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HomeMy WebLinkAbout040-1017-40-000 (3)^^ PRIVATE SEWAGE SYSTEM P`n"M $I. CIOIX s.mvb emiemau»a• INSPECTION REPORT no•mlr No 631229 GENERAL INFORMATION (ATTACH TO PERMIT) GWwrun to No agnin N(1)(mll CiyVliup. i R®N > Charles&Amy Bailey TOWN OF TROY e 040-101740-000 OMee. . ,n n,mm.nna w DO AL RAV1 M,n 0428.19.611 TANK INFORMATION ELEVATION DATA MANUFACTURER CAPACIN STATION IIS HI FS ELEV segw �nj}� I I LbD nmmem 7.Z6 "..'23 /00 I D /2z rn CAR; r yl Er. -m 34V1 15C-4 0.3S l019.9 xuaWn Blap Sc l f erne TVHl oriel TANK SETBACK INFORMATION suw omin 7B6'K yZ TANKTO PM1 y} WELL SLOG Vwtwuru G jar-6,rc TN 0 1L S.BB 45.pj 94, s.pea II EXi$T Di �. Re GOT7 r33 ST. :kr >ZS • 2 5 • M Tel 8.44 86.6 M/a W b 73 A6Asvpi Am.N ea sy.wn TL s O PUMPISIPHON INFORMATION Ts 7.04B 'b ManwaEurar Dommentl stt )5&5 1 RLq MWaIN maer fvy� 6nde 3.a 88.3Ej GN LI INnN.17 o-rem Lenslx Bie rL.1111111111 Tw+u' P7r.i— 4,55 !d D.q) 9043 SOIL ABSORPTION SYSTEM & t W In a ,,,ern 3, L(a�, rN or3 r>v.w Va RMn R SYYBFEMTO (wven ov`AI PM1 U' 1>5O' BLOC WELL >50' W (Elb'1 M UNIT I "I••5i Tv�i DISTRIBUTION SYSTEM R iR iwN oR Lonam_B. �w=:in In vrgAI�rr.A u�m sp.n� smmm.Onv o.om.°n;Um.2.5'-3.5 r.ne; Ex. %!z" w.I m W" o.a oNn 1614 COMMENTS. (mewaacoeedn mienMa, pareunapiment eR) Inspeaionbi mspeellon ice Lwllm 537FRANCES AVE L� �VCV\t5 aM SbfCnhirM$ Im- 1✓ 0/ !�S TI>x BM Oaampilen-d.ldeM 5)1; . s/Q �Y6�-k OR Nor}I.. F.j x)a-ios.e Mam-iAA44 ddexdr .moe�an..r- .NXAO/R — 46„d,,s%O�Fn� nn Reamreai S.Z I31. �s;;ia 'a,ror,aalenn,Nwnrnn,n.an, Z � JF�fxn�g d _. .n�'� .5� sspa.m R 3MN �nl saly- aMal- oil 12 ZRI B.Ierv•m O'kel DIVMn ml w woebNpmX As, P 0 M. 7162 Madem, VJF707 7162 ,e,, I'mNNAM Ina filed I, IF �317Z9 _ — annary Permit Application le I IN u elalw. Am CAN. milmlIN., wN eeeMANIN, "ora br"� r"®«.awlvls �Wm wib. w.krwMmE4u I .IS... ba...M. "..maNdwermew,"ININeb.n � B X5 �. %nv"r ✓ Xy., m,a o.ae.lt r.n -RACK s.,.. �✓ 0.�X' 0.J�]—IE� AN AM [I/ "ANNININ1-5aw 55�a/L (n57-5'erred, II. ar" of BUMIN(III ell Jel."If) s l....,wbM-x.,weer",a.",Po.n�— /Heels ❑fwe,,umme.i-me.nw0. ei".1�uN DS ❑c,n.r ❑aw01-0�.�a roe ❑vlll•E•a fewer ZONE°`"°r III Typ of perelll: ICM1rtLetly we be, o" IN A Comelele llm B lfeppBnble) ❑IN snem "l ❑.neon."ux re al Mpssemae, am. y q q5 W IPr Bi �, l/!(cM/6MA-. DaNnik,wee open."Naw. Ocampapal DIftenelalurl X O.Iw seers, 7 <ea Iv elroWT99 aemKe. oeeowevlee Cneeb.Ilml. all III �Alarw m1.M�.,.enlm ❑nl..m.eNIC.