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Home My WebLink About022-1083-10-200St. Croix County Planning and Zoning Wednesday, February 08, 2006 at 12:21:38 PM Detail Sanitary Information Page I of I Computer I1: 022-1083-10-200 Sub/Plat: NA Section: 29 Parcel M 29.28.18.449B Lot: 2 TNIRNG: T28N R18W Municipality. Kinnickinnic, Town of CSM: Vol. 09 Pg. 2644 1/4114: NE 1/4 NE 1/4 Owner: Johnston, William 1097 Prairie Moon Drive (off Liberty) River Falls, WI 54022 State Permit: 208930 Issued: 03/24/1994 POWTS Dispersal: Non -plumbing Sanitation Permit: New County Permit: 0 Installed: 03/24/1994 POWTS Detall: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreabnant: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Mary Jenkins Yes Schumaker, William check data - from notecard only $0.00 Jim Thompson Signed Off: No Maintenance Scheduled Pump Date Pumped 1 st Notification 2nd Notification 3rd Notification 3/24/2006 JOHONSTON, William 937•Sth Avenue Stillwater, MN SS082 Address Site: Permit No.: 208930 New System - Trench NE4NETS, Sec. 29, T28N-R18W, Town of Kinnickninnniic) Lot 2 3/24/94 William Schumaker Parcel #: 022-1083-10-200 02/08/2006 11:01 AM PAGE 1 OF 1 Alt. Parcel M 29.28.18.449B 022 - TOWN OF KINNICKINNIC 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 WILLIAM G & SANDRA L JOHNSTON O - JOHNSTON, WILLIAM G & SANDRA L PO BOX 367 RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' LIBERTY RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 5.100 Plat: N/A -NOT AVAILABLE SEC 29 T28N R18W PT NE NE & PT SE NE Block/Cando Bldg: BEING LOT 2 OF CSM 912644 5.10 ACRES Trect(s): (Sec-Twn-Rng 401/4 1601/4) 29-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1067/280 WD 07/23/1997 1067/279 TD 07/23/1997 1029135 LC 2005 SUMMARY Bill M Fair Market Value: Assessed with: 143862 387,700 Valuations: Last Changed: 011/1112005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.100 80,000 312,000 392,000 NO Totals for 2005: General Property 5.100 80,000 312,000 392,000 Woodland 0.000 0 0 Totals for 2004: General Property 5.100 40.000 231,300 271,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 212 Specials: User Special Code Category Amount Special Assessments Special Chargeess es Delinquent Charg Total 0.00 0 O St. Croix County Planning and Zoning Detail Sanitary Information Computer* 022-1083-10-200 Sub/Plat: NA Section: 29 Parcel M 29.28.18.449B Lot: 2 TN/RNG: T28N R18W Municipality: Kinnickinnic, Town of CSM: Vol. 09 Pg. 2644 1141/4: NE 1/4 NE 1/4 Owner: Johnston, William 1097 Prairie Moon Drive (off Liberty) River Falls, WI 54022 State Permit: 208930 Issued: 03/24/1994 POWTS Dispersal: Non -plumbing Sanitation Permit: New County Permit: 0 Installed: 03/24/1994 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Mary Jenkins Yes Jim Thompson Signed Off. No Maintenance Scheduled Pump Dale Pumped 3/24/2006 6/2812006 6/28/2009 Plumber Other Requirements Schumaker, William 1st Notification 2nd Notification 3rd Notification 04/20/2006 Thursday, September 07, 2006 at 4:08:03 PY, \ Page 1 of I' Additional Notes Money Owed check data - from notecard only $0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNERrJ-5 X;—zl ADDRESS/, duo/ SUBDIVISION / CSM# LOT #e-� SECTIONZ:F TqrN-R1,�r W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Its DU 1;26lJ , ac r; r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 01-� 62 S /( 3- ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:Liquid Capacity: as O Setback from: Well -19G ",i- House 20 ' Other Pump: Manufacturer Float seperation Alarm Location Model# Size Gallons/cycle: SOIL ABSORPTION SYSTEM Width: S Length le? Number of trenches Distance & Direction to nearest prop. line: 3S' Setback from: well: /Ge House_ /DG Other Building Sewer PC inlet Header/Manifold Existing Grade ELEVATIONS ST Inlet PC bottom ST outlet Pump Off Bottom of system Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: ,T % 3/93:jt I.4iCAUQ1Tpertgt jjg&4=ic.29.2UNITEUWAF SW�EA# Labor and Human Relations INSPECTION REPORT