HomeMy WebLinkAbout018-2011-47-000
ovisccnsir Depaelne•rtof Ccrnnw'ce PRIVATE SEWAGE SYSTEM Canty St. Croix
Safely anu Bu a ng Div s Jn $~rntery Pcwm I Nc
INSPECTION REPORT 607024
GENERAL INFORMATION (ATTACH TO PERMIT) Slane Pear, ID No
Pe.'scrsi -tnr- ahc- y011 Pr^oce ma'y Le OcCJ bl se-COrcar'v parecses (Priracy Law s.1: CA t I jimi)
"iit Hoicer s Na- tr C i village Irmislr V Parcel Tax Ne
Kernon Bast TOWN OF HAMMOND 018-2011-47-000
C51 310 L ua Insp. BLd E'ev' BPoI De poon Sec:icnjiav r. Range Ma, Nu.
5 Dpi 3-3 '1 30.29.17.1062
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ~ CAPACITY STATION BS HI FS ELEV.
Septic v /bOO Benchmark 7.1 1 ~9 • S
Dosing Alt. BM r I Ge MAOO I ~OV r i `
01 -Z • Z 165,4#
Bldg. Server ~ 3 167
Hold:rg St;Ht Inlet 49
TANK SETBACK INFORMATION SUHtOutet
TANK TO PiL WELL BLDG vem A r Irlake ROAD Dt Inlet
We
3d - D1 Bottom If
Septic /t,1/~ lea
9S• q
Dos,ng 4j A- f / lleaoe,Wan
3 0 66 f- 3. e~3 . z
Ai Disl. Pope
r a6
Holdlrg Bot System /C _j 14A, -e PUMPISIPHON INFORMATION F r•a'. Grade f p,rt~ /6Z.
Manufacturer Demand L St Cove y
L, Liiii GPM T ,`I J UL, Z •7 /p 3•
Mode Number Z50 'Y;5 I G• /dam
TDH Li , Fr Lion ~ss System Ilean! c; f~ T0I17I ~I
/ J b
Fo•cema.r. La•,ga1 Dial r D M lo':ve _
SOIL ABSORPTION SYSTEM N
BEDITRENCH 'imcP' _er•gth G No O`Treorhes PIT DIMENSIONS No. O`P Is ins le DiJ It igdin')i
DIMENSIONS 3 /,e J Z 1 ~
SETBACK SYSTENI TO TIT BLDG VIELL LAKE;STREAPA LEACHING Man_IacWrcr
INFORMATION CHAMBER OR (r I' iij /1
'yoe CI SYJ1Cni UNIT
fvlodei Numtsr
C__
DISTRIBUTION SYSTEM ii
v ► e ~
HeadervManifold xI DlstnGdtim xlt IcSizc resale Sp.=.cinc Ver eAirh kc
Poesl 1
Lcnglr~ D Lengi- D a Spacino _ _
SOIL COVER x Pressure Systems only xx Mound Or At-Grade Systems Only
D7 t9 Caer Dcet•r Cw:r ,.'17ep:h of xx SCece cjetl xx Mulch=_d
I;r•Jr Trcnc" Ccrtcr z '+'7j BedrTrench Etl,eS ~ Trogai ~ - No es No
- 1 COMMENTS: Ilnclude code oiscrepencies, persons presi elc j Inspectioln #1 Inspecocr u2
Location: '52678TH AVE YY"~C~C
Y"~-~ S 0
F; Il ~o r~
I i AI: BM Description
2 . Bldg sewer length = y Y
- arrount of ccver = L4 Z
Iii
Plan revision side Required? ' Yes
No 71
,lsc either lher side for additional Information t~
Date Irsepctor Signatdr Ci No
'D-9?1C !R 3'E-7:
I ~ (burry (t
