HomeMy WebLinkAbout030-2060-95-000
Wis[ors n De Da'1llent u Commerce CcuCy. I
Sarey anJ B...lldmg Oru s on PRIVATE SEWAGE SYSTEM St. Croix
INSPECTION REPORT Samtaty Per-l Ne
GENERAL INFORMATION fA] TACII To PERr,11T1 >va:e vin: ID Nc 605107
Personal irlpr-atDr you pr3.ide DC u>eJ fur S,. ,DnCary PJIPO5US IPnvacy Law• S IS 34 (t'irtgi 3127461
Pe'- it l I'jIi s i Cry Vlhagr- Igor ;biD Fw'7,1 Tax No
Dan Goldberg TOWN OF SAINT JOSEPH 030-2060-95-000
C5- 3M EIPV: I-SD BM F e•, 51,1 DesreDpan. Serrin- - sen+Rarge:Nlap No
5l-q Q 3 GS j 27.30.20.587
TANK INFORMATION ELEVATION DATA
i YPI- MANUFACTURER CAPACITY STATION BS HI IF S ELEV.
Septic Benchmark
wit 5 /ov0 d) 14309 9~, ry
_T j ucs~ng A Brat
C0V_1~ G 664, S.~L 3Ss G~-
Aerallon cfa SW-Nel
Ilo:mng SITI-It inlet
SVHt Outlet
TANK SETBACK INFORMATION _
TANK TO P11 r :JELL BLDG , *'BrI to t% i I -lake l Dt Irlet
Si in, Dt Bottom ,
u
Donny Heeer+PAan.
Aeration D st. Pipe
3.78 4`~
Holding B;,I System i
Final Grade ,
PUMP/SIPHON INFORMATION Z.
tFS l _ f -
tdanjtac:urer - Demane SI Cover ,r y;• y Gb
GPOA IF
Model Nurnt:er $
t- 1 i/ .J t~~1Y'DY~ S .O -CS
TDH L.ft, n 7 Fnch::n I os! System Head _ I TDH r. Ft
1,L o-
Forrxntam I I LcoglC D a. Dir.. to Y7all
i
SOIL ABSORPTION SYSTEM
BED.-TRENCH '.VC 1 Len,P Ni, Cf Trenches PIT DIMENSIONS No n' I t=. Insice r1 a I Iguln U-p'.u
DIMENSIONS -
`I ! 7
SETBACK SYS TEM TO P.I. BLDG l°JELI. LAKbSTRFA1.1 LEACHING Marulactmer
INFORMATION CHAMBER OR
3; Tyre 0' ~stcm
UNIT MOJN NurnCcr
DISTRIBUTION SYSTEM
Neadel+69a ri`n Uu:na.Gm.. e Hole Sve . Hale Sli - J_rd . Al,Alta.
.c
P O c 3 `1 S( . 7 y I Y c,
Lengfr 1- Dra Len P Die I ' S:actrg 1 l•9 „G
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only a ~<r
I:epID :):'e, ❑epih :)':e• k%DP,D10e, xx Sr,ecedlSSad'Juc xxLlulcr-ed
no7 -e~:,h r,c •la Itedr l•er V, Lacs Iv l
~ . v d c'>~ Ycs n, - yes Nn
COMMENTS: j lnciude code discrepenc,ti persons presen! etcInspection #I: Zf Inspection #2
Location: 55 HOULTON SCC JO L CIR
1.. AI! BPA DescripCOn =
P(er.. dlr4
2.;r Bldg sewer length = Z4 I
-amount of cover-- Obi
CA-
Plan revision Regutre u~ Yes No r Zt, Ir Cr I I I r 3~r r' '
Use other side for additional information.
