Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
018-1029-00-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO 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 Stadt, Wilma Hammond, Town of CST BM Elev: Insp. BM Elev: BM Description: o~ ~ -M 1 GS t TANK INFORMATION TYPE Cx: ~ MAN4FACTURER •~ l.Jee~k.~ CAP CITY oao Septic J~t O~ dC ~~5~ Dosing ++ D~wb e 75D Holding TANK SETBACK, INFORMATION TANK TO P/L WELL BLDG Vent to Air Intake ~ ROAD S d J7~- Septic ~r / W / C~ l0 ( / /z ~ / Z _ Dosing ! ,L / ~~ / Aeration Holding ~~I-.u wrl~u 1-vlnr/.alrl Ivn u.l vlvn.-.. • Manufacturer ` Zp+vl~ ~Jl..~ Demand GPM Model Number 2 A 1 I~ ~ ?.~ TDH LifFF~ •~~ Friction3~s System ~a~ /}-- TDH 9 z~t Forcemain Lengttyb Dial ~ ~ Dist. to well ` ELEVATION DATA county: St. Croix Sanitary Permit No: 506363 0 State Plan ID No Parcel Tax No. 018-1029-00-000 Section/Town/Range/Map No: 13.29.17.208E STATION BS HI FS ELEV. Benchmark Z •7 fat ~7 / 6a '~ gc~Q''~ ° ~ Y~` ~D,7 ~Z Bldg. Sewer z ~m~ a ~- 6.35 9'lv - 37 SbHt Inlet /~ I~J3 ~/ ~ ~ 9, SUHt Outlet ~ ~ Dt Inlet ~ Dt Bottom / ~ ~~ D b ~ S$ Header/Man. 7.~ ~S~ ~~ Dist. Pipe 71 ~ / 7 y 5 • ~-~ Bot System cam Final Grade ~/ S p ejg'• St co~« z.yz q y. ~ o., i ~ • b5 9'S~• a7 .~--• 8 , b 9 , a7 ~( ~ SI~sS ~ 3z SOIL ABSORPTION SYSTEM BEDITRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia _ Liquid Depth ` UIMENSIONS ~ '~ Z, '{ 1 TQ,t~ ~_ _ ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: / .t ~~1-1 INFORMATION Type Of System: ! / I I' ~ r A' .L~ J /' UNIT ; ~ ~, Model Number: D ti J P ,~e~- n G 22 ~ /~/ ~ om . . a I ~ a nIG•TO1Q11T1llAt CVCTC1111 / 11 1 a, .r .....~.~~ .~._ ... _ Header/Manifold ! / _._. ol/r~.. Distribution Pi e(s) x Hole Size x Hole Spacing Vey to Air Intake •J ~,( Length ~ ~ Dia -" p ` Length \ Dia ~ Spacing "i ` G.~~~..~-~ L+l111 /~/1\/CD .. ~e.......a n. n•_(]r~rln Cvc4nmc l7nly Depth Over I 1 Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center"•',". ~ • ~ ~ Bed/Trench Edges ~~ Topsoil ~ es No Yes No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1 Location: 920 Hwy 63 B~{wi 1540p2 (vE~ 1~/4 SE 1/4 13 T29N R; 7~~1A Lot „j„ Coo ~"5 a'~- 1.) Alt BM Description = , 2.) Bldg sewer length = ']d '~'+- Z bGdL(oer„`, y Ca1J-t,`, Omni in+ of nnvor o / / Inspection #2: / Parcel No: 13.29.17.208E ca ~ ( ~ ~~ . Safety and Buildings Division Coun ~ ~~~ " , m m ` 201 W. Washington Ave., P.O. Box 7162 O / j ~ ~ ~~~~ ,~ Madison, WI 53707 - 7 ni ermit Number (to be filled in by Co.) De artment of Co ~erce (608) 266-3151 SO ~p 3 ~p Sanitary Permit Application ~ ' State Plan I.D. Numbe /• In accord with Comm 83.2], Wis. Adm. Code, personal informs • ~ may be used for secondary purposes Privacy Law, s l 5. (1)(m) R E C E I V E U Proj ct Address (if different than mailing address) ~ 9 ~~ I lication Information -Please Print All Information A . pp ~ - ~ 2007 o ~oo~ Property Owner's Name / Parc I # A Lot # Bloc~~ /' / / j'f COUNT Li~$ Property Owner's Mailing Address io n Pro Locat ® ~ ~ ~ . Section / ` ~~ City, State Zip Code Phone Number . ~~ • ti ~ ~ (circle N ~E , II. Type o Building (check al that apply) / t.~ 3 , ~, p ~1 or 2 Family Dwelling -Number of $edrooms Subdivision Name CSM Number ~ ~ ~ ^ Public/Commercial -Describe Use Z. i ti O~nt~ _ ^ State Owned- Describe Use ` ^City_^Village wnship of a vY1 6 i! III. T ype of Permit: (Check only one box on line A. Co plete line B if applicable) `4' ^ New System Re lacement S tem p ys ^ Treatment/Holding 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 lti~t'I k~d-~ ~,'~..