r ~-t ~c , p Sefety antl Buil~ings Dn-Sion - fi~ f~ 1 _
tt ~ ~ 109 3011b'-'NJa ntnoto^AvP BC%?1'2 S>r PetmtWur:br. lu be Bed in b>Col
=I Sp ^I lmdCl n .f 53TCt. 7
~d~~_'p F (vo702~ -
Sr Tr.r+: +u:nn t:unhc
Suitar~ Pamll ~ppliwatf0 '
iu a cvrd.u <with SI s :St l s.. dm t _ s : l 1.'. F u, u the appr pilaL _W'r o unrt _ - _
x required Pn t [ ontaimnk tvta-1' x[mn J -.4P .-ll u. nti ,r ta.e -word ° V, are s. l t i..vd 4 It:,7ta Address ;i: C,3arnt than maiim; aodrasi ~
itc 'Jcpamm~t ucn aoL pi rf t,i real Pc; r.il trt t :inn nu P.c' J, ma, x used I . ^e nn,9.t1''
Tpcses m..Gardance •ana tie nacvL.w 'ait}n _ 'y,►F' 5.~ r`.C-~
t .Vpphcation Information- Please Print All Informtfiuu ~q-\y\-- -
Popetn'Uwn.~': Va't+c _ - iaz <Ib~i V r J! ~.~~rJ
_-1.1~./1/t?rte/ gt,.~`~.'l~:
?iu(xr'y Cyut sMmIn Addrrss ) j A-+Pcns1 :0t:n.
l /LC Lot z
`X/
m Stair n I ' I / 6iP .<de -r'hom Nnmha n,~L _ ' Sahea
' IL'f J'Pe of Building (cheek all that apply ~ a _ _ - -
L/// Subdiwraoo Name
Family Dwellio Sun bcr o! Bcdttm ( ~ yyr~,, ~~.r,/,
6K ya OsYitC_ [SIo" - - ~_C__f~.(2 c //'L(=C
}b~>lia\s:n.'nerual- Ik Jrh: sr _ g`~.+ s _ ❑ in af_- . -
_ 1( ~C~A!~un:i.:r U\vllage of _
'sate (hvueA Do:rike Usr
/ II fowr: of
Q ia}- GeSta tee--~ 7 5 EZHOt.15 Ep [.h -
IIf "f V' eyfl'crtnit: 'Che(k onk on~box on line 4 Complete line B if appki lble) ~p ~
i
nra.rt ~:mh
A. \eu SyS:cm h.p::c -met. tiystcin ~.rr:nmcn 'ug 7ati.d I iC1IVS ModiSCmion to cns[ta: $c•¢em!~plami
a.
- , t Fresinus PertOn Vtunber ane I1alr Lssurt
R. Pe:eil Rmesv'al~ fame, Hcu i..i:m ❑ Chatec cl i'Ltsi+_ L Pcrm.1 Ir.O:dert Sew -
sse ore Lxpmn:u. uw o~
~V:fivtseZF6~n"Cw,_trytuComponentDe, a l<heckallthatapilyl_ _ _ 7Z 1~^.-ar-s..-
,~Tt".aa- res arud m t,d l''t t rr11 i x..rv 7 M1t ii. ie r meun I : S u :f sunzole soil (I M and 23 in of shame sod
'7tifII LTt-x ca -
f i+I-inkci- meat .Creafolc ap•,n n.I~plm't i:IYcII atmnrt:ses've, a,>lau:l
i%El orm ion `y _ q /
t DicpervVl'reat _ 1 -
I r f i Iies~,+u Aypl u nazeugpdsf 15ts r I stet Recuird 'tt [)spe.sal .A.:a PmPo.ed txn - ten EI:v9uoa Y
-LT3nklno I C.apruy n luta: %of U,antfacmrer /--~L Y`_'~u--`
rallcnz <~Iinns I:mn v
Tiew :ar'rs i IxyKi4e Imo: 1 f 1 u _ iz d
VLL ltecponmbility Stattem_ent- I. thr uudrnit oed. u e ra!"Himbiln,- t..r iisullatm of the POWTT 1howo 0o the attached plans.