Dale I•»codorSir;nat_yl C=c N
- SFlry, a~ o
AT Coway 11 Safety and Buildings Division
- 13 I I~I 7,01 W. Washington Ave., p.0. Box 7162 S
ry l 7, Numlxv (to be filled in by Co )
3 0 Madl~on, Sanita WI 53707-7162
A
' C005( 0'4-
Sanitary Permit AppGca~i ~I~ [ fran,~nnn a//mn:r
umrdun>. t ith SPS 35 f'f I(-f) 4 i:. Adm. Ccd a:bmi to t u t uc form W d:a:npwprim gtcem,.:cnai unit ZZ
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1 t it.- t llui ~i ! t e rin u' a 1. p Lc n \c V,:, t : t ti c lo- r of red 1 O\ TS ua, s r,tt ,cd tot Protect AdNCti (ii dllicttnl th:nl 11-1119 uddreil)
mm~t t S,
[n It t t u , a,:a c.l p:w ec n. f 1 o,v iu srouds j
~ n~tsm nd t.t t, nn I nac)Ln r-4d!;,m T.'>. C< I
~t -~Xpplirnl[oa lulo[mnlion -Please l-?rrnt,Ul Infmmnhnu
c~3U ?o~•0 9s-
/4!:: tp fl~e:::'r>\L:ilias:lddu-s U -
Plnp:nt' 1 maboa
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Ckml Lo,
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II. T)7fe of Botldta>; (cheek aB that apply) :t o?~ i a[b"r II
21Cit I U:.II 'tnl;r of L':t
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•'Con m tial ITS rib.. L'sc
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S1.0::;: + Lunb,: _ V,!' s cof l ! CS .r v
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celt 1A 0
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- _ _ I - ' mint Only :1 OIlkr \;ndil icetiaa to Lxislinq Sptem (caplaia)
H. I I!I'.m tltcn 1-ni i-; Pcmlit fir, C TLia?wtins. t•;.I:o\mn6s and l}a:c lsa;d
FYpu..,;o,t t'•,mt't;.w>lir In Sc
1 OC:::: i
N.'1'ype of Pomr s Svae utcornponenl/Device: (Chee6 all that a h)
\m -I rc•. t : L,-C'c c , n l f , o: ~n . r:rJ 2~.f[. t_ t o d . 7..} in. o il.' ^ soil
ltlin [In:7a - JO :,-7 - ~
! \ Ursn¢rxnl/I -eatlncn_t 1f a.t lnfortn~lton -
L :innilosl Idl L;:i t Sd An dicatm t -
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LII Respousrbility Statement u ~ - _ _ 1 M « , ~•u _ -
4 the atMentgned me rcspmeslbfbtyl for iastalhtian of lac PoN'TS atrox'n on 16c att,e7nW pMns,
I Ph n \sn (t nt tj t ctm S ;na It - _ _
,Q(~ Q Dj rs~ -\fl'RS \,tmL;r~ flu is 5s Pao : Sumlr -
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r ~~ef~~.t
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I -icn.[C1Kc
C(. CooAitions afApprov81al/Reasons for Disapproval e`
SYSTEM UWNCl:: 3~ e7VTa~Q CAiv ~~~{t ~ - .i
I 'I. Septic lank, uffluent filt::•r -jr,
I -
dispersal cel; must he sErii(;f!; i mavga.n-~J ~S ~x~~.k ,
f as
per mans emetic h
9 F n Provided b/ pt r1beC
LL2 J.11iSCIpa('k ra 1 ran m •t t l t w., ' r 1
as perapplicablecod~ftjpl n6 rurtbr„iouanJar,:w+umatre~na _s23--~ - 1_-
a ~.-uuly on Iraatlntfltxasnzs It Lobo fafur U
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,63
,,,Nit TA, tie DIVISION OF INDUSTRY SERVICES
10541 N RANCH RD
~,ll~ •':r~_ HAYWARDWI !>4843-6462
Ccntact Through Relay
P S ht:c:Utlsps.m gov+p•ograms+mcuslry-services
wee.v •.v sronsm gov
Scott Walker, Governor
Laura Gutierrez, Secretary
July 19, 2018
CUS I ID No. 220357 .177.A5 Wit *TS Ltswe for
BRADY 1 UTGARD 7ONINCi OFFICE
EITGARD PI IIMBING & IIF:\TING SI CROIX COLNI'Y SPIA
PO BOX 411 1101 CARMICHAEL RD
AMERY Al 54001 HUDSON WI 4016 7709
CONDI'T'IONAL APPRO\ At,
PLAN APPROVAL EXPIRES: 0'.:19;211211 Identification Numhcrs
'I ransaction ID No. 312-461
SFFE: Site II) Nn. 851315_
Dan Goldberg Please refer to both identification numbers,
Houlton School Cir above, in all correspondence with the a_enev.
