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004-1055-60-200
Parcel #: 004 - 1055 -60 -200 03/27/2007 05:01 PM PAGE 1 OF 1 Alt. Parcel #: 24.28.15.376B 004 - TOWN OF CADY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 08/09/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co - Owner O - SORENSON, TOM & ARLA J TOM & ARLA J SORENSON 277 320TH ST WILSON WI 54027 Districts: SC = School SP = Special Pr rty Add �Ss(es): ` = Primary Type Dist # Description 3217 30TH A E SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Vv Legal Description: Acres: 21.576 Plat: 5242 -CSM 21 -5242 SEC 24 T28N R15W PT NW NW CSM 21 -5242 Block/Condo Bldg: LOT 02 LOT 2 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 24- 28N -15W NW NW Notes: Parcel History: Date Doc # Vol /Page Type 07/14/2006 829687 CSM 07/23/1997 958/45 07/23/1997 880/483 07/23/1997 706/291 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations Last Changed: 08/09/2006 Description Class Acres Land Improve Total State Reason Totals for 2007: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 004 - 1055 -60 -300 03/27/2007 05:01 PM PAGE 1 OF 1 Alt. Parcel #: 24.28.15.376C 004 - TOWN OF CADY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 08/09/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - SORENSON, TOM & ARLA J TOM & ARLA J SORENSON 277 320TH ST WILSON WI 54027 Districts: SC = School SP = Special Pr re s(es): ' = Primary Type Dist # Description ' 277 320TH ST SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 4.544 Plat: 5242 -CSM 21 -5242 SEC 24 T28N R15W PT NW NW CSM 21 -5242 Block/Condo Bldg: LOT 03 LOT 3 Tract(s): (Sec- Twn -Rng 401/4 1601/4) f 24- 28N -15W NW NW Notes: Parcel History: Date Doc # Vol /Page Type 07/14/2006 829687 CSM 07/23/1997 958/45 07/23/1997 880/483 07/23/1997 706/291 2007 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/09/2006 Description Class Acres Land Improve Total State Reason Totals for 2007: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 .T Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 488293 0 GENERAL INFORMATION to Plan ID No: S Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 2 C 1 6) 0 1 = TVW5 . �. Permit Holder's Name: City Village X Township Parcel Tax No: Sorenson, Tom I Cady, Town of 00 1- /Oss- 60- ZoC� CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: Z, Irn /,Sr 1 24.28.15. 37 6 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION DS Hi �_S EI.EV 7. 53 qq .73 9/ . Z Septic Uf7� ) OV Benchmark Q r T. f W l z`S Z Dosing Uj Cx9+�� 4 Alt. BM 66 PJ00604 J-* , a 7.3z S*. � 3 Aeration Bldg. Sewer 01 Holding St/Ht Inlet ' W loss 7'�. $g TANKS ACK INFORMATION St/Ht Outlet TANK TO P/; WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic i �G Dt Bottom �( 1s�Z 70' 4 310 �� y z Dosing ! V A- 1 � / Header /Man. 9 4 z � y. z . 'T I Aeration Dist. Pipe 4'.97— R3 $j Holding Bot. System S rJ3 43 �-- Final Grade PUMP IPHON INFORMATION 3.9 Sf. 7'1 Manufacturer ff Demand / St Cov TD - &er5 a tj A- O� GPM, Model Number W&P Q 741- 0 TDH Lift Friction L,osss r stem Head TDH� n ,Ft *� cf ��' $� p� ���7j � L � 1 Forcemain Length / Dia. 2 �/ Dist. to Well N�- 3(Q. ,� $5. , �T • /3 366 SOIL ABSORPTION SYSTEM 5 91. q-5 9'/ , Z_ BEDITRENCH Width Length / No. Of Trenc s PIT DIMENSIONS N . Of Pits Inside Dia. th DIMENSIONS (0 75 I0 et SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAGtIING anufacturer: INFORMATION CHAMB Types Of Syste -7 �� �3 � - I � (�� U Model Number: / � 1 av, 1_ /V VQ DISTRIBUTION SYSTEM 5 Header /Manifold I �, D L/Z� ` �� x Hole Size �� I x Hole Spacing. � Vent to Air Intake s) S t/ S pacing - l / 5 F, ` Length 3 Dia 1 / Length 7z° Dia Z S acin O Z3' SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 0 Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center 6 / Bed/Trench Edges ` Topsoil s No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 3217 30th Avenue Unknown (NW 1/ �� Al 1/4 24 T28N R1 5W) NA Lot 2 Parcel No: 24.28.15. IJJ�oM 1.) Alt BM Description = a �— � 2.) Bldg sewer length = SI�� o L� e.",b ) � - f � - I f - amount of cover Coou_ ov+-� f r ✓�w°`�` P la n Use revis No e other side for additional information. -- J Date Inse ctors Si to Cert. No SBD -6710 (R.3/97) Safety and Buildings Division County ` 201 W. Washington Ave., P.O. Box 7162 St. Croix i sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266- Z93 Sanitary Permit Applicatio State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal infomration ide Trans. Id # 1290091 may be used for secondary purposes Privacy Law, s m) Project Address (if different than mailing address) I. Application Information - Please Print All 0 3,2 1 7 30 v4- Property Owner's Name �� 1 Parcel # Lot L Block # Tom Sorenson �Ul �.� 004 - 1055 -60 2 N/A Property Owner's Mailing Address Property Location 277 320th Street S�'CR NW NW 24 '/4, Y4, Section City, State Zip Phone Number Wilson, WI 540217 715/772 -4509 28 1 4 circle one) T N; R r h II. Type of Building (check all that apply) O }c G S �. '8LA0w, ` ❑✓ 1 or 2 Family Dwelling - Number of Bedrooms 3 Subdivision Name CSM Number 8296$7 Public /Commercial - Describe Use A i r t ❑ State Owned - Describe Use Co k 7 5 0 J � a 0 ity ❑Village ownship of Cady III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. 0 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner / IV. Type of POWTS System: Check all that apply) ' ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil 0 Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirr -1 tin Sand Filter Recirculating Synthetic Media Filter ❑ Leaching Chamber d Drip Line ❑ Gravel -less Pipe ❑ Othe;(expi 5 a �, 5 L /- g V. Dis ersal/Treahnent Area Information: Design Flow (gpd) Design Soil Applic ate(gpdsf) Dispersal Are a R i ed (sf) Dispersal Ar oposed (sf) System Elevation 450 1 o , 450 QQ 450 G) (0 92.7 ✓ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing / Pa �a L Tanks Tanks k_ .7 Septic or Holding Tank 1000 1000 1 Wieser oncrete X ,/ Aerobic Treatment Unit Dosing Chamber 600 600 1 Wieser Concrete X VII. Responsibility Statement I , the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' ignature MPNIPRS Number Business Phone Number Bennie Helgeson 92 715/772 -3278 Plumber's Address (Street, City, State, Zrp e) W1229 770th Avenue, Spring Valley, WI 54767 V / I. County/ De artment Use Onl `lQ Approved j;tsapprov Sanitary Permit Fee (includes Groundwater Dat Is s ed Issuin ent Sign � lJ O ial �(,( Surcharge Fee) C� OQ Q / caner Given Reason for �J O IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent filter and dispersal cell must all be senrkes / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained W pet q*NW* cods / Wdklances. Attach complete plans (to the County only) for the system on paper not less than 81/2 z 11 inches in size SBD -6398 (R. 01/03) � j v N = �- i LL CL V � � j q �� J` ( 2n ell .TES L i J) 7Z? VN LU --47 —..a t-L, f <4c/,Q Q , fl Vi U, LL v f J 4 1 4 f d ILI -If Safety and Buildings commerce.wi. OV 4003 N KINNEY COULEE RD g LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 isconsin www.w www.coe.wi.gov/s sin.go / t i � epartment of Commerce iscosin.gov Jim Doyle, Governor Mary P. Burke, Secretary July 25, 2006 CUST ID No. 220292 ATTN.• POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/25/2008 Identification Numbers, Transaction ID No. 1290091 SITE: Site ID No. 715652 Tom Sorenson Please refer to both identification numbers, 30th Avenue above, in all correspondence with the agency. Town of Cady St Croix County NW1 /4, NW1 /4, S24, T28N, R15W FOR: Description: Proposed Three Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1086964 Maintenance required; 450 GPD Flow rate; 18 in Soil minimum depth to limiting factor from original grade System(s): Mound Component Manual, SBD- 10572 -P (R.6/99), Pressure Distribution Component Manual - Version 2.0, SBD - 10706 -P (N.01/01) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be located and constructed in accordance with the enclosed approved plans and with the component manual(s) referenced above. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular traffic or soil compaction in this area is prohibited. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the tank/filter for maintenance purposes must be provided per Comm 84.25(7), Wis. Adm. Code • Comm 83.22(7) - A copy of the approved plans specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department which may include local inspec tors. P.O.W.T.S. Conditionally APPROVED nFaeRTUFNT OF COMMERCE BENNIE W HELGESON Page 2 7/25/2006 Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(l). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 rard M Swim POWTS Plan Reviewer, Integrated Services (608)789 -7892, Mon - Fri, 7:15 am - 4:00 pm WSMART code: 7633 j erry. swim @wisconsin. gov cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 INDEX SHEET S,qF� zo PROPERTY OWNER: TOM SORENSON III /V os 277 320TH STREET WILSON, WI 54027 PROJECT NAME: TOM SORENSON PROJECT LOCATION: NW 1 /4,NW 1/4, S 24, T 28 N, R 15 W MUNICIPALITY: TOWN OF CADY COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD- 10573- P(R/99) MOUND COMPONENT MANUAL SBD - 10572 -P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section and Specifications Page 5: WLP1000 /600 -MR Zable Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Signed Address: W1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: July 11, 2006 DiVIJ1UP11►t 4ArrCIT H��u vuw�u° SEE COR ONDENCE .� tc)yt.e,r �To►n., S 6r ert So►-, Page Of Synthetic Covering Distribution Pipe ,4.s 7m C 3.3 Medium Sand H _ G ?opsoll F I , D 3 E . , b eon T,A-Ir l e ,, 9 /.a to % Slope Plowed cC�.i.Of 2- 2 %2 Force Main From Pump Layer Aggregate D 1,S Ft. E a. / Ft. Cross Section Of A Mound F . �� Ft. G ..S Ft. A Ft H / Ft. Signed: B_ Ft. K <` Ft. License Number: L Ft. Date: d Ft. Ft. W Ft. Observation Pipe d _ K Z ILLn W --�-- s / Distribution E LL- Of i- 2 Pipe Aggregate I � Observation Pipe Z as<< ,Z)rc� Plan View Of Mound P , (y /. C Parforolad PIP• 061011 1 r C —, C C10 0"1 End View ) Petlwolcd 1 PVC Pipe styli T u�CJe Jo Holes Located on Bottom are Equally Spaced rr� 5 r r � -• ./ 1. If'0.c,G`c��5 --a pitlrlDvllon: PIP, Distri bution Pipe Layout P22LS� R — i S X Y - c� .1- Hole Diameter _jL Inch Signed: Lateral Inch (es) License Number: Manifold Inches DaLe: Force Main " Inches 93.E A)uvn,!x-�- 4 t_Q�-e� k - x 70 l t7o /mss -= 7 d W n e.r ' (v w� �`--'' o Ve� S u n Page `f" of U SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS v fLk -VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 