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Permit Holder's Name: City Village X Township Parcel Tax No: Robe y, James & Ann I Troy Township 040 - 1003 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: l � - D 02.28.19.17A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w 6,15 ICM /�� Benchmark Dosing y Alt. BM , 7 Aeration Bldg �•Q S ��; la t Holding SVHt Inlet 3. St/Ht Outlet TANKSETBACK INF91W TION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / _ Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System 0 0 3s PUMP /SIPHON INFORMATION �� Final Grade �� :��-�� b � 3 c4S Manufacturer Demand St Cover r G PM ,o -Fvr p' Model Number � TDH Lift Friction Loss System Head TDH Ft I'D ,,�� _ — 12,01 Forcemain 11 nmcdh Z Dia. 2 �� Dist. to Well SOILABSqRPTION SYSTEM BL'D RENO idth ( Length No f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME S �30 f 3 1 SETBACK SYSTEM TO P/L B / LDG E LAKE /STREAM LEACHING Manufactur. r: INFORMATION CHAMBER OR , t Type Of System: UNIT v . I5 157+_ -11 Model Numb � - o DISTRIBUTION SYSTEM �, (,>��– Q(� mod Y0 �� Header /Manifold Distribution �xHole Si ze x Hole Vent Fo Air Intake Length --- Dia Length Dia Spa' > 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 L] Yes L No Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 1 d t— I #2: � Location: 580 County Road U Hudson, WI 54R1 6 (NE 1/4 NE 1/4 2 T2 RR19W) met s & bounds Lot Parcel No: 02.28.19.17A I 1.) Alt BM Description = Aga T N i '- t ' '"" ` - 7 - ' n , 2.) Bldg sewer length = qq U !sue GT- �Y' ` .- _/7 ` �. `r - amount of cover Plan revision Required? L; Yes P No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. , a..t.+ .se- .�.,mw.---- .aMr... _._..._r+a___,_ ..e,m..._.ar,r- ____, -" .. _.. dl@ - xsv�- •rmvne ..�.ivwr: e�- -�..sn aaw+ -� _,.. - ........ t y, - z r�t•6' �� if` E "11 A+�„�� "g_.. _..oQ � �.a< �� ����}fe � � ...— ... � 4 �;� �yyfy�a�y,� A � a + F iRf'�N ' ELEVATION 2 p� + �1�.�� y'k� yI .N o...� `�� � .. E � fi.J i..e Z�a 'S �C �.4�a�\ .1 -� M" .�..__..�.,... ... ......_._r..- ,�..e - ..- ..•„v -_. F�j�� .NNVWn +rv,rtam +...w 4 ...vr a.+.vr. , s I P/ (Vq f � D s i zA61e .4 R, 4 -r p Safety and Buildings Division County _ N *i201 W. Washington Ave., P.O. Box 7162 � { C r e scons n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in Department of Commerce (608) 266 -3151 p / / 13 State Sanitary • r • State Plan I .D. Number t In accord with Comm 83.21, Wis. V p t "'°'C4I R/ �°i ^ Proje= ,J ct Address (if different than mailing address) may be used for secondary p ose ' " I. Application Information - Please Print All Information O J'_ Property Owner's Name pp S7. CR Patcel # Lot # Block # n _ t�c� OIkC ZONING OFF�IC G { j/Ga - tv ©3 -/® - cz� Property Owner's Mailing Address ~•Property Location City, State Zip Code Phone Number '� ''4, Section (circle o e�l� 11 11. Type of Building (check all that apply) T N; RL E otC�3' QQ CR`hc Subdivision Name CSM Number c2 Family Dwelling - Number of Bedrooms � AEG p� � y. G{/(/y� , �v illag fi0 ❑ Public/Commercial - Describe Use /� ❑ State Owned - Describe Use 3 Cej2A/ G lJ �(iyy�_ , rElcity ewns hip of `" Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New S stem y El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑ Permit Renewal 02 Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 1 �G 3/ 39 ref as goy IV. Type of POWTS System: Check all that appl Ct pd a - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line Gravel -1 s e ❑ Other (explain) _ V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design ation Rate(gpdsf) Dispersal Area Required (sf) Dispersal Aje e (sf) 11 9ystem Elevation VL Tank Info aci Total Number Manufacturer Prefab Site eel Fiber Plasti Gallons Gallons of Units Concrete Constructed Glass `/► New Existing Tanks Tanks B Septic or Holding Tank Aerobic Treatmeut Unit �` 2-Q /200 ! � Dosing Chamber X ✓ � 5 t i & --- V11. !responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ' Si nature MP/MPRS Number Business Phone Number Plumber's Address ( et, Cify, State, rp Code) - 7- VIII: oun /De artment Use pproved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date ]sued Isgliving Ag Signature Stamps) Surcharge Fee) OS-6- �U ❑Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval Cw U �,QieU 40 Att y compl dip s (to h County only) for the sys on paper n less than 1(2 x 11 inc es in si�y ,Ua z,,s, tAV- SBD -6398 (R. 01/03) Chamber SAS SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Soil Absorption Systems Owner's Name 11 /15/04 Review Date n Y or N Highly Pretreated Effluent 3 ft Suitable Soil Below System , 12 in Chamber /Unit Height 8 ft Maximum Bury Depth 3 Ezflow EZ1203HP & EZ102H 4 gpd Estimated Daily Peak Flow 0.40 gpd /ft In -situ Wastewater Infiltration Rate 1125.00 ft Chamber /Unit Area 50.00 EISA ft / Unit 23 # of Chambers /Units 99.00 ft Proposed SAS Elevation 26.50 Bottom Area ft / Unit I Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 101.00 108.00 1 105.60 130 1 97.77 104.60 Yes — 2 103.60 135 95.35 102.60 Yes 3 105.70 135 97.45 1 �� L- Q r� r� — 7 2, U �. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is finished grade may be required to meet minimum or maximum code standards. I Version 4.0 04/03 P ei c•� 4.0 r` 0 1S 3a J'= 3d' vo F l � � �- � , 7 {wra P yMNi et ' 4 � 3 . �o' ce.�S -�- a • t n 41 TDH Calculations TOTAL DYNAMIC HEAD CALCULATIONS Gravity or Pressure Dosed Systems l owner's Name 0/5/04 Review Date X X Gravity Dosed, or gpd Design Wastewater Flow X Pressure Dosed ft Total Combined Lateral Length Y or N Ey Forcemain Drainback in Lateral Diameter Must use 4 in. pipe with gravity dosed U0 35 ft F orcemain Length 2 in Forcemain Diameter 25 gpm System Flow Rate /. 3 0.00 ft Minimum Design Head 8.00 ft Vertical Lift ��j 0.48 ft Forcemain emain Friction Loss 8.48 Ift Total Dynamic Head 2.55 ft/sec Forcemain Effluent Velocity Choose Pump That Discharges At Least: 25.00 Jgprn at 8.48 feet TDH � fz4, � A 5.71 gal Maximum Dose U 0.0 gal 5x Lateral Void Volume gal Forcemain Drainback 5.71 gal Forcemain Drainback gal Maximum Dose Volume 5.7 gal Minimum Dose Volume Version 4.1 ( 07/03) it s w PUMP PERFORMANCE CURVE MODEL 15111521153 TOTAL DYNAMIC HEAD/FLOW 50 PER MINUTE 14 45 1 EFFLUENT AND DEWATERING 12 40 MODEL 151 152 153 35 °< = 10 152 Feet Meters Gal. Liters Gal. Liters Gal. Liters 30 5 1.5 50 189 69 261 77 291 z 10 3.0 45 170 61 231 70 265 0 8 151 15 4.6 38 144 53 201 61 231 20 6.1 29 110 44 167 52 197 �— 6 20 ' ` 25 7.6 16 61 34 129 42 159 t 30 9.1 -- 23 87 33 125 s 35 10.7 — 22 85 4 40 12.2 — 11 42 Shut -off Head: 30 ft. (9.1m) 38 ft. (11.6m) 44 ft. (13.4m) 2 5 0145088 0 GALLONS 0 20 30 40 50 60 70 80 90 10o LITERS 0 40 80 120 160 20 0 24 0 260 320 360 FLOW PER MINUTE 014508A Model 151 Models 152 / 153 l i s ! U hY r U - �°� AL At-'L.t y! 3 27/32 —�-- -4 5 /8/ • Timed dosing panels available. a s }/� ® a • Electrical alternators, for duplex systems, are available and \ supplied with an alarm. i • Variable level control switches are available for controlling 32 single phase systems. ®' • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik -Box available for outdoor installations. See FM1420. • Over 130 °F. (54 °C.) special quotation required. „ 11/16 12 1 /8 � 1611 - 1 52JI63 Series - 151/152tl53 MODELS Control Selection li a i Model Volts -Ph Mode Am s Simplex Du lex 4 3/a " N151 115 1 Non 6.0 BN151 115 1 Auto 6.0 Included 2 or 3 E151 230 1 Non 3.2 1 2 or 3 SE151 230 1 Auto 3.2 Included 2 or 3 s, SK2064 N152 115 1 Non 8.5 1 2 or 3 BN152 115 1 Auto 8.5 Included 2 or 3 E152 230 1 Non 4.3 1 2 or 3 BE152 230 1 Auto 4.3 Included 2 or 3 N153 115 1 Non 10.5 1 2 or 3 BN153 715 7 Auto 10.5 Included _2 E153 230 1 Non 5.3 1 2 or yrLEC fOiV GUIDE 230 1 Auto 5.3 Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. A CAUTION 2. See FM0712 for correct model of Electrical Alternator E -Pak. Ail installation of comrols, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) i i rased el ddcian. All electrical and safety codes should be followed including the 1110si r ant Nauonai Electric Cade (NEC) and the Occupational 9atety and Flealth Act (OSHA), or (4) float system. RESERVE PU i ERF-D DLSS,G For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. BOX 16347 Louisville, KY 40256 -0347 Manufacturers of. . SHIP TO: 3649 Cane Run Road v Louisville. KY 40211-1961 1(502) 778.2731. 1(800) 928 -PUMP QV4L /TY P UMP9 �NCE I,J http://www.zoeller.com / /Y /` �0 FAX (502) 774 -3624 © Copyright 2003 Zoeller Co. All rights reserved. / p SECTION: 3.20.014 ,�Z4L /TY/ 1��c! FM1919 . 0403 / O Product information , . -: - -- �--.•. --:.�� �.: ��,✓ \. ® Z Supersedes presented here reflects , �r l ® 1202 conditions at time of publication. Consult factory regarding discrepancies or MAIL TO: P.O. BOX 16347 • Louisville, KY 40256 -0347 visit our web site: inconsistencies. SHIP TO: 3649 Cane Run Road • Louisville, KY 40211 -1961 http : / /Www .zoeller.com (502) 778 -2731 • 1 (800) 928 -PUMP • FAX (502) 774 -3624 ZOE1616ER ON -SITE WASTEWATER PRODUCTS AMRODUMO ZOE"" OW -SME "DOS —MM" PUMPS i..vstla'n =aa 4a r1,:,sJ'4. e t.S Y'z'�;. Durable cast iron construction. 