HomeMy WebLinkAbout020-1159-40-000 (2)
F. altn,nn PRIVATE SEWAGE SYSTEM I' St. ClOIX
satcly eta GuJri [ vmslpn
INSPECTION REPORT a•na', vr't N,:
GENERAL INFORMATION H-IAOF fGPER0.11'; 605166
Srarc Plar I N,.
r2rsm!a tom-,Lnr vcu F"u .l rlay nr UseO b' S2CUrv::nry comers j a _aN 'lull
Fie Irn Moldy-, Naar. ~a:iy l a'Jlapc.~t can:h :r Ibr_e lax Nc
stephen & deborah List TOWN OF HUDSON 020-1159-40-000
nbt Elov. m55 31A I Ira 6N Jes:nPl.°in ~ Lectrr n..-, s'tta:: be
t 20.29.19.901
TANK INFORMATION ELEVA?rION DATA
tYr'E 1,14NUEAU I UR=F' CAF'l I Y 6 AI e7N El - III
Septic C1l':If:!1111:1!t. r '1
DI y _ AI! Btvt
j %A 1U~r l~ o{ 41
_ Bloc. Scm~.
folding
_ _ S,14I Isle; 1
TANK SETBACK INFORMATION stmt Ouuet
TANn-1-r P!I RLD'o %cll :n :ar Ilia-( R,,A-, )I l"ll
5°pLC CH CIO1101TL
i
Gosity I leaderlMar.
AeraLUn Dist. Pine r/ ,C J c~r.
Eso:. SYSlenl W _
Flna~ Tirade
PUMP/SIPHON INFORMATION
Manu)aclulcl Uemene S1 GovC*
carat
M odcl Number
IT)- Lift PIrmon System Itoec P II R
Eorcelnaln l erigm ria iir Ic 'l
SOIL ABSORPTION SYSTEM
BEU:TRENCH '.x>lafh _ I,."w, Nu -y Tenene= PIT DI FN I NS Nr, ~I :>iG u~e:l
DIMENSIONS / i -/t M O L~cu:tl Gcpt^ _
SLIBACK SYS-EIV TTY P:f RLCn`-, 'vv=l L _ ^.N LcACHING Atu w!ura.nnr
INFURMATON CHAMBCR OR ~1 `If,~~l~ff
UNIT
C 1 lr i I / 1.iOJel N., Lim
~tK^1
~x DT l`.
DISTRIBUTION SYSTEM
ae-11L1:n,ifold ❑ ;:ribuvpn x Flni. arc var. 5, onp '.tell : q:r Inu<c ~~2
f
Len vr~_
SOIL COVER x Pressure Systems Only xx Mound Or Al-Grade Systems Only '
)snt r ',retf er x, Tear e' x: -ooprd;Sotltlco ex I,l UlUO~
:od. .nr erne , Ft<:1 r. ccpe Ir.
~ Ye: M1o r. -COMMENTS: oi'll::one discreperil persl preset! ldr..i Irl"UMI' n#I Inspector. 9:
/
Location: dS,' I,AAUC Clk
1.) Ail k3Pd Ues::rlpton - -
!.I Blo9 sel lenglr - fl JC ( -
amount of cover' V~t
',ar 1<vsinn Repaired' Yes No
Use (Awl mde to, aodit:onal udormator. /.l
v IF rr
- _ SON/Jdls-
t f-, LI- I' I' I 1400 E Waglington Ave
P.O. Box 7162
"~y SEP 06 2018 ModimWIS3707-7(62 &VANYFam" i=& (tn be fdkd .byCo)b'Co.
