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HomeMy WebLinkAbout026-1302-06-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety end Building Division INSPECTION REPORT Sanitary Permit No: • 506282 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: P.C. Collova Builders, Inc. I Richmond, Town of 026- 1302 -06 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: WD 0 ( C� /Y c ( 07.30.18.1583 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benckmark 3,2- /0 3z 100. Dosing Alt BM d� 98 Aeration Bldg. Sewer / Y, s=� 9�- Holding St/Ht Inlet Ht Outlet cf S� -s- TANK SETBACK INFORMATION —� " Z i 5 y(�: yS 7 / ,r TANK TO /L, WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � ! 01) Dt Bottom i v Dosing eader an. Aeration Dist. Pi i , ` '41 .AI` Holding Bot. System X _ Final rade t Sf p Z. PUMP /SIPHON INFORMATION �✓ - �`%� Manufacturer Demand St, oyer pp GPM /O3 !0 Model Number S - TDH Lift Friction s Syste ad TDH Ft U _ QUO h Forcemain gth Dia. Dist. to Well ` SOIL ABSORPTION SYSTEM - -- 1 / BED /TRENCH Width , Length, No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3' �-� I SETBACK SYSTEM TO / P/L JBLDG D WELL LA /STREAM EACHING INFORMATION Ma tur CHAMBER OR w� ✓ L�/t� Ty f System: �p�� �h >�� Model Number: U ' � V d '' DIS IBUTION SYSTEM Header / Distribution 4' f (t x Hole Size x Hole Spacing Vent to Air I � e Length d '" r Dia Length Dia Spacing�_� t . SOI OVER x Pressure Systems Only xx Mound Or At - Grade Systems Only p t Depth 9 P p p Yes No Bed/Tre Cent / 3 �— Bed /Trench Edges Topsoil of xx Seeded /Sodded xx Mulched l Yes ]N, COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1:�/ Z / C/ Inspection #2: Location: 951 165th Avenue New Richmond, WI 54017 ((NW 1/4 SE 1/4 7 T30N R1 8W) Ninety Fifth Street Site of @ Parcel No: 07.30.18.1583 1.) Alt BM Description /, z(.�r� I�7.fiU!'Z_. GfJ� - P�?clsL�1i1J7 / I� G 7�h f 2.) Bldg sewer length - amount of cover Plan revision Required? I' ;Yes 1 o Use other side for additional information. Date Insepctor's Signatu Cert. No. SBD -6710 (R.3/97) coir merce;.m.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 J -� J C 'r s co n s n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled to by Co.) t iepartnoent of CoaMmerrae 564 State Transaction Number z I K Z— Sanitary Permit Application / In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for to -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide a used for secondary /' o ur-poses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 5-1 / 1. Application Information - Please Print All Information !! Property Owner's Name Parcel # Property Owner's Mailing Address Property Location 1 2- Govt. Lot City, State Zip Code Phone Number A & L %. /., le Section S / , r I circ w T�L� N; R or 11. Type of Building (check all the L Lot # Fan' vDwelling - Number of edroo P � _ tyE� Subdivision Name Bloc (.S UC�(.�. J ' ❑ Public/Commercial - Describe Use 2001 City of CSM Number ❑ Village of ❑ State Owned - Describe Use • Town of bit,} Gelb -J Ib4-1 111. Type of Permit: Check only one box on line A. Complete Gne B if applicable) A. ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New / List Previous Permit Number and Date Issued Before Expiration Owner k IV. TYDe of POWTS System/Component/Device: Check all that apply) �f No - Press urized In- Ground ❑ Pressurized In- Ground ❑ At -Grade 11 Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaUrreatment Area Information: a Desi n Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Disper al Area Proposed (st) T �ystem n Vl. Tank Info Capacity in oral # of anufacturer Gallons Gallons Units New Tanks Existing Tanks 0. Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume re z. bility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si MP /MPRS Number Business Phone Number Plumber's Address (Street, City, State, ZipC de) - / \ ^ 8 I U VIII. ount /De artment Use Onl Permit Fee Date Is d Issuing Ag Signature Approved ❑ Di pro C1� $ ��� 1 / 13 Ow Reason Denial / / / IX. Condig"j W "L*Reasons for Disapproval k5J• r J. Septic tank, effluent filter and dispersal cell must all be sendae& i mailer � t.J ol as pe r management plan provided by plunbar f. 2. AN setback teyuirerrfents tnud be rtwM>tairted P Dods om. Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 1 I inches in size SBD -6398 (R. 01/07) Valid thru 01/09 v v 14 CAI rin 3A 8 Ln Op WTW I zl ti , L zz 'S .3 V Kl �- (! t� ? 5 SON b'7 J3 V76 PLOT PLAN PROJECT P.C. Collova Bldrs. Inc. DRESS P.O. Box 489 Somerset Wi 54025 NW 1/4 SE 1/4S 7 /T 30 / 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 7/30/07 BEDROOM 3 CONVENTIONAL XXX IN -GROUN SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 hL BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 91.8/91.0 7' below qra Alternate Benchmark Top of 1/2" pipe @ 100.3' Plans Designed Using Conventional Powts Manual Version 2.0 Well is to meet all - 273' Property Line setbacks required b Vent` - Y� WDNR >6„ Quick4 Stand ra - of Cover Leaching Chamber B. with 20.0 ft2 of Area 4' Long 12" 5.8ft ^2 /pair of end caps Grade at S em Elevation 34" A B -4 i 30' Pro 3 30 , ST 30' 20' Bedroom Houses 150' 1 B- �� Vents i 6 ( 20 B- Svc 2 -3' X 66 Cells with >3' Spacing 20' B- 15% Slope (slope % increase 406' Property Line xou go down slope) ' Property Line 44' P. L. 9 PLOT PLAN PROJECT P.C. Collova Bldrs. Inc. DRESS P.O. Box 489 Somerset Wi 54025 NW 1/4 SE 1 /4s 7 /T 30 / 18 W TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 7/30/07 BEDROOM 3. CONVENTIONAL XXX IN -GROUNDSSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 IL BENCHMARK V.R.P. Top of Survey Iron ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark SYSTEM ELEVATION 91 .8/91.0 7' below grade Alternate Benchmark Top of 1/2" pipe @ 100.3' Plans Designed Using Conventional Powts Manual Version 2.0 Well is to meet all 273' Property Line setbacks required by Vent WDNR >6" Quick4 Standard -W Leaching Chamber B.M. of Cover with 20.0 ft2 of Area 4' Long 12" 5.8ft ^2 /pair of end caps 4 Grade at System Elevation 10 3" B -4 30' Pro 3 30' ST 30 20' \ Bedroom 150' House B- -- Vents 6 IF 20' B -2 d 2 -3' X 66' Cells with >3' Spacing 20' B- 15% Slope (slope % increase 406' Property Line as you go down slope) 300' Property Line 44' P. L. Wisconsin Department of commerce O ►f SOIL EVALUATION REPORT Page of Division of Safety and Buildings accordance with Comm 85, Wis.�A /dm: county Attach complete site plan on paper not less than 8 1/2 x 1 inc �C�GE�i�D s"� �wp17L include, but not limited to: vertical and horizontal referen point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and I tion and distance to nearest road. Please print all informs ion. AU G 2 -5 7005 Revi by Date /9 Personal information you provide may be used for secondary p xmes (Privacy Law, s. 15.04 Property Owner ZONING t Rf Locati n 1 1/4�� 1/4 T 3O N R E( W e. eo /lam V C. Prope es Mailing Address Lo Block # or M# e /3 ax 1 ,SIi+�Tltr- CRY State Zip Code Phone Number ❑ city C] V Town Nearest Road / O 1 DoZJ Construction Us sidential / Number of bedrooms Code derived design flow rate J"?