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HomeMy WebLinkAbout038-1091-70-003 ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT Owner � i r f n Address 074, Pee " G p �° City /State r c. S 017 COUNTY ?fJNINGOFFIC Legal Description: Lot Block Subdivision/CSM # 'V4 9 ' /4 & Sec. AA T, N -R1�W, Town of r PIN # U3 g -'• `P/ " 7 a-zb3 Ra. 3i. " - 7 c- SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/PC /D!�? Setback from: House &A_ Well 62!!� 114 .e Pump manufacturer Model ^ Alarm location -- (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Aak Width �°� Length 5,� Number of Trenches Setback from: House 70 Well // S PAL 7-5 Vent to fresh air intake f /4� ELEVATIONS • " J Descriptiop of benchmark S �oY'nn�. -S1' Elevation /4V Description of alternate benchmark 7,o'v Elevation IF Building Sewer 4 ST/HT Inlet 7 7S• ST Outlet- PC Inlet PC Bottom Header/Manifold 1, 75 Top of ST/PC Manhole Cover Distribution Lines () T-9, Bottom of System (,c) �- () ( ) Final Grade ( ) t ( ) ( ) Date of installation 31i71 ? her U numbe x315 26 State plan number Plumber' S signature License number 1 5 Date /lJlfy Inspector Complete plot plan or WisconJn Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT CriblX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 7)0-7&6Z> Permit Holder's Name: ❑ City El Village ❑ Town of: State Plan ID No.: UGL I Ovev+ %W rl 'G CST BM Elev.: Insp. BM Elev.: BM Description: 54wi,G kS Parcel Tax No.: t ( 0 r S � car t Ke. - C-STs 0 '47 -It' l l -70 TANK INFORMATION ELEVATION DATA 4 3 JI TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmar ,�� /p� /p© Dosing At �- $m q Aeration Bldg. Sewer 4 4 Holding Inlet to -o C f7 TANK SETBACK INFORMATION S)4R Outlet 61 97. TANKTO P/L WELL BLDG. Ventto Airintake ROAD Dt Inlet �✓ Septic 17 pr NA Dt Bottom f� Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System 95 PUMP/ SIPHON INFORMATION Final Grade VJ-7 Manufacturer Demand � I�a�aHc I 3 100 .22— Model N er GPM TDH ft Friction S TDH Ft oss ad Forcemain Leng Dia. Dist. To Well SOIL ABSORPTION SYSTEM TRENCH Width I Length. J r No. Of Trenches PIT No. Of Inside Dia. Li d Depth DIMENSION T I DIM EN 1 N SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Ma acturer: SETBACK CHAMBER Mo el be . INFORMATION TypeO t (C>4 O Syste 70 DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _ ° Dia. � Length Joy Dia. � Spacing AST/H sG Z7�� 7b� SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over � xx ep th Of xx Seeded /Sodded xx Mulched Bed / Trench Center Bed / Trenc dges ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 1/414 o, e 1Ne,4( ( cAhd ov� 4tie, N VJ corv& 47if- 605e , Plan revision required. ❑ Yes No Use other side for additional information. , �� �a SBD -6710 (R.3/97) Date Inspector's ignature C .• Y0 6 �� - S f /L TD ��� /ASS C►.5 6 D a U t I f j 4d �r u SANITARY PERMIT APPLICATION •DILHR cou In accord with ILHR 83.05, Wis. Adm. Code � + 0, ro STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. 