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HomeMy WebLinkAbout040-1203-30-000 Wiscosisjn Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix ' Safety and Building Division INSPECTION REPORT Sanitary Permit No: 506357 0 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)]. Permit Holder's Name: City Village X Township Parcel Tax No: Loney, Greg Troy, Town of 040 - 1203 -30 -000 CST BM Elev: Insp. BM Elev: BM Description: D Section/Town /Range /Map No: j. C�J O) _ (0 2 0 I 35.28.19.939 TANK INFORMATION C ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ` Benchmark I os, I^ too. �0 W f Dosing Q V'vj l n� Alt. BM Aeration \ Bldg. Sewer ed ) - Holding Ht Inlet TANK SETBACK INFORMATION S Ht Outlet �• C TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom �� -- - m \ - - Header /Man. 2- Aeration Dist. Pipe I) ` Holding Bot. System Q qY- I 7-r 3 9 ) a rY PUMP /SIPHON INFORMATION Final Grade (� C? Manufacturer Demand St Cover GPM Model Number nl�L 1 _? . 2 9190 TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well O SOIL ABSORPTION SYSTEM r PITBED/TRENCH Width Len th No. Of Trenches DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '� y� SETBACK SYSTEM TO l � P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System. UNIT Model Number: DISTRIBUTION SYSTEM 3 g Header /Manifold lll:butVn stri � x Hole Size x Hole Spacing Vent to Air Intake r Pp(s) r Length � Dia q Length Dia Spacing_ SOIL COVER x Pressure Sy stems 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 E] Yes D No [:] Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 20 Dry Run Road River Falls, WI 54022 (SE 1/4 SW 1/4 35 T((2��8N R19W) Cernaho� Addition Lot 3 Parcel No: 35.28.19.939 1.) Alt BM Description = J CSC@ '�k 2 mit) RAd cm t mA �_WLR_ \A_�kd . gems 4 c�.i 2.) Bldg sewer length = - amount of cover = u S k 1 '� l i\ D Plan revision Required" ❑ Yes No Use other side for additional information. ga Date Insepctor's i n Cert.No. SBD -6710 (R.3/97) 1 commer'ce.Wl,gov Safety and Buildings Division County 201 W. Washington P.O. Box 7162 sco ns n Madison, WI 7– 2 Sanitary Permit Number (to be filled in by Co.) t i oepartnertt of Commerce 50 Sanitary Permit Application State Transac�t mber In accordance with s. Comm. 8321(2), Wis. Adm. Code, submission of this form to the appropriate govemmenta J unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing ress) submitted to the Department of Commerce. Personal information you be used for secondary i A ^ J � /� A p urposes in accordance with the Privacy Law, s. 15.04 (I)(m), Stars. , ' r ��J y YZ 1. Application Information - Please Print All Information Property Owner's Name Parcel # AIX V OCT 0 3 2007 ;�D..-'_ 3 D.. Property Owner's MailVlg Address Property Location ST. CROIX COUNTY G Govt. Lot City, State p ode � l4- y "ry Zip C /4, Section � k !� " - Z c:�. i6 ✓+�•�1. T N R E } IL T+pe of Building (check all that apply) Lot �" 1 or 2 Family Dwelling - Number of Bedroom Subdivision Name +C:.E h � O CA-5 ❑ Public /Commercial - Describe Use Blo s ❑ City of ❑State Owned - Describe �1Use CSM Number 11 Village of Z , I�iP Qj - 1 8 -7 7 IN- own of Ill. Type of Permit: (Check only oA box on line A. Complete line B if applicable) 6 A ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Oth,7N d ficAio t S stem (explain) B. ❑Permit Renewal El Permit Revision L1 Change of Plumber [I Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Yype of POWTS S stem /Com onent/Device: Check all that appl k Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) Pretreatment Device (explain) V. Dis ersal/TreatmentRrea Information: Design Flow (gpd) / Design Soil A lication Rat gpdst) Dispersa r Dispersal Area Propose (sf) System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ? 