i
sanitarx emit Application T" ~n~
In x ~ ~ 363~22(Qk' snbnimion of lfiu finfp}~~ tW Wvcnmmnd MR '1 PC
the u. - aarn'tary Penwt. NOW Apgaranon form for swbowaed AoW TS an, wbmWto
of Sedety and wemmal Savwm Pbwml mforMsban Pml~ Address ( dr0'aad tlamt nwil addrar)
in amordance wah the - 18w k IS. 1 m Stag Ya+ WM* may be usM for xcoodmy -~SA
I. Mew lustmatlaa -1'kase Prat A t.
Y iaaaraawMra /A E
Propmry (hwner'r Name ~ ! / ` I ' a a
STE J(WEA) ~E130PAP LIST ParetlA
PITV"()%na`s Mailing Addrea 020-57y-yo- tlo6 C~t Lot _I
cm''.1u Swe z+n cnae P+b.s xreoba r, Swann 2
> / U DS 0/t1f Wl _ 50//0 (Cade one
il. Type stBwBd{ws (tJaeck an Nat apply) I d A v T N; I
ft-_ E a~
1 or 2 Family 1Tvdlmg-Number of _ O Suhdmmnn Name
Pale ck a ve kI c-16or5
D PublioC'.anmacid - LVM is U.
D ceyor_
D Slate, kvnW- Dw"ft the tCSM Nwmbe. 0 Village of
Z CQ v `ry{fI J Town of l lb5a/ -
Ill. Type d Per~iL- (Ckeek o "we A. Compieaa Mae B if appt mbb) -
D NM Sysftan -
Roplaement Systan TmSWWnO4OI&ng Tank Repleonnen( Chly. D Odw 10 &J" Sydem (OVIR1e)
B. PErmix Rwewal ❑ Pmna Revnim
Befire F~ratim D ChOW OfPkmba D PaAmn Tkerfa to New Vat Previaw - Nmehex and Dare kmted
7-3$53 9' 3- H91,,
11" 111ml al 1111,111 111111111C 1,11 R
Ckwdt an dm
Amy)
IMII°'"d m-Gnxard D AWmde D Moud? 24 in ofaauMe aril D Mond ~ 24 m u*obk awl
I1Wdnig'1 oM C1 OUer Disperyd CamPorrrrr (explain) a I/t/ J
V. DiesaawkTrew art Area laks~tloc ❑ Pewamas Devace(e>aplarng__
Dmgn ] Fin~ 9pd) D ip Soil Applialim Rate( pirperstl Am )te9rmed IS Dopaad Mm
Nqmrd (sQ F]evrmxr 1
0.7
~j a 9 00 - ~S 50' J
&,q z. 17. Tarok 4fi CaWCity in low td ~ A 0o of Moea
Gdhw Gdkaw units - L
New Taub Fyya"T~ ( e v
n B X
-Captic uajLl~;awk c /o }~~y ♦ N N 4. 1~ 4
WT. 91a4a10at-
Flum1w. 1, tie awderakaea, mamma, rowedway 6e im wktlaa arm, POta'IS siaww OR tie arbeied at
i Name (Pnm) P9 's Srgrrque
iI/MPR.S Numbs Pine Nunba
sS fu~(ti m S 2 zv~37 715- 57~I-2%s~ '
Hunt ' Addrexs (SUem, Car, . State. zip code) ,CS r Ht E 57
Cl+c7b7? ~y L Il
WILL a i)c rtaaoa/ uw on
Approved i Permit Fee Daft z1o
e M gen Si
omw ' Res In, Dmwl S a/ ' w
IX. Coved' wae pprovai
1. ..o cif: r1 07'ni
v 1
a'sper.•:" cell rust eil ce ..1c ' 'nt. e• I
as g»r nacayement pkn^'o `i9ed by ylwniber.
2. Al "R** rocurer.. ems mrut ~'i-,a,r:t..it
ti
88 par atp ki"'t cdr'r. /:Mirtamm.
Asarrra~Nwerr.wra~a.,r.r.re.u.c~y+b..Aq.ri..araaa:et a.riw 1. d.. J
tiA -6398(R. 08/14)
li
Plot Plan Page r,? -of ',7I
PROPERTY OWNER: 5TOOEAI E. i bEsC)P--AH K. L,5r 1` = 40 Fr.
