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HomeMy WebLinkAbout026-1147-15-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420587 0 GENERAL INFORMATit i (ATTACH TO PERMIT) State Plan ID No: Personal information you provide'rluy be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: O'Connor, Phillip & Nancy Richmond Township 026- 1147 -15 -000 CST BM Elev: Insp. BM Elev: BM Description: 1150 . 1 /0 - 0 1 /\J VJ L. T - Co 2n) e 4--r3 fq r ! ro TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic U Benchm - '% 1 � Z /d - 6 Z Dosing b) liYt (A Alt. BM 5 / `,� W i ozn Z. y6 X06 • y. Aeration Bldg. Sewer / 7 0 1 8 3 IF Holding _ St/ t Inlet l 9• i, �. 7 9 9 D TANK SETBACK INFORMATION -§U Ft Outlet - TANK TO P/L WELL BLDG. Veto Air Intake ROAD Dt Inlet � Dt Bottom >7S Y /3,79 _o Dosing H eader /Man. '- D y/ Aeration Dist. Pipe , ,Lee O � l 6 boo. Holding B o2 °� D0• .Z1. .o PUMP /SIPHON INFORMATION �� al Grad, Manufacturer Demand St Cover GPM / �U /7 Z Z Model Number b 4. tj�ae -AA TDH Lif i Friction L,Q.ss Systery,l le,,�c(, T D I ,S-s Ft Forcemain Le gth Dia. 2// Dist. t Well , 7 ' SOIL ABSORPTION SYSTEM r C4 >46 r Q,t;s dk C 4- 1 1 1 -44 . ✓ BED/TRENCH Width Length No. Of Trenches, PIT DIMS IONS No. Of Pits Inside Dia. Liquid Depth D ONS IMENSI LuI SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM L C G Manufacturer: INFORMATION CHA ER OR Type f System: f 75f \ ,�,\ U Model Number: DISTRIBUTION SYSTEM / � /JI Header /Manifold Distribution 9 � �� K 6 x Hole Size x Hole Spacing Vent to Air Intake j Pipe(s) •C t-r/j / � Length " Dia_ Length .� Dia Spacing /�ej 3, D TlOrn SOIL COVER x Pressure Systems Only Z� xx Mound Or At - Grade Systems Only s Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil A Yes � No � Yes FS No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 1 / / /./�, / 3 � Inspection #2: & /7J� /d> /'�v Location: 1444 146th Avenue New Richmond, WI 54017 (NE 1/4 NW 1/4 24 T30N R18W) Ri hfnond� do�Lot Parcel No: 24.30. 8.1073 - v~ 1.) Alt BM Description = 755e - & Q3 ) 2.) Bldg sewer length = YO t - amount of cover 3.) Contour = y , lJ � `Y I I Dl - - - -- -- - - r - T - Plan revision Req u' i rd� - , s [, o / - - - Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's i nature Cart. No. Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 14SCOn-Sin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not - q( 3 K n f 7 Y I state owned.) Attach complete plans (to the county copy only) for the system, on paper not l ss than 8 -1/2 x 11 inches in size. County ,r State anitary Permit Number 11 Check if revision to previous application S Plan I. D. Numbe ..��--^^-- 1 jQr' t4 1 -1 790 Gax 67 �fl s - 'T�orldf . lh. 4-, I. Application Information - Please Print all Information, Location: '-h ProDerty Owner Name Property Location ( �� D /� 2 16 114 il/1 /4, S Ta{l,N, R'gE (or per Owner's Mailing ddress *14 Lot Number Block Number S7 So ST CROIX COUNTY I S City, State Zip Code P ne Nutr Subdivision Name or CSM Number �W vtu f' Wf 1J 1 5 so 4Y Z V14� u)5 II. Type of Building: (check one) ws P✓s ❑ C i t y e Q P 1 rn or 2 Family Dwelling - No. of Bedrooms : 3 h, PQa,. T V i l lag e A " t�N (D Public/Comercial (describe use): own _ own L' ❑ Sta - Owned Nearest Road o z - WD - t - D A 26 Sk C-to S arse ax Number(s) III. Type o (Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. New 2. U Replacement 3. U Replacement of 4. 5. 6. 13 Addition to 45tem System Tank Only Existing System B) Permit Number ate Issue ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) -rte p,e OJ - & Ate- • Non - pressurized In- ground Mound ❑ Sand Filter ❑ Constructed Wetland • Press urize d g In- round Tank ❑ Single Pass ❑ Drip Line • At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area j Area 4. Soil Application 5. Percolation Rate System Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. ft.) (Min. /inch) Elevation * qq � - 0 a Z- r— 1D0� / /03. / f - VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ a a d�2 o VIII. Responsibility Statement 1, the undersigned, assume