yl(,
Depth to
limiting
factor
Remarks: -
Boring # \o 31 Z
='
Z' 14
Z $ -t8 102 3!6 — sl c sbh rives. e.S
3 �g -°►(� 1o�crz �f6 S b S5 -
Ground
elev.
1 ot.1 fL
Depth to
limiting
factor
311�-
Remarks:
CST Name: — Please Print Phone. 715
Arthur L. We erer
egerer Soil- Testing & Service -P 0 Box 74 River Falls WI 54022
Sgnature' p - "� S Bate CST Ntxnhe�
of — q —15 -� - Z1-gS -MO0576
Page of I �
��ERlYOWNER 6�1SS1�2 — FOLD SOIL DESCRIPTION REPORT —
ARC EL I.D. N
"i
Depth Dom Structure inant Color Mottles Texture Consistence Baxidary Roots GPDM
3oring # Horizon In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed
0..\3 \.u� -t\i. ZLZ � L Zms�h w�'�►- Cw 3v� o•s o- �j;,.
Z Na ZL ... ti o't Q 3 /y s yvt C S
Ground 3 Z6 q2 lo`tQ y�6 f;
elev.
19• I It. t,
I,
Depth to i
limiting :i
facloL
nl
Remarks:
Boring # , L Z v►1 s �k
s �k w�'FY- CS o.S "a'
Ground
- ,
Depth to i .IN•
limiting
`� 3''
Remarks:
_ L 'L SVT
0 -10 �o` -t \2 �-L t w�'F1 Cw
Boring # 3v`F o.S o°
5 Z �o ��`�►t 3!y -
3 Zg 9y 1o�Q � Z S� M I
Ground
elev.
Depth to
limiting
tact? 9
Remarks:
Boring #
[3
1 1•
.i
, .1
Ground
ft. I
I
Depth to I! i
limiting
factor
Remarks: _ -- —
PLOT PLAN Page 3 of 3
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715.. Y 4.25 -.0165 1.4 00576...
CST
CST Signature Date Signed Telephone No.
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Lahr and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 i an must include, but
not limited to vertical and horizontal reference point (BM r f e, scale or PARCELI.D. #
dimensioned, north arrow, and location and distance road. .rj -
APPLICANT INFORMATION- PLEASE PR1N --A X. N N REVIEWED BY DATE
V .
PROPERTY OWNER: SA �g 1) . <S S l ; G tm, 4 ' PROP OCATION
R dy J G. I 1�: 1/4 K11) 1 %4,S 9 T Z$ N,R 1 E ( W
PROPERTY OWNER':S MAILING ADDRESS i LOT # OCK # SUBD. NAME OR CSM #
LP , i r+iA:. ( --
S t3 tQ . (> LOV 1`x'1 S
y G �p v Rp .fYA r-. ,,� i t 'F
CITY, STATE ZIP CODE P I , ll nNG0F):K ILLAGE MOWN NEAREST ROAD
`i�Ups
01v, 1, J 1 S t( (fit .3a "6 13 t'I R.� `( 821r�1v/} l.�Nt
[kl New Construction Use N Residential /Number of AddifiQn to existing building
j I Replacement [ J Public or commercial describe
Code derived dairy flow VSo gpd/8ET51zoo►n Recommended design loading rate o -1. bed, gpdfft 6 - trench, gpd/ft
Absorption area required - bed, ft - trench, ft Maximum design loading rate o -1 bed, gpd/ft 0- trench, gpd/ft
Recommended infiltration surface elevation(s) 52a ►-s of 1r -3Q Plt6La 3 . It (as referred to site plan benchmark)
Additional design/ site considerations - r�Z ej e- *tn "*-� IEFb
Parent material 5 0 \') N Flood plain elevation, if applicable N- A It
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for stem E4 S❑ U R] S [I U ®'S D U ® S ❑ U [3S EI U EIS N U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Trench
3 -tip ► o _ L lc� `- R. z, t z — L 2, � a b k gym. h C w 3 v 'F o. S 0-6
2 14 zy Vo1- f q o.s
Ground 3 Z4 4,0 1D ` lZ. 3 1 L w1 �� C S iD. S o. �o
el
ft yo -q R. yl(,
Depth to
fimiting
factor y
Remarks:
Boring # l 1 0- 8 \Z 3 Z - L Z
3\J n, S €o. 6
4
2
Ground
elev.
