HomeMy WebLinkAbout020-1333-80-000 r
NOTICE: Please provide the following:
r
• A plan view sketch showing everything within 100 feet of th qy tem. 01x '
1
NlN
O NG OFF GC ~ ; `
• Two horizontal reference points to center of septic tank manhole 9V
• Show alternate benchmark, if applicable.
PLAN VIEW
T,
Sc.atE I~lo z
m3 Y rt d
1 s M
-IT
>1 A
-76
ni F 1 = /d
3z ~ S~
a \
I~c~vS E , efl G
I25oed41. ST. JS,xsa a~r'~31
INDICATE NORTH ARROW
ST- CIWIX COUNTY ZONING I)EPAItTMENT
AS BUILT SANITARY REE'ORT
Owner-5h4l /1'1 I LLF-rt
Address (.S9' E rt/W pLE L.+!~►c
City/Stale I-F v a o w s yb ► L,
Legal Description:
Lot l Block Subdivision/CSM #13 4) > 1-.4 N V S :PQ A i ljL 1
, Sec. , T N-R W, Town of {-tv DSo 14PIN N OZd -13 3 J' 8 d
SEPTIC TANK -DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturerLA)r 14 rZ Size ST/PC/ZSD/ Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(BOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: Kf (L-'n ~TnfWidth 3 ► '
Setback from: house Well P2 Went fresh air iinntbakeof Trenches
ELEVATIONS:
Description of benchmark I r dC !~)X, f t~ ;'T L ll.-J ?
Description of alternate benchmark ~a le o Elevation 14 7.
-rnyyN Elevation
Building Sewer ST/HT Inlet Z ST Outlet 7, 9 S' PC Inlet -
PC Bottom - Header/Manifold (O` Z Top of ST/PC Manhole Cover S, 1
Distribution Lines O I D r Z 40 O /p, O
Bottom of System ( ) l Z O l Z , IS ( )
Final Grade ( ) 6,0
( ) ( )
Date of installation~0 //1/MPermit number 3 20 255 State plan number
Plumber's si nature ` n
g License number ~0 Date
Inspector
(bapklc plot plan
I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Countft. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita ~y,P~.(WW :
Personal information you provice may be used for secondary purposes [Privacy w, S. 15.04 (1)(m)J. 33 L lJ L
❑ _Village Town of: State Plan ID No.:
Permit Holder's Name: HUDysQN
HILLER, SAM
CST BM Elev.: Ins BM Elev.: BM Description: C Parcel o.'
a~-1333-80-000
TANK INFORMATION ELEVATION DATA A9800444 1o/2Q j'
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 7 - AS Benchmark
c;.
Dosi ng- 16J 60
Aeration - ~ Bldg. Sewer C.r~`f'. < p
Holding St/ Inlet 7,(,' d~ 5 ✓
TANK SETBACK INFORMATION St /)K Outlet
TANK TO P/ L WELL BLDG. pVe Intake ROAD Dt Inlet i~
Septic r~ I c NA Dt Bottom
Dosing NA Header, n /d- ,7 /~7.~ 1~ ✓
7 7,
Aeration NA Dist. Pipe
Holding Bot. System / /lJ' 106r- , 617
PUMP/ SIPHON INFORMATION Final Grade.,''
Manufacturer Demand dC3'
Model Number
TDH Lift Loss ction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width ! Length I No. Of Trenches P T No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS a
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA w
INFORMATION Type O /Jguv ('rrsct~ R i AMBER Model Number:
System: :5%; ~OR UNIT
DISTRIBUTION SYSTEM
Header /AAaftt% d / Distribution Pipes x Hole Size x Hole S g Vent To Air In ke
Length -2- Dia Length r Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- de Systems O` n1y~.__._,_,
Depth Over cy„ Depth Over y m xx Depths xx Seeded/ Sodded xx Mulched
/Trench Center B/Trench Edges Topsoil; El Yes El No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,SE,NW 659 RED MAPLE LN-BADLANDS PR LOT 18
Plan revision required? ❑ Yes 011> o l~
Use other side for additional information. 9 /v
SBD-6710 (R.3/97) Date inspector's Signature Cert. No.
