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HomeMy WebLinkAbout038-1024-50-000 /Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: PAsonal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)l. 353323 • Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.: Star Prairie Township 1 raM s IA = a 9 8 0- D Insp. BM Elev.: BM Description: n � . Parcel Tax No.: aD. D " • 0 LST $3 M4 _ 5`�° "' �" F,°"' - R"" -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic �.� 25-0 /:f570 Benchmark 10 10(.10 1CD D 1 Dosing c ,,,,,,. i- Alt. BM � 103.2 1 .5 lo 1. - 40 Aeration Bldg. Sewer �d� �.f q p' S q a. } D Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic la p' .— B1 -- NA Dt Bottom 15.1 85 .93 Dosing " " C ID , NA Header / Man. R 99. 2D , Aeration NA Dist. Pipe 2, 9 I. I V ' Holding Bot. System 99. 0 PUMP/ SIPHON INFORMATION Final Grade see_ K&tL) Manufacturer < Demand cf S 9b, 60' St cover Model Number 4 �j GPM 1 v,10 TDH Lift 12.q� Friction.. ,9 Sy 5 TDH Ig.ob Ft X 12 x� Forcemain Length 7 0 ' Dia. Z " Dist. To Well SOIL ABSORPTION SYSTEM BED I TSIENCM Width r Len b th No. Of.isew�e ms PIT No. Of Pits Inside Dia. Liquid Depth EN I N 8 3 Iak�oQS DIMENSION SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING factur SETBACK CHAMBER INFORMATION Type O n (� S¢e ►o odel Numbe . System: mpu.� g > /00 Io n Al.. 4 >150 w� +Id�dS OR UNI DISTRIBUTION SYSTEM " "' C .o) I o r "U." S• Header/Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake � Length _:L Dia. 3 Length __� D Dia. Z Spacing 6 �� 34 " 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 Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (incl code discrepancies, persons present, etc.) Inspection #1. 3/3 1 / °O Inspection #2• / / Location: o Zty Road H, New Richmond, WI 54017 (SW 1/4 SW 1/4 5 T31N R18W) - .31.18.105A 1.) Alt Bcription = bow•x a� s EAR ��,,� b �9 seauo r . A - 2.) Bldg sewer length= 85 > � . o ' S�- cm-4v aver 5 I1 . 5e,u ` - amount of cover L = � , � J c,r, g g S = 3. 3.) contour = 9�•`l �C7��eT a 3 D j e wQ 101.1 ) © -, 1" "� ff1 -6 6- .,kQQ 03 °�,`.°" 150 +- {{T = l 5) etLk Fie,.. •yt.G��k Ja.((I- Plan revision required? ❑ Yes X No Use other side for additional information. SBD -671Q (R.3/97 Da a spector Sign ure 5 Cert. No Ew �Zk pub, LF- . F. s . Jtms a �e� } , ..JQ S � K � weea,mod l8" ea`Q csuei r erg w•e+ , a� t U, S 6AA. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: .e 3 3 E Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: ' Safety and Buildings Division Count INSPECTION REPORT St. Croix . GENLRAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353323 Permit Holder's Name: ❑ City ❑ Village ❑ ToWn of: State Plan ID No.: Strohbeen, Russell Star Prairie Townshi CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 038 - 1024 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark (,lo /f>/. /O joo, Dosing �j Alt. BMA �, S Aeration Bldg. Sewer Holding St /Ht Inlet 1�3p '8 •8d TANK SETBACK INFORMATION St/ Ht Out — TANK TO P/ L WELL I BLDG. Vent to Air Intake ROAD Dt Inlet Septic ) NO / ti ( - 161 f NA Dt Bottom -4" $'S `1 3 Dosing ti l a a ' NA Header / Man. z Aeration NA Dist. Pipe 2.0 99. /O Holding Bot. System a ' } /0 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover 5 60 Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length (��� Dia. 2 w Dist. To Well !fi SOIL ABSORPTION SYSTEM ;p E,,� BED Width ! Length 3. 0 o 2 f c�� PIT No. Of Pits Inside Dia. uid Depth DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK 1CHAMBER INFORMATION Sy A )rte > �r� . /So ) Isp I 5 /OR UNIT Model Number: DISTRIBUTION SYSTEM C'I` 6 ` � 3.4- 3• = R�, V 6:;, • ,2 . Header / rAAnjf41d µ Distribution Pipe(s) Hole Size x Hole Spacing Vent Air Intake U 2 N r f / u � rr ` ----- Length • Dia. J Length Dia. Spacing (C 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 Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 3 /3( / tro Inspection #2: / Location: 702 County Road �_ n New Richmond, WI 54017 (SW 114 SW 1/4 5 T3 IN RI 8W) - 5.31.