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HomeMy WebLinkAbout018-1042-00-000 n 3 N S ~~ 0 O i O V c m 3 C ~ a (D fl. W N m ~ y ~ 7 ~- ~ N 3 N ~ ~ `~ A C ~ N N N 3 a a o v ~ cn zN m cfl D N ~ C ~ ~ W N 3 O O ~, 0 ~ ` Z 0 ~ 3 o v ~ ~ O s m CD C fD 3 m 2D D c a a m n o' ~ ~ a~ O O Z ~ a o ~ C N r ~_ r ~ n y ~. ~ tQ ~ c A ~ N fD a~ °o a x 0 'm 0 °o ~- c~cnoi ~ O :•' O ZJ d ~ i 2 f d a ~ ~ ~ a ~ a = O O N O O q=j 3 c'o co 3 0 o a ~ovv~ A O O -ovv N ~ .. 7 K Z Z Z D D ~ v m y N C N N Q 7 O f. fl. ~ ~ a O :i 0 3 !~! Z m o ~ C 7 a 3 d o O n Ci N 'fl ~ ~ N _ ~ O N O 3 iv ao 3 •`° ~ v ? ~- N ~ 0° o f D °o ~ o o. ~ ° a 3• .. ~ d V W v n y -~ -~ to A ? n J ~ K A Z O .. ~ 7 m~tO z A ~ m A d A7 R A'+ ~I C ~s O D O A ~y A n N w ti 0 0 b ~0 o ~, ~ ti a i I I cn 3 ~ ~ ~, z ~. < < c ~ T Q 7 7 ~ N ~ ~ ~ N d C/1 N N N L o °o ~ coo c c ~ ~ w ~ o -~ m cQ ~ ~ j IN ~ ~ ~ ~ n o W N N ~ O ~ ~ p ~ ~ o I ~ ~ I ~ I a ~ z ~ I s~ `_, m _m ~ z m I p ~ 0 -- ='' O ~ w s N .t ~ ~ ~ ~1 C ~ ~ (D N f I I I ~~ ~ a Oa ~ a I ~v ~ o ti c a ~ ~ fD ~ I ~ uni o I m ~ N n ~ fl. N O I o OA ~ i 7 ~ t~0 ~ Ul ~ I = O 3 N_ ~ C N n O O a~ d I a I ~ I ~ I ~ I o O °o ~- ~v~o ~ ~ ~ 3 ;ti ': O V 1'1 N ~ O ~ N ~ O o w '~ H ~ ~ ~_ ~ V ~. _ a s rn rn ~ W N O O N 0 0 = o °o ~ 0 ~ ~ ~ a 0 ~ 0 N N N A -ovoo `" m .. ~ °: 3 °-' ~ .. K Z "'~ Z D m ~ ~ ~ fD N O ~ F N .-. N r a (D ~ (D ~ O c 7 a W ~ a 3 O :'•' m ~ fD a w m c~ 3 m T c a z 0 3 v ~ C '•~~ ~. A 1 ~ ~ C3 ~ ... co m 3 ~ ~° ~ a N "! _~~~ c ~ ~ S ~ C ° °° c5 A: ~ °o o ~ '3 ~ M ~rcn ~ 3 ~ ~ i ~ ! rt d fD y s~ ~ ~ a (A ~ ~ N A Z COi ~ ~ e_ A 2 O .. ~ O m ~ '° II A T1 Z m A I O w1` w N 0 b 00 00 ~ ~ /* Wisconsin pepartrt>ant of Commerce PRIVATE SEWAGE SYSTEM Safety and BuHdings Division INSPECTION REPORT qrf GENERAL INFORMATION (ATTACH TO PERMIT) Personal infomtation you provice may be used for secondary purposes [Privacy L.aw, s.15.04 (1)(m)1. R Permit H er's Name: Q City Q Vi lage Town o de, Dorotha Hammond Township ST BM E ev.: 00.0' Insp. BM E ev.: 150 • ~~ BM Description: ~. = CSt g ln~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic STIN l,Ll~ k.1t16W ~p Dosing Aeration • Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Airlntake ROAD Septic > `(p ~ > Zop~ .-•~ ~-8' - NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manu durer - and Model Nu er GP TDH Lift Ilion System TDH Ft Forcem ' Length DIa. H Dist. To well SOIL ABSORPTION SYSTEM ELEVATION DATA ounty: St. Croix Sanitary Permit No.: 370282 State P an 10 No.: Parce Tax No.: 018-1042-00-000 STATION BS HI FS ELEV. Benchmark .ZS' OD, ~' Alt. BM Bldg. Sewer , St/ Ht Inlet StJ Ht Outlet ~,g,~.