HomeMy WebLinkAbout026-1108-60-000 (2)d
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Y nrffitosTC 10 4
AS BUILT SANTTARY SYSTEM REPORT
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OWNER
ADDRESS
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sEcrro* I ,._3q I{-n_-LE_w, Town of
sT. cRorx couNTY, wIScoI{sIN
Lor # ll/ t
R,Ytruc-^rd
PLAN
Ot^I EVERYTHING I^IITHTN ].0 O FEET OF SYSTEM
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37
TNDTCATE NORTH ARROW
J Bcar.;
l't5*5'
-
,-
E
,
Provide setback and elevati.on information on reverse of this form '
Provide 2 dimensions to center of septic tank manhole cover'
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BENCHMARK:
ALTERNATE BM:
dt
House
tE!
Model #
! otsher
SEPTIC T
Manufacturer:
setback fron: WeII
Punp : Manufacturer
Float seper ation
Atarm Location
widrh: I g
Building
Pc inlet
Sewer
ANK ,/ PUMP CIIAI.TBg G--'t?--
ER / IIOI,DI}IG TANK INFORI.{ATION
Liquid Capacity:
Size
GaIlons/cycle: _
A
.. SOII, ABSORPTION 8Y6TEI.T
7 Number o n
Final grade ?7, e
3
Distance & Direction to nearest prop
setback fron: wetl: 65l House . L)' oxh",
iEIsfr]gifc[Its
. line: 11..* to'
Header/Manifold
Existing Grade ?+,s
DATE OF INSTALI,ATION:
PLUMBER ON JOB:
LICENSE NUMBER:
TNSPECTOR:
3/93.jt
o.Bottou of sys tem tr
tt
ls6s
. Lodarfiard".Rr,cnfieuuy.4 . 30 . 18 . ffiBltgttv{ft; *Brtt' Labor and Human Relations. s"tetyi"a sriia'"siD,"iiio" . INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
rm s NameH age
D,
n 5p.
///,)(
BM Dei.ription
tl
rmaoty
State Plan lO No
Parcel Tax No.:
o25-1108-60-OOO
TYPE MANUFACTURER CAPACITY
Septic
Dosing -
Aeration
Holding
TANK INFORMATION
TANK SETBACK INFORMATTON
PUMP / SIPHON INFORMATION
SOILABSORPTION SYSTEM
ELEVATION DATA A9300150
ELEVSTATIONB5HIFS
y'.6a'/od. d'Benchmark
Bldg. Sewer ,^*+(r'r'Q9lat -<-4
lnletst/
?r,70's;5t/Outlet
-/ttDt lnlet
> [L(Dt Bottom
Headerl&r:
r,@'?o,,lJ'Dist. Pipe
g,bs'qo,3.1'Bot. System
Q.7a'F2,.il'Final Grade
Acz,<4k1.GTPDemand
Ft
ta
s
Model umber
TDH Lift
Forcemain Length _
Manufactur
trtTEh
Dist. To Well
TDH
4'.-(Ll
76tst lz|:s,.2
II
ffitt
III
MEMI
:-TANK TO PIL WELL BLDG.Vent to
Air lntake ROAD
Septic 55 /<'9'*t t*NA
Dosing NA
Aeration
Holding.-
I
IP
BED / TRENCH
DIMENSIONS
widthp/LenstZ) /No. OfZenchei ,Pt+brurrso-[s-No. Of Prtt lneide Oia Liquid Depth
SETBACK
INFORMANON
SYSTEM TO PIL BLDG WELL LAKE / STREAM LEltr{nl€_
CHAMBER'
OR UNIT
tuianulacturer
).rype Ol ,,
System:*/o5 ^G5 l*Mrrd!$tuI0.ber.i__-_---l
DISTRIBUTION SYSTEM
Vent To Air lntakex HoleSize x BoleSpacing
,.ng.Ln j2!4Dia
HeaderllEiE Distributron Prpe(s),,/ / ./
rcasth J/. o'a -f spat ns /z-
xr seeded,/xx Mulahed
EYes ENo
Depth Over
Bed /La!+fcenter s:al Depth Over
Bed / Tlat Edges 0:'a"xx Depth Ol
Topsorl
LOCATION:
sott covER x Pressure Systems Only xx Mound Or At-Grade Systems On v
COMMENTS: (lnclude code discrepancies, persons present, elc.l 4l {rr
.3 .18.60
Oer,z
RICHUOND 4a&c4.-'7,*.rr./.o5-r
t;-,q
%"-U"/r..-4r( L, lr.-"u:rfl,C a,/a4
Plan revision required? E Yes d
us€ other side for additional information 7 /2 A3 I r I
sBD.67,o(R osort!15 d.;k tlu :{Date
A)
lnrpector'r Sig nalure Cen No
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SBD$398 (formerly Plb€7) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Salety & Buildings Division, Owner, Plumber
IItrIILHFIt-ffi,l- Ei-il--.J=;rffi-I
SANITARY PERMIT APPLICATION
ln.accord with ILHR 83.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the systeh, on paper not less than
81Ax 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT I]{FORMATION - PLEASE PRII{T ALL INFOR}IATIOI{.