\ .105A c�s 1.) Alt BM Description = 's'; '�e. �7v �� C3. S k 3 2.) Bldg sewer length = 1�5 r 2 4 t - amount of cover = > to , a-/ Z 3 (� g ` � j 3.) contour= I f 6� �•ULU at 18 s �ev<r ou�•r - 3 ' 3 r as L) P(ew +(1) Fe QQ Plan revision required? E] Yes ® No Use �ther si j e for d Iti n I 'nfctr a i n. F� F - 1 FT I I I SBD -67 0 (R.37 '-Ei 4 3 - 3 r—ev Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: " f �. ;... .. _. v a _ „ r -" , d E r w Ae. + ; N E , } P { } A_ e t S € i s € € W - 4 -4- 4 s 14- 4 - 4 440 .. .m, m 3 i F s .� r� " T [ E f a 3 1 a _.,. _.. .. �_ __ _ .. __. 1 _0 E } TV .__�_ _ ..�...._ ...... ... ... ... ....r —_. .._..... ._ ,..f .__ _ _ _.. ._ F [ � y i ? e ; t Y kv 4—t -, tt 3 F E € , € , 1 __ T-- k VL. i Ad Jj, �m .... "e m,_w e � i . 1 mm m, ._ 1 c;rff # Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue ��isconsin P O Box 7162 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. /� t•C • See reverse side for instructions for completing this application State Sanitary Permit Number 353 3a.3 Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)), State Plan Review Transaction Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION « =g Property Owner Name Property Location Scj /4 S 1/4, S �' T 3� , N, R (r) Property Owner' ailina_4cldress ,/ Lot Number Block Number 7 /-/ Cl t , State I Zip Code Phone Number Subdivision Name or CSM Number II. TYPE BUILDING: (check one) ❑ State Owned ❑ Its Nearest Road ❑ vil age � j Public or 2 Family Dwelling - No. of bedrooms grrown OF �Tp ✓ ��-c -� �� 111. BUILDI G USE (If building type is public, check all that apply) Parcel Tax Number(s) S. 31 1 / or-)4 1 C] Apartment/ Condo Qr( 3 d _ S a 2 ❑ Assembly Hall 6 [] Medical Facility/ Nursing Home 10 E] Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______System -------- System ------------- Tank Only --------- - ---- Existing System _- ____ -- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed and 30 Specify Type 41 Holdin ❑ o ❑ P Y Yp ❑ 9 Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 63 ' n 42 C] Pit Privy 13 [] Seepage Pit 6eax 43 ❑ Vault Privy 14 ❑ System -In -Fill cc� VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade CC /) Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ClQ C� ��' �G� Z Feet °Feet VII TANK Capacit in allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks T nks Septic Tank or Holding Tank >< ❑ 1:1 ❑ 1:1 El Lift Pump Tank /Siphon Chamber S �i7- q c� ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' e: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code . l I 8 �` ; S cad 7 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved U nitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved E] Owner Given Initial /sv Adve ' �S 3 �- erse X. CONDITIONS OF APPROVAL / REASONS FOJR DISAPPROVAL:�G rAa t ti - ,94e ���-S fx.%, c042, SBD -6398 (R.12199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in.ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. If. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII_ Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon - tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 1,15 fDrm; and F) all sizing information. -- ---- - -------- -- - ---- - ----- ---------- - ---------- ------ ------ ---- - -- --- - ----------------- -------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings • 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TDD #: (608) 264 -8777 hsconsin www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary February 29, 2000 CUST ID No.226900 ATTN: POWTS INSPECTOR ZONING OFFICE SHAUN R BIRD ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 01/01/1900 Identifica u rs Transaction ID No. 29840 Site ID No. 187527 SITE: Please refer to both identification numbers, Site ID: 187527 above, in all correspondence with the agency. ST CROIX County, Town of STAR PRAIRIE; 702 CO HWY H, NEW RICHMOND 54017 Facility: RUSSEL STROHBEEN 702 CO HWY H, NEW RICHMOND 54017 FOR: Description: MOUND SYSTEM FOR RUSSELL STROHBEEN Object Type: POWT System Regulated Object ID No.: 650067 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. 