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HomeMy WebLinkAbout010-1044-10-000 (2)county: St. Croix I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM UUv Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Duane & Jaqueline Rosauer I TOWN OF EMERALD 010-1044-10-000 CST BM Elev: Insp. BM Elev. IBM Description SectionfrownJRange/Map No: 102.0' 18.30.16.269B TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic V V I Dosing 2K+S Aeratio Holding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ventl1to Airintake ROAD Septic >Sbl ...6_'r 12' IZf �2m, Dosing n Aeration If Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift FrictllawKss System Hea TDH Ft Forcemain Length Dia Dist. to Well SOIL ABSORPTION SYSTEM ELEVA STATION BS HI FS ELEV. Bench r`4 rl �'rk (UrrQ.� DTa Cry s rta.. S a Alt. BM Bldg. Sewer ' in t re St/HI Inlet r S lOS,25' SVHI Outlet 5 z �7 • 1 o,t•os1 I 11 Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover It 1.0 pct.20 f Di �r 8•z lo.z Io2.o' L? BED/TRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO PI WELL LAKEISTREAM LEACHING Manufacturer INFORMATION CHAMBER OR UNIT Type OF System: Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size z Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacmg SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only Depth Over Depth Over xx Depth of xt Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil ® Yes Ej No 1:1 Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1 1/Z2-/2o20 Inspection #2: Location: 2108 CTY RD G u� '( � 60 1.) Alt BM Description = l S T W„ yt-kok2 CA" 2.) Bldg sewer length = 12 ryt,c�Gi'l'n ,amo u nt of cover 1 A lt /:&I� j /� ;)efnc-�pAa.�y,.ter�olG Gav+r is tJ�A-r:N�! IN i 3.0 Plan revision Required? Yes No Use other side for additional information. SBD-6710(R.3/97) D Insepctofs Signature Cerl No. [CC EN CAD 2 A�LD :2: Z4'2_ APR 16 2020 Safety and Buildings Division �: I . �'t! ;' Sanitary PermitNumber (to be tilled 'm by Co.) ! i 2 1 W. Washington Ave., P.O. Box T162 pit Pi ,� St. Croix County Madison, WI 53707-7162 X — Community Deveiopm nt 61W83 ` Sanitary Permit Application Stan Transaction Number In accordance with SPS 383.21(2), W is. Adm. Code, submission of this form to the appropriate governmental wit o 4ZOOM Project Address (if different than mailing adtrev) is required prior to obtaining a sanitary permit Note: Application forms for stat"wned POWTS are submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in aroordana with d¢ Privacy taw, s. 15.040 m), Scats. I. Application ls,fotmatloa - Plunge Print All Information Property Owner's Name ,i: - .) Parcel a 1 e ! 1 ' `� / �' ' m � P 010_ 0 e{ Property Owner'a miumit Address Property Location f Csovt Lot �,� /, W Y., Section City, T Zip Code Phone Number ` ! (vl % Qr erek ^� T�N; ItEon` ' 11. Type of Building (cheek all that apply) Lot Is bdion Name Suivis ,� �CTor3 Family Dwelling -Number of Bcdroamn ...�� f� Block 8 ❑ City of ❑ Public/Commercial - Describe Use ❑State Owned -Describe Use ❑Village of +_ Town of /1'G(�5J-lr CSM Number �� 111. Type of Permit: (Check only one box on line A. Ctrmpkte line B if applieabk) A' 0 New System ❑ Replacement System rcetment/Holdmil Tank Rep4mnera Onty Modification to Existing System (explam) �r • flNK B. ❑Permit Renewal ❑Permit Revision ❑ Charmge of Plumber ❑Permit Trsefer to New Previous Permit Number and Date Issue,New /GG � yC t/f Before Expiration Owner A3(/n7 � IV. Type of POWTS S tent/Com cat/Device: Cheek all that NmkkL ❑ Norm-Preanuwd In-Grwd ❑ 1 scumizcd Io-Ground ❑ Ao-G ound> 2/ in. ofwiable soil ❑ Mound <24 i& ofsuitable soil ❑Holding Tank O Other Dispersal Component(explain) ❑ Pretreatment Device(exptaml