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Wisconsin Depa;ment of Commerce PRIVATE SEWAGE SYSTEM
Safefifand Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATT~aQ PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township
Vrieze, Robert and Laverne Jean Hammond Townshi
CST BM Elev: Insp. BM Elev: BM Description:
Ivo.ao ~Je~• ~ S~J~^ N W Car.ti~va..
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
lq-locl
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic ~vF.Ot ..~, ?~ f LZb t ~--~ ---
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Fri n Los System Head TDH Ft
Forcemain Len Di Dist. to well
County: St. Croix
Sanitary Permit No: 453366 0
State Plan ID No:
Parcel Tax No:
018-1028-70-000
Section/Town/Range/Map No:
13.29.17.2080
ELEVATION DATA
STATION BS HI FS ELEV.
Benchmark ~ / ~ ~
ivi.f ,~~
Alt. BM
Bldg. Sewer q,~ Z ~
SUHt Inlet
G.~f
~r y.2t
SdHt Outlet
~. Lo
4 3 . g`I
Dt Inlet
~'
Dt Bottom ~,,,
Header/Man.
Dist. Pipe ' E
G ~.~y S'
8.3~ 't Z.1 `{
1L.19
Bot. System
g.3'
~1.'S4
Final Grade ~~. ~~ Se.e ~~
St Cover f ;~
`~ N . $ t
;.ep a1 • '~
18.i~1
SOIL ABSORPTION SYSTEM ~j .~ 33 ~~
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS . Of Pit Inside Dia. Liquid Depth
DIMENSIONS 3 y~ • 3
SETBACK SYSTEM TO P/L BLDG WEL LAKE/STREAM LEACHING Manufacture />/~
`
INFORMATION CHAMBER OR !
~'- ?7
Type Of System: ~
~® ~
~„ (,O ,,,. •? S •
/~.~ /~ UNIT
Model Number.
DISTRIBUTION SYSTEM ~'' ~~` t < < ~-~its..~ c. L.
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to A~ Int~~e b s
~~
~-I Pipe(s) --- 7SV i n .all
Length Dia Length Dia Spacing
-J~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ___-
I ]Yes ~ No ~ ,,,
U Yes I ''~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: eC / /'~ /~ Inspection #2: / /
~rw~
Location: 910 Hwy 63 Baldwin, Wf 54002 (SE 1/4 SE 1/4 13 T29N R17W) NA Lot Parcel No: 13.29.17.2080
S~/~,, V~J w t' ~ ~` : w s .,-,l ..~ s A'f ~' 1 ~•. 1 *....v ..~- ''{ ..L t
1.) Alt BM Description = `(N ~ (~bs~-+'/c$ .o o ~~- ~-'~ fin, ~,o r-} -~ „~ „d (ya -{-~~,r, ~~
2.) Bldg sewer length = y?~ OCQ ~.~~ SG~ '-' °l~ a.~e.~. .~.~d. 9-tl.S t g~ ~c ui- ~g .
-amount of cover = 8'~ q bG~ ~.R ~ ~,(. (-L•2 ...-r, ~ xc~.i0.io r S~•~
9' /~-(2 A7Jx~(3~ 1 Sa.r.~~_/w~ Q rc s wat ~... Jas- b ~.r.cn ~ e rc.~. ~.rsn. o/!~
1 Jl7 ~J El G Y c..~ : Gl~~ ~(; 6 c,~ e/Z. [o ~..t S lr~..b~
_~ _
- a ~ _ - -- - ~ -_ -t . _..- ~ _,
Plan revision Required . Yes , No ~ i c-_/7,,~ - --- - - -~ ' ~ ~
- ,/~
Use other side for additional Informati ~ ~~~_T ~ ~""~ I_~-`~_____~I
SBD-6710 (R.3l97) Date Insepctor's Signature ~ Cert. No.
etv~~t' . v cs N c : ~ P--
Safety and Buildings Division County ~ ~~,
201 W. Washington Ave., P.O. Box 7162
`
nsin
i Madison, Wl 53707 - 7162 Sanitary Permit Number (to be filled in by Co )
seo ((i08)266~151
Department of Commerce
Sanitary Permit Application _ ~
ersonal information you provide
Adm
Code
21
Wis
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83
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may be used for secondary purposes Privacy Law, s15.04(1 Xm) roject Address (if different than ma ling address)
1. Application Information-Please Print AllInformati n pcP+~~r~~ ~]
~![...L. ~C~VYI Q.
Property Owner's Name
f
2e
V Parcel # Lot # 81ock #
'
Y
e
R a~ ~QV er»e.~eah (~ ~ 7, - CSC
.3 ~
Property Owner's Mailing Address
~,z~~X ~:~~~~~
:~ ~ Property Location
s~ ~3
63
qi o w .