responsibilityA the POWTS shown on the attached plans. P�MbeeName (print) i no stamps): MP P sin o. Buess Phone umber @[ t� �Iz Z1S=Z�S -Z� IMP Plumber's Address (Street, City, State, Z' ode St IX. County/Department Use Only Disapprove Sanitary Permit Fee (Includes Groundwater Date Issued ing A t Signatu stamps) IIApproved ❑ Owner Given Initial Adverse Surcharge Fee) Determination Conditions of Approval /Reasons for Disapproval: y am-- _ � �,�r , c� 31 �NnWAIM /V(�X �� � � ao73-�•— aft' ���,�,�.t� Y' X13_ ( ao P s I [+i]T L7l10 /D A7 /M\ r 0 ' e_o w%,% Kv -Mw - Z4 %0 -tit w QL C C— c ( uV o) - + Z o 4-L> I C-4 V Z c.0�0 (-4� � q _t A C l i _�1 Safety and Buildings V isc . 4 003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 OnSin www.commerce.state.wi.us /sb Department of Commerce www.wisconsin.gov Scott McCallum, Governor Philip Edw. A Secretary November 18, 2002 CUST ID No. 139462 ATTN: POWTS Inspector TODD L SINZ ZONING OFFICE T L SINZ PLUMBING INC ST CROIX COUNTY SPIA E5609 708TH AVE 1101 CARMICHAEL RD MENOMONIE WI 54751 -5520 HUDSON WI 54016 CONDITIONAL APPROVAL � SX 7 PLAN APPROVAL EXPIRES: 11/18/2004 Identification Numbers Transaction ID No. 808103 SITE• Site ID No. 653322 Phil & Nancy O'Connor Please refer to both identification numbers, 146th Avenue above, in all correspondence with the agency. Town of Richmond St Croix County NE1 /4, NW1 /4, S24, T30N, R18W Subdivision: Richmond Meadows - lot 15 FOR: Description: Proposed Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 881244 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. t --� • Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the septic tank outlet filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. • Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). COndihl jally A nnnao _ TODD L SINZ Page 2 11/18/02 Owner Responsibilities Continued: • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, 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 left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Gerard M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 jswitn@commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 Henry F Grote, Certified Soil Testing r R F�E� r N vFo Phil & Nancy O'Connor - Mound vA�C o� i'1 CC jy zoo Transaction # BCpGS o/V. Construction Materials and Techniques All materials must comply with Comm 84 and be installed in accordance with manufacturer's specifications. Construction methods must comply with the following Component Manuals: Mound, SBD - 10691 -P (01 /01) Pressure Distribution, SBD- 10706 -P (01/01) Location: Lot 15, Richmond Meadows NE 1/4, NW 1/4, Sec. 24, T 30 N, R 18 W Town: Richmond County: St. Croix Date: November 20, 2002 Owner: Phil & Nancy O'Connor Address: 11651 0th St., E. Lake ' le, MN 55 Plumber: T Sinz Signature: License # P 39462 Attachments: 6748 -Plan Approval Application SBD -8330 page 1: cover 2: design criteria & calculations 3: plot plan 4: system cross section 5: plan view, lateral detail "� 6: pump tank exit detail �—i, W Ir INU U 7: pump curve DEPARTMENT OF COMMERCE 8: system management DIVISION GiAA FETY AND BUILDINGS SEE CORRE Q NDENCE page 1 of 8 Design Criteria Residential Wastewater Contaminant Load: 30 mg /L < BOD < 220 mg /L Anticipated septic tank effluent 30 mg /L < TSS < 150mg /L Fecal Coliform > 10,000 cfu /100 mL Fats, oils, grease < 30 mg /L Bedrooms x 100 gal/bedroom/day x 1.5 4' g allons/day h g Y g Y draulic load Y Design Calculations In situ designed loading rate 0. gallons /sq. ft. per day Depth to estimated high ground water >,3 4 in. Depth to bedrock in. Cross slope at system 3 % Force main length 6� ft. of Z in. Manifold /header length 20 ft. of in. Drain -back 3• y5� gallons Lateral length @ g'•o ft. of NL in. Lateral elevation 6 ft. @ bottom of lateral 3 Lateral hole size Alb in. @ 36 in. ( I.