19 Chet r� o previapplication –See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY LOCATION gp 1 5 % A)kY /a,S dQ T i,N,R E W PROPERTY OWNER'S MAIL; G ADDR S Nl S , LOT # BLOCK # P CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Of C S o II. TYPE OF BUILDING Check one CITY ^ NEAREST ROAD ( ) F1 State Owned Q VILLAGE : jJ c TT eL ❑ Public N 1 or 2 Fam. Dwelling -# of bedrooms a PARCEL TAX N ER( ) III. BUILDING USE: (If building type is public, check all that apply) ® 38 — p 0 _ bo 1 E1 Apt/Condo -1 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 in line A. Check line B if applicable) A) 1. � New 2. El Replacement 3. El Replacement of 4. El Reconnection of 5. El Repair of an System System Tank Only c Existing System Existing System B) W A Sanitary Permit was previously issued. Permit # )? 7 x Date Issued �) V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 El Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ 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 COL42 q 99. t09 Feet 60 Feet VII. TANK CAPACITY Site in ciallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks strutted tic ank O ^ ,_ Lift —Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of nsite sewage system shown on the attached plans. Plumber's Name (Print): PI er's Signatu : (N to ps) /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, to e, Zip Code): gS; A 1 / �� fV [ IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date I ssued Issuing f�9 S na (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) (p C/ Adverse Determination VU X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber PAGE or _ CrUSS :.z fr�4A Alr 1111.14 And OD►4IMIGA Pipe ®a zoA Ai 'Q—' ('y '—. J"� AYY /•r:. jAVqj4gQj6 a 12•A4or• �V•nt Cap Gf.d. Sy0 i� 20 , 42 " Above Plpr •• Coal Ilan I " y�{ A) S � l 7 T o O�•d• �V.M Pip d 110 Or Co..�ln "zv f tic i r` .�_ yQ.opal• T•• • 0 0 0 --- •go14 Pip• ° Pulaol•d PI . ° 'Co In Y• Gylov 1 T.wallnollnp AI Oo11oM Of 3r41un Ibo, SOIL FILL DISTR1@UY101.1 PIPE 2 "OFA G GREWIF. _ / APPROVED yS�j/r{E7lC COVER � OR 9 ,, OF sTsAw �r OR MARS" 1{qy 1:LEV. OF FEE'r k7t �' /i AGGREGATE —� 1)iS'rRl15UTI011 PIPE 7U BE AT LEA57 AWU A7 LCAS7L0 1fJCNES BUT 1.10 MOR U y BE ORIGIQAL GRADE FINAL GRADE j Mx1muM DEPrH of F-Xe-AVATIo'j MINIMV Fi{ o!'i Ot{It,1►Jgl, 6911Da WILL BE � • 11 OEFT11 OF EXCAVA r-A e IGll�q� -- —__ INCHES �iR4O WILL 6E INCHES d • SIGUEO: LIGEtJSC IJUM6EIt: DATE:.. �� Wisconsys Department of Industry SOIL AND SITE EVALUATION of 'Labor and Human Relations Page Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County //pp include, but not limited to: vertical and horizontal reference point (BM), direction and 5 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information Re 'ewed W Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). / c, g Property Owner Property Location r — Govt. Lot /Y ti 1/4 IVU /4,S T N,R /,f +ri(or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# i 57A S i iJ F C 3 1. C.5 /Y\ u 1 s /Ys City State Zip Code Phone Number c Road r 7! i ) ,)/ (, . _501y ❑City Vill e [,� Town �y C New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow s L} gpd Recommended design loading rate r7 bed, gpd /fF trench, gpd /ft Absorption area required �'� 3 bed, ft ft Maximum design loading rate bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) 95. 