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HomeMy WebLinkAbout034-1029-20-000 of(�E tv / % q �, :2 7 � r ® 0 ■ C C E z \ w = r 0 0 2 n , m m o = _ ; ] ®- _ _ i 2 2 cn . Q - CL �K \J�k�� G) § k ; i ol ) \ ri / § E, 0 G c c a E; / \ ^ { , , (D : o E F © © CD / > ± ¢ n: 2 i E « � cn § § \! 2 [ ;z § � — K 2 2 M M"a 0 a . 7 f o 0 o p : 0 / §» A \ \ / 3-1 § g \ ; o CD �im m k \ PI) ` 4 z � f � } o } k / ( 4�• o c r \ 3 2 S z § 2 / ® co) / k { � P .. [ . . E { 2 � § / �s> § CD \ § CD ECL & . Fe\ k§z ( � /d( # k < ; \0 o . , , 87 �$ k � ƒ @ CD \ )i }® S E , � d Wisconsin Department of Cgmma-V PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: • 399553 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 xm)). Pemut Holder's Name: City Village X Township Parcel Tax No: Thompson, Duane I Springfield Townshi 034 - 1029 -20 -000 CST BM Elev: Insp. SM Elev: BM Description: "Z ` I 41 k — c S Ad TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark (fie c sv tm / S-W , CID Dosing l.e Alt. BM VP Aeration Bldg. Sewer Qo4'i �— Holding S Inlet 1 1. 33 SUHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic y I > 160 IF > 10b —, Dt Bottom I `, 3 y • 8 .� Dosing � �. 4 / Header/Man. •�Z pZ. �� Aeration Dist. Pipe 7 � •8o Z Holding Bot. System e ll . ./v � ` PUMP /SIPHON INFORMATION Final Grade L Manufacturer Demand St Cover , Z Z r GPM U-91 Model Number •� „ ` 93.23 i t �o . 9. TDH Lift Friction oss System Head r � TDH Ft 4. .fo2- Forcemain Length / Dia. Dist. to Well 2” SOIL ABSORPTION SYSTEM ,. / 4. RE C Width Length I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIM S 3 Q SETBACK SYSTEM TO C BLDG IWELL LAKE/STREAM LEACHING ManufaF,turler� ` INFORMATION T Of S tem: CHAMBER OR ,,.,�.t lt�•�+�' yPe }'r O UNIT J 1 > )dt> ' MQIt/S DISTRIBUTION SYSTEM Header/Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake Pipe( > �� r Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedlfrench Center Bed/Trench Edges Topsoil ® Yes [I No rx Yes DS No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection fl Inspection #2: / Location: 919 Cty Rd W Glenwood City, WI 54013 (SW 1/4 SW 1/413 T 9N R15W) NA Lot Parcel No: 13.29.15.203 1.) Alt BM Description =� too 2.) Bldg sewer length = �, 'L 5-C. - amount of cover = ? 3) Plan revision Required? [] Yes O( Use other side for additional informati on. Date SBD -6710 (R.3197) Insepctor's Signature Cart. No. _< pd a )! r3 ?' Sanitary Permit Application I 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 ` * resin Personal information you provide may be used for secondary oses u Madison, WI 53707 -7302 Department of Commerce p [Privacy Law, s. 15.04(l.)(m)]. (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only).for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if wAision to previous. application State Plan 1. D. Number 'Sv- Cg0k)C sS3 c Ir e I. Application Information - Please Print all Information Location: Property Owner Name „� �� ! 1 Property Location i! A o Atl P,5 A/ 1/4 5kIA, S T, ,N, RAd w) W Property Owner's Mailing Address COU►� d Lot Number Block Number or City, State Zip Code ; Phone.Number — <;' , ,'; Subdivision Name or CSM Number II. Type of Building: '( heck one) ❑ City A 1 or 2 Family Dwelling -No. of Bedrooms: ❑ Village ❑ Public /Commercial (describe use):_ f�/`�� y ATown of r ❑ State -Owned Nearest Road 62 ) 3 K 8 - 1 ( "45f Parcel Tax Nu ens) 040 / III. Type of Permit: (Check only one box on line A. pp tca NET � A) 1. ❑ New 2. AReplacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) — 10b 64C 4 hNon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: r,� r j 1. Design Flow (gpd) 2. Dispersal Are 3. Dispersal Area �/ 4. Soil Application 5. Percolation Rate 6. Syste Elevation 7. Final Grade Requiredbc{3lp Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) D ` Elevation O /. 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 X hod / `view ❑ ❑ ❑ ❑ Pa /Y1 X 5"Od d o fw,6 0, VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the P OWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MPA� No. Business Phone Number Plumber's Address (Street City, State, Zip Code) //� ze" IX. County/Department Use Only i ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Sign tune (No stamps) Approved ❑ Owner Given Initial Adverse Surchar a Fee) dD Determination X. Conditions of Approval /Reasons for Disapproval. o w bz SBD -6398 (R. 07/00) C 4 PU #,J FAlJ& C) 0 IM '■■ �l ■� ■■ '■■■■■■■■■■i/■■■O ■ NE'r3e ■ ■!