— ft.) Spacing C( holes /lateral 3 �R holes total Lateral volume `R 9 16 gallons Total lateral discharge rate gallons /minute @ Z• �� ft. head \'�etwork pressure compensation losses ft. Elevation difference ft. ( m es') I riction loss ft. @ 2 - gallons /minute Total dynamic head L ft. C 17.01 1'ump /sipl9rn 4 gpm @ 7 - 0 ft. of head Manufacturer �"° � Model Dose volume gallons Lit - t /si} hon tank gallons Septic tank gallons LI'lluent filter O "T ' -t4 I& Measurement pump on and off 5�. � in. I leight alarm from tank bottom �3• in. Reserve capacity 411+ gallons , �dk:s yes Page Z of '� r • 1 Y�.{ l � / `► Pryc �, �O �A.�A 0�� { l 1 0 � J�` a�.K nn tt ' 2 n o n o — c OA e t o) � I I I SP/ I r o c �Setl U l i m I 0 I = -A� Qe : �• a �C s,, ,.,:1 c.,, �I i � I t F „ 1 , O . ti I 1 Iv d C-0 V SAP .Q Z. \ \ \ Qa. 4•o Il•• Z.u• O ¢.I.cxls 2—v -N ?r.� rZv 0 roc \c � ; 4•' PuC. c.. P py�wy�`:er, �..p�lt �o ,00�'o�. • � vec.'� � �a,c�,c{ �c. I � C-66 p r• • t- Q. � -4 � ,"ti/ V s` v t �j e x t C p �,• ,.�. ; v e� � O.ti't uJ+ S� cd• ��- 0 O l i e 7 31o•O A �� \ 1 ,•� 0 r \ 6 to a� � • � � WEATNERPROJF LACKING covaR JUNCTIC 1► � Ll/A/�N /NG box Z DNGOVVtGT --, T > A T no NDIST D 9 Sol 24" I.D. MAN U01.E V 7 ti g AP�'kOVCD ! / S►(r. U PI/fa �Ql 3' O.rrc I o g'L 1- 1 413 - O N - o e } `T�v h OwY1a a P� Co.2,REr� I 6�.oGK I I SEPTIC t rr 1 S � PECIFI • CA - riOki$ I � 00 5 0 TA f MAQ UFACTURER; IJUMBER OF DOSES: PEK TA►-IK SfZC ; ` �� - �� GAl_1.0A15 1 DOSE VOLUME A AFr1 " UFACTLIKLR: S IAJCLUOIWG 6ACKFLOW: —+4.14 VA., r IwITCH TypE; w`\ CAPACITIES: A= 1.0 WCHCS OK 8= Z INCHES OR 2�'g /•1AIJUFACTURCR;o¢ -`� G�.:�. j C ° 5 �0 UCnES OR }��� MODEL A.IUMDEK', l5 Z- vA IN,, HES GR JWIT�H T'd PE; �/^QJve+av . �A _ , -- 1JOTE: PUMP A►JO ALARM ARC T3 BE ►�I►J DISCHARGE RAre Z�'� GFM IN57ALLE0 01U SCp#, T VERTICAL pIfFERC1JCf OETWE[U FEET PUMP OFF AID OIJTRIbUTIOw PIPE,. 13 '� 02 - -05�� �- ' ^",!kv'MLJM uCTWORK SUPPLY PKE&SUKE . . . . + FEET OF FORCE MAIN X 1.7q FT✓ FEET }O�t Yoo /LFKICTIOU FACTOR, FEET (�D Z< TOTAL O'd JAM IC HEAD � l'i�.� -b FEET A'� QiME1,1610A1G OF TA►JK: LEAIGTH - -LIQUID �t• Z 1 --- -` .__ ; W D T H --» DEPT H 'OTAL DYNAMIC HEA6 /CAPACITY HEAD 'CAPACITY CURVE PER MINUTE _FLUENT AND DEwATERING N MODEL 152/153 - - of w w MODE. 152 153 5 - - 50 r Feet Meters Gc . Lters val. L; ers 153 5 69 261 1 77 291 12 � 40 ' 0 i � — — ----I- 152 — -- -- - -- 0 1 4. 53 20' 61 231 a i 20 6 1 1 44 1 6,7 ! 52 197 , 30 -- -- - - - + -- -- 8 25 7.6 34 1 4 2' a 2z 57 30 9_' _ a 20 35 J 7 - s 401 12 2 - -- -_ oh Vc.ve z;� 0 r 014508 20 40 60 80 100 GALLONS •_ITERS 0 1 1 1 80 160 240 320 FLOW PER MINUTE -- - - f CONSULT FACTORY FOR SPECIAL APPLICATIONS Timed dosing panels available. o a Electrical alternators, for duplex systems, are available and supplied with a an alarm. Variable level control switches are available for controlling single phase systems. Double piggyback variable level float switches are available for variable level long and short cycle controls. Sealed Owik -Box available for'outdoor installations. See FM1420. O ver 130'F. (54 °C.) special quotation required. 1521153 Series 1521153 MODELS Control sele Model _ Volts•Ph Mode N152 _ 15 1 Non 8.5 1 2 or 3 SN152 1 1 5 Auto 8.5 Included_ 2 or 3 E152 230 _ Non 4.3 1 2 or 3 1 . - - - - -- - - -- - -1 " 20r BE 152 230 1 Auto 4.3 Included 2 or 3 N153 115 1 Non 10.5 1 2or3 BN 153 1 Auto 10.5 Included 2 or 3 SELECTION GUIDE - -_ _ 15 1 E153 2 1 Non 5.3 1 2 or 3 BE 153 _ 230 l - - Auto 1 5 .3 i Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. CAUTION 2. See FM0712 for correct model of Electrical Alternator E•Pak. All installation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump, MAIL TO: P.O. BOX 16347 7 Y Louisville, K 40256 -034 Manufacturers of. Z SHIP TO: 3649 Cane Run Road [' o ® Louisville, KY 40211.1961 Qv4L1TV 1 6 LIMP9 S NCE �9�J (502) 778.2731 • 1 (800) 928 -PUMP http: / /www.zoeller.com PUMP CO FAX ( 774. © Copyright 2000 Zoeller Co. All rights reserved. System Management Management of this -system is critical. As a condition of approval of these plans this system management section must be reviewed with the owner, and the owner must be provided with a complete set of plans including this management section. If problems