HomeMy WebLinkAbout020-1286-60-000 (2)aTc - 10{
AS BUILT 8ANITARY SYSTEU REPORT
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ADDRESS
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sT. cRorx cot NTY, I,{IscoNsIN
Provide setback and elevation information on reverse of this forn.
Provide 2 dimensions to center of septic tank manhole cover.
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E+autBENCHMARK:
AI,TERIIATE BI.{:1^,*,J F^-.,n E1-, ?tO.sS'
AEPIIC TANK ,/ PUI,IP CIIAUAER ,/ EOI,DING TANK INFORMATION
Manufacturer:Liguid capacity z 9<ruo &+<.&'\OrNbsetback fron: well other
Pump : Manufacturer NA Model #4 size NA
Float sepera tion Gallonsr/cyc le:,\./A
Atarm Iocation A/A
width: S
'iSoIL ABSORPTIoN sYsTEu
Distance & Direction to nearest prop
setback froa: weJ.)-z -@{,-,House
EIJEIIAIIONS
Building
Pc inlet
sewer ?t9
. line: So,^"tt 52'
t other
ila
' sr rnlet,
Pc botton N A
?o2. ?"' sr outlet 1ae,)s'
Punp off NA
Header/Mani fold o ys tem
Existing crad€ ?OL./o'Final grade 7X.l<'
DATE OF INSTALI,ATION:
' Bottom of s
PLUMBER ON JOB:
LICENSE NI'MBER:
TNSPECTOR:
3/93:jt
n'/Pis 3ses
'roclBnst,€HD€ffir
Labor and Human Relations
Salety and Burldings Divilon
&.1. 2e . te .,ffi rrlfrrtHlviuE **tM c. t. h.
GENERAL INFORMATION
INSPECTION REPORT
(ATTACH TO PERMIT)
Permit xoideit Nartre:
qll!
^I!.!TY rrE:lrmlpns
E City E village
I{IIDSON
Q[own ol
TSTBMEIE!:--
iav /a
lnrp. EM Elev BM Description:
'. zroi ,;2 5Lt y'ri !',r' , r ,)
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY
Septic /d.u,u*-.,2.o t o
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
PUMP / SIPHON INFORMATION
Manufacturer Demand
GPMModel Number
TDH Lift Friction
Loss
Svstem
F{aad TDH Ft
Forcemain Length Dia Dist. Towell
SOIL ABSORPTION SYSTEM
A9 3 00112
unty
State Plan lD No
Par(elTax No.:
o20-2866-OO-OOO
TANK TO P/L WELL BLDG.vent to
Air lntake ROAD
septic 7o d13 -r5 NA
Dosing NA
Aeration NA
Holding
IIIIIIIII
STATION B5 HI F5 ELEV
4a4. loBenchmarkt.3 3 9 to. v9
5.C9 Q6 u. -.>Bldg. Sewer
st/ Ht lnlet 1.5 qoa,cl 7
St / Ht Outlet 7, -1
:.."
(iol '? -\
Dt lnlet
Dt Bottom
Header / Man ?,. t "r Y..i:
Dist. Pipe n
,j
Bot. System 7"tt l 40r,ai
Final Grade 5, )ti
IITII
BED / TRENCH
DIMENSIONS
width5 Length No. Ol Tren.her4 PIT
DIMENSIONS
No. OI Pats lnride Dia Liquid Depth
SETBACK
INFORMATION
SYSTEM TO PIL BLDG WELL LAKE / STREAM LEACHING
CHAMEER
OR UNIT
Manu{acturer
r,tpeol 1at,)
Sytter r,j..,, Cl'.?L.77',arf ModelNumber
DISTRIBUTION SYSTEM
Header / Manifold
Length _ Dia
Dirtribution Pipe(s)
Length _ Di.Spaong _
x HoleSize x HoleSpacing VeotToAirlntake
SOIL COVER x Pr$sure Systems Only xx Mound OrAt-Grade Systems Only
Depth Over
8ed / Tren(h Center
Depth Over
Bed/Trench Edgei
xx Oepth Ol
fopiorl
xx Seeded / Sodded
EYes ENo
xr Mulched
DYes ENo
COMMENTS: (lnclude code discrepancies, personr present, etc.)
LocATroN[qfuDsoN.?1.29.19.,NE,NE,1OT #16 & 17,
V'*Yi; ':? "d;1.: sF fi ol- , f ,s
ffi',' )-,ic :,'t'u- jt l, L iv \ \,i\i' oA! 7,' q,qq c.'.11
c.t.h. a
T P- a""'Q a'za-
5
Plan revision required? E Yes E No
Use other side for additional information.
