HomeMy WebLinkAbout020-1101-75-000
v orsnDenatl-en:rrCr^ erra PRIVATE SEWAGE SYSTEM Ccinr' SL Croix
INSPECTION REPORT Santar/PemaNu
GENERAL INFORMATION IATTACH 10 PF10,1I T j stab Plan IC N, 605106
PP snral irfonnat on yc.i pmwtle roay ae u?.en'n• <gror la,, ou p~. JS -n:aCy L,I, s 1 C4 11 )imll
Pc•Im I - IOlacl's N ome C0.'v Vlllape Ta/nsha Parce.ITax No.
Roger & Caroline Baker TOWN OF HUDSON 020-1101-75-000
CST RM F er Insp HM Flev 861 Descnot on Sector~'uxn: Rangeflap Nc
(3r►/~ I 65T 34.29.19.404B
TANK INFORMATION ELEVATION DATA
IYPF MANUFACTURER ;A-11 CAPACITY SIATION /BSr I FS CLEV
7 ~j /Cn
Bcnchmalk `{S6 /eI'S
All. Bre,~1 7.76
r-14AII e. 119,3
Aeralion Bldc. Sewer t c
Holding l' St'H: Inlet
TANK SETBACK INFORMATION St, H: Outet 1qr
TANK TO PIL :"JELL BLDG. 'vu -~I:c ' m:ntc ROAD D: Inle:
~Gw\
Sept c 'r _ r 7 A r nt Bottrm `
JO ti0
Dos no HeaderR,13i,
77-
Aeration Dist. Pipe 417'. Z
97.(a
I Irad.rg Bot. System final Grade PUMP/SIPHON INFORMATION ,Manufacturer Demand S; Cover I ,7a
OPN1 rv1.`dcl Nun:l?ur !S /f//~C
TDH Li't Fcc;wn Loss System H TDH Ft
Forcerlain pn Ih DIS:. IdV"u]: _
SOIL ABSORPTION SYSTEM
BEWTRFNCH AL'tr engtn Na Ot Tren;:hes PIT DIMENSIONS Nc Of Pit, Ins de D a. Liy_ni 3,1101
DIMENSIONS -179 ~~1 A 13
SETBACK SYSTFM IU P:L BLDG ViELL tAKEiSTREANI LEACHING Man.dactu•
INFORMATION CHAMBER OR J- r~ f jrc~
Fyne of System ,
UNIT p,totlel oer S~
DISTRIBUTION SYSTEM ~l l 9~19~/9 57 ~r
HesderT 3-ib / I Dis n9u]ipn r. Ilolc Si.c x F ;oaz:ir3 F-11 I Air In:a.e
1en91r /Z .'tench P.,ia --Ip 3.:inq
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
I' 0"r Dep'h _r r D,p'h c1 xx MUIG'A•C
H. Ilrlrrht rn'e 3. Z-7 Iiecf lr r. I :{pry: I ^seil .
L. Nu Yes Nr.
COMMENTS: :Include code discroponcies, persons plesem, etc.i Inspectior A Inspection N2:
Location: 651 CTY RD N (~,t:.~..5 I-'6 ~•G~J O ✓ ,
1.) Alt BA1 Descnpaon
21 Bldg fewer length = E>+<i6~ :1 ~r 6~~ ~G.~,~L-. L~~e~ Q•
- amount of cover - -74 Plan revision RequireV Yes No $
U48
se other side for additional Information 23I
Date I^sa .tcis aline Con. No.
