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HomeMy WebLinkAbout020-1419-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No- GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 592170 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. N Permit Holder's Name: City Village Township Parcel Tax No Water's Edge Construction TOWN OF HUDSON 020-1419-20-000 CST BM Elev: Insp. BM Elev: BM Description: r Section/Town/Range/Map No: 00.O 20.29.19.2660 TANK INFORMATION ELEVATION ATA TYPE MANUFACTURER N CAPACITY STATION BS HI FS ELEV. Septic W JA f: b S lO~ / Benchmark 1O o. 0 163. Dosing pvMn;Z~~• A / Alt. BM Aeraflbn Bldg. Sewer ing y S ~ tInlet 61 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ~J/ h ) Dt Bottom Dosi , Hea7r/Man. 711) Aeration Dist. Pipe , Holding Bot. System -T rtmaLGrade PUMP/SIPHON INFORMATION Manufacturer ( errand St Cover FORS ~ zy~ J GPM I i Z Model Number TDH Lifts, Friction Loss System Head / TDH Ft Forcemainn Lengt 1 Dia. /i Dist. to Well ~J O I~ SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengthb ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid th DIMENSIONS Z7 1 / SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type S sROW 4-ZZ 113 ~ UNIT Mod14 tuber: DI UTION SYSTEM 61p L4- /mil n~yek/n$ Bader (d ~r Distribution x Hole Size x Hole Spacing Vent Air l% / Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over ^ 7 Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil J o No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 857 CHEBEK LN * N0 ,GI) 11JJ ~ oh~)C-~--7~ n l""ll lei ~ / D / ha~l1 J d 1.) Alt BM Description Ve 2.) Bldg sewer length = Dq l 1 ` O ID vl YG r C , - amount of cover - ~L.- , 1 tv **.7 UVc r ~l(1 S'~j~ n al ~i ~jpK~ ,p~,06 0kS qef X144- cli~'1vv bP f a "II Plan revision Required? 0 Yes Y-No Use other side for additional informati n. '1 LP Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) - - R, E- 11 iu to Sort Di7 tsu~,i , 3 dt,tt ~'aslunuton a e O CT 2 (C5 ' l7_ Bo.. 36? 5 ,star; Permit Numbe. ?tabcfilled in bti Co-t P S Lladtsan. 1b 1 i ()7-7162 y - - ST. CROIX COUNTY Z O - ~y~~ lil ups ':ion I to anhr~erml Applicat - FZ3NXT6 " to accordance with SPS 3S3? i (n) W~ i 1dm Code. submission o, t( is fon > HpKXP > rcaurcd Pnor to obta!nm~ a sannar; pennit. Noie: Application torms ion 5E rroit.c..,tltir~s, G. th,lcren[ titan ma~lin<< address) iu Denartm nt o Safe \ and Professional Services, Personal information sou pr, n 3mo. es in accordance with the Pri 1 att s t 04(1}( ny, Stats - - - irI C~EaE.r L✓. € Application Tnformation - Please Print All Information 857 i'-open} Ottner's Name llt : C1 4)ATEn S ~p6E G on7S1"A4GT/an7 ~/i4i!1E"s j~/tuEtE~L - 030- 111 1 "0?o -00c, property Ottne, s %,l ail int_ Address Proper i . ~atir+n)U ~ 3 a/.7 Gcs r~ ~u~` iiovt. Lot Citt State Zqt Code Phone Mumbet S&J N6' Section .7D (e one) /LSaw! ~r ,j -Voa7 7/-r 7.1. -o 76y 1. 