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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER : f > 1 ~l1 if f~J✓/> TOWNSHIP SEC. T N-R -L-LW
ADDRESS ~j /t r ST. CROIX COUNTY, WISCONSIN
C~yyl
SUBDIVISION r!' LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILUR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
+t~
l
a
13'
C" /tN r\
c
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: ZC-l C
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: f%
Number of feet from nearest Road: Front,O Side ,\,W Rear, O f ) feet
From nearest property line Front,O Side,® Rear, O 7'5 feet
Number of feet from: well building: 63L/1
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. _
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench: `
Width: Length: _°1 ? Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear,O Ft.
Number of feet from well:
Number of feet from building:
i
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
H s either a drop box O or distribution box O been used on any of the above soil
a sorbtion sytems? (Check one).
H LDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
~2
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.G. BO;:"7969 BUREAU OF PLUMBING
MADISON, WI 53707
M" (CONVENTIONAL ❑ALTERNATIVE State Plan l).D. Number
❑ Holding Tank El In-Ground Pressure 1:1 Mound (lf assig ned
NAME OF PERMIT HOLDER'. JADDRESS OF PERMIT HOLDER: INSPECTION DATE'.
Joseph Schmidt R. R. 1, St. Joseph, WI 54082
BENCH MARK (Perm-- reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. T. ELEV.
NE SE, Section 20, T30N-R19W, Lot#4, Stout Sub., Town of St. Joseph
Name of Plumber. MP/MPRSW No Coumy Sanitary Permit Number:
Donavin Schmitt 3205 St. Croix 69659
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
/ /J PROVIDED PROVIDED
/ ~CS ❑YES ❑NO ❑YES ❑NO
JI _
BEDDING: VENT DIA.'. VENT MATL. HIGH WIT R NUMBER OF ROAD. [HOPEBUI LDINGJVENT TO FRESH
ALARM FEET FROM INE i AIR L T
YES ❑NO l' ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING'. JLIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONSPER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PHOPERTV 11'111_1 BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NF AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 11-INGTH IDIAMITIR IMATIRIA1 AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH IN0F OIDISTR PIPE SPACING; COVER JINSIDE CIA #PITS LIQUID
9 TREN ES M RIAC PIT DEPTH
DIMENSIONS 2, r
GRAVEL. DEPTH FILL DEPTH IDISTF PIP" DISTR. PIPE DISTR. PIPE MATERIAL: NO R NUMBER OF PR OPERTV WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV INLET ELEV. END PIPE , LINE: AIR INLET
'2 O FEET FROM J,
NEAREST►
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH;BED 7PTH OVER TRENCHBED UEPTH OF TOPSOIL . SODDED SEEDED MULCHED
CENTER GES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. CIA.. ELEV.. PIPES. DIA.'.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: JBUILDING.
FEET FROM LINE.
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIJBN T RE. TITLE.
DILHR SBD 6710 (R. 01/82) ^y- -
~a Wisconsin APPLICATION FOR SANITARY PERMIT
► ILHR COUNTY
OEPFFI"fT1Enr OF (PLB 67) UNIFORM SANITARY PERMIT #
InOUSTRV,L R.OR6 HUR1Rn RELRTIOnS J/` ~Y
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
c sx, o ff d
PROPERTY LOCATION CITY:
F1/4 5,C-- /4, S , T_70 N, R E (or)o TOWN OF: S7_/ a~ k
OT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
u IV C.
TYPE OF BUILDING OR USE SERVED
)(11 or 2 Family Number of Bedrooms. ❑ Public (Specify):
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
E J Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total # of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: A^`C '
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site
tru S g>ass Plastic
Gallons Tanks Concrete Cons
Septic Tank Capacity
Lift Pump/Siphon Chamber
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signat o Phone Number:
"I'M C&A Z77-1 c7pl_Z-1725 _Z.,"
Plumber's Address: Name of Designer:
7r
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
El Owner Given Initial
S ' Approved Adverse Determination
Reason or Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
' r
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
r
' Parcel 030-1044-20-120 03/30/2005 10:19 AM
PAGE 1 OF 1
Alt. Parcel 20.30.19.160F 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
* ASP, RICKY L & ADELINE C
RICKY L & ADELINE C ASP
1433 47TH ST
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 1433 47TH ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 4.700 Plat: N/A-NOT AVAILABLE
SEC 20 T30N R1 9W PT NW SE LOT 4 OF CSM Block/Condo Bldg:
VOL 6 PAGE 1556
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
20-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 904/338
07/23/1997 904/336
07/23/1997 865/348
2004 SUMMARY Bill Fair Market Value: Assessed with:
5086 194,300
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.700 98,900 92,300 191,200 NO
Totals for 2004:
General Property 4.700 98,900 92,300 191,200
Woodland 0.000 0 0
Totals for 2003:
General Property 4.700 44,800 75,700 120,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
n
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of 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 C:70-5
5--c l/a
Location of Property4 Section T,7,0 N - R W
'T'ownship
Mailing Address
Subdivision Name JQG{ 1 _
Lot Number
Previous Owner of Property t C/f(~~►~' % Q( J i_
Total Size of Parcel
Date Parcel was Created 3 0 I-M6
Are all corners and lot lines identifiable? ~ , Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number s„3o as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty De(,'
2. Land Contrac-
3. Other record o
In addition, a certified survey, if available, would be helpful tk, avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We.) eelti6y that aXX e-ta,tement/s on thi/s 6onm are true to the best o{ my (outs)
knowledge; that 1 (we) am (are) the ownerW o6 the pnopvLty danibed in this
%n4onmati.on 6o", by vcAtue o6 a wa Aan,ty deed teeonded in the 064ice o6 the
County Reg-i~s,ten o6 Deects a/s Document No. j' 3; and that I (we)
pne,sentYy own the proposed site ite bon xhe sewage dosa,e /system (ort I (we) have
obtained an easement, to nun with the above descAibed pnopeAty, 6otL the
cor,steucti.on o6 said sy/s,tem, and the (same has been du,Cy neeotded in the 066ice
o6 the County Reg-i,5-tea oA Deeds, as Document No.