1511152/153 EFFLUENT SERIES Model 151 comes standard with a glass - filled polypropylene base. (For Pump Prefix Identification see News & Views 0052) Corrosion resistant powder coated epoxy finish. S jid tainless steel lifting handle. I - Assembled with stainless steel bolts. Non- clogging engineered thermoplastic vortex FOR SEPTIC TANK - LOW PRESSURE PIPE (LPP) impeller design. AND ENHANCED FLOW STEP SYSTEMS - Model 151 - 1/3 HP passes 1 /2" Solids. SS P11A EFFLUENT MEMBER Model 152 - .4 HP passes 3 /4" solids. SUBMERSIBLE �P�mo M90 AND SUMP ® O Pf*f m F 3 PUMP SEW ASN. 1 1/2u NPT DISCHARGE Model 153 - 1/2 HP passes /4" solids. Motor - 60 Hz, 3450 RPM, oil- filled, hermetically sealed, automatic reset thermal overload protected. c i p Carbon /Ceramic seals. C us ? Tested to UL StandardUL778 Upper sleeve bearing and lower ball bearing running and Certified to CSA in bath of oil. Standard CSA22.2 No. 108 20 ft. UL Listed power cord with molded 3-wire plug. N151/N152/N153 & E151/E152/E153 nonautomatic 1 NPT vertical discharge. BN151/BN152/BN153 & BE151/BE152/BE153 packaged with Piggyback Variable Level Float Switch ft BN and BE standard models include a 20 . variable 1/3, .4 & 1/2 HP, 1 Ph 115V or 230V level float switch. Operates at temperatures to 130° F (54° C) in ° effluent applications. All models include a 1 x 2" PVC adapter fitting. t� Note: The sizing of effluent systems normally requires variable level float(s) controls and properly sized basins to achieve required pumping cycles or dosing timers with nonautomatic pumps. POWDER COATED TOUGH'" a p o ' .,. iUloaei Bi�iS,eh•v. Manufacturers of... h igh 4 { cfflUdilt pp QZ 4L /7V PUMPS S11M.- 19,7, " 0 Copyright 2003 Zoeller Co. All rights reserved. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Divisionof Safzty and Buildings �� i a , with mm 8��VEr' C4xrnry Attach complete site plan on paper not le Win es ' size. Plan must include, but not limited to: vertical and ho ont r �tiog and P f� / oO /O _ 6 p� percent slope, scale or dimensions, north arrow, and location dis o rleaO6 I, n I I,p, C/ Please print all information. Review by Date 5r. cRUx cv J��, Personal information you provide may be used for secondary purpos Privacy 9©4NG*FfFl6k. Property Owner i U lovy Property Location Govt. Lot t l� 1 /4 1/4 S T G N R E (or)49 Property Owner's Mailing Add ss - i ,+' V 11 , Lot # I Block T#Subd. Name or CSNW S 0 1' iw� City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road W i S �, ( v [;3 New Construction Use: Residential / Number of bedrooms Code derived design flow rate (0 d GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material CU G C ' i Flood Plain elevation if applicable General commes -7- and recommendations: S Q 97, v r ` '�� _4X&rK�� [_7 s � Boring # (❑ Boring q_r pit Ground surface elev. Depth to limiting factor f 3y 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 ICl/ Si ' wl Ic "VAC'— C S iv Z Z yl } jc r r �( S, c' Z, . 6✓ t !� e Boring # ❑ Boring , l a Pit Ground surface elev. f G3 w it. 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# •Eff#2 I C. ( ✓ P 5 7 r ?", 1' 3/ , ✓ 6l 3 YY' r •� 1A Z -72 r 3 i. Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 1 30 mg/L CST Name (Please Print) Si9craty[e CST Number vv ry ✓ _ Z S 30 Address Date Evalua Conducted 7 ` Telephone Number f Property Owner G & I Parcel ID # Page of E] Bonn -ft, , Boring # P� pit Ground surface elev. �- Depth to limiting facto in. Soil A Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff #1 •Eff#2 Zwt C 5 v : — Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 ❑ Boring # ❑ Boring C1 Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 Effluent #1 = BOD > 30 1220 mg/L and TSS >30 < 150 mgA. ' Effluent #2 = BOD, <_ 30 mg& and TSS < 30 mg& The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an altemate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SOD4Mgr.soo> I • PAGE_.j OF f LOT# LEGAL DESCRIPTION - V- �'/ S Z T L �N R or NAME �' `J SCALE: BM 1 ELEVATION o U BM 1 DESCRIPTION n U �- �` a d O U r BM 2 ELEVATION G/ BM 2 DESCRIPTION ' ,1 SYSTEM ELEVATION I v ALTERNATE ELEVATION CONTOUR ELEVATION 3&o ��• Q S ti , 3 A Lam' l9n � Z SIGNATURE .. DATE POWTS OWNER'S MANUAL MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner 6, Septic Tank Capacity pod gal ❑ NA Permit # Septic Tank Manufacturer p NA DESIGN PARAMETERS Effluent Filter Manufacturer 2 ❑ NA Number of Bedrooms 100gpd/bedroom S ❑ NA Effluent Filter Model _ pp ❑ NA Number of Commercial Units NA Pump Tank Capacity p gal ❑ NA Estimated flow (average)* yo,- gal/day Pump Tank Manufacturer u , , rss-- ❑ NA Design flow (peak), estimated x 1.5* y.;rgal/day Pump Manufacturer Zoe ,r,._ ❑ NA Soil Application Rate al/da Pump Model , / ❑ NA g y Influent/Effluent Quality (NA ❑) Monthly Average ** Pretreatment Unit [3 NA ❑ Sand/Gravel Filter ❑ Peat Filter Fats. Oil & Grease (FOG) < 30 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) < 220 mg/L [I Disinfection ❑ Other: Total Suspended Solids (TSS) Manufacturer: Model: 5 250 mg/L Dis ersal Cell (s Pretreated Effluent Quality ❑ Monthly Average * ** p ound (gravity) ❑ In- ground (pressurized) Biochemical Oxygen Demand (BODs) < 30 mg/L ❑ At -grade ❑ Mound Total Suspended Solids (TSS) Fecal Coliform (geometric meant 5 30 mg/L [I Drip-line ❑Other: <10 + cfu/100m1 cEfteaching Chamber Manufacture Maximum Effluent Particle Size 1/8 inch diameter Model E Z /,0 3 Approval Stipulation *Wastewater Flow Verification on and calculations: Soil Application Rate . 7 gp &B? Area Req. f (Other than bedroom based) Absorption Area Credit per unit ft Minimum Number of Chambers r3 ❑ Aggregate Design Flow/Loading Rate= fe min ** Values typical for domestic (non - commercial wastewater Materials: all materials must comply with WI Adm. Code and septic tank effluent. COMM84 and be installed per manufacturers specifications ** *Values typical for pretreated wastewater. and approval letters. DESIGN CRITERIA ❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.a1.1990) ❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler. Publication 15.22 ❑ . "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6 ❑ "Design of Conventional Soil Absorption Trenches and Beds ". R.J. Otis — ASAE Publications 5 -77 and "Design Manual — Onsite Wastewater Treatment and Disposal Systems ". EPA 625/1 -80 -012 October 1980 ❑ SBD — 10570 —P (8.6/99) "At -Grade Component Manual Using Pressure Distribution" ❑ SBD — 10567 P (8.6/99) "In Ground Absorption Component Manual" ❑ SBD — 10705 —P (N.01 101) "In Ground Soil Absorption Component Manual" Version 2.0 ❑ SBD — 10628 —P (N.6/99) "Recirculating Sand Filter System Component Manual" ❑ SBD — 10656 —P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual" ❑ SBD - 10572 P (8.6/99) "Mound Component Manual" ❑ SBD - 10691 —P (N.01101) "Mound Component Manual" Version 2.0 ❑ SBD - 10595 —P (R.6/99) "Single Pass Sand Filter Component Manual" ❑ SBD - 10657 —P (8.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10573 —P (R 6/99) "Pressure Distribution Component Manual" ❑ SBD - 10706 —P (N.01 101) "Pressure Distribution Component Manual" Version 2.0 ❑ Drip -line Effluent Dispersal Component Manual for Multi-flo Onsite Wastewater Treatment Units MAINTENANCE AND MANAGEMENT MAINTENANCE MONITORING SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months cM�year(s) (Maximum 3 yrs.) Pump out contents oftank(s) When combined sludge and scum equals one -third (1/3) of tank volume Inspect dispersal cell(s) At least once every ❑ months ear(s) (Maximum 3 yrs.) Glean effluent filter At least once every ❑ months ear(s) Inspect pump, pump controls & alarm At least once every 3 ❑ months ear(s) ❑ NA Flush laterals and pressure test At least once every ❑ months ear(s) ❑ NA Valves At least once every .❑ months ❑ year(s) M NA Other: At least once every ❑ months ❑ year(s) A Page of START UP For new constriictidn, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment "process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. OPERATION The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water - saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit eels and seeds bones and food solids such as those produced b a garbage disposal should be minimized. Toilet tissue is the only P P Y g g P Y paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, disinfectants, P esticides, antibiotics, solvents etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. Cl Valves Valves shall be operated in the following manner: Alarms Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back -up of sewage into the dwelling or surfacing. INFECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). gtic Tanks Component Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any backup or ponding of effluent to the ground surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective locking device to prevent accidental or unauthorized entry into the tank. When the combination of sludge and scum in any tank exceeds one -third (1/3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Rump Chamber/Treatment Tanks Component The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of the filter. Any service needs or repairs shall be promptly taken care of. round Gravity Component Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. Page of ❑ Mound, At- Gradq, In- Ground Pressure The inspection -shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to ensure that equal distribution of effluent is occurring to promote the longevity of the system. REPORTS Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative Code. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code. - All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. - The contents of all tanks and pits shall be removed and properly disposed of by a Septage 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 other inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: / -IMLA suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption 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 lines and wells. Failure to protect the replacement area will result in the need for a new soil from existing and proposed structure, lot lines 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. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN 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 THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLE POWTS MAINTAINER Name . ar ��c� Name Phone 9 3 cZ Phone SEPTAGE SERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY Name Agency Ste• C Ab Ix C&M pl i 2V- rI r Phone Phone ti-lS7. bfo V_ \WPDATA\EH\POWTS OWNER'S MAMAL.doc Page of r ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND • OWNERSHIP CERTIFICATION FORM Owner/Buyer -L- Gc,y ►rt yti ' rl Mailing Address Z 0 i !r>� P�'c� ( / C a 7 j� �J S�� W i c2 �p Property Address (Verification required from Planning Department for new construction.) City/State �w n ( )l Parcel Identification Number oo LEGAL DESCRIPTION Property Location At '/4 , U E %4 , Sec. �;Z , T a` 3 N R C LW, Town of ►�" o W Subdivision ,/� e; i h rA v�J Q 15 l y , Lot # Certified Survey Map # /%(�A , Volume , Page # Warranty Deed # - 7 7 5c1 /ti , Volume (o 7 , Page # 7 L Spec house yes no ' Lot lines identifiable Q!9 no • SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pimping 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. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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 Department within 30 days of the three year exp' te. SIGNATI qV&PPLICKN DATE OWNER CERTIFICATION Uwe certify that all stateme �ts Wthis are true to the best of my /our knowledge. Uwe am/are the owners) of the property described above, by virtue ed recor ded in Register of Deeds Office NA_ L l / 30 /C�A SIGNA DATE • * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. Parcel #: 040- 1003 -10 -000 10/15/2004 09:42 AM PAGE 1 OF 1 Alt. Parcel #: 02.28.19.17A 040 - TOWN OF TROY Current OX ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): * = Current Owner * AFFOLTER, GARY GARY AFFOLTER 604 BRUMMEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC escrip iotiot n: Acres: 6.540 Plat: N/A -NOT AVAILABLE SEC 2 T28N R1 9W 6.54 C IN NE NE E��0 FT Block/Condo Bldg: OFN790FTOFS .34 FTOFE1 /2 ^ _ uw ; 02-28 Tract (Sec- Twn -Rng 40 1/4 160 1/4) Ste! �3h�. �'1�� 02- 28N -19W Notes: k—'V so ` l Parcel History: "' -z Date Doc # Vol /Page Type V 1W 4, y 2004 SUMMARY Bill #: UFO Market Value Assessed with: Use Value Assessment Valuations Last Changed: 07/15/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 6.500 1,200 0 1,200 NO Totals for 2004: General Property 6.500 1,200 0 1,200 Woodland 0.000 0 0 All 6.500 1,200 0 1,200 Totals for 2003: General Property 6.500 1,300 0 1,300 Woodland 0.000 0 0 Total 6.500 1,300 0 1,300 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i Parcel #: 040- 1003 -10 -000 10/15/2004 09:42 AM PAGE 1OF1 Alt. Parcel #: 02.28.19.17A 040 - TOWN OF TROY Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): " = Current Owner AFFOLTER, GARY GARY AFFOLTER 604 BRUMMEL RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 6.540 Plat: N/A -NOT AVAILABLE SEC 2 T28N R19W 6.54AC IN NE NE E 360 FT Block/Condo Bldg: OF N 790 FT OF S 2327.34 FT OF E 1/2 NE 1/4 EXC RD Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 02- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 2004 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/15/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 6.500 