�! .r' ■'■■■■■■■ NEON ■■SEEM ■ ■ fl■■■■N■`%■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■MMEAM ■N ; ■ ■�■■■■■■■■ ■ ■ ■■■■■■■■■■■■■ ONE ■■■■■■■■■■■■■1 ■■■■■■■■■■■■ " ■■■■■■■■■■■Nl�i1l'�EE■ N■■ ■ ■■■ ■ ■■■■H ■■■N■■■ ■ ■■ ■■1!►!No ■ ■■■■ ■■ ■ ■ ■ ■■; ■■■N ■■ME■■■ ■■ ■■■ am a ■■■■■ ■ ■■ ■ " ■ ■ ■�7pUllf ! ■ ■■■■ ■N ■E■ ON ■EEOEEONOEE►�.IO■ ■E■ �ENEN'�. -E'EN■ Iwo ENNO■■■■■■■■■■OSE■■O \ sa■■■ ■ ■■■ ■N■■■■■■■■■WM■ !9■ ■ ■ ■■M\\�E■ ■ ■! 'nN ■■■ ■ENNEN GEE ■■ ■ ■E■ ■E\ \ ■F�on -" O■■ E■EE■E ■E■N■NEE■ MORE \ ■M�'1. ■ ■NEON ■■■ ■ ■■■■■■■ ■■ ■ ■■ \1 \am ■ Mom N I MIMMMMMMMMMMMMMMMMMM 1'- � EI � M ■ ■E ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■Er1MA M ■ N■■O■■■ ■ ■ ■■■■■■■■■■■■■E■■ IM v ■ O■EO ■ NON ■■■■■N , M- ; mom , •u ..cd \1 b6CIMM am Imam a IMY= ..�R5M EMU. I! r 9 01,905 -No NONE 9. Emil ■MOO ■ONO■■ ■ ■ ■mm"W" Emu mum ■�, N■ ■ ■N ■■■■■■■■■■ ■i�ON ■ ■N■ No i■ ■■OE■ MIN OEMEN■■ ■E■ ■ ■ ■E HE ■ 0 ME MIN 0, COME low N ■N ■ ■ENO ■■ ■ ■ONE ■ONO ■NONI11� ME am ■■N■ ■ENNN■EONNN■■■ 111 ■ NON'. 0E , �E►2NON■OEO Moo ■ II ■ 0 0 Me F; 71 174 M- pi mom No MEMO H M NONE NONE mimmom MENU so NO■ENNmom N■E ■NO■ ■ ■O ■ ■! 'ON N■ ■NO Mom NN ■E■EEO ■ ■■ ■ S1 PO, mm NEON ■E■■O■ ONo MEMO WE ■ 0 ■MEMO ■■NEON ■■■■■■■■■■M■■ � C,,,,6 S,,ZA s PI Wisconsin Dtc partment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safet�t and Building Division Sanitary Permit No: i" , INSPECTION REPORT 399553 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)i. Permit Holder's Name: Village X Township Parcel Tax No: Thompson, Duane Springfield Townshi 034- 1029 -20 -000 City CST BM Elev: Insp. BM Elev: BM Description: i f too —Cs TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � Benchmark i / Lie t~ s-� oroa 5--W , I S Icy Ia t:A Dosing Alt. BM Aeration Bldg. Sewer C4Va`i Holding St/Ht Inlet ��.3� �� �S� St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / r / Dt Bottom (� , 3 y • g •� Dosing k4l / t) ♦ Header /Man. • 4Z 92 • c f ( Aeration Dist. Pipe ' � •8o Z Bot. System `�• 0 • Holding `!, p , Final Grade PUMP /SIPHON INFORMATION -, Manufacturer Demand St Cover , Z Z S GPM 4� 2.9b Model Number d ' TDH Lift Friction oss System Hea TDH Ft Forcemain Length / Dia. Dist. to Well N/ � 2 a SOIL ABSORPTION SYSTEM CAa„,.. 6�wj RE C Width Length f No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMIER31IMS -3 SETBACK SYSTEM TO BLDG IWELL LAKE/STREAM LEACHING Manu ugey t INFORMATION CHAMBER OR lt`^e Type Of System: 1 I �_ UNIT Model N �b r: t^kf. . > ao > '8 o tt�.n w, s - /o DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake � / ir_ Pipe( > 1� r Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of 1 xx Seeded /Sodded xx Mulched Bed/Trench Center Bedrrrench Edges Topsoil Yes ❑ No Yes :11 No ] COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 1 fl Inspection #2: —� Location: 919 City Rd W Glenwood City, WI 54013 (SW 114 SW 1/4 13 T )N R1 5W) NA Lot Parcel No: 13.29.15.203 ��� 1.) Alt BM Description =� G� 2.) Bldg sewer length = -L 2 5.0 L �� - amount of cover = 7 N 3) 4- STS. Plan revision Required? [J Yes No 0( 0� 02 �{ Use other side for additional information. Date �Inseppcdtors Signature Cert. No. SBD -6710 (R.3/97) Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must >J include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. D O percent slope, scale or dimensions, north arrow, and location and distance to nearest road. , t , -:4 Q Please print all information. a by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 11,4 e, Q Govt. Lot 1 /4, j � 114 S/ T e� N R /.- Sa W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# O. City State Zip Code Phone Number ❑ City [3 Village N Town Nearest Road /e ,�v I CZ )2 - / 1 1 /" 12/ o al ❑ New Construction Use: % Residential /Number of bedrooms Code derived design flow rate PQ Replacement rublic or commercial - Describe: Parent material 4 /A ' 1 h G Flood Plain elevation if applicable General comments i and recommendations: & oe5 00 _j E] Boring a Boring # pit Ground surface elev. o ft. Depth to limiting facto� in. 'r .. "i ` ication fZate Horizon Depth Dominant Color Redox Description Texture Structure Consistence . Boundary Roots tPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0-9 s — v qt o' a 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 31. Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L ase CST Name (Ple Print - - igna CST Number G a0-,),Y Address Date Evaluation Conducted Telephone Nurnber a� 0 • i 4 Property Owner fLy_�t°i / !s ,s0/y Parcel ID # �J �©0 9 P?e— OA Page of Boring # ❑ Boring 1 4 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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 •� e M /V 1 Boring # ❑ Boring U Pit Ground surface elev. -% ;Z' ft. Depth to limiting factor rEff#1 oil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#2 0 ' 0 .t i joy � r is 2 Boring # E] Boring 1:1 Pit Ground surface slay. ft. Depth to limiting factor in. Sal Applica tion Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#1 I `Eff#2 ` Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA- ` Effluent #2 = BOD 130 rng/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. SOD -8330 (8.6/00) Az oyn 1 won- yI — ,—' F L F I- 4 --4- - A _ 0 i i ---I- I f �I i . 11 I }} I r L I�j � iill � i f � � i I.. I ,r POWTS OWNER MANUAL 8Z PJJfttvt Ur-V'c4f' "J"'s -- -- r SYSTEM SPECIFICATIONS %1,11IFORMATION Owner Ne Septic Tank Capacity lae7c7 gal ❑ NA Permit # Septic Tank Manufacturer kies ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Z l_ ❑ NA Number of Bedrooms El NA. Effluent Filter Model — p ❑ NA Number of Commercial Units NA Pump Tank Capacity J f— D gal ❑ NA ted flow (average) gal/day Estimated Pump Tank Manufacturer 4_ ese 11 NA d Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ❑ NA Soli Application Rate �� gaVday /ft Pump Model �p ❑ NA Mo thl average* Pretreatment Unit ❑ NA influent/Effluent Quality y ❑ Sand /Gravel Filter ❑ Peat Filter Fats, Oil 8t Grease (FOG) 530 mg/L ❑ Mechanical Aeration ❑ Wedand Biochemical Oxygen Demand (BODs) 5220 mg/L ❑ Disinfection ❑ Other: Total Suspended Solids (TSS) 5150 mg/L Manufacturer Pretreated Effluent Quality ' ❑ NA Monthly average* * Dispersal Cell(s) Biochemical Oxygen Demand (BODs) :530 mg/L JX in- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu/ I00MI ❑ Drip -line ❑ Other: Maximum Effluent Particle Size A inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency At least once every O months j8(year(s) (Maximum 3 yrs. ) Inspect condition of tank(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Ys) of tank volume Inspect dispersal cell(s) At least once every 2 ❑ months A Y ear s ) (Maxi mum 3 yrs.) ever ❑ months gyear(s) Bean effluent filter At least once e ry Inspect pump, pu ❑ months year(s) ❑ NA um controls :alarm At least once every Flush laterals and pressure test At least once every ❑ months ❑ year(s) f8[NA Other: At least once every ❑ months ❑ year(s) pkNA Other: At least once every ❑months ❑ year(s) NA MAINTENANCE INSTRUCTIONS ins pectio ns of tanks and dispersal cells shall be made by an individual carrying one r; the f o l lowing e Servicing Operator. �Ta Inspecua Plumber, Master Plumber Restricted Sewer; POWTS Inspector; PO Maintaine or r, g tank(s) to Identify any missing or o din of effluent I dentify any cracks or the ground s urface• must include a visual inspection of the tan The dispersal volume of combined sludge and scum and to check for any back up or p g d to check the effluent levels in the observation pipes and to check for any ponding of a mediates visually 1 cell(s) shall be Y mP� and req uires the i m the ground surface. The ponding of effluent on the ground surface may indicate a failing condition q notification of the local regulatory authority the entire When the combined accumulation off sludge and scum In a n y tank e goriand disp o in accordance ch. 113, Wiscoi contents of the tank shall be remov e b S g Administrative Code. ement The servicing of effluent filters, mechanical or pressurized P shall co by a certified POWTS Main�talner.nY °they , pretreat maintenance or monitoring at intervals of 12 months o A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START lip AND OPERATION f the POWTS check treatment For new construction, Prior to useo tank(s) for the presence of painting produce or other c em that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the cony o%r rho ranir(s) ramovPd by a ienwe servicing operator prior to use. � Page of / System start up shall not occur when soil condltlons are frozen at the Instradvt surface. During power outages pump tanks may fld above normal highwater keels. When power Is restomd the excess wastewater will be discharged to the dispersal cell($) in one large dose, overloading the cell($) and may result in the badtup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator •prior to restorinv power to the effluent pump or contact a Plumber or POWTS Malntalner to assist in manually operating the pump controls to restore ncrmal levels within the pump tank. Do not drive or park vehicles over rinks and dispersal cells Do not drive or park over, or otherwise disw or compact the area within 15 Net down slope of any mound or at-trade sod absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floe; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; psollne; grease; herbicides; meat scraps; medications; oil; windnv croducts pesticides: sanitary navkins: tampons; and water softener brine. A$AN DON EM ENT When the POWTS falls and /or Is permanently taken out of servlce the following sups shall be taken to insure that the system is proprr(y and safely abandoned In compliance with ch. Comm 83.33, Wisconsin Administrative Codes All piping to tanks and plu shad be disconnected and the abandoned pipe openings sealed. The contents of all monks and plu shall be removed and property disposed of by a sept.age Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: d A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorpdon system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon by required setbacks from existing and proposed structure, lot tines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at that time. O A suitable replacement are Is not available d ue to setback and /or soil limitations. Oarft advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to Identify a suU* rep" t area. Upon failure of the POWTS a soil and site evaluation must be perfo to locate a sultabte replacement area if no replacement area b available a holding tank may be installed as a last resort w replace the failed POWTS 0 Mound and at-grade soil absorption systems may be reconstructed In place following removal of the biomat at the inflitradve surface. Rreconsuuct(ons of such systems must.comply with the rules in effect at that time. < <WARNiNG> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIiN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT, RESCUE OF A PERSON FROM THY INTERIOR OF A TANK MAY BE DIFFICULT OR IM 5 KIR1 F. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 19 / iAl Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name . Aarroncy sf L' O / Phnn• Page d COMBINATION SEPTIC TANK /PUMP CHAMBER (No Scale) 4" CI Vent Pipe with Approved Locking Manhole Cover Approved Cap, +25' From Buildings W "th Warning Label Attached � Weatherproof Approved Junction Box Vent Cap -� 12" Minimum Final Grade -\ 6 Ki nimum 4 Minimum Quick 18" Minimum k ;.___ Disconnect i 1/4" Weep � Hole Baffle.- xA6 eL• ' • * A _� a � i A fJL 8 Alarm B On C *APPROVED Off , JOINTS WITH APPROVED PIPE D ' 3' ONTO Conc. Block ' SOLID SOIL i 3 of Beddinq Under Tank-/ Note: Pump and Alarm Are On Separate Circuits Number of Doses: �5 Per Day ' Gallons Per Day /# of Doses: Gallons '. kVolume of Backflow:.......+ 1 �,� Gallons Tank Manufacturer: Total Dose Volume: ........ = l06' �Z Gallons Tank Size - Septic /Pump: Zo o Gallons Alarm Manufacturer: 1 rr fis70 Model Number: /a / Capacities: A�inches or Switch Type: G + B inches or a Gallons Pump Manufac C-- o y L S + C =inches or Model Number: + D_c inches or -� - Gallons Minimum Discharge ate: GPM Total ..... = inches or Vertical Difference Between Pump Off and Distribution Pipe: Lo Feet Minimum Required Supply Pressure: ...... . .................. Feet D D Feet of Force Main x j, friction Factor /100 Feet: + F eet 2 Inch Diameter Force Main Total Dynamic Head: ... Feet Internal Tank Dimensions: Length Width ` Liquid Depth Pei cud h ��-,3 Date License a2 sZ Signature e Number � � /y,2�(�_ s I 12 DUSYRIAL RD. ­ Goulds ' ON, WI 54016 Submersible Effluent Pump ,- C 3871 EPO4 40 4 0 . EP05 APPLICATIONS • Fasteners: 300 series • e es Fully submerged in high ■ Motor Hous(ng: Cast iron Specifically designed for the stainless steel, grade turbine oil for for efficient heat transfer, following uses. • Capable of running lubrication and efficient strength, and durability, • Effluent systems dry without damage to heal transfer. • Homes components. ■Motor Cove tic cover with integral handle r. Thermoplas • Farms Motor: Available for automatic and and float switch attachment • Heavy duty sump • EPO4 Single phase: 0.4 HP, manual operation. Automatic points. • Waler transfer 115 or 230 V, 60 Hz, with 1550 models