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STC - 10 4 AS BUILT SANITARY SYSTEM REPORT ocr
OWNER ~/AA/ L~l S ~crvrv i,"V y
ADDRESS //19 -~(o 711 S7
~GIYr_se Al l~i' S <101~
SUBDIVISION / CSM#_ A&MOZ41 LOT #
SECTION T 19 _N-RW, Town of ST, e05,4?4 c}
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f3~`1
s~~~~ yon l2p
- /ooo G-t .5"7"
i
I I T ORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
s
t :
BENCHMARK: Zo p -Ah eD r STi4A-e F %00 °
ALTERNATE BM: Ag , 5-
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:- Liquid Capacity: fppo
Setback from: Well 1'1oTlN House other
facturer Model# Size
Float 7seperationn Ga e:
Alarm ation
SOIL ABSORPTION SYSTEM
Width:- Length 7,6' Number of trenches Z
Distance & Direction to nearest prop. line: $S` Alof jy
NOT AIV
Setback from: well:Y,oT House ,9-C Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off A(A
Header/Manifold
,I* . 4090
Bottom of system
Existing Grade Final grade I~.S
DATE OF INSTALLATION: ~Q-
PLUMBER ON JOB:OQ
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin,Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299002
Permit Holder's Name: ❑ City ❑ Villag Town o : State Plan ID No.:
AVIS, DANIEL ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/b j l~J 030-1024-70-000
TANK INFORMATION ELEVATION DATA A9700
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /3 1 '
Dosing 9 z
'
Aeration Bldg. Sewer . 5,5 q12, 1
Holding St/Ht Inlet g 7.a8'
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic > 3 NA Dt Bottom
O
Dosing NA Header/Man. 7` 3,r ar
Aeration NA Dist. Pipe *?._?9 9 s ,i '
17 s_ Holding Bot. System g+ 33' '7 u,70 41
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ,7 J a~ ~l 7
Model Number GPM
TDH Lift F ' Ion System TDH Ft
CIS mead
Forcema' Length Dia. I Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manu acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type O ~nz o ~ CHAMBER Mode Number:
System: 3 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
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 xx Seeded/ Sodded xx Mulched
Bed /Trench Center t' Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 6.29.19.100,SW,SW 1125 30TH STREET BLK 3
2 Cut ~3 t_~tzj ~~,:,rL~-yam ~ ,~►~.~C,~~
17toil .rU/U_ 412 J w, _
Plan revision required? ❑ Yes No
Use other side for additional information. /D ~e-
SBD-6710(R 05/91) Date I sp aor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH t
SANITARY PERMIT NUMBER:
a r
Vi SANITARY PERMIT APPLICATION 2018E. W and shnlgton Ave lion
sconsin
Department of Commerce In accord with tLHR 83.05, Wis. Adm. Code Madison, 7969
Madison, WI
WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. ~-f- Cr(~!x
• 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 Z re " 002-
[Privacy Law, s. 15.04 (1) (m)].
//o15 V Qom' E] Check it revision to previous application
State Plan I.D. Number
1. APPLICATION INFORMATI N - PLEA E PRINT ALL INF RMATION
Property Owner Name Property Location
j4o 1 /4 GU 1/4, S G T,2 , N, R I f' E (ore
Property Owner's Mai Iin Address Lot Number Block Number
//,29 o psT ~9 I At,
City, State Zip Code Phone Number Subdivis n Name or CS N tuber
C!/ ` S o ( > y I~o y 1 l 306.5
II. TYPE F B IL IN 3: (check one) ❑ State Owned ❑ it earest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms .3 Town OF S?. S Q S~
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 0& . a 9• /9. /0O 0 3 0 j 4) ?a
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, [g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
______System --------System Tank Only Existing n 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Dd 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
`s s0 • 9670 Feet I 9P, 0 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of r Prefab. Site Fiber- Ex er.
Gallons Tanks Manufacturer s Name Concrete Constructed glass App.
Tanks Tanks
Septic Tank or Holding Tank O~ - e ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumb
AIAA& er's Name: (Print) Plumber' Si nature: (No Starr s PRSW N Business Phone Number:
P umber's c dress (Street, City, State, Zip Code).
a2 6--
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
~I Approved ❑ Surcharge Fee) ,
[]Owner Given Initial
Adverse Determination Sv
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6998 (FL 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS.
