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HomeMy WebLinkAbout030-1077-10-000 (2) I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CI'OIX Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597352 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. AV6 Permit Holder's Name: City Village Township Parcel Tax No: PAUL & WENDY LOUDAS TOWN OF SAINT JOSEPH 030-1077-10-000 CST BM Elev: Insp. BM Elev: BM Description: of S ction/Town/Range/Map No: , 27.30.19.2748 or C U ras TANK INFORMATION In/ LEVATION DATA TYPE MANUFACTUq ; 3r CAPACITY STATION B HI FS ELEV. Septic Benchmark f V y. ~ 161 . Dosing ^ OM D „Q t Alt. BM Aerttibn Pt` ~ Bldg. Sewer 12' 7 , _Ht Inlet zs 2: 91Z 5s- St/Ht Outlet TANK SETBACK INFORMATION TANK TO /L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Kh ( Dt Bottom 45, Ull r Dosing ~ ea der an. J Aeratio Dist. Pipe / b Holding Bot. System q 7 Final Grade ~r PUMP/SIPHON INFORMATION / q, Manufacturer )~fL.~ GPMand St Cover JL M .0 Model Number 6N ;S-1 jTjQ,H TDH Friction Loss System Head [V (J . Forcemain Len( I Ll JlDia.1 Dist. to well - SOIL ABSORPTION SYSTEM 9 ( t / BED/TRENCH Width =ngth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Dept DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: / INFORMATION T e Of System: , / CHAMUNIT BER OR Model Number: -W 11 0 5 ,JwI V ~lv) L DISTRIBUTION SYSTEM T Header/Manifold Distribution x Hole Size x Hole Spacing V WAI ke Pi Dia L e s Q/~~ Length ength Dia Spacing e SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over \ xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center lBedfTrench Edges ! / ~ Topsoil yeg Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: oil Inspection #2: T Location: 654 PERCH LAKE RD ( VV~11~ Q\ 1~ v 1.) Alt BM Description = ~ f 1~p r 2.) Bldg sewer length = S) ` 1 C~WIJ~ - amount of cover = t S 19h S~`C(~,~ °7 ou Plan revision Required? ❑ Yes No Use other side for additional mformatio SBD-671 0 (R.3/97) D Me Ins ctor's ig atur Cert. No. I i t_f , j industrServ ices Div is County j 2017 1400 >v Washington Ave SS S APR 19 P-O• Box 162 ' Sanitary Pem'iNumber (to be filled in by Co.) ` Nladis I - 07- 2 { j ST. CROIX COUNTY 4 7- J Sanitary Permit A 1* State T,ansactionaN mber PP lcaiFr~~~Iol; In accordance with SPS 333,21(2), Wis Adm- Code, submission of this form to the appropriate covemmental unit I is required prior to obtaining a sanitary permit- Note: Application forms ror state-owned POWWTS are submitted to i Project Address (if different than mailing address j the Department of Safety and Professional Services- Personal information , ou pro ide may be used for strovdu,, .purposes in accordance with the Privacv La-,v_ s. 15.04(l)(m Stats- I. Application Information-Please Print All Information` ~v S Ei1t~i1 L IICE rQD. Property Owners Name / Parcel Y 7- ~u~ IJE~Dy LouA~dS oa- 03a -167 Property Olvner s Mailing Address Property Location i ~23q _ .JD Govt. Lot f Cint State 1 7_.ip Code (Phone Number Section 7 f one) !y o0 9 rig Y (circle o If Type of Building (e eel; ail that apply) j Lot T , lit l or 2 Familv Dwelling-Number of Bedrooms - Subdivision Name t3iock a - ❑ PubliclCenunercial - Describe Use ~ l S ~Tty' of (n,OJsr✓ w ❑ State Owned Describe Use CSM Number t+ iit3 e of q q , J ~p / p + / ! / / I 2 rJ D iP foxvil of ~7 r ~~s6.