HomeMy WebLinkAbout020-1487-15-000
PRIVATE SEWAGE SYSTEM St. Croix
rdsconsH Gr :~9 »C cr c-nnrce
sael and Bw amg :rn INSPECTION REPORT o`a-n.-ry Pe ^»1No
605117
GENERAL INFORMATION (ATTACH 10 PERN11 I i ,I;na vls^ C Nc
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Oevering Homes TOWN OF HUDSON 020-1487 15-000
-6VIIe~ nsp BL'"'- Wit De^cr clc -cue-:TCwu4tangc; IJ:p NO:
(END-r' Hp o~ 5 23.29.19.3106
TANK INFORMATION ELEV ION DATA
TYPE IJANLTACTURFR CAPACITY STAI ON DS HI rs ELEV.
SeG~tic L /1~~-> Benchr•.iarR 1(XQ.nA AO.Q'l
~r'g N1. BPA QI
f.erat on - - - Hltlg SC•ncr 6
~/1.~~1^ QI~I ,70
Hnld r- - - - _ - - 577-1 N'lut P.193~/ I Yf 0 CJ
S['Ht k;11; CI
TANK SETBACK INFORMATION 13.20 l '
lake R':,'A.I) Ot Ltlel
-ANK I:i I'tl AF_. JLCG s ltoA in
Septic 1 1 r Dt Bottom
Ccsing _ Hcider;6dar•. ' 1a400
Aelaticn - :iisl. Pipe
Lf w L
liClcirg _ Bot. Syste•n
-final :,lade 11_
PUMPISIPHON INFORMATION
totanufaeUne' !)emard StC •er
GPh, .ik>rceor p
Mode u.,W)e,
TDH LIR fret cr I css Syslem I lead TD- R
=UI .C,1'3In LCP ~tI' Lira Dist 1o :^;-1:
SOIL ABSORPTION SYSTEM
BEDITRENCH ::1" , ^lC] Vc Of Tr rms _ PIT DIMENSIONS Nc. 01 Pits rnslcc Dia -d Gapr'. L• 5.
DIMENSIONS js C~ l ~9'
11 e
SETBACK S11*17CM T:: - F;L HL C3 V':FIL .AKE-*SI HFia`A LEACHING None=w ( r`
CHAMBER OR
INFORMATION UNIT V.:::-I N.'vtm
r7ve 1 r r
DISTRIBUTION SYSTEM , r 1
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Ilrale Y1a^~ci:f - Du:ion _ -
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Lcupe.is,y_ Ia_- _'+Pacinq -
SOIL COVER x Pressure Systems only xx mound Or Al-Grade Systems Only
r[ Jr arc wx scc:lna&eaaed / sx Vulched -
Dc Ir e~ 1 Uc I'
R d. 7.e rcrl Ccn'nr i Ga 1. r -nch Edges T,ps L l Yes Fl, j °es Mo
t5-/
InSpect.On qL:
COMMENTS: .;Include code discreperclcs, ce,Slvsposerll etc.) Irspecti0n #1
Location: yg3 CA'V,%PASS Lt-A,4 'i At! 30.4 Descriplron= ~t-1S't'•~.PL.a(--,~a•l. Ht:tg sewer length = /Jt..P7,$re~ ,y ~~I S TQ eC`.~ I'4.Ot"i ~LMSc-1o~
- allroi It 01 CJver = I(X 4Ctry.,.~* ,t`- Lr.,..tCA ~,t, a~K"
Flan reeision Reel Yes - No
Use other side'or add Ronal inic'claUbn. TILL u - - -e't No
Cetc In>epCCars > u'
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Safety anc Buildings Division i l
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V7. Tank Info ~~:.:q: R m--T.cti 'F rt Mmmlacturn
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System PLOT PLAN
PROJECT Oeverino Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
1/4 NE 1/4s 23 149 N/R 19 W TOWN Hudson COUNTY ST.CROIX
SYSTEM ELEVATION 92.8/91Blow 8/15/18 DATE 4
BEDROOM
CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC 'I'A li 1255 gallons LIFT TANK SIZE DOSE, TANK SIZE:
911171LOAD HOLDING 'TANK SIZE RATE: .5 ABSORPTION AREA 1212 # of chambers 60
BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE 0 1VE:LI, <If.R.P. same as benchmark
*
477' Property Line B.M. 140'
vent Scale is I" = 40'
unless otherwise
>6" Quick4 Standard noted
of Cover Leaching Chamber
with 20.0 112 of Area
5.611^2/pair of end caps
4' long 1 ~
Grade at System Elevation
34
Pro 4
Bedroom
House
35' 10'
"F
13-2 90' -1 10'
97' O-E 40
Vcnts ~j Ca S_ ~4 Y` `l
J ~.e~(a i.~ l(.euti~ c to c.