1,200 0 1,200 NO Totals for 2004: General Property 6.500 1,200 0 1,200 Woodland 0.000 0 0 All 6.500 1,200 0 1,200 Totals for 2003: General Property 6.500 1,300 0 1,300 Woodland 0.000 0 0 Total 6.500 1,300 0 1,300 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I � l M ,o Ui 2 6 6 7 P 4 7 6 7759 1 IS KATHLEEN H. WALSH REGISTER OF DEEDS Document Number WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Gary Affolter a/k/a Gary E. Affolter, a 10/01/2004 12 :30PR married person, Grantor, and James D. Robey and Ann Marie Robey, husband and wife as survivorship marital property, Grantees. WARRANTY DEED EXDPT ii Grantor, for a valuable consideration, conveys to Grantees, the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00 (the "Property"): TRANS FEE: 463.56 COPY FEE: CC FEE: Part of the NE% of NE %, Section 2, Township 28 North, Range 19 West, PAGES: 1 Town of Troy, St. Croix County, Wisconsin: Commencing at the East Quarter corner of said Section 2; thence N00 °00'00 "W along the East line of said Section 2, 2327.34 feet to the Point of Beginning; thence in Area Name and Return Address S90 °00'00 "W 360.00 feet to an iron pin; thence S00 °00'00 "E 790.00 feet Name to an iron pin; thence N90 °00'00 "E 360.00 feet; thence N00 °00'00 "W 790.00 feet to the Point of Beginning. A VA- o4a `1003 -10 -000 (Parcel Identification Number) This is not homestead property. Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: easements, covenants, restrictions, and rights of way of record, if any, and will warrant and defend the same. Dated this day of 2004. (SEAL) G' (SEAL) Gary Aff ter a/k/fi Gary E. Affolter (SEAL) (SEAL) w Roger D. Bevers ACKNOWLEDGMENT At4Akfl6kT WiC STATE OF WISCONSIN Signature of State o f W isconsi n authenticated ST. CROIX COUNTY this day of 2004• Personally came before me this day of 2004, the above named Gary Affolter kle Gary . Affolter, to me known to be the person who exeouted the foregoing TITLE: MEMBER STATE BAR OF WISCONSIN instrurDwt an owledge the same. (If not, authorized by §706.06, Wis. Slats.) ota P Jslic, f Wisp sln THIS INSTRUMENT WAS DRAFTED BY commi sion expires Lr jlJ� /T_ C. L. Gaylord Attorney at Law P. O. Box 46 River Falls, WI 54022 *Names of persons signing in any capacity should be typed or printed below their signatures. (Signatures may be authenticated or acknowledged. Both are not necessary.) *WORMNT10N PRO'EOO/ONALO COMPANY FOND DU LAC, W03CONOIN OOD456-7021 Chamber SAS SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Soil Absorption Systems JDARRIN ROBEY Owner's Name 10/5/04 Review Date Y or N Highly Pretreated Effluent 3 ft Suitable Soil Below System 12 in Chamber /Unit Height 8 ft Maximum Bury Depth 3 Ezflow EZ1203HP & EZ102H 450 gpd Estimated Daily Peak Flow 0.70 gpd/ft In -situ Wastewater infiltration Rate 642.86 ff Chamber /Unit Area 50.00 EISA ft / Unit 13 # of Chambers /Units 94.O ft Proposed SAS Elevation 26.50 Bottom Area ft / Unit Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 96.00 103.00 1 95.80 115 89.22 94.80 Yes Fill required 2 96.40 118 89.57 95.40 1 Yes 3 98.50 110 92.33 97.50 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is finished grade may be required to meet minimum or maximum code standards. Version 4.0 04/03 N � z 0 a FM U = W D i • ~ F a ~ Z B ~ p UJ i a CL 9� O � � � © U. a a W CY m LU O* �-- LU 1% a. re m = c LU �.■■r J6 a Z nn , 0 � .� Z Ir Z 0 wr co z 0 Z � M L i j C LU Ne a, W O LL W 0 OC � t: w LJLP $ LU 2 CD Ja z CL �o � a J0LUZ � -- a TQOf� DKPIZO2 OD YHO is 999t 99£ STL YV3 ZT -60 NON MIZ10T 715 366 4666 S'r CRX CU ICt.-l.N6.. L�YlYCrirw+n t 4atlni of txr.,.merae SOIL EVA LUATION RE PORT Page of Ohnsion of se,,, t aaixd au'klil gs - - i .ftadi a •te a&e ptan on pear rapt to In es . Nan 111=1 - - -- iti Jude, but = i ritidto verkai aid i I ON F ' ^ PW t.D. y paw.ard stator, w ciirronsitxas, rmtn anew, and lorxCm des neamt:40aa 3 � Please prin all infurrrtaffr�tt. t'Y&A"Ved by t?atrt adLet" wetyouProw "moybdyaad ��yC**'44'tGUM*" F t�p,srty er ` � Pmpeny Location u y (\ Govt. La • JAj 11 *V` - - '.t4 T � �S N R � e (orjl6 Prcrpeity s Fees d ` ��,�i !" t.Ut sl �locat ��tscl htar� rr r sGaill Zip cases ftm Ntmtxlr C7 City O vilage Town; _ _ Newest Road` if l�Mlr► C*- Wuut'w Usaig Residerkal I Nettber cif bealrcxxrac ,, Code derived tiasign ww tare r ]'?�7 l /�, f! L� w GF-) 0 Replatwmant (] Public or commercial - Dew9be: Parent rrs*vW1 _ /) . � ` _ -- _ Flow Plain elevator i1 applicable General twrrawra � and racy tsttandations: r l�, LJ ` t e 0 gtirir q tit pt�t pit oround Surfaift elsv- f = ft.