'h/im \Jeo- tint: 'h Yi;•..anav biP'yIPhS N u;i:r_t ~t :mess f6nnc V . b:.
Piu.-nxr s rWutn- ,,Ntnel. stn', .tale, La +,oi
VLU unri De_arrment Clse f lnh _ _ _
-I ncreJt F. I Date Its'~e? lism ~4er•tt Siesams.
ApProv ed - ppro•. / C.
Y~ ver. F.c~-tic Sor L+r.,t:d S 7 ~ . OD 1-~z~ ~ r
X. ConditirSiSf6~8W1&Zisone for Dicappr0':d n
1. Septt.lark, clprc~ W, rn4 3) U Jaf/!.~ I ~ O ~O (J ~ CC.a. I~ea^-~
Ulwel cfll "'j 1 ill D9 J✓ ~OJV-Q~ J 1-W✓~ ✓~Qln.,a-fis.q(~.~.~
es par tar3liemer' pl n " L lu ,e., net .
2. All rWfh3 k reel. in a(l ti m': ct c n t , /s 1
aaPei.Y'F~rr:blzc ~ rA':.rt'I t r/lYD(~MU+~6~ ,
- 1
xtiaea is cuapkh Vlam for r9r symm aM zvbmh w\\th\)e /'.naory IIenlr w pnprr not kss enan (R/^/i'..~:~,:v 1_1 ,o:ha1+u~ xue I^^ h`~
MD b3g8 ;R ! li i! 1 1 /I -
5~ J~a;~ Mme- I1o~"' S~pAf' J~Ab~a~~(~tm'\ .
System PLOT PLAN
1•Roji c I Kernor Bass ADDRESS 948 LaBaroe Rd Hudson Wi 54016
N~ i NW 1 ; 4S 30 1' 28 Ni R 1 ? W TO%VN Hammonc COt VTY ST. CROIX
SYSTEYI ELEN'.ATION 99.5'99.2'98.9 1.5' Delow qrade 2!25; 19 DATE. 3
BEDROOM
C CNN` EN'1'IONAL A1 -GRADE CONY ENTIONAL LIFT XXX HOLDING 'LANK
N7OL ND SEPTIC T 1000 gallons IAVI 'LANK SIZE630 DOSE 'LANK SIZE:
TANK tiIZE;
HOLDING TANK SIZE LOAD RATE .4 ABSOLU'T'ION AREA 1.25 # of EZ-Flows22.5
BENCHMARK V.R.P. Top of 1" pipe ASS( Nil, I:LEN'A'1'ION 100' Filter Lifctimc Filicr
❑ BOREHOLE (D "'111, ^IL R.P, same as DD'1Dnmark
Propenv Line
34u Slope 99,5-
's-3' X 75' cells with >3' spacing
100.
B. M.
?0' 101.5' System is to be installed along the
contours, the soils will he checked to see
B I 0 R If SV1;WM can be lowered 1'.
Vent, 40'
ll rflctitt Combo I Zink
20'
Pro
Bedroom
House
Pronettv Line
. r,
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 2/28/19
Owner: Kernon Bast
Location: NE 1/4 NW 1/4 S30 T29 N,R17W Lot 47 Emerald Acres Hammond
System type: In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Pressure Distribution Manual (version 2.0)
Page4
1. Cover Page
2. Plot Plan
3. EZ-Flow Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications Sh
8. Dose Tank Cross Sect' n
9. Pump Curve
/i~
Signature_
License number 26900
i,'
System PLOT PLAN
PRQIEcT Kernon Bast ADDRESS 948 LaBarge Rd Hudson Wi 54016
NE I!4 NW tMs 30 rr 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 99.5:99.2198.9 1.5' below grade 2:25,•'19 BEDROOM 3
U:'I'1:
CONY ENTIONAL AT-GRADE CONVENTIONAL LIFT XXX HOLDING TANK
MOUND til•:1'TIC I':1NK SIZE 1000 (gallons [,JET TANK sr/.t-.630 DOSE TANK SIZE
- '
HOLDING TANK SIZE' LOAD RATE. .4 ABSORPTION AREA 1125 H of E7.-Flows22.5
REM1IM1I:ARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter Lifetime Filler
❑ BORE110I.E. a R'I'LL -II.R.P. sameasbenchmark
Property Line
31; Slope 99.5'
B3
50' 3 3' X 75' cells with >3' spacing
100.5'
B.Tvi.