95'
40'
GXLb{[~y~ e~ cwQ l~
10'% Slope
B_3 ~6Ao-ja "'cad
45'
93'
1-3' X 88' cells with >3' spacing
-1-3' X 84' cell - - - Gavin Pass
1-3'X 72' cell
All piping shall be ASTM SDR 30/34, within
10' of tank, piping shall be ASTM F891
System PLOT PLAN
PROM N CT Oeverina Homes A DDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
1/4 NE 1145 23 /T 29 N/R 19 w I-OWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 92.8/91 4' below qrado 81'151'18 4
HATE 616UROOAI
CONVEN'IIONAI. XXX ~),r~~d~- 1CONVFNTIONAL LIF"I' HOLDING TANK
1255 gallons LIFT TANK SIZE. DOSE TANK Sr/.R
MOUNT/ SHITIC '1'A. ' SFLF
HOLDING *TANK SIM LOAD RATE. .5 ABSORPTION ,4RP.A 1212 # of chambers 8I
BGNCIIYI ARK v.R.P. Top of survey iron ASSUME. ELEVATION 100• Filter Lifetime Diller
❑BOREHOLE O WELL xII.R.P. SameaSbenchmark
477' Property line I t0' 10
Scale is I" = 40'
Vent -unless otherwise
>6.. liio ck 1 Standardl noted
l Cover I eachm~ Chamkr
a with 0112 of Area
5.6101/Nir of en'd caps
4' Long
Grade at`~Systcpi Elevation
I Pro 4
Bedroom
} Ilouse
r
140' 15'
' 3' X 122' cells with >3' spacing ST
f B,, 90' i) B-I
A
97. 'Zi
Vents
i
95'
40'
IVS Slope
13 ;3
9 '
Gavin Pass
All piping shall Ix ASTM SDR 30/34, within
10' of tank, piping shall be AST:M F891
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Wisconsin Department of ,r~1p" Q1 SOIL EVALUATION REPORT Page _of
D.oscon of Safety and Buildrl)
in accordance with Comm 85, Wis. Adm Code
Attach complete site liar on paper not leas lhglill Wk 11 inches in size. Plan must
include, but not limited to, vertcal and horabnyl reference point (BM), direction and Parcel I.D. _
percent slope, scale or dimensions, north avow, and location and distance to nearest road. -
Please print aff information. Reviewed by Date
PersonN Irdormsaon yw p meY".sect for secondary WrPCees (Prwacry Law, s. 15.01(11(.)1 `
Property Owner Property Location
Qe,JC Govt. Lot 174I tl4 S2_ N R f ( W
Nano or CSM#
Property Owners Me ' Address Lot # Block # S! ir
City State Zip Code Phone Number 13 city ❑ lage Town Nearest Road ,Q
_Lrq W_h, w Construction Uselcyyesidenual I Number of bedrooms Code denied design flow rate GPD
❑ Replacement ❑ Public pin/ commercial - Describe:
~~nn ~
Parent material 1.. _r_ c.~[[Xti~-_ Flood Plain elevation if applicaGe
General cormlenL
end recommendations.
System Type ix 7n,!2 fE'e~` _ System Elevation. _
Borrigit fO'7t~
Ait Ground surface elev. l_ ft Depth to Ihniting factor in.
- - Soil Application Rile
rPio izon Depth Dominant Col Redox Desuip0on Texture Structure Consistence Boundary Roots GPD#F
in. Munsell Ou. Sz. Cont. Color Gr. Sz. SR _ 'Efl#1 'Ef1#2
t
n I L.