Town of Saint Joseph lit
St Croix County
FOR:
Object Twe: POWTS Component Manual Regulated Object ID Ao.: 173582±
Maintenance required: 450 (;PD Flow rat:, Systcnt(s): Mound Component Cv9anual - Vcr. 2.0. SBU -I pG91-F (N.01i01,
K. 10 12): Lilluenl Filter CONDI
submittal described above has been reviewed for conformance with applicable \l'isconsin Ad ithi d B-
and Wisconsin Statutes. 'I lie submittal has been CONDFI ZONALLY APPROVED. 'this system toc teZ V M AND P
and located in a.cordance with the enclosed approved plans and with am- component manual(s) i •renccd aboNDjMjGN OF IN
'l'ire owner, as dclincd in chapter 101.01(10), Wisconsin Slalutes, is responsible for compliance w It all code
requirements.
A copy of the approved plans, specification, and this letter shall be on-site during construction an open to
inspection by authorized ieprescmtatives of the Department. which may include local iaspectois. II permits
required In the stale or the local municipaliq shall be obtained prior to commencement of
construclion+installation r'opciation. !S SEE CQRAU
In ,raining This approval the Division of Industry Services resen•es the rihht to require changes or additions should
conditions arise making them necessary for code compliance. As per state stars 101.12(2), nothing in [his review
shall relieve the desi;,.ner of the responsibilirv for desirnint a safe buildinr„ structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above ]ell addressuc shall provide a copy of this letter and the POW I'S management plan to the owner and anV
others who are responsible for the installation, operation or maintenance of the POWI S.
Sincerely, Fee Required S 250.00
Fee Received S 250.00
r- Balance Due S 0.00
Edwin A '~raylor.
Waztcwaicr Specialist , F ivision of Indusny Services \\'iSML1RT code: 7633
(?15)63;1-3ISI . Mon-fri. 8:00 a.m. - 4:30 p.nl.
cdwin.tay lori'diwi_cov
MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
INDEX AND TITLE PAGE RECEIVED
II O3iOli;
Project Name GOLDBERG
JDu5 ~ RY SERVICES
Owner's Name DAN GOLDBERG
Owner's Address: 1652 IDAHO AVE. E ST. PAUL MN. 55106
HOULTON SCHOOL CIRCLE
HOULTON WI.
Legal Description 5 7 - Ta n N - ~G -amil
Township: ST JOSEPH
County: ST. CROIX
Subdivision Name: HOULTON PLAT
Lot Number: 1 Block Number: 8
Parcel l.D, Number. 030-2060-95-0000 P ALLY
DYED
Plan Transaction No O ESS?ONAL SERVICE
JSTRY SERVICES
Page 1 Index and title
Page 2 Data entry
Page 3 Mound drawings
Page 4 Lateral and dose tank
Page 5 System maintenance specifications
Page 6 Management and contingency plan P(p ENCE
Page 7 Pump curve and specifications ,
Page 8 PLOT PLAN
Page 9 SOIL EVALUATION
Designer. BRADY UTGARD License Number 220357
Date. 07/0 18 Phone Number. 715-760-0946
Signature: /
J Designed Pursuant to the
Mound Component Manual for POWTS Version 2 0 SDB-10691 P (N 01/01). and
SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)
Version 3.11 (R 06/01) Page 1 of 9
Mound and Pressure Distribution Component Design
Site Information
R Residential or Commercial Design Note: Sand 611(D) p ulaiions assume a~
300.00 Estimated Wastewater Flow (gpd) Table 83-44-3 in-situ soil treatment for fecal
1.50 Peaking Factor (e.g. 1.5 = 150%) colaorm of 36 inches
450.00 Design Flow (gpd)
1.00 Site Slope
98.53 Contour Line Elevation (ft)
27.00 Depth to Limiting Factor (in)
0.50 In-situ Soil Application Rate (gpd/ft2)
Distribution Cell Information
56.25 Dispersal Cell Length Along Contour (ft) = 8.00 Cell Width (ft)
1.00 Dispersal Cell Design Loading Rate (gpd/ft2)
1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point
in the distribution Y
Pressure Disribution Information network?