20 101.E System is to be installed along the
contours, the soils will be checked to see
B-l 0 B-2 if system can be lowered 1'.
Vents 40'
IWITeutt Combo Tank
20•
Pro 3
_ Bedroom
llousc
Property Line
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Cl
6. m io
T3 C LL
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
=1LE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tanic Capacity gal ❑ NA
-
Yemtit # Septic Tank Manufacturer _l - G NA-
DESIGN PARAMETERS Effluent Fitter Manufacturer_ 1 0 NA
Number of Bedrooms I _ fJ NA Effluent Filter Model r 0 NA
Number of Public Facility Units l il~-NA Pump Tank Capacity al 0 NA
Estimated flow (average) gal/day Pump Tank Manufacturer NA
) Pump Manufacturer NA
Design flow (peak), (Estimated x 1.5
_ _ aaUdav _ -
Soil Application Rate 9a1/deyllt Puinp Model r r 0 NA
i Monthly average' Pretreatment Unit
Standard Influent/Effluent Quality
Fats, Oil & Grease (FOG) i S30 ril G Sand/Gravel Filter 0 Peat Filtef
Biochemical Oxygen Demand (BODs) i t220 mgfL L] NA 0 Mechanical Aeration 0 Wotland
Total Suspended Solids (TSS) <_150 mgiL Disinfection 0 Other
Fretteated Effluent Quality Monthly average Dispersal Cell(s) LJ NA
Biochemical Oxygen Demand (BODs) s30 mg/L ~^1, n-Ground (gravity) G In-Ground (pressurized)
Total Suspended Solids (Tss) _30 mg1L G At-Grade ❑ Mound t
Fecal Colifonn (geometric mean) -'AW cfu/100m1 0 Drip-Line - 0 Other _
'Maximum Effluent Particle Size )y in dia. 0 NA Other 71 NA
iOhher' (the, IJ NA
'Values typical for domestic wastewater and septic tank afluaet. other Z MA
IAINTENANCE SCHEDULE
Service Event Service Frequency
S (Maximum 3 years) D NA
[Inspect condition, of tank(s) At least once every. - ~ earr~y(s) -
Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume - 0 NA
- - - - - - - J month(s)
inspect dispersa'. ooli(s) At least once every: ;wear(s) (Maximum 3 years) C NA
/ Cl month(s) U NA
Clean effluent filter At least once every: Year(s)
nsPect pump, pump controls & alarm At least once every_ month(n) G NA
.year(s)
lush laterals and pressure test At least once every: 1-1 month(s) G NA
0 year(s)
Jfhec
At least once every D month(s) G N
- -=year(s) -
Dther. - ---JJI----- ❑ KA I
MAINTENANCE INSTRUCTIONS
inspections of tanks and dispersal cells shall be made by an individual uarrying one of the following licenses or cortificahons. Mauer
Plumber; Master Plumber Restricted Sower: POWTS inspector. POWTS Maintainer Seplage Servicing Operator. Tank inspections mast
'include a visual inspection of' he tank(s) to identify any m'ssmg or broker, hardware, Identify any cracks or leaks. measure the volume of
:ombined sludge and scum and to check for any bade JD or pending of efflaeni on the ground surface. The dispersal uell(s) shall be
~visaally inspected to check the effluent levels in the observation pipes and to c;hecA for any ponding of effluent on the ground suifaue
The ponding of effluent on the ground surface may indicate a tailing condition and requires the immediate notification of the local
"egulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (7,t) 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 '>13, Wiscons,n
Administrative Code.