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 construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 02/25/2000 r FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 KEITH A WILKINSON, POWTS PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (715) 524 -3630, FAX: (715) 524-3633, M -F 7 AM - 3:45 PM KWILKINSON @COMMERCE.STATE.WI.US WiSMART code: 7633 cc: RUSSEL STROHBEEN PLOT PLAN PROJECT Russel Strohbeen ADDRESS 702 CTY Hiahwav H New Richmond Wi 54017 SW 1/4 SW 1/4s 5 /T 1 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 2/20/00 BEDROOM 4 CONVENTIONAL IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND )= SEPTIC TANK SIZE 1250 Gallons LIFT TANK SIZE DOSE TANK SIZE 765 HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 500 BED SIZE 8'X 63' BENCHMARK V.R.P. Top of Screw in Power Pole ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H. R. P Same as Benchmark SYSTEM ELEVATION 98 . 2 Scale 1" = 40" 0 P.O., ;T �• Well C RECEIVED t 'CE ENS D F CD p BUILDpB FEB 2 4 1994 DEPAR SAFEST pN oN�s►or►oF SAFETY & SLObb. DIV DE NCE E V 0 RF ESpON 2q g q B.M. L� Existing 4 Depth of Building Sewer ❑� Bedroom greatly excedes 42 ", and ✓ Well House thus will not be insulated B -2 �- 80' ✓ " % Combo ST /DT Slop e Tank is to be Area 25' Below Mound is properly bedded to remain undisturbed and provided with a lockdown cover ST DW with a approved Old System is to be warning label pumped and buried Overflow Pipe County Road H I � r� Designer —4LJ DaC ;•.1U " pi 4" Observation Pipe Perforated N on-Woven Filter Fabric $elow Filter Fabric r ,bistribvlion pip ASTIR C - 33 Send �► �" Topsoil - " o t ..__ �sr 7 % Slope fled Of t��- 2112 Force iti+laim � \ low ed Drain Rock From Pump Layer "Q / Cross Section Of A Wound System Using E, A Bed For The Absorption Area F $S �? G ,.�.. A a Ft. 6 �3 Ft. I .. Ft.. J ,J.}� Ft. K. Ft. L „ Ft. w 31. Ft. 4. Obsef Pipe ° A - - - -- ----------- - - - - -• 1 Force Moira W ,^ -- ---- r•. + _ From Pump •t 0 Distribution Bed Of 'Y,'— 2 Pipe Drain Rock Z \ 4 Observation Pipe Permanent Marker pipe or Rods Pi View Of Mound Utina Q 9 t For T Absorpti Areo ti • ` 1 Perforated pipe Detail i End View Pertware� �,�' End Cop i" RvC P.oe Lotaled on 86110rn, Are Equally Spaced P� PVC forte Alma F4K&T NOLG MILYT To Cenntt }ton PVC Manifold Pipe Otelri�ul�on Pip* Last 1401* Should et Next To End Gap End Cap � Dislrrbufton Pipe Layovt P Ft. R , Fj. X _.?'t7 Inches Y .Inches Signed. Hole Diameter Inch 6 7 Lateral 2 Inches? License Number: t� � Manifold �_ Inches Date: o�'o'�o `' 0 Force Main cP� Inches # of holes /pipe invert Elev4tion of Laterals �Po Ft. y SEPTIC TANK & PUMP CHAMBE CROSS SECTION AND SPECIFICAT 4" aCI VENT PIPE 12" MIN. ABOVE GRADE r; WEATHER PROOF >'A' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W/ PADLOCK 9 FINISHED GRADE 4 CI RISER WARNING LABEL 7 6" MIN. ABOVE G ADE .r ...-4" MIN. 18" IN. 6" MAX. *� INLET L 1' - WATER TIGHT SEALS GAS � TIGHT+ BAFFLE / A SEAL ► APPROVED —i— r ' ALM JOINTS W/ APPROVED B PIPE 3' 0 I i ON APPROVSO PIPE 3' 'SOLID SOIL �— + + ONTO SOLID SOIL C 1 PUMP OFF ELEV .8 ,OFT. LD OFF ** RISER EXIT t_ -: � PERMITTED ONLY IF UNK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS G� x�a� _�l�l�m� t ��a��bac� ZGS SEPTIC / DOSE � TANK MANUFACTURER: NUMBER DOSES PER DAY: TANK SIZES: SEPTIC lo'2 0 GAL. DOSE VOLUME INCLUDING O GAL. ----- F LOWBAC K DOSE _ _ . 