E Center or End Manifold
4.00 Lateral Spacing (ft) If N above, enter the elevation (ft)
2 Number of Laterals of the highest point.
0.188 Orifice Diameter (in) (e.g. 0.25)
2.50 Orifice Spacing (ft) = 10.23 ft2/orifice
2.00 Forcemain Diameter (in)
80.00 Forcemain Length (ft) Does the forcemain drain back? Y
88.00 Pump Tank Elevation (ft)
3.25 System Head (ft) x 1.3 13.05 Forcemain Drainback (gal)
11.11 Vertical Lift (ft) 50.29 5x Void Volume (gal)
1.44 Friction Loss (ft) 63.34 Minimum Dose Volume (gal)
15.80 Total Dynamic Head (ft) 28.84 System Demand (gpm)
Lateral Diameter Selection Manifold Diameter Selection
in. dia. options choice in. dia. options choice
0.75 125 x
1.00 1.50 x x
1.25 2.00
1.50 x x 3.00
2.00 x
3.00 x
Gallons/inch Calculator
Treatment Tank Information Total Tank Capacity (gal)
1000.00 Septic Tank Capacity (gal) Total Working Liquid Depth (in)
werser Manufacturer -J gal/in (enter result in cell B49)
Dose Tank Information Effluent Filter Information
600.00 Dose Tank Capacity (gal) POLYLOK Fitter Manufacturer
11.82 Dose Tank Volume (gal/in) PL525 Filter Model Number
weiser Manufacturer
Project: GOLDBERG Page 2 of 9
Mound Plan View
-T
.
1/106 _ . . . J
Observation Pipe -
O A
W . I L
B - -
I
Q
O L - -
Mound Component Dimensions
A 8.00 ft E 9 96 in 11 1.00 It K 7.75 ft
B 56.25 ft F 9 50 In 8.00 It L 71.74 ft
D 9 00 in G 0.50 It J 5 95111 W 21 95 ft
450.00 (ft') Dispersal Cell Area 900 00 (ft) Basal Area Available
8.00 (gpolft) Linear Loading Rate 5.63 (ft) 1110 B Obs. Pipe Placement
Mound Cross Section View
Aggregate Dispersal Area
Finished Grade 101 07 (ft) I'
I It1
F Discersaj Cell 99.78 (ft) Lateral
99.28 ft)--00 Invert
Dispersal Cell 1
Elevation E D []3
2
98 53 (ft) Contour Elevation
1 0 % Site Slope
Geotextile Fabric Cover
Shading Key 2- Dispersal Cell See lateral details on
1 Opsoil cap o 1.5 It Page 4 for number. size,
Subsoil Cap o j_ ❑ / and spacing of laterals.
ASTM C33 Sand v t T 0 / F Laterals are equally
El f Tilled Layer E N 0 5 ft TYPICnI Lateral spaced from the
5❑ C Aggregate o o [5] I distribution cell's
centerline in the
A distribution cell (AxB).