•AlI other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
and any servicing at intervals of 512 montrrs, shall be ^ertouned by, a certified POWTS Maintainer.
A service report shall be provided to the local regwatory authority *hi^ 0 days Of Completion of any service event.
Page -of -
that
START AND OPERATION treatment tank(s) IT the Presence of Painting P~ 'Is °r other chemicals of the
For new w construction. prior to use of the POWTS check
may impede the treatment process and/or damage the dispersal cell(s). If high corncenirahors are detected have the contents
tank(s) removed by a septege servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface- r is restored the excess wastewater will be
pump tanks may `til above normal highwater levels. When tin the backup or surface discharge of effluent-
During power outages PM cell(s) in one large dose, overloading the cell(s) and may result r to restoring power to the
discharged is the dupers a Selvage Servicing Operator prio normal levels
To avoid this situation have the contents of the pump tank removed by the pump contr trols to restore
effluent pump or coated a Plumber or POWTS Maintainer to assist in manually operating
within the pump tank. disturb or pmnP the area within
Do not drive or park vehicles over banks and dispersal calls. not drive or park over, or otherwise
on area.
55 feel down slope of any mound or at-grade soil absorptirtnance and prolong the rife at the POWYS:
Reduction or elimination of the following from the wastewater stream may improve the floss. djapem; disinfectants; fat: foundation drain
antibiotics; baby wipes; cigarette buts; condoms; cotton swabs: degreasers; dental ;s "mss oil) painting produce:
(sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat pesticides: sanitary napkins; tampons; and water softener brine.
ABANDONMENT shall betaken to insure that the system is propeilY
When the POWTS fails and/or is permanently taker out of service the following steps
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin 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 property disposed of by a Sept8ge Servicing Operator.
• After pumping, all tanks and pits shag be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN must be taken, to provide a code compliant
If the POWTS fails and cannot be repaired the following measures have been, or
replace ell system: ant sod absorption syste►r -
Asuitable replacement area has been evaluated and may be utllized for the location of a replacem
protected from disturbance and compaction and should not be infringed upon by recluitled
The reks frome xiarea should be the replacement area will result in the need
for existing and proposed structure lot lines and weer. Failure to protect systems- must comply with the rules; in
for a new soil and site evaluation to establish a suitable replacement area. Replacement
effect at that time. advances in POWfS technology a
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring
holding tank may be Installed as a last resort to replace the failed POWTS. failure of the POWTS a sal and site evaluation
❑ The site has not been evaluated to identify a suitable replacement area. Upon be installed as
must be performed to locate a suitable replacement area. If no replacement area is available a holding tarn may
a last resort to replace the tailed POWTS.
Ies in effect following ttemote of the biomat at the infittrative
❑ Mound and at-grade soil absorption systems may be reconstructed
time.
surface. Reconstructions of such systems must comply <<WARNING>> vrith the
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR PDEATH MAY RESULT. RESCUE OF A
HE TREATMENT E tNK UNDER ANY CIRCUMSTANCES.
PERSON FROM THE INTERIOR A TANK MAY
ADDITIONAL COMMENTS - _ ~
pOWTS INSTALLER - - - ~wTS MAINTAINER
Name
Phone Phone l
SEPTAGE_SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name y~ nJ Name
Phone Phone
and 383.54(1), (2) 8 (3), Wisconsin Administrative Code.
