Loading...
HomeMy WebLinkAbout651387 020-1145-40-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Mark Schiltgen & Carolyn Lopez TOWN OF HUDSON CST BM Elev: Insp. BM Elev: BM Description: 1 ram' . 8 /O C1. a o � +b inn 4ils��e s. TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic c i Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic f Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand Model Number TDH Lift Fri ' n Loss System Head TDH Forcemain ngth Dia. Dist. to Well SOIL_,PBSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651387 State Plan ID No: Parcel Tax No: 020-1145-40-000 Section/Town/Range/Map No: 17.29.19.763 STATION BS HI FS ELEV. Benchmark ,13D DI.3D IDD,Dr Alt. BM Bldg. Sewer C t SUHt Inlet if l I SUHt Outlet 3 c11, q r l �•� Dt Inlet Dt Bottom Header/Man. Dist. Pipe D 6-"(0 Bot. System S-�jv S. SV q5•'� 96-.Sd Final Grade / r`,5-D q 9- gD" St Cover 1c&We_ 1, V alve- 1¢er Car -V4 q>-7v 94, 6 a, RENC DIMENSIONS Width '� I Length / b 1 !O No. Of Trenches —7 (2 ) \ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur ` INFORMATION Type Of System: (n� rava Pivl. 0,\,-Q a ( 1 r / S CHAMBER OR UNIT l y� ' Tay+ Model Number: r 'r i3, td DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole x Hole Spacing Vent to Air Intake Pi e(s) � r rD i `j Length Dia Leng Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Over xx Depth ofxxSeeded/Sodded xx Mulched BedtTrench Center TBedprench Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 21/312d2,f Inspection #2: Location: 975 WERT RD 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover P W¢esu 01ter Co v�V1Cr1�e9e I r vision Requ e ❑Yes ;KNo/ cj Use other side for additional information. / 2`�R1M,—.g�t L� ��D�1) h I R C.R �2Al2 4J�tc'(Lwor-ig9Lttfe,¢L�wM1t �(___ , , Cert. No. � Industry Services Division County ! �nr -r.vv t �• 4822 Madison Yards Way Sanitary Permit Number (to be frllcd in by +� `D� P $ 4 FEBf [] Madison, Wt 53705 ��•'•--. P.Q. Box 7162 Madison, WI S37U7-7162 r �% R<tlltfmilRl�j�@Vi'�tjQih?`� anttaly Permit Application Slate Transact Number In accordance with SPS 383.21(2), Wis- Adm- Code, submission of this form to the appropriate governmental unit Project Address (if'different than mailing address) is required prior to obtaining a sanitary pen„it, Note: Application forms for state-evned POWTS are submitted to tl,c Department of Safety and Professional Services. Personal information you provide may be used for secondary r purposes in accordance with the Privacy Law, s. 15.04(I)(m), Slats. C.. n ��*--1-- I, Application Information - Please Print All Information Properly Owner's Narne� Parcel Property Owner's Mail igng Address L„ Property Location -7 � � J c ��C I- _ G avt. Lot City, tate 'Lip Code }'hor,c t`urnlrcr %, Section_ T N R E r w 11. Type of Building (check all that apply) � Number Hedroonts Lot #��, � f Subdivision Name 1 or 2 Family Dwelling - of (/ Block # ilic/Coecial - Lsrbe Use �_]City of Slate OtAned - Describe Use 1 Village of _ CSM Number Z6W pq_Tawn of III. Type ofPOWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C it applicable.) A. F]New System lacen,ent System ❑athor Modification to Existing System (explain) Additional Pretreatment Unit (explain) Ind a ._ Design 0[her l`ype (explainl �HaldingTank in Ground [�]At-Grade ❑Mound (conventional) C. Renewal Before Revision hange of Plurnbcr �1'ransrer to New Owner I.isl Previous Permit Number and Date issued L� Expirntiun + J IV, Dispersal/Treatment Area and Tank Information: Z ,c LL Z 2 93 Design Flow (gpd) l?csign Soil Application Rate(gpd/sf) t spersal Ar;a Rcyuired (so ispersal Area Proposed (sl) System I Ievatinn Capacity in Total a of Manufaclurer a Tank Informatioi, Gallons Gallons Units �t�l- (�f�p� �•� �\( ` —` v o v_ v n New Tanks Existing Tanks 4 [3.0 t7 tg u ,7 iz 0 p.. Septic or Holding Tank Dosrng C11anrUet V. Responsibility Statement- I, the undersigned, assume a onsibility for installation of the POWT5 shorn on the attached plans. Plumber's Name(Print) Plumber' nature MI'/MPRS Number Business PhoneNttt lber ` P[Utntjer's resStreet, City, Stale, 'Zip CcttleJ VI. County/Department Use Only Approved Disapprov Permit Fee Date Issued z�812o2�{ Issuing Agent Signature son to 1 SSA— Cnndition� nl Apl,rova ��ui�zs-i.