HomeMy WebLinkAbout034-1088-80-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 538891 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No,:u-Il c~
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. -E%~f'~ ttd 7
Permit Holder's Name: City Village X Township Parcel Tax No:
Krin le, George & Ma Springfield, Town of 034-1088- 0-100
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
10 (yX ` 28.29.15.571A10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ,N's CAPACITY STATION BS HI FS ELEV.
T a %4c-~- chmark
77 3OO
d1 S'I 2,15 /bZ.)S 14~~
Dosing Alt. BM
sPr
Aeration t~~d~ cz G / Bldg. Sewer %'9 2.7
T✓
Holding St/Ht Inlet r l/C
77
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Wei
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Li Fraction Loss System Head TDH Ft
Forcemain Length IDia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS "
SETBACK SYS TO P/L LDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type stem: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) w~,~._..,-,._
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems.Bn
Depth Over Depth Over xx Depth of r S66ded/Sodded jxx Mulched
Bed/Trench Center Bed/Frenct? Edges Topsoil 0 Yes No Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 2930 Hwy 12 Wilson, WI 54027 (SW 1/4 SW 1/4 28 T29N R1 5W) Village of Hersey Plat Lot 1,2,3Blk24 Par I No: 28.29.15.571A10
1.) Alt BM Description =
3 0 ,
2.) Bldg sewer length Soe)Y a. -6
II PeV p~ ape.
- amount of cover F'I le~ 1 C
q2-
Plan revision Required? Yes o ~ 6 ~,Y~ - 7
F
Use other side for additional information.
Date Ins ctor's S ture Cert. No.
SBD-6710 (R.3/97)
~Drte- o ~
v Safety and Buildings Division County
m ~r 201 W. Washington Ave., P.O. Box 7162 St. Croix
Madison, WI 5370-7 - 7162 Sanitary Permit Num er (to be filled in by Co.)
3
(608) 3
Departure t of C mt
Steat~ Sap' \ } G~ it Appli~ie.~,; ^ State Plan LD. Number
In accor with is. Adm. Code, personal information you provide
ay or secondary purposes Privacy Law, s15.04(1)(m) Project Addres's / (if different than mailing address)
1. Application Information - Please Print All Information l~ 30 / l 4091,
Property Owner's Name Parcel # Lot lock #
Geor e& M Krin le E S 10-Z 3 2
Property Owner's Mailing Address Property Location Vi'( ,r C
PO Box 41, 2930 Hw 7i Cvv A_ Z 12avd S~ "`J
I ( - City, State Zip Code Phone Number S W'/,, Section 28
Wilson, WI 54027 715/772-3326
T 29 N; R 15 W
II. Type of Building (check all that apply)
X 1 or 2 Family Dwelling - Number of Bedrooms two Subdivision Na}ne CSM Number
Public/Commercial - Describe Use ,AV` A
❑ State Owned - Describe Use ❑City_ Village XTownship of
Springfield
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. New System X Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
Non -Pressurized In-Ground Mound ZHol Moun d < 24 in. of suitable soil At-Grade Single Pass Sand Filter
Constructed Wetland Pressurized Ino eat Filter Aerobic Treatment Unit Recirculating Sand Filter
Recirculating Synthetic Media Filter Leachmi me Gravel-less Pie Other (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil ~qTlication Rate(gpdsf) Dispersal Area R quired (sf) Dispersal Are Proposed (sf) System Elevation
150 /•-JANl
VI. Tank Info Capa in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
septic or 3000 3000 1 Wieser Concrete X
Aerobic Treatment Unit
Dosing chamber
VII. Responsibility Statement- I, the unde ; assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) um er's Signature , MP/MPRS Number Business Phone Number
Tim Mittlestadt MPRS 227548 715/235-4634
Plumber's Address (Street, City, S"' Code)
2819 Knapp Street, Menomonie, WI 54751
VII . Coun /De artment Use Only
Approved ❑ Disapproved Sanitary Permit Fee (includes Grou dwater Date Issupd Is ng Age p Si tamps)
tJ~f I,
El Owner Given Reason for Denial Surcharge Fee)
IX. Conditions of Approval/Reasons for Disapproval
3.33
nAttach complete plans (to the /County only) fort the syst m on paper qot less th /2 s 1 inches in size _ i
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CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project KRINGLE
Owner George & Mary Kringle
Address PO Box 41, 2930 Hwy 12
Wilson, WI 54027-1416
Legal Description ,SW,S28T29N/Rl5W
Township Springfield County St. Croix
Subdivision Name N.A. Lot No. N.A.