~iy a4 E 111. Type of Permit: (Check nIy one box on line A- Complete line B if applicabb ) j i ~Ner*. System i J Rtpfacetnent System f 1 TreamiezW-loiding Tank Replacement Only y i n Other Nloditication to Existing System (explain) I Ii - - List Previous Permit Number and Date Issued B. j D Permit Renewal D Permit Revi-iion Change of Plum ier ❑ Permit Transfer in Nc%v I Before Expirdbon i ONner ( t l , l 1~y1~ Q7/i Il'. pe of POti"TS System/ComponentfDevice: (Check all that apply) k,Y I)WNon-Pressurized In-Ground D Pressurized ht-Ground D At-Grade D Mound > 24 in. ofsttitable soil D Mound <24 in. ofsuitable soli f~w~ r D Iloldine Tank= --D OtherDispersal Component texplain), D Pretreatment Device (explain)-_- r Dispersal/TreatrMnt Area Information: l Desist Fto;v (spd) Desist Soil Application Rate(2p Disoersa1 area Required (s Dispersal Area Proposed (sfy Stistem Elevati 5'SQ ' Al l //1;T 11-73.8 ~ 1 96.0 Tank Info Capacirv in Total of tvlrmufacturer 1 Gallons Gallons Units 1 ( L a 1 = 1 N ac Tanks Existing Tanks ( I J y 3 wll&~- 16 i Septic or i4e}dim*-?~i: 1 / ~_/OaG ! /G'SG / fi ESE- C~on7G~f E7"6 ~ C7osirr~ ~o rt w L VI l_ Responsibility Statement- I, the undersigned, assume responsibility for installation of the POIt'TS shown on the attached plans. Plumber's Name (Print) Plumbers Si n t e y4P,15S Number Business Phone Number .l o ~~K { 31Jy6 1714 1,7,?-JWa6 Plumbers Address (Street, City, State; Zip Code,) ~ rr i Vill. County/De artment Use 0n1j 1 Permit Fee Dar issu ' lssuins. ntSignature Approved D 1 ta n for C?cnial ✓~3/ vi' t`. Condition Vic`, 'or isapproya) - ui3pet : i cell rytraf 0 be _c S r r,,- it ec 2~pML~ t ss',per marigerrWwf plan p!c'iaed by plumbe. f Jlv ~ 2. A AdbacK'ree~ -On mast rxt* t: «rt, it E f 1~. A 3 t- ~f as per wiicAbla cc& I ~:rdlnama. U Altaeh to complete plans for the svsrem d submit to the County only on paper not less than & vii x I I inches in size SBD-6398 (R. 08/14) h CY 44 - - - - n t N1\31 - ~ V tt 1 i { i Nk. lij tj 4 r v QN. R\ x o a it" f= `ry t" ~3 V. M 3 1' R M tt tt X ~ tt ~ K ~ Q v Rt o -In 51 Ra 11 » a ~ ~ Ns -3 .rt eta _ _ ~ + qtr e T, eatymnent Ss LT--,d;a, -d Tuttle Pie I -v;t.c ffA41 f 41E',0QY L J vitJEcJ~ cu ,P D 5 - 3 - ~d. ~.JLita4a0 Powrs w /~Nw/0 CN,f~v~E-2 OwRe_-'s Address - 6 929 GJy~Q~A.r l✓AY ~oo_ D,BuaY /`1N .$-57.5 S j ibC~-Msioa Nam-c: L at Number: ook-Nz ber: - - - arcpl LD_ Number: V,03a - 78 agc L r 2 p4a ~ r'/~ //#~r~d' ~sJ is ~flr?rJ/ri x 4 s5 - s C 3/o J va9@ sY fF/}~ad llJ~e?~DdFOlllilC~ G Gs' tJc' age _ G~fJ 7s . a-z'W - /'Y'AK. j&s, %ls fp t ~c!< ; ~fl.d' ~ ,rte' > e ~ ~i~,l~.% L ~i✓/frJG c' /~z/r°O Page G ` ;,?awe of Designer; o d.r I.C4,e ' . censeNtt ber: /1P- ~2313l Dom: S- ~3 -~ot7 Designed _ . # to the- Following P© S Component I'vh .U J - - - - 'nt. s __it'i n4yY a 14, 1 Q o .x h H a q Y Q 4 0 L. 10 ac ~ ~ J ~ h 1 1 ti c ` h o h V ~ a 4 ~ ' c in < b i h 3 1 : vi w V IJ < to U „ v a 13 3 a W 14, V h In In y~ O p 1. ~ 4 Q ~ ~ O 0 i v W a , h ~ ~ C `a. l K 1 o v v a r-t- h -r-r-- h +-t o t hra 4 h W r4 +h a D i - - CO- IE3r ~ "TRON °~'~'~IC 1 A l~~!trP~. NFP \~'~i nl~~BER i~-J'_C 3 IOC Cie 7 ~ I O!'ct!WING CIO T TO SC AL E) MANHOLE RISER r? GOIFER 'r"{14AL GrrWOE: f¢$r S-9r' J 84,25 tf ! L. (8)} 4-0 ii>ftfll7Y i Vet - t ANT: j tSiuGc gi o st d Sclf[8Ca 8:'!8y ltZtli j / eci!O' 3 i1C(S} as manhole(s) I~C=manhole(s) io; D(OQci dCalit2gc} B ~ ailamg - 1 E=t-mitt =icad S=+rdien ' _ :iGI1lQ±2~ - cap ' 3UILDI``NGpSEq~rV jE s Vera L~`er w4.r U~.il!l L}}}~ / I 1 _ ( t 1aar3V2u .U f- I i ;t: 1%!ertirrc =aaf ;siscn_ti J jUmCT10M Eor t iepgl E~- i;tAtdHOL= fi- _(n m tmal,r[aeil--;---- °-1 I ~'_h~1T•' ` • • , v rfi~lrfr. ~ yr/f///1.Iflijrfii~~ is/~//~/rrsir~r-^i1 Jl%/ii~ii!