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HomeMy WebLinkAbout040-1213-60-000 c (D o0 0 M y ~ C O tl h ~ O N b O d li r CO M X 60 60 O Y C f0 (n O y O z 7 c LL 07 3 0 O -0 O Q 0 M ~ N z y m d a c 0 t02 c t m z p v y o fA 1- j IF m Z C E -a I a ~ M N 7 C (0 N (n C, Of U) N L CO Q z m z w z N ° C -?5 ~1 Q m E y % m U i O d~ m o m O N m N y O G O a c (D U) U) E 0 caaa z OVA f0 y y IL r2 7 O O y N } Q J U 2 rn IM M C5 10 O N O N N C O E 0 m co C 'o (n ) N ~ sT 'O m Q <A m o 0 o H c Q RS 9 N 06 d j N (D M r O N O C V O O O Oi 'o O C O :2 C 'O N N C M aj m p N C O O 4..i ~ H2 r G- y U M N A P f~ N ly N OD .rM d C N r E co O w N O Z C (n 0) w IL O r , EL L: a r~ 3 7 FORM - STC J\ 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION_y_T 2 N-R icy W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION X to LOT /p LOT SIZE x/A PLAN VIEW SHOW EVERYTHING WITHIN 10 ET OF TEM fd P,Qoo4a 7y fl~~J inks ~ \ Li fd' kJ~~ s~ 'r- C,, T-, C4c'f.vc2ur Cc SC iti '/O Gr f_ (J inJl ~ori ~N 5 Acs rim/ l ~ 3/QiCNtf ~E U c 4,PK - T P - T~ SEtPric Tiw O~ FPNvN~ p~D. / SO'r 3S EFFUticc,T vE -T JE~r a/,rK .o a6 sc..yo .sr 36. ~~T .ccr fnJLST ~ 'Q7 - Svu-rM Fi15 r t P,,wr~y piPoPr,{ry/tip L...vE SourH 9°Pci /Ty(iNf Al, SC f4d INDICATE NORTH ARROW - BENCHMARK: Elevation and description: ~p Alternate benchmark AIA SEPTIC TANK: Manufacturer:_LJ,~sE,P Liquid Cap. /oooe-- Rings used:_2_Manhole cover elev:io Final grade elev: /o<l,Aso Tank inlet elev.:22Q.03 Tank outlet elev.: No. of feet from nearest road:Front ~ Side , Rear Ft. O 3' From nearest prop. line:Front side ✓Rear Ft. a, No. of feet from: Well_ I3' Building: is" (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE i PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed : Et,cy. fa.9o' Trench : Seepage Pit: Width: ifd " Length 36 " Number of Lines: 3 Area Built/ ~.Fr Exist. Grade Elev._ /O/- yo " Proposed Final Grade Elev. /00, 5/o" Fill depth to top of pipe: S-11/' No. feet from nearest prop. line:Front ✓ Side Rear Ft.ioo- No. feet from well:) 3' No. feet from building 4S" HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: i No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE : / i PLUMBER ON JOB: LICENSE NUMBER: ~(.~1J~s 3395" 6/ 9 0: c j ~~fPPA ~~vs --tic DEPARTMENT QF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. f3OX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SE, NW , 8 , 28 , 19W R2 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town Troy Re _ Holding Tank ❑ In-Ground Pressure ❑ Mound A 'R -e- i t, 1r T.n f- 1W A qM6 ;)q (a N M L ER: ADDRESS OF PERMIT HOLDER: INSPECTIO DA E: ®-76 Bob & Joyce Emery 490 A Praire Lane,Hudson, WI 5401.6 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: i Zappa Bros.(Mark Statnk ) 3395 St. Croix 128807 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: I ' + (t i.' ca AYES ❑ NO ❑ YES ❑'NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: El YES ©NO El YES El NO NEAREST C" DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: MP/SIPHON MANUFACTURER: WARNING LABEL LOCKNG COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONT OP R IONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ ES NO NEAREST -10- 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, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIP MATERIAL: NO. D STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPE FEET FROM LINE: AIR INLET: L NEAREST I 100 ~_3 C 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 ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: RVATION WELLS; [__1 YES [__1 NO OBSE E:1 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: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL] NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: ER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO COV ❑ YES ❑ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for dit. _71 Reverse Side. SIGNAT RE: TITLE: A rM491riCrator SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION COUN TOILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /a 6Q~ 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 ,&d ' Jp ?5,A E y :5Z Y. Ic/I~/S 'F Taf , N, R 19 E (oK9) PROPERTY OWNER'S MAILING ADDRESS LOT # aft BLOCK # Llln/ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Y, ",oso/j W / S a., t_o ~T>c K Ao& II. TYPE OF BUILDING: (Check one) ❑ State Owned E:I VILLLLAGE : NEAREST ROAD _7;~dy C< di OWN ❑ Public E91 or 2 Fam. Dwellin of bedrooms-? PA ELTAX NU E III. BUILDING USE: (If building type is public, check all that apply) /v 9 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 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 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1 s~ ; /asst Fr ism„ . e,- 9 3 5G • 90 Feet 00.3 © Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed -1 R Septic Tank or Holdin Tank T /ovv >E a Lift Pump Tank/Si hon Chamber El I El I El I El VIII. 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 ' natu e: (No Stamps) MP/MPRSW No.: Business Phone Number: - 77 Plumber's Address (Street, City, State, Zip Co e): .57- /`pct /J S e7~ Sol C~(o IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issued issuing Agent Signature (No Stamps) urcharge Fee) fo - S' f G ` VR-Approved El Owner Given initial / Adverse Determination / IL 741 3. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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 6r the. State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. 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 if tanks received experimental product approval from DILHR. VIII. 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 115 form; and F) all sizing information. - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) ~nvCT~ GJesT PLO 57 ~ipoP6~?~ PLOT & CROSS SECTION PLANS q. ZAPPA BROS. EXCAVATING INC PLUMBING UNIT PROJECT 0~6 NEW 00-As ..141 5 CS ?~Peisao ~(~oQ ~o~ ~Md ~E•ucHM~{,r ~P oG \ wEc~ CA ic.C o0 t.OGST~L \ -o L~~CV /c°Jt9 ' ° sc' y -mss ~ 5T C'.e~.~ Cou.vTV C At Iooo CAt S<PTic ~i4.vK wrri! /o' ~T I7 Dr C_T A'r '~N~GT C- C~f~T~CT ANA \ ` G' ~ C.1 • C'.CciE•vvu , s'n.s//7cccricw a..-~ A -A .r'6 ~1 S fl~ 3 S 303,/ pvL ~~s T c~ L.fT'~ DID So.~aE,4sr ~F%uca.✓r/N~ l~l P.e v A ~ E NO scJµTN ~aPoDd.('TY~ivC SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL GRADE I 'r 7 7 -F Z= 0,7 7777 7 in 4' CAST IRON VENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE SIGNED: MARSH HAY OR SYNTHETIC COVERING LICENSE: ~ 5 33 9'S MINIMUM 2' AGGREGATE DATE: J OVER PIPE DISTRIBUTION PIPE ~r TEE SOIL T STING BY: vd 5~ ELEVATION BED W AGGREGATE BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW TESTIS COUPLING TERMINATING 90 FT, AT BOTTOM OF SYSTEM 1 W ~ n too ~ ~ ,o 0 .n r n n y 0 Z 1 b n z r 2 n Cn v n \ REc `T cy -31.568 7t AS • '3 g ?