HomeMy WebLinkAbout008-1019-60-050 (2)SANITARY PERMIT APPLICATION
ln accord with ILHR 8i).05, Wis. Adm. Code
-Attach complete plans (to the county copy onty) for the system, on paper not less than
81Ax 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATIO]iI - PLEASE PRINT ALL INFORTIATION.
EIItr
--
HFI
7
COUNTY
ST. CROIX
STATE SANITARY PERMIT#
a "(f ,r?,"#*-r#os appr ication
STATE PLAN I.O. NUMBER
PROPERW OWNER
JEROME WYNVEEN
PROPERWLOCATION
SEylNW%,S7 T 2qN,R L6 e(or@
PROPERW OWNER'S MA]LING ADDRESS
1160 LOCKHORST
LOT #
N/A
BLOCK #
N/A
CITY, STATE
BALDWIN I4/I
ZIP CODE
s4002
PHONE NUMBER
1 7Ls 1 684-2842
SUBDIVISION NAME OR CSM NUMBER
N/A
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008-1020-30
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VILLAGE:EAU GALLE
ll. TYPE OF BUILDING: (Check one)State Owned
Other: Specify
lll. BUILDING USE: (lf building type is public, check allthat apply)
NEAREST ROAD
47TH AVENUE
10
11
12
13
Medica! Facility/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Office/Factory
ApUCondo
Assembly Hall
Campground
Church/School
Hotel/Mote!
Outdoor Recreational Facil ity
RestauranUBar/Dining
Service Station/Car Wash
E puUti" E't or 2 Fam. Dwellinffi of bedrooms 3
lV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
B) E n Sanitary Permit was previously issued. Permit #
54
Date lssued
Repair of an
Existing System
Reconnection of
Existing System
Replacement of
Tank Only
A) 1.8 u"* 2.
System
Replacement 3.
System
Other
trtr 4t E notoi ng Tank
42
43
N A
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA
REQUIRED (sq.ft.)PROPOSED (sq. ft.)
99.94 loo.-Feet
VI. ABSORPTION SYSTEM INFORMATION:
600 1000 1000
Experimental
30 E Specity Type
4. LOADING RATE
(Gals/day/sq. ft.)
.6
6. SYSTEM ELEV
97 .9498.77 Feet
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution
21 fl uouno
22 A ln-Ground
Pressure
11
12
13
14
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fill
Pit Privy
Vault Privy
5. PERC. RATE
(Min./inch)
7. FINAL GRADE
ELEVATION
CAPACITY
in oallonsVI!. TANK
INFORTIATIOil New
Tanks
Existing
Tanks
Plastic Exper
App.
Total
Gallons
#ot
Tanks Manulacturer's Name Prefab.
Concrete
Site
Con-
structed
Steel Fiber-
glass
Seotic Tank or Holdino Tank t 200 1200 x t-t1MIDhIESTERN PRECAS T
Lift Pump TanUSiphon Chamber
VIII. RESPONSIBILITY STATEiIENT
l, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP/MPRSW No.:
32L5
Plumber's Name (Print):
BENNIE HELGESON
Plu
>.--a
s Signature: (No Business Phone Number:
(7L5 | 772-3278
Plumber's Address (Street, City, State, Zip Code):
\]L229 77OTH AVENUE, SPRING VALLEY, WI 54767
7
\X. CANJNTY/DEPARTMENT USE ONLY
,Mr,o,"o
{mps) ./a--/
\*1CIS'-
Disapproved
Owner Given lnitial Surcharge Fee)
rmit
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I I
I.Ir-rr-ilTTITII
SBD-6398 (formerly Plb€7) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
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INSTRUCTIONS
A sanitary permit ib valid for two (2) years.
Your sanitary permit may be renewed before the expiration date,. and at the time ol renewal an:r' new
critsria in the Wisconsifl Administrative Code will tre appiicabi.?.
All revisions to this permit must be approved by lhe permit iisurng authoritt
Changes in ownership or plumber requires a Sanitary Permii -:r anslef/F r) n."u.,.i 1 Firm isBtl 6399;'c be
gubmilted to the Lounty prior to installa{9n.