15 ' ' I�AL. ,� 5 ALARM MANUFACTURER: CAPACITIES: A = 20 INCHES = l - GAL. MODEL NUMBER B = _2 INCHES = GAL. SWITCH TYPE: G3 C = /r SINCHES = S PUMP MANUFACTURER: = INCHES MODEL NUMBER D SWITCH TYPE: PUMP R ALARM WIRING AS PER IL.HR 18.23 WAC REQUIRED DISCHARGE 5 RATE � GPM ' FEET FEET IFFERENCE BETWEEN PUMP OFF AND D25'fRIBUTI ON PIPE .. FEET 3 VERTICAL D FRICTION FACTOR - FEET IS. + MINIMUM NETWoRy Esg� FT /100 FT. . 0 -FEET 1RCEMAIN X TOTAL DYNAMIC HEAD s R +- DIAMETE LENGTH /✓? S--' WIDTH INTERNAL DIMENSrONS OF PUMP TA NK: S LIQ ID DEPTti Q / l� / C2 {90v D P - - -- LT C EN S E Fr 0 ry\ I En g i neering - • r`- Performance Data 40 i 30 Pump Characteristics Pa /Motor Unit Submersible W" 2( Manuel Models SHEF4OMI SHEMOM2 Autonsusk Mode SHEF40Ai SHEF40A2 1D r Horsepower _ 4/10 I Full Load Amps 12 b.S Motor Type Shaded Pak (4 Pole) LLL R.P.M. 1550 0 10 20 30 40 10 60 70 Phase 10 GPM Voltage 115 1 230 Hertz 60 Total Head {fee!} i 10 14 1l 21 25 28 30 35 Temp erature 120* f Max. Fluid 70M IA (m} 3.04.3 1 "5.2 1 b.l 7.6 " `8.5 8.8 10.7 NEMA Design A GPM {US GPM} 70 60 I 50 j 40 30 20 10 0 Insulation Class A (titers sec} 4.4 3.8 -� 3.2 2.5 1.9 1.3 Discharge Size 1 1/2 KPt Di Data Solids Handling 3 V vvar hi 2a Elrs. 3.7A — 6.5 /e" (168.27) 1. All dimensions in inches. (Metric for Power Cord 18/3, SJTW, 20' std ( 42 � —5 ° (1271 —1 international use), (30'opHanaq s �!e' j 2. Component dimensions may Materials of Construction `x'42' vary t 1/8 inch, Handle state ss steel 3. Rol for construction purpose 3.716' DISCHARGE Lubricatin Oil Dleiectrk 00 (88.42) 1 -1i2° �40'r unless certified. Motor Housili Cast Iron FLOAT SW;TC 4. Dimensions and weights ate Funio Casin _ Cat Iran approximate. Shaft Steel { Mechanical seal Faces: Carbon /Ceramic - -- -f<S 5. We reserve the ri to make i Shalt Seal Seat Body: Atsodsed Steal ! -- --- f revisions to our product and their Sprinif Stainless Steal ( specifications without notice. Behr Best" Imp eller Exalawed Thermoplusfle Upper Bearing Bronze Sleeve Beertn 2 9 2� y lo• is^ Uwe[ Bearing swok flow Ball l eaft (256.76) Bottom � — Plate Pol ester Codted Steel Fasteners Stainless Steel r 92.07 2"(50,8) (92.07) Lags Engineered Thermoplastic i _ 4 B Hydro - vatic' Pumps, Ashland, Ohio Alt Rights Resorvacl. HYDROMATIC °' - Your Auti,anzed Goat Qlstributpr . WaRkNIM i Asbland, Ohio 44805 Tel: 4t9-289 Fox' 419281 -4087 Web Site. wx+. pentoirsuma corn �Utir tact. SS/11M tf10ES IN ALL MAJOR CITIES AND COUNTRIES ;cllu+ sages u! year pluae,lirerlory for your fatal Dlstribmol CD Citttf i �'U? 66£30 i 198 5M "'pyan:e;ti* �''�' ••' ,'"c�� N , B U'riu nsin Department of Commerce SOIL AND SITE EVALUATION n of Safety and Buildings Page of of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County 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. # 31 -lad APPLICANT INFORMATION -Please print all information. I R viewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1 —31 _ Z � Property Owner Property Location 5 4-/- D Govt. Lot.3 L O 1/45L 'Y/4,S S T_ ,N,R 1 E (or) Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip CodL& PhoQ Number ❑ City ❑ Village ;R Town Nearest Road 'eid ez , ,5Y,0 ? )0 7-_5Y.7; ❑ New Construction Use: J WResidential / Number of bedrooms Addition to existing building r eplacement ❑ Public or commercial - Describe: Code derived daily flow j gpd Recommended design loading rate 2 bed, gpd/ft �' trench, gpd /ft Absorption area required - �� bed, ft2 Tpo trench, ft Maximum design loading rate Z bed, gpd/ft Z trench, gpdfft Recommended infiltration surface elevation(s) U • Z ft (as referred to site plan benchmark) Additional design /site considerations 93+a Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure . A A T f -Grade System in Fill Holding Tank U = Unsuitable for system ] S U %S U 0S NU 0 U ❑ S ' D(U El S U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench F Ground 3 as y SOY. �/ C / .'_/ - �'l — /46/9 11414 V/0 Al P elev. Depth to limiting o in. Remarks: Boring # ZM g _ I ©'/y 3! �- �'s off►"- - S ' n gig`° 3 41 �✓�P Ground 4. 