I Q Q 2~`0 Indu a, Su\i DI%
0 SIV~ r+ 1411111 +A I ..neon:Avc -
sp nC}' PIs. H c?16 Qa~X
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Sanitary Pie nit Application S
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I I .)only pm I hi, I. r•, I I I n+ u I 11 I G I: an: I + r J I U\ I s I. - . J I PmI,❑ \Jdts.: a J:IICtrnI imam malls, a,Wrcvs)
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I \p lhcatinn Information Please Prnl AR Information -
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I\.I1pe o11UN ISSvwm'("otnponxnCDe\ice: (1 heck all that apply) Cta~
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\ Utcpcrsallt'reatma•nt :\t la Information: - -
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5!So~ 5/ /has _ _.1~ /~saaG.S
\ L Tank Into (.1! I I III - I I I of T
Gallon, Ga!I I I V .:I, I ~~~j -
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144~Lw~-Fn :A
/00 /000
IF- 21
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111 Respoa+llnht% Stalentel I, the toselm, "Id o r ponsihilitr far itntxll xti not file 1'0\1 I b shown on the allsched plans. -
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FILL ~1~1 IND "a
I\ ( ndiliuo IF \ppnrs uPltr. sous fm buapprus al (j~ _
SYSTFMOWNI-R. ~p am ~
t. Septic tank, effluent filler and L-t) MCL.Ao I
dispersal ce.11 m,ISt be serviced f maintaned 7b r)
as per Inarlagement plan provided by plurrb,:r. ll~
-2--f\N setback regmirerrI! -t--'Pe-meil~ed -,,,i .al,. m~ r n.nl. n:a. ynnrr nor In, er,n a 1 : x u Inrlw. In ,,.r
as per applicable colefordlnati eS-
SH D-639R l R. (IR' I •I1
P;mc 1 of-,
Private Onsite Wastewater Treatment System
Intlex and Title Page
Project Name r(oJe4r 16AC4/✓f iLx&t- ~-44. ~JLR3u0- O~rS 6C"I Cfnl+/
Owners Name:
Owners Address- G 5/ Le. t1o. /l/
-~ose , w r syo/6
G/,Z Y/9- GBaS ~
Legal Description: StJ, NE 3 y~ t IYt19 -
Municipality: Town, %414tgc, (-f)of 1r40toJ
County: ,ST, ~i10/X
- - I
Lol Number Block Number. SM Number:
Subdivision Namc_ GS/ Le. zo._ ,N -
Parcel11). Number: 0.70 -//o/-7f 000
Page I Index and Title Paec
Page Plot Plan with Cross-Section & Plan View
I
Page." Septic Tank Specification,
Paged rierE< ;*,,rMbnoauon
I'.,cle 5 filter Intbrmalion
I
Page 6 PO1i'TS ()w-ner's Manual & Management Plan
Page 7 POW'TS Owner's Manual & Management Plan
Name of Designer: f oN e:tK r I , cnsr d /y0- .T3/3YG
Sh nmurc' ~y Z//t-= Date 7- / 5"- 76/8
DeM ianed pursual/it g Il,r folln_ w~nr P(M I ( umponent Manual and LISPS 351-335-
SBD- 10705-P t N.01 01 R i nI "In-ground dud ,lhsorhliun ('umpancn 11:mu:d'• V crsion 1.11
Auachmcul, Still Ftaluautin Report
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POWTS OWNER'S.NL\NCA1. AND MANAGEMENT PLAN -
111 L I\f RMAI ION Sl -SI IM SPE( IFICA'1'I O\1
k nn it Sc ua T oils Cap nth' - f¢2-. d 71
Scpn,: Tank
UI - UII. FIZKS El(luem I dtcr Mai ufaclurel EST g", 71 X N
7 \ A~,
V nLu of 6 h cools I lUU_l'PdhcJm, m, 3 - _ -
Gllluuu I Iiter Model b
F-/o
Numhu of 7 AA
C im ns . i:d _ nrtd - - I Pump iar k Capa i -4-
al R X,4.
p
Fs it vamd flue I n~ ag~l _-app galidn\ mp Tank M17:muleUUrcr f O N:\l
Design flow (DW'I'1 c. umatcd I.? u -
/So ahday Pump MantlJOUIer rl AI
101 II Applicaunn Itatc P11 \kxicl 71 N
Picucntrtt llnil (Qd N:\)
InilncadFllhmm C11a0(v (O AA) Mnnthh' \vcr.lgc
fats Oil \ Cirexsc Iff)(iY `(1nnll. 'J 1vrd:( ir:rvcl Finer O I'calFiller
Biochm0icai Oc. Oar Demand eBODS) 7 Mcenarneal :\erabun O Welland
"'0 ate~l. 7 Dnndacnon 77 Olh;r.