Orrsrte sewdge systcnrs .nust be properiy rlrc.i 'ldr,,.ic ''t,," ' .'. t3r1. c\ n,. ' 'r : ,. :.;r'.,.: L. :' ,',.' ,'- ''.'
pumper whenever necessary, usually every 2lo 3 years.
lf you have questions concerning your onsite se\,rage system, cc'ntacl your locai code admirist!'at{). or the
State of Wisconsin, Satety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include
Property ownsr's name and mailing address. Provide the logal description and f,arcel tax number(s) of
where the system is to be installed.
Type of building b€ing served. Ctreck only one and compiete # ol bedrooms iJ 1 or 2 Famiiy Dwelling
Building use. ll building type is Public, check all apfiropriate boxes lhat apply.
Type ol permit. Check only one in line A. Conrplete line B if permil is fcr tank replacernent, reconnectron, or
reqatr.
Type of system. Check appropriate box dependino oa syslem ty:le.
Absorption system info!'mation. Provida all inlo!'n,et;on .equesi''d 'n #1 7
Tank irilormation i-rii itr l!,i (apai:iiy of ev:liY i)(,n a.':i1,1-rr €\;ii'i' i,i;:. 's![ir:i',1,'! g;. i ,',s.:'i:;:,i.':,
tanks anC r,'.rnUfacturer's,ranre illdiciriep,r::'a:,ur.irli;Lriilt,i,u.::-:;e-.a,,.,rd..;,.;rl.r.ti;-ti-.,j:.
septic, ptilrp/siphon ,lnd holding tar,ks fJr iir r; !y:rir\f' Chect' r' :;r'i'r , :. -,i:.lr,r,a ', - I la,'
e;'ip*rin r'liltitl prc'duat app.ove! f rom Dil-hii
Vlll rtesn,'osibiiity stalernenl instaliil'g J)iumt],Jr rsrli'Iil' rr, n?.r1e 'i,f.'i\!,!,,'ir,e..,v!,h 9:. ('r(.,:r'i?ii, i,'e!,:. i--!
lvlp, ctc.), address and phonc nu,f bet. PlLlnrber |rlus I S;ajn ai,i,i;,,,11 nn ir.. .n
lX. County/Departrnent Use Only.
X. County/Dei)artnrent Use OIriy.
asmplete l-.lens and specilicaltlon: not Smaller tharr ii; .. I: l|:rrr:e: z'L'.:t i.r s,,lj,\ .lt {r to th. .-.' 1t! l .
plans n'iL,-:t, r.-]i.le th! r0!l,j+i-,!l .l Dlol l'.in ,.,,.1,-. 11 ;1 .1o,, ,.. ";lh ,a ..,,:, tr,i:. rO;
nil:iir,:..\!aF!l:'],5ei:,t|/1;1kl,j-ari,,il]i}i'|eatln1-'|.3|'!r|i;:'''
:l!eair!S "rnd lnr.aS or'rr'o {,r Siph.',i tanks ,liqtr;h'rl',"t [:r,,rs <..r,.t.-,,,...tj,,,...:,srdr]-,! ,olicl.ir.,
-::35 :ind i,iii: i|r-,1i -:i',,i lhe )u,ll,,,n Ser.i,ti I ) ' ,' . , ' , I . : :.. ' ,..i'i,? .1,\"':i. r. :,r.i,pii.::,:r,-,i ::
C) ccnrplete specrfrcatinrts lor putrps and L:onlruls; rjlsg ,,i,,,:jiri, t)icv31 r)ir ,iriiL'c,:...j-: tr,cticrl :csl;: i,uirr!'
performalce curve; pump model and pump manulaa';urer. D) c:',rss secliorr r',f iie siii absorption slsterl ii
__ required ty the county; E) soil test data on a 1i5 iornt; 3n{ F) ail sizing 'nlormation.
GROUNDWATEN SURCHARGE
1983 Wisconsin Act 410 inciuded the creation ol surcharges (fees) :,:r . numbcr or
regulated praclices which can effect groundwater.
