HomeMy WebLinkAbout030-1048-10-120
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w FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER AA1 zf~f- o-ly y toal- TOWNSHIP ST Zo re&&
f a,
SECTION ,t , T~0 N-RW
ADDRESS All, 6TY ST. CROIX COUNTY, WISCONSIN
LOT SIZE
SUBDIVISION S TO cl j LOT
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
5CAUF / yo
N
W EL`
1
NpaSE 11 1
1 ~
N 1 ~
1
00
fi
ho t
INDICATE NORTH ARROW
BENCH14ARK: Elevation and description: A,/= LOT S 7-4-An
.Alternate benchmark
SEPTIC TANK:Manufacturer: 1,1jigger's Liquid Cap. )e0Q
Rings used: 0 Manhole cover elev://6,pOFinal grade elev: /Z2~
Tank inlet elev.:41,6(' Tank outlet elev.: 113,35~'
No. of feet from nearest road:Front , Side, Rear Ft._,2_00*t0
From nearest prop. line:Front , Side, Rear Ft. ;,L'10r
No. of feet from: Well (o if , Building: `13
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom o nk elevation
Pump on elev.: Pump of ev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distanc om nearest prop. line: Front_, Side_, Rear Ft.
istance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit: YA
Width:- Length /Qp Number of Lines:- ,Z Area Built 1506
Exist. Grade Elev._ It) 9 Proposed Final Grade Elev._ 1,09
Fill depth to top of pipe:__ -70 l'
No. feet from nearest prop. line:Front , Side , Rear Ft.j
No. feet from well:-UD-_No. feet from building /
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of b m tank:
Elevation of inlet:
No. feet from ne prop. line:Front , Side Rear Ft.
No. feet om: Well , building T, nearest road
arm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB:
_
LICENSE NUMBER: 3ZO6-
6/90:cj
I` DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR r/~D O SAFETY & BUILDING
LABOR & HUI/IAN RELATIONS / DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
Mp,pl' (~L,ft ; t~'1~ 0 1 9W State Plan I.D. Number:
WNE 7YY CONVENTIONAL El ALTERATIVE (It assigned)
Town of St. Joseph
Mound
Lot #2 Stout El Holdin9Tank El In-Ground Pressure ❑
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Anthony Woulfe 700 8th St.N,Unit C,Hudson, WI 0 6 7
REF. PT. ELEV.: '
$
BEN H MARK (Permanent reference point) DESICRIBE IF DIFFERENT FROM PLAN: C5 E T. ELEV.eS
-,17-,
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Don Schmitt 8~r 3205 St. Croix 149034
SEPTIC TANK/HOLDING TANK D 8 0 5 Le G _ /
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELE TANK OU WARNING LABEL LOCKING COVER
/ PROVID PROVIDED
~LkeX5 C'rac. :
rC'~-i to~ 3, 5 ES ❑ NO ❑ YES O
BEDDING: VENT DIA.. VENT MATL.. HIGH WA NUMBER ROAD: PROPERTY WELL: UILDING: VENT TO ESH
J~j
ALRM: FEET FROLINE` / AIR INLV. .1
ESTl
❑ YES ❑ YES
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: TWA PROVIDEDLABEL pROVING OVER
FRESH
YES NO ❑ YES ❑ NO ❑ YES ❑ NO ENT GALLONS PER CYCLE: PUMP AND CON RATIONAL: NUMBER OF PROPERTY WELL: BUILDIN AIR INLET:
(DIFFERENCE BETWEEN FEET FROM LINE:
YES ❑ NO T
PUMP ON AND OFF E]
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, cgnstructio shall cease until MAIN
the soil is dry enough to continue.) 1
CONVENTIONAL SYSTEM:
WIDTH: LE H: N DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS:
BED/TRENCH LIQUID
TRENCHES: / MAT AL: PIT _
DIMENSIONS - SO a
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MAjLj N ISTR. NUMBER OF PROPERTY WELL: TBUILI ING : VENT TO BELOW PES, ABOVE 9OVE ELEVJ ET:
ELEV. D: Pr7. PIPE FEET FROM LINE: pNAIR INLEfit 07/07A NEAREST ~"~O rrr/
MOUND SYSTEM: Mound site
plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL C ER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO. OF LAT L SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE (FOLD MATERIAL: N0. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKI G:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: CO ATERIAL: VERTICAL LIFT CORRESPONDS T
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES O
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPER BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES :1 NO YES ❑ NO p NEAREST
in in county file for audit.
