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HomeMy WebLinkAbout040-1144-40-000 r' ST. CROIX COUNTY ZONING DEPAR CI L !I w AS BUILT SANITARY REPO, Owner Address City /State St 5r e r �? yr CROX COUNTY Legal Description: e"OVAGC1FFlGE Lot �— Block — Subdivision/CSM V '/4 5 10 '/4 A LL, Sec. 1 4 T2LN -R-9 W, Town of T�o 1144 -4 10- M.1 q, 14Ai 0 SEPTIC TANK — DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC) / Setback from: House 12 ' Well >su' P/L 7z' Pump manufacturer_ Model Ljc D 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 i Well P/L 7 5 ' Vent to fresh air intake 2 S ' ELEVATIONS Description of benchmark s E c r h Elevation d 0 0, D o� Description of alternate benchmark 1 57,-e/(2,' r i o' p y Elevation 5 8 Building Sewer R 8.5 ST/HT Inlet 8 P , e � ST Outlet- c PC Inlet PC Bottom S 3 � Header/Manifold cl 7.1 S Top of ST/PC Manhole Cover 4a. 8 Distribution Lines ( ) q . 1 5 O ( ) Bottom of System( 9 6, 15 () ( ) Final Grade Date of installation 6 / F Permit number 3 0 7 3 State plan number ? 1 y a 9 Plumber's s' ture 00d L License number a o S S 4 Date / a/ Inspector 6) 1 Complete plot plan Or Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Y' Safety and Buildings Division Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3F19""_: Personal information you provice may be used for secondary purposes [Privacy Lay, s.15.04 (1)(m)]. Permit Holder's Name: Village Town of: State Plan ID No.: RONNESTRAND, CLINT SP ❑ — 11 4 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel To"-,- 1044 - 40 - 000 (0 D (DV - og 1 w►n Sarver or dy%a icer' TANK INFORMATION eLEVATION DATA A9800162 TYPE MANUFACTURER CAPACITY STATION S HI FS ELEV. Septic w eS� IZSv Benchmar 2 - 7 2, 77 Zg - 7, Dosing ov`� 7SU �1��.r�,nn q1, 25 3 65 93 • 3 Aeration Bldg. Sewer Q1,2g - 77V Holding - St /Ht Inlet Jr.o 5" TANK SETBACK INFORMATION St/ Ht Outlet TANKT 1 0 P/ L WELL BLDG. Ai to ROAD Dt Inlet irintake Se ti _', S Vt.- 12 � � - � NA Dt Bottom Dosin ti� N/ol 'r Z NA Header / Man. Aeration NA Dist. Pipe go 7•/ Holding Bot. System /D /.q 5 PUMP/ SIPHON INFORMATION Final Grade Manufacturer C. I Demand Sf. rA6,vjh01e (0 1116 Soo 2.Z8 Model Number �j ( NA GPM � l�M So /oo TDH Lift( S 7 Friction p System TDHI . 6 nFt l l`�M if ZED, 5 /o/ Forcemain Length ���/ Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM , y� TRENCH Width Length 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid D DIMENSION (o DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM L ACHING cturer: INFORMATION Type O CHAMBER M umber: Syste ve V"j (p� OR UNIT DISTRIBUTION SYSTEM Header/Manifold 1 Distribution Pipe(s) x Hole Size x Y Hole Spacing Vent Air In a e 11l s�> Length( Dia. Length A Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 1 / Depth Over xx Depth Of V xx Seeded / Sodded xx Mulched Bed /Trench Center 12 � 1 Bed /Trench Edges Topsoil 12 Yes ❑ No Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) S 60 3 IS LOCATION: TROY 10.28.19.146A,SW,NE 679 COULEE TRA L '-T, al In/G(( K04 I �sfal[L�(CJ i✓t`1(ucfCb�1 . 105 2,I{. 19Z 4 A tthL 2) CcvKs�•G sound gS � �ts. g s z il . 