~e. ~s' 342.02 12. 169,379 SO. FT. ' 3.89 ACRES . So~D . M t~ '7 o M 115,073 SO• : FT. -2.64 ACRES 87.702 SQ, FT. (SEE DETAIL B LOW 2.01 ACRES e - TO BE REMOVED UPON ODD EXTENSION. so . ` p T _ +YO 3 262.91' _ 2".OQ' • r ' \ \ 1 kl 61190200e W R3o.91 *Y it a! It 1 r ~j :A Igo, 79' P , .r s O 2 013 .SQ. FT. r~ ,,4rM 3 'ACRES a 87,139 SQ. FT. 2.00 ACRES. 4 223.00' il► b .UQI#IT DRI~ItaAIA►N , 1 t t lit 10 9e, Q0.S' SQ. FT.. ,h a N ~~g a F4 2.26 ACRES • B7. 170 SQ: FT . , 2.00 ACRES, 07, 075 SQ. FT. { a 2 01 • . J1CRES y - 'S O CID 5 p L,1~ 842.68' ,•,z. t' 1a4,>iS` - - 380.00' - 2, 7.73'.. N880 37'41* E $60.09•' 801JTH SINE OF THE' SE i/'4 O THE NW • 1/4" ' OF SECTION d. UNPLATTEQ _ - !-ANDS ~ , . AMATTER OF PERSONAL TASTE , 5; t r ..MnY~F wI n.:LM.74v : MODEL TS15-1 F~t i y la l l ]41CHMOND ~CICCCCC❑ Shown with optional fire e.) ~CICCOCC❑ C1CICCICIC s • t ✓ s! DEVONSHIRE (Shown with optional fireplace. x .r r so t M .k w I r 1 i~ t 3 L 4 ' 1 M OAKWOOD '"^n Syr, mom- al~wa~ - Illustrations and floor plans are artist's conceptions of typical homes and do not necessarily represent final plans, designs and elevations. Final plans approved by ® W'wkHomes- "a""" dealer and home buyer take precedence over artwork and may differ from artwork. ApladuClolV Gt8U1&VSYM. .ft T -J JITTJ TT- _`1 i . ii ! wv _LLLL -do 1 7 7 U - - - i i N I , it At). i i 7 16 i 3 S , 'i i i i i a r`- F i t~ N ~ N NMI- - mm A F I I 'Y ~ r i i _ t w ww QWo Z ❑ ono. UJI Q oZw -T i - UHU U) C/) Q 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR ANb PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS ` MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: E TION: L R~ TOWNS H I P/MUhI1jMkALAX*: OT NO.:BLK NO.: Slj8DIV1 ION NAM G 1 V4 /T fti/•Y , or T1~JE~ l/PIC COUNTY: pp MAIL N ADDRESS: `~-TCPo >k Dag-CBoyd: Er^t e0t USE DATES OBSERVATIONS MADE NO. B C L TION: STS Residence (AtiX , New ❑Replace I i. p pP. 9 /996 4 90 SOtt8 K 74 ~t QL/RKr1gR.A i r. RATING: S- Site suitable for system U- Site unsuitable for system L5 S, A- PI 'A' r^ j LL,UT CON ENTI NAL: MOU : IN•GRO ND -IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) 91S ou 1s out s ou M s ou DS Zdu co~~ ; ro.,>a . & t If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: C t_rQS,T Floodplain, indicate Floodplain elevation: rY La:LY-r PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 4th ELEVATION OBSERVED EST. TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B ' '6.66 $Z 46 N~ a, /0', 4-scis Rol&AS( /TS`*&e..r -S4(,r~ o„ T $ /t1S 6" B- /0•S6 /02.27 4141-4 ra: > /&So ' SL-TS -84Srt9'tit4t. h* CS46t a n1' B- 3 /cal , U9.3 n~o,~ > d~ r9'8c~c 2'' S[ ~s'geN $ CayeLE SL ~Qst"/at~ ~O~L~;'n~ S B- 4 9,Sa 99.)0 rJot~ > 9. SO 19"LL-M /4'&#4L '9364L440 71'SeN Cst G- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER IhtCkMS AFTERS WELLING -INTERVAL-MIN. p I t p I PER INCH P. I s.6o K0 C o 3 > > > .c P. z 5.30 101. 10 3 > Z > Z! > c P. 3 .30 Aowc .2o >1- > < P• P• 10 10Z Q 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. 46.Qy 1"to'r ~AN oN p~J~r25~' , 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 1 rint TESTS WERE COMPLETED ON: /~~4£ycty ~ON&(SOkj .~o u r5o►V Sc,k YINN4 /NC APRIL. II /990 ADDRESS' 4 4 CERTIFICATION NUMBER: IPHQNE NUMBER(opiional) 07 'S Ec.CA.,k s 1/0 dso0. 