€5~~.:~ i,/,N;R . i ,1 ♦ 14-- /10 t I 1/ ,z T'Eie. ow. F Ii 4°!1 ~ 1-,s~-~ :!i7Et? '1 11 r~ i ;i arL? nr iFPROVED cFF;_UEit7 hF FFR ~ f =E LUE ~ ~ ! s p: = =Lv:ii REr,-)-UIP,EDOt=OUsiL-- i _ t f.< aiat?_ anIcManuiaciurer l~1/FSE.c ~o.JC,c~r~ i1Y,11 Q81I~r~~cSiv't'ate sOt'j ySL! f';jv :3e"ticlPUMD iank model /0-06 /Leo number of, daily doses S. S /8.3 f0 '-1 actual dose lrolwmt model number 7791,1,< ffZL-str I rorcemain vLlume 9-6 G6 . /L 3 71•.1re Ct float St3+i?ch ,VEL,ygwIz- 1. ;;ciual dose volume iga!10 S) y iG[at dose volume - Volume ad lorcemain) /.~..!3 - g d = 8~• fi uent pu np mane aciurer 2c re tEIL -ffluent pump model number /S1 PUMP -1 ANIK CAPACITIES Reserve above Slam? 20, S inGhas = 3 YY Zgalfons wil Iimunt pump discharge rata (C-l"MI) p?a o I ;tarn float abo~fe on ;toaL =2 ;nc les = 23. 5 aiiens {C) Ordoy tloaa ii'ieasurment -4LE inches = w..7 Fallon (s) - - Veriicai lift (pump off to disidbuiion lateral) 7. Q Or; iloai abokle ianlr botion 8.0 Inches = gallons (h) sysiern bead (distal pressure'A 1-03 feet) TANK DIMENSIONS & PUMP CHAMBER SPE F GAPONS Friciion loss in the Torcemain Go x- d 1 Total dymamic head JDLK') > / Length /So l'lydth y 1 iauid depth 3, " Gallons pe, inch 1,1.76 i TOTAL DYNAMIC HEAD FLOW wig PUMP PERFORMANCE CURVE PER MINUTE MODEL 151,111521153 EFFLUENT AND DEWATERING 5'u - l ,t 45, 153 r MODEL 151 152 153 45 - Feel I ,e[ers Gal. a ters Ca! Liters C,at Liter i o ( 3.=, '---k- - s _ _ ( s sa 1189 = _ 261 TT L - to 152 ( i j 10 &0 45 1to +61 231 70 265 _ l -..0- ' 'r 15 4.6 33 141 1 53 201 61 2_31_ L L K15' 220 6.' l 29 .ti 167 52 I i97 s/r l ( 25 j 7.6 i 16 61 34 29 42 159 s ^ - i.. - .-----I--- 34 i 3.1 _ - 23 -S' 33 125 2,2 - - 1 1 32 Shu.-ofHead-. 30tt.;SAS,' H (11.6m) 1_. 44 it 1134,- et l l C1 _ i Model 151 Models 152/ 153 10 N 39 40 e:, w 1C9 GALLONS Y--- -.r- - _ L'T=A` 0 40 37A - - _ 4F9 FLOW PFR b11`BiTE 0?45C~2n 3 ha n r, Timed dosing panels available. - - Electrical alternators, for duplex systems, are available and supplied with an alarm. Variable level control switches are available for controlling i- ' single phase systems. Double piggyback variable level float switches are available :=I for variable level tong and short cycle controls. j - Sealed Owik-Box available for outdoor installations. See n s F X11420. • Over 130-1 4'C, SCecia .uota;or fefj,i aa, s4.,_I Ll # SK2444 SK2064 951 1~2?i53 MODELS Control Selection Model Volts Ph Mode Amps Simplex_ Duplex A 01 115 1 Noi 50 2ar3 ?tv151yy 1 ,15 1 Auto 6.0 Included 2 or; 151 ) 230 1 Non ; 3 2 2 or 3 _ ; ; 1 1 230 i Auto ! 