HomeMy WebLinkAbout012-1059-70-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division '
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
'ermit Holder's Name: City Village X Township
Stoddard, Dennis Erin Prairie, Town of
;ST BM Elev: Insp. BM Elev: BM Descri tion: o
/ ~l~~p JO'D . O
TANK INFORMATION E NATION DATA
TYPE MANUFACTURER CAPACITY
Septic
Dosing 1
`^y'
Aeration
Hol Ing
TANK~ETBACK INFORMATION
en o it na e
ep Ic ~' ~ 1 , ~ ~ Z ~~ '
osln9 ti ~ ~ ~ ! 1 3 ? ~
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PUMP~IPHON INFORMATION
anu ac urer eman
6 GPM /
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county: St. Croix
Sanitary Permit No:
488123 0
State Plan ID No:
Parcel Tax No:
012-1059-70-000
Section/Town/Range/Map No:
27.30.17.412
STATION BS HI FS ELEV.
Bench~mYayk O J ~~~ f~ 0 r
"
Alt. BM
Bldg. ewer ~~~
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DIMENSIONS ~! ~5r f
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INFORMATION CHAMBER O
! UNIT ~---
uw i r~rov i iv~~ a~ ~ r can !~
h Pige(s)
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Lengt pa
ng
ngth Dia
JVIL VV V CR x rressure ays[ems vnry ~-~cx rvwunu v~ .+~-v~auc .ayaacn~a v~~~y
Bed/Trench Center
Bed/Trench Edges vc~::
Topsoil
Yes + i No
'Yes No
,
~~/]
WC- ~ " - -
COMMENI°5: (Include code discrepencies, persons present, etc.) Inspection #1: V c..q~/ Inspecrion ~~:
Location: 1854 130th Avenue Baldwin, WI 54002 (SE 1/4 SW 1/4 27 T30N R17W 40 acres t n ~ /
e~- rcel No• 7. .17.412
!~ ,~ , e ,~)
1.) Alt BM Description = / " ~^""~"'
Jo~3! l i ~
10. Ig /~~
C.
~' `s a~.(v 6
.
2.) Bldg sewer length = 2 3 ~- ~
-amount of cover= ~~,,.,~onnal ~-
'~ „"" `~".` .~i~-c~`id~ lo~~k3 Ip,y$ (G.lr) II,Z,?•- ~~~
(u'~'~ 1. ~5 ' ~~ 3 ~o
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Plan revision Required? i` % Yes i ; No /
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Use other side for additional information.
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SBD-6710 (R.3/97)
1! ~"l Y Il
ur togs Division County ,
~~
` 201
W. Was~t t ve. ~O. Box 7162 J
•
,SCO~~,~ ~
a lson, 7162 Perm
er (to be filled in by Co.)
t N
umb
Department of Commerce (608) ~VE i
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Sanitary Permit Applieatio state P an l.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information ou proxt 20
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I. Application Information -Please Print All Information ST. CR ...~Gt-µt2
Property Owner's Name rcet # _ I ~ Lot # Block # -
Pa
R4
~„S>~-k-0 ~ .~
It?
Property Owner's Mailing Address Property Location
~ 8 S y t ~o ~` ~.w .
Section ~ 7
~`~ V" '
J~ ~'
City, State Zip Code Phone Number •
~
~aQ~.Cf-r-r-. (~3. 400 ~, 5400,,2 7/$ ?Q6 5 3 J Z (circle )
T ~ ~ N; R~
E
II. Type of Building (check all that apply)
~ Z _
J S Atuta:bef--
vi
i
rrtdame GSAQ
S
bd
l or 2 Family Dwelling - Number of Bedrooms -
u
+
s
a
,
^ Public/Commercial -Describe Use . ~
} ~-
^ State Owned -Describe Use ^City_^Village Ii~Township of
III. Type of Permit: {Check only one box on line A. Complete line B if applicable) Q ~'~' ~~~j ~- ~ -~ ~ ~'
A.