(except where nom
LegalDcsCdpUOre GQT S SINE &Ropg- osia~ -i OF Tt1E SEi Q-b e A ePn
e 20, Tz4h, JZ)4h1~ T-CWV OF-#MD 5O A/, Sr MOrx COUAJ
I. 350
VJ( WAJSiN • 020 - 11 sq_va- 000 ~ z ntiau n u c E
North
e,
v
(i`
Top of VE/VT-;4 --ASuNicD
00
~ ~yfSfING~ ~
U
~ ~ 0 ~ moo
axzo \~7 ya0 Qi ~ diWBtL
7. k1ke,
,h
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~"1 qL
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Site location:
Jim
<i
i
PAGE 1 OF
In-Ground Gravity Plan
Index & Cover Sheet
Version Corn~Wtt Um al 110112)
Pg 9 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Flan View
Pg 4 of 4 Management Plan
Attachments: E 1iJALTKATrR 5Mcf5 lication for Re '
FILTER cznnn ~s7 e s on Report & Site a
-ILTeK E T Jt( f}'I'IE~ME~TT
Project Name / Description
Owner Name(s): -TE E. Otto ALW K. Liss
Phone: _
Owner Address: MAUD CtKC LE , flu p - ouJ Zip: G
Project Address: CSR e
Govt. Lot: yE 1/4 of se 1/4, Sectiai zc T zy N-R 1 EQor W
Township: +1 ub5nN County: 5T c Ra()
project Parcel ID G c - t i s - C- 00
Designer Information
Designer Name: L J, LV -14 JaPt(e7 Phone: W5 _ Z6 - f 17.E
Designer Address:25'-19T I<IN6frTHtAk5 Cf -amgy V.Wl Zip: 8'sp
Eanall: ko((rsferdesycn ou+(coK ee)n .,.w ,t r
sap~#e~f4 stamp
License Num
bey: 'Sq-007 `~'o'=.
Remarks: '
UPPC
. ~ z
Afp
Signature:/ l~G D - Date:
ao+i~l n~ied on ndMnued copy.
Plot Plan Page Z-x*,V
PROPERTY OWNER: SYOtfEu E. ~ bEBoFZAH K- LOST 1- 40 Ff.
(except where rented)
Leem oemiptton _ Lot $ FBI Ue HECS+TS ~ pF ENE sE1`r _
tee. zo. Tzgd, R19►J4 TnwV oF Wunsonl. sr crza,x eowu 350 ytc,~s
LAJ(5eON51N• O2-O-1159-yO--Oo0 4qz A4AAADeIx-C(E
North
l
v
.TOP OF VENT ~j-5su MAD
j tiXtst~n~ FSFDn
4 20 ffi W ~tL
~ } ~ 4e~30 4/i94fF
l~
Site location:
0
arm. uu ~
5 l ~ 57
PAGE 3 4
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PAGE 4 OF 4
In-ground Gravity Management P an
The owner of this in-ground wavily system suet be responsible for as perpetual operation a rod maintenance pursuant to
reyuilviments of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2). Wisc Ack . Coax, this system shall
be considered a human health hazard if not maintained in accordance with this approved nt Plan.
Furthermore, all inspection and marderiance activities; shall be performed by a ngktored Mdrksiosr in
accordance with SPS 383.52 (3). Wisc. Admin. Code.
Mmxknm Disne Area OoeraNna Limits:
DmW Flow gpd; BM 5 220 m90; TSS 5150 mgt' FOGS 30 mgl._,
tnsoaeON Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, aft)
o mechanical malhu cuon (tie., pumps, valves, switches, floats, etc.)
o material fatigue (Le., leaks, breaks, corrosion, eta)
o solids volume In anaerobic treatment tank(s) and army distribution appurtenance(s) (I.., distribution f drop boxes)
o neglect or improper use (i.e-, exceeding design capacities, prohibited activities, etc.)
o extent of porting in distribution cep prior to dosing
c do" Irregularities - if applicable (Le., pump re-cyding, float switch settings, etc.)
o electrical components - ff applicable (i.e., wiring, connections, switches, controls, alarms, etc.)
o distribution lateral or lateral orifice pugging (measure lateral distal pressure - com to design spedfication)
U surface discharge of effluent or sewage back-up into structure served
Malatenance Check§M MAINTAIN EVERY 3 YEARS (or when mmc ry)
c 3e00c and dose tarik* shall be pumped by a certified aepfage servicing operator licensed under s. 281.48 Wis.