I kind $nspcnurJ Suhds it S\j r _ I ill mug L I \garui a<nuc-_ Mudd:
Pr reatcd C I luem Oualue iX NA) iMonibl Av01Ill I Soil Nbsorp0on Conm n ctit ! 71 NAI
Rh!chcmlc.d Osvrcn O.:nclnd IBI)U~. ' _ai n_. ( N to ,round lbravnvt "l In-rrouod(pressurcecd)
( oral Sus tended Solids ( I SS) L '7 iAt grade ❑ Mound
5. 31) at1
Fetal Collforill 1•tc,o nw nc mean) n 1)[111 line -1 Others
tll Mitt IWhitt. - - - - -
I : Vut:cal Uistancc Funk Dullom I,, Strv icu {'ad: L ~
Mastmum 1:11iucnl l'siiic, Si'rc I:I, ocil iiallctc, i Horwomal Distance Tank(s) toScrcicc Pad- 7e - i
Dispersal l:ml N1(g.;NltnlvI \uothcr: AFit 74 ire n. Qu'c,c CN.~nbEtiS _17 VA
Calculations:
Sod Ihslx; rsal End Cap Mnspcrsal Unit FISAi
MIT ;\pplic.uim Rate Asa Rauuirer, - 1.:11\ - or ((gush \\'idthl_ - li Units or Tonal I iq;oi .,i Trench(,) .S7 4AO,, ec s
I)VSIG\ CKITEkIA
I'I Oc _ ~j'S //S3.B fps
u t l r .sore I)stnhun n\ n A. 1 ♦ nc
I l I Soil 4hsnrpliott 1\+lemc" PuMk.wou 9 G (SS1V\dP Lauv:ali
O 'ICC f t:w0.eh Mowed Com nnrcnl vFmurl A Isnn I _
❑ 'F7. Non Wound (nm potent Manual" \ crown h .llltbtl'i
71 S I3D- IOgi.I P(It I l?) •',\I Grade Camponcnl r\Inmval Using Pressure Dise"buhnu" Version 2.0
XSUD 1070, P (N.01'01)"In Ground Soil Absorpt(on (.nniponcnl.Manual" Version 2.0
7 SRD - IOh91 l' 1X.0101 )''Mound Convp.,nenl Manwl" Verdun'_ 0
i O SIM 1065' I' (K.0 99)1) ip Gas F.:)lu nI Disposal Conipoucni Manual"
7 ~M) IuiOh-P N.(11'JI) "Piss .Ir Di_lnuutl)I Compouant AFmtal s cl-,m 0
MAI\'I F\ \\('F: \I0\1.1'0121\G SCIIICDI-I.F. - \l:\I\•1'F:\ \\'CE A\U \L\\.\UF:V F: \'f
1 rsur Fvrm _ tense I rvgmmt
11 nq l _et 1 I I1 Ahsr I ar fShn _k l t s 11 nnnuhs _}i33 vca"s 7 Orherr
IL 11 r I'ur 1 A Inn Cvl ,111reuvall;:cot u II At , '7 _ nic alts 0 i C ,'s RNA
rlh i, ,n at•i.,..r~la ll, ra 1 VIA,. t. ,.:.a. 7 ...rnd,, 7i`aa> MN\
SIART_UP AND OPERATION: Far ncn conslnlaion, prior to using the POWTS hcch trt::auau Ianki>) rol do src(OL:C .I pointing
ploducU or other nc~mirak That mac impede the u'caunenl pntcess andlur damage the dispetsai eellia) )f hiri: coneenllauons are ;Iererled nave
tSr.:nntcn t<pr iho :aai;i.l rouo.cd Or a squage scrvieini oper:::ur prior In use. $vsla•m start up shallnnl occur when soil conditions arc frrnen
at the irlliltratise surface.