1 � "' j, �.� � °�' v ,'°, • 2 New Tanks Existing Tanks .r y c y -2 R t, . 4V t. kl Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb e 's Signature MP /MPRS Number Business Phone Number It 78 Plumber's )Qdres (Street, City, State, Zip Code) — 9(, 1.4 94-1-4--1 V Ill. County /De artment Use Onl Approved ❑ isappro Permit Fee Date is ued o7 Issuing Ag Signature 11 Given Reason for enial �So �/10 y IX. Condit ®t0VVN":easons for Disapproval ` ,. 8spdc t&* emuent f4er and �`� dispersal cell must all be sr / maintainad as per mansperneM plan provided by pkimtier. rM U b �^ 64, GQv> 2. AN edback trust be millMained I as gpploft code / ordirlikim. Attach to complete plans for the system and submit to the ounty only on paper not less than 8 112 x l l inches in size SBD -6398 (R. 01/07) Valid thru 01/09 A�KWO M3T$Y�', bms 'Wil IMKA. Ar6t :+h.$ r 16 t R! " 2q` ?V!9:- 9"S ?rt: t2Ul11 :'4': 3b ?TMM2!G Wily upq Vi; Ct+,... nF; G 5 b wmlVu6rn !d ;aum : , t4mi Aosdl%a IIA a r, �Jfl6tflb � J 't>r- : �kt6�ligO6 181'; ti t 1" I� f f / ,t'l� / 4 r �e? � _y..'^� ' L ,+� l�f ^'�' � • —./ e'! i �`�5�..°7" ".,�^. has: ..'r I g i "r f �._, _ __'• -. �.P. N 1 _a. INd - -'� y am. a ..�a. ° - -- ___... ___ _ Y i i 0ja NE ,pll_rIA4 AV t 1 / 44 v C ey ` 3 I t 1 11 1 1 J OL � C • HYDRAULIC EXCAVATOR kg ® LIFTING CAPACITY A A: Reach from swing center Conditions: B: Bucket hook height • Arm: 2900 mm 9'6" C: Lifting capacity • Boom length 5150 mm 16'11" Cf: Rating over front • Bucket .65 m yd (SAE heaped) Cs: Rating over side - Bucket weight: 500 kg 1,100 Ib. B 9 :Rating at maximum reach • Lifting mode: On C PC160LC -7 Shoe 800 mm 31.5" Unit: kg/lb A 1.5m5' 3.0m10' 4.6m15' 6.1m20' 7.6m25' BMAX B Cf Cs Cf Cs Cf Cs Cf Cs Cf Cs Cf Cs 7.6 m '1950 '1950 25' '4,300 '4,300 6 `311X1 2950 '1750 `1750 W 1 '6,800 5,500 1 '3,800 '3,800 4.6 m `3900 2900 '1750 `1750 '1700 `1700 15' 1 '8.600 6,400 '3,900 `3,900 `3,800 `3,800 3.0 m `7600 '7600 '5400 4500 '4450 2750 3100 1850 '1800 1650 10' '16,800 `16,800 `11,900 9,900 '9,800 6,100 6,800 4,000 `3,900 3,500 1.5 m 10900 7600 "6850 4100 4400 2600 3000 1750 '1950 1550 5' `24,100 16,700 '15,100 9,000 9,700 5,700 6,700 3,900 '4,300 3,400 0 m 7950 7050 6700 3800 4200 2450 2950 1700 `2250 1550 V 0' `17,500 15,500 14,806 8,400 9,300 5,400 6,500 1 3,700 1 '5,000 3,400 -1.5 m '5500 '5500 `10050 6950 6550 3650 4100 2350 '2850 1700 -5' `12,100 '12,100 '22,200 15,300 14,400 8,100 9,100 5,200 '6,300 3,800 -3.0 m `8550 `8550 `11250 7050 6550 3650 4150 2350 3650 2100 -10' '18,900 i '18,900 `24,800 15,500 14AN 8,100 9,100 5,200 8,000 4,600 -4.6 m '8600 7300 '5800 3800 '4800 3200 -T -15' '19,000 16,100 `12,800 8,400 "10,600 7,000 'Load is limited by hydraulic capacity rather than tipping. Ratings are based on SAE standard No. J1097. Rated loads do not exceed 87% of hydraulic lift capacity or 75% of tipping load. 15 �Z-.► ! 3 War Deparim" of Canrnerce SOIL EVALUATION REPORT Page of Divisionb(Saiety and Widings In a000rdarrce vddr Comm 115. v11k. Adrn. code 09 Agadu oomiepte e Dian on paper not Zees then 81t2 x 11 inches in size. wen must County 5T'- Q e0(1C ixirrde. but not Wnked to: verbal and horizontal refers m point (SK. direction and PWW I.D. p ��lQ • �� 0 p • OM percent elope. scde or dlaw rsioru:, mm it anew. and tor�tton and distance b nearest road. Please print all information. P6F"" k*Wft% M You jxCW may Lahr. IL 15.04 (1) MIL °� Ift P . Properl 12 Lo,v y ' p (f tee L 49 VI - Y 1 ' E GaR LA NE im ' im s 3 TZQ N R If E Properly s t+Aei6ng Address Q 0 Lot # 13104* S Subd Name or M 20 _ ( DR ' 3 C&" wtj0vs 4P917'i