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HomeMy WebLinkAbout020-1165-60-000 Wisconsi n Depa PRIVATE SEWAGE SYSTEM County: St. CrOIX Safety and Buildin INSPECTION REPORT Sanitary Permit No 538766 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No'. Flattum, Jerome Hudson, Town of 020- 1165 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: •7� 6 J �� e k 17.29.19.1006 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Ben ilea ar �.�{•{ D . �j �.l. g 1 T / 4 �i{ L"_ Alt. B Aeration / Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFOR ATION �• 5 TANK TO P/L t WELL BLDG. Vent to Air Intake ROAD Dt I t $• • 7 Septic $� �� De n _ Header /Man. 9 9 . Sy Z7 Aeration Dist. Pipe n Holding Bot. System /0• Final Grade /�`� g PUMP /SIPHON INFORMATION -3 .1 Manufacturer Demand St Cover GPM Z • /OZ . LJ�.. GOJ Model Nu r TDH 'ft Friction Loss System I TD Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 i / O 4. vjl 3 C SETBACK SYSTEM TO 7 P/L JBLDG WELL LAKE /STREAM CHAMBER OR Manufacture INFORMATION Type Of System: 7 j M / UNIT Model Number: a J : Gk 24 P/ ts d r^ V r C. `� DISTRIBUTION SYSTEM df / I d — ► I 4— Header /Manifold // Distribution x Hole S ize x Hole Spacin g Vent to Air I take +7 Length Dia T 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 /So ded xx Mulched Bed/Trench Center /- 4Y!5 Bed/Trench Edges \ Topsoil es No Yes Ne (P r COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: I / _ Location: 470 Brookwood Drive Hudson, WI 54016 (NW 1/4 SE 1/4 17 T29N R1 9W) Park View Estates IV Lot 89 Parcel No: 17.29.19.1006 fir . C� 34 � b� S -6I� e le,_ � " 1.) Alt BM Description = ' 2.) Bldg sewer length = 1/G�"� ��T i ^ �•� «a A - amount of cover j A � Plan revision Required? ❑ rs (42 FL ti Yes (o � I Use other side for additional informaon. �� - -� - - Ce t No Date Insepctor's gnature SBD -6710 (R.3/87) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. C roix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 538766 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No Flattum, Jerome I Hudson, Town of 020 - 1165 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /TownlRange /Map No: 17,29.19.1006 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Da. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size I x Hole Spacing Vent to Air Intake Pipe(s) 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 1 xx Seeded /Sodded xx Mulched Bed/Trench Center Bed /Trench Edges Topsoil Yes ❑ No _j Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / _ Location: 470 Brookwood Drive Hudson, WI 54016 (NW 114 SE 1/4 17 T29N R1 9W) Park View Estates IV Lot 89 Parcel No: 17.29.19.1006 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑w Yes 0 No Use other side for additional information. - -- -- — Date Insepctor's Signature Cert No SBD -6710 (R.3/97) t carnmerce.wl.gov d Buil ' on County 0 1 W. Washin O. Box 7162 ! sco n sIi n Ma ' 707 7162tt ,� Sanitary Permit Number (to be filled in by Co.) 4 t epartMerd of Commerce `Lv� 53T Sanitary Permit Appal atio�, Go��,oF State Transactio � WIF In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this rrr► to the tt� mmental unit is required prior to obtaining a sanitary permit. Note: Application s for`IF ' POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you pro 'de>x sed for secondary p urposes in accordance with the Privacy I. Law, s, 15.04 m Q Stats, 4tt .1, `�6 /3 I. Application Information - 'PI ase Print All Information / OQIC q� Property Owner's Name Parcel N c urn OZC3 - 116 s- .00h Property Owner's Mailing Address Property Location 4 1'74 Yo G d Y 1­ Govt. Lot • �t li7 City, State Zip Code Phone Number ./4 — �/ Section �? (circle