he property ewno a Icspousrble tin the opembon and maintenance or Ihr P(1R`TS and submission of required nepons. The quantity and
quality or the wa>teaeatcr snnarn Hill affect the ptrhu:nrncc and lonlitvity ,Iy,,ui POUTS . Tkc iu..tall.rGun Of warcr-,avhrv appliaotes and
tis:turca alpng with prompl repair of leaks reduces file Pas1c1V'dcr %olnnte. Also the brine or waste I-rum haler soltencn, non removal units,
other clear water trcIanwin dc,rces and Ibwalahon Jr:uns should I>c discharged to the ground surliaec %,I.cneyer possible- Note. this does not
includc lawulry xasle, shower:, dmMvalar. .:IC.
I Ills svslcut Is desi_'ned to handle domestic su'ength wavcnatcr, huWCVtt, file dispomd or loud based greases, oils, vcyclabler Join peck,
seed., bones, and food solids. such. a> Ihosc produced by o garbegc disposal should 1Jc mmir vcd. Foilet tissue is the only paper ;hat should
be discharged int, the >vnlcm. Other non-biodegradable ,icon. such as lmby sips,, l:r..pons, ttlnmry ,eq K' , wrda.ma, r: igav ow bun,.
dental floss, and cotton swabs, should opt enter the svslcm. Chemicals, such as petroleum producls. paint. disinlectants, pesticides.
I
i
rte,, r.. ,'r iin_ _ i I~,,. n. r n.Li ,l.~ u: t„d It,i rr:co.h art Lt _ ,G:n 1 r'u :I fi:
~ ;LCnh C, nrpnnrnt,. r nurpactioo II snow uvur the dis}>crc.l anti m:ty cause it to It Cckk4 tip,
!~VEUIJONS & MAIN'I. E.NANCE: Inspcclion shall he made by an individual carryin_: Inc ol* lire li;llawing lir:cnx-
_riratiims. tWasier Plumber. i\iastcr Plumber Rcsuicicd Server. POA'TS iviaintainer, or Seplage Scrvsmg Opcrator(per the ate:c.:;..
11 tenanec Schcdulci. ark inspecli<ns must inchrde a wsuai uupeclinn of the tank to idenlily any missing us inuken haniv::
i~_. ailk anv cracks or leaks. mcasurc lire volume of combined slud,,c and scum and che.k fix any backup or goading of effluent r. ~.I .
mi sm{ace and test all electrical equipment such as pumps and alarms. Any defects shall be prnanptlq corrected. Lxpo.ed ofxr.in
-.tc: Than S inches in dimns5cr shall be secured tvil'o aliceiive Lxkinv devices to prevent accidental or unauthorized entry the tanks.
.a the combination oCsiud;!c and scum many tank exceeds one-third (1.1i) or niorc ol'the tank volume, the entire contents o tf.c
,:tall be removed by a Septage Ser%Icing Operator and disposed of is accordance with Ch. Nit 1 13. Wisconsin Admin. Cog"
sea icin•_ mechanics must be )a•m ided it vcrticai is:-1 i tcet or Xiuu'inlntat is >I50 liet and instructuas to be pnnlded befog'.
~utlef Ii I teri s) shall be ins;+ccied and cleaned ro remove any acCmnalated aoiidzaccotdim• to nuuunanurcr'sspccrl7cutxnu. Sn G.
°1cd Iturn the filter shall he retained in the lank- Filler cleaning may he necessary at snore ficyucrlt intervals than stated III h:
:~:ntcnance schedule to keep the sysusn operating.