79 N. , itr Zito( - 11. T% Pe of Building {check all thaC apply) Lot r. - 3 J~ i Subdivision Name ;91 orri milt Dneiltns Number of3edrooms AA lU Publicicommercial - Describe Use w f i-~-te o f V,p CSNI Number L ltaSL+ ~,)+cnei - [li'= er1tUC UsY 111. TN~pe ot'Permit: (Check only' o box on tine :S. Complete line 11 if applicable) - - --~a j~ New S%'stemi J Replae ntent S}stmt L; Treamrent'tfolding Tani: Replacement Oni: ~ Other Modittcation to t sisunY S}siem (exPlani T List Pret'ious Permit Number and Date issue.; B. ❑ Perin Rcnetral ❑ Permit Revision ❑ Change of ('lumber ❑ Permit Transter to Nett 1 Before Expiration Otoncr - 0 - i~ T~-pe of PO« FS System/Component/Device: (Check all that apple) kkd N0n-Pre5surl/ed In-Ground C Pressurized in-Ground 1t-Grade ❑ Mound 24 in. of suitable so.i ~ P: c_,incl i of suttab7_,oil Iloidina Mani: Lj Other Dispersal Component (explain)-_ Pretreatment Dc%ice (explain) _ V. DispersaltTreat ent area Infonnatiun: Desien Ffo% tepd} De:i~=n Sail Application Rate{, slt Disper; i Area R~ sre f 1 Dispersal :1~ca on ~cu tstl stcm Llcrsiton r 5'so ! , 7 3 y--- - . `•'1. "lank Info canacitv ill Gallons Galiot3s l '.inns L: ik, ~ - laistim_+ 1.atki l ~ ~ 61 E ~ ~ i 1 'l ..n- tt s Y I S Door!' { /DOO } - ' 1664 I t?c in_(3mtnbcr } ~ ~ ~ ~ d60 ~ ~ ~ » ~ ~ t f V11. Responsibility Statement- I, the undersigned, assume respousibilitN For installation of the POWTS show it on the attached plans. Plumlicr's carte ti'rintl Piumher'= at rc MP iitWS Number Business Phone Number _ I a7 3 13 SSG 7/S G 7.? - S.2G 4 111un7ber's Address (Street. Cinv_ State, 7tp Co 'c j /V d 98 Sr. h~~y. a s sii~Qa.~o, ~./3-73G V1 Y. Coun".lDe artment Use Only _ PC Relit tee i?atP C[iC - ISSUtt?3 ill Srvat'Jrc j ~1 1 ,,pprr, 1(r - l . od / 13 IX. Condrtt$e$~Casons fo. 1?tsapprn al i tat,tt, ett~,sNt r :3 eA%, dlsperwal cell must e(1 . ices n d nt '_r, as psrMonagfinent plan provided by plumber. 2. --M1'tsethlilCklna4tliMer~enls'mustbemainta.ined ss per r lcebla code / ig&nances uuhe, in ciir t., a _ C vl V v i ~ P c-t I \ 7"1 t M M~ •.I t(g a v Q L~ ~ o v Z- ' z u y ~ s OZ v W a R . o ~ `o ~ ~ ~ ~1 Q Z QO o ? p 3 Z a v ~ ~ V i,^~~ v x t~t• ~ O ~ ~ ~ ( fl ~ J ~ • 17 ~ ~(y~ ` Q 74, 44 k k v It V -C'C TO.Ual _ t re4 .S ~~IGtS C OR1sr~luc r/Ln1 - 3 -.~4. ~n11 /tn4.,~4 PocJ rs .r PurrP GNAriB.6'~~ Name: 1;1 il4ly" leSS: _ 30/ 2 Go rlr ~~E'. 7/S 760 - o 7,o5l SW, NE 0-ma, ~T. Cno/l~ Zy Al ~:lE arce-I YY F1 ~ l age G 1.- ,>>d .>r' ;j'f ~/Z9 SS " G i total ~%~i' 11~,/ ✓,/c r -r f.+fs'~~'l~ G~ ~e✓~~Jsft~'/9eaJLi»° L...rwr" tl:::~ ?gl pgeZ1 ik c~`.ut'b/ L of/' U s /damr'/dd.a 3_ a m e cif Le ? er, o/v y~_Et,eE i~ e INT oar: x.313 y6 sig?eiP~ uttotheFoLoWig POWII ~erlert € izai a~c~ P5 ~i "oil Zi)S ?`f ~ C}? v~-,~Q ~r tl~a t53 s0 h. L IZ. .0) SPO' ? 0,70 _ 2 ti r ~ V V VS Q' . n rs ` r 0 0 Yy g j ± t UZI i h ( - It 141 - 3 0~~ ~ ~o 0 ot- -s -zl 144 o R S~ If y i , y r u v IQ to Z o eC R v :o Y y~ R`r R t~ t, CID - .•'}`;`l~ p`,' 1` a' = -in 1 AtNK-r-} i tlr Ut t(ib-tL-, MG 1\43T MANHOLE °iSET 2 COVER - - ~~.i J ''air t~79 i _,roijno Sut°ar~. away (ror 1 ~ {118f $ . ,S } 4"J Uet~t p: CVtP F I ~I1t ; Jcailf o}GtS~ for proocrdisin2Cge) j/ ~3.ilding _ „t f0' i3 t}iS} a5 t1cC=SS_ f i f' i •iGP1T2:2~ ,_..ead :zanRCie T~2-~ i 'Vent C~m ! f t_,ncs J j~ $2,3D / ; r Apaaved L az9na r:~ieni;o'a t 77 j ( zUh1C.