�noon.w .. .m n, ofXeem"NA. VII V.I. ,aVfn. n. I.r.m lo°IMXW (IN) reser �l Are O :o 0.7 0,rpem"," B.a...11n 57 rehavese n swnexnor, ou ys.sa el.w.8es, VI r.Yl b Nala in TMO Ad aa+ P�ji.i Izz kk e "x"Yjen4 ac va .r E,. WINAM ex0 . �ei313& I.�nw.,.xnro. Gnlnl 76-,hC-Gsco '32 .e"P �R- 2we Gr/' b ect VIILCq Ne n °e ',I 95�eo s 119 ZI Ix. eoMtlooMnMmbMwnMema. Be...13 G'i i.cs MOf� .les a m 'mv 0iryersalIII a. III 11, ml ramlarea aper�1. f'+011. cn5 Cvl� ElF w V^i} q , rdr:e,+„i iq,l m memeu0 bl 2 AllsM., nu']1 li m.elcmwl be mae7 ll�p, 9 »=m"rph hi, "j, .,,mee .,.,. `V Ex:Sa+ry iwe.4vsy+. 4. eileew rwJ as ease ""eee."e....». ......r,. �..e.., _"M.", W ,,::..1.. INNI. MI C,ares,. bFIE'Us IB Ilan 5) OV I e-Sleelll rmi` a fYfk.. r 011,,kmnl. ao Pr+aferj. owrw-r-� cl— v Plot Plan Cop%, Qv Site location: Vd0 Bqo rate zw f � i = ao FT. lq_blckh.* S.tM A4 eE PAGE 1 OF 4 In -Ground Gravity Plan Index & Cover Sheet Ownpwnnl Manuel Desgn Reran Ices Version 2 0, SBD-10705-P (N m101, R 1 W12) Pg f of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersal Area Cross -Section & Plan View Pg 4 of 4 Management Plan Attachments: Enclosures: canswr Spao _ - POWTS A�phcation for Review PiMSpem Soil Evaluation Report & Site Ma ¢ Flv. SDeas Project Name / Description Owner Name(s): Chanel R. Jr & Amy N. Bailey Phone: — _- OwnerAcidness: 527 Frances Avenue, Hudson, WI MP: 54016 Protect Addrrsc (SAME) Govt. Lot- NA NE 114 of SE IM. Sectbn 04 . T 28 µR 19 E ❑or W Township: TROY County: St. Croix Project Paroel ID a: 040-1017-410-000 Designer Information Designer Name: MaryJo Huppert Phil":716 .426 -1775 Designer Address: 28497 Hine Armors CL. Danbury, Wl MP: 51830 E-mail: hcllistenlesign@outlook.com ,Mcx,' ulp"lulflk License Number. 1859-007 Ramada: /� ! MA?I,r 7: e (%%hC5 I1i aF HUPI'ii.T t a 01559 '*ea Signature: / tl�w�en.�nna+ /,a/ Ea Dale soon' Plot Plan Par za 41 PROPERTVOWNER: CRMLFS —y-- r= 40 Fr. �W �emlVmn: WTHE NE! lo+®pt�Me mxJl Tly� Ri 04 0 nu0- to ]- yo.- Doo S. aD AaREb .�LFKk— Ma gll�. North XV w Site location: 7� rol� /0..m' IN -GROUND GRAVITY DISPERSAL AREA °ip°°'x'4^"""•' JA*fem Elevation Trenches with EZ1203HP Bundles EXISTING: WIESER 3-ft Trench (down -sizing credit) 125p ADDING POLYLOK ,/ Gapes mxs I w N n �� alew, flrxmxx 7L6 ILL Ir TYPICAL TRENCH CROSS SECTION VIEW Imxx4 L — .,.J �,-�, (No Scale) OBBEPVPI%IN PPE CETNL S~ EIMM 55.50 q W aai 1[/plWl pmme Holman 3q xoms�i a e.