This document vies drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(t)
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Septic-Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer Pump Manufacturer
Tank Model Number L- Q - Pump Model Number
I otal Tank Capacity Alarin illanutacturer
Max. Bury Depth Marm Model Number ti
Switch "Type
Filler Manufacuircr ~I otal Dynamic I lead (TT)H) - Feet
Filter Model Number E.Icvation Head
_11Z-
Distal Pressure
Network Loss
Minimum Pump Performance RequiredForcc Main Loss S
GYt, a' tt TDI1
Total
Outlet Manhole Min. T' Above Grade W ith
Locking Devicc, Inlet Manhole Manhole Min. I" Above Grade
6" Below Grade Sealed Watertight Securely Mounted ti'ilh Locking Devicc
Weather-proof l
t-~ Junction Box ! 1
- - - Tinished Grade - - -
Vent Nfin. 1 Disconnect
Above Grade Means
With Vent Cap
Outlet Filter
Inlet Inlet Baffle
Switch Settings and Reserve C apaan)
Tank - Weep
,hintc - GYI f
A D nicnsion Inches Volunte Gal. B Hole
(al arm) B 2 3 D Off Elevation C
idose ) C q~ / 0 Ft
! , Bottom
{dead) D 1) Elevation
~I otal yZ~ L7~/ 2- Ft
GENERAL INSTALLATION: the septicidose tank is bedded and back filled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may riot
be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device fpadlock)
installed. Piping at the inlet and outlet is of approved material. connected to the tank with watertight fittings. and
laid on stable soil to prevent scithug or sagging. The fierce main is Sleeved with 4" Sch. 40 PVC to bridge the tank
excavation and the sfecve is sealed watertight. Hccirical service complies with NEC 100 and Conan 16.28.
02 '0 IJ Yagc of
250=SERIES
113 hp Sump/Effluent Pumps for Professionals!
ALL MODELS FEATURE: MOTOR SPECIFICATIONS:
• Rugged 1 /3 hp motor, oil filled with 1/3 hp 115V 5.2 amps 60Hz
thermal overload protection. Thermally Protected 8 Permanently Lubricated
• 1 /2" solids handling. (PSC) Permanent Split Capacitor
Maximum Fluid Temperature: 140"F
• 1-1/2" discharge.
• Hermetically sealed motor and switch cavities, DIMENSIONAL DATA:
and permanently lubricated bearings. Weight: Model 257:20 lbs.
• Liberty's LINI-BODY casting - a solid, one- Height: 10.5"
piece housing that eliminates the lower motor
seal ring found oil other pumps. Major Width: 9.6" (manual model 250)
• Epoxy powder coat finish PERFORMANCE CURVE
• Vortex style impeller for superior PERFORMANCE CURVE
solids-handling. Made of high temperature 25
engineering polymer.
• Fasteners - all non-corrosive stainless steel. 20 c
• 416 stainless steel rotor shaft. v
t 1s _-i s =
250-series Cord Lengths ° a
s'
10
Model 10' 25'(-2) 351(-3) 501(-5) ti
250 Standard Optional _ Optional Optional ~ 5 2
w
251 Standard Optional Optional Optional
253 Standard Optional Optional N/A 0 0
257 Standard Optional N/A N/A 0 10 0 30 40 50
U.S. Gallons Per Minute
10' cord length standard on all models. For optional lengths, I
adcl "-2, -3 or -.5•' suffix to model number. 0 38 ra 11-1 I56 192
Example: for model 250 with 35 cord, order 250 3 1 hers Per Minute
EFFLUENTMODELS
~T LIf = Tr.
Model 250 Model 251 Model 253 Model 257 VMF
Manual, no switch. Quick-disconnect Wide-angle float with VMF switch, magnetically
wide-angle float, series (piggy-back) operated vertical float -
mercury-freo. plug, allows manual operates in a 10" -
wp operation of pump. diameter sump.