� GPD j o Replacement ❑ Public or co / mmera l - Describe: - - - - -- - -� Parent material G'C.ca�/ T �� Flood Plain elevation if applicable R General comments Q and recommendations: 5 s - ,e,r,.- t, le- ✓a te l 1' 0 �J 0 o Boring �7�., 9 # pi Ground surface elev. � _ ft. Depth to limiting factor L in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 A;A K sn CA jD i 4 C] Boring Bori # O Pit Ground surface elev. E�� , ft• Depth to limiting factor m • a Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Efff12 6 '3 3 /z 2 r e0l C-4 L� ` Y L- y S 1 a� a 6 Ib Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BOD _< 30 mg1L and TSS 130 mglt CST Nears (Please Print) Si CST Number Bird Plumbing, Inc. Shaun Bird 226900 Date Evaluation Conducted Telephone Number Address 715 - 246 -4516 1008 192nd Ave, New Richmond, WI 54017 —� l Property Owner Parcel ID # Page of ang # ❑ nng a it Ground surface eiev. DI ' / ft• Depth to limiting facto in• Soil A pplica ti on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 '0422 F,' w :3 Boring # FL Boring R] 1 it Ground surface elev. ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Redox Description Texture Structure Consistence Boundary Roots GPDIfP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 3 _ r ✓t , ❑ Boring # ❑Boring Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Sal Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GPDIfF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 • Effluent #1 = BOD > 30 5 220 mglL and TSS >30 1 150 mpt ' Effluent #2 = BOD <_ 30 mgA- and TSS < 30 mg/L y ou need assistance If to access services or The Department of Commerce is an equal opportunity service provider and employer. Y need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 2648777. SOD4330 (R.60)) I I _ , - Soil Test Plot Plan Project Name P.C. Collova Bldrs. Inc. Shau r Address P.O. Box 489 Somerset Wi 54025 #226900 Lot 6 Subdivision 95th St. Site Dat /18/05 N W 1/4 SE 1/4S T N /R W Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 91.8/91.0 *HRPSame as Benchmark Alternate Benchmark Top of 1/2" pipe @ 100.3' v Scale is 1" 40 , unless otherwise 273' Property Line noted 0 3 97.5' B-4 30' qg _V 20' 95.5' 150' 93.5' B- 91.5' 0 ' 90.5' 60' 5' B -2 20' B- 15% Slope (slope % increase 406' Property Line as you go down slope) 300' Property Line 44' P.L. NINETY FIFTH STREET SITE (A COUNTY PLAT) Located in part of the Southwest Ouarter of the Northeast Ouorter and port of the Northwest Ouorfer of the R¢G6TE1P5 OFFICE 5outheos1 Ouarter of Section 7, Township JO North, Range 18 West, Town of Richmond, being Lot 4 of o Certified Sr. CRODL CO. WLS. Survey Map recorded in V lume 19, Page 499J at the Register of Deeds Ofhbe of SG County, Wisconsin. n e� WM A. c• v A SEC. 7. T 3300 N., F S W. r = TOWN OF RICHMOND ST. CRUZ% COUNTY W T. SCALE 170TH VENUE N-th 114 Corner 5ection 1-Ja -16 (Shaft of R.R. Spike found) --PLATTED LAOS N W �' N 88 E 491.40' ( y ^J' leJ.4s Jn9s $ F2 y S E • ryry N. WE. =99J 0/ LY-we £asbnent 160TH A NUE II 2 9 8 � to � 241 onus 255 acres mv. px 104,995 sg.. ft. I /1, /70 sq. fl. ��n L.60-989.9 u L.B.O. =9950 LEGEND toT > 66'W/de.b t Drainage . " -Ant C, ariM.t .. -.. ....mar s «Bon carne. Monument or Record I °o ..�, r "'°"� O Found 1" D. I ron Pipe N S 'a b > ). N $ \E 81 N.WE =987.9` O Set O. 1 -1/4" % 18" Iron Reba, g• \ 721 _ (weighing 4.303 lbs. per linear foot) n L'I. v Nee95yB•E m p FOUND FOR OTxEP POT CORNERS .Re• MDN PE (WEIGHING IR' U. REx 1 ^ / mess'sew -NEAR FOOT) UNLESS OI 11- SHOWN, Building Setback Line . ('Do, I ED AS PI P 0 - Proposed Driveway Local on O I I ar 95 sp 6 O to - - 12' Utility Easement c I O L.80. Elev.lon Or LOwnl LO7 2 I� Allowable Building Op-mg i 1) I 1; B M.W.E. 100 -Year High Wale Elevation F o IZ) I^ acres IC 1.81 IZ � 91 -h .i qe Topeaf Iron I 'I� is I .r 79.009 aq. ft. r l a 11. l is 1 � IW.9Y O D9?ES: II I 1.e9�gnea NO OWNER OR RESIDENT SHALL DO ANYTHING I� i I� 92485 WHICH WOULD INTERFERE WITH OR C IANGE THE I� I ' • 1 OF OF THE APPROVED COMPREHENSIVE WATER DRAINAGE AND SOIL EROSION PLAN FOR THIS PLAT !