12
~ ( t
I
i_
r- Boringlit Boring i
l
Pit Ground surface elev. _ ft. Depth to limiting factor _ 1 1n. Soil Applicaboin Rate
Hatton Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD#F
_ In. Munsed ou. Sz. Cor Cola Gr. Sz, Sh. 'Eft#1 -Eff#L
C
I
Effluent #1 r SOD. > 30 < 220 TSS > 5G mxy& ' Effluent 42 = SOD. < 30 mg/1- and TSS < 30 m4k
CST Name (Please Print) Siynalurc _ CST Number
Bird Plumbing, Inc. Shaun Bird 226900
adnress Date E•raluallon C nductod Tolopheine Number
1432 120th St, New Richmond, WI 54417 ~1j ' % 715-246-4516
Property Owner. Parcel ID # Page of
it ❑❑l Daring ~-J
Pit Ground surface elevf _L-~ N. Depth to limiting factor _4L in, sod Application Rafe
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bwndary Roots GPD/fF
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#l 'EN#2
1/, Z
L40
I
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft- Depth to IimiOng factor in Suil Application Rate
Hannon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsea Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •EN#2
i
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to uniting factor in.
Sod Application Rate
horizon '*pth Dominant Color Redox Description. Texture Stru Consistence Boundary Roots GPOM
M. Munsell Ou. Sz- Con,. Color Gr. Sz. Sh. •Eff#1 'EH#2
'Effluent #1 = BOD, > 30 - 220 mgrL and TSS >30 < 150 mg& ' Effluent #2 = BOD, 130 mg1L and TSS 30 nxyt
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264.8777.
Shur)w(xAWi
Soil Test Plot P n
Project Name Oevering Homes aun Bi
Address 1433 Cernohous Ave Suite A
New Richmond Wi54017
.STM #226900
Lot 10 1 Subdivision Hunter Hills Estates pIL a 6/15/18
- 1/4 NE 1/4S 23 T 29 N/R19 W Township Hudson
Boring Q Well PL Property Line County ST. CROIX
B111 or VRP Assume Elevation too ft. Top of survey iron
System Elevation TBI *HRPSame as Benchmark
.M.
"
477' Properly Line B 140'
Scale is 1" = 40'
unless otherwise
noted
140'
B-2 90'
97' B-1
95'
40'
10';; Slope
B-3
4i'
Gavin Pass
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System PLOT Pi.;\V
rRl_oFcT Oeverino Homes ADDRESS 1433 Cernonous Ave. Sa to A Nem Richmond Wi 540'7
1,4 NE 1;4S 23 ;T 29 N:R 19 H't'owN, Hudson CUCNTSST.CROIX
sSSTF.bi ELEVATION 98.898.4 4.5 below Grade 1) 4 'rE 7129'18
BEDROOM
0NN'vN'TIONAL XXX C'ON% I:N'1'ION'AL I.IF'T HOLDING TANK
NJOL NU SI:I''I'IC TANK SIZI: 000 gallons LIFT 'TANK SIZE DOSI TANK SIZE
HOLDING TANK SIZE I_.O:AD RA'I F, S ABSORPTION ;%RL:x 9:13 # of chambers4A_
BENCHMARK N.R.P. -op o` survey iron AS56n4F. I:LEN.a'noN lou' Filter Li'eiirlc Filter
1:01:1'1101.6 AA'I'LK x IL R.1'. Same as benchma'k
.Iasi, Dr ac
~j tI I I
Vale - 11/`'T - I \j
i
Pro,
11DUSc
145'
ST
z
X 94' cell. with spacing _i'
90
1
310"
N enty'
l lUl
i
1
45 l
Siope
9(
ZS ,nt
>6" Quick-l Standard
of Cover Leaching Chanibe-
e„ ~n it1 20.0 i1' ui \t'ca
~.f fN'_'?pair of end caps
4' Long -
Grade at system Elevation
416' ProPcrt Line '4
All pipin..,hal. he -\S Ml SDR 3O:314. within
10' 01 tank. piping shall he ASTNI FS91
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 7/28/18
Owner:Oevering Homes
Location: 1/4 NE1/4 S 23 T29N,R19W Future lot "AQ Hunter Hills Estates Hudson
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4. 6. Maintance an tigency Plan
7. Filter Cross Sec io
Signature
License numb 26900
System PI.O'I' PLAN
PRO.Itecr Oeverino Homes Abblu•:SS 1433 Cernohous Ave Suite A New Richmond Wi 54017
114 NE 1/4S 23 29 N/IL 19 w TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 98.8/98.4 4.5' below grade 7/29/18 3
DATE BEDROOM
CONVENTIONAL X)(X CONVENTIONAL 11.111' HOLDING TANK
1000 gallons LIFT TANK SIZE DOSF TANK SIZF.
>touNn sl;wrtc TANK sv1.
- HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46
hk BENCHMARK V.It.P. Top of survey iron ASSUME ELEVATION 100' Filter Lifetime Filter
BOREHOLE.. O WELL *11.It.P, same as benchmark
Jack Drive
Scale = 1/4" = 10'
Pro 3
Bedroom
House
145'
ST
2-3' 94' cells with >3' spacing 25
B.M.* B-1
90'
30'
]03'
Vent.
50'
lOl'
Slope
45' B 3
Z 99'
- S vent
/1_ >5.. Quick4 Standard
t~f2. of Covcr Leaching Chamber
with 20.0 1't2 of Area
t-onw 12" ~.6it^2/pair of cnd caps
Grade at System Elevation
•116' Property Li ne 3'1
All pipings shall be ASTM SDR 30/34, within
10' of tank, piping shall he ASTM 1891
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber
5.6ft^2 pair of end plales To be >1' above grade
/ Finish grade elevation
/ Typical Installation 103.5'
01 t /1 Grade Vent
3' 41'
X30/34 Septic Tank 3
5' Lon- I 5 i' Long I
Grade at System Elevation
36" Grade at System Elevation
Spacing- 5'
2-3' X 94' Cells
Same on other end Observation tube/Vent
At end of cell
A
B
23 chambers per cell
System elevations:
A-98.8'
B-98.4'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _,of-
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic ianR Capacity 1 -1 NA
Permit
Septic Tank Manufacturer j 0 NA
y
A
)ESIGN PARAMETERS Effluent Filter Manufacturer
❑ NA
Number of Bedrooms FI NA Effluent Filter Model 0 NA
Number of Public Facility Units a NA Pump Tank Capacity INA
Estimated flow (average) al/da Pump Tank Manufacturer Design flow (peak), (Estimated x 1.5) ;_2 auda Pump Manufacturer Soil Application Rate al /ft`
Pump Model Standard Influent/Effluent Quality Monthly average' Pretreatment Unit Fats, Oil & Grease (FOG) 530 ni 0 Sand/Grave! Filter 0 Peat Filter
Biochemical Oxygen Demand (BOCt..) 420 mi 0 NA 0 Mechanical Aeration 0 Welland
Total Suspended Solids (TSS) c150 mi Disinfection 0 Other.
Preheated Effluent Quality Monthly average r-"At-Grade ersal Cell(s) C NA
Biochemical Oxygen Demand (BODs) 530 mg/L-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) ~0 mg/L -176 NA 0 Mound
Fecal Colifonn (geometric mean) c10' it/100ml rip-Line 0 Other
iMaximum Effluent Particle Size /e in dia A NA
NA r.
L X-0 "Values typical for domestic wastewater ano septic tank offloent- Other " NA
AINTENANCE SCHEDULE
Service Event Service Frequency
inspect condition of tank(s) 0 month(s)
At least once every: (Maximum 3 years) 0 NA
Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA
linspect dispersal cell(s) At !east once every' _ O mons
_ yyy9year(s) (maximum 3 years) NA
Clean effluent filter At least once every: 0 month(s) U NA
i ~ i /_,FJ years) _
nspect pump, pump controls & alarm At least once every. 0 month(s) 0 NA
0 year(s) _
Flush laterals and pressure test At least once every: 0 month(s) 0 NA
0 year(s)
i)ther. At least once every: 0 month(s) G NA
0 year(s)
Other. '-0 NA.
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual canyiny one of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POkArrS Maintainer: Septage Servicing Operator. Tank inspections must
snclude a visual inspection of the tank(s) to identity any missing or broker hardware, identify any cracks or leaks, measure the volume of
combined sludge and scum and to check for any back up or pending of effluent on the ground surface. The dispersal cell(s) shaft be
visually inspected to check the effluent levels in the observation pipes and to check for any pending of effluent on the ground surface.
Erie pending of effluent on the ground surface may indicate a :airing condition: and requires the immediate notification of the local
regulatory authority.
Wher. the combined accumulation of sludge and scum in any tank equals one-third (h) or more of the tank volume, the entire contents of
he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconi
4dministrative Code.
All other services, including but not limited to the servicing of effluent fitters, mechanical or pressurized components, pretreatment units.
and any servicing at intervals of 12 months, shall be performed by a certified POWTS Maintainer.
a service report shall be provided to the local regulatory authority •xithin 10 days of completion of any service event.
page of
START UP AND OPERATION ducts or other chemicals ft t
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products
may Impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents Of the
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface. wastewater will be
During power outages pump tanks may fill above normal hightwater levels. When power is restored the
surface excess discharge effluent.
effluent.