Parcel ID Number 034-1088-80-100
Plan Transaction ID Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Tank details Page 5
County Agreement Page 6
Pumping Agreement Page 7
p+NochM ev.l; ~ S` o ~ ~ ~-e s
Design ttlestadt
Signature Phone No. 715/235-4634
License Number MPRS 227548 Date 11/08/11
Designed pursuant to:
Holding Tank Component Manual For POWTS
SBD-10571-P (R.6/99)
Version 2.0 (03/01) Pagel of 7
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10571-P
6/11/1999), and the St. Croix County Sanitary Ordinance.
1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 600.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements. -
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 10 business days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWT$ and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with Comm 83.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons should be contacted:
a. Installer Tim Mittlestadt Phone: 7151235-4634
b. Service Provider Tim Mittlestadt Phone: 715/418-1705
c. Co. Zoning or Health Dept. St. Croix Zonin Phone: 715/386-4680
. My _ _
11.
Project: KRINGLE
Transaction Number. Page 4 of 7
Oct-27-2011 12:23 PM St. Croix County Plan/Zoning 715-386-4686 1/2
SEPTIC or HOLDING TANK SERVICING CONTRACT
ontraot Date
This contract is made between the
Tank Owner(s) Name(s) and Pumpers Name
We acknowl ge the Installatl of (a) septldholding tank(s) on the following pr(?.ierty:
Provide legal description).* & 2. 0 S~ . w" i z
9, -2i 9 U-
--.T--------
1. The owner agrees to file it copy of this contract with the local governmental unit (St. Croix County
Planning & Zoning Department) to document maintenance by a certified septage servicing operator as
required in Comm 83.52(1)(c)2. Wis. Adm. Code and the approved Component Manual.
2. The owner agrees to have theseptic/holding tank(s) serviced by the undersigned pumper and guarantees to
permit the pumper to have access and to enter upon the property for the purpose of servicing the
septic/holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can
service the septic/holding tank(s) with the pumping equipment. The owner Au-then agrees to pay the
pumper for all charges incurred in servicing the septic/holding tank(s) as mutually agreed upon by the
owner and pumper.
3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for this servicing of
theompkelholding tank(s) on a monthly basis. The pumper further agrees to include the following in the
monthly report:
a. The name and address of the person responsible for servicing the septic/holding tank;
b. The name of the owner of the septictholding tank;
c. The location of the property on which the septic/holding tank is installed;
d. The sanitary permit number issued for the septic/holding tank (if known);
a. The dates on which the septic/holding tank was serviced;
f. The volume in gallons of the contents pumped from the septic/holding tank for each servicing;
g. The disposal sites to which the contents from the septio/holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a
change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a
new service contract with the local governmental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Ow er's Signature(s) Subs ar) on this date:
own0 aye Date
Pumper's Name (Print) P per's Slqnstu Note
VIM
Pumpers Registration Nurhbef Commission Expiration
OAR
M
RECEIVE'
Wisconsin Department of merce S IL EVALUATION REPORT Paw of
Division of Safety and Buiidi
with m 85, Ws. Adm.
' f
Antj
flfi 1ft 11 in as in size. Plan mu
-A-Lplak t ]as yt~i -S.