2:25 FROM DOOR, WINDOW OR JUNCTION BOX APPROVED WITH CONDUIT MANHOLE COVER FRESH AIR INTAKE W/ PADLOCK E WARNING LABEL 4" MIN. ty" S.D. „ I I8 rntN• INLET WATER TIGHT SEALS GAS - TIGHT � /APPROVED FIL A SEAL JOINTS WITH Pot /b � SAS` ' ALM APPROVED PIPE APPROVED Y B ON 3' ONTO PIPE 3' F_ SOLID SOIL ONTO SOLID C i ' SOIL PUMP OFF ELEV . /0a I FT - —i'-- OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS c t SEPTIC / DOSE 13 - X_ — �== (5 . TANK MANUFACTURER: ( ' 0 IeSer TANK SIZES SEPTIC �0G GAL. ,r, DOSE VOLUME INCLUDING DOSE ( GAL i/y, �- 3CF OWBACK: , /,FL GAL. ALARM MANUFACTURER: IsL. L _ CAPACITIES: A = /9 INCHES = > t 69GAL. MODEL NUMBER: 10 B = 2 INCHES = 3_ GAL. SWITCH TYPE: II PUMP MANUFACTURER: 20e1'e� C = 7_ INCHES = f /],�Z GAL. MODEL NUMBER: d D = INCHES = /SG' -� L• SWITCH TYPE: �c� REQUIRED DISCHARGE RATE . ,1 (o GPM J' PUMP C ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET a`�'S FEET + MINIMUM NETWORK SUPPLY PRESSURE + /'T _ FEET FORCEMAIN X _ FT /100 F TOTAL I DYNAMIC A HEAD •�= ti.y � _ ___l EET WIDTH DIAMETER INTERNAL DIMENSIONS OF PUMP TAN LENGTH nPTFF 'i - / ��• 7 (Sc Pte, . Ttoc ��F�S.L Se w_ /c2 1 « SIGNED: LICENSE NUMBER: DATE: 1/88 150" -- WLP1 /600 -MR ZABLE ! TANK SPECIFICA11ONS 00 ; �� DIMENSIONS: . ; .� , • WALL:- 3" BOTTOM: 3" COVER: 5" i MANHOLE: 24" I.D. i HEIGHT: 56" O.D. ---------- - - - - -- ------------------- - - - - -- LENGTH: 150" O.D. `MDTH: 84" O.D. BELOW INLET: 42" O.D. LIQUID LEVEL: 36' WEIGHT: 14,795 LBS. TOP VIEW INLET AND OUTLET: 4" BORE WITH STOP FOR QUIK —TITS, FERNCO SCALE: 1 /4" = t' GASKET, CAST —A —SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLES: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) 4" VENTS LIQUID CAPACITY: 27.88 GAL /IN (SEPTIC) ti .1 ri 16.76 GAL /IN (PUMP) LOADING DESIGN: 7' 0' UNSATURATED SOIL OUTLET - - -- - - - - -- INLET co 3" W3716 US HWY 10, MAIDEN ROCK, WI 54750 SIDE VIEW 800 - 325 -8456 SCALE: 1 /4 - = 1' MODEL WLP1000 /600 —MR ZABLE SEPTIC /SEPTIC, SEPTIC/PUMP OR SEPTIC /SIPHON JANUARY, 2000 rn M P1000 600 -VR CJwV1 `�c1 yt �or�n S c n w w TOTAL DYNAMIC HEAD�CAPACITY HEAD CAPACITY CURVE 3 7/8 - 6 1/4 4 PER MINUTE MODELS "140/4140 EFFLUENT AND DEWATERING 4 5 / 8 Ft. Meters Gol. Ltrs. 14 5 1.52 91 344 0 0 3 7/6 45 10 3.05 84 318 + 0 15 4.57 76 288 ° 12 40 I I/2 - 11 1/2 NPT 140, 140 20 6.10 68 257 35 25 7.62 59 223 F 10 30 9.14 49 185 30 35 10.67 38 144 40 12.19 21 79 B 25 45 13.72 5 19 12 5/8 qq Lock Volve: 46' = 6 20 4 5/16 U_ SK1524A > 15 0 a J Q 1 0 10 2 3 7/8 6 1/4 • • 4 11 wig a I S 4 5/8 0 3 7/8 U.S. GALLONS 10 20 30 40 510 60 70 80 90 100 110 ° LITERS 80 160 240 320 400 o 0 FLOW PER MINUTE 010904 ° 11/2 - 11 1/2 NPT CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and supplied with 16 13/32 an alarm. I • Mechanical alternators, for duplex systems, are available with or without --� alarms. 4 5/15 • Control alarm systems are available for 1 phase pumps used in simplex —1 SK1524B system. See FM0732. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable SELECTION GUIDE level long cycle controls. • Sealed Qwik - Box available for outdoor installations. See FM1420. 1. Single piggyback variable level float switch or double piggyback variable level float • Over 130 °F. (54 °C.) special quotation required. switch. Refer to FMO477. • Refer to FM0806 for 200 F. applications. 2. Mechanical alternator M -Pak 10 -0072 or 10 -0075. 3. See FM0712 for correct model of Electrical Alternator E -Pak. 4. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) 140 Series - 53 lbs. 4140 Series - 73 lbs. or (4) float system. 14014140"" MODELS Control Selection Model Model Volts-Ph Mode Amps Slmplex Duplex N140 N4140 115 1 Non 15.0 1 or 1& 5 2 or 3 3 4 E140 E4140 230 1 Non 7.5 1 or 1 & 5 2 or 3 & 4 p CAUTION BN140 BN4140 115 1 Non 15.5 1 or 1 & 5 2 or 3 & 4 All installation of controls, protection devices and wiring should be done by a qualified BE140 BE4140 230 1 Non 7.5 -- Tor 1 - &5 2 or 3 &4 licensed electrician. All electrical and safety codes should be followed Including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX 16347 Louisville, KY 40156-0347 Manufacturers of. . O SH IP s 3649 Cane Run Road Loui 14 T Louisville, KY 40211 -1961 p�Pa S,vcE /999 (502) 778 - 2731.1(800) 928 -PUMP http.lAvww.zooller.com PUMP FAX (502) 774 -3624 0 Copyright 2001 Zoeller Co. All rights reserved. RECEIVE[ Wisconsin Department of Commerce AP � (§IL Page of -a Division of Safety and Buildings in a dangslwM ;gpMroftWf , County Attach complete site plan on paper not less t st include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revi d by Dat Personal information you provide maybe used for secondary purposes (Privacy Law, s. 15.04(l) (m)). D� Property Owner Property Location Tom S (o t-,e &so q Govt. Lot A) W 114 a V T a g N R E (or Property Owner's Mailing Address Lot # Black # Subd. Name Qr CSW X77 -7PO - Fh, S+. Pendtn City State Zip hone Number ❑ City ❑ Village own Nearest Road ��15or1 (1�r S'yoa c�1 ) 77�-4 �'l� A- [3 Construction Use: 2esidential / Number of bedrooms Code derived design flow rate ys� GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material t !7 Ll�(� ___ Flood Plain 1 elevation if applicable ft General comments * U - ! / 1 f r - S Q t 4. /� CQ� and recommendations: GGSG �� X 7 S �� L C ®vL-f - b uL� mil .. � 0 (AV\ k) F1 Boring a Boring # 2' Pit Ground surface elev. 9 - ft. Depth to limiting factor Z& in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure EConsistenc Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 9 Ic)vk — :L a tt f 3 s s Se L �t cV 3 Boring # F1 Boring CMG 1 7 2-pit Ground surface elev. d 0 ft. Depth to limiting facto in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff #2 % D - 9 10Y -:5 i L sbk 3 i t C- * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 1 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ignature CST Address �0. 1 /41 ate Evaluation Conducted Telephone Number Property Owner T6 VK J 0 re s n Parcel ID # / Page of Boring # ❑ Boring FT Q p t Ground surface elev. S ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 a 7-20 lc)Vk 3 S;L I n nk s I Lt) t a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Eff#1 `Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. El Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 I 'Eff#2 ' Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30:5 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 5 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 100) i Property Owner l ® "K S 0 rcf V I S 0 n Parcel ID # Page ;) of _ Boring # O Boring 3 E pi Ground surface elev. � S ft: Depth to limiting factor in. Soil A ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 C-) a 0 3 S ' L k D YA sb rL-) F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I - Eff#2 F Boring Boring # Ground surface elev. ft. Depth to limiting factor in. E] pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. SBD -8330 (8.07100) To vv-L ©reA,5ov\, - - 3 o 4-k 0 4e.- pro�oS�dC CO �1cce�� As s ho w v` 38otk /S e, yd p F for oP.