^ New System ~ Replacement System ^ TreatmendHolding 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
~_
N. T e of POWTS S stem: Check all that a I
® Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^
Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^
Recirculating Synthetic Media Filter ^ Leaching Chamber ^ ri Line ^ Gravel-less Pipe ^ Other (explain) t
V. Dis ersal/I'reatment Area Information: ' X ? 5
Design Flow (gpd) Design Soil Application Rate(gpdsf) Di Area Required (sf) t rea Proposed (sf) ys Elevation _ q~ ~3
T/- C}4
~10 T3
SISn o~/ II,~S tro~S .
T - .s~
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site. Steel Fiber Plastic
Gallons Gallons of Units ~~
' ~/~
)
J ~ Concrete Constructed Glass
New Existing ~
~ ~~
a ~,
Tanks
Tanks J
V,~t.w 4
Septic or Holding Tank J p o O 1Q,00~c„ ~~ ~ ~~
Aerobic Treatment Unit
Dosing Chamber I fOSO
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
r~ ~, I~~ 1, NQ c k v~ t lc is3 oA~, s-c~t.,;•~~ r~'~--I ~? I a '7 i S ~'~ 4 3 3 2
Plumber's Address (Street, City, State, Zip Code)
9 e~ l~ ~ s R ~~ ~ : s-vo ~3
VIII. Count /De artment Use Onl
Approved ^ Disa proved Sanitary Permit Fee ( eludes Groundwater Date Issued Issuing Agen`Signature o Stamps)
~
^ Surcharge Fee) ~ `l/ L~ r l ~~ /
/
er Giv J ~p
IX. Conditions pprov 1/ val 3` G' S ~ ~ ~ ~ (~ ~
SYSTEM OWNER: ) ~=2~+ dG6aQ.r^~(
1 Septic tank, effluent filter and (`p~~ ,
dispersal cell must all be serviced /maintained
_ -~--------,
!
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code/ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x l l inches iu size
SBD-6398 (R. 01/03)
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- a"~2Y.CYENT PIPE
.2S' FROM ODOR
WINDOW OR FRESH
AIR INTAKE
ELEVE ~~" ~'~-`
Ae~..e _....- ~ Q
l8~ MIN.
ELEVATION
9o~3S`
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EXTENDING 3
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ELEV S~. bq FT.
VENT CAP
-YEATHER PROOr
JUNCTION BOX.
APPROVED LOCKING
MANHOLE COVER
ANO WARNING LABEL
12" MIN. j
GRAO~ I
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Cb110UIT
A
B
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4"MIN. ~,
.~ 18"MIN.
:: -.:~ - •°' -• PROVIDE `1 ~ I -- - a
AIRtIGHT SEAL i ''I }
• i I'; ?:
I - ~ ALARM •~i
I ~ ON :;
PUMP ~ ~ II ~ •
'~"'~ I ::
r1J ~ OFF • .
C~1:vCRETE BLOCK
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APPROVED JOINTS
WITH Ai. PIPE
EXTENDING 3'
ONTO SOL10, SOIL
~c,~9'ta P~/c.
TANK BEDDING --- :~......-::.:-:--:-~- _
ELEV. 8 . ~?
* RISER EXIT PERMITTED ONLY -~ TANK MANUFACTURER HAS SUCH APPROVAL
DOSE TANK ~
1~..ANUFACTURER ~ ~~ NUMBER OF DOSES PER DAY
TANK SIEE (GAL ioo~ ~ So Gn,-~ DOSE VOLUME _
ALARM; INCLUDIDiG B~CgFLOW ~[_oZ:aB GAL
MA F.AU CTURER ~~"~ ~-R CAPACITIES
MODEL NUMBER -r- a- A b - d f ,(6-~- . A .'t.1 3%e INCHES OR~GAI,
SNITCH TYPE `nn~.r... B a. '~ " 3 Y "
MANUFACTURER Zoe D 8 '~ p / ~ ~ °~
MODEL NUMBER a NOTE'S Pump and alarm are to be _,
SNITCH TYPE ~ installed on separate-circuits.