Attach complete sit
include, b 111111 a 0j f*WM t (BM), direction and
percent nd distance to nearest road. 0_3q-- = ffio - /00
Please print aN information. rwb Date
Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). IL
Property Owner Property Location
e-o)r al y r 1 Govt Lot 1/4_U 1/4 S 2$ T ZQ N R 15 E (or) W
Property Own Mailing Address j _j Lot # Block Subd. Name or CSM#
t0&) 41 A 2930 %t- Rw° 2 2 3 2
City State Zip Code Phone N City ❑ Village Town Nearest Road
` ISO V-\ ~1 o" 1 I lls) t17 Z-33Zb S r ~n^ t~l~ l~vs 2-Q
❑ New Construction Use: Residential /Number of bedrooms Code derived design flow rate S oCJ GPD
AReplacement ❑ Public or commercial - Describe: t-3, A,
Parent material /0 e s s E 5 Flood Plain elevation if applicable N' A ft.
General comments / +
and recommendations: a colnln eh c, fold/,h /o-- CXX~
C2P Q e
Boring w1 Ind ~lrtova l~
Boring # ~os~ hale
r ❑ Pit Ground surface elev._ ft. Depth to limiting factor in. Soil ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAIF
in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
j, _ 10 ab m ~r 5 i~ qt,
OqR q1 C" Ck
jj4- ;25
/4 M -2-a -1 S j R 6/o 54' --1k' 6v, 0 LA (D
lack P'-K) A +
❑ Boring # ❑ Boling
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
' Effluent #1 = BOD > 30 220 mglL and TSS >30 < 150 mg1L ' Effluent #2 = BOD 30 mg1L and TSS 30 mglL
CST Name (Please Print) nature CST Number
Ms. Loretta Larrabee CSTM224580
Address Date Evaluation Conducted Telephone Number
N2089 Cty'. Trk. Y, Menomonie, WI54751 715/664-8184
Property Owner Parcel ID # Page of
Boring # ❑ Boring
F-1 ❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sal ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soh Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring # ❑ Boring
F-1 11 Pit Ground surface elev. ft. Depth to limiting factor in.
Soil ADDlication Rate
Horizon Depth Dominant Color Redox Description Texture Sure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2
` Effluent #1 = BOD, > 30:E 220 mg/L and TSS >30 < 150 mg/L ` Etfiuent #2 = BOD 30
6 _ < rn9/l and TSS < 30 mglL
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608_264-8777.
SBD-8330 (8.07/00)
Soil Evaluation Report
page 2 of 2
1/4,S W 1/4,S28T29N/R15 W
Springfield township
St. Croix county
LEGEND
113M: 100.0 top of
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contour 6-%-k . @V' C 4
No Comm 83 set back Selo-\\ CA-Oai~v ~
problems C o
Scale P - 30' except Staff e_-*
where indicated far Q
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KRINGLE, GEORGE E & MARY I
STATE OF WISCONSIN BILL NUMBER: 58385
REAL ESTATE PROPERTY TAX BILL FOR 2010 IMPORTANT: Correspondence should refer to parcel rnanber.
See reverse side for knportant nforrnskon.
TOWN OF SPRINGFIELD Be sure this description covers your property. This desorption is for Property
tax bill only and may not be a full legal desorption.