~i IV. T e of POWTS S stem: Check all that a 1 ~Q(Ion -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in, of suitable soil ^ At-Grade ^ Single Pass Sand Fitter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Send Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersaUTreatment Area Information: _ [~_ Design Flo~~d) Design Soil Application Rat~pdsf) Disperse j~red (sf) Dispersa~ ~~s ~ tem Elevation VI. Tank Info Capacity in Gallons Total Gallons Number of Units Manufactu (, J 1 Q ~ l ~ Prefab Concrete Site Constructed Steel Fiber Glass Plastic New Existing ~ v Tanks Tanks ~ ,~ C! Septi olding Tank , ~D - Aerobic Treatment Unit ~ ®~ ~ ~~1 osing C tuber ~ ~ ~ VII. Responsibility Statement- [, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' afore ~ MP/MPRS Number Business Phone Number f P s Address (Street, ity, State, Zip C ~ 6-`~- ~ P s^ ~ ~ `f6o VIII. Coun /De artment Use Onl proved ~ Sanitary Permit Fee (includes Groundwater Date I ued Issuing A Signature o ps Surcharge F ~ /~a ~ ~ ~ ' ~O g 0 Own tven for Denial !J j 1X. Conditions o pprovaUReasons Disapproval \ Q` n s ~s ~ 1 r 3 J a ~Q„~ ~itp a ~ 811ttTEM OWNER: 1. Septic tank,. effluent finer and ~ Gp ~~ I ~ dispersal cell must alf 4e services // main as per management plan provided by plumber. ~ Q'g, ^ 1 o Z 2 All sertback requirements must be maintained ~ J ~~~ ~ - /~ - ~ ~ s ae per applicabe cede / txdinaatxs. ~ ~ a t'.e. Attach complete plans (to the County only} for the system on paper not less than 8112 x 11 inches in size SBD-6398 (R. 01/03) S, Y~~w~~~ ~ ~ ~~~ ~ ~ `~. ~~ ~b fw~.. 6-~t s ~j d,..~ ~~ its ~-o ~. _J / W ~t~co,n ne ~~ . PLOT PLAN PROJECT Wilma VanSomeren ADDRESS 920 Hv 63 Baldwin W_ 54002 SE 1/4 SE 1/4S 13 /T 29 N/R 17 W TOWN Hamond COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 10-05-07 BEDROOM 3 DATE CONVENTIONAL rade CONVENTIONAL LIFT XXX BOLDING TANK MOUND SEPTIC TANK SIZE 2250 gal LIFT TANK SIZE750 DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .7 ABSORPTION AREA 1071 # of chambers 54 ,BENCHMARK V.R.P. Base of siding ASSUME ELEVATION 100' ^ BOREHOLE O WELL *g,R,p, Same aS BM Vent SYSTEM ELEVATION T-1=94 2 T-2=94.1 T-3=94.0 > 12" of Infiltrator Quick 4 Cove 20 ft^2 per chamber 6" Long 34" Ele atio Hyway 63 Driveway ~ Bed house Bed House 10' ~' B 45' 12' 1 Shared Well ((~~ t 70 t [Cec~,l- ~ S ~ yPtr/ PL a. ~ Z - be~C '~ Failed Septic /a oa 5 ~, ((o.~ to be pumped & filled ~. ~ ~5~• ~ ~ ed ~-- ~ ~ ~~ , sa P~~~~ 20, PL t,J; c ~ ~a~ 3 B Io' 20' ,~~s 7 72' ' 9s' 97.5 8U' D PLOT PLAN PROJECT Wilma VanSomeren ADDRESS 920 Hv 63 Baldwin Wi. 54002 SE iia SE leas 13 ~T 29 N1R 17 w TowN Hamond couNTY ST. CROIX F MPRS Byron Bird Jr. 220527 DATE 10-05-07 BEDROOM 3 CONVENTIONAL rade CONVENTIONAL LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 2250 gal LIFT TANK SIZE750 DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .7 ABSORPTION AREA 1071 # of chambers 54 ,BENCHMARK v.R.P. Base of siding ASSUME ELEVATION 100° ^ BOREHOLE O WELL ~g,g,p, Same as BM Vent SYSTEM ELEVATION T-1=94.2 T-2=94.1 T-3=94.0 > 12" of Infiltrator Quick 4 Cove 20 ft^2 per chamber 6" Long 34" Ele atio Hyway 63 Driveway 3 Bed house Shared Well 10' ~ ~ ~~ 1 e.4,l.C~ ~ S R ` PL et. v Z - ~ie~C ' /b©d 5n,~(o.~ _ so P ~~~.