Safety and Bv:ldings Division GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village IR Town of: CST OM ev : nsp BM Elew.: SM Description: / TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing --- Aeration Holding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ato Air irintake ROAD Septic >Sji ��' �� NA Dosing NA Aeration NA Holding PUMPfSH54ON INFORMATION Manu{atfurer Demand Model Number GPM TDH Lift Friction S TDH Ft Loss Forcemain Length Dia. Dist To Well SOIL ABSORPTION SYSTEM ELEVATION DATA ax A9400052p STATION BS HI FS ELEV. Benchmark 8,5/s Gd d�)� 'A -8w. -0.38r &Zs Bldg. Sewer 25' /p,/ (� St/ K Inlet 3" /a3,9S1 Stlyt Outlet 7/gl 103. Dt Inlet Dt Bottom Headed-Mmx- ) 4 Dist. Pipe s,7 ' s /o�). 70 Bot. System �.� 7,5 Final Grade r EP u, }- ►7� 0 4 BED /TRENCH Width Len Ith . No. Of Trenches PIT No Of Pits Inside Dia Liquid Depth DIMENSIONS aDIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM uacturer: SETBACK :LEAC H R ype /Jz.-� u r ?`�7 INFORMATION Model Number: System: �r r p c(c • c j —//0 / T UNIT DISTRIBUTION SYSTEM Header I Manifold „ Distribution Pipe s ,// , x Hole Size x Hole Spacing V_yniio kir Intake Length 42 Dia Length Dia 5� Spacing ,(� - SOIL COVER x Pressure Systems Only xx Mound Or At -Grade s Only J Depth Over Depth Over xx Depth Of xx Seeded /So xx Mul Bed / Trench Center a27 n r G Bed / Trench Edges -�/ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Kinnickinnic.29.28.18W, HE HE, L9t 2, Li ty Road O/lam : U ,6,nw, ol � .f-,-, as,,�.��`r U Plan revision required? [:]Yes No Use other side for additional information. �) S t0(ROSAt) %�/)�'/Zto( i% Date Inspector's ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: CAd116rAl2V DCDVIT ADDI IrATI/1A1 �DI.HR In accord with ILHR 83.05, Wis. Adm. Code1 STATE SANITARY PERMIT # 'Attach complete plans (to the county copy only) for the system, on paper not less than o10030 8% x 11 Inches in size. ❑ Check If revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION dZZ Q A,' _'/4 ''/4, S T , N, R /f E (or)60 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ST ,- —evic 11. TYPE OF BUILDING: (Check one) NEAREST ROAD ❑ State Owned VILLAGE . r ,� , , 4 �, r !Yf ❑ Public 0 1 or 2 Fam. Dwelling-# of bedrooms PARCELTAXI III. BUILDING USE: (If building type is public, check all that apply) nag _ 40 F3_ le' f aU 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ElCampground 7 ❑ Merchandise: Sales/Repairs 11 ElRestaurant/Bar/Dining 4 ElChurch/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 in line A. Check line B if applicable) A) 1. 51 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 12. REQUIRED (sq. tt.) PROPOSED (sq. ItJ (Gals/day/sq. ft.) (Min./inch) /ate o ELEVA IpN QQ Q ct- Feet 05 , Feet VIi. TANK INFORMATION CAPACITY In allons Total Gallons # of Tanks Manufacturer's Name Prefab. ConcreteCon- Site Steel Fiber- glass Plastic Exper. App. New listing ka Tanks strutted Septic Tank or HoldingTanTank Litt Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: lumber's Address (Street, City, State, Zip/Code): f 7 S G O �C �ec d.5- ., , IX. COU TY/DEPARTMENT USE ONLY 10 Disapproved Sa *Lary Permit FW(Inciudes Groundwater r DaleIsamuIssuing Age t Sign a No mpa) Approved ❑ Owner Given Initial ` ��rcharge Feel e_ 146A v rmin n rir X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: OF SBD-63398 (formerly Plb-67) R. 11188) DISTRIBUTION: Original to County. One Copy To: Safety & Buildings Division. Owner. Plumber INSTRUCTIONS 1. Asapitgry permit is valid for two (2) years. 2. Ybursanitary permit may be renewed before the expiration date, and at the 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 & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include! I. 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 in line A. Complete line B it 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 In ##1-7. VN. Tank information. Fill in the capacity of every new and/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 it tanks received experimental product approval from DILHR. Vill. 