+`i~fl Eo ~l) ' 3 it t z"si ta_ i I JS'!r3=id{4C-, orG ^i:S1R_3t c ' f 1 1..=. - I - . ' T-wablLsh=d Fluod ( ff L11I - (t n t - - .t 'f t ~ I1~ ~ i 1 3Ji10 OF iNL tia:=„ 1` r Le 1 1 tuls~ «-t_~ j 1 ill -Ste, -ar t...., t"-` ~ ///lam IJffif/'l/! l /y~iiiri>l`-•. - j S > 3t f'rlff/f/ ftK// L~ l i%/.'//Jt1l'lf/,'•. : - i. ! 1 } rl/ffJ/Jf 2- .'.'-/rlffff! 1%= :,1 1 M l... r-✓~i i ~t 1 t 1-0 ;'71 ire er i i APPROVED EFt LUG} T F } SF-_UENI~ ~ i U=r ;r,.i l ^IC/- PEWIRED ors O~t<< i il;':fcliUidGtUf~i fc//ESEit ~O,fG~tErE ti'l; ,Ciaiijrvjasie-i:+ciEriiv4', St1 1 Ss~ is/Pump tank model _ /ooQ /6ao dumber of daily doses 5" y ~ /8. 7ho / -etual dose volume) v`~itl tllBslUiaGitt!"c S ~hrQ i71.{u 5 `r_ i'1 Nodal number TANK i4z r..tT t oiGBiTt~il +10}Ln'tc 8 •Z So c ;i ?O'~isl^',Iitcf? /~ELHAaseRG GWal dose "Giume (gaNaP.U'. $y.d a dose volume - plume Oi lorcemain) '-uen pu-nip nnanufaGlUr@r G~0e --,e -1 T, Beni punt model number /sJUi;'Ps~l O;,FiGi lce eserve abM,& alalM o?D.S iilGCiaa = 3S13.G 33Ho 5 ..E 'ii?ltrt! pump CifSGi}af~i c Fate (GPi;~1 a7fJ nlalunn floa above on i}oat 2 inLifaS = .33..5• oalfonS f i On(Oei ifoat measure men S. 5 has = 5V 2 Eraffons 'B) iicni M (pump oil io dis(ribution laieral) /o s` Oil float 2bove unit bottom 8i4 Inches = 13Y.1 gallons (h) S, stem head (distal pressure -1.3 fee) 9W U!s;ZNSd014S PUIAP CNAvIBERSPEUFiGAMoi S ;oil ioSS In tf18 Torcernaip so I<.d/ , 1 /ss tin y iG t3 _Ita; .na sic nee F tiki S . , o -YO d-wilt .34 111Ch ~.'7 - - TOTAL DYNA(v11C HEAD`F ' 3~ - PUMP PERFORMANCE CURVE PER MINUTE MODEL 1511152.%153 EFFLUENT AND DEWATERIN MODEL 151 1,52 153 Fee! Aeier Gai. Ger, Ga..._I L rs C Leer _ gat 7 191_ 69 ''-5 170 1 c, 3 -26_I 291-5 144 1 53 201 1 61 1.0 44 167 at 1 7_ 20 L^G t - 1 _ t I 1 7.F I tE r29 32 30 - °3 87 33 25 - 35 1 103 22 85 12.2 4 Shuio Mcad_ v7 (9.1m) 38 ff ti 15ml ! 44 N (13 4m( oil - - - Model 151 Models 1521 fib? r I 1z :1US f l i r r::r~ii ~ "l i Model 151 Electrical alternators, for duplex systems, are available and supplied with an alarm. Variable level control switches are available for controlling - sinaie phase systems. _ J Doable piggyback variable level float switches are available for variable level long and short cycle controls. Sealed Qwik-Box available for outdoor installations See - `0 ;alp r 51:1,52M53 MODELS Control Selection i Model Volts Ph Mode Amps Simplex Duplex Non 60 1 or3 Ni51 5- 1 115 1 Auto .0 included c or 3 . ~ BN51 E1 a1 , 23G 1 (don 12 1 2 or 3 8E151 23G 1 Auto 3 2 included 2 or 3 "Easy assembly" N152 115 Non B-5 1 2 or 3 ipump S discharge pipe BN 52 11F = Auto 8-5 Included 2 or 3 f 3 riot included, I 52 23 7 Nor, 4 3 .2 or 3 3 1 BEE 152 230 Auto 43 In„ „ ded 2o,3 U153 115 1 Non G5 2or3/ s - > BN153 115 1 Auto 5 _ lnc uded 2o!3 t 23u Non or 3 3 _ -Jc7-` 230 Auto -,eluded 2 Cr Single piggyback variable level float switch or double piggyback variable level Reduces potential clogging by debris. oat switch. Refer to FM0477. Replaces