~--~. t,J ~ << 30' ~ar 3 F ~~s~7 72' 45' 70' 45' shed PL 20' 10' 20' 1' 98' 97.5 House Failed Septic to be pumped & filled 80' a ~..,~,,,~~ Wisconsin Department of Commerce SOIL EVALUATION REPORT page of Division of Safety and Buildings 11~ wVW14w114~i YYllll VVI11111 VJ, •11h1. 114111. VW~i -- County ~ G `t p ~ Attach complete site plan on paper not less than 81/2 x 11 inches in size Plan must ~ . include, but not limited to: vertical and horizontal reference point (BM), direction and t l l di i rth Parcel I.D. 2~ `O "' L~ ~ ~ percen s ope, sca e or mens ons, no arrow, and location apd distance to nearest road. 0 ~lease print all information ?~~ ' y ~02~ Ravi by Date . ~ v~?S~ m @ Personal Information you provide may bs used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). e~ ~~ / ~ Property Owner ~ ` ~ Property Location / ~ [~ ~ Govt. Lot ~~ 1/4 1/4 T N R E (o Property O w ner's Mailing Address Lot # Block # Subd. Name or CSM# i ~% C' / ` Sta Zip ode Phone Number. ^ City ^ Village Tow Nearest Road / ^ New Construction Use~Residential / Number of bedrooms ~ Code derived'design flow rate C~• GPD Replacement ^ Public or commercial - scri Parent material ~ Flo~~('y~r+~~~ppiica le _ T/g~ tt. General oomrner~ and recommendations: ~ ~` °' ~ = q~- Z 0 C T 0 5 20 0 7 ~ ~~ -~~ ° r- t j ~ y`~ - Q ST. CROIX COUNTY ~ Boring ~ . .~ Bort # ng ^ pi( Ground surface elev. o'~ tt. Depth to limiting factor "~Y ;~ in. ~ Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ''Eff#1 *Eff#2 / _ ,y ~ ~ ~-~~ s ' u~ / Gr ~ /. ~ / •• -. ~t Boring # 3[~ Boring ^ pit Ground surface elev. ~~~ft. Depth to limiting factor ~ ~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *Eff#2 ~ ~ ~ ~ ~= u f ~' ~ ,~ * Effluent #1 =BOO > 30 < 220 mglL and TSS >30 < 150 mglL * Effluent #2 = BOD < 30 mglL and TSS < 30 mglL CST Name Print) ~, ~ ~- ~ Signature ~ ,~~ ~ n __CST Numb 7 f.rln fl'1'1!I !a\M Mf~\ /~ f i Property Owner /~/ ~ t ~~GcY/ ~/d ~f'~~H Parcel ID # Page of ®Boring #Boring ~~ ^ Pit Ground surface elev. _ ~ ft. Depth to limiting factor _'~+ T~ in. Soil lication Rate Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/iF in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. "Eff#1 *Eff#2 /~ ~ ~ %7 e ~ G/ R t ~ V f. '~ ^ Boring 1 Boring # ^ Pit Ground surface elev. ft: Depth to limting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. "Eff#1 •Eff#2 ^ Boring Boring # ..Ground surface elev. ft. Depth'to limiting fi3ctor in. ^ Pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 • Effluent #1 =GODS > 30 < 220 mglL and TSS >30 < 150 mglL • Effluent #2 =GODS < 30 mglL 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 (RO'iN0) . _. ._ -~. J :~ Property Owner _ /i(/ r ~j~ ~~ic,Y/' ~•~"'~f'-~`~ Parcel ID # -- _- - - _ - Page of i ®Boring #Boring ~~ ^ pit Ground surface elev. _ ~ ff. Depth to limiting factor ~~? ~ in. Soil A lication Rate Horizon Depth . Dominant Color Redox-.Description Texture Structure Consistence Boundary Roots GP DIfF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 •Eff#2 f ~ ~ ~ ~ - .. 