_ _ y., '/+, Section
City, State
/ ~~ J
~ Zi Code
G~u ~{
~u ~
` circle
~
~ ~
1~/1 v`i rJ J / or
N; R l
T
II. Type of Building (check all that apply) ~ ~
~, t or 2 Family Dwelling - Number of Bedrooms
^ Public/Commercial -Describe Use
K e ~ /
^City_^Vil age Township of j
^ State Owned -Describe Use
III. Type of Pet~tttit: (Cbeck only one box on line A. Comp ete line S if applicab )
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 Plwnber 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 ^ ]R~~irculating Stand Filter ^ ,~
'PM
M
P
C~
~
p
4
p~,,} I
Y
Recirculating Synthetic Media Filter Leaching Chamber ^ D ip Line ^ Gravel-les Pipe Other (e lain) 1
V. Dis etsal/Treatment Area Information: Y
Design Flow (gpd) Desi n Soil A licatio sf) Di rsal Ar /wired (sf) Dispersal Area ro ed (sf) System ~E/Jl~evation
rJ D
~
'
,
(7 ~ , d , /„~Z G~?. r
45
VI. Tank Info Capacity in Number anufactur P fob ite Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank /DO/')
i
v ! Q SQi/'
Aerobic Treatment Unit /t-~ N~ [~
~
1 /~' n
b~" P~ ~~ O ! Qy~ Qr(~ h
!)osing Chamber 2 ~ ~
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
~ ~~~ A~tile~, ~Q~S~ M 68" ~ ~-20'9 ~ ~~ ~~
Plumber's Address (Street, City, State, Zip C e)
v f~ r 3~'~l l
~ X11
5 w
6 ~,~
Count /De artment Use I
VIII
.
roved
A roved
^ Disa Sanitary Permit Fee includes Groundwater Date Issued Issuing gent Signature No Stamps)
pp pp Surcharge Fee) ~ ~
~ O~
^ Owner Given Reason for Denial
_
IX. Conditions of Approval/Reasons for Disapproval 3~ ) 1 f ~~
~`CL\
~--fin `-~.i
SYSTEM OWNER:
d[
t
~ ~
-
' - t'~
1 Septic tank, effluent filter and ~^a-'-
dispersal cell must al{ be serviced / maintairlel! tyr ~ a.bav~~~ ~ ~ C_e+~Q_
as per management plan provided by plumb6lu ~-1
2. All setback requirements must be maintained /
as per applicable codelordinances. ~ - C~~.T1~s -
_ a-- a .. f f s-.
Attach complete plain (to the c:ounry omy/ ror me syarem u.r~cr o~. ~ ...... a.,... •.. -•-,•.
~~ \
~l
SBD-6398 (R. 01/03)
.~F ary~i)
~cat~er ~
~cfe~ r 5 `~g ~,
is ~e~~' Pig `sf~~"f dry iwe ~, . ~ove
c bgrd~ o~ k t~
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t~ol~.~ ~ s 9'8" D~
p .~ ~s n~~-~s~- ex fst~'~ dry uve l ~ . 1~~
~~ bore~e. ~ ~ ~~ ; ~ d„l1~ ~e..de~e+,-~,n,~1 ~'' s,''fie
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„~,~„~
Wisconsin Department of Commerce
Division of Safety and Buildings
SOIL EVALUATION REPORT page 1 of 3
in accordance with Comm 85, Wis. Adm. Code
^-~--...
Attach complete site plan on paper not less than 8 1/2 x 11 inches in siie. Plan must vvV ~~ ST • GZJ ~ X I
include, but not limited to: vertical and horizontal reference point (BMj, direction and parcel I
D
.
.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ~) ~ -) Q Z g . ~ Q - 000
Please print all information. ~~nz ~ / R sewed by Date
s ~~7 ^
Personal information
id
b
you prov
e may
e used for. secondary purposes P a Law, s. 15.04 (1) (m)).
Property Owner R Property Location
~``~~~Z-r ~ Z-~, - ~ j ~ 1/45 ~, 1/4 S ~ 3 T Zq N R ~~ E (o W
Property Owner's Mailing Address JUL 1 7 2002 Lot # Block # Subd. Name or CSM#
Gl. ~ O ~.v~ b 3 _ _ -
City State Zip Code Pg~n~~l(~bQOUNT ^ City ^ Village ®Town Nearest Road
^ New Construction Use: ~ Residential / Number of bedrooms 3 Code derived design flow rate ~_ S ~ GPD
Replacement ^ Public or commercial -Describe:
Parent material _ G ~C.11~'l.- ~ U~1ti/'R-S ~ Flood Plain elevation if.applicable 1.J ~ ft,
General comments
and recommendations: 2~-~~`~l V~ ~ ~ 3 C'~t(.S ~ ~ e~} 3 '~c ,S p ~ ~1v~vG ~l ~ ~ U h/ t ~ C) F
~ o 'r~vwi ~ ~ ems. ~S ~ 8 ~ ~4~T tZ. ~v . a ~ _ o ' .
a Boring # ^ Boring
^ Pit Ground Surface elev. q, ~- ~J ft. Depth to limiting factor 2 ~ ~ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
o -9 1~~j2 3 ! z - S t ! Z~s b k rnf~ cw Zv`F'- . s . ~
Z q _4 log ~- ~ 1 ~ _ s i ! Z~sb~ mom- c~.v - . S ~ ~
y~
9~0~ ~2.