one) T a F N; R Iq I, OX II. Type of Building (check all that apply) Lot # Ot 1 or 2 Family Dwelling - Number of Bedrooms Q Subdivision Name Biock e� U `_l !,J f' ❑Public /Commercial - Describe Use C El City of ❑ State Owned - Describe Use CSM Number ❑ Village of Ce`t S y /to +- Town of lYI�G�.Y6dlJ ko III. Type of Permit: (Check only tone box on line A. Complete line B if applicable) A ' ❑ New System )Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner -*Tqf 7 g5 IV. Type of POWTS System/Com ponent/Device: Check all that appl It Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in, of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersalrTreat ent Area Information: �c .' P Design Flow (gpd) Design Soil Application Rate( dsf) ispersal Area RequirTf Dispersal Area Pro ed sf) System Elevation ��z (0 VI. Tank Info Capacity in Total # oManufacturer Gallons Gallons Uni p t j y ° Now Tanks Existing Tanks rn w C7 a Septic or Holding Tank BOO re 3 J^ Dosing Chamber VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature 6 " RS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) /,&' 7a 5 C_6 a� Pa-d S G VIII. Coun /De artment Use Onl pproved Permit Fee Date Issued Issuing ent Signature ivenReasonfor ,Y I $ "! - 7�' 5 17 !� IX. Condit �1! reasons for Disapproval c ��,j,. 4 c /i 1 Septic tank,. effluent filter and � t JG ` u" 1 � r o r SJ dispersal cell must all be serylces /maintained 4� U ; as per management plan provided by plumber. !J►ti �e55 r' 2. AII` 0back4 cluitements must.be.rrigintained Att aell to eomple a system and submit to the County only on paper not less than s 112 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 � o C �e.��f5y f�c�l � L,�7� a�9 t.11l�c�kr sT /o Ak 44 M �GY T��� _ G+1�a4� ►s�� Est` /DOD .Sej�'' G .�a Q CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: T& Owner's Address: 'z�7c3 /3� a o /4w vo a C ZEE Legal Description: W W S l7 7- 2? Y zC l4 G0 Township: County: $ G � -o x Subdivision Name: 9c,,r/� Lot Number: g 9 Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer /Plumber: �.' ll • .�- rr y s�� u ,*,,,,-/, 1 4t icense Number: Date: Phone Number - milS-3 Fa- .f Signature Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01). Page 1 G Y a J12+�s �J �G F � ry 6 GL l'✓1 G ^9 a V GGk./ a c4d cL fst` /40 .fe/�: G �.• �se Q ye, e, } Soil Absorption System Cross Section Final Grade 4" Schedule 40 PVC Vent Pipe With Vent Cap ft Leaching Chamber --►► �_� ° ft 1 System Elevation 3 ft ft Soil Absomtion System plan A ft d y ft 1111111111 IN 111111111111111 111111111111110 1 S . Leaching ft Trench 1 Vent Or Observation Pipe Chambers FIN 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model CJ EISA Rating sq ft per chamber Soil Application Rate 7 gpd /sq ft gpd Design Flow + ? Soil Application Rate + G *�z EISA = 9:9 Chambers 2 rows of ,_._/ i chambers each. j Page of � _0 r D r --A N � Z GTE O cyl � O � z O G cn C Z cn _ o m CZ� n m W p m - Do C ;a X f rn = r- U cn Z m m m rn v zCD c p z Q) Oo C) Po N W � U'1 N 0 0 0 o A POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner t i'ti � 1 rseptic Tank Capacity a l ❑ NA Permit # Septic Tank Manufacturer i'CJL' ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer iod /1� 4 /< ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model '�"�,' ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity D a l ❑ NA Estimated flow (average) al /day Pump Tank Manufacturer ey ❑ NA Design flow (peak), (Estimated x 1.5) �Q gal /day Pump Manufacturer a 4 � ❑ NA Soil Application Rate al /day /ftz Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODJ 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve months) (Maximum 3 