�l 3 "pragon be MvarrJiae. 'S TIC .w.xx.Mx.,.: TYPICAL TRENCH Ia�1lo nmemlameepaT mm on p.irw.,l �•I'"sew•` PLAN VIEW (No Scab) a•e w pedmlm legal 10 q oeee„y�� (bololl IbeM legap rA•3.Ufl D —Y------_-- IOPaII Be q M I: IbIM (.00 Ad c0.71-i= 957.�5 1ccMMH O \9 INSTALL PER TRENCH: gg>by),m-r �p FU/xyIT3 EZ1t03M &ape b Amp 8 10.q dvNr O50TE14WW. 300 q. aHI CP f>; IWrtS (mb ManaaeTwnx. w.l T A *3A Sfl bumr®3fik EIBfWN• NA q� B_w1vre x/0 •. `rrwx.+nn..n.a..ga+„wx. fa/j/ bOT TRFNdI x PreagM ElEAera , 355 q• Reeulrp]InnnmlblNxy•85].15 V DbtrButbn Metllod: x 3 banM" = P Po Tobl EISA= 900 q= banc ed manifold RESET In -ground Gravity Management Plan PAGE 4OF4 a1PORTANT 2 center Of mis lnymva 91nererenl end, or mapdww he but wmenw Premium ma murnamnts Outlet on wreirolda SPS%b3Ea, Wlcgynorusbe_ NiwunlmSPS ornthfournc,Mmn.CWe, ber elW, Iu mmbemd a rumen health Bete a rw meXdayd In dmMerm wXn bre e W muen man W emmn yen. wmNemmm,an,repeM are),Weec oa coons clad, Ee pandnwy yyarerlalary POWIS w,nmgrin oytlerce wM SP9 36153(31. Yl Mmm. CCAe. Mulmin oi, Syr: Oaegn Flow = 660 qpd; BOOT 5 tiro ni TSS 51 W inni FOG 530 Or 11111121briticlr t INSPECT EVERY 3 YEARS pyre d um We Of their o nMtemu aeaod it Pmm, user mmdBrm, dc) neadmical mwlurcCPn Ile, pumla, veNe; eMlPnq flwd, ehJ mBMd k5pue 0.a.leake beWXe, mmvion, dnl P m,in5 wit improper emM ienh(c)BM erryyeNMgnbyl adwUrt, oft Ihe., JaMudn/JPr np.eel nWhe w,mpmpen over IIe, arco Pn tlm,gr wpacidet pdugleE Saivmm. Nc 1 themmporempIn aItrou ca, p;um Msrn • dom Irtc,mixN¢s.tlebb(re., wnMP re dlnrjonmo om cmtM xro of dc) • o B«nhurb r, Ito" na. n d Ori N Nothing g Pro sure there h me swrcmq, mnydt, Emem. darts, out d 'tore lntim re,erne Wmri Wo(masvwe Lslereldieypyee_ ryvnpye lP drops soru5nOm) o wRxe dazfearred Mfluedwwwape lVth-up,eno deur,Yuee mrved w c X I MAINTAIN EVERY 3 YEARS (or "an necessary) P s.otic teem.. Mel, 4i pored by a cM,fltl«phpe rommini WentImnxd Uri a. Off, 0 We tmm wren lna vdoms Meopde M uw unto•) sateen• metldM 11n1 me Iowa vweme Pane Unit « NiW Pra' n'dewnm. ge yorW m rmmml Byron pue&®dW NR 113. Video Anne. Cam. P 1ea Am ,Ee,eWayM overt 3'/etetWBW,N A werno Mnwyerymea theme, m«nna xwedli9braafa'Ln✓t ywA'vstive. ASQVIae9 We,rvl Wll Mv+K lla theme, Penn t} Syabm melnbneno bepoeb atoll W W WPfi h1 10 the proper loin Women unit In ecWlnanor wit SPS= 55 Wbc."Or Coda. Repot artyw ""M M1llum m meHue you b: Nabodemieiaal«.m,peret MIKERODEWALD pew, 715A25E200 forri vrm«a wtt ST. C= COUNTY COMMUNITY OEVELOPMEM per, 715-3864680 Ill peremrwePot adieu COURTHOUSE, HUDSON. WI �. 