Si• Ou"l satry art hGaiun nr
P ,,certified
Liberty Pumps • 7000 Apple Tree Avenue • Bergen, New York 14416 • Phone 800-543-2550 Fax (585) 494-1839
www.libertypumps.com Copyright 5?ulxrty Knope:, I...i 21117
Alinghtsrese"ed 11172500-RS•17
ST . CROIX COUNT 't'
SEPTIC 'LANK> 1AINTI-;NANCL ~aJNFF'M 'I'A I'
A VI)
OlIN`h:RSH1P CER 1'IVICATICIN FORM
I K
Mailing Ad(Iress.-/ 14 1!
Property Address 4 ~ AL,,. ~
(Verifiewinn required from Planruge Zoning 0cparl.~-writ fur ne:rv constriction
.j - -
Cit_yiStalc Parcel Idcntilitation Nut thief O18'- 0011- 4f7- eC~
LEGAL: DESCRIPTION
7 ~
Property LocationSec:. N K r/_ 1 W" '1 ixvn of llr.^„,~yZ~
i
Subdivision %'(L -LS'=- ~ = .Lot#-
Certified Survey Lap # _ Vctilule Page # Warranty Deed # Page fi l./ O
SPcc house yes no l or iare> idencriable vc:: no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
ltriproper use and trlanuenancr of ynrn septw s}'scent could ; eMilt in ns Pr,-mature IildrnC to handle wntstrs. Proper
enaintcnance coruisls of pumparg out the septic tank eoeT v Fluor yvvs or snnner, a needed. bS• a hcaarsrd pumpei_ What you lit it into
the system can aMv !he flmrhon of the sepu;! tank as a trcatMen`' stage in ale wane disposal system- Oamrr maintenance
espinrsrbihnas are sg>ecefied in $('omm. k-1,:i2(i) aad cr Ch::ptar 1 5F Croix Co m:y \,rivary t)rdinancc
The propcrh~ owner atuae. to submit tc• 5t. t7o.X County 1 I unri;v~ ti' 7or;.nf; Departnrenr a ert nt5canun li ernl, sii?nrti b~' Ihr
oavaet and by a [Waster plumber. Journeyman plumber, It"Aric.trd plumber or a licensed punrpc[ Vorifymg, that (I ) ,hc nn -irw
n•astewater d[sposal system is in proper opciaunr• c:oi,diiinn auaPnr ('.I after mope:;.ton and pumpLrg (it ❑eccssin"'), the 'V JIAc tank is
Iris than 1~3 had of sludge-
Uwe, the undersigued have read the above rrquirtalwil s and al'roc to mair.ram rho prorate sewage r'.isposal sVatcut will rhr
, landards set hruh, hcrcm, as slit bq the Deparruenl of ( oamtercc and the I)epanmmm o Kahual Resources, 6tare oYyi'ix.ousm-
Ccrlificauun stating that your srplic system has been mritimi,ied must be complew-1 and returned to the St. Croix County Plannri &
&rung Depatttnent within 30 clays of thr three year expiration data
li we certify that all state-rmmt,- on thl four an- Frei. to ncc bast of ut}7om k nuwled;;r. Uwe am'arc lhr: avvnrrfsj ul'Ih:•
rmperty described above., by vulun of a ar only deer( recorded h: Rep,rsart of Der,, Is Office.
Number of bedrooms -
L4
tiKiNAIIIRFOI APP1,ICAN'1(S) DATE
*.*Au7 intiuniation that vs mistepiesemed may result in the sanv!a['y per nu! beings=voked by the li'mumig & Z.urung llepa[m)cut.
Include with this application a recorded w•arr•tr ty cec•d iiotli the !:erisrri of !)..e.f• C(ic: .uFd a ropv u[ dre ccr;ihcd survey map if
refi.rcncc is midi: In the wan'aniy deed.
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I be Uepartulenl of Commerce is an C( ual (I11pultul11tY s:rvIc- plovil ICr and Clllpi,yel. It YVt111c^d m'sisti lwir It, access SCm", w
need Ina(C ial in an 11IM aIC funnal, plcasc contact tic dcpanmsut at (AM 266 A! CI w 1*1 60F-?64F'; .7.
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