.
vlr
ihe monies ro!lected throuEh these s,.ircharges ir.rrl
water L,onta,rnlnation ir)vesliUations and Establishrr...,
r} i i \!. qionii ,i I ': i'L: 'lCl'ral'::'
sBD-6398 (R.11/88)
APPLICATION TOR SA}IITARY ?ERMIT
src-100
thls appllcatlon form ,.s to be completed ln full and signed by uhe owner(s) of the
property belng developeil. Any lnatlequacLes w111 only result ln delays of the permit
lssuance. Silduld thls developmen! be lntended for resale by owner/contractor, ("spee
houset!), then a second foro shoulal be retalned and completed when the Property ls
solil a. nil subEitted to thl.s offlce rrlth the appropriate deed lecordlnB'
Onner ofr Property
Locatlon of PropertY SE, \,J,bJ \, section 7 , rJ.f_N-RJl-w
Townshlp
Address of Slte
Lot Nufrber
PrevLous Or"rner of Property
.!_1.
.:r_\Total Slze of Parcel 375
A.re all corners and lot ll,nes ldentlflabl-e?Yes No
)(No
'.'.
Vo1ume.-andPageNumber&lsrecordedw1ththeRegisterofDeeds.
INCLUDE WITH THIS APPLICAT ION THE FOLLOWING:
A Warranty Deed which lnclud es a Document number , volyme agd PaBe number, and the
Seal of the Lster of Deeds.In.addlELon, a cerELfLed survey, lf aval1ab1e, would be
he1pfu1. ao as to avold delays of the revlewlng Process' If the deed descrlptlon refer-
ences to a certlfled Survey Map, the Certlfled survey MaP shall also be requLred'
PROPERTY OII,NER CERTTFICATI.ON
1 l0/el cutlila that a!2 6Ldlatw.L6 on tfui 6onn Le tttue to th.e bu.4 o[ .nq lo.wtl
i^iiiiLaii;'tii,i-{l-;l-^- (iol ii o*"nnto\ oi thz pttoput'ttl.ducnlbed in tht"d;i;;;;;ilr"'i;^-. i;;il,r"i ii'" *a,rur*q'deed-necoided in -the ll{ice od *he
i:;iryri-n;s:iA{err'ot--beilai-oobient No.' ;.and-thctt.l lrttel wuen4s;;; iie pi;p;iea i,ui lri &L-Iruiie itpoait rytffi 1oa 7 lwel have .obtt'Lned an
nai^iii. rt-,,ttn;ilithih; "6;i-iAa"iui7 pnopni'tq, $ott the cow tuet'ton o( -aaid;A-il::'r',T rh"'a-ii-nii-aiLi-a,7"iiiiiida i"-*{o66iee o( *he coutq Resi'ttott o{
Oeedt, u 9oement. No. . _
-)
s OF OWNER
S:- l7- 9.3
SI 0F co-oI,NE
€-27-
DATE SIGNED DATE SIGNED
73
(rr APPLTC$LE)
\
Malltng Address
Is thls property belng developed for resale (spec house) ?
-
Y""
ir
DOCUIvIEIJT NO ' I WARRANTY DEED
STATE I]AII OF WTSCONSIN FORM 2_'982
4?5502 , vo! ,9'ZLpAcrSzB
{9?9Ph H: lonmei91
hr-rs-band ..and. wi f e
and Bern.ice D. Lohmeier,
convel,s and rvarrarrts to -. ..J-gf-9I[e.-.].{r ..W.Yn.Y-9.e-n -.?ng.
-Joy-ce...W1rnve.€o-,...hushan.d . a.nd . w.i f 9., ..h-el.d rnq
.a.s.--s.ur.vi-vor.sh-i.p .mar-ita I .pr.ap.e-rty .
_rHts spACE RESERVED FOR RECORDING DATA
REGISTER'S OFFICE
sT. cRotx co., wt
Rec'd for Record
. i',.r I i)'{ lggl
AoJ 12 :05 P. li
try.,fl.,W
L..