ears) El NA ry hKy ear(s) y Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: [3 month(s) (Maximum 3 years) 11 NA 3 Wyear(s) Clean effluent filter At least once every: month(s) ❑ NA �* / ,� year(s) Inspect pump, pump controls & alarm At least once every: ;,.._ ❑ month(s) ❑ NA ❑ year(s) Flush Laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) _ Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y,) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by z certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. page of START UP AND OPERATION a presence of For new construction, prior to use of the POWTS check treatment cele) ork high content ations paint chemicals e detected have the contents that may impede the treatment process and/or damage the dispersal of the tank(s) removed by a septags servicing operator prior to use. System start up shall not occur when soil conditicns are frozen at the infiltrative surface. s wastewater During power outages pump tanks may fill above normal highwat the ce ll(s) and may result in the backupcorssurfa a discharg of discharged to the dispersal cell(sl in one large dose, overloading e Servic Operator Prior to restoring effluent. To avoid this,,situation have the contents of the pump tank removed by a Sept a 9 ally ope rating the PUMP controls to power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manu restore normal levels within the pump tank. Do not drive or park vehicles over tanks and disper c ll o n ardrive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade rove the performance and prolong the fife of the Reduction or elimination of the following from the wastewater stream may imp diapers; disinfectants; fat; ; dental floss; POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton s sabRed gfeasee herbicides; Most scraps; medications; oil; foundation drain (sump pump) water; fruit and vegetable peelings; g painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS faits and/or is permanently taken out o 3 the 39 oWisc t ps shall taken to Code: in the system Is properly and safely abandoned in compliance with chapter Comm Ali piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed- The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures- have been, or.must be taken, to provide a code compliant replacement system: d for the location of a repla cement soil absorption 13 A suitable replacement area has been evaluated and may be utilize upon by s stem. The replacement area should be protected from distu and welismFe i re to protect the not be replacement Y area wig required setbacks from existing„ and proposed structure, to result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. E3 suitable replacement area is not available due to s t ac n the soil P POWTS S Barr ing ad in POWT technology a holding tank may be installed as a last resort p sitF tanl 4�IA - desia " I the biomat at th' rem systems may e reonstructed in E3 Mound and at - grade soil absorption of such ystems comply with the nlleffect'at that time. infiltrative surface. Reconstructions < <WARNING> > G ASSES AND/OR INSUFFICIEWr OXYGEN Do No' SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LET CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER AN PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENT5 POWTS INSTALLER POWTS MAINTAINER Name Name Phone 7 l _ _ s ,;Z Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name E afne C. :r, Phone � 3 , f(O - / ' This document was drafted In compliance with chapter Comm 83 .22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK 'MAINTENANCE AGP EEMENT AND OWNERSHIP CERTIFICATION FORM ONvtlerBuyer _ r o y s d z Mailing Address etvf W o c� ,(7r Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Mumber - LEGAL, DESCMPTION Property Location,� ' /A , V Sec. / I , T .2 N R. If W, Town of Subdivision � k!