7tZ~~;L
Sketch System on
Reverse Side. SIGNATU :
ing Administrator
on
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION
4 9 LHR In accord with ILHR 83.05, Wis. Adm. Code CounIL
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 14190 3 q
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
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
062 WOLI L E ^%4 11FN4,S2 T,(?,N,R fQ (or)PD
PRO
700 L, coTti PERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
sr. 1191I'C
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
760 L4 •T
II. TYPE OF BUILDING: (Check one CITY _6., NEAREST ROAD
) State Owned O VILLAGE : T
Ff l
H
❑ Public ®1 or 2 Fam. Dwelling-#~ of bedrooms TAX S J PARCEL NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) V 4/8 0
/
1 ❑ Apt/Condo
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 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. D9 New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 220 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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
5Q REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min...//inch) ELEVATION
0`1 ~ 0 o C/! jQ. 7SFeet .,6 0 Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New P-xisting' Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum s Signature: (No Sta MP/MPRSW No.: Business Phone Number:
DjDQ SC #4 m j TT' 3 >2 ~ ~ 7i:5- SV Y- d s
Plumber's Address (Street, City, State, 'p Code): _
w 1 11.. ~ r
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved S 'tary Permit Fee (includes Groundwater Date Issued VIssuing A ent Signature (No Stam
,N/Approved ❑ Owner Given initial Surcharge Fee) p
Adverse Determination e o ~ -
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: .01
SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
APPLICATION FOR 9ANtTARY PZRMIT
9TC•100
This application form is to be completed in full and signed by the ownet(s) of
the property being developed. Any Inadequacies will only tesult In delays of
the permit Issuance. -Should this development be intended tot tessls by
owner/contractoc,(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 recocdlnq.
Owner of property . f# 17J-if' Lt~I
Location of property/4 /fit Section
Township
Mailln address
Address of site
sebdlvlslon name, S 7-6 u
Lot number Z_ 2 Cs Wt 1f&e..8 pQ. 2j'S!
ti
Previous owner of property + 4
Total miss of parcel T O .
Date parcel was created
Are all corners and lot lines Identifiable? on
__Jls
is this property being developed for resale tepee house)? as 0
volume _and Page Nu~nbes ? as recorded with the Register of Deeds.
- - - - - - - - - - - - - - • - - - - - - - - - - - - - -
INCLUDE
WITH THIS APPLICATION T112 POLLOWINCe
A WARRANTY DtND which Includes a DOCUM=NT NUMBER, VOLUM& AND PAOt MUMat11, and
the BRAL OT THS RE0I8TER OF Dx9D9. In additlon, a certified survey, If
available, would be helpful so as to avoid delays of the tevlewing ptocess. It
the deed description references to a Cee;tlfled survey map, the Catttiled sutvay
Map shall also be requited.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (outl
knowledge; that t (we) am (ate) the owner(s) of the property described In
this Intotmatlon torm, by virtue of a warranty, deed gt carded in the Office of
the County Register of Deeds as Document No. ?~6 8 a I and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to tun with the above described property, tot the
construction of said Pystem, nd the same has been duly recorded lot the Ottlee
et the ounty Register I Dae , as Document )
J~
s gnattsca vt wnec gnatute of -Ownet III ileac et
Sate of algnatuts Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
` 468978 WARRANTY DEED
W FAQ
_Richard 0. Stout and Janet P Stout, husband REGISTERS OFFICE
and wife survivorship marital property, ST. CROIX CO.WI
and Maud H Stout, a single person, Reed for ReCOrd
I conveys and warrants to Anthony P. Woul f e and NI AY 00 31991
Linda J. Woulfe, husband and wife, Gt 8:45 A.MAA
C~ty~,X1C,
a' Register of Deeds
RETURN TO
the following described real estate in St. Croix County, I
State of Wisconsin:
Located inpart of the NE4 of the NE4 of Tax Parcel No:
Section 22, T30N, R19W, Town of St. Joseph,
further described as:
Lot 2 of CSM recorded in Vol. 8, pg.2351, in the Office of the
Register of Deeds of St. Croix County. This lot is subject to a
66 foot wide private road easement as recorded in CSM in Vol. 3,
pg. 861.
This is not homestead property.
(is) (is not)
Exception to warranties:
r1
Dated this cal day of May 19 91
(SEAL) EAL)
• Richard 0. Stout *Maud H. Stout by Richard 0. Stout,
Power of Attorney
"I- ~,P- (SEAL) (SEAL)
Janet P. Stout
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St. Croix County.
authenticated this day of 19 Personally came before me this 2nd day of
May 19 1 the above named
Richard 0. Stout and Janet P. Stout
and Maud H. Stout by Richard O Stout,
Power of Attorney
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person s who executed the
authorized by § 706.06, Wis. Stats.) f oing instrument and a wl d@ the same.
THIS INSTRUMENT WA R TED BY
f a,a tout
135 3 wa uZee Tratt
Ct S P1
Hudson, WI 54016
Notary Public i
(Signatures may be authenticated or acknowledged. Both My Commission is County, Wis.
are not necessary.) permanent. (If not, state expiration
date: U I 1 CL ~ a-g 7- , 19
)
'Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208
Form No.2 - 1982
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, _ DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNS HIP/MIjfttZ9X=%0= LOT NO.:BLK. NO.: SUBDIVISION NAME:
NE 1/4 NE 14 22 /T30 NA93d (or) W St. joseph 2 n/a N. Bay
COUNTY: OWNER'S B E: MAILING ADDRESS:
St. Croix Richard Stout R.R.#2, Box 340, Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: 1PERCOLATION TESfS:
Residence 3 n/a EoNew ❑Replace 11-1-90 11-1-90
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN_ -GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
l S ❑U J S ❑U CAS ❑U ❑ S ®U ❑ S Z VI
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 34 BxB
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH MA~ ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.58 110.60 none >7.58 .83bl.1. 1.08bn.l.s.&gr. 5.67bn.c.s.&gr.