Project GOLDBFRG Page 3 of 9
End Connection Lateral Layout Diagram
Laterals crMn.A .,vri th.- A t. L3dtmen5ion 0- Turn upvdbull vnlvo nr clonnnut plu0
P -
rFme'main 7cone!bon I@ XHoles drilled on the bottom ol the lateral
-oed y
via tee or em~a to on tnifnld at anV point. Laterals& forcemain of PVC Sch4v
[psi r'nMM Table 84.30.51
Number of Laterals 2 Orifice Diameter 0.188 in
Lateral Diameter 1.50 in Orifice Spacing (X) 2.61 ft
Lateral Length (P) 54.81 ft Orifices per Lateral 22
Lateral Spacing (S) 4.00 ft Orifice Density 10.23 ftzlorifice
Lateral Flow Rate 14 42 gpnl Manifold Length 4.00 ft
System Flow Rate 28 84 gpm Manifold Diameter 1.50 In
Total Dynamic Head 1580 It Forcemaln Velocity 2.94 ft/sec
Dose Tank Information Locking cover with warning
label and locking device and
sealed watertight
Eleunwl as per NFG 300 and
Comt2ivWA,G - 4 in. min. 1 -1
Disconnect
Tank component is pdAlternate outlet
location
Forcemain diameter
weiser Manufacturer 2 in
Capacity 600-00 Gallons
Volume 11-82 gal/inch A
Weep hole or anh-
Dimension Inches Gallons B siphon device
A 35.40 418-46 C
B 2.00 23 64 Pump off elevation !ft)
C 5.36 63 34 88.67
D 8.00 94.56 D
total 50.76 600.00
_ Dose nk elevation (fh
3" Bedding un er tank 88 00
Alarm Manuafacturer LEVEL
Alarm Model Number DLV
Pump Manufacturer GOULDS
Pump Model Number EPOS
Pump Must Deliver 28.84 gpm at 15.80 It TDH
Project: GOLDBERG Page 4 of 9
Mound System Maintenance and Operation Specifications
Service Provider's Name UTGARD Phone 715-760-0946
POWTS Regulators Name ST_ CROIX Phone 715-386-4680
System Flow and Load Parameters
Design Flow - Peak 450 gpd Maximum Influent Particle Size 118 in
Estimated Flow - Average 300 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L
Soil Absorption Component Size 450 ftz Maximum FOG 30 mg/L
Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL
Service Frequency
Septic and Pump Tank Inspect and/or service once eve 3 ears
Effluent Filter Should inspect and clean at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test month)
Pressure System Laterals should be flushed and pressure tested eve 1 5 ears
Mound inspect for ponding and seepage once every 3 years
INSPECT FILTER ONCE A YEAR
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to Table Comm 84.30-1. have a watertight cap,
and are secured in as shown in the mound component manual.
2, Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code.
3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis- Adm. Code.
4 Tillage of the basal area is accomplished with a mold board or chisel plow.
5 The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion
and help reduce frost penetration.
Lateral Turn-up Detail
Finished
Grade
Threaded Diameter Lawn - = Cleanout
Sprinkler Valve Box Plug or Ball Valve
Distribution
I ateral
Long Sweep 90 or Two
3 45 Degree Bends Same
Diameter as Lateral
Project- GOLDBERG Page 5 of 9
Mound System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
this system shall be operated in accordance with Comm 82-84 Wis Adm. Code, and shall maintained in accordance with its'
component manuals )SBD-10691-P (N.01/01) and SSWMP Publication 9.6 (01+81)) and local or state rules pertaining to system
maintenance and maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death
Septic and pump tank abandonment shall be to accordance with Comm 83.33. Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole risers. access risers and covers should be inspected for watertightness and soundness Access
openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound,
defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an
effective locking device to prevent accidental or unauthorized entry into a tank or component.
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic
tank shall be disposed of in accordance with NR 113, Wis. Adm Code. The operating condition of the septic tank and outlet filler shall be
assessed at least once every 3 years by inspection.