� �, � _____ ---- ._ _______._. �, Lot # Certified Survey Map # : Volume Page # Warranty Deed # _. - - -_.� Volume , Page # Spec house yes no Lot fines identifiable yes no SYSTEM MAINTENANCE AND QWNER CERTIFICATION 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. Owner maintenance responsibilities are specified i &Comm. s3.52(1) and in Chapter 12 - St. Croix Couuty Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 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 lass than 1/3 full of sludge. Iiwe, 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 Planning &. Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this forth are true. to the best of my /our knowledge. Uwe amlare the owuer(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. X Numbe f bedrooms C_ SIGNATURE OF APPLICANT(S) - DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** tnelude with this application a recorded warranty deed ftom the Register of Deeds office and a copy of the certified survey snap if reference is made in the warranty deed. (REV. 08105) noc i�'rc r i�c . WARRANTY DrE-Eti r. > : J ruse -nca�n ten :rsc�re eeann,Nq of - F ' .:1'I T I : 'F Or ,W, 5 SI =� sI : -= 2962 2-6 t h Eam E. lwlkl 1er; a single man . UI e. ti, ' :I^ 8.5__ g 4 Jerome R. Flattum and 4of - Rebecca A. rlattum husband and wife - joint tenants St. Croix Tax Y a eee _NO: Lot 89, Parkview Estates Fourth Addition to the Town of Hudson F_'FU is not t TOGETHER WITH an SUBJECT TO any other easements, covenants, reservations or restrictions of record, if any, but this shall not be deemed to extend any such other recorded encumbrances beyond the term established by law therefor_ I;:.r•.:.9 si 26th :July ��, 85 it Sam E. Miller 0'` EA V) P. 7 TI3is.NTICATI7N A,CKNOWI.L••DGMENT T3 R ETAT[' OF 3:::naLw-r:•(�:/ _- 1. _ _ St. Croix C S nunC. -. 26th n'.rto-ntkaird thi.. c!a of.. ]ti +.... -. 1'tr-- ur..ily (•anal hc•1 - nr,. me this _.. club of July :x.. 85_ the rbrn•c nameri ...... .......... ... .. ._ Sam E. Miller TITI,!_ °.;F - M EP STATE 1:.1P. OF WI (I lrrc, avtft r:zna F•. 7401,611, 11,7i :�;L::. -.. t .,.• , ., r #.. 1 .. , -. J -, •� ,1��{hn j . r D _ !, r.•. .. }r o „< -' ...I u:l noacc I. c u:.. - s.tm•z., i ri GW IN & GWIN _ v -. 430 Second' S "trees �'YGar..�.� a 2 Hudson.,...W_sconsin. 54016 I ,,!;,• St._ Croix c ,^fi a < ( 4 r n a I) I) a!rih +:r!Y,ir,.trv1 nr - rrn•cl •.ir'c�!. i'�.f.! -: - - ��.. :c:-icr "> ncvn,;.un nt.1 Ii not.. , are not t ♦ WARRANTY DT..ETi -_.. 0 ..!.., _.. __ .. _. 'n • 1 -1 - s 4 I gigo Iz 89 Rif 9 00 S IAJ tl g siw ww www. awe ,ux. ..uu aYVnna � =ewm wmne. sY� � AMR MAIFMIr �; � � alll iR� y arx..�a sdM'ux'a'�.+wa�armn +ww�Y�I�M. gyres �wse..�we. w+wwwp.m _.... ww.� _ . +ir•�.. ..._:..:us - �..... ,.rvwx ',�, ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and /or dose tank presently serving the following residence: (Street address) !F2,, ,i 6 e1d located at: , 2pU1 1 /4, -�, 1 /4, Section �� , Town a,? N, Range W, Town of , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yeses_ No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): Permit number (if known) (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP /MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ->` Q IVY J111'� 11 a,f A �I , i s� ✓cam i'1, '� �o1f i L,d �• �o', v�* cow ti�� c►.1 - o,p o� 4L 1'r T La 11 o C— 4 f �✓c ,c Sew " o 97. z� g• 1M0. t l c c,t'� -te b � ys'`fc vw'fi:c.