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% 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; E) soil test data on a 116 form; and F) all sizing information. 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/99) /- o t 9- � yv W bty V r/ KO F . O. d s7 ccx,¢_ /=lQ " 0 r Qr/ iQop t y� All is cf -w 6� V r� -- Z r�p�� 3/� ��y $Y"cisinOwFurtrrwntofIndustry. SOIL AND SITE EVALUATION REPORT tabor and Human Relations Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code Page _ of _,. _ Attach complete site plan on paper not less than q 12 x 11 inches in size. Plan must include, but _ not limited to vertical and horizontal tolerance point (BM), direction and % of slope, scale or PARCEL I.D. s dimensioned, north arrow, and location and distance to nearest road. _ APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Steven CUdd GOVT. LOT NE 1/4 TIE 114,S 29 T 28 ,N,R 18 x yr PROPERTY OWNER':S MAILING ADDRESS LOT s BLOCK s SUBD. NAME OR CSM e - 1 ------------------ _ CITY, STATE ZIP CODE PHONE NUMBER C=VCVVM0= QIOWN NEAREST ROAD Uivc rnllc_ WT S4n22 (715)425-2757 Tcinnickinnic- ILibertv Road I New Construction Use IXI Residential / Number of bedroxns 3 () Addition to existing building _ () Replacement I I Public or commercial describe Code derived daily Ilow 450 gpd Recommended design loading rare .4 bed, gpolh2 .5 trench, gpdnh= Absorption area required 1.125 bed, h2 900' wench, 42 Maximum design loading rate .5 bed, gpdrtt2 .6 french, gpdM2 Recommended infiltration slulace elevation(s) It (as referred to site plan benchmark) Additional design/ site considerations System Elevation 102.00' Parent material Flood plain elevation, if applicable It S a Suitable for System COWENT04AL LtOur+D w GROUND PRESSURE I AT -GRADE SYSTEM w F LL HOLDI:Z luv, UsUnSuilablelofsyslem.t ®S ❑ u E ❑ uI ® S ❑ u I us ❑ u ❑ S ®u IDS ® u SOIL DESCRIPTION REPORT Boring 0 Ground 61oi, 105.0% Depth to 6uliang f:tlur Boring 0 L: Ground elev. 101-,A2 IL Depth to limiting factor Horizon Depth in. Dominant Color Munsell Mottles Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sn. Consistence BDxa4 Roots GPDiIt= Beu Il(Lra -10 10YR 4 2 None is 1 f sbk mfr gs 2f .5 .6 2 10-66 10YR 6 4 None is 0 Pf sg ml gs 1f .5 1-.6 6-112 10YR 6 4 None is 71 0 ry sg mfr -- -- .5 1.6 Remarks: mr r i[s]'EMIC� Remarks: Name:—Pleaw Print 715) 4 June 1r 1993 3074 SOIL DESCRIPTIO1� IiLPORT fa9a—cl--- PROPERTY OWNERStcwon r3tAr3 PARCEL I.D. i GI'Urtt' De th P Dominant Color Moores Structure Texture Gr. Sz. Sh. Consistence Y Roots Bea I�rvr Boring # Horizon in. Munsell lOu.Sz.ConLColor m.I 1 0-8 10YR 4 2 Non I 6- 3 2 8-30 10YR 5/3 None is 1 f sbk mfr s 1f .5 i .6 -- I..6 _ Ground 3 30-11 10 6 4 None—-- i etev. 103-33 IL Ugth to f6iirtg lactor Boring # 4 Ground elev. 106.5 IL Depth to Wiling factor Boring # 5 Ground elov. 102.35 IL Depth 10 limiting lactor Boring # Ground elev. _ IL 0opth to 4nuling laclor Remarks: as s 1f -- ' .5 1 0-10 0-34 10YR 4 2 10YR 5/3 None None is 1 1 f sbk fr mfr 2 3 4-92 10YR 6 4 None is O f s m -- -- 5 6_ 6 6 rid marnn. 1 0-9 10Yr 4/2 None is 1 m sbk mfr as 2f 2 9-30 10YR 5/3 None is 1 m sbk mfr gs 1f .5 _6 3 4 0-70 0-96 10YR 6 4 10 6 4 None None is is 0 f sq 0 f sq mfr mfr qS 1f .5 _.6.- IM NP - numaj r - ----------- r. Remarks: LLD T PLAN- Scale Lot N Aloe+of T1,;s koi ;s Cou<rc6 wItk A;- Y T T .7 -c T Q x W..acohsinDopaundntatlndusuy, SOIL AND SITE EVALUATION REPORT Page _o1_._ L"or and htuuum Relations Division of Salety i Buildings in accord with ILHR 83.05. Wis. Adm. Code Attach complete site plan on paper not lass thiin 812 x 11 inches in size. Plan must include, but St Croix PARCEL It limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. _ APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Steven Cudd GOVT. LOT NE 114 NE v4,5 29 T 28 ,N.R 18 x1liqi4vi PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK Su6D. NAME OR fSM >r Drive CITY, STATE LP CODE PhONE NUMBER EPMCP&OM DOWN NEAREST ROAD ni uav- tall a_ wT Sdn99 (71 SJ 425-2757 1Cinnickinnic