9s.3q Io� i�q 1$l9� Pan revision required? LJ Yes ;K No Use other side for additional information. ,SBD -6710 (R.3/97) Date Inspector's Signature - Cert N t Vi sconsin SANITARY PERMIT APPLICATION 2 01eE.W and Buildings D shngtonAve sion 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 un - than 8 1/2 x 11 inches in size. C;ro t • 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 ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan LD. N I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N 71 q,2 7 Propert Owner Nam Property Location 1 t iv'r Onn G s �� 1/4 yV 1/4, S [ G T � 8 , N, R f A(or) W Properiyp tier's Mailing Addr V� Lot Number Block Number City, St//atGtee VV Zip Code Phone Number Subdivision Name or CSM Nu II. TYPE B ILDING: (check one) ❑ State Owned qtr _ Nearest Road Vilae Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 1 40 III. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) 1 ❑ Apartment/ Condo Q 4 6 - to 44 4 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. E] Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. E] Repairofan ___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 NIVIound 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 6OQ 5f 1 1. - q1 I Feet f g Feet Capacity VII. TANK in Ca gallons Total # of r Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass App. New Exist in structed Tanks Tanks Septic Tank or Holding Tank 75d / 1 W C e� �.�.! 19 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 750 1 2 - c;O I cii V ' © 1 ❑ ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: ( Plu ber's Signatur : (No Stamps) MP /MPRSW No.: Business Phone Number: _ p - r ( F' GiSO JP OZI IS � ' S' /7.S Plumber's Address (Street, City, State, Zip Code _ A f,�/� ✓��Oa� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Is Agent Signature (No Stamps) H Approved ❑ Owner Given Initial rJ � !>ti► Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber Safety and Buildings 1 A 2226 ROSE ST LA CROSSE WI 54603 -1905 \*1 sconsin G. Thompson, Governor Department of Commerce William J. McCoshen, Secretary April 09, 1998 CUST ID No.220554 ATT7V: POWTS INSPECTOR CARL P HEISE 1042 S MAIN ST RIVER FALLS WI 54022 RE: CONDITIONAL APPROVAL Transaction ID No. 71929 APPROVAL EXPIRES: 04/09/2000 SITE: Site ID: 4807 ST CROIX County, Town of TROY SW 1 /4, NE 1 /4, S 10, T28N, R 19 W CLINT RONNESTRAND FOR: Description: MOUND Object Type: POWT System Regulated Object ID No.: 11408 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes listed in the regarding line above. 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. 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, Y DATE RECEIVED 04/09/1998 FEE REQUIRED $ 180.00 &RDWIM , PO OWTS 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 MOVE THE EARTH CARL HEISE EXCAVATING 1042 South Main RIVER FALLS WI 54022 RECEIVED CARL P. HEISE APR - 9 1998 Owner (715) 425 -2175 MOUND SYSTEM SA; %c i Y t RLi-, DIV. FOR BEDROOM RESIDENCE LOCATED IN THE SW��` OF. THE r q OF SECTION _, T _aN, R I�W, TOWN OF � , O Y , •' (',rat k. COUNTY, WISCONSIN. INDEX PAGE 1 of 6 TITLE SHEET t, - PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW -CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAY - OUT PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED .FOR 0- VV•T•s't C URT RON NE NI Co�iditio t l Y 1067 Al. SIUr:,LI) AVF E F Qy D