3.2 Included or 3 "Easy assembly" ,152 15 1 Non 8.5 2 0 3 4X ` 1 \ , (pump 8 discharge pipe 3N152 115 i Auto 85 Included 0 3 not included.! E152 230 1 Non 4.3 1 2 or 3 BE 52 230 1 Auto 1 A3 Included 2 or 3 , ` u f 1153 1:5 1 Nor 105 1 2or3 _ % _Bid 1531 115 t 1 kl o 10.5 ln~ ded ' or 3 53 250 Nor _ 3 2 d 3`;~ , I switch.. Refer to Ftv14477. Reduces potential clogging by debris. flioat Replaces rocks 2 See FM0712 for correct model of Electrical Alternator E-Pak. Made of durable, bucks under the pump. , noncorrosive ABS. t-arable level control switch 10-0743 used as a control activator. specify duplex Raises pump 2" off bottom of basin. 3j or :;4) fsc.z,i s';aem. Provides the ability to raise intake by adding sections of II/T or 2" PVC piping. d CAUTION Attaches securely to pump. Accommodates sump, dewatering and effluent applications. f AIOT=: Fv12ke sure float is Free from obst-uctien. rCr un!j !aI a rP e;; S., L.,Jr a cn~t teei°C~ in re tre iesi r Qf eve t~ Zoeller pump. O Copyright 2008 Zoeller Co. All rights reserved. K;E L0%vner AUL t WL J®Y 60u0,~ S i Septic Tank Capacity 1 Fernlit ; Septic Tank ivianufactt:rer ! cS g LOwTCd, Ci N-A _I { Effluent Filter it=Ianufaeturer X?A \r r j Effluent Filter iviodel Number o Bedrooms (IOO A"Z gpdfbedroom i) 13 . I Pump Tank Capacity ( BOO 'Tal ❑ N_L Number of Cainmercial Units ~ Estimated flow (average} ; - 'Dump Tank ivianufaeturer 11 A,11,rxrC Loj c4. t ~ _t I , 300 Cal!da ; I ZG4 1LEe ❑ -NJ"' ! l ! j cai Pump Manufacturer Design Row (D?F), estimated .5 9Y-0 9d-% { - Pump lviiodel i lS/ t NA Soil Application Rate gar/day r' Pretreatment Unit x NIA} Infiuentliffl ert Quality (W NA) i y,Ionthly AveT, -ae ( F 3 i SandiGravel Pilter ea? Falter Fats. Oil 2. Grease (FOG) j < 30 Frig/L ( viachanicai a era=.ia;i F= 1:let?2nd Biochemical Oxygen Demand (BOD;) I i < 220 ; I El Disinfection 01 Other: I Total Suspended Solids (TSS) InQ 9 L j kdanufaciurer: Model: < 15G rng/L j Soil Absorption Component (0 NA) II Pretreated Effluent Quality (ER `A) ivionth1 Average t i Ax ?n-_rounc (v;avlt~ ? i ln-ground (pressurized) Biochemical O xvizen Demand (BOD,) 1 < 30 rne:L i ❑ grade J iviound I Total Suspended Solids ("ISS} i 30 i' gt Fecal Cfllltflrnl (eeoinei:riC mean) L I 0 Drip-line 0 Other: <1G C1%1100ml { ~ert;cal Distance Tank Bosom -to Service i eau. /a? 1 N-laximium Effluent Particle Size j Its inch diameter ~14orizontai Distance Tank(s) to Serv=ice Pad: 1d4 D' sase--M_ Jniz M4 r-4 aP 0IL14 1-/ Z'A Ca'C3latic. s:• Soil DisDersai EiI6 Cap (Dispersal U714 ETS-4. ; or _^_toyiication mate = Area RrMuired - EIS: - { r r>nLli ' ;stl_ - iris or ~ oia' Ler.?tii of Trcachti sl SO . S7 ed9.y6E~5 { ❑ "Design of Pressure Distribution i,;et vorks for Septic Tank-Soil Absorption Systems" Publication 9_6 (SSVi'ivlP lvlanuai} L, "f CC Flowtech Mound Component ivianual" Version 1-2 i -EZFlori' viound Component Manual" ?%ersion " 0/2007 0 w2 71 S731-3 - ? MLI-P (R.,: , r-:}Fade .,omponent i4ianuai Using ;3ressi<re Distiibuiion-' Version ?.v 1 ~VSBD - 10705-P (i1.01/0 ) "In Ground Soil Absorption Component Manual" Version 2.0 0 SBD - 1.0691-P (N.01,011 "Mound Component 1`lanual" ; ersion 2.0 El SBD - 10657-P (8.6199) "Drip-fine Effluent Disposal Component ?•.j`anual" { ❑ SBD - *1 0706-P (M0110 l) "Pressure Distribution Component IvianuaP' ersion ? C' 4 ❑ Other - _ r. 71- -E I ---%iC' ,IC"';:v- - - :3.