54015 heyde%tke qn d mitt into tie rgpvad, IaWemd. «mnoed PaauY tto 10Si MIMI (1). Woe IAN1. No go]Ru}(tt emrrli®Ioow Mommw of )' medetim of In Poirri Phil by umd un yptwed bytlmdaptaMadpn acroldanw wM SP53SC, VJiac. gdmin CtAe. 920ru enm PM In MB geMtl@I dryylM WvhMnl ndrypnwn of tlW POWTB cmn« � repahM, t •lull tie redygtl provyanl b agannettledPottmrof byadele epencyN rwiw aM apppry. Aa Pr in onuntldispersal wrymeminW nn .beemnm and reyamd M e mdemnidvero aiapwm o>rt+«rmr b a Pentlem.rm In, Of eemPla rem. B If use Or the PO it no checormyad, it shell be so n«med In immanence wIM SPS 39333, Wbc fNmh Cry. q INSTALLATION INSTRUCTIONS •- I =•-.. Pt: 1221PL-525IPL-625 FILTER INSTALUTION INSTRUCTIONS LL .,.,..pro n . _ MAINTENANCE INSTRUCTIONS I 11 1 if JI\ rPI> .,,.. �,... USE NUnnCd 6Lo>E4 WHENCt ELNINGRL?ER INIETOPENNG 41 Q' OIA POLIETHYTENE PEPCAEIIC BALL a — 2dT5 — mao -- -1200 R00 — �uTASGNC WATERtRE 1.25 ( WE30E " 0120 v l50\ �TOP" FRONTNEW log 4aJPR TO RECSW: PART NO L<-157 30115tf3PE ARAM ) 301N(RR ADAPTER) 30142(HWSNG) 'TRAWL OF UALI _ice -� —Brat wEw — --- --- PL-122 HOUSING BOTTON%AEW PART NO. -30142 MATERIAL -POLYPROPYLENE u�. LaN �%z -a IW MIN m 3 F O maz m -D mo O r O A Cf7 m y➢y W r TV O nl A➢ y y ➢z F `oy z� flL�N a NOM CIICIETE SFPTC MANUAL xwr un p waE w �800- - \� flEV JPN PO10 W5-8456 4A EZ GEOSYNTHETIC AGGREGATE I. INFILTRATOR TECHNOLOGY EZflow by innards la an environmentally friendly reolaceaent to uadirenal sto and wtt drTnh a Rang m9,neemd geoaymbenc adympate modular aesgn The Ezdow sntem 1$ deelgnae to arpro.9 infiltrates porlormayme, by Ishesurall the fines aced seem � hit stone. and red IW mmpamlon and ambmrtem as lath with stone. Hedssembled units mduda a a" or a- Vedoratea µce wnoundcf by aggregate and held in place win a sfiande heal-ehengthe nemng. The product comes in easy -hycontour sand fn' tangms and in a mates of s, 10,12.13, ar is Icnee Lightweights ev W nand polysryrma .a. INFILTRATOR' Compared with stone and pipe, benefits include: aways clean and free of m,m Bundles are gwck to'.nsiall, saving costs on heavy TMduxry and labor Modular wnarrcuon at sman u•a it to match happy dlmenears!a mint sysem shapes mtl axes Engineered for ohe met storage and absorpiron eHloencles • Ably tR cotour along sloped sites and around from