9 lev r'f l_ Depth to limiting '6 r in. Remarks: CST Name (Please Print) f Signat qe hone No. Address Date CST Number oo SOIL DESCRIPTION REPORT PROPERTY OWNER ,( L�� �C,�2�Q- �1 �- -� Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench fZ Lf r� Ground ; Depth to limiting f for Remarks: Boring # Ground elev. tt. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; xa ' Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) � Soil Test Plot Plan .Project Name Russel Strohbeen Shaun Bird Address 702 CTY Highway H New Richmond Wi 54017 C '#226900 Lot 1 </4 7i lsion - ---- Date 11 /11 /99 S W 1 /4 S W T N/R 1 8 W ownship Star Prairie [� Boring (� County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Screw in Power Pol System Elevation 98.2 *HRP Same as Benchmark Alt. BM Top of Steel Fence Post @ 98.8 15' Well 100' B.M. 0 15' 45' B -3 Well 15' 0' /Alt. 35' fsting 4 M room 80' 90' 80' se 50' B -1 B -2 30' 7 % 100' Slope 5 T D W Overflow Pipe extends accross road and discharges into swamp k I T� 4 I County Rd. H ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND. OWNERSHIP CERTIFICATION FORM - i Owner/Buyer Mailing Address Property Address 1 c�. L� (Verification required from Planning Department for new construction) City /State 1- Parcel Identification Number _ z, 2 z S LEGAL DESCRIPTION Property Location > d./ '/, %., Sec. . T�N -R _aW, Town of k'Pr "- 0-- Subdivision Lot # Certified Survey Map # Volume . Page # Warranty Deed ## Y , Volume , Pa e # y �_ g Spec house ❑ yes 5- io Lot lines identifiable la'yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature 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 master plumber, journeyman plumber, restrictedplumber 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. I/we, 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 retumed to the St. Croix County Zoning Office within 30 dayA, the three year expiration date. SIGNATURE OF APPLI ANT 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 graperty described above, by virtue of a warranty deed recorded in Register of Deeds Office. C �2 .2 1171 - SI NATURE O PLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with 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 i Na, a.s. Warmly Dey --Abw* Fwn tNTATZ OF WIDOONSINt S'�� '���.E l lso& 166 Wis. autatar) Porn Na a , — � �� f Re� co dfordt .3 h�I. I l q day of__ Octoer__q D.197,� ii 0 AuMdum Ma by Alvina Strohbeen I I' RegKfar of reeds grantor , of St Croix County, Wi onsin, hereby conveys andwarrantsto Russell R. Strohbeen and Eunice Strohbeen, husband and ji wife as joint tenants grantee S ,of St. Croix County, 6Visconsin,for thesumof One Dollar and other valuable consideration the following tract of land in St. Croix County, State of Wisconsin: I i Northeast Quarter of Northwest Quarter (NE4 of NW's) of Section Eight (8); and the Southwest Quarter (SW4) of Section Five (5), excepting therefrom the West 350 feet of the Southwest Quarter of the Southwest Quarter (SW4 of SW�) of said Section 5, lying South of C.T.H. "H ", as now located, all in Township Thirty -one (31) North, of Range Eighteen (18) West; also A parcel of land in the Southwest corner of the Northwest !Quarter (NWT) of Section Five (5), Township Thirty -one (31) North, of Range Eighteen (18) West, described as follows: Beginning at the Southwest corner of said Northwest Quarter (NW4) of Section Five (5)• thence Northerly along the West line of said Northwest Quarter INW4), 362 feet; thence South 48 24' East, 545 feet to the South line of said Northwest Quarter (NW'); thence I fiester'_y along the South line, 407.6 feet to the Point of Beginnint,, containing; 1.7 acres. ; tt This conveyance is given in satisfaction of a land ccntract between the parties, dated June 7, 1967 and recorded June 8, 1967 in the office of the Register of Deeds, St. Croix Countjt, Wisconsin in Volume 433 on pages 282 and 283, Document No. 288566. TAX EX24PT 3n Mitntoo Motrtot, the said grantor has hereunto set her h:: rd and senl th::. j 16 day of Cotober A. D., I" i Signed and Sealed in Presence of �. �._.