develop with the adsorption system or any other system components, the installing plumber, T.L. Sinz Plumbing, 715 -235 -2644, or the St. Croix County Zoning Office, 715- 386 -4680, should be contacted for assistance. General Proper functioning of an on -site disposal system, "septic system," is significantly dependent on the volume of water which flows into the system and the level of contaminants in that volume. The lower the volume of water and the lower the level of contaminants. the better and longer the system will function. Typical system components include a septic tank or compartment to settle out solids and contain greases and oils, a filter on the outlet of the septic tank to retain small particles of the same density as water, a pump tank or compartment to allow a dose to be accumulated, a pump and controls, and finally some type of soil adsorption cell to recycle the water in a manner to protect ground water quality and public health. I . If the septic tank is installed prior to sheet -rock and /or painting. pump the septic tank before normal use begins to ensure adherence to contaminant load design criteria. 2 Install water- saving appliances whenever and wherever possible. 3. Repair even small water leaks as soon as possible. 4. Never pour grease or oil down any drain or stool. 5. Garbage disposals are not recommended; if you must have one use its . aringl b p Y sparingly. 6. No paper products other than tissue should go into the system. 7. No chemicals should go into the system. 8. Avoid surge flows of water; try to spread laundry throughout the week. 9. Septic tank effluent must be less than or equal to the design criteria specified in page 2 of these plans. 10. If septic or pump tanks are no longer used, they must be properly abandoned. 1 1. if construction timing and weathercould create a frozen infiltration system, weather - proofing with plastic sheetingand heavy mulching may be required to maintain a functional system at start-up. Maintenance � j"111 ' R /-�w 1. The septic tank must be inspected every three years by a properly licensed person. 2. 4+eee"ma the septic tank must be pumped to remove solids and scunn; pLnnping is required if the combined scum and solids volume equals one third of the tank volume. 3 3. When the septic tank is pumped, any solid's in bott� the pump tank must be pumped, and the filter must be back - washed into the septic tank to remove accumulated material. 4. Periodic observation pipe inspections should be made by the homeowner to examine the state of the in -situ soil adsorption cell. Quarterly inspections are recommended; a licensed plumber should be notified if effluent is consistently ponded in the adsorption cell. 5. If this system contains specific treatment components other than those mentioned here, maintenance requirements will accompany their specifications. 6. The pumping components for this system include an alarm which must be installed and remain on a separate circuit from the pump. If the alarm is activated, minimize water use and notify a licensed plumber for service as soon as possible. The system allows reserve capacity to accumulate some necessary flow until normal service can be restored; this volume is minimal, and no more than one or two days should pass before any necessary repairs can be made. 7. Avoid compaction such as vehicle traffic within 15' down -slope of the adsorption system. 8. Avoid disturbing the system itself such that might encourage erosion or disturb the required seeding of the system. 9. Particularly avoid winter traffic such as sliding or snowmobiling which might compact snow and lead to increased frost depth. 