[ "cruHni rc,
the follou'ing described real estate in
State of Wisconsin:
S b..-.-C.r-o-ix -County,
Tax Parcel No
South Half (S2) of the Fractional Northwest Quarter (f'rf - NW'6) of
Section Seven - (7), Township Twenty-eight North ( T2BN) , Range
Sixteen West (ntOW), except a One-half (l/2) interest in a strip of
land Twenty-six (26') feet wide along the North (N) side of said
real estate deeded to Henry Heebink for road purposes. The West
Fifteen Rods (Wf Sn) of the SouLhwest Quarter of the Northeast
Quarter ( SWtr of NE% ) of Sect i on Seven (7') , Township Twenty-e ight
North ( T2BNi, Range Sixteen West (ntOW) , except a One-half (l/2)
interest in a strip of land Twenty-six (26') f eeL wide along t,he
North (N) side of said real estate deeded to Henry Heebink for
road purposes. AND further excepting that certain parcel described
in a Warranty Deed to Phi 1 ip L. Nelson and Patr icia A. Nelson,
recorded May 12, 1972, in Volume 484 of Records, at Page 165,
as Document No. 31OZt4.
dbSoe,t #.dl-
This -- i-S- -.--.- homestead property
(is) S{xxoty
Excepticn to rvarranties: EaSementS and f estriCtionS of record.
Dated this /tt
( sEAL)
{9s9ph t1 :. L.9!fe 1er
( sEAL)v
.Be rn i C e- . D-,....Lohme 1 e f
ACKNOWLEDGMENT
AL)
EAL )
day of
AUTHENTICATION
Signature (s)
I
TITLE: MEMBER STATE BAR OF WISCONSIN
(rf
Z by $ 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
.---Tha-m-a--s-..-A cCo rma ck
- - - -B-a.t d-1v- I o- r- - - -![ I - - -5- 4 002
STATE OF WISCONSIN
St. Croix I
I
SS.
County.
Personally came before me this
lUrlu.(ry.9f.Joseph
(, -.--.-- 19-.9.1.- the above named
H . Lohme i'er and
Bernice D. Lohmeier .lA-]------
to me knorvn be the person --S-
foregoing u t and acknow
-t
7.futnrr A.. Na?.Matt
q
L*
\f isconsin
rtj!rr.1,1,ka.
1 ir 11
Blorrk Co. I
Notary Public .-.St.,---CroiK .- --County, Wis.
My Comnrission is pern'tanent.(If not, state expiratipn(Signatures may be authenticated or acknowledged. Both
arernot neeessary.)date:
.Namec of peraons signlng in any capacity should be typed or ;rrinted below their sigtratures
STATE BAR OF WTSCONSIN!-onM lJo. 2- l$lt2WARRANTY DEED Legal\vi"
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STC 105
SEPTIC TANK MAINTENANCE AGREEMENT
St . Cro lx Count Y
+OU'NER/BUYIlR
ROUTE/ BOX NUMBER /)
CITY/STATE
PRoPERTY LOCAT IoN : 5E \a,{ /V!/-\, Sec c Lon 7 ,
Town of E G- //..
Subd lv le lon '
St. Crotx
a maxlmum
whlch was
eccepted t
ounera of
SICNET)
WT
Flre Number Z/.73
'/. L? ,f ///2
r 2F N, R 16.._w,
St. Crolx CountY '
Lot number
tJr*"^
IJL' ,?73
Irnproper use and ma lnEenance of your sept 1c sysEcm could result ln
tte premature fallure t,o handle urastes. Proper maintenance c(rll-
elsts of pumping ouE Ehe septtc tank every Elrree years or aooner I
tf needed, by a l lcensed septlc tank pumper. WhaE you Ptlt lnto
the BysCem can af fect Ehe functlon of Etre sept1c tank us a tre.rt,-
ment atage 1n the waste dlsposal syst,em.
CounEy resldenEs mav be ellglble to recelvc il Brallt l'trr
of 607. of the cost of rePlacemenE of a falllnB system,
1n operatlon prlor to July 1, 1978. St. Crolx CotrnEy
hts program 1n August of 1980, wlEh the rcqulrement tlrat
a 1l neu, _gf_g_t_g11g agree to keep the 1r sys t ems proPe r I y
malntalned.
The property owner agrces to submlr Eo st,. crolx county 7.on lng a
certlflcaElon form, signed by Ehe owner and by a master Plumber'
Journeyman plumber, restrlcted pluml>er or a llcensed Ptlmper vcri-
fylng that, (f) Ehe on--slte urasteurater dlsposul system ls tn Proper
operatlng condlElon and (2) after lnspecElon and pumPlng (ff nec-
essary), the septlc'Eank 1s less than L/3 fu11 of sludge and scum.
CertlflcaE lon form wl11 be senE approximaEely 30 days prlor Eo
three year explratlon.