~ ~•Z!o q(o • 99 ~ Ot Inlet ~--~ Dt Bottom - Dist. Pipe 5~- fi Bot.b~st+em S~- Final Grade (a,2~ 9~,9to~ St cover x "~. ~. s-o I 96 ~ r(S " (~,.k -tom Ja..r.r1~••~• ~ ~ 9 S'' q6 30 1t~D- RENCH Width 5 r L ng th ~ Q Trenches PIT No.Of Pits Inside Dia. Liquid Depth O eac, . I M I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACH G acturer: SETBACK INFORMATION TypeO ~ r ' _ CRAM O IT M e Num r: 1,V • System: ~3 ~ ~ > cx> DISTRIBUTION SYSTEM Header / Mani Ip d., y r Distribution Pipe(s) ' x Hole Size x Hole Spacing Vent To Ai; Intake Length ~ Dia. ~ t _ Length ~ ~ Dia. T Spacing (o "`' 8~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over ` xx Depth Of xx Seeded I Sodded xx Mulched I Bed /Trench Center Bed /Trench Edges I Topsoil Q Yes Q No Q Yes Q No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection # 1: Ofo /30/ 6U Inspection #2: l-t-~ Location: 1587 Highway 12, Hammond, WI 54015 (NE 1/4 NE 1/4 19 T29N R17W) - 1 .29.17.289B c.~a~"~ 1.) Alt BM D scri = I pr;~, • S,~~a,,.~,. 2.) ldg sewer length = -~- ~'$ g.~ ~ ~ ~.~ -amount of cover = ~rs~`~j (Gr'"~ • q,1 ~ 4s.lo 1 D • ~ b ~. ~3 •SS 3 ~ 1~.~e.c-~-Ir r~. ~s.QA i.~-4~r-~-s. ~'.t.~-•~CE) 9. s y ^~ `r ~1 I ! ~ Z 8 ' ~ C 9 2.9 ~ ' 1 Plan revision required? ^ Yes No Use other side for additional informa~t~ion. D 3 0(o I ( S (` SBD-6710 (H.3/'8~ Oat ~ ~~ ~~~es~'to s Signature Cert. No. i~ ~ ~~- ~~ ~ s~~ ~~ ~~ - ~ s~`" ~~ ,~ 5,~ ti~B ~`.~ ~~ i ` ,~ . ,~ ~~ O _ ,~ r ~ /~ `~isconsin Department of Commerce 1 ~ '' SANITAR PERMIT APPLICATION In accord with Comm 83.05, Wis. Adm. Code Safety and Buildings Division 201 W. Washington Avenue P O Box 7162 Madison, WI 53707-7162 • Attach complete plans (to the county copy only) for the system, on paper not less County S~ ` than 8 vi x 11 inches in size. . J /`O ( • See reverse side for instructions for completing this application State Sanitary Permit Number 3~flZ~Z Personal information you provide may be used for secondary purposes p Cneclc if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan Review Transaction Number I. APPLI ATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner N me O f'~Q rt ©~~ Property Location .,~~ ~ t is ~ t ia, S Q T /~ 9, N, R j ~' E (o r~ Prop ~ y Owner's Mailing A~ress `7 _ Lot N/ ~ / r Block Number S 1 2 f JJ . 'f' /f Cit ,State ~ Zip Code Phone Number Subdivisi me or CSM Number a ~ D (7/S~ - .TYPE F B ILDING: (check one) ^ State Owned ~ !ty l Nearest Road Public or 2 Famil Dwellin - No. of bedrooms ~• vi lage own OF 2- 111. BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) 1~_'At ~ n, ~_Qq Q~ ~ ( /, _ ©~ _ _. ~ m ~ g' ,_~ ~ ,Y 2 ©O 1 ^ Apartment /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 only one box on line A. Check box on line B, if applicable) A) 1. ^ New _ placement 3_ ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an ______System ____y S stems _______ TankOnly______________ Existing System ________ Existin~System B) ^ A Sanitary Permit wa eviously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Se age Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 eepage Trench 22 ^ In-Ground Pressure ~ /X ~~ / 42 ^ Pit Privy riv y 13 ^ Seepage Pit l~~ ~ ~~(~, 43 ^ VaultyP /~ 4 ~'~ ~ 1 ~ ~ ~ 14 ^ System-In-Fill ~ ~-~~ ~ k~ L /~.e~~''~ VI. ABSORPTION SYSTE~ INFORMATION: 1. Gallons Per Day 25~tbsorea 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade ~ Requi d (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ¢1 Q 3.