V. DispersaVIrrestguent Area Informatloo: Design Flow (gpd) Design Sal Application Rax(gpdsf) Ditpersal Area Required (s11 Dispersal Ara Proposed (sf) System Elevation 1_� VI. Tank Info Capacity in Total Is of units Manufacwrer S. Gallons Gdlore v 2y Ong ,tg; New Tamka Existing TaeW Septic or Holding Task / t(_ losing CkeMer VIL Responsibility Statement- 1, the undersigned, mum resismisibility for iasfaRatdon of the PON"IS shows, oo the attacked m Plumber's Natne (Print) Plumber's Sigrature MPIMPRS Number Bmirim Phone Number J37 7iS 703 ., kg_i ' Number's Address (Street City. State, Zip ode)/ L Conn /De rtmwt Ise On �9g ❑Disapproved Permit F�aa�s— Issued gAgnIt Sigrptmre ),Approved ❑ Owner Given Reason for Denial :2 Q� IX. Coodhbns of Approval/Reasons for Disapproval 311/E S=�Ltt f SYSTEM1111-04- OWNER: �,Y 1��,,�� (�q� ` 1. Septic tank, effluent filter and nll' dispersal cell must be_serviced ! maintained . (I � S Lz S4:(U d A alh..Q ArQ e� as per management plan by f provided plumber. lal s� as ra licablec a �°a'f""J) ir°y�er•rrje.tlyr per PP a or ins ces' Y�►/,v�Jgpr TD',`[D. N lM0 �M �bt►'11Ar' 8 SBD-6398 (R. 11/11) PLOT PLAN PROJECT Duane Rosauer ADDRESS 2108 Ctv Rd G Baldwin Wi 54002 SW 1/4 SW 1/4s 18 /T 30 N/R 16 W TOWN Emerald COUNTY ST.CROIX SYSTEM ELEVATION 100.5' BEDROOM 3 CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallon LIFT TANK SIZE DOSE TANK SIZE 630 BOLDING TANK SIZE LOAD RATE 1 .0 ABSORPTION AREA 456 # of chambers none BENCHMARK V.R.P. Top of fence post ASSUME ELEVATION 100' Filter SimTec IDfine ❑BOREHOLE O WELL .H.R.p. Same as Benchmark »BD%L 6%P,5rK—IoC 4*Ni6L_ PAWef 0-e0e g� .rlcsRJ 5 33 33 w. fi C DEN � So RE�Lf>C� 1'J NiM ��,G0? Existing $�' - 0 V I s&Z / 1 1000 gallon /� 132b' Property Line T �K 8T septic tank S Existing 3 r bedroom house JYerflow 30• Tank is to be properly bedded \ and provided with lockdown Line is to be insulated � covers with approved warning underdriveway 120 labels Huffcutt 1 0' Dose Tank Scale is 1" = 40' unless otherwise noted i 2 Grading is to be done divert run-off away from system V .ounty Road G V \ % Slope B-3 Area 15' below system is to remain undisturbed NB.M.* ri B RECEN APR 2 0 2020 St. Croix County April 20, 2020 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2022-04-20 Plan Review: PWTS-042000028-M MARY JO HUPPERT 28497 King Arthurs Ct Danbury WI 54830 SrrE: DUANE F. & JACQUELINE ROSAUER 2108 C.T.H. G Town of EMERALD Saint Croix County Total Amount: $80.00 FOR: Description: 450 GPD 0 Bedrooms — Tank Replacement) Maintenance Required DIVISION OF INDUSTRY SERVICES 2331 SAN LUIS PL GREEN BAY VA 543D4-5211 Contact Through Relay http:l/dsps.wi.gov/programsriindustry-services v .vdsconsin.gov Tony Even - Governor Dawn Crlm - Secretary CONDITIONALLY APPROVED DEPT OF SAFETY AND P90FE5SIONAL SERVICES DIVISION Of INDUSTRY SERVICES -r The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • Abandon Existing System per SPS 383.33 • Divert surface water from POWTS Area. • All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5 • Insulate building sewer beyond 30 feet per SPS 382.30 (1 I)(c) • Tank Installation to follow all manufacture's recommendations. • Verify property line(s) prior to installation. • Well setbacks to meet chs. NR 811 & 812. Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. 