5BD-6710 (R 0s,91)
1 5o q3 4 (,--?
Oate ln ctor'sSignature Cert No
I
Sanitary Perlnit No.:
1q?ltql
tr,ILHFI SANITARY PERMIT APPLICATION
ln accord with ILHR 8i1.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not less than
81Ax 11 inches in size. '1
-See reverse side for instructions for completing this application.
I. APPLICANT INFORiIATION - PLEASE PRINT ALL INFORMATPN.
COUNTY
STATE SANITARY PERMIT # ,/
/q3 /sz
Check if revision to previous application
STATE PLAN I.D. NUMBER
PROPERTY LOCATION
Ala,i ii it,s e t r Qq,N,R /? E (or@PROPERWOWNER /4r ((or^ Vent-ueas
BLOCK #LOT #4-t?PROPERW OWNER'S MAILING AODRESS
.{rf/ Counr" R/ 4
0-/t
ctw,
,4"
STATE
D3o*J
ZIPCODE
S{otG
PHONE NUMBER
()
SUBDIVISION NAME*(a"u OR CSM NUMBER
V;;;;;;-r" 4, o a sr,r r 4r4K
VILLAGE:
1
2
3
4
5
trutrtrtr
6
7
8
9
a<]
o
trtrtrtr
lll. BUlLDll{G USE: (!l building type is public, check allthat apply)
ll. TYPE OF BUILDING: (Check one)State Owned
NEARESTROAD I Ia.TH 4
Medical Facility/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Office/Factory
ApVOondo
Assembly Hall
Campground
Church/School
Hotel/Motel
12 E Service Station/Car Wash
13 E other: Specity
10
11
Outdoor Recreational Facility
RestauranUBar/Dining
X proti" E t or, 2Fam.Dwellingrfl of bedrooms
-
lV. TYPE OF PERlllT: (Check only one in line A. Check line B if applicable)
A) 1. EI r.r"* 2. E Replacement 3. E Replacement ol' System System Tank OnlY
B) E n Sanitary Permit was previously issued. Permit #
4.5.
Date lssued
Repair of an
Existing System
Reconnection of
Existing System
Other
V. TYPE OF SYSTEII: (Check only one)
Experimental
30 E Specity Type
Non-Pressurized Distribution Pressurized Distribution
2'l E uound
22 A ln-Ground
Pressure
41
42
43
Holding Tank
Pit Privy
Vault Privy
11
'|.2
13
14
Seepage Bed
Seepage Trench
Seepage Pit
System-!n-Fill
2. ABSORP. AREA
REQUIRED (sq.ft.)
/ 44SsqG
3. ABSORP. AREA
PROPOSED (sq. ft.)
lSoc: sq fr
4. LOADING RATE
(Gals/day/sq. ft.).?
5. PERC. RATE
(Min./inch)
7. FINAL GRADE
ELEVATION
/aS.?S1e"
6. SYSTEM ELEV
flot. oo?eet
VI. ABSORPTION SYSTEM INFORMATION:
CAPACITY
in oallons Plastic Exper
App.
Prefab.
Concrete
Site
Con-
structed
Steel Fiber-
glassNew
Tanks Tan ks
Total
Gallons
#ot
Tanks Manufacturer's Name
V!I. TANK
INFORMATIOI{
1cco o /Lt),rE 3 {iSeotic Tank or Holdino Tank locs
Litt Pumo Tank/Siohon Chamber
VI!I. RESPONSIBILITY STATEMENT
l, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP/MPRSW No.
),1//, sr?g Business Phone Number:
(?t{ | 33c-?YStt
Plumber's Name (Print):
Z,+Ze &"t.{.^.,..
S!c:t(*)O.\)
Plumber's Address
t$
IX. COUNW'DEPARTMENT USE ONLY
Signatiha{!
{do'o'"0
Disapproved
Owner Givan lnitial
Adverse Determination
Etr Fee)
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
/c-'/
SBD{398 (formerly Plb€7) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Salety & Buildings Division, Owner, Plumber
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2. Wal Rd.