ST P OQ A L M S 5 1 D ttEs1 Of COMMER Cs 612 _ d F s ETY A C� g l-� g q -1 ,v s�N4 u SEA CpR RES NDENCE P,REPAR D IDY Care P, else CST 3314 MPRS 3378____ 226 55q 1042 South Main Street River •Falls,WI 54022 PI OT PL SCAL E 1 �= 40� 3.0 � AC, 1 1 4 f i I � 6c pvc 2�'_ct r►� OL w T tt for 0� Or / t r A �' 95 ,Ic r�►o�o�r r � n' Designer No Date Non —Woven Filter Fabric 4" Observation Pipe Perforated Below Filter Fabric ,Distribution Pipe ASTM C -33 Sand {H G I Topsoil - = = - =- - -- r EL 9 7. Slope \ Bed Of { Y'— 2 %2 Force Main �'­.Floweo Drain Rock From Pump Layer D 1.0 Cr oss Section Of A Mound System Using E L 2� A Bed For The Absorption Area F —j G 1,0 A (_ Ft. e7 I.5 6 �� Ft. I to Ft.- J �_ S Ft. K G. Ft. Alternate Position Ft. of W 25 5 Force Main Ft. 14'Observation Pipe -� A I _ Force Main W 0 -- {------------- - - - - -- ' From Pump 3 p Distribution Bed Of 'V 2 % Pipe Drain R OCK I � 4 Observation Pipe Permanent Marker Pipe or Rods LI i Pion View Of Mound Using A Bed For The Absorption Area PAGE OF • - �� � �1 of Designer No Date Perforated Pipe Detail L �• End View " End Cap b\ % y 'PVC Pipe � gfl Lost Hole R Holes Located On Bottom Are Equally Spaced Q v }Iti PVC Force Main + From Pump .7 Q PVC Manifold Pipe ' Distribution Alternate Poeltlon Of Pipe " Force Main From Pump Last Hole Should Be In End Cap Near The Crown Of The Pipe, End Cap D Pipe Layout P 41 R 3 x ,S 8 Y Hole Diameter �4 Inch Lateral 4 Inch(es) Manifold 3 Inches r i Force Main Inches ST J 'I Holes /Lateral 9 0 aR SE TANK & PUM_P_C CRO SECTION AND SPECIFICATIONS t �T 4" CI VENT PIPE 12" MIN. ABOVE GRADE E WEATHER PROOF >_ 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED; FRESH AIR INTAKE WITH CONDUIT MANHOLE COVi FINISHED GRADE 4 CI RISER W /,;PADLOCIG t 6" MIN. * F1' ARNING LAB7 y ABOVE G AD E ,.,. 4 MIN ' 18" IN. 6'� MAX. INLET WATER TIGHT SEALS GAS- t TIGHT i ►► f - r 4 I1 GAFFLE A SEA1a i APPROVE-61 CI PIPE ALC1 , 3' ONTO B ' PIP3. SOLID � t ON SOLID SOISOIL C Es;,,k{ PUMP OFF ELEV . OF'c' RISER sEX] D PERIT 9 IF :TANK ?u HAS APPROVAI 3" APPROVED BEDDING UNDER TANK.: CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE��' TANK MANUFACTURER: 1�t1 l S C C., CJruC NUMBER DOSES PER DAY: TANK SIZES SEPTIC 1250 GAL. DOSE VOLUME INCLUDIN z{ DOSE '15O GAL. FLOWBACK: 4,4 GAL. ; ALARM MANUFACTURER: CAPACITIES: A = INCHES = MODEL 1?UMBER: VLV --- ,;k SWITCH TYPE: car T3 = INCHES � ,_•, .� — � ; GAL PUMP MANUFACTURER: C = 1 q .,INCHES MODEL NUMBER: W� 311 M q4 SWITCH TYPE: 1►Y►cr D INCHES =} GAI. REQUIRED DISCHARGE RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 160.23rWt! VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . . 13, 9 FEET,,, ' + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . 2.5 FEET a,= + FEET FORCEMAIN X • ,42 FT /100,FT. FRICTION FACTOR . l —��-- . 7 FEET , ,° , ,; TOTAL DYNAMIC HEAD = _ _ 1211 FEET ,} INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH DIAMETER { LIQUID DEPTH SIGNED: LICENSE NUMBER: DATE: b 1f 1 /88 Goulds Submersible Effluent Pump VINd 3885 a Overload protection must smooth operation. Silicon can be operated continuously °'xi &peg signed for the be provided in starter unit. bronze impeller available as without damage. • Shaft: threaded 400 series an option s Upper and . ■ Bearings: PP stainless steel., ■Casing: Cast iron volute lower heavy duty ball bearing �x •Bearings :'ball bearings type for maximum efficiency. construction. ra its upper..and lower. 