�1 Pc,Pf�cc�c��crF,� S - - 13 {� t 1 Q �L r 38 Era.rc a_ fls el Ss_ � 6o r �'t� �c arcs o � A ' --• — r• v� C) CA x v� G C3 � K w ` H o N ON u- � �R v 1 (0 ~ z - H Gn r OD 1 N 1 ^ V N O N 1 Z4 Z c Q U � ti E N r n (� r �. m E O F� (D H, V rt Q. C C o 0 DE INDUST MENrOF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS DUSTRY, DIVISION LABOR A ND PERCOLATION TESTS ( 115 ) MADISON W 7 HUMAN RELATIONS ` (H63.090) & Chapter 145.045) L OCATION: SE TION: p� TOWNSHIP / / �': O SUBDIVI�SIIONNAME: f� (,t) 1/4 s 1� I /T,Z 9 N /11/ q �lor L�Gt J v !/�t �rJ J.�-• COUNTY: OWNER'S/BUYER'S NAME: A I L ING ADDRESS: 6 USE DATES OBSE RVAT IONS MADE 1-3 NO. BEDRMS.: COMMERCIAL DES RIPTIO PR FI E D NS: A N TESTS: ❑ Replace Residenceew 7� �� 7 So.`/ �•,`p ' � 6 RATING: S= Site suitable for system U= Site unsuitable for system S A ,Lv ONVENTI NAL: MOUND: IN- GROUND-PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) .9S ❑U RS ❑U ®.S 0U D S ZU [IS NU I C AM IY L O P � If Percolation Tests are NOT required DESIGN R ATE' Fif any portion of the tested area is in the under s.H63.09(5)(b), indicate: loodplain, indicate Floodplain elevation: -/jA PROFI E DESCRIPTIONS ! BORINGI TOTAL/ I DEPTH TO G R UNDWATER4i464E9- CHARTCTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH,4k ELEVATION BSERVED ST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) .� ,a ► •681s,.g8,, /s, /./ sh Cs, ICS /.fie � C_ /,3 6"t C j 3.t4 B- aZ �.O /0/19' , ¢� 7 ,0 a B- 3 gy p' 02, �' AA e ,0 A, /s . cs c B- , 0 ` a /, 3' Al a 401 e.- 7 , 0' A .f B -., ,p' /n /.S' le, , 0 04 / B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER ~ME6 AFTERSWELLING INTERVAL -MIN. PER IOD I PERIOD 3 PER INCH P_ y'3' A10 C, ra Z3 P. .S• a a, 3 P. • • oZ. L- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 7 7• X 8 t� -- - -{- , aT r ..._ I � - - I JAL Lew fA I O I Z i f , F Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Z1/, TOWNSHIP /ySoi7 _ SE(:. 17 T Zf N -R I 'to ADDRESS (�K/' /�s7� Z 8 Z ST. CROIX COUNTY, WISCONSIN SUBDIVISIQN /4"P/' u/ LOT �� LOT SIZE PLAN VIEW I Distances and dimensi.)ns to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM b 4/6 ' ys � � "'5 1 zSsxyy of 3 INDICATE NORTH ARROW i2 L'A7 (`LIMA DV Tl.. ., ..ESL., ..t_ ___ -.._ __i ___t____ _ _ _ __ _ _ • IQ j .. - 1 - - r oCO) ! -0 0d �o 0 o cn z o O C V N • 00 \ CD Z n N C U) Cp O ? 3 CD co m O N CL 3 O Q C 0) O O � C1 7 A O r7 Cn C V O O K O O r. 7 N W O O C O go U> A eo '° a °o 3 CL 0 4 c v N N "aim CD 4 t4 CD z 88 or CD !� CA cn 0i 0 rt 000 cn a r ti v, w O Q �vv�, R ° CD ° v 3 y co CL N N N Z _ z W z < O CD 0 n� O D CL m CD !r • CO (D w N c m N w m °- n. 3 Z (D _ O A Z n O O v C1 A 7 o. O J C V CD CD G M y z ° o c) B m m z W CD A N C1 Q 0 C1 =r N O c CD O to 3 v C 7 O 0 m N a 01 a O A CD CD CL � CD m z — o =, v CD N 7 0 A n O CD 60 OC'ro qb f0 O O yq Parcel #: 020- 1165 -60 -000 10/07/2005 11:33 AM PAGE 1 OF 1 Alt. Parcel #: 17.29.19.1006 020 - TOWN OF HUDSON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner JEROME E & REBECCA A FLATTUM O - FLATTUM, JEROME E & REBECCA A 470 BROOKWOOD DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 470 BROOKWOOD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.003 Plat: 2284 -PARK VIEW ESTATES 4TH ADD SEC 17 T29N R19W PARK VIEW ESTATES 4TH Block/Condo Bldg: LOT 89 ADD LOT 89 1.003 AC Tract(s): (Sec- Twn -Rng 401/4 1601/4) 17- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 717/184 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/26/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.003 24,300 133,400 157,700 NO Totals for 2005: General Property 1.003 24,300 133,400 157,700 Woodland 0.000 0 0 Totals for 2004: General Property 1.003 24,300 133,400 157,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 109 