1~ ,.,x. a Boring # ^ Boring ~ ^ Pit Ground surface elev. ff: Depth to limfting factor in. Soil. lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ett#1 'Eff#2 ^ Boring # ^ Boring ~ ` ^ Pit Ground surface elev. ff. Depth to limiting factor in. Sofl lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff° in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 "Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mglL ` Effluent #2 =GODS < 30 mglL and TSS < 30 mglL 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 (807/00) i Soil Test Plot Plan Project Name Wilma VanSomeren Byron Bird Jr. Address g20 Hy 63 Baldwin Wi. 54002 CS #220527 Lot Subdivision Date 10/5/2007 CountyR ~~ C'~O~ T SE 1/4SE 1/4S13 T 29 N/R17 W TownshlpHamond Boring 0 Well PL Property Line# Alt. BM ,BM or VRP Assume Elevation 100 ft.Base of siding System Elv T-1=94.2 T-2=94.1 T-3=94.0 SCALE 1" = 40 ` Unless other wise Noted H.R.P. Same as BM POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner ~ ~~j 4~ e/') Permit # DESIGN PARAMETERS Number of Bedrooms -~ ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~ gal/day Design flow (peakl, (Estimated x 1.5) B jp gal/da Soil Application Rate al/day/ftZ Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand IBOD51 5220 mg/L ^ NA Total Suspended Solids (TSS) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y$ in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity --d al ^ NA Septic Tank Manufacturer t lvCe~ ^ NA Effluent Filter Manufacture ~ ~~" ^ NA Effluent Filter Model ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer {~ ^ NA Pump Model ,d ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Celllsl In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTFNANr_F C[_HFIII 11 F Service Event Service Frequency Inspect condition of tankls) At least once every: ^ yea~lsj(s) (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY,1 of tank volume ~ NA Inspect dispersal cell(s) At least once every: ^ month(s) (Maximum 3 years) ~ year(s) ^ NA Clean effluent filter At least once every: ^ monthls) ~ year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) year(s) ^ NA Flush laterals and pressure test At least once every: ^ monthls) ^ year(s) ^ NA Other: At least once every: ^monthls) ^ 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 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 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 (Y3) 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 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 cellls) 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 priar 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 be 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. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ 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 POWTS INSTALLER Name /- n i rC >" Phone --~.~ ,76 ~~ PQWTS MAINTAINER - - Name r //7'I at ~H ~~`'~P Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 2 ~^ S Phone Name ~ V D ~~~ ~p deli ~ Phone ~~ This document was drafted in compliance with chapter Comm 83.221211b111)(d1&If- and 83.54111, 121 & 131, Wisconsin Administrative Code. 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 cell(s-. 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 cellls) 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 fie 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. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ 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 ANDlOR 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 POWTS INSTALLER Name ~, n i rC ~"~,. Phone ~.-~~ 7~~~ POWTS MAINTAINER Name r f j~y~ ~{ LcN ~«~P Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name e r S Phone Name ~ G r p ~ ~X ~ may, ~r Phone !~~ This document was drafted in compliance with chapter Comm 83.22121(b1111(d)&(f) and 83.54111, 121 & (31, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~,~, /jn~ j/~ -.