®E / n e a v ID t h 11 / / f / d3l LA B i /�o9a too,eo l pn / sinp� Omit �-96rj 1 As, f VaI ( rA) Fenc'e Pos ' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 8 FILE INFORMATION SYSTEM SPECIFICATIONS Owner TON SUKENSON Septic Tank Capacity 1000 gal ❑ NA Permit # Septic Tank Manufacturer Wieser Concrete ❑ NA Effluent Filter Manufacturer poi lok ❑ NA DESIGN PARAMETERS 13 NA Number of Bedrooms 3 ❑ NA Effluent Filter Model PL-525 ] NA Pump Tank Capacity 60U al ❑ NA Number of Public Facility Units Estimated flow (average) 3U0 al /day Pump Tank Manufacturer Wieser Concrete ❑ NA Pump ManufacturerZoeller Punip Co ❑ NA Design flow (peak), (Estimated x 1.5) 425 al /day E3 NA Soil Application Rate U,5 al /day /ft z Pump Model NA Standard Standard Influent /Effluent Quality Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L M NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5 ❑ Disinfection ❑ Other: 150 mg /L ❑ NA Pretreated Effluent Quality Monthly average Dispersal Cell(s) 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: ❑ other: ❑ NA 6 t h_, ❑ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: 2 CX ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume Cl NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 2 year(s) C month(s) ❑ NA Clean effluent filter At least once every: 13 ❑ year(s) a months) ❑ NA Inspect pump, pump controls & alarm At least once every: 13 ❑ year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: 3 Cj year(s) ❑ month(s) ❑ NA Other: At least once every: ❑ year(s) ❑ NA Other: MAINTENANCE INSTRUCTIONS made by an individual carrying one of rite following licenses or certifications: Inspections of tanks and dispersal cells shall be Master Plumber; Master Plumber Restricted Sewer; POWTS in 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 a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) OWNER: TON SORENSON ` Page 8 _of 8 _ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence ol'painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents ofthe tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to Assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do 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. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life Of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; Disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat Scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the l'ollowing steps shall be taken to insure that the System is properly and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Administrative Code: • 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 Compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will 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. • A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation 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 (i Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<W ARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Namel HELGESON EXCAVATION INC Name JUHNSO I Phone 715/772 -3278 Phone 1 715/273 - 5811_ SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORYAU MORITY Name JOHNSON SANITATION Agency ST. CROIX COUNTY ZONING Phone 715/273-5811 Phone - , 1, iRr, _ zrkfJ This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and SankaUon agancip ThWa do W "t AWI the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(0 and 83.54(l),(2) 6 (3), Wlsconsln AdminlsUs0vil Code. U" o(Mla doataNntdowaot quaramee the performance of the POWTS. QiiWW01) JUL -25 -06 12:56 PM P.e3 E33035 /! REA'GISTER H. DEEDS ST. CROIX Co. W, AFFIDA FOR MULTIPLE BUILDINGS RECEIVE FOR RECORD ON A POWTS i e7i24izeas i This egrsemant is mad& pureut:nr ro Comm 83.242)(b)s,b, wie. Adm. Code AFFIDAVIT ap•e�rnw t ate Y,an ranee n umber EXEMPT g '�.. ► 49 /.'