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. All permits required by the state or the local municipality shall be obtained prior to commencement of constmction/installation/operation. In granting this approval the Division of Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Thanks, Z;w &asrn!ev &eat POWTS Plan Reviewer— Wastewater Specialist Department of Safety & Professional Services I Division of Industry Services email: tim.vanderleestaawisconsin.gQ Cell: 608-516-6134 PAGE 1 OF 4 Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10705-P (N.01/01, R. 10/12) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 IrA N rl fl F+zEF�v11 n/ j Pg 4 of 4 Management Plan (0n1 FILE) Attachments: Enclosures: TANK SPECS POWTS Application for Review NSPorlw Soil Evaluation Report & Site Map Warranty Deed Project Name / Description Owner Name(s): DUANE F. & JACQUELINE ROSALIE Phone: Owner Address: 2108 C.T.H. G, Baldwin, WI Project Address: (same) 715. 684. 3921 Zip: 54002 Govt. Lot: na SW 1/4 of SW 1/4, Section 18 IT 30 N-R 16 EDor W Township: EMERALD Project Parcel ID #: 010 - 1044 - 10 - 000 County: ST. CROIX Designer Information Designer Name: Mary Jo Huppert Phone: 715 _ 426 - 1775 Designer Address: 28497 King Arthur's Ct., Danbury, WI Zip: 54830 E-mail: hollisterdesign@outlook.com phis space re>cr.ed for approval stamp. License Number: 1859-007 Remarks: REPLACEMENT SEPTIC TANK ONLY CONCITIONALLY AF PROVED KEPT OF 5<,FETY AND Pr_OfeSStON:.L SERVICES DIVISION Of INDUSTRY SERVICES i Signature: �� Date: Onwg 15 nawra requved m each submitted copy. 04 - 11 - 2020 i PLOT PLAN PROJECT Duane Rosauer ADDRESS 2108 Ctv Rd G Baldwin Wi 54002 SW 1/4 SW IMS 18 /T 30 N/R 16 W TOWN Emerald COUNTY ST.CROIX SYSTEM ELEVATION 100.5' BEDROOM 3 CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallon LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1 .0 ABSORPTION AREA 456 P of chambers none BENCHMARK V.R.P. Top of fence post ASSUME ELEVATION 1a9' Fflter SimTec Inline ❑ BOREHOLE O WELL .H.R.P. Same asBenchmark MIOL%L , ST'F- I np '!ORM&- PUXe Sfo. cdto -A--� oWe 5 33 33 Ate• � Existing BE l%� It 10009 / � 132b' Property Line �T septic tank S existing 3 r bedroom house )verflow 30 Tank is to be properly bedded \� and provided with lockdown Line is to be insulated k covers with approved warning underdriveway 14.0 labels Huffcutt 1 0' Dose Tank Scale is 1" = 40' unless otherwise noted Grading is to be done divert run-off away from system .ounty Road G 2 El B-3 Area 15' below system is to remain undisturbed 100' 13 B-1 / 99.5' \V 99' 4% Slope e B.M.* ST «,► COUNTY SEMC TANK MAWINANCE• :, AND OWNERSHIP CHELT1111CATION FORM Owntr/Buyrr 1) u A ^5L— 1 l Q S Q lti Mailing Addrew J-1 D `b rl4a fL2QQD Property Address S M (Vw fosbon tegmred fram Pi�g & Zming Depathmeat for new oma ructiou.) Parcel Identification Number Q / 0 - I 014 - I V -LWV Property I ocatit>nSw Y. Y. ,Sec. /O , T S b N R% 4 W, Town of F J r c, Subdivision ` Lot # — 1- Cerdfled Sa"ey Map # Volume _— PAP # Warranty Deed # r.;� q / b 6 7 , Volume Pegs #) . Spec house yea O Lot how identul" Cy . no SYSTEM MA1fNTSfA AND OWNER CERTIFICATION Improper use god mainaemm of your septic system could result in As prema>a[e Shore to hurdle waste Proper consists of puvping out Poe septic tank every three years or soccer, if needed. by a Housed pumper What you Pat boo the system can affiat die Rmctim of do septic tank as a tread stage in the Wei; disposal rJo mt Owner iaioltmce nespoosibaRks are specified in f Cow a3.52(t) and in Ch plar 12 - Sc Craix Comity sgdE¢s oiarmmce- lbe property ovum aareas to submit so St Craft Comity Planning & Zoning Dapctment a catifiratum fame signed by the owner and by a master phmbe, jogmey0u plmnbe, restricted pb-be or a Hemrd pmnper veci031114 that (1) the On -WIC wampum disposal ayatem is improper opedimg conditim andlor (2)titer iespecf' and, (if neoe stay), db septic emk is im tLm 113 ffiII of sludge. Uwe, the mderigoed have mad the above reqiramcutg and apse to u,imin'he privet aewaae dwporl gyminn with the aamdards sat forth, herein, as set by the