Include Mechanical RPM, built in overload Float Switch assembled and ■ Power Cable; Severe duty • Dewalering automatic resrt, preset at the factory, rated oil and water resistant SPECIFICATIONS • EP05 Single phase: 0.5 HP. ■ Bearings: Upper and lower 115 V, 601st, 1550 RPM, FEATURES heavy duty ball bearing Pump: EPO4 tuilt in overload with ■ EPO4 Impeller: Thermo- cons!ruclion. • Solids handling capability automatic reset. '/4' maximum. p Semi -open design . Power cord: 10 fool with pump out vanes for AGENCY LISTING • Capacities up to 55 GPM standard length, 16/3 SJTO mechanical seal protection. • Total heads up to 24 feel vJlh three prong grounding SP Canadian Standards Assoc13 1!0 • Discharge size. 1 NPF plug. Optional 20 foot ■ EP05 Impeller: Thermo- • Mechanical seal carbon- 1•angth, 16/3 SJTW with plastic enclosed design for (CSA listed model numbers rolary/ceramic -sl,il on,ary three prong grounding plug improved performance. end in 'F" or "AC ''.) BUNA N elastomers ( standard on EP05) ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 F (40'C) core nuous superior strength and 140 F (60'C) inlermillent corrosion resistance. • Fasteners 300 series METERS FEET stainless steel to I • Capable of running dry without damag.; to g 301 ccm,ponen!s I -4-5 GPM - _ . — Pump: EP05 e I _ • 2.5 FT Solids handling capability o 25 l _ 1 /4' maximum. w 7 • Capacities up to 60 GPM. • Total heads up to 31 feet. s 20 • Discharge size. 1' /t' NPT. z 5 • Mechanical seal carbon- 0 15 rota ry/ceramic-slahonary, — - - BUNA -N elastomers 4 0 _ t EP05 • Temperature; '- 3 10 104 ^F (40 ^C) continuous r - -- — 140 ^F (60 ^C) Intermittent. 2 — i EP44 0 00`- -- 10 r1 20 30 40 SO GPM 4 0 2 4 6 8 10 12 m CAPAWY 0 1995 Goulds Pumps, Inc. EHecove May, 1995 81871 Infiltrator SideWinder chambers provide more than twice the infiltrative capacity of stone and pipe systems. From the makers of Infiltrator chambers, And, the continuous louvers of the Infiltrator the products that revolutionized septic and stormwater SideWinder chamber wind fully around its sidewall, management, comes the Infiltrator SideWinder offering maximum infiltration (as shown in the chamber. Designed to replace old- fashioned stone circle inset to the left). and pipe leachfields, these high- strength polyolefin chambers fit in a typical three -foot -wide trench and Open chamber bottom boosts Infiltration. are available in two sizes, Standard and High The Infiltrator SideWinder chamber also features a Capacity. The patent - pending Infiltrator SideWinder completely open chamber bottom which provides chambers sit directly on the trench bottom and latch over twice the effective downward infiltration of a together quickly, end to end, so installation takes less conventional system, where stone restricts the move- than half the time of a laborious stone and pipe job. ment of effluent into the soil. Leaching chambers are Infiltrator SideWinder chambers may be used for a tested and proven technology with over 500,000 any application that is suitable for stone and pipe. systems installed over the past 22 years. However, by offering greater infiltrative capacity The Infiltrator Sidewinder's sidewall and open- chamber per linear foot, these chamber systems can require chamber work together to provide a state -of- the -art as little as half the space of conventional systems, leaching system that is more than twice as efficient as depending on state and local regulations. a three -foot conventional installation. SideWinder• sidewall. System efficiency. The Infiltrator SideWinder chamber features the ' Capacity patented SideWinder sidewall. Standard SideWinder This unique design has 35% more leaching sidewall area 3 ft. Stone : Pipe below the invert than the sidewinder Standard Infiltrator Chamber. sidewall ° i.o �.e 2.i The High Capacity infiltrator Side Winder Chamber System is more than twice as efficient as a same- length stone and pipe system. Polyolefin construction. Infiltrator SideWinder chambers are molded of ■ PolyTur, a proprietary blend of polyolefin plastic that includes recycled resins and is formulated for optimum strength and chemical resistance. It's impervious to wastewater constituents and is stabilized to resist ultraviolet rays. Infiltrator chambers are manufactured using an exclusive patented process to assure consistent high quality. AASHTO H -10 load rating. Infiltrator SideWinder chambers have been