10. Surface drainage must be diverted around the system; avoid landscape changes which might send surface run -off into the system area. 11. Warning: Do not enter septic, pump or other treatment tanks; death may result because they may contain lethal gases or insufficient oxygen. Contingency Plan Wastewater monitoring of volume and quality is not a normal requirement for low effluent strength systems; such monitoring may become necessary if problems develop. Any necessary monitoring shall be done in accord with the requirements of Connm 83.54 (2). Pumping and hauling of wastewater may be necessary while analysis and repairs are implemented. Additional testing, designing. and /or installation of additional treatment components or conversion to a holding tank may be necessary. Page 8 of 8 — - " f ',flRiGiNlAL 1656 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and-Buildings in accordance with Comm 85, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8 %x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and — - -- percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. 02 _ 1 Iq -457 D a -\ Please print all infor atio�� r- r _-V TiLKra I Re iewed By D Personal information you provide may be used for second purposes (Privacy Law, s. 15 04 (1) (mp. �6 �O Z Property Owner NOV Pro Location O'Conner, Phil & Nancy � . eot I NE 1/4 N 1/4 S 24 T 30 N R 1 8 W Property Owner's Mailing Address ST C . - ,( - ) ;X 1.Pt # Block # S . Name or CSM# 1 1651 250th St., E. 7 ii - 0 F Richmond Meadows City State Zip Code Phone Number i y Village V Town Nearest Road Lakeville MN 1 55044 1 952 - 985 - 7243 Richmond 146Th Ave. New Construction Use: _Vj Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement _f Public or commercial - Describe Parent material loess over til _ Flood plain elevation, if applicable _ NA General comments and recommendations: install double trench mound (2 - 4'x 56.25' rock cells) w/ upslope edge of uper trench on 99.6 contour w/ 0.5' sand fill and 0.2 gpd /sq It basal loading FT] Boring # ._._i Boring ✓! Pit Ground Surface elev. 99.6 ft. Depth to limiting factor —_ 47 in. Soil Application Rate Horizon I Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' _ n. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 1 0-9_ 7.5YR 2.5/2 sit - 2 f sbk mvfr cs 1f /m .5 .8 2 9 -24 7.5YR 3/4 sicl 2 m sbk mfr j cs 1m .4 .6 3 24 -34 7.5YR 3/4 - sl 1 c abk mvfr gs If .4 .6 4 34 -47 7.5YR 3/4 sl 0 m mvfr cs 1 m 3 5 -- - -- - - - - -- — - - -- - - 5 47 -55 2.5YR 4/4 f3d 7.5YR 5/3 sl 0 m mfr - 3 5 -T— i 2 Boring # _ Boring ✓!; Pit Ground Surface elev. 99.0 ft. Depth to limiting factor .— 4 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 1 GPD /ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 `Eff#2 1 0 -6 7.5YR 2.5/2 sit 2 f sbk mvfr cs 1f /m .5 .8 2 6-21 7.5YR 4/4 sicl 2 m sbk mfr cw 1f 4 6 mfr gs 1 f 0 0 21 sicl 0 m 0 7.5YR 4/4 _ �. mfr — 4 30-48 7.5YR 4/4 sl i 0 m mvfr I as 1 m .3 .5 5 48-55 2.5YR 4/4 _ f3d 7.5YR 5/3 sl 0 m - mfr .3 .5 j � horizon 4 has some inclusions of Is —� Effluent #1 = BOD 30 < 220 mg /L and TS . >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mgr CST Name (Please Print) Si na ure: - - CST Number Henry F. Grote 222 Address Certified Soil Testing Date Evaluation Conducted Telephone Number E. 4366 353rd Ave., Menomonie, WI 54751 11/1/2002 715 - 233 -0398 Property Owner O'COnner, Phil & Nancy Parcel ID # _ __— _ Page 2 - of -_ 3 7 Boring # J Boring J Pit Ground Surface elev. 99.6 ft. Depth to limiting factor 40 Soil Application Rate Horizon I Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Eff#1 *Eff#2 1 0 -9 7.5YR 2.5/2 sil 2 f sbk mvfr Cs 1f /m .5 _8 2 9 -24 7.5YR 4/4 slcl 0 m mfr gs + 1 m 0 0 3 24 -32 7.5YR 4/4 - sl 0 m mvfr cs - 3 .5 4 32 -40 10YR 4/6 s 0 sg dl as - 7 1.2 5 40 -50 2.5YR 4/4 fad 7.5YR 5/3 sl 0 m mfr 3 .5 - - -- - Vi _ .. - -- - - - -+ - - - - - -- - -- - -_. avoid this area due to horizon 2 7 Boring # _' Boring Vj Pit Ground Surface elev. 99.6 ft. Depth to limiting factor 51 in. Soil Application Rate Horizon I Depth I Dominant Color Redox Description Texture I Structure Consistence I Boundary Roots _ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -9 7.5YR 2.5/2 sil 1 c sbk . mfr cs 1 1f /m i .2 .3 2 9-24 7.5YR 414 Sid 1 m sbk mfr cs 1 m 2 3 3 24 -28 j 7.5YR 4/4 sl 0 m mvfr cs if .3 .5 4 28 -38 ! 7.5YR 4/4 Is 1 m sbk mvfr cs 7 1.2 5 38-51 ! 