~~ ~ Lvr ~~ Mailing Address A ~ Property Address ~/ f (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number ,L~~yJ~ y. JO - oo cs LEGAL DESCRIPTION L Property Location ~~ 1/4 , /~/4 ,Sec. ~, T ~N Rte" ~- " ' Town of /~~ ~ Oh -~. Subdivision ,Lot # Certified Survey Map # D` i!%~Q- ,Volume ,Page # Warranty Deed # ~~~' ~ ~~'-~/ ,Volume ~ ,Page # 02 m Spec house yes Lot lines identifiable ~ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) ~,~ °~ ~--- DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ~• SEPTIC ~Ai~T3C ~ PUM? C{ifiMB~.R CROSS SECTION AhD SPECIiICATTaNS ~+" G:4 'SENT PIPE }2" HIN_ ABOyE 6RRDE ~ ,J~NC~~t3I~ BiIX APPR©vED ? ~-Q` ~t~02i I1C~, i,tlNg©it aR FItEaIs '~-IA I~tTA3t£ WI2H CE3NBUIi MAiNHdLE COVEit ~ER,I'-r' ~ W/ FADLUCK ~ .r; + _ ~% = ,,,, ~; r~ ..-.-...- ~i~iARtiII+{G iANEL FIi31 > ~ _~ GRAaE r ~ ~(~' _ _ .x ~'- FAtLET T .. t ZiA1'£R T~6NY SCAIS GAS- ; TIGRT• ~ _.._~~a.- A SF~ i, i^ i ~Ti:,fi • `• ~QINTS ii;7'~i ~_ i ~ A'LI'T MPROYED P2P~ APPROVE[) 8 _ s N 3` OIfIII Pi~f 3` "~- . ~ 90t.iQ StTIt SAIL ~ P(i?iP OFF ELEV _ FT. --~-- FF D 3° APPROYEI? BE33E7~~G VAIDER TA?~EIC Cp13CRETE PAII ~, ,~ __ /? ~, ~~ f,'~~ /~J~a~.~~zCxT~ohs rf+~r~s~u ~osES DER nA~ = '~__! ___- SEPTIC / BdSE _~ itaH1C HANJgACx'Z,#RER: = .. J("~, ~ GRL. _ DOSE Yfl~ME ~~C~ G,tbL,_ TANK SIZES= DOSEIC „_~y7- C'AL_ ~ LsAL. CA.Pfl~ITI£S~ A~ - ;,~ilCKES ALAR?'! 1SAN~I'RCTO~EA;, ~ - ~ 2 I3~iC8ES = .-~~~L -MODEL ~UM$ER = 8 = ~ITCfl 4•Y~'E: ~ C = INCHES = -;,GAL AI2fP ?SA3~JFf-CTORIIt_ '~- ~ ~ ~ D _ !at •II~CHES = ~~L. MODEL Ht7!ffiF.R = ' _____...-~5------.~ ~ --7`- l~. Z3 wAC S`~dITCN; 3~1'PE_ i~7SEtZ HG AS PF1~ S LHR R£QUIR£i} ~?ISCf#ARGE RATS _.~ . VER?ICAL DIFFEit'~IC£ $Ef'i7E~N PL7t4P t3FF AN'_% UISTltZBif"I'IE~ PIPE- . ± MINIM2.3t3 NE'iWQRK S€IPpLY PRFSSU.R ~/ 1[30 •FT_ ~FR ICTTONI~A€iP1~+U . _ . FEET Ft3RCE~~H X ~~-' ~flTe~iL DYE I~'TrRNAL DFMFNSIOI+IS ~3F pt3HP ~AHK_ ~ ~~ ~ 6~^..~--~ ~- ' I s STvPtErJ= .',~ :188 FEET FEET ~~--FEET --FEET D IAe'iCTER __.__..-- DS`v2 7p.AT ~ : ~fJ~ 7 iICENSi 1+fEII~B~~ ~•d dZ5~E0 00 £Z Uef 0 a z a a 0 LITERS 0 g0 160 240 320 FLOW PER MINUTE CONSULT FACTORY FOR SPECIAL APPLICATIONS • Timed dosing panels available. • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 130°F. (54°C.) special quotation required. HE,4D CAPACITY CURVE MODEL 152/ 153 w ~ w ``~ ~ ~ 50 153 2 40 152 30 8 20 4 10 D 20 40 60 80 10 GALLONS 1521153 Series Model' Volts-P~h i. Mode Am s Simelex I __ Duplex___I _ N152 115 1 Non__ 8.5 1_ 2 or 3 _ 1 l BN152 ~ 115 1 Auto .,. 8.5 Included ' t i 2 or 3 __ _ 1 1 i Non E152 ~ 230 ~_ _.__ .__ 4.3 1 - 2 or 3 - --j BE152' 230 1 ~ Auto 4.3 Included 1 -- 2or3 -- -- N153_ ~ 115_ 1 1, Non 10.5 1 2 or 3 BN153 , 115 1 j Auto __.. 10.5 Included -- 2 or 3 _ E153 230 1 Non 5.3 1 -- 2 or 3 -- ' --t - ---- BE153 , _ 230 _ 1 Auto _ 5.3 Included -J _2 or 3 D CAUTION Atl installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes should be followed Including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING MODEL 152 153 ' I Feet Meters Gal. Liters Gal. 5 1.5 69 261 77 l~ 10 3.1 61 231 70 15 4.6 53 201 61 20 6.1 44 167 52 25 7.6 34 129 42 ' 30 9.1 23 87 33 35 10.7 -- -- 22 40 12.2 -- -- 11 -1 -s I ~~ 3~ ,c ;5- ' _. ~, ~ ---~ - -i Lock Valve: 38.0 Ft. (11.6m) 44.0 Ft. ( rm)~ 074508 3 2~/ -i -- r i2 I/s ~... -- SELECTION GUIDE SK2064 1. Single piggyback variable level float switch or double piggybacK variable level float switch. Refer to FM0477. 