Sfals. when the vok ms of soil" in the tank(s) si each one.Udrd (tf3) the Nqu14 volume of tM tank(s) or
as reyu;red by local ordinance. Disposal of contents snap be Pursuant to NR 113. W Ilsc. Admin. Code.
o Effiuerd ft t d shall be inspected every 3 years and shell be cleaned when necessary to remove any
accumulated solids according to manufacturers specifications- A servicing period wo always be greeter than 12
months.
System maintenance reports shall be submitted to the proper kxn d government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or maihuwtion to:
Name of Individual or company. / ,n
- - _ Phone:
Local goverment unit _5T• C"()C Cb.NkM V J i Ty DE OtlOPAA a NT Phone: 5- 3 - qW
Local government unit addresv- H u DSO wT- z
Any defective part of this system shall be repaired. replaced, or removed pursuant to SPS 38 51 (1), Wier Admin.
Code. Repair or replacement of failed or malfunctioning components shag comply with SPS Wisc. Admin. Code.
No i(Odud for chemkW or Physical restoration of the POWTS may be used unless approved ft depwirri It In
accordance with SPS 384, Wisc. Admin. Code.
Corpinaencv Plan i
In the event that arty failed treatrttent component of ties POW[S cannot be repaired, it shall tilt replaced pursuant: to
a Plan submitted to the appropriate agency for review and approval. A taped in-groutd disper 181 componerd may be
abandoned and replaced by a code-complying dPgxw al component it a pre-determined area of suit" sods.
3ystarn Abondonnorrt
If use of this POWTS is discontinued, It shah be abandoned in accordance with SPS 383.33, isc. Admin. Code.
i
Quick4.
The Quick4' Plus
i LTRATOR Standard Chamber
Serhis
QuIck4 Plus
The Quick4 Plus Standard hamber
offers maximum strength through
its two center structural columns. i
This chamber can be install in
a 36-inch-wide trench. Like the t° _ ®1
original line of Quick4 chambers,
it offers advanced contouri g
capability with its Contour wivel
Connection TM which permit ~ turns
up to 15-degrees, right or I ft. It is
also available in four-foot 1 gths to
provide optimal installation flexibility.
Quick4 Plus Standard Chamber Benefits:
The Quick4 Plus All-in-On 12
Endcap, and the Quick4 P$riscope Two center structural columns otter increased stability and superior strength
are available with this chamber, . Advanced contouring connections
providing increased flexibil in r . Latching mechanism allows for quick installation
system configurations.
• Four foot chamber lengths are easy to handle and install
Supports wheel loads of 16,000 Ibs/axle with 12" of cover
i
I
Maximum Stren th
o Standard ClaMber
40&
sl:e Quick4 Plus All-in-Onc 12 Endcap Quick4 Plus All-in-One P=riscope
34"W x 53"L x 12"H Benefits: Benefits:
(864 rnm x 1346 mm x305 mm) May be used at the end of chamber Allows for raised invert installations
Effective length row for an inlet/outlet or can be 180° directional inletting
48" (1219 mm) installed mid trench 12" raised invert is ideal for serial
- - - - Mid-trench connection feature allows
applications
Louver Heigh construction of chamber rows with
8"(203 mm) center feed, as an alternative to
- inletting at the ends of chamber rows
storage Capacity Center-feed connection allows for
47 gal (178 L) easy installation of serial distribution
systems
In"d Height Pipe ipe connection options include i Certified by the international
0.6" (15 mm), 5.3" (135 m co I Association of Plumbing
8.0" (203 mm), 12.7" (323 m) sides, ends or top and Mechanical
- - Officials (IAPMO) a
APPROVED in
U44 Plus Standard' iitml:0'I -
/ 1 Dr I I II~\' 1y 11 1' 111 1~111ra+-{~; I~Lrli6~ III- ~I FI
1 r lr I 1 11 YI
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FFF DIIYt LLNGPI
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V4n~SUWFpPIP[ MULL
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~~IL~' INVCm
HOW VIEW S01- VIEW
INFILmrvon WATM TECHNOIo01EL.