12 9 ft (as referred to site plan benchmark) Additional design /site considerations, i Parent material 1 c� 4 S Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system s❑ U NS ❑ U S❑ U I' Ps ❑ U ❑ S MU [Is 9 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots g in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench (( 5 Ground IL" ` 1 :� VA N h , � • y elev. Depth to limiting factor ; k, 9L2 in. Remarks: Boring # LIU /4 9 7, S fir-{ S 05-1 vn 4r Ground elev. / aD ' ft. Depth to limiting factor n. Remarks: CST (Please Prin Signature Telephone No. Address Date CST Number 76 /f s >> -2 ;,,t 1 5�/ Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page _ of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY Attach complete site plan on paper not less than x 1 In hps "fttsize. Plan must include, but St. Croix not limited to vertical and horizontal reference i dir en o of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and,�ista a to 'es road 038- 1091 -70 APPLICANT INFORMATION- PLEAS.,PRINTR�J�RMAT1 R IEW DBY DATE • Zr PROPERTY OWNER: ��+ } r �• ROPERTY LOCATION Dale Bonte ` y�piX OVT. LOT NE 1i4 NW 1 /4,S 22 T 31 N,R 18 8(or) W PR 1526 TY HillsidelLlC A Cpl lG LOT # BLOCK # SUBD. NAME OR CSM # INO -4 na csm vol. 5- Pq 1459 CITY, STATE ZIP CODE R ❑CITY ❑VILLAGE MOWN NEAREST ROAD New Richmond, WI. 54017 X Star Prarie Ct rd. "C" [x] New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building I ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft •8 trench, gpd /ft Recommended infiltration surface elevation(s) 99.69 ft (as referred to site plan benchmark) Additional design / site considerations alt. area system el. == 98.25' Parent material outwash Flood plain elevation, if applicable na It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem I ®S ❑U El El 1 91S ❑U ®S ❑U ®S ❑U El NU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. BoLnclary Bed Tuch .................. ................. .................. ................. 1 0 -15 10yr4 /3 none sl 2mgr mfr gw 2f .5 .6 2 15 - 7.5yr4/4 none is 2mgr mvfr gw if .5 .6 Ground 3 27 -82 7.5yr4/6 none ms Osg ml na na .7 .8 elev. 10 Depth to limiting factor +82 Remarks: Boring # 1 0 -10 10yr3 /3 none sl 2mgr mvfr gw 2f .5 .6 2 10 -24 7.5yr4/4 none sl 2mgr mvfr gw if .5 .6 3 24 -80 7.5yr4/6 none ms Osg ml na na .7 .8 Ground elev. 103 ft. Depth to limiting factor +80" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. New Richmonjil, WI 54017 Signature: Date: 11 -15 -97 CST Number: m02298 STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Dale Bonte New Richmond WI 54017 MPRSW 3254 �4�4 S22- T31N -r18W town of Star Prarie (715) 246$200 lots 3 -4 csm vol.5 -pg. 1459 N 1 BM.= ROW survey stake @ el. 100+ Alt. BM.= top of tel. ped @ el. 102.80' S 557 �6 gM Gary L. Steel 11 -15 -97 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer , __�ctzkL Mailing Address / �d 6 *:t4 c dew � Y,, �Q w-,° -_ /'7 Property Address Ce G // (Verification required from Planning Department for new construction) City /State /I�¢�J I C 1 c.krn mrtr � Parcel Identification Number O 3 8 9 - 7 0 - D 23 LEGAL DESCRIPTION Property Location ME '/4, N W y4, Sec. 20 , T 3) N -R�W, Town of S _a R PA h— -T Subdivision , Lot # `l 6/y3 G'S rr Certified Survey Map # Volume .