5/,Cw><
COUNTY
application
STATE PLAN I.D. NUMBER
PROPERTYOWNER&;-t- C*Av PROPERW LOCATION
ilE Y,5E Yl,s / T 3o,N,R /k E[or) w
PRoPERw ovrlxen's uau-r{e//?t /z?*A ADDRESS
ue.
LOT#.E BLOCK #N/tt
iitrffi]f;'.d u*Saot 7
ZIP CODE PHONE NUMBER
()
SUBDIVISION NAME OR CSM NUMBER
U t*_ b.., ok.
1 E AoUcondo
2 Z Assemblv Hall
3 E Campground
4 ll Church/Schoot
s E Hotet/Motet
NEAREST ROAD
4rmdn l
o aL- ,l 6g- bo
6
7
I
I
trtr
Dtr
R"l
trtrtrtr
h"BUILDING:(Gheck one)OwnedState
P 1mublc or Fam.2 IDwel bedof roon#
lll. BUILDING USE: (lf building type is public, check allthat apply)
10
11
12
13
Medical Facility/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Otfice/Factory
Outdoor Recreational Faci ! ity
RestauranUBar/Dining
Service Station/Car Wash
Other: Specity
il. wPE OF
,r5-
A) 1.E ru"* ,. Xr*tacement s.System System
line B if applicable)
Replacement of
Tank Only
B) E e Sanitary Permit was previously issued. Permit #
4 5.
Date lssued
Repair of an
Existing System
Reconnection of
Existing System
lV. TYPE OF PERillT: (Check only one in line A. Check
Other
41
42
43Pressure
V. TYPE OF SYSTEM: (Check only one)
Experimental
30 E Specify Type Holding Tank
Pit Privy
Vault Privy
Non-Pressurized Distribution Pressurized Distribution
21 E uouna
22 Z ln-Ground
11
12
13
14
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fill
2. ABSORP. AREA
neOUtnEo (sq.ft.)(r#6
3. ABSORP. AREA
PROPOSED (sq. ft.)L{3s
4. LOADTNG RATE
(Gals/daylsq. ft.)
t7
6. SYSTEM ELEV.
g?,s Feet ?'l,g Feet
VI. ABSORPTION SYSTEM INFORMATION:
7. FINAL GRADE
ELEVATION
5. PERC. RATE
(Min./inch)
CAPACITY
in oallons Prefab.V!I. TANK
NFORMATION New
Tanks T
Total
Gallons
#ot
Tanks Manufactur€r's Name
Site
Gon-
structed
Steel Fiber-
glass Plastic Exper
App.
Seotic Tank or Holdino Tank /,D/r)/A I Ft
Lift Pumo Tank/Siohon Chamber
VIII. RESPONSIBILITY STATEMENT
l, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
ilPlMPRSW No.
/5AJ
Ply4nber's Naffirint):
(joA*'{Z u)or> Jv
,,"W'#::T'Business Phone Number:
17lf D lt -5t3t
Plumber's Address (Street, City, $tate, Zip Code): t A il
/ ?e? /8ro l,p- rt/r.s ffoJ),*,1 , t)t -frtr7
/DEPARTMENT ONLYtx.
fioo,o".o .otfu
Disapproved
Owner Given lnitial
Adverse Determination
Etl Surcharge Fee)
ndwater
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
x I-IT-fI-I
STATE
totr previous
(
tr
tr
trtrtr
1. GALLONS PER DAY
4so
l-t l-t
i t
APPLICATION FOR SANITARI PERHIT
src 100
Thts appllcatlon form ls to be completed ln fuII and slgned by the ovner(s)
the property belng developed. Any lnadequacles wiIl only result [n delays
the permtt lssuance. ShouId thts development be lntended for resale
oyner/eontractor, (spec house), then a second form should be retalned
cornplctcd rhen the property la sold and submltted to this of f lce vlth
approprlate deed recordlng.