`.. __'..._ . f..� . "f ...-- .`._...._(Sc. - A _Y.i u_Z.tr.ohheen.. _ - - - -- Frances V Neel _._ —. —.._ _.. _ _..._— ...._..._._ _..._. ..........._...__ .............. %tats of diliioton0in, 1 County S t. Croix 1 II i Personally came before me, this 16 day of October , A.,4.,, 1974 J theabov&named Alvina Strohbeen to me known to be the person who executed the foregoing instrument and acknowledge; Frances Van Ne�iel .� Notary Public, St. Croix County, Wis. My commission expires Jan. 8 A. D., 19 78 Drafted by H endrik W. Van Dyk, A at Law, New Richmond, Wisconsin it eooK 5 05 IN:9. --C►. ct WI& BtatL VM"" *at all ftowww" to be t ded a"n Yaw VIAWY print" or trn•.rltto UMrWM as actom eb. trastw % aranumw wffte r and No",) FAX ST. CROIX COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, WI 54016. (715) 386 DATE: TO: Fax Number. Name: FROM: Fax Number. 386 -4686 Name: KeVI "1 Ge-0-94-4k Number of Pages Including Cover Sheet 3 fteft 9 9 IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: TELEPHONE NUMBER: 3 g i i " ST. CROIX COUNTY WISCONSIN - ____ ZONING OFFICE p N N N a N A Jim -_ ��.: ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road _ Hudson, WI 54016 -7710 (715) 386 -4680 Fax (715) 386 -4686 April 10, 2000 U.S. Fish and Wildlife Attn: Candy Chambers 176495 1h Street New Richmond, WI 54017 RE: Septic Inspection for Russell Strohbeen locate Cat2702 ou nty Road H, Town of Star Prairie, St. Croix County, Wiscon Dear Ms. Chambers: A septic inspection of the above referenced property was conducted on March 31, 2000. This property is located in th SW' /4 of the SW'/ of Section 5 T31 N-R18W. Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found V be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Sincerely, Kevin Grabau Zoning Technician /sm cc: file /Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y: • Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 353323 Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.: S tar Prairie TownshiD I nUAS lb = 2 9 $' 4 0•D Insp. BM Elev.: BM Description: ,�,p� Parcel Tax No.: 00.0 � WD . 0 , i c - ST IBM -4 :1 = 5 a `ti` Pewe.� 1 " 038 -1024-50-000 TANK INFORMATION ELEVATION ATIO DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / 5 Benchmark la 101. 1� 0 Dosing, Alt. BM � l03•7 1 .5 Aeration Bldg. Sewer (0) 4 f q.o' s 9a • -70 r Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Ventto TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet Septic � /�' •, g!' NA Dt Bottom �5.1� $5.93 Dosing 90' NA Header/ Man. q 99.2.D Aeration NA Dist. Pipe 2,0 9 I. to � Holding Bot. System } 9g.yo" PUMP/ SIPHON INFORMATION Final Grade 4 Manufacturer Demand ' -F 50 o �. S 96.6 0 Model Number �p GPM l Z TDH Lift tt•�� Lriction,. Systemz.s TDH�,pbFt o. H ead Forcemain Length p ' Dia. Z " Dist. To Well /c SOIL ABSORPTION SYSTEM BED EN T�EM k Width , Length i No. OfiseMreFres PIT No. Of Pits Inside Dia. Liquid Depth 66 n JS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING actur INFORMATION TypeO n S�e� +o CHAMBER o e Num e . System: Me."U >too > ( aM. cF >!50 �.�e+ldrvlS OR UNI DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length ' Dia. 3 Length C) r b r ' " 9 g �_ Dia. Z Spacing �,f 3G 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 Bed /Trench Center Bed /Trench Edges Topsoil g p E] Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) I { I Inspection #1: 3/ 3 / oo I snection #2: / / Location: 702 County Road H, New Richmond, WI 54017 (SW 1/4 SW 1/4 5 T3 IN R1 8W) - 5 .31.18 .105A 1.) Alt BM Description= bo % 1 'vw+ 5 - V -Ja z b W • se.rw.+ - 2.) Bldg sewer length= 95 -' (A) = f • $ - amount of cover = - . 