Safety and Buildings Division
e-~■■..r■r,t SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County Croy
than 81/2 x 11 inches in size. X
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check if re oll'to previous a-pplication
[Privacy Law, s. 15.04 (1) (m)). if 59 )Rkci A apI Ln yp _ State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
t(_ 1/4v4,5 ~7 TZ,9 N,R E(o
Property Owner's Mailing Address Lot Number Block Number
City, State Zi ode Phone Number Subdivision Name or CSM N ;,b
r djo le
koo-5014 '94 L) 1.4 A/1) s I.- rA IQ/
. TYPE F BUILDING: (check one) ❑ State Owned ❑ C,ty Nearest Road
❑ Village n ,p
❑ Public 1 or 2 Family Dwelling - No. of bedrooms own OF 400,30 1 4-11 L~ 0
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) An. I Q ,~Q
1 ❑ Apartment / Condo 40.::) L40 - / 3 a
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ 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 tsoNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
ystemSystem 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 21 ❑ Mound 30 ❑ Specify Type 41E] Holding Tank
12 KSeepage Trench 22E] In-Ground Pressure 42E] Pit Privy
13E] Seepage Pit jt j (L 7`~ To 4. , 43 ❑ Vault Privy
14E] System-In-Fill
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
Required (sq. ft.) Proposed (sq. ft_) (Gals/day/sq. ft.) (Min./inch) Elevation
&00 -7 G• Feet r 1 Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks q~
is T g an Z d Sit. X ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's ign ture: Stamp MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
a 0 14V)VTO~~ 1 D(ox A ii.) to L~ f A0
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A t Signature (No Stamps)
/15-'.Approved F] Owner Given Initial Surcharge Fee)
Adverse Determination %#a
a
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divo- ion, Owner, Plumber
0.
I
i
13 -L
►F1 t ~ t i ,
WE
t
PL (7
It" e-0 ~ AK,4
rY. ti/ X ~ S
~ 7- 6 C. _
S7 y 8F b ILco
t
't
t
c
m n~ _
is c a (Q " CI)
V
u ti
o ) Sy M
-0 =1 M
o-- b
~Q CD.~
-•t
s • kk,`v.
-U ~ 0
$ s
C
00 o n ~ (D
x , v
_ ~ a d . rry
CA.
! X07 rr1~
w cr
w
co cr
0 (D
~u 41
rn N A
Co. -4 M
® o
o
a ) cn
n. n
~Q m a
® ® u 4
r
Pj
• • • •
C~ A
cc 0 q903 ~ o m o a~i
w mac? m 3~ 0_ca=' c :]Dc?m ? Q
m
0 _
oc ti m CO ~n
CD x •C
X O
0- CD CD
(D <
0 o. 0 ~ n
v
v-1 C,)° N o o
c w o
o
C 3 n~ m co
Cn -0 W _0 CD N A v
U) (0
O v O
D p. w 1 ()1
0 ~ W x
0 _
3 a; .
sE Q x. cr
I ~ ~ Q 0
00
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
1-40ol-and Human Relations Page 1 of 3
Division of Safety and Buildings in accordance with s. ILHR 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 St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - l~/asp print all ihfor)qation. evi ed b Date
Personal intortnation you provide may be sAd~pr seconcirpu ses (Pttwa`c w, s. 15.04 (1) (m)). 4
Property Owner jJ CVLJ
Property Location ~
Richard Stout Govt. Lot SE 114NW 1/4,S27 T29 N,R 19 )(or) W
Property Owner's Mailing Addres ~j Lot # Block# Subd. Name or CSM#
1353 Awatukee~' 1 s c°'~X
18 Badlands Prairie
City State ip a 7o um "tom ❑ City ❑ Village g] Town Nearest Road
Hudson WI 715,,,.E 6731
Hudson State Hwy 12
New Construction Use: Residential / Number of bedrooms 3 4 Addition to existing building
Replacement g Public or commercial - Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate . 7 bed, gl5d/ft2. 8 trench, gpd/ft2
Absorption area required R S $ _bed, ft 2_7 S (1 trench, ft2 Maximum design loading rate . 7 bed, 9Pd1ft2.8 trench. 9Pd/ft2
Recommended infiltration surface elevation(s).
qcL 10 _ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Glacial deposit Flood plain elevation, if applicable It
S = Suitable for system Conventional Mound In-Ground Pressure TAT-Grade System in Fill Holding Tank
U Unsuitable for system ~ s ❑ U s❑ u [ZS ❑ u 9S ❑ u ❑ S [ ❑ s ] U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 1 0-3 10 r3/2 none sl 1mabk mvfr s 2f .4 .5
2 34-E4 10yr4/ none ms _ os_g m_1 gs .7 '.8
Ground
elev.
101 , -5_ft.
Depth to
limiting
factor -
8 4 in.
Remarks:
Boring #
1 0-4 10 r3 2 none sl lmabk mvfr s .4 _9
2 2 40-96 10yr4/6 none ms osg ml gs .7 ,8
Ground
elev.