3. WIle Rido. Ir lror &od u. &
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0ecr Haven Dr
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STC r00
Owner of property =rr CJz:<;l\* VENYTU%:
Locabion of property t-E, L/4 Ne r,za, Sectj.on z-l , t 21 X-n l-?_.w
Townsh i p (5 ?OO=cr.-J
l.lailing address "l\4=5\^Jt3oV4 LOr.o
t-l rrJ OLIS t-,1, tl.tt.lg =cffi\
Adctress of site 5al ca>xly-1 EoAs> \
Sul:division name q c-@\ /- lgpfqpr\11_ trAl"_K Lot no. fa { tl
ot,lrer lromes on property?v ea No
Previ.ous owner of property =r c-PolY uE.ruEr.=s
Total size of parcel 4 A<qz:
Date parcel was crea,ted P\P[2-\L" 31zD \a1, \
Are arr cornerc ancl rot rines identlflable? ,r/ yes No
re thLB property boing deveroped, f or ( epec houee ) ?_yes
vorume -and page Number aE recorded. wlth theof Deeds. '
,,/ NO
i*r"..'
].I.ICLUDE T^IITII TIII S APPI,ICATION TIIE FOLLOWI}IG :A l{AItltAll'I'Y DUED whic}r includes a DOCUNENT NUIIDER, VoLUHE A}tD pAGBllul'tBnR & I'llf, SEAIJ Ot" I'tttr IIEGISTILII Of DEEDS. In additlon; ocerLifiecl survey, lf avallable., iwould be helpful so os to avoicldelays of tlre rovlewlng proces6, If the deed descrlptlonreferencoe to a cort,IfLed gurvey Map, the certlfled Survey HapshalI also be requlred.
I'ROPERTY OT^INER CtrRTIFICATTON
.r ( t*'c ) cert.if y that all statements on this f orm are true to theb9st, of ny (our) knowledge t,hat I (we) am (are) the owner(s) oftlte properLy clescrlbed in this inf ormatlon f orm, by vlrtue of awarranty i.leed recorded in t,he office of the County RegisEer ofDeeds as Document llo. , and that r (we) presentlyov.'ntlreproPoseclsite-to@'clIsposaI6ystem-orI(,"i
obt.ainecl an easement, to run the above descriUea property, f ortlle collstructlon of saicl system, and the Eame hle -been dulyrecorded In the of f J"ce of Cotrnty RegJ.ster of deeds aa DocumentNo.
g nat,ure o ap I Co-appllcant
5
Dat eo fS gnature
nt
This application form ls to be conpleted in fuII and signed bythc otr,ncr(s) of the property being developed. any lnadeluacieivill only result in delays of the porrnlt lssuance.- shoul-d thisdeveloprnent be intended for resale by ownerr/contractor, ( specIrouse), then a second forrn should be retained and conpleted'vhenthe property is sold and submltted to thls offtce wlth the
STC L05
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
owNER/BUY c?4\
ADDRESS -l\+5 7D F.IRE NUMBER
CITY/STATE F4!\NSEA?o.I a 11\\-\EerSrA zr 5344
PRopERTY LocATro*, NE L/4, \E r /4,
TOWN OP
SECTION
, se.
2-\ , rz1 x-n\1 w
CroLx Count,y ,
SUBDIVI S ION 6rc-F(>t F tror)oesrFxt-Lor Nulrern-lliLL].
?AFF-Improper use and maintenance of your septic system couldresult 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 septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system. ,
St. Croix County residents may be eligible to receive a grant
for a maximum of 60t of the cost of replacement of a failing
system, which was in operation prior to JuIy 1, 1978. St. CroixCounty accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained. .
The property owner agrees to submit to St. Croix Zoning acertification 'form, signed by the owner and by a mater plumber,journeyman plumber, restricted plurnber or a Iicensed pumperverifying that (1). the on-site wastewater disposal system is inproper operating condition and (2) after inspection and pumping (if
necessary ) , the septic tank is less than L/3 full of sludge and
scum.
T/He, the undersigned have read the above requirements andagree to maintain the private sewage disposal system in accordancewith the standards set forth, herein, as set by the Wisconsin DNR.Certif ication stating that your septic has been maintained must becompleted and returned to the St. Crolx Co. Zoning officer within30 days of the three year explration date.
S IGNED
St. Croix co. Zoning Office
911 4th St.