3.) contour = 9a•'l�t`5��an3.'a� �_= io l.ro) © , ll�� {� 6• �.,�Q�. gS 3 9 4) 5 54, _ - _.fj."X ISo 1- I.e« v�k aPF"sX }{L = (03 � Plan revision required? ❑ Yes jgj No U R� Use other side for additional information. (o D'D flS 19AMAA. Z 6 .-_ SBD -671Q (8.3/97 _ D�a� jj e p pector Sign Cert. No ` Ex: f*x +-•.I- P P 1 c Lac.AJ so t-cak . Fa: aysks _ Is fL."" o- be.►,.ja -0.0 , +I wee ax." d (8" a« Q Wj vue ST. CROIX COUNTY WISCONSIN - ZONING OFFICE also ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road 1Hudson. WI 54016 -7710 L i (715) 386 -4680 S7 GHOIX SEPTIC INSPECT ON,,/ WA'W - UEST FORM ..r' ZONINGOFFICE Please specify desired test`(."• &'� 1 � t appropriate fee with application. Outside water linre often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. 0 Water (VOC's) $200.00 KKSeptic $125.00 0 Water (Nitrate & Bacteria) $55.00 0 Nitrate & Bacteria J3 Water (Lead Concentration) $21,00 retest $15.00 Owner: Russell Strohbeen Requested by: U. S. Fish -and Wildlife Service Address 702 Qguntv Rd � -H Address: 1764 - 95th St. New Richmond, WI ZIP 54017 New Richmond, WI ZIP 5401 Telephone W: ( 714 _ ) 94,7-9T29 Telephone If: ( 715 ) 946 -7784 Property address (Fire W & Street) : 914 County Rd. H, New Richmond, WI 5 4017 Location: SW ;, SW h, Sec. 5 , T 31 N, R 18 W, Town of Star Prairie Realty firm: Lock Box Combo: Closing Date: _ b)zw- -7- (1 13r e N o fy t ttt- TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Water sample tap location: If needed, kitchen would be the site Is the dwelling currently occupied? 0 Yes KK No If vacant, date last occupied: January 15, 1999 Age of septic system: Approximately 69 years Septic tank last pumped by: Mondor Sep Service Date: October 14, 1 996 Previous Owner's Name(s) : Has remained in Stro been family Have an of the following been observed? OY N Slow drainage from house. OY XRN Sewage Back -up into dwelling. a )d�Y ON Sewage discharge to ground surface or road ditch. OY XVN Foul odors. Other comments relative to system operation: System indirectly dis es to the ground surface after passing through a septic and overflow tank. I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATU R�'.1� c'Gylf�l� j' ( DATE : �/ 2 1/94 wi 003 J OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION N i .n ❑ ►eau ldw� TO BE COMPLETED BY INSPECTION AGENCY System design & /or permit on file? OYes ONo Soil series per SCS Soil Survey: sheet Type of soil absorption system OBelow grd OAt -Grd (]Mound Approx. size 'X OGravity (]Dose OPressurized Ft.Z ❑Bed OTrench ODry Well (]Holding Tank 00utfall pipe OBSERVED DEFICIENCIES (]Other OUnknown Septic tank Setbacks: OHouse OWell ❑Prop. line 00ther Dose tank Setbacks: OHouse OWell OProp. line DOther Mocking cover (]Warning label OPump /Floats c (]Alarm OEle. wiring Soil Absorption System Setbacks: OHouse (]Well ❑Prop. line 00ther OPondin ODischarge: General comments INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title AV 2 • FILED d 'JUN U 7 2000 ► 3 I F xnT� IEENH. NAL-% 624434 2 6 2A00 � R L x W �/ M True Msridion s ? o 9 a " c c N..1 E 0 M s9aa �m< 40.02' I ., ""to W �� o o 1 UNPLATTED LANDS .. D 38.81' 1i +ry OWNED_ BY_PLATTER N z � � z 912 �� 1.21' I 1> \ ' w 1 280 37* s 00 v w w o0 0 0 , .g2'E• �°• i o rn �°• a - -yam 5.9'47 230.06 !sj S09 cNi1 D w N - U, It 92 C►:� N t w � v+ V rn rn o D Q S.I 20 38'W. 1 �� i C:] ` p rn (, a Elso N �r�++ci°ao�i 41.54'- I I C > In w o c c 1 D. i 39.791 ' I M z I II I O 0 � m rn fn �� 1.75 �� I d l� I I / ' I ti W G! N to � I -< I --I I � fl r o o x rn so W LA I�1� DI 1 Z z2p ? 1 ~1 l� I I II 0 O KID W O N N ° m I —q I D I I CR.A. North) Ln � O y 9 OO sq W. V II II 3 0 0 - d, 1 11 Z .178 56 . 248.34' 0 �' M o D Q o C i Z7 l d ;` 208.32 n M M rn e z z .• .• z o �• n In N 1 = I S 4 Q� �- I I� I n '� ti N n' D O F�-t ' VVwwli Ln `L —y 3 rl 1�1�1!