10YR 4/6 s 0 sg dl as .7 1.2 6 51 -56 !, 2.5YR 4/4 f3d 7.5YR 5/3 sl� 0 m mfr - i .3 .5 i I 7 Boring # Boring -- - ✓ Pit Ground Surface elev. 99.6 ft. Depth to limiting factor 39 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDI fl'_____ _ in. Munsell Qu. Sz. Cont. Color I Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -9 7.5YR 2.5/2 sil 2 f sbk mvfr - cs 1f /m 5 8 2 9 -27 7.5YR 4/4 sicl 2 m sbk mfr cw if .4 .6 3 27 -39 7.5YR 4/4 - sl 0 m mfr - cs if .3 .5 4 39 -48 7.5YR 4/4 f3p 7.5 5 /3 sl 0 m mvfr1 m 3 5 I i I I horizon 4 has occasional inclusions Is Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. I f you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3 1 > 1 or TTY 608- 264 -8777. SIM -x io i R 07/00) Certified Soil Testing � `�J `_ (` rc� 1 1 1 'l ` �- Av►b `/ C—O Kh Opt- / 3.¢ Z I � �f C-q ro- ZZZ -4 ze I z 13w ! II (r t 11 2 `_/ � / z I i ♦ l Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ' of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County 0-0 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re� vi iewedby Date • ..JJ�� Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). fe�&J Pro erty Property Location V lu y? Govt. Lot 1/4 W1/4 S 2q T 30 N R E (or) Pro erty Owner's Mailing Address Lot # Block # Subd. N �me or CSM# 7G, oK 10 22 P C Mo✓i Mec City State Zip Code Phone Number ❑ City ❑ Village [A Town Nearest R oad� 2v o ly0 S to New Construction Use: Residential / Number of bedrooms Code derived design flow rate / GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft, General comments Sy S evvk �� f' �/ , y9 p and recommendations: VV tD APR 2 3 2002 ST. CROIX P1 Boring # ❑ Boring G OFFICE Pit Ground surface elev. q� 2o ft. Depth to limiting factor ' 3 t_ in. Soil Application Rate Horizon Depth Dominant Color Redox Description FTexture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 U io Z — z V.. u M � VT 1 -5 - e 3 kv 3F a C C >,s S k - - 5 F-2] Boring # ❑Boring 9 � ,® pit Ground surface elev. 0 ft. Depth to limiting factor �_ in. Soil Application Rate Horizon Depth Dominant Color Redox Description T Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 0 -k 2r-la6K r - (S s 9 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L C T Name (Please P 'nt) Signature CST Number T .S'c��G ter- _ 2 L 3 � 0 Address Date Evaluation Conducted Telephone Number z. 13 �sv' s¢ S � s c° 1 s�io s �l - 9 - 0 Z l 2C17 pro O S SBD -8330 (R07750) i Property Owner — LL G V1 Parcel ID # Page of 3_ 1E KI Boring # Boring . Pit Ground surface elev. 40 ft. Depth to limiting factor Zk ' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 a -V 1 0yr — it � wl cs - C l der C 5 = y C 3 23 C 3� F-1 Boring # Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 ; El ` Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L 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. SBD -8330 (R.07 100) Property Owner Q k G Parcel ID # Page of Boring # Boring ® pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate E-2 Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots -E GPD/ft Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -- 0 LK w�F� C S 1 - S - io — c I �e F►- C s 2k- 3 M F� - F-1 So Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in• il Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 /ft*Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ❑ Boring # Boring Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate GPDif Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Ef� *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L 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- 2648777. SOP4330 (R07/00) + a P V PAGE_f; OF NAM 0 TOT# /s LEGAL DESCRIPTION 1JF X XW/, Z--/ T �;O,N,R, /9 E(or SCALE: I"= /-/0 i BM 1 ELEVATION X00 d BM 1 DESCRIPTION k ✓ + , BM 2 ELEVATION Z U BM 2 DESCRIPTION SYSTEM ELEVATION ALTERNATE ELEVATION � CONTOUR ELEVATION G T ti o o a SIGNATURE �� DATE 14V — e o Q Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601 -1831 , \*is c-onsin TDD #: (608) 264 -8777 www.wisconsin.gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Secretary November 18, 2002 E,vEO EC CUST ID No. 139462 % oO ATTN.