O T2•SU O� Ovillap ®Term Merest Road R�Uw y MfT O New C.arafiucbon Use: M Residerdid / Nundw of bedroanrs ,� cods derived design tiow nde GPO P(Replaceaw t 0 Pubic or commercial - Descrilm Parent materia{ 10 0 55 OV&R 5A ,VP4 D(IJLJ _ fFloodPhilnelevatiori ltapplicable ft � i"°"""er01e 7 Z „ s fyJ < Area. Spot Tested suitable for 9 conventional Inground system (P.O.W.T.S.) '[71 PYt Ground sraraos elev. R Depth tD knft fador in. sw Application Rate %A= Depth Dorrrirrant oakx Rsdoru Description Tedure Sbucb" Conroe Bounndery Roots QPDAF In. Mu nd art. Sz Corm Color Or. Sz. Sh. •ill i y� sZ. z Sh I*u Y 3f .6 / 2 0 ' - d. S " S 4 ® Q pit end fir. 7o ft Depth to Ong feckm �U Er..... j 8d; Rde Moriso Dons Radom Description Tend�e Shuck" Con roe Boundary Roots � IM tiMnsd CAL Sz. Cori. Color er. SL Sh. -� •E�i2 o-/o oy 3 <s� sh N v 40 3 A o 0 3A eon �±e 51L / 'e p - 9T o s 6. • e�rert si = Boo > 30 < 220 mgit. and TSS >90 _< i mgll. • herd 02 = BOD < 3o mgA,. acrd TSS _< 3o mgiL M Name (Please Prang G (� '�— � ( � N * 2-6 .7 5 Address Number 715 -77a - 3 qel2 Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 V y 0 _fC1NAL L On UA mmm �mmmm �__�_m-- MOP-A �mmm MIR mm-� ����1' /CA � � � �'�l►7��� mm� =� r_® ®®® MIR mm MI .. •. .:. ®� ® ®� t mm ®- __� 3 �u>v+p�p ay utbR��t�t � M 3i - 07 C6� GD•�t G ��t,u7" o M J)002 p 71c �9PP�Y. ' � NOr 3o NO / D s l WE $69 AJ f fl -0 pits -12)e 100 q. r 23 - 0 7 Ulbricht & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 30 ��� /� 151877 IS LOT I OF ST. CROIX COUNTY CERTIFIED SURVEY MAPS; AE 3, PAGE 624, DOCUMENT NUMBER 349700. UNP LANDS UNPLATTED NORTH LINE OF THE SWI /4 OF THE SEI /4 S 89 E 9 11 29.64 275. Oo 185.00 149.85' 27299.88 1208% 634.73 �� g ? TEMPORARY 1 y $1 CUL -DE - SAC I / ei 27gQ 11 �co 4 1.28 AC 3 1.56 ACRES 043 1.21 ACRES 1.01 ACRES 3 w / < 5 '� Z %'I- lb op6�� Q"' /35o490g �. S 102.96 151.00 IF 1.26 ACRES ,' s Rio ' © S89 0 5710 E 253.96 O �—/ o ' , ' 3 3p � os" RUN — FF N89 253.96' ® ' /a 19825 �� 789a� 24�� � 11 s0 O A; � 300 5' �O 15.00 0� �� O op 6 ) O 1.43 ACRES 43 �Fo 6 �b l 1.33 ACRES s .� W � L.552 ACRES S89*57 o cJ67' Ln O t K ���!}� Di " 3 2 4245 �� ����p0 �/ Dt ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer fA2:1:* Mailing Address _526 Rtt4 . I�- Property Address (Verification required from Planning & Zoning Department for new construction.) City /State ey-P.t �� - (,lt Parcel Identification Number e9 2D ' LEGAL DESCRIPTION Property Location 1 /4 , -� 1 /4 , See. .3 S, T, N R , Town of t 1/ _ Subdivision (2 e N '4-"9 U-S Lot # Certified Survey Map # 8 5' 1 8 ' 7 '7 , Volume ' , Page # Warranty Deed # Volume & A 8 , Page # l `I Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. 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 Planning & 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number f bedroo s ld v 7 NAT OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner f �S Septic Tank Capacity 060 al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model [3 NA Number of Public Facility Units P' AA Pump Tank Capacity al Estimated flow ( ave ra ge ) al/day al /day Pump Tank Manufacturer Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer A Soil Application Rate t al /day /ftz Pump Model A Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average =n-Ground Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) _ <30 mg /L 6 ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in di ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency � aximum 3 years) Inspect condition of tank(s) At least once every: T ❑ rr� nthls) ❑ NA year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: eQi (s) Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ mo Is) ❑ NA ear(s) Inspect pump, pump controls & alarm At least once every: ❑ month ❑ yeaarr((ss) ) ) ❑ month(s) A Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) At least once every: A ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) 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 back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y 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 NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) I Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) 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. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil 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 floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter 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 another 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: ❑ A 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 and site evaluation to establish a suitable replacement area. Replacement systems must I 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 CONTAIN 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 INSTALLER POWTS MAINTAINER E e F. v� Name ne Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name �� Name K, IF Phone L - 7 72L ✓3 1�0 Phone _ > ( 344 Q This document was drafted in compliance with chapter Comm 83.22(2)(b)(i)(d) &(f) and 83.54(l),12) & (3), Wisconsin Administrative Code. Page of START UP AND OPERATION For new, construction, 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. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil 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 floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter 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 another 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: ❑ A 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 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 CONTAIN 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 INSTALLER POWTS MAINTAINER Name F. v� Name Phone $ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name C� Name Phone Y2- , Phone X30 to` Q This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. - f` t)t;r= 'tlit@It -t+fp �IOSR6�- �'t "-'P'L3Ils`Eg !- _ 10 ¢C3 - • 7iWGS S?ACE R,ESEav�b Pon fter-O§AING D:iATA - - ?0 _ - - - - - - -- IAci23a bed REGt5TER5; �3fFir E_ . THIS DEEc'�, made betwoe � S� C�20I}C C4�, WES. CAM r ' ahfi a`dd * t a ttT'' 3Y - - l s> � ellsist of ftt oc ' +j R co d �sri'�uc . � � -= tsg►�e �: ez�tsis _ deceased Grantor dt9ty'?f - -- -°�— ind _ _ Greaory A., sIE3 . at l�lia p WI; n e s s e t h. ' kM the said Gzaator, fox a valgabl_e conssderativn - conveys to Grantee the LdUOwing descr ;b -d al est2E @,fin ' . C' C3� _ - ,_ . f:i gEPy �A {_Q, e - _ Co.my, State at Wisconsin:: _ t C,'r 5 . frox- 163 Late a (3 ), "Ce• iiiott alt cc to - -_ g'b%M of Tr ' g aithey?lii� _ 73-15 Yt t s _ _5­ ,,; - - _hcme:esd property. ' (is) (is not) Together with alt and 6iligCt1811 the h ari h l appuetenaces thereuRto�beontlr�, _ And llercc2la C�r►io�usug__ ` we- rranrs than the title is good. indefeasible -in fee simple add--free and ctearaf onetimnt res-- �ice�st ttlnicigetl Esffi noising orditmaees,, easeMei is roe .pu2lT c ttl iGiet� altn�d zNSCd>" e` building res'trictlefte. '_t and wdi warrant aAd defend the same. Dated This day of Ap 1 !9 (SEAL) AUTHENTICATION AC.KHOWLED4MEHT S* natures authenticated tE�} —�#E+ te a . of STATE- GAF WISCONSIX Ig St, . Cro _ County. Persortally creme- before. me, this tIl _ day of g Nancy M� BarkU - - . 