ST. CROIX COUNTY 1526/78 1416/359 1069/146 810/77 446/412
SEC 28, T 29 N, R 15 W
GEORGE E & MARY I KRINGLE BSEC 28 T29N LK 24 ALSO W11/ E 45If F ST DJ TO 2 & 3
PO BOX 41
WILSON WI 54027-1416 LOTS VIL HERSEY ALSO TTHAT PT OF
CQ~ u4l~ ABANDONED HAZEL STREET
"Nr' Parcel M 034-1088-80-100
Property Address: Alt Parcel 28.29.15.571A-10
Assessed Value Land Ass'd. Value by Ave. Assort Ratio Net Assessed Value Rate
3,600 5 1.1563
Est Fair Mkt Land Est Fair Mkt M l~ NOT n Value 0.013815034
newsI Unpaid ~Prior School taxes reduced by $ 105.53 A Star 3,100 51 _ - - , Year Taxes. school levy tax credit 2010 % Tax
2009 2010 Taxing Jurisdiction Eat State Aids Est State Ak1s N ~ Net Tax Change
Allocated Tax Dist Allocated Tax Dist
STATE 9.75 9.28 -4.7%
COUNTY 19,087 20,616 204.01 211.88 3.9%
TOWN OF SPRINGFIELD 117,572 119,692 ?91.60 105.48 3.8%
SCH DIST GLENWOOD CITY 1,019,814 1,047,750 474.07 466.16 -1.6%
WITC 7,051 7,206 60.54 62.35 3.0%
Total 1,163,524 1,195,264 849.97 855.15 0.6%
First Dollar Credit 71.79 72.13 0.5%
Lottery & Gaming Credit 81.90 90.94 11.0%
Net Property Tax 696.28 692.08 -0.5%
Make Check Payable to: Fug Payment Due On or Before January 31, 2011 Net Property Tax 692.08
ST. CROIX COUNTY TREASURER $692.08
ATTN: LAURIE A. NOBLE
1101 CARMICHAEL ROAD Or First Installment Due On or Before January 31. 2011
HUDSON WI 54016 $300.57
715-386-4645
And Second Installment Payment Payable To And Second Installment Due On or Before July 31, 2011
ST. CROIX COUNTY TREASURER $391.51
ATTN: LAURIE A. NOBLE
1101 CARMICHAEL ROAD
HUDSON WI 54016
FOR TREASURERS USE ONLY s • a FOR FULL PAYMENT
Pay By January 31, 2011
PAYMENT 10, $ 692.08
BALANCE Warning: M not paid by due dates, instdkneM option is lost
PLEASE RETURN LOWER and total tax Is deliquent subject to xxerest and. R applicable,
v PORTION WITH REMITTANCE v DATE Penalty. Failure to pay on tine' see reverse'
REAL ESTATE PROPERTY TAX BILL FOR 2010
ST. CROIX COUNTY TREASURER Bill#: 58395
ATTN: LAURIE A. NOBLE ParcelM 034-1088-80-100
1101 CARMICHAEL ROAD Alt. Parcel 28.29.15.571A-10
HUDSON WI 54016 [!Otal Due For Full Payment $692.08
y to County Treasurer By Jan 31, 2011
OR PAY INSTALLMENTS OF:
1ST INSTALLMENT 2NDINSTALLMENT
Pay to County Treasurer Pay to County Umstwer
Check For Billing Address Change. I $300.57 $391.51
3Y January 31, 2011 BY July 31, 2011
GEORGE E & MARY I KRINGLE
PO BOX 41
WILSON WI 54027-1416 FOR TREASURERS USE ONLY
PAYMENT
BALANCE
DATE
Parcel 034-1088-50-100 11/22/2011 07:51
PAGE 1 OF 1
F 1
Alt. Parcel 28.29.15.570B-10 034 - TOWN OF SPRINGFIELD
Current ❑X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - HERZOG, LISA A
LISA A HERZOG
2932 HWY 12
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 2932 HWY 12
SC 2198 SCH DIST GLENWOOD CITY
SP 1700 WITC ~j
SP 7070 SPRINGFIELD SAN DIST #1 T
Legal Description: Acres: 0.000 Plat: 01-055-HERSEY VILLAGE& LANDING LOTS 034188
SEC 28 T29N R1 5W PT OF SE SW S 169.75 FT Block/Condo Bldg:
OF THE F1/9 F VACA ED-ADAMq-STRE I Pi AT
VIL OF HERSEY AD Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
ALSO T F ABANDONED HAZEL STREE 28-29N-15W SE SW
Notes: Parcel History:
Date Doc # Vol/Page Type
02/28/2011 932892 QC
08/21/2007 858309 WD
04/12/2006 822641 WD
04/12/2006 822640 TI
more...