DepartQgem of Commerce god me DepaRmmt of Natural Itasomcar, stab of W-Womo, Ccti6cat m stating that ytim septic syalem bee beam mndabmd mmt be o=Wleoed and tetame I to the St Umi: County Phanmig & Zaemg Departmeut wimia 30 dayr of the epee yew eawaa oo. dab. . Uwe eftlLf, that an sta,®amta on this form an true to the bad ofmykm knowleelp. Uwe am�sre the ovme(s) of the p mpeq deannbed above, by vicl s oft wintaly deed recorded in RgOsle<ofDeeds Oflka Number of be home L/Z2-/4L) 'AIWATUtOF APPUCANf(S) DATE •••Any mtotmsrion that is naaapti smbd nay reach in die sanitary permit being revolved by die Phmm,g & Zonmg Departmwt. "• iachide with this application a teecrde I warranty deed from the R igiswr of Deeds OlSce and a copy of the certified survey nap if refer eooe is merle in the wiry deed t, 4' CAST -A -SEAL in T r U � •r a. PUMP PAD TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM 0-1227 REQUIREMENTS DIMENSIONS: WALL 2 1/2' BOTTOM: SEPTIC 3' HOLDING 5' (ADD 1,300 LB.) COVER: 4' MANHOLE: 24' I.D. PRECAST CONCRETE RISER HEIGHT: FL.AI COVER 53 1/4' O.D. LENGTH: 104 O.D. WIDTH: 88' O.D. BELOW INLET: 42' O.D. LIQUID LEVEL., 38' WEIGHT. 6,790 LBS. INLET AND OUTLET: 4' CAST —A —SEAL BOOT OR EQUAL CASKET, CAST —A —SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.83 GALAN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8' D' UNSATURATED SOIL TANK CAN BE USED AS SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN /8 NO FIBER TANK: MIX DESIGN /10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPMAL DATE: PRODUCTS NEEDED BY: Wbrmwl Department or ComTeoM PRIVATE SEWAGE SYSTEM County. St. Croix Sa/eMeaMdltliny Divhlm INSPECTION REPORT Ul%.Z2-/L) s-Wy Pwn'ANo, '3�f' 0 GENERAL INFORMATION P C-L"� (ATTACHTOPERMIT) State Plan ID No ) pL�/ ✓ oz Personal i eorrnetlon WrwIP You prows may be Wed for ndary purposes Maoy Law, a/e.De (txm)I. / O Per d Nara Name: CityVisage Tip Paroel Tax No: O / - ID - Kos f� f J ua+ ¢ E.�.afa td! CST BM tie . BN Elsv. BM Description : bacaoNTorMRargaMp No: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic IS-n /000 Dosing I- tf loos Aeration 5/ r Holding TANK SETBACK INFORMATION PUMPISIPHON INFORMATION Manufacturer !i GPM Model NUmbW O Q' %S F /' Lose rkign System Head Q. TDH F Lw,o Mn I Dla 2 �� b /00/ SOIL ABSORPTION SYSTEM 2 STATION FS ELEV. Benchmark All. BM �� • L o 7: Bldg. Sewer SUM Inlet �/ MOutlet /20r � A Dt Inlet Cfi1 t C OBI i O D Q/- o DI Bottom He n. Z . 33 a_ 13! p .2 . Gsot SystemFinal Gradate �03 411' 2 Ca cir r / / r iml M BED"ENCH DIMENSIONS WiEm � XU Leper -/ No. OIT� PR No. Of PiY YNpe Dfe. Liquid Depth SETBACK SYSTEM TO PIL BLDG Manhcl,rer *FORMATION R OR y'r�1/p)�I / d > i l �' / Model Number !' /� (.v $T»' >' o %� LIPM 1 KICtLWW1 a T a l CM DfMbAon z Hole - Hoy Spacing g L.pn oy h P �^Yf � 2 r sP�7� � 3 /i 1Y//Q�c� ' SOIL COVER K Pressure Svaterm Ontv XX Or At -Grads only 51#7j&d h0M-)-h Topw�Y � a O ©Yr � ®Yr Q No Inspection 01, /D 1 / //�6 Inspection sz: ro r 7 G k;-ADL P1d Parcel No: 2)i16 �� Depth Over Depth Over ofaed/Trench = Carter BGWTre hEder COMMENTS: (Inncflude cods dyaependes, persona present, etc.) Location, 2/Og L7y. a �'I , 1 / f. 304 - Z6 9 23 1.) AR BM Description � � /IPIA' DTHrw �h 2.) Bldg sewer length - r/�A - ernhwnt of cover e N A Plan revision Required? C Yes No I /G Use other tide for additional Information. SBDe710 (R.7r97) �e ,iarf �0 I� County Sankary Fiennit Application ST. CROIX COUNTY WISCONSIN In acmttl with Chaper, 12 SL Crobk County Sanitary Ordinance PLANNING 3 ZONING DEPARTMENT Personal klformattan you provide may be used for secondary pwposes ST. CROCK COUNTY GOVERI%WNT CENTER g [Pdv" Law. S. 15.04(l)(m)1 1101 Cannlchaal Road Hudson, WI 54016-7710 