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i
Lv y7^AT'.u.~'` \ DIVISION Of INDUSTRY SERVICES
PO BOX 7762
ia•,i , MADISON WI 53707-7162
3( j I CN*Ae:t Threx4h Ralar
Soar wawar, Gavantor
Da" Ross, 86"awy,
May 08.2()15
CUSP iD No. 13 6956
DAVID I FNP7
GOVT AFFAIRS WT INFILTRATOR SYSTI-MS INC
4 BUSINESS PARK RD PO BOX 769
OLD SAYBROO CT 06475
Identiricuion Number.
Tr immcile• ID No. 2534224
Site tU N~
He: Dre;crip[ion: LEACHING CHAMBER Pica.e refer to both de-vilification 11im hers,
Manufaetur . INFILTRATOR SYSTEMS INC. abovu, in all Correcpnndencr wish the arnL
Product Name: QUICK4 PLUS STANDARD, QUICK4 PLUS STANDARD LOW PROFILE (LP)
LEACHING CHAMBERS AND END CAPS (trans. id 2534224)
Model Num r(s). QUICK4 PLUS STANDARD (INCLUDING QUICK4 PLUS ALL-IN-ONE 12 ENDCAP
WITH TOP, END, OR SIDE PIPE INLET CONNECTIONS USED SINGLY OR IN
PAIRS AT ENDS OF CHAMBER LINE, OR AS A MID-CHAMBER LINE
CONNECTOR) AND QUICK4 PLUS STANDARD LOW PROFILE (LP), (INCLUDING
QUICK4 Pt US 8 ENDCAP WITH END PIPE INLET CONNECTION USED SINGLY
OR IN PAIRS Al ENDS OF LINE; AND QUICK4 PLUS ALL-IN-ONE 8 ENDCAP
WITH TOP, END, OR SIDE PIPE INLET CONNECTIONS USED SINGLY OR IN
PAIRS AT ENDS OF CHAMRER LINE, OR AS MID-CHAMBER LINE
CONNECTOR)
QUICK 4 PLUS STANDARD, DIMENSIONS: 53.0 IN L. X 34.0 IN. W X 12.0 IN H;
MAX. DEPTH OF BURY= a fL
(E)SA for chambers with or without fabric 20.0 sq. ftlchamber, EISA for Quick4
Plus At-in-One 12 Enclcap installed at fire ends of a chamber row = 2.6 sq. ItJend
cap, EISA for Quick4 Plug All-il-One 12 Endcap installed in-line within a chamber
row - 3.6 sq. ItAnd cap; Laying length of chamber = 4.0 ft., Laying length t Glwck4
Plus All- in One 12 Endcap installed at the end of a chamber row = 1.5 ft., Laying
length of QuIck4 Plus All-in-One 12 Endcap installed in-kw within a chamber row =
0.9 ft-, OUICK4 Plus Standard Upon Bottom area s 9.72 sq. ft./chanlber, Quick4
Pius All-in-One 12 Endcap instated at the end of a chamber row Open Bottom area
3.1 sq. ft./end cap. 0uick4 iMus Af-in-Otto 12 EMeao installed in-line within a
chamber row Open Bottom area 22 sq, ft./end cap; SEE ALSO ATTACHMENTS].