-s , Page # Warranty Deed # J C'' �O / G , Volume / oL y I , Page # V S 2 Spec house ❑ yes no Lot lines identifiable [ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and' by a master plumber, journeyman plumber, 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. Itwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification . stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. A SIGNA T U RE fA PPL ICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 1 ' FILED a 13 a� �; ' 1984 w SEE SHEET 2 OF 2 FOR DESCRIPTION 0� t 4 CERTIFIED SURVEY MAP 9 LOCATED IN THE NWI /4 OF THE NW 1/4 AND THE NE I/4 OF THE NWI /4, SECTION 22,T31N,R18W,TOWN OF STAR PRAIR- IE, ST.CROIX COUNTY, WISCONSIN. OWNED B Y: IRENEBALZART 18980 FENWAY AVE. NORTH s +Q UN,PL DS FOREST LAKE, MN 55025. KK y ATTE LAN ,�•4j��� Y L ''Y � j • WEST LINE OF - _ 1'1 : 2 n THE NW I/4. -_- - aNOC 1 t N0 "E 790.47 65.25 ,� a asm '• �v' m3: ` •r• -•• 418.79' 274.48'. 1 — it 't� w ° po r� yF�� 2 1 X33.84' ;� owi :< 00C 0 �. `,� ` s' l ' 1 'u y '(n . a 02 �B��gJIt110 /l1NV� 1 1 • 1 N c o •Gi N N K W _) 1 ^ r w . DF; v c` op :nf.ri mwo w n f o m of °00 20 Z; A N N A M CID W n 1 Iv F x •1 N N O x • VI m ♦ C G s 1 ,p q u n eNt In a a 9 1 SI.02'10 "W 511.77' um � ! /S.' a 3. 487.18' oZ • O 7 , O p '�ryII { N O O o 01 2 N O• m � k V � ©NtlN a fi b\ Vm Y ♦ N U x ��) •1111 W 'a, •1 N .00 A N m N 4. nI o °. p i o U1 9 E V I N 2 Mz - ,� 1-• b, SI °02'10 "W 477.12' p r� „` �? : \J m N 33 444.11' O APPROVED N / m :V u r o w � l.1 • IE u� u Z N ., v y 0 f11 O I N N 0 . $ I oN� o AC a e m $kP 0 51984 '-• -A i t� l • C-- N N OOS W ' �Y b - 0 En v - 1 :,,SrAXiOIX COU:'IY P. Z y m CQyICfKNUVE VA¢1c5 1:.;. -G N IE a JAN P ONING co - 111.1 SI•02'10'W 473.73' E _4Z to NOTE I11m ^ba °. C 4°, ZAofll it n roa f� BEARINGS REFERENCED TO THE NORTH Ire I ♦n 't' w „Fu.O; LINE OF THE NWI 14 OF SECTION 22. 1 1 yanw ° c�n.'� •� 1RECOkOED BEARING SB9 °46'54 "E). � �• *~ pcN 53.01' ••, _ I 415.88' ' 1 S I_ °_0210 ° .W H•S QUARTER LINE 1 I�'1 470,89' C UNPLATTED �AN SHEET I OF 2 Volume 5 Page 1459 83-143 71115 IeiS 7p11 w,1rnr no,crc� n, (Continued on following page) 13 continued CERTIFIED SURVEY MAP LOCATED IN THE NWJ OF THE NA AND THE NE4 OF THE NW4, SECTION 22, T31N, R18W,TOWN OF STAR PRAIRIE, ST.CROIX COUNTY, WISCONSIN. OWNED BY: IRENE BALZART 1 0 ENWAY AVE. NORTH FORREST LAKE, MN 55025 SEE SHEET 1 OF 2 FOR MAP INFORMATION DESCRIPTION I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of Irene Balzart, owner of said land, I have surveyed, divided and mapped said,parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed* and that this land is located in the NW4 of the NWk and the NEy of the NW4.of Section cy) 22, T31N, R18W, Town of Star Prairie, St.Croix County, Wisconsin, a+ to -wit: a That part of the NWk of Section 22, T31N, R18W, lying north - erly of C.T.H. "C Town of Star Prairie, St. Croix County, Wis- consin, being more fully described as follows: 0 Beginning at the NW corner of Section 22; thence S89 ° 46 1 54 11 E along the north line of the NWk of said section 2609.10E to the Nk corner of said section 22; thence S1 °02 11 W along the North - South Quarter Section Line of said section 470.89 to a point on the centerline of C.T.H. "C "; thence S89 °52 "W along said cent - erlina 677.00 thence S89 "W along said centerline 509.94 thence easterly 225.411 along said centerline, also being the arc of a 1000.00 radius curve wh is concave southeasterly and whose long chord bears 383 °17 "W 224.93 thence S76 °50 along said centerline 1227 to a point on the west line of the NWk of said section; thence NO °22 along said line 790.47 to the point of beginning. Contains 33.23 Acres including the Apple River( 30.14 Acres to the water's edge of the Apple River), subject to C.T.H. "C" right -of -way