structurally tested by a registered professional engineer. The chambers are available with AASHTO ratings of H -10 (16,000 lb/axle with 12" of compacted cover). Nominal chamber specifications. Standard High Capacity SideWinder SideWinder Size, W x L x H 34"x 75" x 12" 34"x 75" x 16" Weight 29 lb 36 lb Storage 73 gal/9.8 ft' 115 gaVXMW l?, /y Ae ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/ "e ly 4 CA Mailing Address _ '71 9 D ��� e'rf�%!JD D all, � , X, Ki / ✓�� Property Address (Verification required from Planning Department for new construction) tVCu o a � Q ^ T � Parcel Identification Number 4 �� — �� o� C74:51 0 City /State ��P, / LEGAL DESCRIPTION Property Location `Gc) y4, � V4, Sec. 13, T o2 9 N -R�.W, Town of /e tor Subdivision ---- , Lot # Certified Survey Map # , Volume _ . Page # Warranty Deed # -!�W T 2 , Volume _�9 . Page # Iz Spec house ❑ yes 0 no Lot lines identifiable ❑ yes 4 no SYSTEM ANCE Improper use and maintenance of your septic system could result in its pre mature 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 Zoning Department a certification form, signed by the owner and by a mast,orplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal 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 requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 ys of the three year exp on date. /q/ of SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) 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 property describe ve, by virtue of a warranty deed recorded in Register of Deeds Office. !o /J4 /U gr — M A — TURE OF APPLIC DATE An information that 's- represented may result in the sanitary permit being revoked by the Zoning Department.* «« Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U74 NN A re AL Ne 61 _ i . 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' — !— � __ � -- ! — _ — - - -- —� — — — — - -- — — - -- II — — — j t _, r 1 i ( —a- � �- -- � -- - -- - ' -: - -- -- i ! -- I ; — - — -- -- - — - — �.� �_ ►�_ � �� -I -- - -!__ _� I , - - -, � � � � , -- �� ! I C� - -� - -- � � -�— � i - _ � E_ , _ � - � - _ _ - -� - � - -_ �- - — . I -- - - - - i 1 I I I ' �` �_ � � �__ - 1 - - -- � j -- � _ � - - _. ! I __ i � � __ i - - -- - - - � - - -- � i� � i I i s-- --�- � 1 � � � � I I ( � � � � �_ � - - I � . � �_ - - -� f ._.. - I __ i _ -- - -�- -- 10/17/01 WED 09:16 FAX 718 388 ;667 REGISTER OF DEEDS X1002 a .54 07'! W�+<RKA!QIV 111 a 3.9 : , X63 — �ttC'.�t.tENT NO �.— t � d Gorgon tr. �1*[t.l - }t , MAY 2 C 1496 0 `'thomptro7. 1 s n. 4:45 r• Ct�H1Y' i d, a! N',It: uYl. lJ1 _. — . . – �,• , , , � t r4 on J '�>fliV A FIRM, S G .C. thr Irlttnvntt; drtinfa't :rd'. .tats• v .... _- _.. O i (�' �!R [��t� p ywte t.l 1 \' :.,ntsn: 10 SE COND S . R0 BOX 1 OE HIJOSON. W1 54016 • , v 17i "3t CN M i4n4 W Southwest p[tatrter of the Soathva t✓ - a , r. (qr Est, rr`;) of Section Thirteen (131 'iown5 Twenty -et `tort. t. F-1 ; ( t5 } Nest. Sunjwct to a reservat of fi,''y er' , n ]f .ti t•Iit -r =,i i hts to t'-- Fodaral T,and SanX OE St- Paul. 6> = � ttl ..s :T, by virtta of that cartdin deed recorded Sec t:'.- ' rltte ° 'L" Lt g l iri G : UJ "_ r1 O ° . vQCOC�3� at Page 150. '!this. 1 5 nvt �— •hutT,rst��1, , rk.; Excepttenh,warrantita; EBS2mentS �t..r 96 Dat. d thto i -- �. day u1 OEAU SEW .. —.— ;pr tin AUYNENTICATION AL9:r ov -AE AT to tC i:. '�' %4Cr +I •tro„ F a~ ,anti c -u ithr site `ns � _��. JAY u. authetu=ted this _. day u { l9_.... — jf !t} �3 �c .tbrie wm.•d d 3v>~E n C Sm ,. t`t � • S ' rrl •LC•: MEMBER STATE BAR OF : ; 5c� .Siu -- ___ (I{ MCI. suthunsdd by 1 W Sta •a +a me t� tt •?c x } �• fidi!" Lutrui,ca att! RtM•,V... t damp, ' y Q THM INSTRUMINT WAS UHAF ff;t 11" T homas A MCCo r-ca :lc! d ( < Batldwin r WI .5 HOC 5 � � tv otu F sbl�, i � t..— . �, ;:� - '• _ —_ ,e (Siy*natures may ix authrnt:catr- cu' ack o, uutr. air nut pl}' ., :muss„ w !.: m�ncr! If nut. • lido S'c+�[ty -`^ Jrtt nece -swry•) i • I+In,pH of fxr+MY cJdnu,lI ,n any =U - -i¢y Shuvi<. w ly.. f tlf pnigd ,hr,r , , : - ...� �. Jr �� t �„py y , • � ,JC 9TFff ak ,' WISCti„ J5,' - . 1..w,L.te ++•► WAF ANTY DEIfJ - Fcrm ., • 2 . 19sS1 ti• . } Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County �- Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 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. / , - p Please print all Information R 'awed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). , Z� 2 Property Owner Property Location �A O Govt. Lot ,SL(f 1/43 1 /4 S/ T.