rocks or bricks under the pump. See FIN10712 for correct made; of Electrical Alternator E-Pak. Made of durable, noncorrosive ABS. able level control switch 10-0743 used as a control activator. specify duplex Raises pump 2" off bottom of basin. .Ioa. s.stem . Provides the ability to raise intake by adding sections of 1'/z' or 2" PVC piping. h Lh~`?l~~ Attaches securely to pump. Accommodates sump, dewatering and effluent applications. P•.OTE: Make sure float is free from obstruction. `Cl" Lt ' Ove _c el 0f J ?r. Eb . = safety rdCri.i l5 2rl{,jaleef,,.I ti-,c E if 'es ~ J - hyright 2003 Zoeller Co. All rights reserved. SYSTENR SPECIFICATIONS Owner A TFR S COLE Lo.,a S~-auc r~o.J Tank Manufacturer' f f DES Lr2 ~o„ eta, r l Permit = { 1 W Septic [11 Dose i lfolding vol'ume: 1060 (5 - i Tan1{ Ivianufacturer: Gt~lesc- L hL DESiGiI+ PARAMETERS i-l Number of Bedrooms: 3 ❑ hA l~ Septic l~ Dose [I olding Volume: fe oD teG? - Number d Public Faeifityl~ntCS: _ ('i+"• rvlVertical OtsianGe Tank EoiLDm(S) t.0 Service Pad: /O QO vtimated (average) F io,,-:, : (gaii'dav) ; lOr{-Oritai [distance ank(s) t0 JeP.ICe ~c ~ i Specific servicing mechanics must be provided if vertical is >15 feet c, Design (peak) Fia4,' = (esamatao :.o}• yS0 feat/day) j i horizontal is >150 feet- 5peciiic ins,ntctions to be provided on ba`.- - SST In Situ Soil Application Rail: aaitdaytft ; 1 Effluent Filter Manufacturer-. Standard (Domestic} l E^lUeni ltionthty average { Eiilueni Filter Model: niuent% ~ Pals, Oil a- Grease (FOG) _<--O Ta;L P' imp ivianumc:ur er' Q -,C 4 6IC Bia:hemical Oxygen Demand (BOD,) `_220 mgiL Ei }'1^ j Pump MDd?l: otal Suspende^ Solids t T SS; S150 mgJL J - ;gh Strengih Inftuen(rEf luent i"'lonthly avc-ace i Pretre2 merit Unit t (FOG) >30 ma1L ivianufacturer (BODsj >220 rngP_ i A i © .9 ;Mechanical Aeration meat f=ilter I ss` >150 mgiL t: i bISIS}iet'.llJri D' etlone atreatcd Effluent NAcinthly average ? Sand/Gravel Filter J Other: (BOD5) <_30 mot; i Soil Absorption System TSS) <30 mgiL NA In-C--round (pressure) i !eti (a r:v Fecat soli€ar. (geometric mean} s1O ln-Ground i-,--- , ❑ Al-Grade mound iv,-~ximurt Eta cent Particle Size in dia. El NIA ❑ Dry Line i-' Mel: i j if, er. ~ Eta Other; E j E /.lF~c r.a~ran Qu~u~ y ~.O G NA.r,66a. t tki T 1\1 CE SCHEDUU: Service Event i Service Frequency E. 1 W;'lrhen combined sludge and scum equals one-third (,a) of tank volume -mD out contents of :anii(r,? k [jll"1)tten the ltQl L`da.Br ?laRr is aCiiVa ed 1' At least once ever V: (t~Ia: Imt1m 3 y@ar5i 1 j i;Sport COnditiDn Df tank(s) i fear(s) (Maximum 3 years) NIA 1 inspect dispersal cell(s) Pd least once ever;: year(s) 1 'V 1=1 ! 2 monih(s) dean esiuenr filter ieast once e er ,18ar,cj !;a month(s) iti'A inspect pump, pump controis & aiarm 3 At leas; once ever': 3 ,ear{s} L month(s) jr gE l ;;-iush laterals and pressure lesi i At least once, every:. 