2. See FM0712 for correct model of Electrical Alternator E-Pak 3. Variable level control switch 10-0225 used as a control activa specify duplex (~` or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve sa`ety factor is engineered into the design of every Zoeller pump. __---- - MAIL T0: P.O. BOX 16347 ~ ~ ~ ~ Louisville, KY 40256-0347 Manufacturers ol. . Z ~ ~ ~ SHIP T0: 3649 Cane Run Road ~ \ Louisville, KY 40211-1961 p pp~ ~~~~~ /~ ti ~~~. QU/1UTY ~UMP6 eJ/~ ~e%I~ - / ~~~~ ~~ (502) 77~~ 31 • 1 (800) 928-PUMP http://www.zoelleccom ~ ' (502)774-3624 -- - -- - © Copyright 2000 Zoeller Co. All rights reserved. St. Croix County Occupancy Affidavit for a single POWYS servicing Two Dwellings via PIMS G1. /rttia S~1aaQ~ 1.E f3a.rb~.r~, k. c-b.f: o~~l~•~rsa:~-~ /~ ,p n.,...l E ,- .a ~.-!,. ,~ 5 ~-e.x .~ /Yt . t/o<... S~o.M efe.,r\ Name - (Owner) Typed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume - Page - Document Number g2o5~7 St. Croix County Register of Deeds Office: A parcel of land located in the SE '/ of they E '/ o~ection ~.3 , T~ N - R ! ~7 W, Town of /~c~ rvimor~ St. Croix County, Wisconsin, being duly described as follows (include Tot number and subdivision/CSM or detailed legal description}: Sew Gc C~-~-c~e ~ i~~i~~ ~i~« ~uii ~~E~ ~i~i~ ~~iii ~i~~ ii~i~i ii~~ iii 861890 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 10/08/2007 08:OOAM AFFIDAVIT EXEMPT p REC FEE: 13.00 PAGES: 2 Name and Return Addres q2o ~~..-~ ~ 3 b/S - /dz l- /O - ~C] __ J Parcel As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWYS) serving the primary residence is sized for S bedroom(s) with a design wastewater flow of ~So gallons/day. (DWF calculation based on 150 gpd /bedroom @ 2 persons bedroom). Two dwellings will be connected to the POWYS via Private Interceptor Main Sewer (PIMS) in compliance with Comm 82.30(12). A maximum of lb occupants are permitted. There are currently a total of 5 occupants in these residences, therefore the POWYS can be considered code-compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWYS design, the system will be undersized to accommodate any increased wastewater flows andior contafninani loads and may be subject to premature failure. I also acknowledge that I will disclose this information to any parties interested in purchasing this pro erty in the future. Dated this ~ day of Q~tQ~~ >~1~./ / * a r ba r LZ ~ ~o ke,c'so ~.. * cJ , n e~~c.~.~. AUTIiEN ICATION Signature(s) authentic~te~l t41is, i~~~ day of .. ~~ * '~`\G din Ti;T~ ~,M R::S'~ BAR OF WISCONSIN a~~ authorn-z~ec~by § 706.06, Wis. Stats.) n THIS IN[,S~TRUMENT WAS DRAFTED BY -_~ (Signatures may be authenticated or acknowledged Both are not necessary.) * ~'.eJ~v~ /j~l. lea ~, S o ,m e ~ ~ * / M ~7 ~'0. dL ACKNOWLEDGMENT STATE OF WISCONSIN ) )ss. St. roix County. ) Personally came before me thisS day of the above named r r; s-7~~~~rSDh - -~ t~ c-t'-~.~ f to me known to be the person(s) who executed the foregoing instrtunent and acknowledge the same. * ~~~,~ - 1~h1~ Notary Public, State of Wisconsin My Commission is permanent If not, state expiration date: Date: ~ "THIS PAGE FS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" /3 This information must be completed by submitter: Qpy~ument title. nam r t rn da and ejM (~j required). Other information such as the granting t of ~°uses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. ~; Use ojthis cover page adds one page to your document and 52.00 to the recordlnP fee. Wisconsin Statutes, 59.3!7. r~ ;;, Number I Document Title St. Croix County Occupancy Affidavit for a single POWYS servicing Two Dwellings via PIMS ~caf+Pafc.. K _ C1..c';~a(J~et'sav~ de+~eft-5... d E.,~esc=3L.