4prii, 1981 the above named _ TITLE: MEMBER STATE BAR OF WISCONSIN Marcella Cernohn"s (Ii root, authorised by § 706.06, Wis. Scats.) �— -1h:s instrument was drafted by - IdsncY • II'$l>4 - _ �. w . /3t�d"'pi r kno_ n to be the person -_ who executed (lie. fore- 4 - -�� = •` V Y am and ac nowle ed the same. -- _ b • s # -� - H_ ty G. Ben son (Stgnatures may be authenticated of ackiiowl f otTi :g. - are not necessary.) Public_ C County, Wis. COmm'ssion is permanent. (If not, state expire�tig -- - '3j �NII /r! CY1t4S52��ll ate : �_7/� � 7 �•) ry amee of persons signing .in any eapecity.ntuc t tee Eype- d- .oF I9 _p�inted belo v heir signatures. wARRANTV OECD -STATE DAR OF WISCONSIN, FORTS NO, 1 -1977 - � . • � A - � � � ■ � � « E � � � ƒ 0 / E / m k $ i } z 0 E ¥ co \ $ 0) 0 k ® § 2 / R B CL R k 3 § . §2 :a t ■ 3 o. � � E § � � ■ . � r c //ƒ �§, 2 \ 2 0 3 o � ® K / 7 7 % n r CO) cn ■ o c T z o 0 0 \ �- 0 ƒ 7 } § § § §' w 3 _ v q { cn m d � J $ � k \ § & � / o \ . i } CD m 2 / ° ] _ g ° k � / (D ca s } k / $ 7 o . q § ¥ � E 2 . D ± }0 § _ � 0) z ( \ ( j CD / $ � � f \ � � ■ t � \ _o �m I � Parcel #: 040 - 1203 -30 -000 12/15/2005 07:44 AM PAGE 1 OF 1 Alt. Parcel #: 35.28.19.939 040 - TOWN OF TROY Current I X I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner GREGORY A & LORI J LONEY O - LONEY ' GREGORY A & LORI J ' 20 DRY RUN RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): " = Primary Type Dist # Description " 20 DRY RUN RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.560 Plat: 0164 - CERNOHOUS ADD SEC 35 T28N R19W 1.56A CERNOHOUS ADD LOT Block/Condo Bldg: LOT 03 3 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 35- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 103624 276,300 Valuations: Last Changed: 07/22/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.560 41,200 224,700 265,900 NO Totals for 2005: General Property 1.560 41,200 224,700 265,900 Woodland 0.000 0 0 Totals for 2004: General Property 1.560 41,200 224,700 265,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 108 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 q�l i AS BUILT SANITARY SYSTEM REPORT OWNER Q VISN� TOWNSHIP T1 �. O 'T' SEC .=T ZSN -R I ADDRESS ��4V` �^ COUNTY, WISCONSIN nn tCti v 2 1 46 z,Z SUBDIVISION , ��2� O �'�.LOT LOT SIZE PLAN VIEW Distances and dimensions to meet of H63 requirements �� RFrF q OC7- FU RING WITHIN 100 FEET OF SY M ION 81981 B ti i i i Z _ O F � Irld#ade ro thjArrow f _► SC L BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: • CO 0 /0 SEPTIC TANK: Manufacturer: 1Q tQ- Liquid Capacity: 1 0 4 0 QHQ, -, Number of rings on cover : k Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cyc e gallons; total capacity o distribution lines gallon:. size oT pump head; gallon per minute horsepower brand name•of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: -- Number ot pits Feet cliameter feet liquid depth seepage pit in et pipe- elevation bottom of seepage pit e evation feet. , SEEPAGE BED SIZE: number of lines wi th lerigth� �tile depth SEEPAGE TRENCH: width —— length PERCOLATION RATE CLj}�S I REA REQUI D REA AS BUILT O 5 DATED D - S I PLUMBER ON JOB LICENSE NUMBER REPOR`E OF INSPICTION - 1NVIVIOUAL S1 -WAGL SVS Q'a" �/ Sari( tahil I'ehrn 1 • State Sept' 1AM1 Township `�- _St. Cru i x Cimn tq n rrr t in n j P _ r' c xtiuLot N Sub Zvi -aion� ;I Pf IC TANK gaE'fune Number oK eompaatmen,ts � tnnov ►urn:' Well j -__ S� Build. ng – � 12% e('ope Hi g h w a -ten �-- - -- 'I M P1 N G CHAM81:R Size gall Pump ManuAa e.r - Number Of DING _IANK Si re _ gallons Numb h u6 C m h.t e.nts Pumr)e -- At nm S tem 'r a tanee Welt Buitding 12% slope H.i.ghwate.n \R; ORPTION SITE Bed The.nch ititanee �no�n: t ele Buitd g _ 12$ -- H.ighwa.tea 1 ;tiORPTI ON S ITE DIMENSIONS 1 Wi dth oA t4gneh At ' g red �J Le'nyth 66 each tine. At Depth o6 hock below tile. ;r► N a lin fi :� Depth 06 hock aver. tile � y lota4' rength u6 ti nee At Depth o6 tile below grade, 2 � <.n Vietanee be ;weep lines At Slope o6 VLe nch in. pen 100 At 1"4,44 uG �ur�liun are,c � { Type afi Coven: Paper a etr - aw 1 1 O W N S I O N S Numbr -r o6 pate vef around pi.te yeas na Outs.