of landstenlrg • Lightweight system Is padect bnepars and fight rob sed s Eall hand carried into posmner reducing time and labor E' Or ie' length with simple than. internal couplers Easier cleanup at the joy sde vrm the ehmmaflon of stone Manufactured hwn recycled materials rather than a mnm natural resource A slide vmety of dumefers and mnfigunial to fleet any psmlmhon pebrioslonays needs Approved in many iunad¢tmna vem an increased enlalancy all reducing drainfled size Backed by the leader In the msie wastewater Industry BUMIe System ConfiguratlDtw: Available in T, a', s'. 1W 12", 13' aM ta'tlameler burni. SEE am O)"GET cal P and INFILTRATOR' a"'re' xM«. dii the hnumEv ni as 1D^ ma 1z mm Wa1Naa. sae wm wlll a ea,al« z Bvarem Nmmala« I aeNNaeam aeon eanalN mamatarand armla a ILP iaEll dLon, Rre«are vlin which a .d aiMnmarwn Rwe Is field mNaumwlmmthe rm cmmDarmP pipe e. anmal alnd wu0liaaa mmaawoIATM s.B,nal« am and arRlael, wireal amaxnm bo«Ire aeniif ,ad sYmnmm aeRraRram INFILi WR WATER TECMNOLODIEB 6TWIDARD LIMITED WARRANTY ,I Th. ardepiree dame, ON man Of ON, thrinquen Ear ad ry q pal'ipheafuml xM IN � W+wT+aX ap RUN mmrM wenu mina ISen amfear mpman®.rgrveON e �ON rvgry in OF serema uhm �rtn�aup®ens®nmamuNmXawv.miemnguaun ,�NUW 01rn[uNinp w.wxoim'ua ap¢ort¢mvimuucurnlgena aaua PUFFEEN ampan an wvremr w+ uem awuwm nuNuxm�.w mie uNs ma �r e«m ON u X Of w m�e mahm�n of ndif aan va.vmnry uur mm owun OF um�1 EZBow 1203H - GEO NATIVE BACKFILL ESTABLISH 6"MIN. COVER VEGETATIVE COVER OR PER CODE FILTER FABRIC F \ =1 4"PERFORATED PIPE 12"EZBow BUNGLE (TYP 36' MIN TRENCH a WIDTH E NOTE. PRODUCT CONFIGUTION AND INSTAUL TION DEPTH MUST COMPLY PATH APPLICABLE WEZflow REGULATORY REQUIREMENTS"' ST. CROIX COUNTY TONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence (Streetpddress) i;Al G...us n,.0 located at. IIE 'A, 5 & Y., Sectmn Town_ D N, RangeI? W, Town of f2W , St Croix County Wisconsin Upon inspection, I certify that 1 have found the "(a), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly Most recent date of inspection or service I/2L/gow Did Row back occur from absorption system? Yes_ Nos?