� �••"®",.^ " I \ , / A .� SYSTEM OWNER. u- 9, #i t n ffl I n Sep c a k, a uent fi ter a d dispersal cell must be serviced / maintained as per q 1 p 1u,� ,�, ,5e A�. 14,20 : ja4 J `_a "Y' `c management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code / Ordinances, mincli to cornplele plans ror the system and submit nr nie t unnty only on livk1wr not Tess snrrn a lea a r r ,ncnra m e.cc SR0-h399 (R. 03/21) System PLOT PLAN PROJECT Mark Schiltoen ADDRESS 975 Wert Road Hudson Wi 54016 1/4 1/4S 17 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 96.5/96.4 3.5' below qrade B-1 DATE 2/7/24 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1 /4" = 10' Wert Road COPY Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 6.6ft^2/pair of end caps Grade at System Elevation 50' �40 0' B-2 25' Drainfield >6" of Cover Vent Diverter 12„ Valve 4' Long >� 34" 25' 5, T 4--.0.7 a 6, Filter Tank 25, 3 Bedroom 1 House B- '.M.B 35' 40' 2-3' X 66' cells with >3' spacing Vents 15' B-3 Property Line 2% Slope .0' Well Bird Plumbing Inc. Shaun R. Bird 1432 120th St. New Richmond Wi 54017 715-246-4516 2/7/22 Subject: Mark Schiltgen Septic at 975 Wert Road Hudson To whom it may concern: My nar system at the system is co Sincerely, / . shaun MPR 226900 s aun Bird, and this letter is to serve as verification that the septic )ve pro erty has failed and needs immediate replacement. The septic y fd and has consistently backed up into the house. Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 2/7/2024 Owner:Mark Schiltgen Location S17 T29 N,R 19W 375 Wert Road Hudson Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Sectio 4-5. Maintance /and,;i*'ency Plan 6. Filter Cross Attachments: S Signatul;d .//`" #226900 System PLOT PLAN PROJECT Mark Schiltoen ADDRESS 975 Wert Road Hudson Wi 54016 1/4 1/4S 17 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 96.5/96.4 3.5' below qrade B-1 DATE 2/7/24 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark Scale = 1 /4" = 10' Wert Road Drainfield >6" of Cover Vent Diverter 12" Valve 4' Long >� 34" 25' 5, T Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 6.6ft^2/pair of end caps Grade at System Elevation 6 Filter Tank 25 3 L50' Bedroom House 40' AB-'.M.Eel 35' 2-3' X 66' cells with >3' spacing 2% Slope Vents 15' B-3 Property Line .0' Well Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber w ith 20.0 f`t2 of Ai -ea per Chamber 6.6t't^? p.ti -ref end plates _/ Typical Installation f nt Gradea-�30134 Septic Tank 31 To be >1' above grade Finish grade elevation 100.01 )Vent 5 R' [.car�t� �--Gradc at S`rstem Elevati011 36 " Grade at System Elcvatioll Spacing 5' 2-3' X 66' Cells Same on other end Observation tube/Vent At end of cell A B 16 chambers per cell System elevations: A 96.5' 13 96.4' POWTS OWNER'S MANUAL & MANAGEMENT PLAN page ar FILE INFORMATION Owner Permit # DESIGN PARAMETERS Number of Bedrooms ❑ NA Number of Commercial Units ANA Estimated now (average) I -7*' al/day Design flow (peak), (Estimated x 1.5)gal/day Soil Application Rate galtdyIff Influent/Effluent Duality Monthly average' Fats, Oil & Grease (FOG) S30 mg/L. Biochemical Oxygen Demand (BODS) 5220 mg/L Total