( de di ameten� t Depth below i.nfe t Total abeonpti.on ar.e Area required ,t 'Nti1'ECTED – TITLE ICI "RO U _ DATE _ 19 DATE I9 K 'I AEON I OR REJECTION ' 1 s d�L AL 1 13778 REPORT ON INSPECTION OF SANITARY PERMIT # 1 Name and Address of Permit Holder Person /Persons at Site (2 )Date of Inspection ame re s, cense o. o ns a Ong P umber Time of Inspection 3 INSTALLATIO CONSISTS OF: [:]septic Tank ❑ Seepage Trench []Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System (4)BENCRUM77 reference 05 escri e: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: M DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? [- ❑ NO Wired? []YES ❑ NO 8 HOLDING TANK: Manufacturer of gallons ; construction ; depth to the cover ft; If septic tank is being used are baffles removed? YES [ ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? [ ❑ N0; Locking device on cover? [ ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe - elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? []YES ❑ NO (13) Has system been installed in floodway? ❑ YES []NO Floodplain? YES [] NO DILHR -SBD -6095 N.0 /80 Signature of Inspector • State and County State Permit PLB 6 7 Permit County Permi # , emit A »plicati�n for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: � "V\ B. LOCATION: '/ �� '/4, Section TI NT R 1 - 7 E (or) W Lot# City Subdivision Name nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCC Y: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY Q 0 © Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or S Ch _ Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New X Replacement Alternate (Specify) Seepage Trench: ' No. of Li e Ft. Width Depth Tile depth (top No. of Trenches Seepage Bed: Length WidthI�_ Dept h Tile depth (top No. of Line Seepage Pit: Insid� ter Liquid Depth No. of Seepage Pits Percent slope of land - t o o �O Distance from critical slope WATER SUPPLY: Private Joint ❑ Community El Municipal ❑ Owners name as listed on EH 115 if other than p owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH - 115 prepared by the , Certified Soil Tester, _ NAME O ��.�(b 0-{;�� C.S.T. #.� -d 44A Z and other information obtained from G'(Z, Q (owner /builder). Plumber's Signature P # Phone G Plumber's Address V 1 O PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. k ... _ v.M _ ..� .,.. .. , . .. � .. a ...... .__ ,.,. i t e »._ � f 3 F c { e e� r .:.� t 5 I � 3 { .tea ,. _._„,s.,e.._. ..,e .__.e. _.._ __ .._ _ ..... .e ...�...M, .. _.mom _ .�.�, e .. m '_ m m�...a a m' t 7 r t 7. P. .._...� j { 3 � c � { F [ .m ...... .. ... „�.. ... .,.. .,., ...q, �. . ... ems. .e. .._...w.� ..,_. .. .... �.., . �, ....�. ,.. .,..,. .. ..... ... .. ..., e. ... .ma.. h i Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application - - Fees Paid: Stat Count O-v to Permit Issued /R ' (date) - Issuing Agent Name / Inspection Yeso State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 E• 115 Rev. 9/78 of 2— REPORT ON SOIL BORINGS AND PERCOLATION TESTS 7 WISCOIOSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 1 7 ,- 6 LOCATION: fL %, sW X, Section 3 ` 5 ,T 2e N,R Lt E (or) W, Township or Municipality .3 .N ®tiovs /IDDi i�a�/ Lot No. 160 ,Block No. County Su rvision ame •c` p�� I !