� CO T -3 , %I 1.56' ocraa Pv THIS INCLUDES BUT 1S NOT LIMITED lO BUILDING UPON,^ 67,952 sq. /f. OBSTRUCTING, ALTERING, FILLING, OR EXCAVATING OR '� PLANTING IN ANY DRAINAGE EASEMENTS, WATER I Z h 4 / 4 r DRAINAGE DITCHES. WATER RUNWAYS. WATER 'O Iy0 II N •U' CULVERTS. BERMS OR GRASS SEEDINGS. '� 6 1 p •{t• BEARINGS ARE REFERENCED TO THE NORTH JJ JJ' SOUTH 1/4 LINE OF SECTION J, T.30N., R.16W., WHICH IS ASSUMED 70 BEAR NOO'32'03 "W. \ :� N THE PARCELS SHOWN ON THIS MAP ARE SUBJECT i0 89'27'57'E 381.80' I I STATE. COUNTY AND TOWNSHIP LAWS. RULES AND rnrn 7 m . xe907 / , RECUTAN (LE. WETLANDS, MINIMUM LOT LE, ACCESS To iy R -g, _ 57F�AVH11.lc- - PARCEL. ETC ETC.). BEFORE PURCHASING OR DEVELOPING ANY Z PARGEL CONTACT THE ST. CROI% COUNTY ZONING OFFICE g '171 AND THE APPROPRIATE TOWN BOARD FOP A-CE. I NI - - - - - 5.06 B JSJ 2 / 59 owes 68,814 s9. ft. N - ' WE =9750 I I u 5 J 4 4 N°4„" 201 ones N � I I 200 ocias 67.549 sq. /I. 6 9. 2. a' 87,2J7 s9 /t. L.80. =9710 $ •s G L.B.0.=971.6 8 [7\v i 589'17'31 "W G 7883.72' SouM Lkre f the JJ I3J' p _ N- thwest 114 It - q p O G the Southeast 114 C -- PLATTED LANDS so 1 corner seauoh - - -- --- ---- 7 -JO -re 8 (Found aw»inam aL' 1 m L'aunty Monummt) _ L \ k M I Jl t1�1 r� 7111a1' CURVE TABLE GRAPHIC SCALE CURVE I RADIUS DELTA ARC - CHORD I CHORD BEARING TANGENT BEARINGS CI 167,00 99'51'21' 291.05' 255.59' N39'32'16.5'E N89'27'57'E N10'23'24'V C2 23100 99 403.91' 355.20' 1 N39 NI0'23 N88'55 LOT 11 233.00 51'21'19' 208.84' 201.92' N15'17'15.5'E NIO 440'57 - E LOT 10 233.00 30'06'34 122.45' 121.04' N56'01'12'E N4 - 57'55'1 N71'04'11'E ( lx Fees) LOT 9 233.00 17 72.62' 72.33' N80'00'13.5 N71'04'29 NBB'55'58'E 1 Ixb = loo rt C3 167.00 99.19220 289.50' 254.59' S39'I6'17'1 SBB'55'58 - W SIO 23'24 - E C4 233.00 99'51'21' 406.08' 356.60' S39 32'16.5•W SIO 23 - E S89'27'57'V LOT 7 233000 29 119.58' 11827' SO4'18'43 5 SIO 23'24'E S19 LOT 6 233.00 27.49'46' 113.17' 11206' S32 55'44 - W S19'00'51'V S06'50'37 - W LOT 5 233.00 42 173.33' 169.36' S68 09'17•W I S46 S89 f JOB F W1057SD43A Prepa by Phone Na. (715) 246 -4319 F0. No. (7' 5) 246 -3830 SHEET 1 OF 2 P.O. Bo. 325 New Richmond, WI 54017 U 2 8 2 y P 12 0 797821 tl State Bar of Wisconsin Form 2 -2003 KATHLEEN H. YALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., MI Document Number Document Name RECEIVED FOR RECORD 06/16/2005 10:00AN WARRANTY DEED THIS DEED, made between David J. Kieckhoefer and Pamela A. Kieckhoefer, EXEMPT # husband and wife REC FEE: 11.00 ( "Grantor," whether one or more), TRANS FEE: 876.00 and P. C. Collova Builders, Inc. COPY FEE: CC FEE: ( "Grantee," whether one or more). PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following Recording Area described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property (if more space Name and Return Address is needed, please attach addendum): Part of the NW ' /4 of the SE '/4 of Section 7, Township 30 North, Range 18 West, + . Town of Richmond, described as follows: Lots 1,2 and 3 of Certified Survey Map _ recorded June 6, 2005 in Vol. 19, Page 4992, Doc. No. 796820; AND Part of the NW '/4 of the SE '/4 and Part of SW '/4 of the NE '/4 of Section 7, Township 30 North, Range 18 West, St. Croix County, Wisconsin described as follows: Lot 4 of Certified Survey Map recorded June 8, 2005 in Vol. 19, page 4993, 026 - 1024 - 30 - 050 and 026 - 1025 - 40 - 050 Doc. No. 797062. Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated a • is (O t J-oy S ~ ) I( (SEAL) (SEAL) * *David J. Kieckhoefer h-LQ,vr ) (SEAL) ( av ) "FLU 'yl�.t� (SEAL) * *Pamela A. Kieckhoefer AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF ) ) ss. COUNTY ) TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on (If not, the above -named David J. Kieckhoefd it '. authorized by Wis. Stat. § 706.06) Kieckhoefer. ' , husband and wife eli � .E � " to me known to be a person(s) who exe e* k'f4[egoin?` THIS INSTRUMENT DRAFTED BY: ins d a 1 he same. =�t N ,. U U • v i Attorney Kristina Oaland = O Hudson, WI 54016 * D fJ i9 t�L�A L ' Notary Public, State of My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS 1S A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIE WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO - PRO'"' Legal Forms 800.655 -2021 www.infoproforms.com Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. via the inspections pipes at the ends of 3. Once eve 3 ears, cells are to be inspected P every Y the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge Into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 C e y Plan Option # . If system fails, determine cause of failure, use alternate area and install new system in tested replacement area. Option #2. Install system at a lower elevation, by removing chambers, removing biomat, and install new system. Option#3. No adequate area is suitable for replacement area, and system elevation I holding tank as last resort. cannont be lowered. Instal g . 3. Replace any other failing components as needed. Plumber: Shaun Bird 715- 246 -4516 St. Croix County Zoning 715- 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 • ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner EX , ��1 ©vQ Owner/Buyer Q Mailing Address --7Q5 kI 1 � �, Flo c%rnef sr A SLO 0,�7 Property Address 1 V i wz �A� 1 (Verification required from Planning Department for new construction.) City /State Parcel Identificatjon Number 04 — 0 aq SO ­ bS LEGAL DESCRIPTION NO '/4 , F— , Sec. , T N R _W, Town of R.CNAM Property Location Subdivision S �\r c�� , Lot #. Certified Survey Map # , Volume , Page # 11 Warranty Deed # 7 Y , Volume , Page # V Spec house U yes 1(no Lot lines identifiable yes U no SYSTEM MAINTENANCE ( Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix County 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. Uwe, the undersigned have read the above req a n a maintain t wa osal system with the standards set forth, herein, as set by the Department of tjer a partm # ��te of Wisconsin. Ce cation stating that your septic system has been matnta�ned r e St. Croix County Zoning De a ent wit in 30 days of the t year expiration date. n� X115) ` 294 -32 - t /a� 0-7 SIGNATURE OF APPLICANT 34 260TH S T m 45 I ,R�. DATE OWNER CERTIFICATION ��+ W `�`L Uwe certify that all statements on this form are true to the best of my /our knowledge. I /we am /are the owner(s) of the pro a describe above y virtue o arranty deed recorded in Register of Deeds Office. RC, LOLL ILDE 5, INCIs SIGNATURE OF APPLICANT PRODUCTION OFFICE DATE EV'W * * * * ** Any information that is misrepresented may result in the sanitar f b4��7��'"''e3My the Zoning Department. * * * * ** Include with this application a stamped warranty deed from the Register of``d n ��77LL�� ppJy of the certified survey map if reference is made in the warranty deed. OWLA, WI 54020