2r(sj j nontr(s) ❑ f\lA 1 -^i Other: At least. once ever'- v=a(ts) _ LJI NA "ith :;AIiN T F=NANCE INSTRUCTIONS ,Deciions of (ant s and Sail absorption sysiei s shall be trade by an individual carrying one O! illG i011owlna licenses Of GBt iiiCBiiUnS: i:' aster Plumber, iviaster Plumber Restricted Sewer, PO'AITS inspector, POV!TS iviiaintainer or Seotage Servicine Operator (pumper). c" k, inspections must includes a visual inspection o. the rank(s) to identify any nisring or broken h2rd'Alare, idenli~I anv cracks or (Saks, 771easure the volume or combined sludge and scum and a crack for anv back up or ponding of erlueni on the around SLlr 2ca. The soil --sorption system shall be visually inspected to check tae effluent levels in Lila OtlSeNai30n pIC?3 and to check for any ponding of diluent -'he ground surface, The ponding Df eiluen an the ground surface- may indicate a -tatlinS7 condition. and rcr3Utr°S the Immrdlalc ~.outlc2lion of the locai reguialory authori r. or more of the tank volume,'ine entire en the combined accumulation of sludge and scum ;n any treatment tank equals one-third `hole NR 11 ° ntanis of the tank shall be removed by 2 Sepiage Servicing Operator (purnper1 and dlspa52d of to 3CGDrdanG° `IJittl c• gcansin Administrative Code. D"trier services, including but nai limited to t'ne servicing of effRuent-ilters, mechanical or pressurized comaonenis, pretreatment units, a ` SetnllCin'j at. lntePlOis -.T <_i iTloR~h~, ~h311 be pets form. ed by a certified PO I/ T 3 Maintainer. 7 SMART UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemica!s may impede the treatment process and/or damage the dispersal cell(s). a tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltia,;- -:;r _ During power outages pump tanks may fill above normal high eater levels 'bl;nen ooxer is restcrec ire uxerss ~raasiade 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. I o 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 ,vithin 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 wa !:''n 5 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 POVV" . ibiotics; baby wipes; cigarette butts; condoms: cotton swabs; degreasers; dental floss; diapers, disinfectants, fat, foundation dry, n np pump) water; fruit and vegetable peelings, gasoline; re~ sv; h __I Ides r-~ea s, il ...e,' a ions o o rating predicts ;_sticides; sanitary napkins, tampons; and water softener brine B;< NDONMENT When the POWTS fails and/or is permanently taken out or se~a ic- ,,iu.: ens a•. t , :.-M !s ro er;., and safely abandoned in compliance with chapter SPS 383.33, l~rlsconsin Administrative Lcd . Ali piping to tanks and pits shall be disconnected and the abandoned pipe openings sez.:ec i he contents of all tanks and pits shall be removed and properly disposed of by a Septage ` - C After pumping, all tanks and pits grave! or another inert solid mater-. ! CONTINGENCY 1.11 If the PObVTS ` ~._ement systen suitable replacement area ShCUlb be protected fion; disturoar:ce aric cornpact,oi', and should rim De ,ntringea upon Dy iequiFe aatbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the nee, .r a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules it fact at that time. _ •^C7in.:v e suitable replacement area is not available due to setback and/or soil iil ding tank may be installed as a last resort to replace the failed POWTS c site has not been evaluated to identify a suitable repi3Cement area anG cla or -past be performed to locate a suitable replacement area. If no replacement area is availadle a holding tar,. ; may be installed as ast resort to replace the failed POVA.rt"S. 