~0,; Elevatio ~ 3 " ~ ~ L93- ~ Feet 98•~ Feet © G . 5 VII. TANK INFORMATION a acct in altos Total # of Manufacturer s Name Prefab. Site st l Fiber- Plastic Exper. N i i E Gallons Tanks concrete act ee glass App ew x n st st ed T nks Tanks ptic T nk r_Hnldina Tank ~ h B~ Q /1 OA.f! Li Chamber ^ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu bar's Name: (Print) Plumber's Signature: (No Stam s) ~ /MPRS ~ Business Phone Number: chv,~~F ~ t / ~~7 / /s-~YQ-33~~ Plumber's ddress (Street, ity, State, Zip Code ~ S- ~o~ 3 w IX. COUNTY / DEPAR MENT USE ONLY ^ Disapproved Sanitary Permit Fee ondudesGroundwater ate ssue Issui gen Signature (No Stamps) Approved ^ Owner Given Initial Surcharge Fee) ~ ~ Z S ~ ZO r .Adverse Determination - X. CONDITIONS OFAPPROVAL /REASONS FOR DISAPPROVAL: 2F s ~~r~ ~~08 GCp/a:H = ~+c SBD-6398 (R.72199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber f INSTRUCTIONS t' 1. A sanitary permit is valid for-two (2) ye~r . 2. Your sanitary permit may be renewed Ede "ore the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be ~F plicable. 3. All revisions to this permit m ust be app~o red by the permit issuing authority. 4. Changes in ownership or plumber requilrc s a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systemsmust be properhy nairitained. 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 qr site sewage system, contact your loca- code administrator or the State of Wisconsin, Safety and Buildings Divisiorh, 608-266-3151. To be complete and accurate this sanitary ~rmit application must include: I. Property~owner's name and mailing.~c dress. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. ChecM: >nly one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is publNc check all appropriate boxes that apply. IV. Type of permit. Check only one on li~~ ~ A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate ~ c depending on system type. VI. Absorption system information. Proilri ie all information requested for numbers 1 through 7.' VII. Tank information. Fill in the capacit >f every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate pref~~b or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check~e cperimental approval only if tanks received experimental product approval from DILNR. VIII. Responsibility statement. Installing ~I ember is to fill in name, license number with appropriate prefix (e.g. MP,-.,etc.), address and phone number, Plumbe~~r nust sign application form. IX. County / p~partment Use Qnly. ' ` ~ `~ X. County /Department Use Only. ~ ' ', _ Complete plans and specii~ications nit smaller than 8 1/2 x 11 inches must be submitt~~l t~,the county. The plans must include the following: A) plot plan, c'awn to scale or with complete dimensions, laca~i of holding tank(s), septic tank(s) or other treatmem: tanks; buNlc ing sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorplt on systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation N'E ference points; C) complete specifications for pumps and controls; dose volume; elevation differences friction loss; piu np performance curve; pump model and pump manufacturer, D) cross section of the'soil absorption system if requWrE d' by tt~e+t©ui~ty; E)-soil test data on a 115 form; and F) all sizing information. ------------------------------------ ~! GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creaii~.n of surcharges (fees) for a number of'rtgulat.~d practices vviiich can ' effect groundwater. ,~ .i. _ The monies collected through these surch~a~ ges are used for monitoring groundwater contamination investigations and establishment of standards. .~ ,. ,D o r arrt~ a I~o ~ ~ 1 s$ 7 t}u' y ~2 s-~6~3 ~2~ 78/ ~, ~~ ~/~~i ~ i ~ ~~~ r ~ - !~o °° 7 2 ~ ~~ ~' ,~_~ ~6~ ~- 7~ °~ ~- ~ ~~ ~°~ ~~~ r _~ ~ .~~ a-t ©d ~ ~ " ~ ,~~, ~\` ~~~ ~ ~ x .~ ~ ~~ v ~ o~ ~ ~, ~t P ~ ~ ~~ ~$ (y U~-D Jri- , 5 C~ i ~~~ ~ ~ 1~-' f ~ - ~r ~' ~ 6, "~ ~~` ~~ ©o .r --~.. -------_ • ~ 3 ,.~1~ 5~-i L.a. v.. 1 ' ^ o f~ ~ /~s iN~y d- r~ , •Wisconsin Department of Industry, Labor and Human Relations Division of Safety and Buildings SOIL AND SITE EVALUATION in accordance with s. ILHR 83.09, Wis. Page ~ of Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must """"`y s?: ~j(~Q~ x include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. # b/~• is yz . oa • a~-~ .., APPLICANT INFORMATION -Please prin ~~imafion: ~- Revi ed by Date Personal infom~ation you provide may be used for second s (Pri Law, s. 75.04 (4) (m)). ~ G Property Owner . ~ Pro Location Dop~q- ~•A- ~ oJ~E' `° REC~i~~ ~ p~m~ Q -7 Govt. of /V~ 1/4/V~ 1/4,S ~ 7 T Z9 ,N,R ~ / E (or)© Property Ownes's Mailing Address _ ~ { . `!~y Lot-# ~ Block# Subd. Name or CSM# ~sg~ wy ~Z ~_.+,, ~~k~ a ~3 ~~.iao • ~. City State Zip Code .~PF1;pne Numt3~J p ' `' ~ ,-,~ Ne,~a/rest Road f f/t-/yMONv i ~/ • I S yGlS C~~ ~~~ rte! it)' ^ Vi la M f'Yt.v ~I iD I ~r ~~ ! Z ^ New Construction Use; l~ rtesidential / Numbe 4 om Addition to existing building [a'~?eplacement ^ Public or commercial -Describe: Code derived daily flow ~ ~ gpd ~ Recommended design loading rate ~ bed, gpd/ft2 S trench, gpd/ft2 Absorption area required bed, ft2 ~~ trench, ft2 Maximum design loading rate • ~ bed, gpd/ftz s trench, gpd/ft2 Recommended infiltration surface elevation(s) ~~- • 3 ft (as referred to site plan benchmarlt) Additional design/site considerations ~N.S'~"~/ Lp !r- ~`i4'~~o~y ~/'~'GL'-ls Parent material /OAS $ OIJ.Cv S/~•,V,p)/ d ~TW~ ~~ T ~! Flood plain elevation, if applicable ~~ ~ ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Gra a System in Fill Holding T~ u unsuitable for system C9 s ^ u ~^ u p's ^ u C9's ^ u ^ s ~i ^ S C SOIL DESCRIPTION REPORT Boring # Ground elev. 4 ~ •~_ft. Depth to limiting factor ~in. Boring # ~. ~~ Ground elev. 97, (Oft. Depth