°. •?r'CE Cf3~-?.iC i i~{1n?711R57eCi t3!it:{5+. IRSDZCt Ci.1Sp2rSal :.e11(S), clean -filter t IP,~ST CnCE 13 months `9 3 ;'Cars ❑ Other - Inspect pump r°_' pump controls.. alarm, pretreatment um: I At least once ever-,,: 0 months R 3 years El XNA F!usIh, and pressure test iaterals least once ery : ❑J a?onihs k 3 yeae s ~ 24A _ U_ _ For rie.v CCRSLrr1CEICn, pFICF to use Cf the 0Y-VT5 chest: tCi:aii3]eitI i3n?i(5) rOr i )E presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellis). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System sil-rf =up small not o_eur i'iieri sot€ L'itnditiones n-2 fi-oze- al The ptioAerty 7!'~iler iS respOnsihle for the operation and inainienance of-, lie POWTS and submission 4i ret?uired reports. The quantity and quality of the waste\.,ater s-ucam. \vill a"ect the performance and tongeviv, of your PO WTS. The installation of water-saving appliances and f i :•tures along A ith prompt ropair of leaks reduces the wastewater volume. Adso the brine or waste from water softeners, iron removal units- other clear ;:`ater treatment devices and foundation drains should be discharged to tie ground surface -whenever possiaic_ Note: this does not include iaundry waste, sliowers, disliv.,ater, etc. This system is designed to handle domestic strength wastawater; hog=rover the disposal of food based nreases and oils,-vegetable/fruit peels and seeds; bones, and food.solids such as those produced by' a garbage disposal should be minimized- Toilet tissue is the only paper that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons; sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, Page S of 7 - C' o~ 7 S::~;. t UP AND OPERA T iONI ?ace F o, new construction, prior tc use of the POi/vTS check treatment tank(s) for the presence of painting products or other chemicals tha; may impede the treatment process and/or damage the dispe sal ceil(s. it ^:ty ' co :cenirations are deiecteG have i 1e con a nt tG - 'the tank(s) removed by a septage servicing operator prior to use. u!Ystem start up shall not occur when soil conditions are frc-.1 - n ;!ir2ti,J su acc. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater wili be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge o+ effluent. To avoid this situation have the contents of the pump tans: removed by a Septage Servicing Operator prior to restoring power to the of uent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels vvit;iin 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 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the foilmWing from the wastewater stream may improve the performance and prolong the life of the POVVTS: antibiotics; baby wipes; cigarette butts; condoms; cotton skinrabs; degreasers; dental floss; diapers; disinfectants; fat, foundation drain s::mp pump) water. fruit and vegetable peelings: gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener briine_ 1 hen the POSITS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly ar;d safely abandoned in compliance with chapter SPS 383.33. Wsconsin 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. c 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. w.. ''.r.t- ii~jGENCY PLAN !f the PQWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant re; i ;cement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. ie 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 eject at that time. A. suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POVVTS technology a holding