QUICK 4 PLUS STANDARD LOW PROFILE (LP), DIMENSIONS: 52.0 IN L X 34.0
IN. W X A 0 IN H; MAX. DEPTH OF BURY= 8 IL
[FI.SA fa chambers with m without fabric - 20.0 sq. IlJchamtow; EISA for Qulck4
Plus All-in-Om 8 Endcap instakld at the end t a chamber row = 2.3 sq. tt.feM cap;
EISA for Qu1dt4 Plus All-in-One 8 Endcap Instatlad wv-1ne p4Mlin a chamber row -
2.0 Sq. 0lend cap; EISA for Quid14 NWs 8 Endcap instated at the end of a chamber
row = 0.7 sq. ftJend cap; Laying length of chambers - 4.0 ft.; Laykv length of
Quick4 Plus AM-irt-One 8 Erdcap ir*lvd at Ute end of a chamber row . 1.1 fL;
Laying length of Quick4 Plus All-n-One 8 Erdcap installed In-line within a chamber
row _ 0.9 ft.; Laying length of Quickil Plus 8 Endcap Instated at the end of a
chamber row = 0.4 ft.; Qu1CIt4 Plus Standard Low Profile Open Bottom area = 9.77
sq h./chamber. Quidc4 Plus All-in}One 8 Endcap installed at the end of a chamber
row Open Bottom area = 1.4 sq. flJerd rap; quick 4 Plus Allat-One 8 Endcap
Installod In line within a dwnbef row Open Bottom Area = 1.2 sq. ftJenci cap; Quick
4 Plus 8 Endcap installed al the end of a charnber row Open Bottom Area . 0.4 sq.
ftlend cap SEE ALSO ATTACHMENTS]
Product File 20150111
2534224 uAVa>U;trrl. utir z sB nn
I
i
The speciticatiom, and/or plans for Mss plumbing product have been reviewed and delerminad to be in
compliance with rs SPS 382 through 384, Wisconsah Administrative Code, and Chaptors 145 and 160,
Wisconsin Stalin s.
The OepaMnent reby issues an approval based on the Wisconsin Stauttes and the Wisconsin
Administrative GoJe. This approval is valid until the end of May 2070.
This approval rsedes the approval issued on 1 111 1 /201 4 under product file number 20120137.
This approval is rNrtgent upon compl'ianco wtth the fallowing stipulallon(s)
• This product t be installed in accordance with the marxufactimes printed instructions, product
approval, and plan approval. It there is a conflict between the manufacturer's istructioru and the product
approval andN plan approval, the product approval and/or plan approval will take precedence.
• When this pr is installed in a dispersal cell that is sized based on the EISA rating stated in the
regarding of the product approval letter, this product must recent wastewater having a 8005 value
less than or al to 220'TU3n a TSS value less than or equal to 150 mglL and a roG value less than or
equal to 30 on a monthly average.
I
• when this pr rt is installed in a distribution cell that is sized based on the HSA rating stated in the
regarding of the product approval biter, this product must be installed in irxlividual excavations that
create a row chtambers that are horizontally separalud from other rows in other excavations by at least
3 feet The 3- loot measurement is measured between the closest outside edges of the leachig
chambers. I
i
o When this product is installed in a distribution cell that is sized based out the EISA rating stated in the
regarding b14 at the product approval letter, the datrib $jm cell design must allow at least six incites of
pordirf in uhe%chamhers without back0ow of waslerc+ter into to drainpipe that darbarges into the
chambers.
- When this prt is installed in a distribution wA that is sized batted on the EISA rating stated in the
regarding blod of the product approval fetler, this product must be installed in a distribution system,
which has he op of the distribution eel at or below original grade.
- When this product hs installed with geotextYe fabric on the skies at this product in a distritwtiw, call that is
sized based the EfSA ral" stated in the regarding dock of the product approval letter, the EISA
rating with f must be used to size the system.
When this W -t is installed next to each other in a da:trhbirtion call that a NOT shed based on the EISA
rating stated the regarding block of the product approval letter, the effluent distribution area is equal to
the length time. s the width of the chambered area. The use of geotextle fabric in this type of installation
is optional.