� Depth to factor � � � � _ in, S_ od lippliwticri Rate i Hor> w D&O Dcrninatnt Collor Ndox tjssQnoon Textwe bbvcture C ns'istanca Boiuxivre Roots 1 GPD)flf mumseil C U. S. Com COW Gi. Sz Sh. _ 'Effifl •EW I 7 i w" , kq/' ( 4J a_ aC rdl i f IL CY3 Pit Grocn d 6+eafece elev. A3-(0Q cepti: to kTffbrg fdi;lor % irct. _ Swi iicallon fate Hatizm Ditri3th WninaY CxAor Rsdox om'aripdon TexaUde SuAwbuil. C4risLswnce Smnday Roots GPD1W _ in. , Mcatsni tau Sz Com Ce errr Gr" St $rr, `Efi#11 *& *2 a gg I _ CfBuant M : SM a 30 iS 220 m g L. arid TSS 4% 150 mg L • Eftwtt *2 = BOO, a 30 mgfL arid 7B 3 0 m ot CST Nam ^wle lint} 1 CST Nwmt r � Addnss --�- � ' Eva awn 0wriacted TWO01 one > }�i }0 2. r'yti .t/ I.2 L r✓ / `z ° C� { Ad - c'� / .�r %'1S 7Ci . . q r y� ^t _ - - NE COR. SEC. 2 I 4 360 NF //4 NF 114 i s 17 c 17 o A m o � 1 360 526.30' j 01 s 17 B 254.66' OD � P x � 20 � Y c Zr T -28 -N • R -19 -W T- HUDSON'E' PAGE 30 See Page 112 For Additional Names. - GILBERT RD _ _ _ _ _ Nell& Ow l t i 1on & _j ^ Jo 49 Ik4eeet 1 u J s v is 5 Maaine w Wlloos- D a c au • �' n 20 SchB 0 tgen 2 R & son 40 Ig u..'' 20 2 s .E s '�ul DEERWOOD m Barbara o a DR cc 92 Garbe ` Tx Ya 39 102 3 aZ w c s 6 12 TOWER RD s is DwWa B a cc i Gordon Helen as s t Mute W ta�eida } & Marie Larsen 20 1 40 40 c a Knott Family m ° u Trust Trust u U F s es. 158 80 Lenertz O to "° 98 m �- - -- -- $ - - - - - - -' - L7aaw t � �: .� 1 N 3 CCOULEE :m ' � 2 38 _p% RR� J � ^ i reamer 119 40 s S0 L t If r Ronald ^ I Susan lyn Anding � VicbUd n § 190 S _ 37 M �-> R& Barbara 4 9 1 t I Frederick Garbe & Ruth 19 S; 73 An American t I Materials r_Rbwl tha .d 3 176 = RoW O Ra i G,kp Xs 5 5 — $_ —C 180 4pL_ 63 141 m 40� �€ M & oelter - Dev I 79 , � j � i 103 I Rr + Trust Inc 11u Ion k7 x u�e 117 T 1191 B)rr 125 W 6 a Nara,. Wrot>.ac I ,� u 12 GLOVER RD 44 g 13 ; °jat 41 60 Dar 5 1M G Taut } Clair & Doima *er s o E Allen & ' 00 S av id Harold 77 ( Wilcoason 133 Al l Hanson Morrow 160 aa�� 42 S 73 3� I of a I LM _ Trl 146 _ r __ _ — Kadu7n Dean & y — = Cn Wider 5 J r Donald = — - — - — - rus \ Salim P H K 4I Trust lberrtt 4� 81 35 I J Br Inc ; LN � so I 16 "< I 4 ru 6 113 CHAPMAN DR ►► N 2 I cha �n f 1 �,� Trust all �� 4 � 158 I � l I'v '; iG � {�1 M / 248 Orin & �Q R�3o r ry ��WIWs Norman N — _ Johnson 86 1 _ � 188 r^a�r � Dw�rr s 1 -- v D - t DO M tbOn r 8 I Warren S ue • s >r— a {{ " u 40 40 40 74 F4 fey x i xr'vre 930 lal 74 �9 HIlls Golf Bauer I University I Ddi 4 1 155 Wlsconsln R BJERSTED 10 13 n 65 LN Philipp &`� p cc m Patricia 1 risen 115 0 6 5 ' 3 ' S 241 g — . 147_ 57 Orin & I - — - " 00MS �� tc pp Nancy o�.. I Patrida lawc Lynn & z Johnson I o I �une z I Feyer- I rosi z eLKn r 20 - 80.40 2 75. 54 97o 100 10 MM L Mj SAO /Sym 201 a �b 194 iz�� George a I (f 1.1,1 4• Nelson 188 --f 6l 135 u PIERCE CO. Safety and Buildings Division County ,� ' 201 W. Washington Ave., P.O. Box 7162 7`- X , Cons in Madison, WI 53 Sanitary Permit Number (t a filled in by Co.) Dep artment of Commerce (608) 266 151 R EC 3 9 Sanitary Permit Applicatio (fir r l+ VP I.D. ' N - .., b , In accord with Comm 83.21, W is. Adm. Code, personal information y u provQ I r may be used for secondary purposes Priv y 5.04(1) ) 20 rent than mailing address) sr I. Application Information - Please Pri ZONING CT-I Property Owner's Name l ff / Parcel # Lot # Block # VAWtes �� U Cfb v - to - ma Property Owner's Mailing Address Prop Location rM rK I � ` G '' /< City, State Zip Code Phone Number , _�/L' /., Section u S m j _ 'k S ircle o T N; RE or II. Type of Building (check all th ply) _ S 54- 2 Family Dwelling - Number of Bed s �� �- eta bdivision Name CSM m umber ❑ Public /Comercial - Describe Use �p El State Owned - Describe Use ❑City_ gillageV vo nship of , Y� III. Type of Permit: (Check only one box on line Complete line B if applicable) d A. w S Replacement System ❑ System atment/Holding Tank Replaceme Only ❑ Othe ification Exis ' S B. 11 Permit Renewal El Permit Revision ❑ Chang f ❑ Permit Tran er to New List Pre s it b and Da ssued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) CJ2'tdow- Pressurized In- Ground El Mound > 24 in. of suitable soil 11 Mou < 24 in. suitable soil ❑ At -Grade 11 Single Pass San Filter ❑ Constructed Wetland 11 Pressurized h1- Ground ❑ Holding Tank ❑ Peat Fil Aerobic Treatment Unit 11 Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter 11 Leaching Chamber El Drip Line 11 Gra -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requi d (s Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Number ' efab I, Site Steel Fr Plastic Gallons Gallons of Units W'`� crete Constructed Glass New Exist" ng Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit D Dosing Chamber VII. Responsibility Statement- I, the undersigne P utnber's Address treet, City, Sttate, ip ) 7 ' ty for installation of the POWTS show n the attached plans. Plumber's Name (Print) Plumber's MP/MPRS Number Business Phone Number Min 1< � ate- S o� /3 - ,, Code S h'Lr VIII. Coun /De artment Use rN A pproved El Disapproved ee includes Groundwater Date Issued Issui Agent Signature (No Stamps) 25��- ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval 3 , � � � , z- � � S SYSTEM OWNER: �X .4o 1 Septic tank, effluent filter and �� - -� ,- l dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances roc, 4 if� re ctxtQ ° r ,e d tM 2 tltS Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size , SBD -6398 (R. 01/03) ( 1 r . � � � `� � , tip _ �� �.t� ' \\ .. _ ` \ �� � C � .j � YYr 7 � y k ' y 1 PAGES OF ,3 NAME: __ LOT# LEGAL DESCRIPTION :__1 /4_1 / SCALE: PL � ELEVATION: / OG O t J_Z k BM I DESCRIPTION:, BM 2 ELEVATION: BM 2 DESCRIPTION: 4o p 64- L "VG SYSTEM ELEVATION: SYSTEM TYPE: coa U� ln'1i'2s VX l V i z ti ! k t SIGNATURE: DATE: __. copV r PAGE.3 OF NAME: q e LOT# LEGAL DESCRIMON:__1 /4_1 /4,S_T_,N,R,_E(or)W _ L I SCALE: l "= ELEVATION: / OG , C) ` BM I DESCRIPTIONA n�- 4 OC- BM 2 ELEVATION: BM 2 DESCRIPTION: SYSTEM ELEVATION: SYSTEM TYPE: eoA u Al?l vtca _ /o , C=L- -Q B &n2 �( � f A i E / m r i 0 s f i F l I • SIGNATURE: DATE: I w,sin oepe�tmePt otcommeroe SOIL EVALUATION REPORT Page Divlslan of Setoty and Buildings *1 in somdarrce with Comm fib, Wks. Adm. Code county s �� Attach complete efts plan on paper not less than 8 t o x„ ir+oh.etnraira Plea �: ;; include, but not Umtiad to: vertical and hortzontal rdersnce point (844,4, 40d Parcel I.D. percent slope, scale or dimensions, north arrow, and lxetiai and distt }five to nearest road. Please pr/ all kflbf mefttl. Re Dat Personal it b n Lion you rn.y b. Us.d saeone.ry rpo s {PrivdE,y tale. t: 1$ 41 41) (m)). G Property Owner i Property i;ocation ( 3 Q S Z T Z 8 N Rly E (or) Property Owner's Medirtg Address Lot # 81odr # Subd. Name or CSM# /CL C� City State Zip Code Phone Number (❑ City Cl Village ® Town Nearest Road 1 New Construckl n Use: ® Residential) Number of bedrooms _ � _. Code derived design flow rate _ Q -- GPD ❑ Replacement ❑ Public or commercial - Describe: Parent materlai _— O J � Q S k Flo Plain elmdon If applicable General Comments ." — ' — G � — � .._. and recommendations: SySf�� (1 / " 16 �6r i 1 soft 5 Pit Ground surface elev. [ s , � _. ft. Depth to Uniting factor _� , in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfif Im Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. '011#1 •Eft#2 0- 1- L o — -SL W" soft ❑ Q Pit Ground surface elev. %�� _ ft. Depth to amov IMW _ in. Sol AP0ft~ Rate Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Soundary Roots GPDKf in. Muned Qu. Sz. Cont Color Gr. Sz. Sh. 'E1f#1 'EfW 2B - -4 1 . • Effluent 01 -80D 30 tm& and T8$ z-30 150 mptt. ' Effluent #2 = BOD <_ 30 mWLand TS 130 nglL CST Name (Plane P ) CST Number Address / Date Evaluation Conducted Telephone ber 0 el (i10flD'HI OftWQHS I 'LLL8 All - iS[£-997,1491e ;uauWedap *10 1aeia03 aseatd `jeauo3 a4surM(g IIB ul 1 " ew lQ*U �o saainlas ssaaat of aaur3ts�sse paau no�C31 ja"ldma put iap!Aoid aoW= f"runuoddo linbo us s4 aoi*wwoo jo luawut&a aq,L - Ow O£ 5 SSl Pus 116w O£ ; 9 009 = Z# ivafi3 . 71Bw OS > O£< SSl pus Iraw OZZ S 0£ < 1.# wens . Z03. M3. '4S 7S "S W03 'ZS no paunn to AWdO WOW fiepume 9vuePIsu00 ean4an4S ex"61 UOP409e0 xopoki xNo'J mmuma 41de0 uozpoH qua P •,n ` ,opal Supqj W tudea g - --- -- • fin= punw0 lid o # duNos Ougae Jgo0Iwo 'zs nO psunn W zwaaJ swop Nepuno9 eouala4suo0 e,r�pngs a"mi. uoq*=9a xOpaa 1.qoosmuitwa Wda0 u Met, uogeqw� PS — �a4asf �ul1!ugl WdeO -4 - - -- - -- •nsP eawns - punw& Rd Supos [] # 6upog NAA , ,, — 4z j ) I-P Z#03. I ma. '4S - ZS . JO MOO IWO 78 no IPSusW tx &WOdID SIOOH tispunog eouegsuoo ampn4S at wi ugdimsea xopea joloo jueupop 4►dea I uozpoH s3e21 vog eQs j 'W ' JOPRt duWa as Ladsa - 4 �� - 'AOP GOV"$ punOrp 3!d ® # $u EY I 1✓ SunOS El - -•� .10 7�? abed - _� --- # 01 Iswed -'__ � � 0 XewA0 I�edOtd PAGES OF 3 NAME: I LOT# LEGAL DESC CPTION: 114&f 1 /4,S,� TgL N,R,JfL_E(or)o SCALE: I"= 1C , ti ELEVATION: IOrJ U ,t a BM 1 DESCRIPTION: , z6,0 BM 2 ELEVATION: BM 2 DESCRIPTION: +012 I -- SYSTEM ELEVATION: SYSTEM TYPE: 000 Ue A ' j . 1; LE AmZ �I o V I DATE: SIGNATURE: ��— O