� 9 I'/ REC FE6: PropertywMer(s) * gr(s)A race TRANS FEE; COPY FEE: n-r 5 0F 42 A Se P CC FEE: PAGES; Z Lcp ptian o rvpergr .. N w)ly, Nw yq, 5;Lq,TaBAl if t w Parcel ldentlAarnurn er .5 •5t,, ' plan to have multiple buildlnpa connemd to one Pnvete Cnalle Waerowator Treatment system (POWTt3) oil properly owffid by ntw. "f'7l Property addreea -�+"� t' ^ .��j _ _ st'1 "�' l.✓ y ,(, f�, `t •'"` r ,. y � Building di>:Cr'iptivns: � S G. Pcs! •e $ E Th! droposed POWTS system operation and mint nanca w111 be my respor<algnhy. E �. • •. • • • t ■ • • Date signed:" �wride Name (Nrintj Subscribed un sworn b be ffw on Ncterized Owen W iatire ctaty e �)� 1 �c'�'t �.r�. �ip'�►llL.x.J►� � 'xV Cone's Address My eomm Sion a' r ,x'17 ,.3 �'` e. -� erg r .9`��:� 7 _ .. � ��� �.�. JUL -25 -06 12:56 PM P.04 It OOCU�A£NT7MQ• I $ TATF. IDAROFWI,°,CQlvSlh OM,r:2 —!!i= ' MIS l ilACEMI ;`,l,M 'if i+rpNAi.•)HJitiuWrA WAM Rte' Y D ,,Ut ti 4S 4W 4r91 958 -A:i 4 �u1� a1 =F�c .�_.�.__...__.._ REGIS ! r,.►FtK - AND PBS: Pt t,;MveLQ -%) ST, Om cu., ,-tr�L c ,�. ol. .. � _.... ... _.. _ JUL 0 21992 :. a 4: P. M Coma; 2 And *arranla to_'!�M :��t j AR�.A _ A - ' FE N •�N W ATS 107 K, YAlltY- Wi .541ti7__. $0 Attun1. TO the following QasCrIDW real etlatr, I . CRnIxR — .— Counly, _._.. -- $Itle of wirkontiin: ........ _ .... ......�.� Tax P►roN i; "THE NW 1/4 Or NW 1/4 W SDr. ION 24 tN T0A`Nfh1P 26 NORTH Or RANCE 15 WEST" • � hfin� „ •c lw� t Thrt NO!T ... hurniLtP�prolhlrty , ExCdOh•;n to WiKflritlai' WINE Crated this 4 .ISFAL} —_ _.._ ... .� .,,, (SEAL) AuTHErnr, o,tu,`1 ACKhO * L Eu4M[t+ r STATE OF %APSCONSIN ea. Count ♦�rhnr,t,earr ;hir___-,__aar of_ 19 _. Pesonafly Cain before me this dit o} the rno- -maned _ Csarreth and PeF�«Y H� ,Gun:lssryon _ T►TlE lUE4tf3EA — $TA - TE BAR 0 — t 11) h01........_. _.._.. fo `i rhown to be jlts tW; r ':ta {! hu S'FAItM] Ihof eurhrr.: =d ; r § 706 06. WIS ' rHlSih.'y.��rE4T1rYf5:r:•r'[ 'ar - L � *. �x..� :% 829F.8 VOL 21 PAGE5242 KATHLEEN H. WALSA - -- " REGISTER OF DEEDS ST. CROIX GO ' L WI RECEIVED FOR !{ ECORD 07/14/2006 03:05PH CERTIFIED SURVEY MAP REC FEE • 1.1 (be 'SURVEY MAP .CO PY FEE: 3.00 CERTIFIED S PAGES: 2 Thomas and Arla I Sorenson Located in the Northwest % of the Northwest % of Section 24 Township 28 North, Range 15 West, Town of Cady, St, Croix County, Wisconsin. N LEGEND INDICATES 1 "O.D. x 18 IRON BEARINGS ARE REFERENCED PIPE SET (MIN. WE • 1.13 LBJL.F.) TO THE NORTH LINE OF THE A SOIL BORINGS (PROPOSED SEPTIC SYSTEM) NORTHWEST 114 OF SECTION 24, T 28 N, R 15 W, ASSUMED AS 0 SECTION CORNER MONUMENT (AS NOTED) S 89 0 48'18" E INDICATES FENCELINE OWNER'S ADDRESS SCALE IN FEET 1 ■ 300' 277 320TH STREET WILSON, WI 54027 160 6 10 20 30 o , ' UN_P_�AT- NORTHWEST CORNER -_ Z; �; 6 ! 8 '1 SECTION 24, T 28 N, R 15 W U N -- LATTEQ LANDS I NORTH 114 CORNER (FOUND COUNTY BERNTSEN , SEC710N 24, T 28 N, R 15 W ~ I I SU L) RVEY NAI S 89'48'18" E 2639.84' — AYNU1 ' (FOUND 1" IRON PIPE) Q — J �- - -- -- --- 'r0 '' 10 — — 809 1319.9T — — — -�: 656.96' 63 8 89°4 ' 3.80' LINE F_ LOT 1 3 ' i�+, 600,651 SQ. FT. W LOT 2 OR 13.789 AC. ;0 939,872 SQ. FT. °�) I (550,171 SQ. FT. OR OR 21.576 AC. a N . 