~~ DISCHA RATE ~~' GPM
VERTICAL. DIFFERENCE BE ~ PUMP OFF AND DISTRIBI~TIO~T'PI 8•~ FEE ~~gZ
# MI1~IM~tM NETWORg SUPPLY PRESSURE ~~~• T
f. /~ FEET OF FORCE MAIN X ~ a < < FT/100 FT -
FRI CT.ION FACTOR ___...__.__. ~ = .~ • ~5 FEEET
^, TOTAL DYDTAMIC HEAD r, I y. 3~v FF,ET
TANK SPECS:
EACH ]. INCH OF DEPTH EQUALS / • v GAL DMp ~ ~ 9 ~ • 3
INTERNAL DIMENSIONS OF T.~Ng :' ~~,,,,,.,,~ ~ _ ~~ _ ~ p
- LENGTH N. A• ---
~IDTH nt.~F, 8.~ ~
:LIQUID DEPTH 3~
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PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
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• Wisconsin Department of Commerce ~'p'-E J
Division of Safety and Buildings _
irssalr~(?Li34,1 ~Ra;~..,.
~~ ^ •
TI N REPORT Page of 3
Adm. i
~G OFFI ~~~
Attach complete site
lan on
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~e County ~ ~ • /~ ~,~ ~
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per no
ess than rT2Rt
k ze. Plan (~1W
.
include, twt not rmuted to: vertical and horizontal refen;r~ point (BM), direction and
percent slope, scale or dimensions, rrorthamow, and location and distance to nearest road. Paroe} 1.D.
G 12. -' / ~ 59 - ~ O ~ boo
Please print a/I inlrormation. Re ' p~
Personal hdomiation you Pr~~ may be used for secondary Purposes tPrivacy law. s. 15.04 (t) (m)). ~""~
Ptopertyt~lAin6r
De nn /' s S-f-oclol av~cl Pn~pertyL
5
Property Ownel's Mafling Address Govt Lot / /4 S 2.7 T 30 N R I~ E (or}
185 /3oT~ ,~~~- L.~ # Block #
- - Subd. Name or CSM#
State Zp Code Phone Nwnber
old wi n W 1 5~f oo
(?!5) 796~53i2
^ ~ o Vilage .}a'Town .Nearest Road
ERIN PR~R l~ __ 1 /36t" Apt:
tJse:~ Residential / Number of bedrooms 3 Code derived desi~ floor rate ~ 50 GPD
I~ Repiaverr-ent Q PubGe or commercial - Desaibe:
SANDY G V'/ WAS ~. Flood Plain a Y.
General Q0""ten~ Area "~ Spot Tested suitable for r~ ~ «A.2 0 , ~ ~/~
and ~~~~' a conventional in rounds tem P.o.W.T.S. ~ ~'~~-T•--
,~
~' C91 v~, nr.a~ ~ ~ 1n4.D~Q S
i ' [ ft_ na~f1, h, rv.nfav, h,•f.,r
Florizat
DepBt
i
Domir>artt _
Redarc
Texture - ~
Structure
Consistence `-
Boundary ~
Roots Sal Rate
GPD/t!r
n. Munsefl (hc. Sz. Cart. Color Gr. Sz Sh. 'Etf#1 'Etff/2
~ a -8
3 /o Yk 2l -- .~ r» 1 ~-Fr C tfF . (~ • 8
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(0 6 6.112 l U ~(~ 5/'f - S p, s ~.,,, ~ _ _ ,~ ~~
Q # 1 A Pit „~ Gro1 end ct ~rFara olov ~ ~~ ~~ a ~ ~ / i~
I'On Depth
in. DOrrrllnant
Mansell Redwc DeSt,~tl0n
Qu. Sz t :ont. Color
~ 6 -2- ~ l b ~'R ~~- -
2 26-35 yR'~f/ -
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Texture Structure Consistence Boundary Roots GP D/(t~
Gr. Sz Sh. 'Eff#1 'Etfif2
.~ / SFr- 5 v-~ . ~
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S 2m b k yh-f l' ~ S - . p
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gent #1 ° BOD ' 30 < 220 nglL and TSS >30 < 150 rrlgA. ' EiRuent #2 = < 30 rrglL TSS < ~ rngiL
CST Marne L8 l~T -
s ~'S99.3"S~
Evaluation Condl~ed Telephone Nunber
28/2 /vim ,~,,~ S~2r-Je7UA1.c_~, wl !O• /7-p5 ~7i5
~ 772-34}2
5 i TE /~>~"~TS /~ ~ /2~~oX ~D~S•
For issuance of permit signlnq ,
Contact; Ulbricht & A~ ''~ ~ ~ ~ ~ ~ -~_
Registered private w : ,consultant and plufnbera M GovL~ ~,~
2812 10th Ave. S ~ S ~, ~ v f- , , .