,.-,ns should be tested on a regular basis by the home owner. Ii an alarm sounds, contact ❑n individual licensed to service PO\\'; ~
is nunnaliv is I day reserve under regular opcnoin" renditions. however water should be Conwrl,cd until art' problems with I I.
'.•vr ant cortected its prevent hack-up u(scrvage into the du'ellin_ or sun lacing.
.3:1\DO\YIENT: When the PO\\-rS tails and:or is pem:analik Tal.cu out of serer, c the Bellowing steps c
,,,auto is properly and salciv abandoned in compliatwc• %%ith Ch. SPS 313.> Wisconsin Admin. Codc:
All piping u? tanks and i,ihs shah he disconnected and the abandoned pipe openines sealed.
I !x contents of all tanks and pits ::hail he removed and properly disposed of by it Sell lage Servirmg, Op
:\Iter pumping, ail tank: and pits shall be excavated and Icmoved or their covers renrovcd and the
:4avel. or other men solid mawria!.
:0, l INGENCY PLAN: 11 Itre 1'UIVI S tails and cannot he mpaircd lire ibllowing nreasures have been. or mull be t:dccn, in proviti:-
rornpir art Ieplaceneull Sy glens:
s. niiat is rcoi:r, a s of area hiss occn Cvalualcd and may be utilized for the localion of a rcplaccmcnt soil absorption system. I
rcpiaeancnt :au:r should ire pruleele(i Ciotti disturbance and compaction and should not be inivinged upon by required setbu,l~.
tom existing and proposed gln¢lure. lot lines and Wells. FAure it) protect the replacement area renders it unusable. Rcplat 1.
"stoma must comply with the sinus it uncut at Tile time ill replacement
suicthlc rcplacenrent area is not avi ilabic dire In setbaci, anvil t soil limitations. Marring advances iu POWTS icchnolog,•
'ruidin_", talk Islay be irslaflCd as a tax! rcsnn m replace dic toiled I'M I'S.
! 1 he silt hits not been evaluated to identiF, it minabtc rg6au lnvIII ar.•a upon Relate of tix ('OW i S a soil and sac evaluation W
'm pcrtlxmed to fecmc a suilabie reaiacnnun area, II nu replaeenhenl area is available it holding tank may be it l:dlad its il
:c
nznrt ire replace the failed POW I S_
-I inund and at-grudu suit absorption systcnhs max' be reconslitiI in place fielluwimp rcausal et the itiumat al the 1111-111Mtiv,
,urYac0. Rcu?nstructonseRw('h sy rdcros must cumpiv with th; rules inef feVi at Thin lime.
~~~<\lVG SHVI C, Pt ail', :%ND OFIALR 1'RI{:\1'\IE\'I LANKS MAN CON I'I:\V IF IA AL (;ASSES AND!OR INS: IFRIF\T
\F GEN, D(/ :NOT ENTER A St•: ll W, PIA11% Oil Of7H(R TRI:ATMF:NT 'T'ANK 1ADF.R ANY CIRCUMSTANCES. DE:\TH
~7\\'RFSI ice.RI•SCULOFAPERSON I ROM THE IS' FERIOR 01 \TAN'K MAYRF.DIFFIC 1.11A OR IMPOSSITILL.
rl )ITIOA;~L COM;••tiiVl'S:
- :l\' FS INS I'%LI.ICR PON\"i:S MAINTAINER
1,'.~. J QLi✓ f,ELK L~. /YP' ~3/.i"IG - 1 \"nr EtKE - _-Lu,a01J4
net T/Jt' L 7.7" ,SdLG Phone:
7/S 67.7- $,tCG
~ITTAG'F. SLR\'I('I,VG OPERATOR (Pumper) Z LOCAL REGULATORT' AUTHORIT'i q
.a..-re s,mte: 5j" ~.CaX gin, eir.vuJ. dSuCL-
I I . r.:. i,ur.•.. yy- his .4%
Wisconsin Department a1 Safety and Prolessinnal Serv,ws Page 1 of 2
Division of Industry Services
SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code II Cddnty
ST Croix
Attach complete site plan on paper not less than 8 112 x 11 rches in size. Plan must include. 'r -
but not I;rrred to vertical and horizontal reference pent iHIM) direction and percent slope ' Parcel LD.