of
of
by
and
the
0mer o[ proper ty
Locatlon of property Nt Vq <F Ll40 secblon 4 r 2,o N-R // u
Tovnsh I p R, .-h,,"^^r.".,^-t
Halllng address //? r t.? /Ln-,'-
lln,t R' t r-rlwr.r^r,'--\ r ^-fr 5? of 7
Addreag of slte OL4+\t-
Subdtvlaton name t ) t r-,t '-. -\K
Lot nunber C c
Prcvlous orner oI property
Totel glze of parcel .41
Date parcel uas created l'Y1 q,^c I* t1 $.1
Arc all cotnerg and lot llneg ldentlflable?eB No
Is thlg property betng developed for resale (apec house]? Yes X no
Volurne LB 3 ""a Page Number / /) ^, recorded ulth the Reglster of Deede.
INCLUDE UITH THIS APPLICATION TIIE FOLLOTJING:
A UARRANTI DEED whlch lncludes a DOCUHET{T NUHBER, VOLUT{E AllD PAGE Ht HBER, and
the gEAt 0P THE REGISTER 0F DEBDS. In addltion, a certified survey, lf
avallable, vould be helpful so as to avold delays of the revlewlng process. If
thc deed descrlptlon references to a Certtflecl Survey Hap, the Certlfled Survey
l{ap sha I I a lso be regu I red .
PROPERTY OIINER CERTIFICATION
I(Uel certlfy that all statemente on this form are true to the best of ny (our)
knovledge; that I (ye) am (are) the owner(s) of the property descrlbed lnthta lnformatlon [orm, by vlrtue of a ]rarranty deed recorded in the Offlce of
the County Reglster oI Deeds as Document No.7?t t6 ; and that I (lile)
preaently ovn the proposed slte for the sewage disposal system (or I (ve) have
obta lned an easement, to run vl,th the above descr ibed property, f or h.he
constructlon of sald system, and the same has been duly recorded ln the Officeof the ounty Reglster of Deedsr is Document No.l.
s gnature of Ouner Slgnature of Co-Ovner (If Appllcable)
o'? - oq -q3
Date of Slgnature
Er
Date of Signature
OO(:Uf,'l.rr t a!,::U)RY\.
391s00
WARRANTY DEED
sfATu. Ir.tR oF wtscoNslN FoRtl 2-1082
vo, [iSJr^,;rI417
Charlci n. Hego6ii an{ {ancy E. U"goo-1r,' tiu.sUrni-.alrqvlfc as .J.olnt T.cnqtq
(onvpr. and $iirr.ntc to . Gcrald E, Ccdy 9d. Cyrtthla C. .Cody, ... busbsnd end vtfo ao Jotnt..Tcnaal9................
flEGtgItaS orfrcE
6r, ciou( co., wE
kCd, ior l.cDr{ thk l8t
d"yd;[-,ro---tC14
I 8330 A tt
lhc foih)wi:rg d.lcribcd l.al rstlta in
27 th dyo(
AUTlIENTICATTON
//*1. / fr*r"."-
C!:arlcs R. lhgo/n
/?arrcr1 Z fl)t7cuz,)
llancy E. Magoon '
Ccntu, 21
I{cr Rlchaod, lll
,,s81
( SEAL I
( SEAL I
St.ote of WiscoNin:
Ily 5l fcct ol lot 5 end Ely 62 lcct ofLt 6, Vlrbrocl r s Rlvcr Vlcy lddltlm to
?l! Psrc.l No:
th. TourshlF of nlchsnd, b.ln8 t P.rt of th. I{ot'th half of thc So,uthcest
qu.rt r of Scctlon lr lornshlp !O, llort'h R.rtc l8 Wc!t.
sJsl:e a
i.ll?
This .. .lf. .. . ho est.xd J,.or€rrr.(is) (is not)
l:xcolticn to $8.ranti?r: nO aleaptlons
l,ntrd this
Signature(s,
Fobnrary
{sE.{L}
(SEAL)
tulhcnticated this --.-.-..doy ot -----.' 19.--
ACENOWLEDGMENT
STATE OF WISCONSIN
.... !!-..9.T.9.$....... co,n,r.
Personolly came before ma th
, ts.8{... ttre :rbov! narne.l
)
ir.....27..th.aay ot
F.ab,..................
thrlp;..8,. $rs9oB..Attd..!tqlc[_.E., .f_{tsggp
to me kno$n to be the perjort *'ho erccuted th.
fo.c!.oin.{ instru cnt xnil acknos'lfll(e
TITLE: IIEItBER ST.\TE BAR OF WISCO,\*SI:i
{ll not. -....
authorizcd by S ?0ri.06, $is. Stlts.)