►Z N R �� ilk W Property Owner's Mailing Address Lot # Block # Subd. Name or CSW O. City State Zip Code Phone Number ❑ City ❑ Village W Town Nearest Road /e tyw a' !c. o/ ( ) / /P /� d 100 0l ❑ New Construction User Residential / Number of bedrooms Code derived design flow rate GPD PQ Replacement ubblic or cojnmercial - Desg Parent material h �/r rn ��{ L/ b. Flood Plain elevation if applicable _ ft I mp General comments and recommendations'.:, ; (` V 9�� O / _ AMT 1 ❑ Boring 0 o� in. 171 1. / Bon # [� Pit Ground surface elev. -�f t. Depth to limiting fact it Ap pill" ... R Horizon Depth Dominant Color Redox Description Texture ' Structure Consistence . Boundary 9 *` in. " Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. �^ 'Eff#2 0- 6 vJ 8 n Boring # ❑ Boring ��., ft. ? pit Ground surface elev. ,�� G� Depth t limiting fador in. Soil Ap I r; �On R �o Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 10- IPV A S e ff 2 - C AIFR Cs I , S 1 0YRaij /�'( ✓F Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOO < 30 mg/L and TSS < 30 mgtL CST Name ('Please T igna CST Number G ?a I.-,) Adder Date Evaluation Conducted Telephone umber Property Owner U W IYe- r W,50 N Parcel ID # �✓ y 110 9' ; 261 "O OO Page of Fg -1 Boring # ❑ Boring R 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/fF in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 0 e 4 - A G . Q Borin o Borin 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/fF in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 a- a s e Boring # O Boring Ground surface elev. dJ ft. Depth to limiting factor In. fo Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Str Consistence Boundary Roots GPD/fF In. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 — i c % � s / I ad< --: 5 ' M o F 0�4'� ��. � L �e f oO•�"3� o to� o� t'iPe we Effluent #1 = BOD > 30 1 220 mg/L and TSS >30 < 150 mg1L Effluent #2 = BOD < 30 mg/- 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. sao -oso ca.wool no MENEM MEMO am-0 Boom 0 Ill OWN 0 Ill EEO ■ ■f1EE ■ ■ ■ ■V ■EEE ■EPEE ■EEM ■E ■E ■■■■ Mi ■ ■■ ■M ■M■ ■ ■■ ■Y■ ■■ ■M ■■ ■M■ ■E ■■■ ■■■■■■ ■■■ ■E�■■■�7 WE EEEE■ ■■■ OP. IM ME ONE ■■■■■ ■ No No ■■■■. ■ ■ ■ ■�■■■r� ■�+ ■ ■ Emommom ENE MEE MEMNON NNE-1 an am ■■EEE■EEEE■EaE ■■ ■E ■ ■ ■r/■►!�.��r�•��- 'x. ■ Ego EM" MEN 0 0 NONE Ill ON VC. i ■ ■■ ■ ■ ■E ■E ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■1�/'��l�M■ ■ ■ ■■ ■ ■ ■ ■ ■ ■E ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ f �illl■ ■ NONE No Ill ME 0 No Ill Ill Ill o I ■ ■F�■ ■ ■ © ■% Pl MEN IllEE ■;��. one RONNE NNE R MVA� 110 E III OIMM MEE■■ ■■■■■■■■■ Mir ■M ■ ■ ■E■ 11 li ENE ■■ ■ ■■ ■ ■MM ■■■ ■ ■E ■ 11 1■ ■E■ ■■ ■■ ■ ■ ■■ ►I ■E li■rE ■M ■■ ■ ■ ■ ■■■■■ ■ ■■■■ HE ■■ �■ - 7 ME ■M■ ■■■■■■ Ili■t■■ ME 01 IR4 "I OEM ■ ■fl IEEE ■M■ MEEMM ■MME MME ■■ �■ ■■ ■■ ■■■■ ■■■■■■■■■■ ■ ■! . I■ E■ ■ MME ■ ■ ■MM ■E ■E ■E ■ Sti'! 0 Mw Ilk ST. CROIX COUNTY WISCONSIN ZONING OFFICE M Nouns ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road r w= Hudson, WI 54016 -7710 (715) 386 -4680 FAX (715) 386 -4686 NOTICE OF VIOLATION COPY October 4, 2001 DUANE THOMPSON 919 CTY. RD. W GLENWOOD CITY, WI 54013 RE: Failing septic system at 919 Cty. Rd. W Town of Springfield - St. Croix County, WI Computer # 034 - 1029 -20 -000 Parcel # 13.29.15.203 Dear Mr./Mrs. Thompson: As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 254.59(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code, and Article 15.04 of the St. Croix County Zoning Ordinance. This system has failed under the definition in § 145.245(4)(b) Wisconsin Statutes (Category I). This violation was first noted on 10/04/2001. The violation noted is septic effluent discharging to zones of saturation. An on -site inspection on 10/04/2001 did reveal the septic effluent discharging to the zones of saturation. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed as of 10/04/2001 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQUIRED ACTION: By November 4, 2001, contract with a certified soil tester to have a soil evaluation conducted. The soil evaluation will determine the type of septic system needed and it's location. Then contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The septic system must be installed no later than June 1, 2002. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. I look forward to working together to resolve this matter. Si cerely, Kevin Grabau Zoning Technician cc: file I� ST. CROIX COUNTY f. WISCONSIN ZONING OFFICE M M b M ■ — ■nor ST. CROIX COUNTY GOVERNMENT CENTER _ 1101 Carmichael Road '••' Hudson, WI 54016 -7710 (715) 386 -4680 FAX (715) 386 -4686 NOTICE OF VIOLATION October 4, 2001 COPY DUANE THOMPSON 919 CTY. RD. W GLENWOOD CITY, WI 54013 RE: Failing septic system at 919 Cty. Rd. W Town of Springfield - St. Croix County, WI Computer # 034 - 1029 -20 -000 Parcel # 13.29.15.203 Dear Mr./Mrs. Thompson: As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 254.59(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code, and Article 15.04 of the St. Croix County Zoning Ordinance. This system has failed under the definition in § 145.245(4)(b) Wisconsin Statutes (Category 1). This violation was first noted on 10/04/2001. The violation noted is septic effluent discharging to zones of saturation. An on -site inspection on 10/04/2001 did reveal the septic effluent discharging to the zones of saturation. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed as of 10/04/2001 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQUIRED ACTION: By November 4, 2001, contract with a certified soil tester to have a soil evaluation conducted. The soil evaluation will determine the type of septic system needed and it's location contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The septic system must be installed no later than June 1, 2002. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. I look forward to working together to resolve this matter. Sin erely, evin Grabau Zoning Technician cc: file IM CMM* d fWsa. R. V" St. Grol Zoning Office Fax � 6i6 � 0 a�ses•t To: j Jd C' `� From: 'J" Fax: ( 6 O —, q6 7 97;—,) Pages: PttotK-- Date: Re: CC: ❑ Ucgent ❑ For Review ❑ Please Comcnent ❑ Please Reply ❑ Please Recycle o Comcneats: a 1 I - 3 - 7 r Sanitary Permit Application I Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W Washington Ave. See reverse side for instructions for completing this application PO Box 7302 N &cans Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privac Law, s. 15,04(lxm)]. (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only). for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if radsion to previous. application State Plan I. D. Number SS3 L Application Information - Please Print all Information Location: Property Owner Name „ r : ' } Property Location �! e o s0 K/ 1/4 51( l /4, S T;2 ,N, Rll�r) W Property Owner's Mailing Address Lot Number Block Number _ City, State Zip Code . ; Phone Number Subdivision Name or CSM Number ls- o A F .S 3 ,� /.� ; X0,3 II. Type of Building: '( heck one) ❑ City ji( 1 or 2 Family Dwelling - No. of Bedrooms: — ❑ Village ❑ Public/Commercial (describe use):_ �/� —� 6,4 Town of lol ❑ State -Owned ,� /�( /e Nearest Road t K g t 46 3 5) ( / �v Parcel Tax N r mo d— OOD'� III. Type of Permit: (Check only one box on lin A. p tca e A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. 5. 6. ❑Addition to System System Tank Only Existing S ystem B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued ,j' Type of POWT System: (Check all that apply) .X A7 - 10b . ` A Non- pressurized In -ground ❑ oun —� ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: r,L r 1. Design Flow (gpd) 2. Dispersal Are 3. Dispersal Area _.- 4. Soil Application 5. Percolation Rate 6. Syste Elevation 7. Final Grade Required( Proposed Rate (GalsJday /sq. ft.) (Min. /inch) ` Elevation O / So 44.45­0 16 S' P r, 7 q/- 9° �'. 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 X Gov t ❑ ❑ ❑ ❑ o ,b 0. VIII. Responsibility Statement I, the undersigned, assume responsibility for i nstallation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MPAMW No. Business Phone Number G Plumber's Address (Street City, State, Zip Code) �v / e wood Gi7` 4. L 43 IX. County/Depaftment Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Sign re (No stamps) Approved ❑ Owner Given Initial Adverse Surchar a Fee) eD Determination 2?g X. Conditions of Approval /Reasons for Disapproval: ad Par Au ,,A 6, _ s cat to cmh._ oz.x&-�� . 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Im I■ ■■n■ ONE ME M ■ fly" ■ 0 ■■ NONE M■■■■E■■ ■ Moan ■ 1101 Orarotael ft�oaa.� "" St. GI C Office Fax �rtslaes�ses•tsx ` From: IjLL To: / Pa Fax: 9' 7 Z 3 s Phone: pate: Re: CC: Pl ease Cot�ament O Please Reply ❑ Please Recycle ❑ Urgent ❑For Review ❑ PI tr Cotttcneafs: (,(, Cc vl J'1' L