scale or dimensions. Toth arrow and localior and dislarce to nearest road. 020.1101-75-000 _
Please print all information. Reviewed by I Dale
Personal information you provide may be usetl for secontlary purposes LPrivacy Lave. s. 15.0441 inn)l.
Propety Ow'r e' Prcpeq• I ncabon
Robert and Caroline Baker Govt. Let S'v4 A NE V. S 34 - 29 N R 19 W
Property Owners Mailing Address - Lot # Block # Subd Name or CSrA#
651 (AY RU N 1 CSM 07-1988
City Stale Zip Code Phone Number ❑ City ❑ Village Q Town Nearest Road
Hudson WI 54016 (612) 419-0825 Hbcson _ ICTY RD N
❑ New Conslmclion Use LEJ Residential: Numrero'bedrooms 2 Code derived desig•) flow rate 3=- GPD
U Replaceme,)t U r,J2 is or ecnm ereial -Describe
Parent material Sandy Outwash (Fluvacuents) Floodplain elevation if aPO:irahle NA ft.
General comments and recommendations' Recooarl in-grouts conventional'O,N7S trenches at 40" nlax depth with 0.4 gpc:ft2 loading rate. j
LF = 76-
l Boring -
1 1 Boring # 0 pit Ground surface elev. 1006 fl. Depth to limiting factor ys in.
Soil Application Rate
Ho-izor I,.I ti iort id ,.ahri RrAur Or i girl inn l.~x Lr'a ~b :Ure r „rs_trnse tiu inda,y' R=s GPD;Ft'
111 M Jnscl: Do Az. Cont. Color Gr. Sz Sri 'Eff#1 -Eff#2
1 0.8 10YR 2.:' - 1 2nlabk mvfr cs 3c-vf 0.6 0.8
2 8-22 1OYR 212 - I 3•nsbk mvfr cs 2m-vf 0.6 0.8
3 22-35 1OYR 14 - cl 2nlabk mfr gs 2f-vf 0.4 0.6
4 35-55 10YR 4.4 (25%gravel I grs Os(3 loose cs If-vf 0.7a 1.6a
5 55-9h 10VR514 - s 0s0 loose a5 1vf 07a 1.6a
6 96+ gravel
Es Boring
2 _I Boring # C t 12
_ J Pit Ground surface elev. 99.98 N. De.pw to l,milirg factor _ in
' Soi! A lrcafron Rate
lorizo-l Dr=p1 Conlinan• Colcr Redox DescriPtion ?exture S411:1ure ^,on. i^>t^rce Recr"arv Roos GPDIFt'
ir.. ":hn iscll Ou. AL. Cmu. Co'er G! 5z Sh _ -lff#1 'Eff#2
1 0-8 1CYR 212 - I 3mgr rn'r gs 2`-v' 1 0.6 0.8
2 8.16 1OYR 312 - I 2csbk rnfr gs 1vf 0.6 0.8
3 15-47 7.5YR 3r3 a - -1fgr 110F as - 0.4 0.7
4 47-62 1 OYR 416 (5'a grave'; grs Osg loose as - 0 7a 1.6a
5 62-112 tOYR 5:4 (10"', gravel) grs Osg loose - - 0.7a 1.6a
6 tti+ gravel
Effluent #1 = BOD. > 30 s 220 mg;L and TSS - 30:; 150 mgr.. ' Effluent #2 = BOD. > 30 s 220 mgfL and TSS > 30 s 150 myL.