B-2 7.33 110.49 none >7.33 .83bl.1. 1.00bn.l.s.&gr. 5.50bn.c.s.&gr.
B 3 6.91 109.50 none >6.91 1.08bl.1. .83bn.l.s.&gr. 5.00bn.c.s.&gr.
B4 6.50 108.50 none >6.50 -00bl.l. .75bn.l.s. 4.75bn.c.s.&gr.
-
B-5 6.42 107.95 none >6.42 .75bl.1. .42bn.sil. .58bn.l.s.&gr. 4.67bn.c.s.&gr.
B-
deciaml' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD 3 PER INCH
P_1 3.85 none 3 6 6 6 <3
P_ none 3 6 6 6 <3
P_ none 3 6 <3
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 106.75
3
E 3 3
r
A43
E 3
o \ `
E
TN
E
3
E
V
-
E
~ 3 4
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel 11-1-90
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave. New Richmond Wi. 54017 2298 15- 46-6200
CST SIGN
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
HUMAN RELATIONS
LABOIR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN
N All 539709
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/M( XNW= LOT NO.: BILK. NO.: SUBDIVISION NAME:
NE V NE 22 ~T30 H "9xF (or) w St. Joseph 2 n/a N. Bay
COUNTY: OWNER'S B E: MAILING ADDR SS:
St. Croix Richard Stout R.R.#2, Box 340,. Hudson Wi. 54016
USE
NO. BEDRMS : juUMMEHUAL DESCRIPTION: DATES OBSERVATIONS MADE
Residence o :
3 n/a (vew ❑Replace R TESTS
11-1-90 1-1-
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENT31jUgS IN_ -GROUNDPRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
~S ~U ~S ❑U EIS ®U ❑S Ell conventional
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS pa a 34 BxB
BORING TOTAL ELEVATION P H TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED I H TO B DR CK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.58 110.60 none >7.58 .83bl.1. 1.08bn.l.s.&gr. 5.67bn.c.s.&gr.
B-2 7.33 110.49 none >7.33 .83bl.1. 1.00bn.l.s.&gr. 5.50bn.c.s.&gr.
B 3 6.91 109.50 none >6.91 1.08bl.1. .83bn.l.s.&gr. 5.00bn.c.s.&gr.
4 6.50 108.50 none >6.50 .00bl.l. .75bn.l.s. 4.75bn.c.s.&gr.
B-
B-5 6.42 107.95 none >6.42 .75bl.1. .42bn.sil. .58bn.l.s.&gr. 4.67bn.c.s.&gr.
B-
deciaml' PERCOLATION TESTS
TET~
NUMBER DEPTH WATER IN HOLE TEST TIME DROP I WATER L V FL-IN HES
AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D RATE MINUTES
P_ 1 3.85 none 3 PER INCH
6 6 6 <3
P_ 2 -T-74- none 3- 6 6
P- none
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 106.75
.-F111 .-T
rtf
70
s
J
sla4~ " 1
.W
10
t
. 111
E ,
~rl
i i
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print
TESTS WERE COMPLETED ON:
Gary L. Steel 11-1-90
ADDRESS:
1554 200th. Ave. New Richmond Wi. 54017 CERTIFICATION NUMBER: PHONE NUMBER optional):
2298 15- 46-6200
CST SIGN
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83)
OVER -
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER.- '
ROUTE/BOX NUMBER ,,,7-
FIRE NO.
CITY/STATE x✓ f `C t
ZIP
PROPERTY LOCATION: ,.r! 1/4
1/4, Section Z , T_10 N, R,~ W
'0~~ Town of '7a ,l
St. Croix County,
Subdivision _ jlJG1T Lot No. Z_ C-sm I)ot_ ~i ~q,a,3Sl
U
Improper use and maintenance of your septic system could result in its .
ture
failGre to handle wastes. Proper maintenance consists of pumping out theeseptic
tank every three years or sooner,, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a
$3000 of the cost of replacement of a failing system, whichtwasrin Moperion
prior to July 1, 1978. St. Croix County accepted this
1980, with the requirement that owners of ALL NEW SYSTEMSpagreemtonkeepustheir
systems properly maintained.
The property owner agrees to submit to St.
~ Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman lumber,
restricted plumber or a licensed pumper verifying that p
wastewater disposal system is in proper operating condition(landthe on-site
(2 ar
inspection and pumping (if necessary), the septic tank is less than 1/3,fulltof
sludge and scum. Certification form will be sent approximately 30 days prior to
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 Department 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.
SIGN
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
V
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