15 Fax (715)3864666 Attach corntift plans for the system on paper not less than 6-12 x 11 mdres in size. County Sanitary Permit f ❑ Check k revision to previous application It 1. Application trYorma•orr - Print all kdartoalbn on: Propeq Owner' , � ,� s�J,,.,Sir S DuANi5 F. � J t4U- Ros�u N, R I E ProportyOwneft'l I - Addnes LO Number Block Number — ky. State z4 Code Phone Noma Subdivis or CSM Number tAu-Wrnl ur SyooZ pis-�Sf-39z1 arw 3 ❑vutap own of w t or 2 Family DUhV - No. of Broom ed.: ❑ PubadCumnrarclal (describe use): ❑ Sfataawned Rood � U. Type of Parrett (Check only one box on lire A. c box on We applicable) Ks) 1.6 Repair ❑ Reconnection .[ ❑emu bon A) TANK cA Sanliauon I B) it Nu - Date Issued State Sanitary Pernik was p"W ously issued — IV. Type of POWT System: (Cheek all that apply) ❑ Non-presskaced la -ground Mound 2 24 . s l soil ❑ d 5 24' son end A,g ❑ Sand Fikv ❑ Ckv>9sucM rid at r ❑ ❑ Prassur®d ingtound ❑ Holdug Tank Single Pass ❑ At -grade ❑ Aerobic Treabnant ❑ lating V. nalmarrt Araa 1 1. Design Flow (gpd) 2. DispWg Area 3. Dispersal Area 4. Sou Rate FF 1 bS 16. System Elevation 7. Fwl Wade �S6 _ Proposed pamiday/sq- VL Informati CapakYy in Gallons Total 0 at Manufactur le Fe[3 Gallons Tanks Q Ngrybng Tanks Tanks Ir !CS I, Responsibility Statement 1. the undersigned, assume responsibility pa for rakhacommnebmUrsjt wnason,ineteaadon of none ng for S on Uw drod plans. A icense is not required for tarralilt repair or Him Installation of nlation s • Phurgbees Name (print) kWX4PRS R f 3.No I M S� a Addtasa (Strad, City, Slate, Zip`GCoda) ioS C 60 WFEW C-A a VW. County ll.. Only DisapprovedSantary Pernik Fee Dale Issued Issuing Aged Somit" (No atampa) ❑ Approved Owner GNan Iniset Advanx I Detarmina5on Comtltiona of ApprovelfReasons for Disapproval: Rev: 6I05 R CMVEDD APR 2 0 2020 St. Crmx County Community Development Advanced Septic Installation 715-703-3235 Septic Inspection Report Buyer or Loan Applicant: L )CL,C/�l7:<o/ T Inspection Date : oZ Property Address: C9 100 ('oldLo ltC- - Aproximate Age of System: �QT Type of System Conventional with absorption bed or trench Pressurized mound system Other(describe) Observations Conventional with drywell Holding Tank A visual inspection indicates that the septic system and all its components are located the proper distances from the dwellings foundation, well, and property boundary lines. The tank(s) have been pumped and were physically entered and were completely inspected and is/are Free of any structural defects and are functioning properly. The tank(s) were pumped but not entered and appear to be free of any structural defects and appear to be functioning properly. The tank(s) >t'-in(S 6)2.d6P- - A- f -+krs Tin ° ' 1. The tank(s) were not pumped but from readily observable f tnres,itappears_ to functioning Properly. Determinations CJ A visual inspection indicates no evidence of system failure at this time. The system is adequately Sized and is not disapproved for current use as per WI Admin. Code, Chapter Comm 83. A visual inspection indicates the system is functioning, but failing, as described in section Stats. Repairs are needed � as follows: 7-R Pj NEB S �$PkCC-- YI i5d 4- rv;)oA1e,N4'S Ae6 Co De r'OMj)llt}A�, A visual inspection indicates that the system has failed and is disapproved for current use. additional information on system if required, see additional attached pages. Certification The Undersigned cannot guarantee the continued acceptability of the private sewage disposal system due to Unpredictable factors, which could later detemdne the life or code compliance of the system. 10 7I sp ctor / sanitarian iihnalure License # Type of license(i.e. Master Plumber,DNR,POWTS