• When this pr t is ihstalod with geelextie fabric on the sides of this product in a distribution cell that is
sized based o the EISA rating stated in the regandiirg block of the product approval letter, the geolexti e
fabric must r K all of the following specifications:
Geotextik shat he non-woven
Weight st all be 0.35 ozlsq yd to 1.5 ozlsq yd
. Apparent ning size (AIDS) shall be 20-30 U.S. Save (ASTIA D-4751).
For mound dei s, see the manufacturer's propriety mound component manual for this product line.
For m rxrhd de. see the manufaelurar's propriety mood component manual for this product fide.
2534224 UAV1btEV'16 tag3 5&0015
The department' in noway erdosing this product or any advontsing, and is not m%pox*bte for any situation
which may result fiom ft use.
Sirx~rdy,
Glen Jones, M.S.
^i7WTS Product Fenerrer
;:4tonte: (608) 267 2fi$
:ax: (608) 267-9723
emak glen. ".gue
he DSPS is oom iticd to sewl.ce excellence. Visit air survoy at:
wrsc, ~iu~,eym enuey.cam/s/dspsisa.s[omer~alisfaciiun
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/04y* STe/0itBJ 9. ' _1)i 56ex 9ft k• V5r
Mailing Address 492 MA "13 C iKe4e=
Property Address
(Verification required from Planning & Zoning Department for new co )
City/State dub NkU Parcel Identification Number Q,,Z ll5~J- U-ooo
LEGAL DESCRIPTION
Property Location NE 56 , Sec. 2t) , T 9 N R _W, Town of U xo
Subdivision Plat: 'PuE C-~KDUE EIc~NTls , Lot #
Certified Survey Map # Volume _ Page #
Warranty Deed # (before 2007)Volume YJ~ !Page ft Zl
Spec house Oyes0bo Lot lines identifiable0yesono
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to hand) wastes Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed p per. What you put into
the system can affect the function of the septic tank as a treatarent stage to the waste disposal system. O at 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 certifi4ation form, signed by the
owner and by a master plumber, joumeymar plumber, restricted plumber or a licensed pumper verifying thit (1) the ontita
wastewater disposal system is in proper operating condition and/or (2) attar inspection and pumping (if n ary), the septic Link is
Icss than 1/3 full of sludge.
I/we, the undemgned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, harem, as set by the Department of Safety And Professional Services and the
Statc of Wisconsin. Certification stating that your septic t o returned d t Resources,
system has been piimained must be completed tainte to the $t Croix
('ormty Planning & Zoning Department within 30 days of the three year expiration date.
Uwe cemt'y thm all statements on ' form are true to the bet of my/our knowledge, Uwe am/are a owner(s) of the
property described above, by virtue of a ty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNATURE OF APPLICANT(S) /
DATE
`Any information that is misrepresented may result in the sanitary permit being revoked by the Planning Zoning Deparb ant w
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the Oertified swv
reference is made in the warranty deed ty map if
(REV. 04/12)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the f (lowing residence:
(Street address) , ~~4g~ ~1t .'Y ~e located
at: ''/0 Section Z, Town- N, Range 167 W.
'town of l _GI, St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: ___gallons _ minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known): -
Permit number (if known)
(Li ense Plumber Snature) (Print Name)
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06. Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
1
Form- STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 91(-'uann /[1c•T TOWNSHIP ya0 SON SEC. T _N-R W
ADDRESS R,,T// 2 ST. CROIX COUNTY, WISCONSIN
HYI) SON to
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A Sep,
1 h~
N 1 (Oct t
c~ REV 66•
90USL;'
Q ~
1
M /
~f00.0
~ortA~` X44 0c- R 0
N AOe2 - 97.51
'jA /.,ence? 97 yo INDICATE NORTH ARROW
BENCHMARK: Describe the vertical. reference point used 5W / a 7- S TA z'e-Z
Elevation of vertical reference point: 1,01110 Proposed slope at site: saJn