540! ( ~ % ;58&- Adso CST SIG RE: DISTRIBUTION: Ongmat and one copy to Local Authority. Property Owner and Soil Tester. )ILHR-SBDb395 (R. 10/83) - OVER - r ~~oa~3 a aaa~w , • I ~ ♦ III \ I \ it S-8 \ - OS °zd ♦ d~~a I ,oS ~ .d ns o l Ael .00' 001 rt0' LVTr•~ '►~►1S9D~ ,rvoNda~1 ~ dol'7i~~W1+,N~o Q~~ddlel .yam 10 if <r5 r,{ r l •t R 1~ ~Z 1 ~ k ry' sc*; N SEPTIC TANK MAINTENANCE AGREEMENT St. Croix Countyr n OWNER/BUYER n} x ~~o ycIL~T..- 0 --7- yr7 p ROUTE/BOX NUMBER Fire number_ d CITY/STATE ZIP y15'911)J1 PROPERTY LOCATION:'. Li k,,t i Section T,P-e N, R, W~ Town of Zn V St. Croix County, ~Q_• Subdivision _ Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes.--Proper maintenance con- sists of pumping out the septic tank every three years put sooner, if needed, by a l'ic'en's'ed' 's'ept'ic tank pumper. What Y the system can a ect e' unct on o, the septic tank as a treat- ment-stage in the waste disposal system. • St. Croix Countyy residents'maX'be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, wh c 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 's't'ems 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 g mater plumber, veri- journeyman plumber, restricted plumber or..a license pumper fying that (1) the on-site wastewater disposal system is in proper operating condition and •(2)•after inspection and pumping (if nec- essary), the septic-.tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year'expiration, y 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- :r w ment of Natural Resources. Certification form must be completed •d and returned to the St. Croix Count oning Office within 30 days of the three year expiration date. SIGNED DATE ' 2 6 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. I APPLICATION FOR SANITARY PERMIT ETC - 100 This application form 1s to be completed wlllsonlydtesultein delays of the property being developed. Y 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 o\b c- SL 1/4 . UD /4, Section T- Location of property Township ZIA (r C~ ~Y U m IY~i~ %1 -5 7 U /l Mailing address Address of site ~'r ri C C r-~E- Subdivision name 9r; c K /}n(c~ Let number o Previous owner of property Total also of parcel Date parcel was created # R. aR' ? /d i'P Z - Are all corners and lot lines Identifiable? -I._Yen o is this property being developed lot resale toper house)? as X o Volume 3 and Page Number 28 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DECO which Includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and the ORAL OF THR RBGISTBR OF DRRDS. In addition, a certified survey, if avallable, would be helpful so as to avoid delays of the reviewing process. if the deed descclptlon references to a Cestlfled Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(Vs) certify that all statements on this form are true to the best of my (out) knowledge; that I (we) am (ate) the ownet(s) of the property described In this information form, by virtue of a warren ~Y deed recorded in the Office of the County Register of Deeds as Document No. -f~5 p~ 6D • ; and that I (We) Presently own the proposed alto for the sewage disposal system tot I (we) have ob ed an ement, to run with the above described property, for the E s Id system, and the same has been duly recorded in the office as Document No. - of y tar ads, co wou llgnstute of Owner 114na of C Owner (If Applicable) -1 . Date of Signature to 61 Signature