to limiting factor,/ in. Remarks: CST Name (Please Print) Ana ER-r- u u~ec ~~7- Address Signature Tele hone No. Date CST Number ~~ v 2~- zoa-a z Z~ 3~ s Ulbricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 Horizon Depfl~ Dominant Color Mottles Structure i C B d R t GPD/fl2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ons stence oun ary oo s Bed ,Trench o . ~ y .o ye 3~3 -~ ~ ~~~,~ ~s ~, w zf . q :. s -~ ~o ~ s~ ~ a,~ ' - . Y ~ , s ' a _ ~ ~•8 0 ----- ' S~ Remarks: / o • ll ~o ~ 3/3 - L /f S,dk dS w ~ f . y ; . 5 ~. s - sc ~ a~ ,~.. / ~ ,, ~ ' s 7. s s~ /ash s c - • ~~ .s w! nn-- .r PROPERTY OWNER ~ ~ Roo ~ PARCEL I.D.# Boring # .~ Ground elev. .,~ft. Depth to limiting factor 7 ~~in. Boring # Ground elev. ft. Depth to limiting (actor in. Boring # Ground elev. ft. SOIL DESCRIPTION REPORT ~, Page ' ~ ofr Horizon Depth Dominant Color Mottles T Structure i C t B d Roots 2 in. Munsell Qu. Sz. Cont. Color exture Gr. Sz. Sh. ence ons s oun ary Bed ,Trench ~ 3 ~tS io 5 ~ L f b~ .~-~ ~ / f . s ; . ~ s. y ,. s ____ ~ i ~,e cs - , ~ .. S . ?. S SL S ~-f,,~. - -- , S ~ . ~ /~ ~~ ' Remarks: Horizon Depth Dominant Color Mottles Structure B d R t G D ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence oun ary oo s Bed ,Trench Depth to limiting factor in. Boring # Ground elev. tt. Remarks: Depth to limiting factor `n' Remarks: SBDW-8330 (R. 08/95) Remarks: `' l~rv y. ~ ~ ~~ , /3~ 0 N SCA-G~ ~ ~ ~~ - 3 d ~ ~ ~4' Z R~~~MS' .- cv(9 18 z B •> 0 1 •• ; ~ - ~ 1 ~\ ~~ ~ ~ ~ J~ ~ J~ ./ \ , ` ` 79 ~ ~o ~ ~ ~, 32 _~ ~,\ ~ ~`~3 ~ ~ ~ ~ ~ i~ ~~ ~~ \ ~. ~ ~ t 1 I ~ ~, ~ ~ N ~ 5~W "~ ~ ~ ~t ~~V' NOTE WLLL G~~S OV~° 10~ ' ~hS T p~ 'T'EST S iTE ~~ ~ ~ _____- T°P cF coNG,t~~, s~o~c~ ~ ® sw r~ P ~,~ v, = ioo •~' i8y WIC,) q6 ~~~~~sT' S~pTt'c T~~ o. ,~ . ~~ ~~- fo~~~ ,~ _._-~ ~=- T°~ pf /v~ii,vu,~-~ vF,vTc.4ho~ oc~ s ysr. y ~< <' , ~ ~ rJ r' ~~QC~.= 9~,~ . • ' NE COR. SEC. 19 j tom. \ . ~~~ ^~.~ i w'2 ~ . ~~~ .. r ~ 2898' $ 610/103 ,~ a ~'~ ', ~ ,~ ~E ~/4 -- NE 1 4 / 289A '` W - _ I .~ ;r r ~ ~ ' v . -i~*z ,~ ~~ t ~ `3 _ i Yak, '. }~- ~~' . ~~~. •,~ ~~' - ;. ti ,, i;.~- ,• ST. CROIX COUNT." ZONING OFFICE CERTIFICATIO'd STATEMENT 'FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to _certify_that Ihave in~;pected the septic tank presently serving the ~~,~/LQ- /~ residence located at: (~~, ~~_;•, Section ~, T_L~N, R~~~1 Town of ~~~~~ Upon inspection, I certify that I have found he tank and baffles to be in good condition, and,~it appears to be functioning properly. Last time serviced: r -- ~~00 Did flow „back occur from absorptic;an system? ~~ Yes No (If n<.;, skip next line) Approximate vo~ngth of time: gallons minutes Capacity: ~~'.~ "`',.~.~" o~,1GC'~~ ''~ ~~n P Construction:. Prefab Concrete ~ Steel Other ~~ °~- Manufacturer : (I f known) ~` ,~ ~ • ~ - _~ ~' . ~, -age o~,~-w-T`a~Qn/k (I f known) : 1 ¢ I -3 ~ ~/~ ~ ~, ~~r ~ !~Z"- -'Q'tJ~' ~f f~1 r i ~ ~ -~=b = S /r !~ ~' T.~~s.~-~C~ ~o- 'CS ~_ (Signature) (Name) Please print _:. {.