• POWTS Inspector TODD L SINZ Nw 2 5 � o 2 �N-��r ZONING OFFICE T L SINZ PLUMBING IN SS _ CRC k FF�CE ST CROIX COUNTY SPIA E5609 708TH AVE Z pN1NG 1101 CARMICHAEL RD MENOMONIE WI 54751 -5 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/18/2004 Identification Numbers Transaction ID No. 808103 SITE: Site ID No. 653322 Phil & Nancy O'Connor Please refer to both identification numbers, - 146th Avenue above, in all correspondence with the agency. Town of Richmond St Croix County NEIA, NW 1 /4, S24, T30N, R18W Subdivision: Richmond Meadows - lot 15 FOR: Description: Proposed Three Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 881244 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the septic tank outlet filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. • Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). TODD L SINZ Page 2 11/18!02 Owner Responsibilities Continued: • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, 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 left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Gerard M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 jswim@commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 Henry F Grote , Certified Soil Testing FRI 10.31 rid 711 346 4646 ST CRY CC ZiDNM @001 S't,' CRflYIG Cfl � A4���'f S�PTEC TANK I��NAl AND OVRORSHIp CERTIRCATION FORM i tl�u� Msilta& Address GUZ s yon 7 (V = Awmmqwmd ftm DTwtmcw fOr Dew Parcd � o 4C 2tM Sor O T N I ' 34 I W. Tfl'wU Of property �- Subdvi4w M e �d o Lot cwtirwd surfty Aup # 57 f LAS - - —= V*ta1D --- L2— P4br- # 34 q Wan.mty Deed # , volume Pap # Spec houm 0 yts Lot limn ldwtifiablt)dy+es D no MMUM MAT OMMANGE asap fgs�s�dss�cmcv�ldcc�tmis 'pce�'e� ffi � to � as � aoES _ Pto � acm caftsba atpumpbs out d ze up& tam every dwM 7== Wqncr if ww4W by can eta ft fboc6M of tbt svpdc tdc a4 a xW iR tb c waste &qxnd s gir to svb to $t. t� Zoning Doy"bCO'd a form, sipad ty d* owaa td d by a ��edacs t� {I)tbaoa- si�e�vad��o�ds� lsiar andpttf�. it3 � &sE- ywc, do sa d"sigmW bm Eesd fte abom and AgM vs m de Vwwc sm#V sy m m +O, oo sand l ���p�s storc.ndtb��ufNs� etaft dM yw se p& nsftm hu bece vakA=W w= be cvgpbwd ud 3e=wd to do SL tkow O=W Zuuzft Offimwo+ 30 & c dw= doft- Is DATE °f I (We) to an m on &A fa ate � is sbc tip. of my I(out) 6c &wn bF VkMC of a died tmc-&;d i PARi"er of Dcod* Offim A DAM AAPP t�ind�hY cbr Z+�oso$ 3 "� tbds vfo&xft& a IUM wwsaY decd tam tbs. RqPsftt of Dw& end a top# at &* 5wvw UQV If &a wmasy dned Tom ZBSZSCZST�T 1VJ TZ - TZ Z+OQZ.rOZ+"TT U 2 0 19 P 2 6 2 C=, --3 t!E; a c -:, STATE BAR OF WISCONSIN FORM 2.1999 KATHLEEN H. WiLSH Document Nurnbcr WARRANTY DEED REGISTER OF DEEPS ST- CROIX CO W , This Deed, made between HilIV21C De velopment rafted Liability RECEIVED FOR RE CORD Partnership, a Minnesota L Liability Partn -22-2002 10:00 All Grantor, and Phillip C. O'Connor and Nancy L O'Connor, husband and wife REC FEE 11.00 TRANS FEE: 79.50 COPY FEE: CERT COPY FEE: Grantee. PAGES: Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix -- County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot 15, Plat of Richmond Meadows in the Town of Richmond, St. Croix Name and Return Address County, Wisconsin.Subject to a perpetual easement 30.00 feet in width for public drainage and utility purposes adjoining the public roads as dedicated in said plat. goA, 07-h.-qcg� 026-1070-50-000, 026-1070-60-000, 026-1070-90-000,026-1070-90-000 Parcel Identification Number (PIN) This is not homestead property, (is not) Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of October 2002 Hillvale Development Limited Liability Partnership AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN IS. County authenticated this — day of Personally came before me this day of October —, 2002 the above named Ifillvale Development Limited Liability Partnership, a Minnesota Limited Liability Partnership TITLE: MEMBER STATE BAR OF WISCONSIN (If not to '"own b It w ho executed the foregoing ins tfu authorized by § 706.06. Wis. Stats.) e