Hudson, l.ll 54016
DATE:5 L z,/rs
a
Wisconsin Depa.rtment of lndustry,
, Labor alj Human Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adm. Code
Page / of r
COUNTY5r C*orx
PARCEL I D #
REVIEIVED BY DATE
PROPERry OWNER:
3+. C ro ix /"n jt*r e.s
PROPERTY LOCATION Zq ,N,R /g E (or)wGow tor n/E 1t4 N61/4,5?-/ T
PROPERW OWNER':S MAILING ADDRES$
7l 4-r -S a,,-d.l,u -c RooJ
LOT *
l6- t1
BLOCK #a UB D NA IItvl E R CSI,4 #
N} (-,Q OS /,,r{,osrtr .P*
CITY, STATE O zIP cODE PHONE NUMBER
frr'rtr7 "a- Da /t l\1ruc 7 (6rzl Sr'/-272o
CITY DV rrrAoE ETowN I#r.llsov I
NEAREST ROAD
CT N' tt ,,f "A'
Attach complete site plan on paper not lessthan 8 112x11 inches in size. Plan must include, but
not limited to vertical and horizontal relerence point (BM), direction and"/" of slope, scale or
dimensioned, north arrow, and location and distance,to nearedt road.
APPLICANT INFORMATION-PLEASE PBINT ALL INFORMATTON
p( New Construction Use [{ Residentiali Number of bedrooms I 1 Addition to existing building
[ ]Replacement ( Public or ommercial desqibe
Code derived daity flow
-
gpd Recommended design loading rate bed, gpd/tt2-trench, gpcl/fl2
Ab6orption area rEuired
-
bed, ft2
-
trencn, fl2 l,taximum design loading rate bed, gpdltt2-Uench, gpd/tt2
Recommended inf i ltration surf ace elevation(s)(as referred to site plan benchmark)
Additional design / site considerations
-
ft
S = Suitable for svstem
U = Unsuitable fo? system
CONVENTIONAL.(s Du
MOUNDEs tru
IN.GROUND PRESSUREES DU
AT.GRADEEIS DU
SYSTEI'II IN FILLKs Du
HOLDING TANKtrs {u
SOIL DESCBIPTION REPORT
Boring #
Ground
elev.,^gltt
Depth to
limiting
factor
> t.zs
Horizon Depth
in.
Dominant Color
Munsell
MotUes
Qu. Sz. Cont. Color
Texture Structure
Gr. Sz. Sh.
consistence l**Roots G P D/ftz
Bed Trerrfi
B,o.44 toYQ q/Z /6t(e Ou.q)rt'' I C I o.7 o.B
B-A4 99 ttyP.4 /4 FS A rT1
b
V)r\l I o.1 o.E
I (J
I
i
Boring #
Ground
elev.
QnS.rl rt.
Depth to
limiting
lactor
> B_!3_
Remarks:
Remarks:
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(-,{as ^.r SnQl0
OJ ,o.tICthIASfiqAn d)o-l /6yQ +/SB,
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3 (o86)ou Phone:CST Name:-Please Print IAtvY
p.9t N u},Soru S4o rAess:
93 csT Numbe''3(tr4
6
Date:
ISignature
SOIL DESCRIPTION REPORT Page z 3ofPRoPEH\Y oWNER
PARCEL I.D. #
Boring #
Ground
elev.
9c6.3(n
Depth to
limiting
,'Sl$t
Remarks:TaPS6r4 /VdS 8ee^r S:*r PPcA .
Horizon Depth
ln
Dominant Color
Munsell
MotUes
Qu. Sz. Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence BcLrrdary Roots GPD/ftz
Bed Trendr
B.o-/l lovl.+ lS S Onv)fVl C I o,1 o.tr
8.n-21 7.s) R 414 5 ,ID
6.m,3>rhl c I o.7 o.t'
B=27-s3 /6y< 413 S
,.o
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l t6YR, s/4 S o I D
9/)nl I o,7 6.K
0
Boring #
Ground
elev.
ffi121,.
Depth to
limiting
factor
7 t.r;
Remarks ' SJxa Sr^rA F,.z- oVrl{ 6Bo.-l^rs,
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Boring #
Ground
q,i5[i,,
Depth to
limiting
factor
> 9.qz
Remarks:,(U\r LJ.,,C,A
Boring #
Ground
elev.
It.
Depth to
limiting
factor
a I NT
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Wisconsin Department of lndustry,
Labor arti Human Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adm. Code
Page I of )
COUNTY5r C*orx
PARCEL I.D. #
REVIEIVED BY DATE
PROPERTY OWNER:
5+. Cro i x U.^
PROPERTY LOCATION Zq ,N,R /g E (or)wGow. Lor n/E-1t4 N61t4,Szl T
PROPERTY OWNER':S MAILING ADDRESS
7/{g -Sa. ,,dLu.o Bo ^ol
LOT #
l6- t1
BLOCK #
CITY, STATE
/1t/,'-.a 2 a-o o lr <
J zIP CODE PHONE NUMBER
fqal sdt/Z? WA f///-r z?o
DclrY !v N l*'2',i'ioll"* "A,
Attach complete site plan on paper not lessthan 8 1/2x11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and"h of slope, scale or
dimensioned, north arrow, and location and distanco to neareist road.