Spring Valley, WI 5471 ~o W G o/J~.S
715- - ~~~ M M~til,~j
Ulbricht & Associates $ ~ ~/~ ~~
M"~ ~ ~ Private Sewa a Consuita 5 f'~"'~~
~S•S~ da ~"~ 2812 10th Ave. ~ S y (~
f Spring Valley, WI 54767 ^ Ill s ~j ~ /~OG~
~- BI . CoM-~ ~P ~ ~t',w~ f
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S~-o ddard °', ~y i 2~o.s9-7o-cod Z
Property Owner Parcel tD # ~ Page of 3
3
# ~8 ~
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®pit Ground sruFaoe elev. q !r .93 ft. factor in.
Sod Rate
Horizon Depth Dominant Redox Description 7exlure Struc6rte Consistence Boundary Roots GP D/tf
in. MurrseQ Glu. Sz Cork. Color Gr. Sz Sh. •Eft#i •Eff#2
~ p "~'`~ l[, Yi22/2 "_' ~ 2 m bK ~~ r C ~ 3 v~
2- /~+ ~-5~ ~o +r'R y'/~ ~' s iC I 2 m bK f i C ~ v-f - ~{ . ~
3 ~~5 7 .sr~e `gym - S C 1 2 rh hK- -v-fl~ a 2v~f . ~
~ `~".~`t 1o he.5/~i S ~ s w- / a w I ~fi ."7 /~ (o
5 7`~- ~ UYR5l4• m 3 ~.SYR /~ 5 O s yv- ~ ~ -- - ~ ~ • ~
~ ~ -`I~ ~vrRS/~ - - s p s m ~ ~5 ~ •~ /•~
Boring #
^ Pit Ground surface etev. ft. Depth to rrtni6rg facts in.
Soil Rate
Horizon Depth Dortdnant Redox Description Texdxe Struc~ae Corrsisterxx3 Boundary Roots GP D/tf
in. MurrseH Qu. Sz Cord. Color Gr. Sz Sh. 'Eff#1 'Eft#2
~~ # ^ ~n9
^ Pit Ground surface elev. Depth ~ factor in.
Sod Rate
Horizon Depth Dominant Redox Desaiptim. Texture StrcxXrxe Cor~tence eorsxiary Roots GP DIfE
irr. MunseB Qu. Sz Cork. Gr. Sz Sh. •Eff#i 'Eff#2
Effluent #i = BODS > 30 < 220 mgi~ and TSS >30 < 150 mgll. • Effluerk #2 = BODS ~ 30 ntgR and TSS < 30 mglL
The Department of Commcrce is an equal opporttmity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 6U8-266-3151 or TTY 608-264-8777.