2" NPT discharge adaptable ■power Cable: Severe duty t TM • Power cord: 20 foot :< �• for slide rail systems. standard length (optional y rated, oil and water resistant. lengths available). ■ Mechanical Seal: SILICON Epoxy seal on motor end 4 Single phase: - CARBIDE VS. SILICON provides secondary moisture •'/3 and'' /'HP -16/3 SJTO CARBIDE sealing faces. barrier in case of outer jacket tams Stainless steel metal parts, damage and to prevent oil withl.i b,V or 230 V three BUNA -N elastomers. wicking. prong plug: .x ' y r • i 1 ;' HP � 14/3 STO With ■ Shaft: Corrosion - resistant ■ 0 -ring: Assures positive bal' leads , stainless steel. Threaded sealing against contaminants ! copabillUes, "'';fihtdphase " design, Locknut on three and oil leakage. '� 4�•''Js�;' X4/4 STO phase models to guard { i t W�4 r5 leads r:On` CSA against component damage AGENCY LISTINGS jSM d0le,'20 foot ; on,accidentalreverse rotation. fett'; JW SPIN :■ Motor: Fully submerged in SP Canadian Standards Association high -grade turbine oil for lubrication and efficient heat UL underwrlterslaboratories xr FfE:AY�ItES O eat/g�licon��� transfer. seat; °;300 impi Cast iron, semi - ■ Designed for Continuous e'er- 5 Steel rPetaI Operation: Pump ratings are �' N elastomers� opert,.no `rf�clog with pump - out vane for mechanical seal within.the motor manufacturer's 8 recommended working limits, a protaction: Balanced for 04 bhtinuous °) intermittent METER n t • .astt#30b series so r j — _. _. SERIES: 3885 qq SIZE: %* SOLIDS .daps Olt dty 80 RPM VARIOUS �+ a0.f 0 + - - —► 5 GPM E1 _._ 70 Et 5 - - + t 20 — — }' Rr - �0 V3b V, o x= ``, 46 - - - — - . � 7 P2 0 V A; 10 — W ith Ig ' T It �P'200/230/ ; t - - - - - - L x,'35bOR 0 - 10 , 20 30 40 50: 60 70 �80 90 100 110 120 130GPM 4 . r 0 10 20 30 m CAPACITY ,e �99+GIoultls,Flumpa, Inc. Effective May. 1995 83885 .a��"z- ' f2 -c�?c •-�t. ��r���c;�r � r�-;� ��i2��� ��z, 2_� ���� fi� Wisconsin Department of Industry, _ Labor and Human Relations SOIL AND SITE EVALUATION Page of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County C,/ FOX 4 Include, but not limited to: vertical and horizontal reference point (BM), direction and l a0 /l x. percent slope, scale or dimensions, no h arrow, and location and distance to nearest road. Parcel I.D. # �t3v,PT— Z//? APPLICANT INFORMATION - Please print all Information. Re ewes y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). �1?8 Property Owner d n Property Location � Q %V T ON/(��ST/� 'V�/ Govt. Lot 54 Z J 1/4 /U� 1/4,S T ,N,R If E (or Wo Property Owner's Mailing Address Lotj I Block# Subd. Name or CSM# OU O - c lo 1667 n. 71W _ L City State Zip Code Phone Number Nearest Road SY' !