1 b►,1 ft
Depth to
limiting
factor
C) L 4
Remarks:
CST Name: - Please Print Arthur L. We erer Phone. 715- 425 -01.65
_ ergerer Soil Testing & Design Se.r_vice:- P.O. Box 74 River Falls WI 5402.2
b L� 6 Dates . (T Mi -
—I ZI - mst445`6
PLOT P LA N Page 3 of 3
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CSTSignaiur� Daie Signed . Telephone No, _ CST #
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Derision of Safety & Buildngs in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Vcx) L )C
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference pant (BM), direction and % of slope, scale or PARCEL I.D.#
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: -SAQ,$ p'[t R . G Ej S S 71v G tM PROPERTY LOCATION
��D ��►� t'c �-D r'1 • E0 RD GGVF --Eta S 1= 1/4 (J 114,S 9 T _Z N,R I c ) E ( W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
y S D N1. G L-p uEv- �Akt� I — Lo V 1` LL S
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (MOWN NEAREST ROAD
`�'fUps pN, t'V j 5 V 0L PI S) 336- l3 1 TR,p ` 32t P11Vq LKQR-
[� New Construction Use M Residential /Number of bedrooms u>J h1.NVw tJ [ J Addito to existing building
j J Replacement I I Public or commercial describe
Code derived daily flow \-So gpd/8f_'bizoorn Recommended design krading rate o 1. bed, gpd/ft e• b trench, gpd/fl
Absorption area required — bed, ft - trench, 9 Maximum design loading rate o-_7 bed, gpditt 0- 8 trench, gpoltt
Recommended infiltration surface elevation(s) 5F_ ti oTtr dQ P►r6 3 , ft (as referred to site plan benchmark)
Additional design / site considerations - TNZRDj e-WQS V_er-z) h IE!b
Parent material Flood plain elevation, if applicable N- A • ft
S = Suitable for system CONVENT!ONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem WS ❑ U ®S ❑ U INS ❑ U ®S ❑ U CR S ❑ U EI S M U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourg Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. f Bed Trench
:{" -_1W Y
{
J o -t. �pyQ z LZ Cw 3Vf o•S o.b
Z >4 zy �oy3Jy 4. o.s
Ground 3- Z4 10 `-t sz 31 C - �: Z bh rn `�h c S o. S o. b
lob 8 fL g -q7 vlz 1l L y l(,
Depth to
limiting
fa�CiQ
Remarks:
Boring #
o -$ 1 0`L VL - 3 i,. CO-w 3v 0.S o .6
lo `-L2 3lf, s c sbk my r
3 �g -°tl� �o�cR Ylb S Sg 'wx )i
Ground
elev.
lt 'l.l fL
Depth to
limiting
factor
90
Remarks:
CST Name: — Please Print Phone:
Arthur L. We erer 715 425 - 01.65
ress "
z eger.er Soil _T esting & _Des_lgn_ SexvAce ^P 0. Box 74 River Falls, WI 54022
.. PLOT Page 3 of 3
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t ) 425- 01 �� M QQS-76 -
CST- _Signature - -- Dade Sighed T_elephone_No. __ CST #
ST CROIX COUNTY is
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ,
o�F�e 7-4 r J ��9y
Mailing Address 5
Property Address
(Verification required from Planning Department for new construction)
v Nv-
City/State 2ZL g2 `e _ Parcel Identification Number v L/o. - is 2 s - -2 v
LEGAL DESCRIPTION
Property Location, E %., .L4) Y Sec. � 1 10: - N -R ZLW, Town of Ro
Subdivision aL e k'F'oz l l/L L s Lot #
Certified Survey Map # Volume . Page # /S .
Warranty Deed # Volume . Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM :1 -ML41N I'ED ANCE
Improper use and maintenaneeof yom'septic systemcould result in its prematmre faffare to Dandle wastes.
out the consist o f
die pum ping
oa Of Septi tank as a treatment tc tank every they Years or sooner, if needed b a licensed ��
maintenance
can Y pumper. What you put into the systaui
stage is the waste disposal rystem.
The property owner agrees to submit to St. Croix Zoning Department a certification f
��P lo �. signed by the owner - and by a
°�YmanPI� �ctedplumberora licensedpumperverifying that (1) the on -site wastewaterdisposal system
is m Proper Operating condition and/or (2) after inspection and pumping (if necessary), the scptic 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
da of the three expiration date.
GNA OF L
DATE
OWNER. CERTIFICATION
1(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
iG�RATLIRE P�rtY d bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
OF I:ICANT ` / G' / g �
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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