�— (if no, skip next line ) Approximate volume or length of time gellons_minutes Tank Capacity. Construction Prefab Concrete Steel Other Manufacturer(ifknowa): ", .wwsl- irtcow- Age of Tank (if known): 9/"Jo Permit umb (down) 15337f 41`e&4*aC f2j�YLD Mftn§6dPlumber Signature) (Print Name) /3,44/ (Lie Number) sv PRS 14 Zd 14 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s 145.06, Wisconsin Statutes)orlicensed disposer (NR 113 Wisconsin Administrative Code) Rev. 22012 AND Plopmty Addmm f87�E_ (vmllfuemregPhedem wmneP [xpmmmlfm m,r _ CRy&w K4nc,o Pmml Id fifi<a6w Numbs 04t) 017-Ho-oeo in, I.D a IPTION Pmpmty f.amt A✓E'h $E V, Sea —�L, T-2rN-R-LLW, Town ofr_, Sobdivisim jR. eAh 6 A/ Y rM A Lot#_ CerRRed Garvey Map q cm'~ t;" y _ ' volume Wanmty Da« 0 _ `"/.lV9sy voh= POW Spm home o yoaxm W Imes idmt5ebla)x3 o m gKom MAINTENANCE 1m rumWm.mmp.u¢ofYmrteeptic.YMowolErtdllio iurym.lum4ilvemhwpew..u.Itopcm.io�m.ux .wwmarw"'l��Ps uvi me.ePue motmm mrte Xmemmmm,umtlMby•ucmvl P^mwr. vrnu rw wi bm ue.rn=o� ®.uam me rm,m„ ar ma .� ma ... me.mme .uqe m me .bs al.ww msm m.OmPl�mbaP�r%owa.Dabmbmilm SY Qort iuoiof R.Hrmrmr. wE! .im lou4.�h3'ma owrt.vE M. YmmPM1mb:..emrt..eiPl®bsm.licmagpmrm'.m%mBm4(1) rtr cowJe wubnimEl.N.I.Ymem s m PON Wm.HoB wemem.emm 2).«m �Pmu®.m wmpve (irmrmrrl me.wdv mti. he w.e in mi m.nwm. IMa me mlmiw.dh.veme me.imemwommo.m.ersmm.louivme Pe�+m vede aiw Imr®.nm me.mmua. .xrma m.ia.. ay me o.Pmmmore.®ma.m m uwmmiorwm.i Putatm, sus erwixmim reemu® .um«mmruv uw=m�®e..n�m.+mi:a®mu. �sme.m �<mmemrm s. aoae�r� I,e omu.imm oo d.n arme ma>� w�.ow a.s. 2131oo sfOiA'111RI+ OF MeuCANf VATS OWNER RTI ATION I Iwe) aatl%mY.p.mmo�p ®Wa fmm ae ioe m b bml olmY (ae) Ina+/iMee. I lwe).m Im.) tlw wal.) of m<PmwmYb mLal.bwgbY.ime of. ^..rtmYdeed IeeeMedm PeP.mr ofD Ol ATU 0 2 9<@IANRB OF APPWCANI "'e• Any wrnmulwo l ti. mLL�q%®redm.Y rmWIW lW mimrY Wmll belo8rtvoevd y'the loolNa c, .n IoeluE[Mlh 1W sppllulms.tlmpd vq.oydsA mu me ped.Im MpeNe o®c . m%of0 mtlbL s..Y m.P if rtfamae6 mEe m me vmm0'Emt �p � /f'<u.'S.'o,.✓ PNNr.MNNmwPiHrm j&&%ANITARY�PER LICATION^aRmWSai Nrarm.vnmm,-71W w(aunrycopy OMyl s�a I.ss Vein [umq B IQ a 11iMIPiweinone ^apF1� va a Seerevdr Maldldtrveuorofd rdnaia4 u 20� uusmnnrrnminwnen Jux29 35-33i2 p..m.�wm.m�Iaem.«..-..�..e«..mw P'+wylem.. l5dnllmp. 9 W i.L."' IMti� nwrycnn.wmr /�. 1.65 Al' Taf N.Alp EloSSO .mP^yO.a aN� wmM baxumaer r tip.iw cN' N 1 1mM. wiroo-lveure.r (c1NMlane) ❑SteM0eknerI Ix.eew NMIc IdlFemll gvalli -No. ofineMedns vc 111. BUILDING USEI Rr «eevgryd.pWv,uM.e y3gnappyl Te.xu. Imnsif 1 pNtlrmtlo Ip6uverWirell OlieedlaiJ Facifity/Numing Nome Fa[Illry 3 p 4mriNmuM 7p Uku"Mse Sala/Wpan 11 0OulEmrRweeNmel RMaWenl/Nr/gnlrq a 0 ChurchiSclooni Bp Hk p Sxvice Salon/4r WerM1 S ❑ HOMI IMotal9 p Wfical Factory 13 ❑ OMar: m.ory N. PEOFPER I (CM1M ONyanaboa on line/.. Geckboa Online%ifappllcaWa) N I Nex I, p Replacoment 3. p Myazamemof a p bconnecNonof S p Rapalr Ofan _____________Tenk OMy____________._Ea1et ASy_5r-wn________ E.