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8.1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; Q soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater. -
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL EVALUATION
REPORT Page i of 3__
Lptbor and *Human Relations
Division of Safety & Buildings
o
r k 83.05, Wis. Adm. Code
. '1, COUNTY
Attach complete site plan on paper not/less than ft_oiaches in siz4. Plan must include, but St. Crnix
not limited to vertical and horizontal reference point (BM), direc,t,iSS~~n and °/dlof slope, scale or PARCEL I.D. #
dimensioned, north arrow, and locatio 4P nid dis~ @~ talr ar*cad. ' 030-1024-70
APPLICANT INFORMATION-PL RINTR~ 0 R M N REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
1/4 1/4,S T N,R Xk(or) W
ti.ri GOVT. LOT SW w 6 2c)
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1129 30th. St.n, na csm pending
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [JfOWN NEAREST ROAD
] New Construction Use [ Residential / Number of bedrooms [ J Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate . 5 bed, gpd/ft2 .6 trench, gpd/ft2
Absorption area required 9 0 0 bed, ft2 7 5 0 trench, ft2 Maximum design loading rate ._bed, gpd/ft2____a_trench, gpd/ft2
Recommended infiltration surface elevation(s) 95.00 ft (as referred to site plan benchmark)
Additional design / site considerations n a.
Parent material outwash Flood plain elevation, if applicable fta ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM' IN FILL HOLDING TANK
U = Unsuitable fors stem Eks ❑ U CIS ❑ U Cis ❑ U 13S ❑ U [RS ❑ U ❑ S CCU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch
1 1 -
2 12-24 10 r4 4 none sici lcsbk mfr 9W if -9 -3
Ground 3 24-47 7.5 r4 4
elev.
98 . 6 Eft. 4 147-82
Depth to
limiting
factor
+82"
Remarks:
Boring #
1
2 2
-26 10yr4ZA
mfr 9W
Ground 3 26-54 7.5 r4 4 none ms o
elev. 4 54-82 7.5 r4 6
98.18.
Depth to
limiting
factor
+8 2 11
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200th. Av New Richmon WI 54017
Signature: Date: 4-24-97 CST Number: m02298
PROPERTY OWNER Dani 1 Davic SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # 030-1024-70
Depth Dominant Color Mottles Texture Structure Consistence Bandary Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxtl
9. f
2msbk
3 1 0-11 10 r3 3 none
2 1
Ground 27_91 7
elev.
98.1Zq.
QSg
Depth to
limiting
factor
+A
Remarks:
Boring # none ?mqhk mfr 9w 9f
0-19
none sicl Icsbk mfr aw if .2 .3
2 12-30 10 r4
.7 .8
Ground 3 30-52 7.5 r4 4 none Pis osa elev. 4 152-82 7.5 r4 6 none fs osa fr na na .5 .6
98.06 ft.
Depth to
limiting
factor
+82"
Remarks:
Boring #
1 0-10 10 r3/3 none sil 2msbk mfr 2f .5 .6
5
9 in
Ground 3 125-50 7.5 r4 4 none ms os mvfr na .7 ':.8
elev. 150 _ 78 .5 .6
98.00 ft.
Depth to
limiting
factor
+7g
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Daniel 1554 200th Ave.
CSTM2298 Davis
STM2 3254 SW4SW4 S6-T29N-R19W New Richmond, WI 54017
town of St. Joseph (715) 246-6200
N
1"=40'
BM.= top of NE lot stake @ el. 1001
Alt. BM.= top of 21, pvc pipe C el. 98.55'
1
P~
AC C, Z8
~D
Gary L. Steel
4-24-97
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 6-,& i' I C . Da u: -c r,, Ax e Ka y e vt P, Qa L1%S
MAILING ADDRESS _ Il 2 3 0
PROPERTY ADDRESS 1l 2S- 30 n S't e-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE J S o, , U) j .s~ N1-9
PROPERTY LOCATION -5 W 1/4, SW 1/4, Section T_2j N-R_Z_W
TOWN OF c) Sc eVh ST. CROIX COUNTY, WI
SUBDIVISION-'
LOT NUMBER
CERTIFIEDSURVEYMAP . VOLUME PAGE± LOT NUMBER 3
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 licensed septic tank pumper. What 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 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 system properly maintained.
ro rty owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by mate lumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-si astewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: ~/llAi,e,~
DATE: 6'19 - 9 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 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 recprding.