.____--_
rQ 3.4 .~~
•~3
t./3
Boring # ^ Boring cc
® Pit Ground surface elev. ~ o- b ft. Depth to limiting factor ~ ~ O.3 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2
0-9' 1o~le.3~z - si l z~f~~~ ~~fr cam, zu~ •5 -g
Z °t -~ ! OK23~i, ~ sit z~ sb~ wj~H- ew - -s - ~
3 ~q-~~ ~.S~,~ly - s~ s,r. ~ s9 ~ ~ - _~ ~. z
q ~. 9z
O
- tmueni;<ci = t3UUs > 3l) < ZZO mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = BODS < 30 mglL and TSS < 30 mg/L
CST Name (Please Pnnt) Signa re O Z 1 I ~ CST Number
Arthur• L. tdegerer ., ~ ltd 220254
Address td e g e r e r S o i l Testing & Design S e r v i c e Date Evaluation Conducted Telephone Number
421 i1. P~iain St. River kalls, fJI 54022 -1 ~1'-O Z 715-425-0165
Property Owner V ~- ~ `, Z ~,
Page 2- of 3
Boring # ^ Boring ? ! D ~
® pit Ground surface elev. 6- 2 ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redoz Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-4 i~~~31~ - sit 2'{'sbk w,~r cw zv~ .s . ~
Z -S3 1D`1~z3~6 - ~)~ Z`{'Sbk m`~-~ ew -- •s •f~
-3 S3 -ID ~•S~1R3(y - S ~ 6t- CUs 1~ ~ - ..~1 ~- Z
~. rr+w X
8?. 90~? 2.5~
^ 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 Rools GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
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/ft~
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
'Effluent #1 =BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BdD6 < 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 (R.N00)
4
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SU 1.1 Pt`3 '~'E
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Scale 1' = 30'
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Page 3 of ~
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~~Q-bZ 715-425-0165 220254
c~z_!66
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CST Signature Date Telephone Ilo. CST Alo. Job PIO.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of v
FILE INFORMATION
Owner ~~.r V/'i~te..
Permit # ~ .~
DESIGN PARAMETERS
Number of Bedrooms ^ NA
Number of Public Facility Units A
Estimated flow (average) 3 d (~ al/day
Design flow (peak), (Estimated x 1.5) ~ SV al/da
Soil Application Rate ~ • ~ al/day/ft2
Standard Influent/Effluent Quality Monthly average*
Fats, Oil & Grease (FOG) 530 mg/L
Biochemical Oxygen Demand (BODE) _<220 mg/L ^ NA
Total Suspended Solids (TSS) 5150 mg/L
Pretreated Effluent Quality Monthly average
Biochemical Oxygen Demand (BOD51 530 mg/L
Total Suspended Solids ITSS) _<30 mglL ^ NA
Fecal Coliform (geometric mean) <_10° cfu/100m1
Maximum Effluent Particle Size Ya in dia. ^ NA
Other: ^ NA
*Values typical for domestic wastewater and septic tank effluent.
SYSTEM SPECIFICATIONS
Septic Tank Capacity ~~~00 al ^ NA
Septic Tank Manufacturer war ~- ^ NA
Effluent Filter Manufacturer ~,~. ~ ^ NA
Effluent Filter Model ~ [,~ Q ~ ^ NA
Pump Tank Capacity N~ al ^ NA
Pump Tank Manufacturer iN ^ NA
Pump Manufacturer N ^ NA
Pump Model ^ NA
Pretreatment Unit
^ SandlGravel Filter
^ Mechanical Aeration
^ Disinfection
^ Peat Filter
^ Wetland
^ Other: ~NA
Dispersal Cellls)
'~In-Ground (gravity)
^ At-Grade
^ Drip-Line ^ NA
^ In-Ground (pressurized)
^ Mound
^ Other:
Other: ^ NA
Other: ^ NA
Other: ^ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
~
nspect condition of tankls-
At least once every: ^ monthls) (Maximum 3 years)
earls) ^ NA
Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA
Inspect dispersal cellls) At least once every: ^monthls) (Maximum 3 ears)
3 i3 year(s) y C] NA
Clean effluent filter At least once every: , ~ `~'monthlsl
[~ year(s) ^ NA
(nspect pump, pump controls & alarm
At least once every: ^ month(s)
~ ^ yearls) ^ NA
Flush laterals and pressure test At least once every: ~ ~}' ~ yea~~sjlsl ^ NA
Other: At least once every: ^ month(s)
^ year(s) ^ 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 tankls) 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 cellls) 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 IY3) 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 14/01)
Page ~f
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 dispbrsat cdfl(s1. 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 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 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 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.