~`}' S}-c.ac,.. M /a.t. Sim ete/` Name - (Owner) Typed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume ---- Page ~ Document Number 820568 St. Croix County Register of Deeds Office: A parcel of land located in the SE '/4 of the SE '/4 of Section 13 , T 29 N - R 17 W, Town of Hammond , St. Croix County, Wisconsin, being duly described as follows (include lot number and subdivision/CSM or detailed legal description}: Beginning at a point 80 rods North of the Southeast corner of said Section 13; thence South 200 feet; thence West 185 feet; thence South 75 feet; thence East 185 feet; thence North 75 feet to the point of beginning. ~~iu ii~i~ ~i~ii ~~i~i iii~i ii~~i viii ii~i« viii iii 861 VVtJ KATHLEEN H. WALSW. REGISTER OF DEEDS ST. CROIX CO., WIC RECEIVED FOR RECORD 10/08/2007 08:OOAM AFFIDAVIT EXEMPT 1t REC FEE: 11.00 PAGES: 1 Name snd ReturS~ did-r~~ W:fw.4 9 7A edt..,.~. iv 3 2.x.0._.. _ [_j-L. S~ooZ Parcel Identification Number (P[N) OIR-1029-00-000 As owner of the above described property, I acknowledge that this dwelling will be connected to a single Private On-site Wastewater Treatment System (POWYS) located on an adjacent parcel via Private Interceptor Main Sewer (PIMS) in compliance with Comm 82.30(12). The POWYS servicing two dwellings is sized for 5 bedroom(s) with a design wastewater flow of 750 gallons/day. (DWF calculation based on 150 gpd /bedroom @ 2 persons bedroom). A maximum of 10 occupants are permitted. There are currently a total of 5 occupants in these residences, therefore the POWYS can be considered code-compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWYS design, the system will be undersized to accommodate any increased wastewater flows and/or contaminant loads and may be subject to premature failure. I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the future. Dated this S~ day of ~~~J LJPY , ' /,O G~~aty. J '~/t 1 ~i.,r. ~ Q ~ .. . ;3' .S~ * $ a C arc, ~ Gl, r.'~~str-~~ Ef ~n .'~ - ~_ * ~ J . E,1 ~L.Q~ AUTIIE ICATION Signature(s) authenticated this _ _ day of * S }e.~e.~ M. J~.ti So.r.-.e.lc..~ * ACKNOWLEDGMENT STATE OF WISCONSIN ) )ss. St. Croix County. ) Personally came before me this S day of f1`fo b~°-~ ~ /'~ ~ the above named ~k•hu.rot. K ~~t's7-nah Grp S`~G///it ~1 QM St9YJ')~rtotn at TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ' t to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED B~'"`;~~ ., c R { Zee., `,na Tr1•~,n"'~~'~:,n .~' ~•~ ~ ;~ 'sue' * ~'_ =. r-- m ~ : ?: Notary Public, State of WISCOftslf7 (Signatures may be authenticated or ackt~wl'ed~c~. ~ '•'~ r t~ .~My Commission is permanent. If not, state expiration Both are not necessary.) >~~'•. • a _.•A'Y c~,• date: i1`~;...`•T•I.~ Date: /~y ~~d/~ "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" Ij This information must be completed by submitter.~ document title. name & return address and PIN (tf required). Other information such as the granting 1 o~.Tauses, legal description, etc- may be placed on thisftrst page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and 4 ~ DO to the recardin¢ tee. Wisconsin Statutes, 59. SI ~. ~- ..