/1 rt0 :U m \ - n W Wk -k Lg — — — 1 � I I Ir l3 I.i 0 o — .A N a - - -I 1 ► 1(U1 I w Lo CD D rn 1 (11 1 \p I ° Oo 46 cn m O , 100 iW C7 n V1 �W44 mm I (�� Ia1r r/ � 1� `° cut Lr 1 3 x O cn e c �' 1 � I---I I _ 1 / MA. South) 0 < C) ; m rn O( I D I - C �, S.1 20'36'W. 308.51' 126.94' n o O 3 tn '� I / 1 266. o 97' Z x Nom° "y 02 _ �o Z1 1—I © -� O 3 C3 IJ o ° V ! �' o m I a 1� h ST CROIX COUNTY -< ;o D N c r • I IC ti V Planning Z Wing and Parks Committ z —I Al Iz ul p m I� / w w f>♦ / o �, o J N 0 7 2000 In -� rg g H �/ ��� /o• (3 tiw co o p cn (J1 (ANN(AO /� W V O % V j N G W N N N / , �/ [ It riled WIflllrl Of O (n K ° b. o ` to ti , va a ap ol te appro a M A NN u0'lo� RI a n/ o w D fl andv�� I m Z 0 z �� Ir K,c r'f' MID Zm. —I Ln pr rt `o I�IM O N v ` D. m S c c I r /Ir \` % IDID M M o H •c o n n I �---q ( Z CL y i° ' 3 0- m I I �Id O N1 m CL M rn v �+ x c ' M I r I OD w D I IT11 £ _� o ro c m I , 11 2 °° I TJ c m rn p 3 Z 1 `� o N p 0 4b' ti \o D c� �' 0 �^ cr 3' o o v 1 ° o o V n ;o m m c m � 1 �� N M CL N o I 1 rn O o CL cn c m I 1 11 c� la r 4i D i I 11 W 41 �W •• - O M cq 4i �0 4i p r CL / i — � I � � , Ln Z l�D to �� Q j CD 14 M / ` 1' / \ �/ I I N.1 0339E 47629' m x o .r 40.01' � I 436.P8' 0.62' EAST LINE SW1 /4, SECTION 5 N \� N.10339'E y,.,. U NPLATTED LANDS_ A Ln 0 OWNED BY R❑DNEY RIVARD _V- -O-L� -14, 3669 r- 11/ UL/ yy lUr, uy: LL rAA r to 400 4uou 01 IAA VV t.v1411v" Wj Uuz ST. CROIX COUNTY WISCONSIN ZONING OFFICE t t lips r , ■ ■ ...,, `�� ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road ,Hudson. WI 54016 -7710 r (715) 386 -4680 6 ti SEPTIC INSPECTXO.N,, / WATioRre.MST .'R UEST FORM Zfl!W�GC�FHt:r J Please specify desired tesO <- &i ire �' t appropriate fee with application. Outside water tin re often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. 0 Water (VOC's) $200.00 KKSeptic $125.00 0 Water (Nitrate & Bacteria) $55.00 ❑Nitrate & Bacteria b Water (Lead Concentration)_ ;21,00 retest $15.00 owner: Russell Strohbeen , H6y, Requested by: U. S. Fish -and Wildlife Service Address: 702 County Rd l # H 0 Address: 1764 - 95th St. New Richmond, WI ZIP 54017 New Richmond, WI ZIP 5401 Telephone W: ( _ ) 94,7 -5792 Telephone 10: ( 71 S ) 94C, -77 4 Property address (Fire If & Street 914 County Rd. H. Richmond, WI 5 4017 Location: SW ,, SW - I - ,, Sec. 5 , T #� ~W, Town of Star Prairie Realty firm: Lock Box Combo: Closing Date: I S . I os c- l � TO BE COMPLETED BY PROPERTY OWNER 7l PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF 'PHIS FORM* Water sample tap location: If needed, kitchen would be the site Is the dwelling currently occupied? 0 Yes 9K No If vacant, date last occupied: January 15, 1999 Age of septic system: Approximately 69 years Septic tank last pumped by: Mondor Se tic Service Date: October 14, 1 996 Previous Owner's Names) : Has remained in Stro been family Have an of the following been observed? OY N Slow drainage from house. OY XQN Sewage Back -up into dwelling. )d�Y ON Sewage discharge to ground surface or road ditch. OY )ON Foul odors. Other comments relative to system operation: System indirectly discharges to the ground surface after passing through a septic and overflow tank. I certify that the above information is complete and true to the best of my knowledge. -� OWNERS SIGNATURt� /,`('C -; t DATE: z��,'- 1/94 1 0003 i OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION I N d 2 s e • TO BE COMPLETED BY INSPECTION AGENCY System design & /or permit on file? OYes ONo Soil series per SCS Soil Survey: sheet Tyne of soil absorption system OBelow grd OAt -Grd OMound Approx. size 'X # OGravity ODose OPressurized iZ Ft.2 OBed OTrench ODry Well Molding Tank OOutfall pipe OBSERVED DEFICIENCIES OOther OUnknown _Septic tank Setbacks: OHouse OWell OProp. line 00ther Dose tank Setbacks: OHouse OWell OProp. line OOther Mocking cover OWarninglabel OPump /Floats OAlarm OElec. wiring Soil Absorption System Setbacks: OHouse OWell OProp. line 00ther OPonding: ODischarge: General comments N INSPECTORS SKETCH OF SYSTEM LOCATION Inspector Title