103.35 ft.
Depth to
limiting
factor
9. 6-in. Remarks:
CST Name (Please Print) Signature Telephone No.
l/~°a. n~- .tea `i ~c ~e•-, ~t'+~_ ~ ----~~,....,r~ ~~~r - ~~G t
Address Date CST Number
~e s~ ✓ o/c f' ~ ~ 9 ~a 7 9 Qo
f Richard Stout SOIL DESCRIPTION REPORT
• PROPERTY OWNER Page 2 of 3
PARCEL I.D.#
3oring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 1 0-3 10 3/2 none sl lmabk mvfr !as 2f .4 5
2 32- 9 10yr4/ none ms os ml s .7 ,.8
around
)lev. ,
10 2
depth to
imiting ;
actor
8 9 in.
I
Remarks:
3oring #
1 -36 10 r3/2 none 1 lmabk
2 6-9 10yr4/6 none s s 1 s - .7 -.8
4 ,
around
elev.
102. 19 ft.
Depth to
imiting
actor
9 Din.
Remarks:
Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # 1 -12 10 r3/4 none sl 1mabk vfr Cs 2f S
5 2 12-4 10yr4/4 none sil mabk mfr s if .5'.6
3 3-9 10yr4/6 none ms sg 1 s - .7-8
Ground
elev.
105. 05 ft.
Depth to
limiting
factor
gin. Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95) -
~Q
0
o
~6r
.Y
o ~l
C
y Is
I.06q
JG
. 1
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Sri y1 M ~L , rte
Mailing Address ~/3®X r S
Property Address 60 W i~ L
(Verification required from Planning Department for new construction)
2 d` 1 3 3 3 a
City/State y S 0~1 W I Parcel Identification Number!)
LEGAL DESCRIPTION
Property Location c--, C '/a, '/a, Sec. Z' , T 29 N-R Town of N p50 A)
Subdivision 13 A D 04 ~J 0 5 A 1 f l f- , Lot #
Certified Survey Map # a Co , Volume , Page #
Warranty Deed # 7 Volume 1 3 Z , Page #
Spec house yes ❑ no Lot lines identifiable fA yes ❑ no
SYSTEM MAINTENANCE
Impiaper 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, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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
days of the three year expir ttiiion date. cy
A O APPLICANT DATE
„ ~1s03 MER 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 rape. rty a`ie5cribed a ve, by virtue of a warranty deed recorded in Register of Deeds Office. Q
(D/%/
NATURE OF ` PLICANT DATE
Any informatio- that is miS-represented may result in the sanitary permit being revoked by the Zoning Department.
i
Include with this dplication: 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
p STATE BAR OF WISCONSIN FORM 2 - 1982
t S8O111 WARRANTY DEED
g
R DOCUMENT NO. . I '7 pal' / RE
Off-
RICHARD 0- ' ST01111' Rwd fW u-4
i _ JUN 4 21998
8:30 A
conveys and warrants to _ SAM V MTT.T.F'R ~ R~.`
~ 1
wtain.
THIS SPACE RESERVED FOR RFCORDwG DATA
NAME AND RETURN ADDRESS
the following described real estate in qt- -Croix County. 5-A/~j ~jl LL C R
f State of Wisconsin: n D O Y` / S/
I
Lots 18 and 21, Plat of Badlands Prairie, 14VavoN
1 Town of Hudson, St. Croix County, Wisconsin.
Y.
i - PARCEL IDENTIFICATION NUMBER
t_
I
p
p TRANSFER
o
FEE
6
I
I r•I' ~
This -i s not homesuad property.
(is) (is not)
Exception to warranties: easements, restrictions, rights-of-way and covenants V
of record, if any.
i
Dated this 90th day of --May A.D., 191x_.
Richard O. Stout (SEAL) (SEAL)
E
_ (SEAL) (SEAL)
:r
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ State of Wisconsin,
ss
- St. Croix
-County
authenticated this day of 119- Personal- came before me this 211th day of
Ham 19_1$_, the above named
_}2i =hArd n_ CtIn11t "A
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by §706.06, Wis. Stars.) e to me known to be the person who executed the foregoing
!~i 4-r mstrunknt and acknowledge the same. t
'•f l J }
THIS INSTRUMENT WAS DRAFTED BY f1 F It Y
Janet P. Stout ►
w~Tr~ y_ Vi. inia R. Gartman a
-1-M Awa-tukee-Tr-
-CIO Notan•Public, St. Croix___ County, Wis.