'JUnd 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. «',RNING>> S -TIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT 7, iTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A SON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name i_ -/©N•s1 ~E[KE - 313Y6 ' Name cN~ AF,4 ec C',,,:~E4xe `L~*rv8~.~~/ Phone # 7lS G 7,Z- S,?Gd Phone 7is L72 -S-.?44 SEPTAGE SERVICING OPERATOR (PUMPER) - ? LOCAL REGULATORY AUTHORITY Name Name Phone Phone s 71S ,x'86/ -'/G b'O Tnis document is intended to meet 'he minimum reouiremenis of ch. SPS 383.22(2)(b)(1)(d)&(f1 and 383.54(1), (2) & (Ti, 'Aisconsin Administrative Code. Q . Q LL v r J V f ° l~ Ql .s~.wy ® d' -0, 11 5 Ml ~ x ' °aW J 5d is ° > r C. C V - - rw J O ~ ='a.~ ~ CJ L ~ J ~ - ~ G f+1 ~ ° C J i'• Y - zl- v j z o ~ ~ ~n 3 n ^J J d C a v v-~ m p - 1 m G U +l G U .J` N - v r ~ ~ V Z . r1 ~ rf n r ~ r ~ 33 _ J ~ ~ V G G = v t. „fit ~ . mrt n _ - 's$, O ate. J J ~ 0~ .s t ~:d ST. CROIX COUNTY ~~Co SEPTIC TANK MAINTENANCE AGREEMENT AND Nov OWNERSHIP CERTIFICATION FORM 10:0 1~j~ Owner/Buyer rA~ 1 l S ~~✓d.~~ F~OPn 1 + 4~ Mailing Addres s C) 0\ Property Addre j (Verification required from Planning & Zoning Department for new con ction.) City/State Parcel Identification Number LEGAL DESCRIPTION r Property Location 1/4 , 1/4 , Sec. , T N R W, Town of 13 '-T Subdivision Plat: Lot ~ Certified Survey Map # Volume , Page ,'t' Warranty Deed # (before 2007)Volume , Page # Spec housed yes ❑ no Lot lines identifiableyes ❑ 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 §SPS. 383.52(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 Safety And Professional Services 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. Uwe certify that all statements on this rm 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 warr ty deed recorded in Register of Deeds Office. Number of bedrooms ~1. J014ATURE OF APPLICANT(S) DATE ***Any informa ' "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. 04/12) O4( L% x- I ol-6 Q-M~ 8\OUVA3-Q 2IOYH3lXa. )SH3I43 ~F wr,Tiw ]uf~.AlWv ITS IVIL4` Mg WEN 1. 1 0. ~ `6 ~V 1 ' NOI.L MUSNOD 99(13 sugly lcl o f $ a 5 a `EF G a 3 6 !t• Al i I ~1 s i u~4 LI [Bill ~ z i / LJ~®~YJ ~ ~l ,fin I m Ill i m Han \ I o I z ~ ~ Q j >Q a IU . w. w i. r i \TVtd N07I,VCltiil0d ~ J1393fIJ na-181-51L lid I TeMsi03 JR9n•,IlfKVatcunv•WIDOW" a a NOMfIUJ SNOD aOaa saaiVm = W I~ ` I Z I ~Iliil ~ i ~ i } - E`j I f I i , - - i - - ji~ Jr I I V, 4 r Q V - - - - ; E - f ax I i I ~I y~®~8SL619C~SiL 71d 9IW6LM 9 Lain lt%VA+S' u.»iiaa S ~W9 dom. ZN1\'F~l Q~~~7 ~ ~vnx3smm • Ailwve m TnLHaaLC+s :019 3Yid :M11 ~ - t NoI. fiRLsNoo 39ag s2Iuvm o n Q J Q ¢ W G i ~ E a q 7 8 In , ' a~ tea. ~ o z s t CID Qx I I