�(J( �iV• JSIO� (�p�Z)(yy�' �/ 1 0 CRY El villa e Town 4eu /ee— . New Construction Use: Elgesidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow (.06V gpd Recommended design loading rate 7 bed, gpd/tt S trench, gpd /ft Absorption area required bed, ft2 st'� trench, ft2 Maximum design loading rate bed, gpd /fl ' S trench, gpd /ft Recommended infiltration surface elevations) 3 ft (as referred tasite plan benchmark) "Additional design /site considerations s� r � � 0,4>6- 66,XVa-4P Y SYs T . Parent material �Di1µV �OL�S QI� �- �-- Flood plain elevation, if applicable x ft S = Suitable for system Conventional Mound In- Ground PPressur AT -Grai System In Fill Holding Tank U = Unsuitable for system El S 2 E. U El L� U El El ©I` ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots , in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 6)./1/ /o y,C' 311 L. /fS& "7W S 17c . q :. S i y. ioYre 313 170CS 4k �iP CS If s Ground 3 •3 / Ye 31 S2_ 1 7 SA F 4-01 CGJ — • Z–' • 3 elev. 17. n • y p ,r / / // 2 � ., •s J� s►► Ship ! ' �r w . S ; . Depth to • 7 �d Y/� J ` } s/� I / /►at �/ ' Z ' 3 limiting factor 5 / Remarks: Boring # 0 •7 /o 3 1 Z 7.21 16 VA yYe SL 1� � 7,e C 5 / ; .S . 3 3 z /•so rev 3/ OS e d e �c�' �SO Ground 109/e y %6 p L S lt S ate• , 7 •� el . Q v. o• ( laYX i1W -f I - t no tS S - fSi& 0 � — — . ; S ry 0 ft . Depth to limiting factor 5 _0_ in. Remarks: CST Name (Please Print) Signature Telephone No. 'f�oR T e i G�T �N 71Y • 3 jf�; •�'!�S Address Date CST Number Itllydw6t t ♦e�nnifltan — - � /n _ - - — vs U3 Ln � zx Aj 'C v p .y o - p, : N tj 0 b v Z 0 y ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C I I' ►1-1 o P, E, a n C1 Mailing Address �0 7 a lower e Property Address Coulee T a (Verificati required from Planning Department for new construction) , City /State Uvc j�rl q01 %a Parcel Identification Number V qc -II J V-�O LEGAL DESCRIPTION Property Location 5 W �' /4, NE ' /4, Sec. /0 , T --� F N -R Town of - 7 - ro r y Subdivision , Lot # Certified Survey Map # , Volume I a , Page # 34"/0 . Warranty Deed # 5 7 8 3 , Volume /3,/ P , Page # 6 Spec house ❑ yes I no Lot lines identifiable J� 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. 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 � t property described above, by virtue of a warranty deed recorded in Register of Deeds Office. l dl /T l 5 / 9 7 0 1 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 1 � ' FILED -9 APR 2 9 1998 ► KATHLEEN H. WALSH 10 Register of Deeds 578081 ti SL Croix Co.,W1 CERTIFIED SURVEYMAP RICHARD BURT JR. Part of the Southwest 114 of the Northeast 114 of Section 10, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin. UN rrED LANDS S BB • 41 ' 09 "E 290. 75 ' "� KE COR. SEC. /O, r28N, M 1Q4 L /NE SW //4 X /14 R19W, /COUNrYSURVEYOR'S -- 12s.y —J � S 96 447/37 "W ' 290.62 �� I MON.) I 4.&J N _ W O j 2 O ff! R OAD S ETBACK LINE i ? 14J tn 1 ^ Q � ° 13'39' W LOT 2 I �1 '134.35 Q 3 _ _ _S 85° 38_30 W 259.22 - Q ku .WIDE DRAINAGE EASEMENT _ 2 I p I ( 1 2.0 2.O WATERCOURSE) 1 2 O 3.00/ ACRES I O 2 Uj N J o O 130, 704 S0, Fr. 1 p J I. > O h 2.9 // ACRE W In LU S EXC. ROAD R.O. W. 7 J I 3 � N 126, 797 SO. Fr. W m R y a v i m to i Owner's Address: N o 49 Long Lake Road m \ , x Mahtomedi, MN 55115 o W A a � M JI Nf.. x!'1 1 ' 1 jI ,. 4:179!1 „IP::, A(88 4/'09 "W 29.73' " UNPL LANDS .�9- 0 J •Indicates 1” x 24" iron pipe weighing 1.13 lbs. /lin. ft. set. R O Previously recorded data. 3F9 d<,; ;,' „0;{ 9 • it 4+117 r t:dE1 E //4 COR. SEC. /O, r28 N, R 19 W, !COUNTY SURVEYORS MON.) O 25' 50' /00' /50 200 ' 300' .al1tA /1111 /� /Ii_