Owner of property ; P C, K Q r e vt ,o; c
Location of property S u) 1/4 S W 1/4, Section 6 T-2-cL-N-R__L_?_W
Township s t,~ Mailing address _ //;L9 p tom- 5t ,
~u~so~. W1 S Zo/b
Address of site 5- 3 p S~- u, &)Z S-yo/,
subdivision name CSM Vb l p~ ~3 53 Lot no. 3
Other homes on property? Yes No
Previous owner of property
~P ~ plMnhr~
Total size of property /06 /~cr~5s
Total size of parcel --5 e5
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes --X--No
volume 3 and Page Number 302 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
,-I-(we) certify that all statements on this form are true to the
best of zr (our) knowledge that-l-(we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No., and that.-I---(we) presently
own the proposed site for the sewage disposal system or-I- (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signaturje-o licant 'V v
p Co-A p cant
Date of Signature Date of Signature
. ` li
f DOCUMENT NO. RTATZ BAR OF WISCONSIN FORT[ 1--lf>! rwu s►wea ss~so roa saeoae~»e sera I
WAR I
44559.1 ! """TM ~o
R~
- 1 REGISTER'S ONCE I
This • $ need, made between Sr. Mix . Juae _ IS,.. Wald1F.4.f f . and.. ~~~Q ~ , ca,
W...-Johtta.9_A..also known as Bradley M. Johnson - - - Qer d for %CO~
i
- - FEB 2 1989
6rsad+ac of 10
A . M
and----- Alani~el_.C....Aavx;,.-and.lGszBm10
wife. as aurvivarahip marital..praperty
WitneMeth, That the said Grantor, for a valuable cow"eratiea
,
conveys to Grantee the .ollowin described real estate in aaTY11N Tp
5t
County,
State of Wisconsin : 94 u if l C. Dd", s
i Ttt z 3 e,(A6
The West Half of the Southwest Quarter; the West Half of u" Sy0 66 _
I( the Northeast Quarter of the Southwest Quarter; and the
I North Half of the Southeast Quarter of the Southwest -Moz Pared No:
~
Quarter; all in Section Six (6), Township Twenty-nine (29) North, Range Nineteen (19) j
{ West.
Excepting from this conveyance a parcel of land in the Southwest Quarter of Section 69
i fl
Township 29 North, Range 19 West, St. Croix County, Bisconsin, described as follows:
Commencing at the West quarter corner of Section 6. as the PLACE OF BEGINNING; thence
East on the center line of Section 6 for 1897.4 feet; thence South parallel to the West;
line of said section for 1147.88 feet; thence West parallel to the center line of said
z ~
section 1897.4 feet to the West line of Section 6; thence North on the West section lin~
of Section 6 for 1147.88 feet to the PLACE OF BEGINNING.
This deed is given in final performance of the Land Contract between Benjamin Lindemann
II and Belle P. Lindemann, his wife, as Vendors, and Daniel C. Davis and Karen P. Davis,
j~ husband and wife, as Purchasers, dated January 18, 1969, and recorded on January 21,
! 1969, in the Office of the Register of Deeds for St. Croix County in Volume 448, Pages
473 and 474, Document 294992.
Exempt from transfer fee and return under Section 77.25(1).
This is not
homestead homestead property-
!I ( (is not)
( Together with all and singular the hereditaments and appurtenances t>bereunto belonging;
jl And.-June-_M. Waldroff_-and.-Bradley-_M,-"
warrants that the title is good, ~ indefeasible in fee simple and free and dear of eacnmbrancea except subject to
existing highways and easements of record, and to liens or interests created by the
act of default of the grantees, if any.
and will warrant and defend the same.
8th February
Dated this day of
1989.....
5 ,
- - - ----(SEAL) (SEAL)
`J ,June K. Waldroff
- - - - -
---(SEAL) 41 "'"(SEAL)
• radley V. Johnson. /!</'A Bradley M.
Johnson
ACKNOWLBDOMENT
_ H- ;iald~€ aad
&gna re a 3t..... STATE OF ifcLSCONSIN
_ sa.
x. -------S--t---. -Croix ----------.County.
19. Personally came before me this -.----..8th-.day of
FP-b 19.-89.. the above named
June N. Waldroff and Bradley W..Johns on
d A/K/A Bradle - .
- -
Y M_. Johnson to me known to
-
ITLE: MEMBER STATE BAR OF WISCONSIN -assignees named in tfie Final Ju'dgemeiit in
- - -.--_t
(If not . the Estate of Belle P. Lindemann, and
authorized by 706.06, Wis. Stdts.)
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
d d x u a x x x 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
January 13, 1999
RE: Septic Inspection for Daniel Davis located at 1125 30th Street,
Town of St. Joseph, St. Croix County, Wisconsin
Dear Mr. Brewster:
A septic inspection of the above referenced property was conducted on October 28, 1997.
This property is located in the SW'/a of the SW'/a of Section 6, T29N-R19W Town of
St. Joseph, St. Croix County, Wisconsin. At the time of the inspection, this septic system
was found to be code compliant for a three (3) bedroom home.
If you have any questions regarding this, please contact our office at (715) 3864680.
Sincerely,
Mary J. Jenkins
Assistant Zoning Administrator
/sm