12.630AC. EXCL. TOWN (918,954 SQ, FT. OR Z� 9 ROAD RIGHT OF WAYS) 21.096 AC. EXCL. TOWN �. ROAD RIGHT OF WAY) W co AA o. 1 1,, W S 89 °26'45" W CL: �s� 190.16' g 5, i v fv r �.r Z W I N 87 °32'15" W 526.27' 32.59' 493.68' �o °s I6 6� SHE LOT3 z (` I F _ ' �D� WELL DWELLING ' W/GARAGE W S sEPTIC ° 34.01' 533.18' ° - 1284.42' -- 499.17' 785.25' SOUTH LINE NW114-NW114 ' - -- - -- ' 3't 2't N 9 °58'27" 1318 ; UIVPLATTED I66'I NOTE - UNP�ATTED.�ANO Z; LOT CONTAINS 197,915 SQ. FT. LANP_5 OR 4.544 AC. (185,122 SQ. FT. OR 4.250 AC. D(CLUDING TOWN ROA W; RIGHT OF WAY) �%scoNSr,� W • •• � LAURE L^E • e • i W e ZELDF-NVILLE HY 13 z WEST 114.0 ORNER , • � 3 SECTION 24, T 28 N, R 15 W DATED: W1. e ' to (FOUND C OU N TY BERNTSEN MARCH 22, 2006 .•°• ••,��� °•soo•° J Fp S LAND THIS INSTRUMENT DRAFTED BYJERALD L. LARSON SHEET y OF 2 Vol 21 Page 5242 CERTIFIED SURVEY MAP Thomas and Aria J. Sorenson Y Located in the Northwest % of the Northwest % of Section 24, Township 28 North, Range 15 West, Town of Cady, St. Croix County, Wisconsin. Description That certain parcel of land located in the Northwest 1 /4 of the Northwest 1 /4 of Section 24, Township 28 North, Range 15 West, Town of Cady, St. Croix County, Wisconsin, more fully described as follows: Beginning at the Northwest corner of said Section 24; thence S 89'46'18" E, (assumed bearing on the North line of the Northwest 1 /4 of said Section 24), a distance of 1319.92'; thence along the East line of said Northwest 1 /4 of the Northwest 1 /4, S 00 °03'51" W, 1315.49'; thence along the South line of said Northwest 1 /4 of the Northwest 1 /4, N 89 °58'27" W, 1318.43'; thence along the West line of the Northwest 1 /4 of said Section 24, N 00 0 00'00" E, 1320.15' to the Point of Beginning, containing 1,738,438 square feet or 39.909 acres, being subject to public roadway easements over Northerly and Westerly portions of said parcel as shown on this map, and all other easements and restrictions of record. State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Thomas and Arla J. Sorenson, I have surveyed and divided the lands shown hereon in accordance with official records, - Chapter 236.34 of Wisc >ansin Statutes and the Ordinances of St. Croix County and that this map and description are a true and correct rej resentation thereof. Dated: March 22, 2006. NOTE: Each parcel shown on this map is subject to State, County, and Town laws, rules and regulations (i.e. wetlands, minimum lot Size, access to parcel, etc.). Before purchasing or developing any parcel, contact the St. Croix County Zoning (office and the Town of Cady. APPROVED c JUL 1 4 1006 It not rbcorudu wunin 3u Uays of approval date approval shall be null and void S GONS '* A e °•• °... °ee• a LAURENJZI e - o e o' M PHy e * • 1713 i •• ELDENVILLE,e 0 Wt. • •• e e ° eeee• • THIS INSTRUMENT DRAFTED BYJERALD L ORSON � LAND gJ SHEET 2 OF 2 Vol 21 Page 5242 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer 7 M Mailing Address 4 7 Property Address Ja r d 4,1\ (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number U 0 J/ —/ a 5'S — 4,6 LEGAL DESCRIPTION Property Location &/ V '/ , . A/k,� V4 , Sec. _, T U N R /S W, Town of Subdivision , Lot # D, Certified Survey Map # �� ��7 , Volume l , Page # Warranty Deed # 9e6 , Volume , Page # u Spec house 0 yes 411 no Lot lines identifiable byes 0 no SYSTEM MAINTENANCE AND OWNER 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 in §Comm. 83.52(1) and in Chapter 12 - St. Croix County 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 less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05)