;:S f Name (Please Print) Signature CST Number
Ryan Bechel1330832
Acdress Uxle rva uation Conducted I rr'cFhcre Number
3,- i_rnnun Viev, DR. Rod 'A'iag, NIN 55066 19118 I5$", 9"-a0i1
Bo•i~g
3 Boring # ^ I ':rr. i,,,l styli r rl~, 9!f If,
i'.i-.tor n.
Soil Application Rate
Horizon Depth Dolmnaa: Color Redox Description Texture Structure Consistence Boundary Roots GPDiFt`
In. Munsell Qu. Az. Cont. Color Gr Sz Sh _ *EfMt 'Eff#2
1 0-12 1OYR 212 - 1 3mgr m4 cs 3m-v' 0.6 0.8
2 12-28 1 OYR 313 - 1 2msbk mvfr gs 2m-v' 0.6 0.8
3 28-43 10YR 413 - 1 2msbk mvlr CS 2m-vl 0.6 0.8
4 43-rti tOYR bA - Is imgr mvlr cs lm-vf 0 /a 1.6a
5 60-16 7.5YR 414
j10°'n graven grs OSg loose cs t(-vl 0.7a EO 6a
6 76-88 2.5Y 811 2.5Y 6:6 vfs-fs Osg loose as - 0.4 6
Bonng # ❑Bonng -
❑ Pd (:n.nmJ surface elev. ft prp•.r„clurlLn~-: 'arl;r
Sod Applicalio I Rale
rorizon Depth Dominant Colo, Redox Description Texture sli'l( le Consistence Boundary Roots GPD1F1'
In. Munsell (;u . Az. Cunt. Color Gr. Sz. Sh •Elf#1 'Efr#2
Boring # ❑ Boling -
J n Pi! Griun_ s-.i^ace Bleu I! Depth to Innif•nC far.!Gr in.
11110 Rate
Soil A 6cn
Horizon zon Depth Do_m_m apl Color Redox Cescnplion Textile 3r. StnrSzcl.:ve Sh. Boundary
In. Munsell Gu.{'¢ . Cont. Color Consistence Boundary Roots GPDfFt'
i •EN#1 •Eff#2
i
I
Effluent#1=BO7. 3J 22J frig!. aid TSB 30_1511 rl11;II Effluent#2=BUD.`30= 270 ru;1L arc TSS; 3~-1h11 rna!_
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34 -Lci
Siu'~e} Volume 0 8
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
I'll i S Is to Ccrtl'Iv that I Iw%e InShCCt.'d the
SI iJRp; 5~111!~ :;ndJll! ;;iltiL' l;lnl<
I~. ~:IL~~ A!Il_ ~'c
~OStot~ lo«LS [Clsn i I'll C°
~I~ Waited
.i(JInl - 3 u- 1 I U_l1_ 'il ~S1
l IW.X [_oull', ~'~~I:.iUnsln.
h~ln in~ll~c,:un_ I ~~r1i1r IhIII I have found the tank(s), to the nest of my
nu~~~led_e. v, ii, rorl.~_,rm to the reyuiremcnls of SPS. 384.25. and it (they)
:Tear(s) to be functioning properly.
lost recent date of inspection or ser- ictr
d flow back occur from absorption systc:nY Ye; No X
no, skip next line.)
\pproximate volume or Icrioll- Wt iM,- 0allons 1l•;nutc
ulk Capacity:
oiarUC6011:
, Pre ia1 ('uncut. X titcel Other
\1 -unrfacturer (i f kno~~, n
,r nfTank lif kn~r,~;~1: -
P~r,n'umhcr(itl;nrn~ni
'I i Plumber Si_,11;111,!. ; (Print Nam )
~u~e I l'c f~ 2 3) 3 q 6e,
2s-_ Icg
m to be completed by licensed plumber (Dept of Sarety and Professional
ices Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
K 113 \Visconsin Administrative Code)