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art;IM~ Viewer Page 1 of 1
http://72.21.230.178/website/LRPortal/ARCIMS/MapFrame.asp?PIN= 12/14/2005
POWYS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~'
iFILE INFORMATION
Owner
Permlt # ~/_~'g' /~ 3
DESIGN PARAMETERS
Number of Bedrooms ^ NA
Number of Public Facility Units ANA
Estimated flow (average) 3 O p gal/day
Design flow (peak-, (Estimated x 1.5) ~ ~O gal/day
Soil Application Rate • Y al/da /ft2
Standard Influent/Effluent Quality Monthly average"
Fats, Oil & Grease (FOG) <_30 mg/L
Biochemical Oxygen Demand (BODS) 5220 mg/L ^ NA
Total Suspended Solids (TSS) 5150 mg/L
Pretreated Effluent Quality Monthly average
Biochemical Oxygen Demand (BOD5) 530 mg/L
Total Suspended Solids (TSS) _<30 mg/L ~NA
Fecal Coliform (geometric mean) 510° cfu/100m1
Maximum Effluent Particle Size Y8 in dia. ^ NA
Other: ~ NA
*Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity / 00 o al ^ NA
Septic Tank Manufacturer ~ ~,~,~, ^ NA
Effluent Filter Manufacturer ~~~ ^ NA
Effluent Filter Model ~ _ f d P ^ NA
Pump Tank Capacity ~ So al ^ NA
Pump Tank Manufacturer (,J ,~,,,~._, ^ NA
Pump Manufacturer Z o,-~Q~s-~- ^ NA
Pump Model (~ ^( cj 8 ^ NA
Pretreatment Unit 1~NA
^ Sand/Gravel Filter ^ Peat Filter
^ Mechanical Aeration ^ Wetland
^ Disinfection ^ Other:
Dispersal Cellls) ^ NA
~~ -~rQUnd (r vity)
$
t
' ^ In-Ground (pressurized)
^ Ato
Gr
a
d
e ~ ^ Mound
^ Drip-Line ^ Other:
Other: ^ NA
Other: ^ NA
Other: I
^ NA
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ^ monthls) (Maximum 3 years)
3 ®, ear(s) ^ NA
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ^ NA
Inspect dispersal cell(s) At least once every: ^monthls) (Maximum 3 years)
,?j yearls) ^ NA
Clean effluent filter At least once every: ^ month(s) ~
.3 ®year(s) rn a.a.. , ^ NA
Inspect pump, pump controls & alarm At least once every: t 1 month(s)
lS yearls) ^ NA
Flush laterals and pressure test At least once every: ^ month(s)
1$ year(s) ^ NA
Other:
At least once every: ^ month(s)
^yearls)
^ NA
Other:
^ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to 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 IY,1 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)
Page ~ of -
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals.
that may impede the treatment process and/or damage the dispersal cellls). If high concentrations are detected have the contents
of the tankls) 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 celllsl in one large dose, overloading the celllsl 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 following steps shall kie taken to insure that the system is
properly and safely abandoned in compliance with chapter 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 sod 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
evaluation must be performed to locate a suitable replacement area
may be installed as a last resort to replace the failed POWTS.
area. Upon failure of the POWTS a soil and site
If no replacement area is available a holding tank
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.
< <WARNING> >
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
IlucTe~ ~ GR
~.,...
Name
Phone •7 l 5 - ') `~ Q ' 3 3 IZ ~
~~nrwn_e c~evreuur~ naFRnTAR IPUMPERI
Name ~,~, S ~-.. $.w~~-P
Phone •-f [ S - 1 ~ ~ ' ~ ~ s a?
n ~~w,~,TA
CV YY 1 ~7 IYI/i
Name 11• ~ /'~~~~~.~
~~
Phone -I t S- 7 `t~- ~J~-~-
EGULATORY AUTHORITY
LOCAL R
Name
S-~•, ~,
Phone -7 [ 5 - 38 (c °^ S{ 8 O
This document was drafted in compliance with chapter Comm 83.22(2)Ibllt)(d-&If1 and 83.54111, 121 & (31, Wisconsin Administrative Code.
• ~ ~ . ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owne uyer _~~~~-~- 5 ~~~o~~-
Mailing Address % ~ -~'Y / ~ Q ~D, ~ tie- ,
Property Address
(Verification required from Planning Department for new construction) -
City/State I~ ~-~'~~ ~~ ~`~~'~- Pazcel Identification Number
~s o r 2 ~ /dloo -- oo - o-ao (. ~f /S~
LEGAL DESCRIPTION
Property Location S ~ '/4, ~ ~ '/,, Sec. ~ 7 . T,~,N-R ~ 7 `W, 'own of E~.-..,,. P~~ .
Subdivision ~~ • ~ t- Q~~ .Lot #
Certified Survey Map # '----~ ,Volume Page # ~-
-Heed # .Volume - .Page #
Spec house ^ yes ~• no I t 1' es identifiable ®, yes ^ no
SYSTEM MAINTENANCE ~-.- c~~' ~rw~ls,~ a ~ ~.~.~Q . ~Uo ~mc~e.. ~---
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. oper 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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, 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 Zoning Office within 30
of the three year expiration date.
~a~3~d~
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
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
e property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
~~~~- ~ l a ~ 3 ~ o~
SIGNATURE OF APPLICANT DATE
****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ******
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
ArcIMS Viewer Page 1 of 1
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