over the southerly portion; as shown. Also subject to any and all easements, right -of -ways or conveyances of record. APPR $EP 0 51984 Dated this y day of Ay CsV J� ,1984. SS. ,` 1/11 �, EmiVE / _ 11 (� y COAE►AEEIENSI VE .. > JAMES M, ti James M. Weber S-1804 WEBER Kozel, Wagerer and Assoc.,Inc. S• I 60 1 _ River Falls, WI SPRING VALLEY f Volume 5 Page 1459 f �ff SU N % 83 -143 This instrument drafted by SHEET 2 OF 2. Safety and Buildings Division , - SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. - `�sconsl n P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. ST Iv • See reverse side for instructions for completing this application State Sanitary Permit Number d7G The information you provide may be used by other government agency programs E] Check if revision to prev s application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I ' _ - Property Owne Name Propert Location o N I_ 1/4 L,U 1/4, S T , N, R J rE ) W Prop; wner's Mailing , itess Lot Number Block Number 66 b k 1 N City, State Zip Code Phone Number Subdivisio Name or CSM Number N.Q, -K; Inn© 5 0 l ( 7 (s ) �•5a4 S 0 II. TYPE F BUILDING: (check one) E] State Owned E] C it y Nearest Road C] Village ^� Public 5j 1 or 2 Family Dwelling - No. of bedrooms g Town OF ST'oL- rci,r, -Q- l R� C III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo 0-3 9 - )0 9( - 7® -0 0-3, > 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, New 2 E] Replacement 3 ❑ Replacement of 4 E] Reconnection of 5. ❑ Repair of an ____System System Tank Only 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 93 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ 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 a Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft_) (Min. /inch) o Elevation 16f_3 (P yle � � / A 16 7 Feet /05. /a Feet a t cc VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing strutted Tanks Tanks 17�a t �r 1:1 El El 1:1 El Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu tier's Name: (Pr PI tier's Sign tur ( o Stamps) pJMWMPRSW No.: Business Phone Number: �ex`v w e rs J IS& . 7 ! S �l Plumber's Ac dress (Street, City, State, Zip Code): 10 CY L A IhAb I'd j Lio t IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved - Sanitary Permit Fee (includes Groundwater Date Issued Issuin ent Signature (No Stamps) Jo Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 1 � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety 6 Buildings Division, Owner, plumber lo t , eal p �y 3 PAGE OF — :m Glib Ak 1111#16 AAd Ob/srvollon Pipo 1An14,— 12*Abov (2), Apps ovid Vaal Coo . flnol Grad• 20. 42' A bova Plpl1 To final O loch 4* Cast Iron Vsn! PIPa uarM Ilo Or S n1A•1k Co•Yr In Ovot 1pa� 01 � 1 r16vllon Plpa , 0 0 o Y j AV91 84 StlbPIP$ ° Pulaolad o PIPa II'�lov - "•Co,pllno TwadnoUny At Oouoa� 01 SlNam j 1l . P r o u 5 c D 1- j 9 ra cl •c Vc,)J I on / DI STRIBUT10f.1 PIPE SOIL FILL 2 �°FA�GGR GATE -/� • Appp",VrD OR 9 O gyNT► +ET,c covcR A' ^l- F 57it1�W OIL MARS HAy F,LEV, of yy► L ' o P.'�' UT i t` Iz AGGREGATE DISrRIgUTIOM PIPE To BE AT — � AUU AT LEAST ; _- ES LEAST t0 1►JCH[L 8UT LIp MORE THAW 42 INCH IuCIgES BELOW ' GRADE FINAL GRADC twviuM N p nj OF E)<e FKo ' MINIMV o R 16 VA . 6 D w1 Al O 5 F T1 1 OF FACAVATIo" �,� G RA1 WILL BE � Mr-HES _ �� I If �AL GRnvk W ILL ES E INCHCS SIGIJE,D: i LIGEUSC UUMBE11: DATE: TTo