< <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 IMPrrOSSIBLE. L~ ~ /~,~ ~-f j ,~,J
ADDITIONAL COMMENTS rD~y sYSd~e-~, naS ~ ~6-beI ~iI11/f' l~-~ae~ ~ !O~ JhS~~~`~
Sh „~,., ~ ~nl-~~ ~1~ . ~t1.,~~ ~ ~ ~v he~c np~c'a~ ~c clect~c~ ~ C~;11 ohe o,f- ~t
POWTS INSTALLER
Name ~JG?~ ~ ~
Phone ~ (,
POWTS MAINTAINER
Name ~ ~ ~ rS tn1 ofN~t}No
Phone ~~" ~-7 "S ~ U
SEPTAGE SERVICING OPERATOR (PUMPER)
Name ~~/`10n . ~i Jr f{
Phone ~ - ~ ~7
LOCAL REGULATORY AUTHORITY
Name ~• CRO/X 6UlV ~N/N
Phone ~~~• , ~~
This document was drafted in compliance with chapter Comm 83.22(2)(b)(t)(d-&(f) and 83.54ft), (2- & f3), Wisconsin Administrative Code.
^ 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.
N~,v~ Far' Svv'e
OwnerBuyer
Mailing Address
ST CROIX COUNTY ~
SEPTIC TANK MAINTENANCE AGREEMENT ~
s
AND
OWNERSHIP CER'T1~ICATION FORM ".;
(~ C
1~ i~' 1 (~®Z C ~
~10 Hw
Property Address i I l.d ~ I W
(Verification requCi.~red from Planning Department for new construction)
City/State ~~~~~~ n "~' ~~ ~~ t®~ Parcel Identification Numb ° e
LEGAL DESCRIPTION Q f u
Property Location ~ ~ %4, ~ ~ '/4, Sec. ~ ~ . T ~ r N-R ! ~ W, Town of f I a ~1
Subdivision .Lot #
Certified Survey Map # ~- _ , Volume `-~ . Page # ~`'~ I ~ ~ y
Warranty Deed # ~ ~ Q ~ ~ ~ ,Volume -r J Page # °~ 7
Spec house ^ yes ^ nit
Lot lines identifiable ^ yes f~ no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeymanplumber, restrictedplumber or a licensedpumper verifjringthat (1) the on-site wastewaterdisposal 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.
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
days of the three year expiration date.
IGNATURE OF APP ICANT 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
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE O APPLIC DATE
*****«
**«*** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department.
** Include with this application: s stamped warranty deed fiom the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
~Q'JiT Gl AiM DEEC
Robert Vrieze and Laverne Jean Vrieze, husband
and wife
:,.-.. Robert Vrieze and Laverne Jean Vrieze,
husband and wife. holding as survivorship
marital property
_~ ,., _~, ;~ St. Croix. f ,~r~ ~~.
. ~ .. U+ a
REGISTER'S OFFICE
ST. CROIX CO., Wi
Recd for Record
~naPi t 19~?z
of g: YS Q. M
~, a ~.
a~~~-„ of o~,.d,
C~,~ :,,~
Br=ginning Eourty-eight (~!8) Rods North (N) of Southeast (SE)
corner of Section Number Thirteen (13) in Township Number Twenty-nine
(29) North, of Range [Number Seventeen (17) West, thence ~Tor':.h Thirty-two
(32) Rods; Thence blest Thirty (30) Rods; Thence South Thirty-tiro (32)
Rods; Thence East. Thirty (30) Rods to the Place of Be?inning.
EXCE?T those parcels described in Volume 314, page 199, Document No. 251649,
Volume 344, page 201, Document Vo. 251650, and Volume 345, page 179,
Document No. 252705, in the office of the Register of Deeds for St. Croix,
County, b4isconsin.
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Robert `frieze
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La~Jer•ne Jean Ur•ie~e
St. Croix
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® Farm R Hernc Publishcn, Ltd. $T. CROLK COUNTY', WLSCON.~W ~ +~~~
See Pages 135-14U For Additional Names. (Residents -Owner or Renter)
ERIN PRAIRIE PAGE 53 +.2p.h n.VE ~ $
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oCth ^,b'E 60ih A`JE RUSH RIVER PAGE 21
PLEASANT VALLEY PAGE 21
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