SI ATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
IN
INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
NDUSTRY, DIVISION
LABOR. AND P.O. BOX PERCOLATION TESTS (115) MADISON W1 3707
~Hl~Pff+N RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/A46Wr PA iTY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
~0 '/ate 1/4 T30 1,1/11j, (or) W os~~ - h ~VZA
COUNT OW ER'SNAME: MAILING ADDRESS:
'AS CtZ)
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence Z New ❑ Replace _c~
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
Ell DU ® S ❑U Z-S EA ❑ S ®-U 0 S /F9U 1)1114
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: It Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED- EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B-
B-
B-
B-
~S! PERCOLATION TESTS
LTEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
."'tea WFTERSWELL INTERVAL-MIN. PERIOD? PERIOD2 PERIOD3 PERINCH
SO O lye -3 C9 7
P-
P-
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. Try
SYSTEM ELEVATION
€ € t
F
ell 4 ~ ~ ~
I
T N
6,L 1 F =
~q
E
,
i -
56
e ,
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 (pr' TESTS WERE COMPLETED ON:
ADDRES ' CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGN U, g:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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a,..€zSE n: We °[,t °.:vici.i €s J E;?ny € {,lHe £h cinn:Ans m! 4'<:7d"31pi£,ing..'}-s£ vilm p
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DEPsTRY, T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING
'!1V'UuS
LAUNR ND P.O. BOX 796
PERCOLATION TESTS (115) MADISON, WI 5370
HUyVIAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION: SECTION- TOWNSHIP/Mt+Ntt;tPA-t-.l LO NO.:BLK. NO. SUBDIVISION NAME: TY:
__W~
134.
COUNTY ER'S/BEER S NAME: AILING ADDRESS:
DATES OBSERVATIONS MADE
USE PROFI lu l: sic D TONS: A ION TES f
OM S:
BEDRMS.: CMER AL DESCRIPTION:
h ~'Alew ❑ Replace
-Eiesidence Z Jam- ~.5
RATING: S= Site suitable for system U= Site unsuitable for system
CONVcNTION.AL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
~_,~s Uu~ ~s ou au ~s ❑s u
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: q s_ ( Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS A~ ~Z
I ri
IRCR!NG1 TOTAI._- DEPTH TQ R !JNDW<`•TER-!NG ?LS CHARACTER OF SOIL WITH I Hillr iESS, CR, TEXT UI,E, ANu DEPTH.
NU BEP DE21H...IN. ELEVATION OBSERVED ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
13-
MC) Ai (Z
-
s s~
e3 S'I 383 ~.L.
(07 63
7 Ai
-
IB-_± T4 3_ 75 83
/00
g3
B`--------- - -
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
PER INCH
~ NU~MBERI INCHES AFTER SWELLING INTERVAL-MIN. P RI D 1 PERT D
PP- i--
F L_ 1
are the hor
a' \ll
'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe wh
n`al and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction d perce
p
of lard slope. _ °7 1
SYSTEM ELEVATION
I
l
_ -j - -r t
(,t) (Y) r3-r K,e:.~ R- . 101 _
Q
- -
_ _
UG
2 C,
r' -41 i
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1, 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
' dministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
_ TESTS WERE COMPLETED ON:
(NAME (print
A , CERTIFICATION NUMBER(optionaD:
DDRESS.
- Z Z F6 Z 6 -(O
iCJ CST SIGN E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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St Croix COU-
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OWNER/BUYl:K--
ROUTE/ BOX NUMBLR ~T /,J Fire N/uumber
C I T Y / S T A T 1s
PRl)PERTY 10CATi0N: Secti,,u fn (J , i__30-_N, R_/7_-W,
Town of_ St . Croix County,
Subdivision Lot number Y
I
Improper use and ntaintenanc,r of your sepLir ~ystew could result in
its premature"failure to handle wastes. Proper ntaiuteuance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed- septic- tank puIII f>er. What you put into
the system can afiect the tunetion of the t.(-•pt_.ic t- ink as a treat-
ment stage in Lite waste disposal system.
St. Croix County residents may be eligible to r u c e i v c it grant. Ior
a maximum of 60% of the ost of replacement oil it failing system,
which was in operation prior to July 1, .1978. St. Croix County
accepted this program in August of 1980, Wit It the requirement that
owners of all. new systems agree to keep th,~ir systems properly
ilia iit taiit ed .
The property owner agrees to submit to St.. C C 0 i X County Z0„int; a
certii'icatioit form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a li-cense<i pumper veri-
fying that ( i ) the on- site wastewater disposal system is in proper
operating condition and (2) after inspeL.tion and pumping (i-f nec-
essary), the septic tank is less than 1/3 full of sludge and scum.
Certification torm will be sent approximately 30 days prior to
three year expiration. H
CD
OWE, the undersigned, have read the above requirements and agree
to maintain Cite private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- w
went of Natural Resources. Certilicatiort form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of Lite three year expiratimi dale.
SIGNED
DnrE U~
1---- - - - - - -
St. Croix (i;ouuty `tuning O11 iL'C
P.O. Box 9i
Hanunoid, W 54015
715-T)6-22'19 or 715-425-8363
Sign, date and return to above address.
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