Liberty Road (}t New ConSlludon Use (}{J Residential / Number of Dewooms 3 J J A0614n 10 existing DWOing ( I Replacement I 1 Public W commercial descrilia Code derived daily flow 450 gpd Recommended design loading rare .4 Oed, gp*42 •5 uencn, 91)a1112 Absorption area required 1 ,125 oed, h2 900' vencn, n2 Mawnum design baling rate , 5 bed, gpdrtt2 .6 veMA' gpan2 Recommended infiltration surface elevation(s) It (as refaced to site plant banctmark) Additional design / site considerations System Elevation 102, 00' Parent material Flood plain elevation, g applicable It S= Suitable for system I CONVENT�Or" I raour,0 I INGROUND PRESSURE I Aa s O U I ❑ SYSTEM ® u MO s4*4y® u u a unsuitmle for system ®S ❑ u IRIS u IRIS ❑ u Boring it 1 Ground elay. 105_Oft Nplh 10 Wuuting IrcWr Boring it x� 2 Ground eiev. 101-La ft Depth to Wiling factor SOIL DESCRIPTION REPORT Horizon Oeptn in. Dominant Color Munsell tvtomiS Ow. Sz. Cont. Color Texture Structure Gr. Sz. Sn. Consistence Sormy Roots GPOru= BuO I -10 10YR 4 2 None is 1 f sbk mfr gs 2f ,5 1.6 2 10-66 10YR 6 4 None is 0 m sg rn1 gs 1f .5 1.6 -112 10YR 6 4 None is 0 m sg mfr -- -- .5 l .6 Remarks: 0-10 10 r 4 2 None is 1 f sbk mfr gs 2f .5 .6 2 10-24 10YR 5/3 None is 1 f sbk mfr gs 1f .5 .6 3 24-70 10YR 6/4 None is 0 m sg ml gs 1f .5 ' .6 is 0 m sq mfr -- -- NP j NP Remarks: PROPERTY OWNER Steven C%Lldd SOIL DESCRIPTION REPORT PARCELLD.a Boring # Ground eu:v. 103_. IL Ogih to filly g lacwt Boring # 4 Ground elev. 106., _ IL Depth to 4nvtmg I1Ctor Depth OominantCotor Moales Texwre StructureConsistence Horizon in Munsell Ou. Sz. Cont. Color Gr. Sz.* Sn. 8arts�y Roots GPUrI:'_ eco to+� 1 0-8 10YR 4 2 None I 6_ 2 8-30 10YR 5/3 None is 1 f sbk I mfr gs 1f .5 i.6 3 30-115 10 4 None Is-- -- I'6 Boring # Ground elev. 102.35 IL Deplh to wriliN Lactor Boring 9 Ground dlcr. IL OcpN to 6114OQ Ixror M Ln 1 0-9 10Yr 4/2 None is 1 m sbk mfr gs 2f .5 2 9-30 10YR 5/3 None is 1 m sbk mfr s 1f .5 _..6 3 0-70 10YR 6 4 None is 0 f sq mfr as 1f .5 .6__. 4 0-96 10 6 4 None 15 0 f sq I mfr -- --_ �uma�kc• _ —"� Remarks: soo•ea3o1R " • PLD _T__ PLAN 1 ; h�� t. � .,� __. . Scale I"=Go' Lot H ylo�tof 1 's Covc.c•A i�A �i:. rtc_ B % l„ rye„ )3 Flay.IOJ,D SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBEFire Number CITY/STATE ZIP_ PROPERTY LOCATION:Sections•,• T7?-N, R1ZW, Town of I St. Croix County, of number Subdivision r_• Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 'se tic tank pumper. What you put into the system can a act a unct on o. the -septic tank as a treat- ment stage in the waste disposal system. St. Croix Countresidents-may be eligible to recieve a grant for a maximum of 60K of the cost.of replacement of a failing system, whic 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 The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater 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- certificationsform cwill kbessent sapproximately than 1/3 130fdays dprior ge dtoc� three year -expiration. 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 Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED\ DATE I LV St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. 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 C✓ 'l�'a,c� 7de vs few, Location of property,�Z'A-1/4 `t/�1/4, Section _;240 T_.ZEN-R_ZrW Township Mailing address _ ,�, 4 i � r Address of site Subdivision name C Sill (/�9 076 Lot no. Other homes on property?yes_ No Previous owner of property _ SG'� C'ct�f�1 Total size of parcel .5 ./d Date parcel was created �%7%r s yy Are all corners and lot lines identifiable? D( Yes No Is this property being developed for (spec house)? Yes �No Volume 19 7and Page Number y0i 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 & 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 my (our) knowledge that I (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.3, 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 County Register of deeds as Document No. ,5/3 G?r Date of S 3, ature 3 J�-a/Q�/ Date of Signa ur6