[he outlet fitter shall be cleaned as necessary to ensure proper operation The fiber cartridge should not be removed unless provisions
are made to retain solids in the tank that may slough off the fitter when removed from its enclosure. If the filter is equipped with an alarm,
the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending
continuous alarm.
The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 113 the liquid volume of the
tank. If the contents of the tank are not removed at the time of a triennial assessment. maintenance personnel shall advise the owner of
when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not required However. if such
products are used they shall be approved for septic tank use by the Department of Commerce
.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper
operation. If an effluent filler is installed within the lank it shall be inspected and serviced as necessary.
Mound and Pressure Distribution System
No trees or shrubs should be planted on the mound- Plantings may be made around the mound's perimeter, and the mound shall be
seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. rraHic (other than for
vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infihralive surface within the
mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the
mound be heavily mulched as protection from freezing.
Influent quality into the mound system may not exceed 220 mg/L BODY, 150 mg/L TSS, and 30 mgrL FOG for septic tank effluent or 30
mg/L BOD_., 30 mg/l. TSS. 10 mg/L FOG, and 10` efu/100 mL for highly treated effluent. Influent flow may not exceed maximum design
flow specified in the permit for this installation.
The pressure distribution system rs provided with a flushing point at the end of each lateral, and d is recommended that each lateral be
flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test
when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution
within the dispersal cell
Observation pipes within the dispersal cell shall be checked for effluent pending. Pending levels shall be reported to the owner. and any
levels above 6 inches considered as an impending hydraulic failure requiring addhional, more frequent monitoring.
Contingency Plan
If the septic lank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in
proper operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately
repaired or replaced with a component of the same or equal performance.
If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or
replaced in As' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal
media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition.
See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: GOLDBERG Page 6 of 9
ITT GOULDS PUMPS
Wastewater
PERFORMANCE RATINGS COMPONENTS
Tnral Head Gallons Per Item
Minute No. Descuplron
ih. nt.vater;
EP07 EPOi ITp%II e'
1p 45 02 :mnp Ce,iry -
- 3e, 4 Stecnan.o.15`,,-l - -
30_____j_-1I 4o c Ball Rea-rgs
5 Odiiv05 ~
d 01 F,I Yntgr i
(ardor Hnuv nq.
y ~
L~ L
3J ~ 5';a,t
I
1[)
a{
I Po'
Htii4
110 70 2;1 30 -7!I 59 r P',1
3 7 4 fi N I[. m;h
i~
% CA 'A[ ITY
rf
ST. CROIX COUNTY
SEPTIC T tLNK ?vfAINTF,-N.A-NCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerRuyer
Mailing Address ~(p Sr~2 ~C~t>✓!~~ ~(e - s /C/ /Lily. S~ yo
Property Address ,L,~c~e~
(Verification required from Planning & Zoning Department for ❑cw construction.)
City/State
i t~~tcr,1 _1.kk,-4'- Parcel Identification Number Gc7c7o
LEGAL DESCRIPTION
Property Location 'ISM Y4 Sec. ~ 7, T 30 N R rA6 W, Town of 5 T S
Subdivision Plat: _/Y Lot #
Certified Survey Map # - - Volume Page
Warranty Deed # ~U C) C) f (before 2007)Volume Pape
Spec house J yeskno Lot lines identifiable'I yes 7 no
SYSTEM MAINTENANCE AND ONVNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumput,~ out the septic tank ever), three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic lank as a treatment stage ht the waste disposal system. Owner maintenance
responsibilities are specified in y§'SPS. 383.52(1) and in Chapter 12 - St. Croix County Salutary 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.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, &s 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 form are true to the best of my.-our knowledge. f%w•e am%are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
.N er o~om Z /
SIGNATURE OF APAICANT(S) DATE
***Any information dial is misrepresented may result in the salutary 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 warrannr deed.
(REV. 04/12)
O t 'T . I
s rRE-Er.
0000
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