Ttp 5) ti THIS INSTRUMENT WAS DRAFTED BY k d V CT Attorney Kristina Ogland -4616 Notary Public, St tic �f Wisconsin Hud WI Hud _4 - — ----- My Commissi permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) -- `Zr -I-- ) I Names of persons signing in any rapacity must be typed or printed below their signature. Ir ,,(! Vroft rIT Wcm P ar y Fond du L x. W1 STATE BAR OF WISCONSIN 11W-6ss 2021 WARRANTY DEED FORM No. 2 - 1999 Notary P ubl State 0 1 VpsconS' I STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number - WARRANTY DEED This Deed, made between Hillvale Development Limited Liability Partnership, a Minnesota Limited Liability Partnership Grantor, and Phillip C. O'Connor and Nancy L. O'Connor, husband and wife �— - - - - - -- - — - - - -- — _- Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): i Recording Area 4 of 15 Plat of Richmond Meado in the Town of Richmond, St. Croix Name and Return Address nty, Wisconsin. Subject to a perpetual easement 30.00 feet in width for public drainage and utility purposes adjoining the public roads as dedicated d� A in said plat. -9uT 026- 1070 -50- 000,026 - 1070 -60 -000, 026- 1070 -80- 000,026- 1070 -90 -000 Parcel Identification Number (PIN) This is not homestead property. CK) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of October 2002 Hillvale Development Limited Liability Partnership AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ss. County ) authenticated this day of Personally came before me this day of October 2002 the above named Hillvale Development Limited Liability Partnership, a * Minnesota Limited Liability Partnership TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to r own �, be he (s) who executed the foregoing T ins ac o e e t e. ` authorized by § 706.06, W is. Stats.) •- THIS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogtand Notary Public, St to f Wisconsin Hudson, WI 54016 My Commission permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessan * Names of persons signing in any capacity must be typed or printed below their signature. yo@gpyrl fr Company, Fond du Lac, W1 WARRANTY DEED STATE BAR OF WISCONSIN yy public MD- 655-2021 FORM No. 2 - 1999 Notary State Of Vflsc0ns' Q uarter of the art of the Northwest ) arter of the Northwest Quarter art of the Southeast Q Wisconsin !ichmond St. Croix Count i DoT_ DOCUMENT NUMB_ S89 � E 8 — HIGHWAY ___ - -- COUNTY _TRUNK __ d ►� v CENTERLINE OF CTH G a - _ _ —- - - - - -- 459.72' di — 166.88' �� - 856.84' o S89004'34 "E V) CO ��� RIGHT -OF -WAY LINE -- - --- -- 74541 SgFt 0 o — ��� 1.71 Acres ry 06 ry 18 H . - o o 98685 N w 16 �A F -- 2.27 Ac M N oz Z 83788 SgFt ` (n w 1.92 Acres � o \ w� i / C44 Z / A AA � S83051'20'E / 250.93' 1'19'27�E 66.22' I I \ LOT 2. CSM \ / a, \ ,�s9• ��0 PG.234 \ lr u 14 C40 67920 SgFt u 1.56 Acres 3_1 \ �` �• ��F \� 3 SgFt o . 9 J Acres N 78832 — - - - 1.81 Acres o 33 3' _ C38 _ — 105_00' I I it o S79.4g�E 313.32_ 46' 4 18.32 33 33. L55.0 / T "� N7 1V79•48-U. AVENUE 8• --_ _'� 420.36' � - -- G _ RECEIVED HOLDING TANK SERVICING CONTRACT MAR 2 0 2003 ST, CROIX COUNTY Contract Date ZONING OFFICE 3— /d — � ` This contract is made between the Holding Tank Owner(s) Name s) and Pumper's Name 1p jj -1 4P e < C�1 Paw`e �i ,�� d G�1asf� Mph T✓► e . We acknowt6dge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:) Ar Off— / /Y7- (i:-goo -------------------------------- a'(, 3o -lkL e2" -- 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(l)(c)1. Wis. Adm. Code and the approved Holding Tank Component Manual. This agreement will also be filed with the St. Croix County Zoning Department. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volume in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with local governmentai unit and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) Owneejf Si nature(s) Subscribed and sworn to me on this date: i` f�p Today's Date Pumper's Name (Prirtt) � Pumper's Signature Notary Public Signature p�wPr4'S A 1 /4 .�1 Pumper's Registration Number Commission Expiration / '71