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HWMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.43OX 7969 BUREAU OF PLUMBING MADISON, Wr 53707 CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: El Holding Tank ❑ In- Ground Pressure 11 Mound (if assigned) NAME OF PERMIT HOLDER: ___J ADDRESS OF PERMIT HOLDER: IN 4 j Sam Miller (Darrel Wert) R. R. 1 s Box 282 e Hudson , WI / _ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. NW SE, Sec. 17, T29N —R19W, Town of Hudson, Lot#89,Park View Est.IV Name of Plumber: MP /MPRSW No County: Sanitary Permit Number! Douglas Strohbeen I 5432 St. Croix 64897 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER f 3 PROVIDED: PROVIDED: < `! /�'�'�Lf 4) o � DYES ❑NO DYES I�'INO BEDDING: VENT DIA . VENT MATL.: HIGH WATER Nl?M£I.O ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: LINE ` AIR INLE , FEET FR(1M,' s�j J �I �/ r ✓ '.3 ❑YES NO _ t OYES O IKAI S'{ DOSING CHAMBER:` MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO EYES ONO I ❑YES ONO GALLONS PER CYCLE: PUMP AND OPERA, NAL IN UMBER O F PROPERTY WELL BUILDING VEN - TO FRESH (DIFFERENCE BETWEEN EET FROM LINE AIR INLET PUMP ON AND OFF) YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of pl ing FOFC1 LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO. HES. OF DISTR. PIPE SPACING. COVER '. INSIDE DIA.. #PITS: LIQUID .y,y`I!'*F•" °= o/ , TRENCHES MAT DEPTH: M�M111StS:,'I PIT GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL NO. DI NUMBE R OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PI S ABOVE OVER EL V. INLET ELE .END: P. ES LINE AIR I ET: :. 3 X72 NEAREST ,/c) J � � MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER I TEXTURE . PERMANENT MARKERS. OBSERVATION WELLS: DYES ONO DYES ONO DEPTH OVER TRENCHBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER: EDGES. ❑YES ONO ❑YES 1:1 NO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: ` WIDTH: LENGTH. NO.OF LATERAL SPACING: JGRAVft DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: .''. TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. T . PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.. OIA. - . ELEV.. PIPES: �IF(� /riAl HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: - 1 YES ❑NO OYES ONO COMMENTS: ` PERMANENT MARKERS: OBSERVATION WELLS: N �„R�*„ : PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO OYES 1 NO NEAREST` .' I'll � 5, so S. 76 ® f � cry ZL 0,V tA w � Sketch System on R n in county file for audit. Reverse Side. SIGNATURE _ ,✓ TITLE: DILHR SBD 6710 (R. 01/82) w'S` ° nev, APPLICATION FOR SANITARY PERMIT 1 ILHR (PLB 67) COUNTY DE�-RRTmEnT OF UNIFORM SANITARY PERMIT # inDU5TRV, LRBOR 6 MUTRf1 RELRTlorlS k yp 5 1 2 — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER LING ADDRESS M PROPERTY LOCATION �c Son 145E /4, S/7 , Tz , N, R it (or o LOT NUMBER I BLOCK NU BER 1SUBDIVIS ION NAME N AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: Z New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Z Seepage Bed ❑ Seepage Trench U Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity p4!r10j© }� Lift Pump Tank /Siphon Chamber Holding Tank capacity ' Manufacturer: Z. ,w -ff. 1 IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ' 3 Co 5 � & Y TrIl X Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP /MPRSW No.: Phone Number: "0 �^ ,: ��. My') 3 1,217) 3'3 � Plumber's Address: _ Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved Approved ❑Owner Given Initial B Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location o��fii Property SLC ', Section � T N - R fi Township 'l - sla.7 Mailing Address Subdivision Name ��,� /�� c-/ Z�s-Zti-1 S Lot Number Previous Owner of Property 1/cIP (J Total