tank may be installed as a last resort to replace the failed PONNTS- The site has not been evaluated to identify a suitable replacement area. Upon failure of the PQtNI S a sail and site evaluation st be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as e last resort to replace the failed POVVrTS. i:ticund 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 Mth the rules in effect at that time. <~~~mr~R~JIi~iG» SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN! LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. QO NOT Ei 7ER ASEPTIC, PUMP OR OTHER TREATMENT TAKIK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A J _RSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. _,,DDITIONAL COMMENTS POW IS IPISTALLER / POIATTS MAINTAINER Dame ~ 77--N-,,1 1 Name I J i , Phone i 7/S 7~ - 5o7GG Phone 7is- G7z -sat 6 i S =PTAGE SERVICING OPERATOR (PUMPER) - ~ LOCAL REGULATORY AUTHORITY Blame i Name ` i UEUEGoOis~E•✓7 I Phone PhoneI This document is intended to meet the minimum reouirements of ch. SPS 383.22(2)(b)(1)(d)&(f) and 3$3.54{1; (2) & (3), b~Fisconsir Administrative Code_ Ae o, his accornent tc_s not c?_arantpa i"re .rmrr anc_ 12'C •`i S. E f %1 v; } t G V n v ry p y y- ,O- m - _ ~t CL a ~ Q y G vi C. v ~ Z LwU~ m a ~ p c ~--Y o u~ > r5 r L M v V _ H ZE _ y = Q1 LLJ o c ~ " y y v v = IL .n t s ~ -spy _ ~ r _ 2 V O O T 2 ^ s c -m r Q < O r v T 45 IL- a v _ y ti C-`) -C v = w C~ U C f C- aa+ U~ C 0~ pQJ ~ V4j C y y~ C. ` - o es 2e ~ x ~ ~ ~ c- ~ ~ y vn il n ~ .fl lv H m T y 'V Gi Z :J ~ O W M J Y e,, v v ~ O C ~ C m l i.d CY, - r 'f a C G n►Y~ v v ~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address W11"7 1,4e C~ G !ee ' ins' v e~i t c S T;111- Property Address -57 C44 ZAI (Verification required from Planning & Zoning Department for new construe 1 City/State Parcel Identification Number LEGAL DESCRIPTION Property Location /4 i , ~ 14 Sec. • . - T 30 NR i` NV,Town of=CJ~ Subdivision of Certified Survey Map # Volume Page Warranty Deers volume , Page # Spec house yes no Lot lines identifiable yes no SYS"I'Eil~ Ii~AI~I"ICEI~AN ~ ANID Q~NER CERT`Ti~°ICA'I°IC)N Improper use and n;aintenance 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 Y the septic tank as a treatment stage in the waste disposal systenti Owner maintenance responstbiiifies are specified in §Cos nn1 83.SL(1 and in Chapter 12 _ } St. Croix County Sanityr1' 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 veal that (1) the on-site wastewater disposal system is in operatio fymg proper g condition andlor (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we the undersigned have r.a d the above requirements and agree to maintain the rivals sewage disposal sten 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 -mist be completed and returned to the St. C oix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. llH a am/are the owner(s) of the property described above> by virtue of a r Y warranty deed recorded in Register of Deeds Office. Number of bedrooms 4 -i-el - ?TURE GT(S) DATE 4-1 *1 *'*Any information that is misrepresented mar result ii the sanitary pewit being revoked by the Planning & Zoning Department. Include with this application a recorded wamenty deed fom the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 48105)