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GENERAL INFORMATION
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
Dpm,
ENSPONS
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June 13, 2020
CONOOIONAL APPROVAL
PLAN APPROVAL EXPIRES 201-13
Plan Real Pski M2001124-C
Jacque Hawkins
PO Box 2
Wck, Wl
SITE:
Steam queen
XXXXC 1291. o
Parts 026-I165-2G00
Town of Richmond
St Crow County
NE X SE N-522-T30N- R1EW
FOR:
Description Mound Component Manual -Ver.2.0,5BD-
3Bedroom Mound -450 GPD- New -30" IM91-P (N 01/01, R 10/12)
to limiting factor - EFlluent Fiber- Pressure Caba oan Component Manual -war
Maintenance required 2.0, 5B0.30906P 1N 01/01, R 10/12
The submittal deuribed a Wee has keen mewed forconformi with appboble Wixonnn
Administrative Codes and Wisconsn Statutes The submittal has been CONDITIONALLY APPROVED This
syeem rs M the constructed and looted in amordence with the enclosed approved plans and with any
component manuallsl referenced! above The owner, as derived in chapter 101 offal, Wisconsin
Statutes, is responsible for compliance with all code resui iments
No Person may engage in or work at plumbing in the state unless licensed to do w by the
Department Per s 14506. ices
The following conditions shall be met during construction or installation and prior to o¢u W ^W or use
Reminders
Hire site shall be property prepared prior to plowing Any greases longer than 6" shall be cut Fhprt
and removed. To avoid mal any leaves or Iposs organic matter shall be raked up and
removed. Cut trees and shrubw Turn to the ground and leave Sumps. Avoid operating equipment
on the Mound see, R necessary, use only tndM equipment during dry conditions, with rainfall
passes. to avoid compacepn.
A same ry permit must be obtained from the county where this project is hied in accordance
with the requirements of Sec 145.19, Ws. stars.
Inspection of the private sewage system installation Is required Arrangements for nspection shall
be me& with the designated county official in accordance with the provisions of Set.
145.2012)ld), Wla Stab.
e Astate approved effluent filter is required Maintenance information must be given to the owner
of the tank explaining that periodic cleaning of the fiber is required
A copy of the approved plans. specificationsand this letter shall be on etiming construction end
open to inspection W inherited representatives of the Department whlrnmay Include local
inspectors
Owner Regapnzlbllhlez
• The current and each subsequentowner, shall receive a copy of this letter Owners shall also
reserve copy rif the appropriate operation and maintenance manualls) and be responsiblefor
ensuring that P0w7s rs operated and maintained in impounded wth this chapter and the approved
management plan orders SPS341154(1).
In the event this mil absorption system any of component parts malfunctions W as to Create
health haaard, the property Owner must follow the mnOngenq plan as described in the approved
plans
The owgens responsible for submitting a maintenance werrfoban report acceptable to the counts
Par maintenance tricking purposes. Reports shall be attracted at Intervals appropriate for the
component(s) skilled in the aowrs
In gating this approval the Division of Industry Serves reserves the right o require changes or
addhwnz should conditions anse making them necessary for code compliance As per state state
10112(2), nothing In this review shall receive the designer of the respgnaMlty for designing a sale
building, structure, or mmPonent.
Inquiries concerning this correspondence may be me&to me at the telephone number listed below, or
at the address on this letterhead
The above left addressee shall provide a copy of thus letter and the vDY?5 management plan to the
owner and any others who are responsible for the installation, operation or maintenance of P011,75
Sincerely,
./ mhzw1)?0WIP}y
Joshua Rowley
PDATS Plan Reviewer, Division of industry Services
(215) 813 9111
Joshua. rowey@Ar,on9npn
APPROVED
„ a-Iff .
MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
Resgenlal AeplaaMm
MCEM AND TRUE PAGE
Proton Name same 6aean Manama stan"ry Syarem
0.rola Name SMe Delano
Oxners Addoece.
PropeM ALEroes. 12W SI.
LARW Dexnpoon
Parcelln tee NE12SEI4 Sec 23 T39NA19W
TwnNip
RaAmo.!
Carry
SICrOn
Bu4Emagn Name
Lundy MaeWa'e
Lot Number 20 BIock NumdM Na
PMral I D Number 0a 1165,2 DO
Plam Tran Tan No
Pepe 1
Index and mme
Paget
Late entry
Page
Mound dmwmpa
Pages
Lateral and dose rent
Pages
9Mem mamenance specMcaom;
Page6
Management and contingency Plan
Pagel
Pump tuna and spenti`adons
PaJea
Opxnal Fbat 9eMnps
Page 9
9anMry Sne PMn
Deagrer Jacque Kwo ms Lrranw Number MPRSAQnS72
DMe L6IZOO Rcne Number 71Sa9L6
6gnadure
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SBWMP PudlulpnB 6 Desgn alPnawre 0680
2OielrlWleN 10 D br SL 0101A1)ertl
Pmeve DrNndtllan Cangvanl Manuel Ver -101[6P 1N 01.91j
Vernon 70 (R 096012) Pagano 9
-76
Mound and Pressure Distribution Component Design
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SOIL'I ES-IT3R AND DESIGNER OF SANITARY SYSTEMS
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ST. CROIX COLNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
Os Tt RSFMP CERTIFICATION FORM
Owmer/BuYs norve llal+e✓ pp
Mailing Address 632 Zo41M1 St- KOLL-6 lN. SYPL3
Property Address lq3/ 121,
(Vatficata rglluvM God Pleowvg & Zomvg Deparmmt for new wvsvvcpon )
Ctty/Statee(o[w R,cbm.patl I.U, Parcel ldeutiEfwpoa Numbs o21e^/II.S—JVoo
LEGAL DESCRIPTION
Property Locaitoa N// Y.,SSM Z2,T 30 NR /9 W, Town of n.ch.....a,r.�
Subdtvtsmm Plat hwN4l //taefu.ccr Lotq ay
Cerifel Survey Mup 9 pp 11 Vollme ,Page#
Werrauty Deed# (before 200])Volume , Page #
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SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Impeoperuce and mawteomce cfYoar ¢spec rycmm coWd revWtmrtv Patatme fmlmemhmNeweabs Proper
moderate assumed Ofpumpmg Out We septic took every Wee yeas or sower, Seemed, by a licemed pmper Wh&youpurmw
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respoosibmhm are specifiM as §SP6 383 52(1) bad to Chapter 12- S (boa Co®ry Smmay ONdaom
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Numbermfbedrooms .3
SIGNATURE OF AP IC rT ) w DATE
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Include withthe apphcamn a recorded wmremry deed from the Register of)Awic Office sad a copy at ceNfiM if
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