S INSTFUM'Ni Y'AS DFTF:EO BY
John D Welsh
{Sisnrt'rr"r ilry ba ruticnti(rrL,l ,,r r(irn,^r!cltrst. Itothrre not n($s;r]..)
D
John D Welsh
Notr.r puhric 5t Crolx
lI" .'nDtDi..ion ir nerxrxnrnt.l II rot
dart: Dac. 15
0
I
i.\.F.r ,,4 D"E,,.r
WAiRAIITY DfED iTrrE n\n ot lt ts( ossr \!' 'l{tl lj. !- tF.:
+$
:., r .r ,h i -r..,".
$.-f,n 1.,{r r'.,
0l 'ili
OWNER/ BUYER
sTc 105
SEPTIC TANK MAINTENANCE AGREEHENT
St. Croix County
Ct
ROUTE/Box NUMBER il1t tT rtll1 A-"<-FrRE No. I 11 I
zrP 540t7CITY /srATE Nn,.., Br.jmond u)rs. ffi
pRopERTytocATIoN: ilFttq 5E :Vq, section { ,r3Du,a /(v,
R,.';..-,-*trTown of
Subclivision U
St. Croix County,
frL. "+tot no.-5 y'6.bc
Improper use and maintenance of your septic system could result in its prernature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICEIISED SEPTIC TAI{K PWPER.
Uhat you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents l{AI be eligible to receive a grant for a t{lXll{tt{ of
$3000 of the cost of replacement of a failing system, which was in operation
prior to JuIy L, 1978. St. Croix County accepted this program in August of
1980, with the requirement that ohrners of Att NEg SYSTEUS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
[orm, signed by the owner and by a master plumber, )ourneyman plumber,
restricted plumber or a licensed pumper verifying that ( 1 ) the on-site
wastewater disposal system is in proper operating condition and (21 after
inspection and pumping ( if necessary), the septic tank is less than L/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/VE, the undersigned, have read the above requirements and agree to maintain
the private seerage disposal system in accordance with the standards set forth,
herein, as set by the I{isconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning 0ffice within
30 days of the three year expiration date.
SIGNED
DATE o 7 -O5- -? ?
St. Croix County Zoning Office
P.0. Box 98
Hammond, UI 54015
(715) 796-2239 or (7151 425-8353
Sign, Date, and Return to above address
C"YY,
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PAGE OF
-t"osS
L^Jr
Sfor)
S ""I tOr-r. O f A B"o Syr[o.,-,
Froth Alr lnlrtr And Ob:crvollon plpr
Apgrovrd V.nt Cop
Mlnlmrrrr lZ'Abovr
Fln od.
20- 12'Abovr plpr {'Corl lron
Vrnl PlprTo Flnol Grcdr
Ithrrh Hoy Or Synthr lk Covrrlng
]
b
lto 2' Aggr.got.
Ovor Plgr
Ol.trlbutloa
Plpr _ T..
6'Aggrrgotr
Soneoti Plgr P.rlorol.d Plpt Bolor
Cogllng Trmlnorlng Al
Sollom Ol Syrlrm
05 ( D F,^'l rr. cl(?4, s
fCt..r,.ro/1
c or AcGREGATE -1
APPRcvEo $lypETtC COVER
-flATERlAt
oR s" oF srRAw
oR flAnsu HA5
ELev. or 8? 5 FEET...*
Dt.srRtBUTrou p,pE ro Br- AT LE,Asr pO rucHEs BELow oRr6ruAL 6RAoE
AUIJ AT LEAST AO INCHES BUT I.IO MONC THAN LI2 IUCHES 6ELOW FINAL GRAOE
nArulurt OEPrH oF EXcAyATtor, FRon oRt6w{L 6RADE wrLL BE L 5 rucf-rES
ruillnufi gErI oF EXcAVATtoN FRon o(r(,rHAu GR4pE wrLL BE 2o TNcHES
516UEO:
LIC EU SE UUIABE R:
Pno p
l
I
I
DrsTRl Bu'nol.l PtPE
SOIL F I LL
)
'#-a*AG GREGATE
-E
4t)' or li - z'
*"!.rWI
DATE:
l{c3
I
(
t/:- 7<
\ilconsin Deoartment of lndustrv.
lSbor and Huinan Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATTON REPORT
in accord with ILHR 83.05, Wis. Adm. Code
ease / of 3
Atta,ch complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and"/oof slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
SOIL DESCRIPTION REPORT
Boring #
Ground
elev.