TlVlE, the undersl.g,ned, have read tlre above rer!utrements and a!l!'ee
to malntaln the prtvate selrage dlsposal sysrem tn accordance wich
the sfandards set, forth, herelnr 3s seE by Ehe Wl.sconsln Depart-
ment of Nat-ural l(esources. CerElf lcat, lorr form must be compleccd
and reErrrrred Eo t,he St.. CroLx CounEy T.onlng Of f !ce wlElrln 30 d;rys
of the three year explratlon date.
t) A't' I
St. Crolx County T,onlng Offtce
P.O. Box 96
Hammond, WI 54 01 5
7 1 5- 7 9 6-223c.t or 715-425-8363
Slgn, date antl return to above address.
W,,$.
t .- W,1'66n1,^ OeOJ.l16p/.t Ol lnCtUttry.
Labor and humrn Relatront 5UlL Ut)Lnlr I tVrr .\Lt vrr I
" 0 ior '':l(Attach Soil Prolile Location Map - To Scale - On A 5eparate. Signed Sheet) r.r;d';;n, .'.i-:J;u"
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DEPIRTMENT OF HEALTH AND SOCIAL SERVICES
OIVISION OF HEALTH
MAtL AootEgs: P. o. lox 3og
MaotsoH, wrscoNslH 53701
IN REPLY PLEASE REFER TO:
SECTION OF PLUMBING
AND FIRE PROTECTION SYSTEMS
Lffit tqlifit
Dolilt * Grcgerom trarrlusrt, Is,
Baldrln, If ,tffi
Plan Identtftcatton No.TTOfiL?
Dear Slr:
rU& Ltru*l lr*
. ,e cfga ittrfpcal
,is* fil* s? fdsf 116, mfp d frr Otll., *f - iit. erol,r Cffi
Ttrig ts to acknowtedge recclpt of your planr and tpeclftcatlonr for the above-
tndiceted proJect.I{tren referrt nc to thla olan ln the future tt wtlL be absolute lv
Re
neceSSa to uttltze the lan identlficatton numbe a dto The
8PACe8 oeI lcate 1 proPe r feea heve been aubnttted or lf more inforuatlon ta
rcqulred. ProvldlnS plrn rcvlcr 1! not c6plet.d rtthin thirty (30) d!yr, . P.mitto atlrt conrtructton ory bc ierucd lf raqucrt€d. See Saction Il 62.25, llllconlln
Adolnlrtretlvc Codc, for lloltrtlonr ln reference to perDltr to ttrrt cooatructlon.
PrcltEln ry plen rcvLeu for datarEtnatlon of fae! does not hold thc daPart[ant
lttbla ln tha Gvent rddltlonal fecr oay bc requlred upon corpletc pkn rcv{cr.
Prcllrlotry rcviev lndlclte. th. plan revlcr
/5
N Plan accepted for rcvter.
Fee 1r betng returned beclure of f| overpayncnt tr Underpayrment.
Provtdtng one of the two catagoriee abovc le checked, please reutt correct
toteL fee Ln one psyuent. Indlcate plan ldenttflcation nuuber on remtttancc.
n No fee har been remltted. Plans rubmitted wtth no feec wtll be held ln
abcyence until renlttance la recetved. Indleate plan ldcntlflcatloa
number on reotttance.
Addlttonal lnfornetlon required. See attaehed Plb. l0O. The penttt to
start conrtructlon wll1 not be lerued untll 30 dayc after requested
lnfornation ic recelved and lccepted.
tr Plang belng returned. See ettached Plb. 1OO.
S lncrrc1y,
[at A.
Chtcf
Fee requlred tg $
Fec recclvcd is $
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Systcm Elcvation
CST Namc (Ptintf City / I Slalc Zip
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OI^INER
ADDRESS
suBDrvISroN / cslr#
SECTION T
ST. CROTX
Provide setback and
STC 10 4
AS BUILT SANTTARY SYETEM REPORT
lca)
2K w-R-l-L w,
I,OT #/UA
own o f
S B,1a. q U.R.P t Scl .d
T,oF T.P.J.
n information on reverse of this form'
S.ol-
I ":Y r)
/
Jo-)D
k{
P
SHOW EVERYTHTNG I^I
vrEw
IN 1OO FEET F SYSTEM
-!,_
I?)
b2
pooS;.-
s{-t'c
,il1:8
INDICATE NORTH ARROW
Provide 2 dimensio nter of septic tank manhole cover'
f
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BENCHHARK:loo oo <
ALTERNATE BM:
SEPTIC TANK / PUMP CIIAMBER / IIOLDING TANK INFORMATION
Manufacturer:\!\Liguid capacity:/Doo 6J Q/,.