-_:~w ~,~ ~• ~, ~ ~a~axc~4~cetronni mrt ~r~±~~an~r,~~, ~J .,,.; i~`, ti .," ~ t,,~,., ~ ,., ~ ~ - , F' s~r~tkii ~'~ . dip~dil ,: Augus~~ , A. ~„ 10 ~ , ~'~'~#~t 1~3.aZe and Laverne ~Vr~~z~, husband end w~.fe and } P~ i e ~ of the Srst peat, eEnd ~L, .;-, t,~ La+~rence ~. Tian ~lameren and Wilma Van Someren~ hueb~nd ~~ ~ anal 'wife, and ae ~ol;rit tenants ~ part ~~ 2 of the second. pan. Thrt the .slid ~ 1,88 of tl4t &rst part, .for and in considerafion of the sum of ' k~uri~lred Bitty ~:nd no/~.Ob ($350.00) - - - - - - - - - -dollars . . ,;,: ~.~, ~f,. in hand paid bq the said--part 19.8 of the second part, the receipt whereof is hereby ~~ ~'r~d ac&nowledged, ha a given, granted, bargained, sold, remised, released, aliened, conveyed ~- , a'+z~ ?t~ these presents do give, grant, bargain, sell, remise, release, alien.,. convey arrd ;~~} f<t11R said' art 128 of the second art,. their ~ . - P p heirs ~amd assigns ~• a'#ollowi»g described real estate, situated in the County of st• Groix '' ~;~`#iird of'ii~'ftconstn, fo-wit: ~~$~nn1nR at ~ point ®ighty` (80) rods north of the Southeast oorner 4 of "#eat3:bn 1 , in T~wr~ilp 29 North of Range 17 Weet, thence South one ~;k~'an~xad~{I00~ 2'eet thenc2weat thirty (30) rods thence South one hun8red ;> -~(~.t?0) feet thdnae ~aet thirty (30) rode thence ~iorth one hundz~ed (100) ., ~. . ~, f 1. y Y - ~ , - _. o ~_ - T. - .. ~ ,K ..- .. ~. _1 .. ~ - -: .... ~ ~='~$A~Ct'~R. iPv~}}t a71 ~d ~ii~fti'~' •the kereditatnrfttar arid' appvrten*rtpa:t:~therem~t~ belo~~l~g ar ~:ar~~l~ir ;~,~}'rpet~ait~ln~: a~ad-"all>#ha' astarta~;"right, tale, ~'~ritrret~; cl-aim, at-d`smcand,~hd~t~6e~er, ~rf t#e~;:iiaiti, i~t't_~ ~ e Y'~ , ai<1~j~ fFs~t'~art, l~it?rar,lit Ssw ~ttt~itq, atthar.f~,~sass~s~ofon at zxpetiwtancy Gf.:iik ~rrd~YO itr`i ~btfva.,Nn,~. -y ,. ~Srr#erd,# and their'~tlfl~ditl'f~'lt.~d'eppprtdhJtiit~ss. +~ ", . `, °;, ; : .., ;; ~ - ~; z `" ,f ~`,itttq ~ ~t*ID,,+rdr~`~3'a~ +r~ +lda ~ ~ "r ~d`~oith~-,th'i+ herrdlt'aiments "tnd ,~p~hrt~+C`~~; ~ ' ~.`r~?t`~;:.~RId .:~~~ oi' tha,a~fr~ditd pazl,,.at~r~' to '~ - hairs grid ~r~rsfg~r~'d1~5~'~R. R~r~'- ~"~i"d~~ and Le,v~xr~e, v~,a~~ :: ~ .:: ~ .tit. a yr ~!'~ `~' `.ha`I4-+"d*~!2~ S~~'A~r{~~Mr~ra.. lf~r °~, ~ c„~!lwr~'r, a S'!"''; L'am'-•~'3~' ,~a r~ ~ ~ ?~ '~'!d:~ Y~~#3'1'e 3ii~ the~.~ h~ rrrai~dd'st ehttr sli ~ ,.. tit! riraai~l€~" ~d~;S <!~li'ndry~ oC fh~s~ jpxfl~rrta,~$6tyl" gar 9 well. seitd.ot; ~ . ~. ~Car~~ve" ~ ;. . .: j,~;~~:~,~~i-ssr'e~,, pkrfecl,'absolute and ind~feasi6Te rotate tyf tnlte~r ear , ~~>~ ~e~~ ~~~~ ~1i~ ,dra free and ~l~ert from; X11 1»ctimbranots whattv~er,• ~C3 C~'~te. ~3d'. , ~iaT[."5:::4 -"f. ~.. ~',~. .. - _ a .. _ ... -. ~- 4 .r.:tp ~~ ~ -4 .l ~Y. ., _, .. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to ce ify that I have ins e ted the septic tank presently serving the ' ~,. ~ residence located at: s~ l/4, ~~1/4, Section Town~'2 ~N, Range l `7 W, Town of ~.~ ,f~ ;, , St. Croix County Wisconsin. Upon. inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service ~p '(~G~ - D Did flow back occur from absorption system? Yes Nom (if no, skip next line.) M Approximate volume or length of time: .---~~ gallons -~- minutes Capacity: Construction: Prefab Concrete ~_ Steel Other Manufacturer (if /',~ 2 e ~~ Age of Tank f known): ..,~-~ ,n (Lice ~ Plumber Sdnature) ~''~ ~ ~. Gib r v ' 6 i? i'~, ' r`G' ~.~, (Print Name) ~~ny~. (Title) (Date) ~~~ ~ (License Number) MP/MPRS Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code)