?Art
Depth to
limiting
factor. ,,
>34_
Remarks:
NW
5t, Cr"orx
PARCEL I.D. #
P ERTY OWNER:
\n
P R':S li4Al UN ADD
REVIEWED BY DATE
PROPERTY LOCATION
GOW. LOT flli 1t4 5E 1t4,sy I y ,N,R /8 tpOw
LOT #BLOCK #SUBD. NAME OR CSM #
ST ZIP CODE PHONE NUMBER rcrn nvlLl-iAGE N
I ltolc-
[ ] New Construction
}{ Replacement
Use ffi Residential/ Number of bedrooms t ] Addition to existing building
I ] Public or commercial describe_
Code derived daily flow { 50 gW R
Absorption area required _ bed, ft2 trench, ft2
ecommended design loading rar' t 7 bed, gpdlft2_:_.:8_trench, gpd/ft2
Maximum design loading rule ,7 bd,,gpdnz , 8 trench, gpdn2
Recommen ded infi ltration su rface el evation (s)(as refened to site plan benchmark)
Additional design / site considerations
Parent material 'r-Jt d cr,a)t\Flood ft
S = Suitable for system
U = Unsuitable foi syslem
CONVENTIONALEs tru MOUNDtrs nu IN.GROUND PRESSURE&s tru AT.GRADEtrs Ru
SYSTEM IN FILL!s Fu
HOLDING TANKDs Eu
Horizon Depth
in.
Dominant Color
Munsell
MotUes
Qu. Sz. Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence Boldry Roots G P D/ftz
Bed Trcndr
/o -lo /o"R 7tz 9//{ sbt n4,cu)ln II I L
2 /0)t I (
)6vR s/t /s ttebK rnri ( r C t^>l^,-r ,L
3 ;D-s'.l
t /-
/oyR s/L 5 D n 1r I\l C L^),7 ,/
Boring #
Ground
elev.
13'ltt.
Depth to
limiting
Remarks:
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Name:-Please Print
c -5/--)7/Phone:r
/? /gS * /4r<- l-b-J,?rrl" , ,-.,.1 hte 5/6/7Address:
Date: A CST Number:7-b-73 63)Signature.
I
plain elevation, if applicaOte r!/A -
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T;FlrF{iiiif.Ilill*l
tl;Eilf,{
Bodng #
SOIL DESCRIPTION REPORT p.r-&dJ-
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elev.
n
Deph h
limitm.%
Remarks:
Horlzon
/
23
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Dominant Color
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Qrr. Sz Cont Color TExturg Structure
Gr. Sz. Sh./s / lslP
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Borlng #
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Rsmarks:
Bodng #
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glgtr.
_lt
Ds$b
limi[ng
hchr
Remarks
Boring #
Gmund
elorr.
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limiting
hchr
Remafts:
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This is to
servl ng the
certify that I have inspected the septic
res ldence
NE L/4, 5E L/4, sec. I , T?o N, R /9v,
-).,J Upon i nspect I on, I cert i fy that I
be 1n good condltlon, and 1t
6 u-t--Ll^ S(signatur ( Name ) P lease Pr i nt
Lf
itle)(Li cense Numbe r )
z: L- 73
( Date )
Forrn to be cornl)leted by llcensed prurnber (s.145.06,or Licensed Disposer (Hn 113 Wisconsln Administrative
tank present 1y
located at:
Town o f
have f ound the
appears to betank and baffles to
functlonlng properly.
Last tlme servlced lrlc^ocjt \ I 1J
Dld f low back occur from absorptlon system? yes X Uo_(f f no, sklpnext llne )Approximate volume or length of tlme:S cra aIlons /o minutes
".:,::,:;ron: prerab concrete x sreel IOther
Hanufacurer (If known): ilopk,^s G*Je*.
Age of Tank (lf know t) yr>
C^) ..1 \--
l{lsconsln Statutes }
Code )
Plumber (applying for sanitary permlt) certification:
acceptlng the above statement regardlng exlstlng septlcition, T certify that the tank to the best of my knowledgeorm to the requirements of ILHR-83, Wis. Adm. Code (except
In
cond
conf
i nsp
Name
ta nk
r.ri 11for
5/88
ection ope4ing over outlet baffl
c )r; (/ru.,r Jn* s lgnature
e).
fl/npa s lS1-3
,
ST. CROIX COUNTY ZONING OFFICE
CERTI FICATION STATEMENT
FOR UTILTT,ATION OF AN EXISTING SEPTIC TANK