° ~ ~~` _~ 'F (Title) Date (License Number) . ~~~,; - ~~~ Form to be completed by license•:~ plumber- (s. 145.06, Wisconsin ~A 'Statutes) or Licensed Disposer (;~?R 113 Wisconsin Administrative Cade) ~..,~~ ,;a~ti `~: ,i. - - - - - - - - - - - - - - - - - - - ~ - - - - :Plumber (applying for sanitary pea~mit) Certification: ,', ~~ w In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will . conform to the requirements of ILI~2 83, Wis. Adm. Code (except for ~•~ ' inspection opening over outlet ba~:fle). Name ~ S i natu7•e w s g P/MPRS ~~ ~ ~ ~l ~~ 7 ~~ - ~ l.r '"r ~t ~ 1 :. t 1 . ST CROIk COUNTY SEPTIC TANK MAIN'I"i?NANCE AGREEMENT AND OWNERSHIP CER.'I"aFICATION FORM Owner/Buyer ~ o R „~¢ ~~q- /1 ~ ~~' A~tilttg Address _ L' ~ 8 7 ~w ~ ~-~ P~panty Address ~ ~~~~ L~ ~ ~ 4~'O ~ S . (Verification rcquirrd from Planning Ikpartrz~cnt for now constiuctioa) C.~ty/S~aGe ~ ~ arcel Idenll.~ir.ation Number m ~ ~ -- t o Y x - o ~ ~- ©~o ~~ PESC>~rT~roN i Prtapetty.Location ~ %,, ~ %,, Sec. ~, T l2 N-R !7~ Town of ~a. o~,.~ ~~,f~Q ~ . Subsion _ ~~~ z Lot ~=. k a Cet'ti~d S Ma # ~' 0 3 . _ arv~y P ~I'tslume _ .Page # t'v Y_ witcrinty Deed # _3 ~ .~ tf' ~ ~ V~Iume P e ~, f'~.r- / 0 5 ;, ~ ag # r ~ovse Q Y~ ~ ~ LoI )fines identifiable ~ yes ^ no #~ _ ~ _ ~~ ti. rasa ~a~aD~eofy~onrscpticsYs~mooaldPrsnItiaitspt~mat<u+e.~+etobandlearastes.Propermsinbeaaa~oe z ~P~g septi~e talc ev~ety three youa or soaarx, if neoded by s ti~oeasod pQmper. What yon pat iabo the rysbem ,. , expa~ sffisct Qre of tile. aa~c tanic-as. a ~tc+eatmeat sage m the waste disaosal svs~m. PY~ owner agroes to sabmit tD St Cc+oac Zcainl; l.)cpartme~at a ooa form, signed bq iLe owner and Ly a ~ ~- ~~1t~~y~nPt+esbcidodpIumi~era~rali~oea.~. .~..a...... ? ~ , ~ ~`pt OODdttioII and/or aver ~ ' P~ • ~~+~+s ~ ~1~ QLC oa-6ite ~VdStCwa~diSpOSiI sysOCm rF (S) mspcdiaa sad panr,~ing.(if necessary), the mtptic~taairis less .than 1/3 fall of shrdge. . ffiia mrdo~rad Intro read fire abo~ne set forth. .'as sd 1Le ~ and agroc ~, ~vaintaia ~ prorate sewage disposal system with 6u staadatds by Department of Commonoe and fire D~~ ~~~eat of Natural Rte: State of Wiscansia.. C.ertifcatioa tb~t y~ sy~em Las boea maintained mast be oomptc~td;3 and rchranod to the St Qroix County Zoning Office within 30 ;t days of the time year exxpiration date. ~~ ~• / G / (P /l/ S[t~lAT#JRE OF APPLICANT DATE .~1'~'t~F~t CERTIFICAI'IiON I (we) certify that all statenuats on this form are true to ~~, best of my (our) knowledge. I (we) am (are) the owner(s) of tare ~ desccrbod above, virtue of a warranty flood recon~=.;<~ ~A ~Registcr of Deeds Office. ~~~~ ~ . t~lvt f~ OF APPIICANT DATE ~- «"'o'~'s Any iaformatioa that TS mis-ttip may t+esvlt in tic s~ntary permit being revoked by the Zoning Deliartmeat «««««« ~~ [ndude with this applleatioa: a romped warranty doed from tlic Register off' Deeds o~cc a copy of the certifiod su:voY amp if reference is made in the warranty deed '~ s