__NSyRan R) /I SaNtuy Pemlhwx praWnlwrlewW permh NumOee 35-3 4-1 Dela lswzcto V. TYPEOFSYSTEM: (CM1d4oMyune) Nonr...,,.:..ea.nH.,wn preuwuMDieM1Mution EepeHmm.w CIIF« II OSeepyea.e 2I041Ou1N "13Specify Tyry 41014Olalrq TYq IIEZSeePa9e Trench 3lpinCiraeN pr fvlre EI❑Pil Pnry 1305aeppepil aT iynYrAeS 430Vauhhlvy ILQSyetemin fill /C c4..HiS 64i Q Ta7! N. WONSY TEM NF NATION: 1. GMkraM by 315gdp. MOa • lnWlrgpale S. MC RaM E SyatenEW 1 Fwas Setle RewnN lw. h.) Ropdea (sy hl IGalwry/sO h) IMinhdn) EI,Y `/,� / v/ iFwl WL TANK parry MFORYATON in w"kn cMine TOW FWIorN :eflow Tartu Mdmiactdefsxanu maw sr W rl.m. w mou 9oa / nhr r.Te wmeu WIL RESPONSIMLITYSTATEMENT f R)euMely INE, wumarwporedliryMinSYllaVon of MadmM 5yatam SM1llwnontMalYCMa PaM. umWrwm'Olvnl umdlI5Nnmm Uu:umpl Wlnenggne NumY' a v Y eiD `LOUWY/Ut?ARTMEMUSE aONLY ❑DiSemprovol mntd w'�r•'R� �,Td Ob3M1mW µry �AppeovaE pl3wnd Grvenl Ubalmatlm A. CONOMONS OF APPR VIII REASONS FOR DISAPPROVAL: P.wrsIF... .`sg:I ks>t—�a.,/sy'(5� aa. B.-U ,'s Kcyc:'sra�P».. -k o.e iei l.^'7'k 1. AAatuvle "YG"'"v'3i-v"p- a. *fal -- mp✓ a u wis Sandy no Beerm«meloammnPe selpwe�uwvoinrwn PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) P,nmellMmretlmyou pwk,rmv6e wd MeeaWrypugxealPnraryLew ISMflllmll lrwt CIUFIoa ffi Amy dry TO 5 P I60m10,or I„P IOO,eor Imo."1 Awl (Ia,Pvc PP) TANK INFORMATION ElFVATION DATE PUMP/ SIPHON INFORMATION Manula na Model Number GPM TDH U4 Fri S tem TDH Ft Lergtb I me SOILM;O$PTIONSYSTEM(y) U,,,,L, a A v.9t Clpu p price rice JOo00 vnhn3r L• y,^ D LrcvM Ni A, ornu m A, uoua Mqn SYSTEM TO P/L eLLW WELL IARE/STREMI tEAOFINO wn SFTMGI INFORMATION �f CXAMBER 2 IOR UXIT DISTRIBUTION SYSTEM •y peu,vmake en' Length e � en9 Z SOILCOVER , Preened systems only as Mound Or ACGrods Systems Only BD a,.w .o nea,o „o, rD..�M�o C1,1., Ede" .< 22a COMMENTS: (include code aiurepanou'vY present NY`1 In ° ° a Flm Locatlop: 527 Francis A}'cnve, Hudm,} 54016(HE 1)4 bE 1/44TSN R19W). 04,28 19611 t) AILBM Owcriptlon-Ems"^�5a °4^'� w`v. 2,) Bldg aervm ImP - I2.0' amowtotcover- 3)10' cwE/a.+} ,L 4)Rp Ow,uBNp,�.ln.4+s bay-"o-YPa`r_„!'o.wuayLC�4.. 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