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in lore backup resschar power to ft
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal Ieve s
within the pump tank. the area within
Do not drive or park yehidas over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact
15 feet down slope of any mound or at-grade soil absorption, area. he life of the POWTS:
did prolong prolong the if foundation drain
Reduction or elimination of the following from the wastewater stream may improve the performance and
antibiotics; baby wipes: cigarette butts; Condoms; cotton swabs; degreasers; dental floss; diapersWWs, oil; foundation fond rain
(sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is propetlY
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• Ail 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.
• 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.
CONTINGENCY PLAN
If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacepent system:
suitable replacement area has been evaluated and may be ubl¢e i for the location at a replacement sod absorption systeirn.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by rsquit~ed
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the repiscement 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 ruierl in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologM a
hokfing tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tarok may be Installed as
a last resort to replace the failed POWTS.
❑ Mound and at-grade sod 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.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS _
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone~~ Phone
SEPTAGE SERVICING OPERATO PUMPER LOCAL REGULATORY AUTHORITY
Name r_N
Phone ~y 1 / y
1/ /4 This doamerttwas drafted in Compliance with chapter SPS 38;3.22(2)(b)(l)(d)&(f) and 3&3.Wl), (2) & (3), Wisconsin Administrative Code.
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ST. CROIX COUNTY
S12TIC TANK MAINTENANCL ACIRFEMENT
AND
OWNERSHIP CERTIFICATION FORM
(honer/Rn}'er eJe~I~/_ ffGKi - -
_
Mailing Address
GEI 4--lczi
Property Address
rtif~i(cationrrequirad fiom~'lan»ing R 70
ning Department for new construction,) -
< Ity/State va)1~ /0 r7
1 arcei Idenlificalion Number
LEGAL DESCRnYHON
Property l.ocatiotr ;!t /
/ ~r,seo.l-,T l N /
1. L W Town Of I ~7
Lot #
Certified Survey Map H Volume
- Page It
Warranty Deed H Page#
Spec house es n° At liars idenfifiahlp no
SYSTEM MAINTENANCE AND OWNER CERI (CATION \
Improper use and i aimegance of your septic system could rrsulr in its premature failure to handle wastes.
maintenance consists of pumping out the propel,
scnc; tank
the system can affrctthe function o/'fhe septic tartcurry three yeas or suouer, rf ne[•.deet, by a lixrtsed pumper. What you pui mtu
as a treatmerd stage in the waste disposal system. CAvner rnainlenttuce
lv"llsibilit= arc specified in §Coquu. 8i.52(1) and m Chapter 12 - St. (.rmx County Sanuaty Ordinance.
The properly owner agrees to submit to St (}otx County 1'lanrunq do Zoning Deparant tt a ecitdicahun form, signed by thr
owner and by a master plumber, journeyman plmnber, restricted plumtxr or a licensed pumper vetifying that (1) the oil site
wastewater disposal system is in proper operating condition andlor (2) after inspection and pumping (if accessaty), the septic tauk is
less than 1/1 full of sludge.
Pwe, the undersigned have read the, above requirements and aywe to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of ('nmmerce and the, Deparnent of Naonal Resources, State of Wisconsin.
Ccrtificauon slating that your septic system hus been maiulained must be completed and retwned to the St_ Croix Comity planting &
/.fining Department within 30 days of the three year expiration dare,
1, we certify that all statements oil I , (form ate true to the bast of my/our knowledge. 1/we andate the owner(s) of the
property described above, by vittti of a wafranfy decd recorded to Register of Dccds Office.
J
Number of bedrooms-----'
~1UNATCI QF APPLiCANT{S) -
DA T£•.
**'Any intormanon 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 Itr:gisler of Dceds Office and a copy of the certified survey map if
reference is made in the warranty deal.
('REV. 08/05)
Hlii~rl'ER HILLS ESrI'F
L~anoN „:Ir
--i :D N PART OL''P}TI: VW 1 r. OF THE NF, I r .AND P Kt OF THE NF 1%.
I,OC A'1 F I I
AND PART OF TII7: SW 1/:I OF TIM SE 1/4 A NI) PART' OF THESE 1/4 OF TH
I'2gN, R1gW, TOWN OF HUDSON, ST. C ROIX COUNTY,'
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