APPLTCANT INFORMATION.PLEASE PRINT ALL INFOBMATION
ft New Construction Use [{ Residential/ Number of bedrooms I 1 Addition to existing building
[ ] Replacement t( Public or commercial descri
Code derived daily flow- Spd Becommended design loading rate bed, gpd/fi2-tlench, gpd/tt2
Ab6orption area rquired- bed, tt2
-
trench, tt2 ti4aximum design loading late
-bed,
gpd/tt2-tlench, gpdlt2
Recommended inliltration surlace elevation(s)-tt (as relened to site plan benchmark)
Additjonal design / site @nsiderations
-
Parent material _Flood plain elevation, if applicable ft
S = Suitable lor svstem
U = Unsuitable foi system
CONV.(s ENTIONAL
DU
MOUNDEs !u IN-GROUNO PRESSUREEs tru
AT.GRAOEEIS DU
SYSTEI",| lN FILLKs !u HOLDING TANKDs @u
SOIL DESCRIPTION REPORT
Boring #
Ground
elev.
9oo-$tt
Depth to
limiting
factor
> t.zs
Horizon Depth
in.
Dominant Color
Munsell
Motiles
Qu. Sz. Cont. Color
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3Wisconsin Departrnent of lndustry,
Labor ard Human Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adm. Code
Page of
Attach complete site plan on paper not less lhan 8 112x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and"/" of slope, scale or
dimensioned, north arrow, and location and distanceto hearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
SOIL DESCRIPTION REPORT
Boring #
Ground
elev.
Depth to
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9.e 38tt.
factor
> t.zs
COU 5r C*orx
PARCEL I.D. #
REVIEWED BY DATE
PROPERTY OWNER:5+. 2ra i x ilnl-res
PROPERry LOCATION
cow. ror {q 1t4 N 61/4,s2/ T 71 ,N,R /9 E (oQ w
PROPERTY OWNER':S MAILING ADDRESS
7//{ Sondl(a ro Ro-d
LOT #
l6't1
BLOCK #SUBD. NAME CSIU #
()E.T /*d,r"rr,r. Pr
CITY, STATE ZIP CODE PHONE NUMBER
(6rzl
E NEAREST ROAD
CT N' tt f "A',,
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ft New Construction Use [t{ Residential/ Number of bedrooms I 1 Addition to existing building
[ ] Beplacement K Public or commercial describe
Code dedved daily ffow
-
Spd Recommended design loading tate bed, gpd/tt2-uench, gprl/ft2
AbsoDtion area required
-
ueo, tt2
-
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Recommended infiltration surface ele\ration(s) ft (as lelered to site plan benchmark)
Addilional deGign / sits consideralions
Parent material Flood plajn elevation, if applicable
-
ft
S = Suitable for svstem
U = Unsuitable foi system
CONV.(s ENIIONAL
DU
MOUNDEs tru IN.GROUND PRESSUREEls tru AT.GRADE8ls tru SYSTEM IN FILLEs tru HOLDING TANKtrs fiu
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MOPERTTOWNER
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Wsconsin Departnnnt of lndustry,
Labor tnd liuman Relations
Division of Safety & Buildings
SOIL AND SITE EVALUATION REPORT
in accord with ILHR 83.05, Wis. Adm. Code
Page I ol 3
AttachcompletesiteplanonpapernotlessthanEl12xll inchesinsize.Planmustinclude,but
not limited to veftical and horizontal reference point (BM),,dire5:tion and"/" of slope, scale or
dimensioned, north arrow, and location and distance lb nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
5= CRo rx
PARCEL I.D. #
o 5-ID
REVIEWED BY DATE
PROPERW OWNER:,il\*nx MArz PROPERTY LOCATIONe" or
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PROPERTY OWNER':S ttIAlLlNG ADDRESSlc+ct4tn;,? {)e5 .T BLOCK #SUBD. NAMEORCSM# N
51(ro,^ V€.to*(s /, Aos r. fA& K
CITY, STATE
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ZIP CODE
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PHONE NUMBER()fIclTY EVILIJAGE filrowru
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[ ] Replacement
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Reco mmen ded infi ltrati on s urface el evation(s )
(o ft (as referred to site plan benchmark) :
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system
U = Unsuitable fot system
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