Suspended Solids (TSS) 5150 m /L Pretreated Effluent Quality ❑ NA Monthly average" Biochemical Oxygen Demand (BODs) S30 mg/L Total Suspended Solids (TSS) s30 mg/L Fecal Coliform (geometric mean) 510` cfu/100ml Maximum Effluent Particle Size Y, inch diameter MAINTENANCE SCHEDULE Service Event Inspect condition of tank(s) � I At least once every When combined sludge and scum equals one-third (Y,) of tank volume eworcte Cpr+r-IFICATIONS Septic Tank Capacity al ❑ NA Septic Tank Manufacturer © NA Effluent Filter Manufacturer ❑ NA Effluent Filter Model % NA Pump Tank Capacity al NA Pump Tank Manufacturer NA .pump Manufacturer NA Pump Model NA Pretreatment Unit NA ❑ Sand/GMvel Fitter ❑ Peat Filter Mechanical Aeration ❑ Wetland ❑ Disinfecbon Cl Other. Manufacturer rsal Cell(s) D71r round (gravity) ❑ In -ground (pressurized) 11 grade ❑ Mound ❑ Drip -line 0 Other.' Values typical for domestic (non-commercial) wastewater and septic tank effluent. �• Values typical for pretreated wastewater, Pump out contents of tank(s) inspect dispersal cell(s) Clean effluent filter Inspect pump, pump controls & alarm Flush laterals and pressure test Other. At least once every At least once every At least once every At least once every At least once every Service Frequency s7 ❑ months -fi?�year(s) (Maximum 3 yrs.) ❑ monthsh year(s) (Maxlrnum 3 yrs.) ❑ months years) ❑ months ❑ year(s) ❑ NA ❑ months ❑ year(s) ❑ NA ❑ months ❑ year(s) ❑ NA C"r. At least once every ❑ months ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal colts 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 identity 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 pending 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 d requires the immediate notification of tine local regulatory authon ground surface may indicate a failing condition anh' 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechpnical or pressurized POWTS components, pretreattment components, and any other maintenance or monitoring at Aervals of 12 months or less shall be performed by a certified POWTS Maintainer_ A serv!W, report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION For new construction, prior to use of the POTS check treatment tank(s) for the presence of painting products or other W chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. Page of START UP AND OPERATION For new constmcbon, prior to use Of the POVVTS check treatment tars (s) for tghe presence cebonsiare detected have thercont nits chemicals may impede the treatment process and/or damage ge the use. dispersal cell s)- h co tank(s) removed by a sepa9 System start up shall not occur when soil conditions are frozen at the infiltrative surface. [luring power outages pump tanks may flit above normal din�theecell(s)land mays. rresultnn the taaek p nr surface disarla 9e of er is restored the excess wastewater ffluent Operator rsor to restoring power to ttre discharged to the dispersal cell(s) in one large dose, othe contents of the verloading tan removed g um controls to restore normal lave s of avoid this or contact aePlumbefr or POINTS Maintainer to assist inymanu py operating the u P p affluent pump within the pump tank. Do not dm►e Or park vehicles over tanks and dispersal cells. i7o not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. performance and prolong the life of the POWT:( : Reduction or elimination of the following from the wastewater stream may improve the gasoline; tease; herbicides; meat scraps; medications; oil; painting products; antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; dlapers; disinfectants; fat; foundation ra n (sump pump) water, fruit and vegetable peelings; g pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT rmanently taken out of service the following steps shall be taken to insure that the system is properly When the POWTS fails andlor is pe and safely abandoned in compliance with chapter Comm 83.33, ►JVlsemsin Administrative Cade: • All 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 compli 3n replacement system: y be ❑ A suitable replacement area h bebeen e ne vatuated and ma from disturbance and ecompactd for ean and shouldenot be Infringed upon by quplacement soil absoupbon � d The replacement area shouldP _nt area will ed setbacks from existtiiing evaluation toes bstructure, lot linesltatAe and wells. Failure areat Replacement protect the r sylate®msem sit comply with the rrulehe it n for a new soli and effect at that time. ack and/or soli limitations. Barring advances in Pfl'JVfS tecttnologif a ❑ A suitable replacement area is not available due to setb holding tank may be installed as a last resort to replace the failed POWTS. failure of the POWTS a soil and site evaivaoon j The site has not been evaluated to identify a suitable replacement area. Upon / must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installed; as a last resort to replace the failed POWTS. O Mound and at -grade sail absorption systems may be to of �e me s in effect atthat tigine removal of the biamat at the infiitrazive surface. Reconstructions of such systems must comply <<W ARNI NG>> NOT SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/ 0R INSUFFICIENT OXYGEN. Do ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK' UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE Oi A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS U', Q j L/ POWTS INSTALLER Name r Phone POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERAT PUMPER LOCAL REC,ULATORY AUTHORITY Name �-,v %`I'; G'�'c Name i r.c r Phone Phone This document was drafted In caarnpliance with chapter 5P5 383.22(2)(b)(1 )(ri)&(f) and 383.54(t), (2) & (3), Wisconsin Administrative Code. C7 /wr ■rv:5i Wisconsin Department of Safety and Professional Services FEB S 202! 7i. Divisionof Industry Services r t[3 G SOIL EVALUATI RMU U Page of G5 (-7. M--of 7 In accordance with SPS 385, um- COUP Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must. include, St.Croix but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 020.1 145-40-000 Please print all information. Reviewed by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). Date Property Owner A 11 ID Property Location ❑ Mark 5chiltgcn Govt. Lot 14 v. S 17 T 29 N R 19 B (or) W Property Owner's Mailing Address Site Address or CSM and Lot #' 975 Wert Road Lot 70 Parkview Estates 2nd Add City State Zip Code Phone Number � City I] Vallage IEI Town Nearest Road Hudson Wi 154016 r t Hudson Wert Road New Construction Use:R] Residential/ Number of bedrooms 3 Code derived designffow rate 450 GPD JReplacement 0 Pu�ylr is o/r-coCm_mercial —Describe: Flood Plan elevation if applicable NIA ft. Parent material Qutw7sh 7�r��S General comments and recommendations: System Type: Conventional 3.5' below grade at B-1 �p�E Boring # ❑Baring 100.0 90 ME Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate Horizon Depth In, Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt` `Eff#1 •EfT#2 1 0.12 1Oyr312 none SI 2mgr mfr cs 2m .6 1.0 2 12-30 1 0yr514 none CI 2msbk mfr gw 1 f .4 .6 3 30.99 10yr4l6 none S Osg ml n.a n.a. .7 1.6 ��9l� •�D 9,T.g0 q!2 2 I Boring # ❑Boring 101.0 1 1 2 ®Pit Ground surface elev. fL Depth to limiting factor in. I elev. ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az, Cont. Color Texture Structure Gr. Sz. Sh.. Consistence Boundary Roots GPDIFt' 'Eff#1 `Eff#2 1 0-19 1Oyr312 none SI 2mgr mfr cs 2m .6 1.0 2 19-42 1Oyr514 none CI 2msbk mfr gw 1f .4 .6 3 42-112 1Oyr4/6 none S Osg ml n.a. 1 n.a. .7 1.6 o �o� 2 m3.a CST Name (Please Print) Sign u CST Number Shaun Bird 226900 Address to ation Conducted Telephone Number 1432 120th St, New Richmond Wi 54017 14 715-246.4516 v Effluent #1 = Boo > 30 5 220 mg1L and TSS n 30 5150 mg/L ' Effluent 92 = BOD, s 30 mg/L and TSS 5 30 mg1L SBD-8330 (R04/21) Page of Boring # ❑ Boring 101.4 M Pit Ground surface elev. ft. Depth to limiting factor 1 1 2 in. / elev. ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eff#1 'Eff#2 1 0-17 1Oyr3/2 none SI 2mgr mfr cs 2m .6 1.0 2 17-36 10yr5/4 none CI 2msbk mfr gw 1f .4 .6 3 36-112 10yr4/6 none S Osg ml n.a. n.a. 7 1.6 5 •g 9K.8-425a F1Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eff#1 'Eff#2 F1Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eff#1 'Eff#2 ' Effluent #1 = BOD > 30!' 220 mg/L and TSS > 30 5150 mg/L ' Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L Soil Test Plot PI Project Name Mark Schiltgen Address 975 Wert Road Hudson Wi 54016 Bird ;TM #226900 Lot Subdivision Parkview Estates 2nd at 2/7/24 1/4 1/4S 17 T 29 N/R19 W Township Hudson Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of siding System Elevation 96.5/96.4 *HRpSame as Benchmark Scale = 1/4" = 10' Wert Road ro 57 s8•o�. 268. g3 , 3 o. n 0 0 0 0 62 o 0 L71 ACRES 2 200.00 .� 24.19' h :O O o o 69 rn 1.56 ACRES NOTE;ALL LINEAL MEASUREM ONE HUNDREDTH OF A BEEN MADE TO THE t, TO THE VALUES SHOti 58 59 -MATCH LINE - SHEET I -- 325.00'— 2 75 UO' 300.00' 300 00' N 89052'40" W N 89.52'40" 3 -0 u U L; tD CD61 v o 1.72 ACRES U N 300.00 WERT 828.84' N 89.52'40''W 829.27' S89o52'40'E GV V.VV O O O 70 0 ro 1.56 ACRES a M 60 1,72 ACRES 279 92' ROAD i i 71 O 0 1 56 ACRES Oi a: M. 205 OF 7 175 j 200.00' 1 200.00' 200.00 1 225.c T 1050.00' S 84°52' 40" E I ( I f I 1 ! I I I I f I I I I I I 3 I J\ i q 5 I E I I 4 I i I RLY RIGHT-OF-WAY LUE OF GREEN MILL LANE w REEN MILL t0 --- LANE—_—_ - CROIX COUNTY ZONING FICL CERTIFICATION STATEMENT POP UTILIZATION OF AN EXISTING SEPTIC TAN K 'L'1i i s i s to certify Y that I av inspected the septic tank �,ct-ving the /� r P re s e r] t:1. y residence Sectionrest locate(I 4te ""----- Upon inspection`- L .w, 1 owr, r) f tank and baffles to , I certify that Z be in good condition have Pot►tic) functioning properly. , and it a . Ppears to he t tilne serviced: �q 1)id flow back occur. Yes p from a sorption tion system. -- No (If no, ski Al�proximate v �' next Line). volume or length Of time: =t)acity: gallons -- ln.i.,iut:eS Construction.' Prefab Concrete Steel ___ Other h9:arltlfactizrer: (If known Age aP ank (If known),: �gnature} (Name) Please ring---- Zz�' (License to be completed by .licensed Statutes) or Licensed Disposer NR plumber (s.145.06 Code I wiscons r1 ( 113 Wisconsin Administrative ►':lumber (applying for sanitary Permit) Certification - In accepting the above statement re arding existing sort'. conctitian, I certify that the tank 5 l �o t�an)c con:fo:rm to the re he best: of my knowledge w:i )..l inspect.i n opening o ements of ILH Wis. Adm. Code (except for. g er outlet b e tv �r m zt Sz5 at re ,[ MP/MPRS 77-el1 0 051-- CJWX COUNTY � NO. b�! STATE SANITARY PERMIT q�S �Rjs 1DTicANSFEtc,'1.?� :i1CjWAL PREVIOUS NO. 5463 OWNER mw(, scjtrz-r6gtj �. PLUMBER '5kftAJ P> i gL LIC. TOWN OF ■k&bsom SEC La _IT 29 Nq R "-W CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. AND/OR LOT 'FJI` BLOCK History: 1977 C. 168; 1979 c. 34,221; 1981 c. 314 o Note: If you wish to renew the permit, or transfer ownership of SUBDIVISION the permit, please contact the county authority. ISSUINGM-J�� AUTHORIZED - DATE 2 g/2-02 THIS PERMIT EXPIRES' 1? Zq26 UNLESS RENEWED BEFORE THAT DATE `J� SBD-06499 (R11/20)