Setback from: WelI #,
-W--1b oI{ouse -#vg Other t
Pump : Manufacturer Size
Float seperation
Alarm Location
Gallons/ cycJ-e:
SOIL ABSORPTION SYSTEI.{
/& / Number of trenches )width , 5'
Distance & Direction to nearest prop. Iine:Al n,+L <o'/
setback from: r.rell: 132 '
"o,r="
r
? I other
ELEVATIONS
Building Sewer /ngL7 ST Inlet ,l}l , b ST outlet
PC inlet PC bottom Pump Offqq.-77
'3
ffi ,6t gY
/oo.3
Header/Mani foldl Bottom or system [fii oI ,';"g,
Aod-M^EA17.rVW
Existing cradeLott;zq- ??, 6O FinaI grade
DATE OF INSTALI,ATION:a ,:?t ?\
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:1t
qf"*
J-ou.le,.t-
7
3-l/{
Q
Model # (--
9
vHt.,
- d6n'artn*&Ui rfrAtrnlE 7 .28 . l6pflrtflft?fftVfiEt.SysTEM
Labor and Human Relations
safety and surlJrngs Drvisron INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
TANK INFORMATION
TYPE MAN U FACTU RE R CAPACITY
Septic (ll,rfi,;a hr^(ht*t rl Dtoc'o
Dosing
I
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO PIL WELL BLDG vent to
Arr lntake ROAD
Septic 7 So'bor 45 l5,0t NA
Dosing NA
Aeration NA
Holding
PUMP / SIPHON INFORMATION
Manufacturer Demand
GPMModel Number
TDH Lifr Friction
Loss
Svstem
1-{ead TDH Ft
Forcemain Length Dia Drst To Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA A9300137
Permit Holder's Name:
I^IvN\7FFN JIII]OME M tr .TOVEF:
Qfown offl City. I Village
RAII GAT.T.II.CfI.BMTI6V:'
/'
lhsp. BM Elev
/bo/t j4--
BM Description
fl),.;t . -t-.
unty
Sa n ita ry erm r
State Plan lD No
ParcelTax No.:
ooR-1rl).o-?o-ooo
STATION B5 HI FS ELEV
Benchmark /o7 7 5 /oo
Bldg. Sewer
st / Ht lnlet (./t0'/L/
St/ Ht Outlet -7'l /ob -2
Dt lnlet
Dt Bottom
Header / Man 8,q L
7,79
?r.E3
aq qi
Dist. Pipe
q8 'L
Bot. System t0
4.
? t.'z s
Final Grade 7 I /)'7
qq"?/
')
n 0./ h )
BED / TRENCH
DIMENSIONS
Wrdt 5 Length //oo No. Of Trenchesz-,PIT
DIMENSIONS
No Of Prts lnside Dra Liqurd Depth
SETBACK
INFORMATION
SYSTEM TO PIL BLDG WELL LAKE / STREAM LEACHING
CHAMBER
OR UNIT
Ma n ufacturer
TypeOI T/att)
System :-azz.tt C/-5o'?s1 /3.2 ^// fr Model Number
DISTRIBUTION SYSTEM
Header / Manrfold
Length Dra
Distribution Pipe(s)
Length Dra Spacr ng
x Hole Srze x Hole Spacing Vent To Arr lntake
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed / Trench Center
Depth Over
Bed / Trench Edges
xx Depth Of
Topsorl
xx Seeded /Sodded
fl Yes D No
xx Mulched
!Yes INo
COMMENTS: (lnclude code discrepancies, persons present, etc.)
LOCATION: EAU GALLE 7.28.L6.98A,47TH AVE.
t'
()\i
Plan revision required? fl Yes D No
Use other side for additional information.
sBD-6710 (R 05/91 )
7 d3 73 4 (.')I
Date I nspe or's Srgnature Cert No
L
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