(Sig-ateres may be authenticated or acknowleu Bit r l~ My commi>;icn, is permanent. (If not, state expiration date: a,. t
necessary.) '+«..,...•'~Y Januar_ 30,_ 2000
• Names of , e,r-ns ssgmng in. an) c+rxtiy should by typed or panted Ixla tbetr signatures
STATE BAR OF wI VCONSIN W-scas.n LegW E- Co.. nL.
WARRANTY DEED Form So. 2 -1982
Mewa,lu~. W';s
~~1 F 314.76. a 512.94• \J 11l \ \ ` \11
ssiasF v
o ~SO719'14.. Sy~~.6~N uT vrJ
rn 116.97`- ;L 9L M u w \C
wn V \t
M£ NS M „h,Z0.00 N 0 ,0
m 4y . /
CL o ci D 4,'y// o
CI ozc
c y v` 66'62V M „IS,ZG 0U N./
au m
C) IA A b P /
0ZL
m Z D:~ A nl
to !In--m D r7 r0
ark n n11 Y-Jll 1 \
).A . k LA
- r.
m
r.
I Y fn D T ~ • 1
M
:y A nJ m. ~ l l
D :g c co .91'B5f m \
C s I^ i° C 1 t+ jai r 1_ ~c~
n+a
f. ! J A..A-~
r
y J r
Y! f fTl ]
~Dl
• al, w rn ~ \
1 ~ z c ro N ,
U:
T X
t'
"Vol
tS .,J !
p N V
lrA1 \t j ~ N O ~'J ~~n1 ~l
f I
i I b V. 109.7) r
n
f } FAST LINT O 7HE M/2 OF THE SWI/4 OF THE NL-1/4
N-0 0
- Q1
• r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division County T . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarie"t".:
Personal informatiio~~trn~~ you provice may be used for secondary purposes [Privacy L r, s.15.04 (1)(m)].
MILLHolder's SARe: [i fibcdaki age El Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel IDlgu,-~1333-80-000
TANK INFORMATION ELEVATION DATA A9800281
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P / L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Septic NA Dt Bottom
li Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
1 Loss Friction System TDH Ft
TDH Lift
Forcemain Length Dia" Dist. To Well
Fi
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia_ Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes No
COMMENTS: (Include code discrepancies, persons present, etc")
LOCATION: HUDSON 27.29.19,SE,NW 659 RED MAPLE LN - BADLANDS PRAIRIE ~o1-jg
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. -1 F
SBD-6710 (8.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
~•■`r■r. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83-05, Wis. Adm. Code P.O" Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sani~taarry PSermmit NNuf mber
The information you provide may be used by other government agency programs E] Check it revision to previ~pplication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name _ Property Location
)err-t 7 Mc llel- .S F 114 n(C✓1 /4, S ~ T 1-7, N, R E (or)o
Prort y Own~rKailingde Lot Number Block Number
City, State l/~ e Zip Code Phone Nu ber Subdivision Name or?CSM Number
~✓C~S~ &'✓Z 5,vel(6 (7()-) ~
II. TYPE OF -BUILDING: (check one) ❑ State Owned Is City ~sG BarestARoad
E] Public Pi~r 1 or 2 Family Dwelling - No. of bedrooms E .Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo 01?- /-r 333-S-10
2 ❑ AssemblyHall 6 ❑ Medical Facility/ Nursing Home 10 ❑ 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 13E] Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only ExistingSystem 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 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12S Seepage Trench 22 ❑ In-Ground Pressure ss~~ t 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
1,?"7,16) Feet 403. 3rFet
VII. TANK Capacity In gallons Total # Of Prefab. Site Fiber- Exper-
INFORMATION Gallons Tanks Manufacturer's Name Concrete strutted Con- steel glass Plastic
, New Existing App-
Tanks Tanks
e c an r Holding Tank r' 3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ El 11 1:1 ❑ 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's Signature: (No to s) rPM4PRSW No.: Business Phone Number:
X61'-( 715-3r1-(7oti
Plumber's Address (Street, City, State Zip Cod
W. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Iss gent Signature (No Stamps)
Approved E] Owner Given Initial 0t0lp Surcharge F ee)
°7 /611d Adverse Determination JX. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Connl y, One copy To: Safety & Buildings Division, Owner, Plumber
T ~ .
s ;
LOC'tzfi; c. Na~~s ~ ~o~vlu...-•c.~ t ~ ~ s
b
o
5
jf M 2
f/PV
`mss t ~ F
y0o
_ QD
i ~ e ~ Wcl~
r
t
1-76 , 40
e r~ 4
Pa/~ Y u
r
I~