Size of Parcel / Z �Q� ✓'� Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 1�57- and Page Number / Z, as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. -------------------------------------------- PROPERTV OWNER CERTIFICATION I (W e) ce4ti.jy that a.QQ 6 ta-tement6 on this 4o&m cute t ue to the best of my (ouh.) knowledge; that I (we) am (cute) the owneA(,$) o6 the pnopWy dac& bed in -thin in6otcmati,on 6o4m, .by viAtue o6 a wa4Aanty deed neconded in the 064ice o6 the County Regis ten o 6 Deeds a3 Document No. Z 3 I-s z and that I (we) y F• J, L* � ri •,m s,a ` ;,, '.. a - WG SE TION t? T29Ni ;, R19W. TX irZATR OT " 1 r - C137tl�f[ �' T;.�svrarlt�w ti 1 �= #otter tlecg Tvara Tsweotsr i s e t1n Yae+s of iiaieews k 4+e ae T that i1ft R ' t rds in very office, i +tra as a�#.e+ 'QaeiaF sre+ae #a ws a "fi , _ . *A say lam y iiViva ai: is use &lint � �eatteA ! o sr�Ih Aiiilio�. �'� - 7 w, trMSSr• 'I�fN :SARI! RESOLIl?laQli. RMLV'ED, that 1110t.3 of Park View Estates FourdwAddlttm in the Towa of I Hudson. Darrel E. West. and Be A. W ert, owners, is beseby approved by the i 704e Be ird P 4 1 , • wpp atiso mangy i J . Sn;rd owo smen i hereby zertify that'tbe foregoing is a copy of a resolution adopted by the Town Board of the I'own of Hodson, t! � D aLC • Town Clerk t»rtlMst CERTInCATR of DZI)ICATIOr, As owners, we hereby s exlf�p that we caused the land described on thi Plat to be ve suryed, divided, mapped anddodieated o.s represented on this Plat. WA also certify INU this Plat is required by S M.10 or S. 236. i 2 to be submitted to ¢he following for appmval or ob)ectiost Department of D Departmeat os Induetsyv Labor and Human Relations, Town of Hudson, Citlrof Hadsou and St. Croix County. WITNE. She hand and aeal of said owners this _ 1- a day of In YJfieeence of: 1 ` ar �� .. Dame c W ert Aoverly A. Ws STATE OF WISCONSIN ) ST. CROIX COUNTY ) S Pesnonaliy cams before me this - - day of f1 ;� / y _ the above nazae-i Darrel E. W ee LF Beverly A. West, to me known to be the persons who executed the foregoing instrument asst acknowledged the same. Notary Public � r %, 7 mj , . Wisconsin My commission expires 1Z �4_..t/ Mary SY %jec�ary Public «aa c - rIP•ICATE OF TOWMCLERK ' K SZATZ OF WISCON:3IPtj . S'f: CaC1IX COUNTY 1. Rita :bvne, bciaS theadaty appointed, qualified and acting ' Town Clerk of the Town :i. +dson. do hexetsj. , that copse of this Plat were.fory ardezl as at seouired by s. 231s. I2 on -there day of _@i3�1[._ . 1964. and that within the 20 -dry limit set 1•y s. ZA. 2 (3) (no obyectibbns to the plat have been filed) {ati ri ?jrt ?'e: %n r t.; the plat have bo5en rr;sst). r� ' c.. Date Rit tiorna, Town Clerk { i F { StMYZTMIS CKRTUICATIL S I. !mss E. Ruseb Registered Niscousit land Surveyor. hereby ca.xsify to the best of my pratessioual knewiedSo. uaderstaudms: asd be;aef: That 1: hsvo sttvey". divtdsd sad mapped Paris Vtaw Estates Fourth lAdditiaa. located in the NS 1 /4 ei the SW 114 and the IN".4 i t4 of the SE 114 st Seelios 17, T :9N. + R 19v. Town of poison. 8t. Crete C*Gwy, Wisconsin; That l have made e susvey, land divielos sad pW by the dlssctioa of Dauer! r.. Wart end Slevertyt A. Trev%.ewnea of said is". described as foilewrst Conssmere#ag at the ZT /4 cotesr at said SectUa 17; tbeaem 569"22 jm:ssamed baasisgs redetsaced to the wed >`r n -WWT 1/4 Seeltas lies of Sastioa i?, , f beetles sssanaed sfi9'22 { recotded as SWZI% "+df on that: Cewdd -bd Sesys+r ldap rsesedad la Tolman 1, Phae IS4 }. 1332.90 aleet said EAST- liIXST 114 3setsoft. 