� Owner's% ers Name: A fl i 4 ftf S. �it A. Mailing Address: f- • 5 i UE f !�S w /�• c TYPE OF OCCUPANCY: Residence No. of Bedrooms .3 COMMERCIAL r EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT G ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MAD IL BORINGS IWM 3U I & l" n I PERCOLATION TEST 1 V I fSe / SOIL MAP SHEET SAS NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— i 2 /WAI /` P— 7 " , 0 - 13A,. ' ) P,4 P P SL �� O ,P- L7< /� N • S SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- 8 /Vora r` 7 /0 ".WW 11,t). SiY B- S . B �lo>7.e > ° lam .5,�. S/ ", S!/ /3N . f c Lf OW, B- f s B- 3 > /3 "��,Ba Si/ G "�N•Si/ /?N. B_ / •, j,-1',6A1. -b,P . C PLAN V IEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy 1 50 Ff' Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. 60iQ DA41 ep Cat _.... #_� .. z , H L .f/sj f �9 t F Ot C_ j 5 g �• • , 3 3 t H 1, the undersigend, hereby certify that the soil to reported an this form were made by mein accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. .Name (print) Certification No. , Address 3 0 P.�iV 601 . y Name of installer if known ff Copy A — Local Authority CST Signature ER 1 1 5 Rev. 9/78 R 4 Z Z ` REPORT ON SOIL BORINGS AND PERCOLATION TESTS • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION:4 %!/ A) %, Section 3.41'_ ,T 2f N,R �! E (or) W, Townshi or Municipality n Lot No. .3 , Block No. , IWN UP � S P P17 - io�v County ;T ' r 'e 4l y ��++ u ivision Name Owner's / Buyers Name: Q 0 , /�l�s L� Cl Mailing Address: AT' .7 ���If TYPE OF OCCUPANCY: Residence ) No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE• OIL BORINGS Z0 _�/ /Yd PERCOLATION TESTS *�� 20 LIZ /? 0 ' / SOIL MAP SHEET SG NAME OF SOIL MAP UNIT PII-10 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE RUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— P— P— P— P— P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B— . . B N flA)SL > Q „ 01 Aw . S%I 7 QiU . S// " L� B.v , �- 7'' L , /.1'.✓ B— SG 4" Lf . /3u - Oe C5 2.Z 4kf I, S - B— B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and squarefeet of suitable areas. Indicate number of square feet of absorption area needed for.building type and occupancy 5A20 P4- .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. Stv x'07" /bv _ /x.1.7- 11�11•fiL . �1 � _ _T�?/� ; 3 f i - s a . 3 � € f oat l t V �I I I ; -i- — � -- -�-- , : �. E ; - D� y �...- ._�....... a.m.. _.», k .._.... ,. .. _.._ E E € � i 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) 2o�cQ� � Nhlll y� Certification No. �✓� Address RI (AMA) 60 15 ,Name of installer if know AW�� d /lGVy/lyal� Copy A — Local Authority e p. GaDOr'Vs !�'� U �� CST Signature. o Lit V � � po o 0 V v` K 40 m d -� I <+ <- N M y p CL N D O c 7 r- a fir 1 f ter C '1 o � o ul d G O io ' �x F x�i RECEIVED UtC c 1 2007 ST. CROIX COUNTY ZONING OFFICE ST. CROIX COUNTY CERTIFICATION STATEMENT ZONING OFFICE FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: A)E 1 /, SjE:- Sec. T IF Z2 Town of JAA, r,o,� St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and Y P P Y baffles to be in good condition, and it appears to be functioning properly. Last time serviced 1 --�� $� 0 Did flow back occur from absorption system? Yes No kl" (if no, skip next line. Approximate volume or ength of time: gallons minutes Capacity: /2700 -' Construction: Preftb Concrete Steel Other Manufacturer (if known) : Age o f Tank ( i f known) Nr (Si natu ) (Name) PletL Print 6C' 0 ul A0iF - 1-- .22 '-�- -79 (Title) (License Number) D (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - L—A� '&W, - - - --,e ) - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . Name -01 Signature a M PR I- F-