3ae3 &hooc+s SVW%"W 227.7'0 to the point of tbsnee NW,52 .422.00x* theme* 1"t8 tli "E a u.as+ a the Seytherly right�Ilas of Creep bti11 Lane; tbensr NW5,1a40"W 66.00 aiaeg said rightef•*ay lino; tbescs 50 23 *,00 enema's, 379s" 1%.33 tbeeco SWI5 2U.74 theuco Mflt' I-a. t; the e Sar9"lxsl4'^lf 338.00 theaee NW06 16 thenea s84°;SR4"W "6.90 tiwcs Di0!!vf30"16 233.0fM1`thsmnee SWISS14NWr 66.01s;tbsase SV%A3r'k 316.43m; aa thsza 304 W14"W 151.00t,tbeo" NO"37'31"1f 34.I0s; es ebee SS9'tt'Ait"M 146.30 theaocr t "204.4K theacs 0109'15 "E 130.00x; :bonne 3WO6s *ww:322.97s; Oas tar N39 W .iS0.0Qsptbeece 8outhesstsrly S6.15t along. tits tea of a 303.00 rmAiuC . ensys w:lteisheastsrly xh000 chord liars 'W sot59"E 06.17 *y !!race nd19 M I.4 "E' o7.01 towns Sontbeaatesly 136.36 along the arc of a 317: 00s`sadies curers conat ry Aga teaetetris Moot clwrd beats 824 83 133.51 thooco_S3!'Z3s30 "E 143.1c. sberes 027! sl0/ 160.46 thence NOPIssH"E M.". theacs.S3{T'WW Iof.ftt; . #1Naa+ S6�`W30"�t- 2b «1i'1 :!sass BeaLeaststl7r 94. W atdat the era V i a t17.W tr#a►evts sraca :s lfoadmesebriy wimese shord.bosxa S7a'03�1N"'& 95.35:1 timeara . 14!!"ES*Yd lZO'.iW, test I�FosthaastaslY 9.iYr stoo�ss�� tat ester stet 308:60! ta3tus artr♦aereaw llWOAvestesly waoss she" bests ?4W32 WA* thssos Nor*- wsetsslyF 11.#41 ya �7cosa�� tlms ears of s 380.08 radios curve econsnrr BerlT veb w rd cho bees* NV37 6 91.09 thence INM06s30 I30 .00s; tbeurms 0ti¢ 47b.05 :unseen 0ds30 SU.66 to the gout of leallw4ift. That snob peal: is a cow"ce repswourertticn at all the emdetiw bormd *vies 01 WO la" d and the subdivlsian tbereof toads, and Ttmaa a have fatly eeampliad wish the Arosis3oss ns Cbaptet z'.JGa of time W issoasis,. Statotse, tree Vabd1vtstan sad Zosiag Re;alatlona of St. Crc x Coway, tba Town of Hudson Subdivision, Otdisaace. and the City of Hudsoa Sabdivlsioc *Ad BlaWas Ord!. swans. Is servsyinr. d and +n+►M tbs Beane. Oat" We -A dot of M&WRA . 19114 s sod: SStb de of April. 140)4, J!<t!#S - 421 Sv snarl Ssraes twit° Hedsow. Wiseossia: 34416 COMTT TRZ"URMIS CRRTMCATE STATE OF WUCCWXM ST. CROX C.Oi XTT } 1, Us" Jsmm 1.ivet'saors, being duly sleeted, qualiiisd and majing Treasurer C4 9t. Cretx County, do hereby cartifp that the records in my ofj'i;e elmow mmredoesawd tax aces and no naps" pxee et spools! asween OMS as o[ ��-� sffeatbW tbo Sands iastuded in the Pass of Park View Estates Foerah Addltias. Date OCWunty Tressores ZE1KMG Cf3biWTfzx X=Olt3TIGN This plat is hereby approved by the St. Croix County Corn9rthensive Parks, 3Kaaaing an8 Zoning Co.mtm9ttee. q fS 194 Iixte l:bai H ' H y r ST C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d 9 OWNER /BUYE �Z' / ' LIV ROUTE /BOX NUMBER ` `ii Z-- Fire Number CITY /STAT h jr� �.t� ZIP PROPERTY LOCATION: Section /_ , T R Town of A Sp " , St. Croix County, Subdivision i���,arv��►a't�5/Y, Lot numbe Improper use . and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I /WE,'the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to.tho! St. Croix County Zoning Office within 30 days of the three year expiration date. S I G N DATE ' St. Croix County Zoning Office P.O. Box W Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. v_ y � n x � SID � m� �<< o� V �• (p A 7C A A M 7 o w ° 1 ao c o w w �`< w g �`°M� 3�coCO CD C D (D a C o o ) ) � 0 A a C A O � fo p O .� c- c a•' vi N - w v, 7wN ocowCL o' c ((MD N �( Q A v co0� oyc N� 0 A 0 — pj A A O O C 0 � o� a Cc �• CD O � �m ONC�o 0�vewo Z » o y 0 w m D `< A _ cQ 0 "1 w ca m CD amo 3Ncn° D D , c a o N. gr o CC). m w --- --� '< Z0 (CDX N =or a cQ w CO) v ?w 6 acA *cod C m s ID o, so m m tv ° o o o cn �=�co D 3 m A H w a c '~ m a f a, c aw o w ok co —awoo ao v� f acv; C N 0 C %< to .+ (N A m n C �� � N A N O 7 g 0 a C -% w m j co w a 0 < B .. vi �• A CO �z ism • S r i l.V i o� r w LIII W cl ir ! i i 1 I I � ; I s .. t , d