2011 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/31/2009
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 1,800 94,200 96,000 NO
Totals for 2011:
General Property 0.000 1,800 94,200 96,000
Woodland 0.000 0 0
Totals for 2010:
General Property 0.000 1,800 94,200 96,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
1 Ott-27.2011 12:23 PM St. Croix County Plan/Zoning 715.386.4686 2/2
( I IIIIIIIIIIIIIIIIII
II IIIIIIII II
8 044032 9 6 10 6
21
Tx
oonmtent NWW
° ee 946133
St. Croix County BETH PABST
Holding Tank Agreement REGISTER OF DEEDS
tote Plan Transaction Number- ST. CROIX CO., WI
RECEIVED FOR RECORD
11/22/2011 3:09 PM
Name-( er)TPypedor tsd EXEMPT
Being duly IWOM xtatea, under oath, thu
1 REC FEE: 30.00
1. Hdsbe is the ownedpmt owner of the following parcel of land PAGES: 2
/ I
located in Stroix County. Wisconsin, recorded in VOhttae hi~
Pegs 5-9' Document Number] j"jL olx County gister
of Deeds Office: /
A parcel of land located in the K of tbe$-j, '/4 of Section Na ~Ri°"'M
2$ T ;L N R W, Town of
St. Croix County, Wisconsin, being
5Y 75/
follows (include tot no. and aubdilfiaion/CSM or 3 • _ / d
Y0 ~
detailed legal deacr`iption): *ag-30 S! • 2-9 Number (MN)
{ Aarvemordonw.. • } 3 , tla~ r L~ Q. uvawadp 'Wdt O laan*w f And tthat t lkp ar*be k~i ft he insteendon of (a) bd an VW P o ~ ft It F-r- naYwnant or ssrraga~
of the
r
WN* b w saw dte W"Ay, or any otltar A'pa d prhtea maao wggW nar ft~ "Wre a pwwftw under Comm W V& Admin. Coda, or
f ch. W. ft. tifaa.
'.N an Inducement to the county to lout a odWy Permit for she 0bov.d1s9MW pmparty, we 89' to do the 148Ow11W h
I rnke. If tha owns Asuts r have the
1, oNmer sprees to mntam to as appkWo Nq*-Wt1 of Comm K Wte. Adm. Coda re "b Wft ►
wmine dd wAt or the °aparbmM of Cormnamo b pmwrd or abets a
holding aorvicad in response orders Issued by ate gp
e. ib4.5e, state., to powrrrtrhsrral hale (Town) may rfbr upon to pr0pady and eervlse ON auk a
hwrbn haalOf heard umor auk Pioparly at dsealbsd In a. to
a ours b have eau tank b be tanlaad and claps then owner by paring ew.arg. on then aft bii a a speaw smament moaner. ssrvkas
raldaed TM rArarees WE ben aaoaseed a prsoalbad bye. e16070a, sate.
L The QWW apron, pfearanlto Cams 83.64(Y) and Comm axe), Wa. Adm. Cada, b have a wear near kfetsaad In the ekuolun The
wear rAw shell be heaped by a ph nbr authorized by " N Of Cuxmutatoa b mdw such h091011106. tv h 4W I S
oamplyirrg weh Sena NWAaftm end manufsmuram Spe alfcow& The wmar agrees to be Arwwd* r sp, I l- for the purchase,
3. wen r #w DaWWW1t Of (kmmaee 10
to cedar
bu I
ko^ Viand Won a regular * of on basw9W s a read , sardor od W- t to - wow t mw-
3. Owner agrees to pay as charges and cub Incurred by tta wo mentei unit or county for Inspection. pwnpklg, haNeng, r MOW" "Mdrhp
and molnainkrg the WM~Inpp lank in &a a mamr as to Wavent or abab any humor hash hazard Caused by On holdlnp tank. The F
gowmmadd haft N1NWW M wmerof sty waft did shall be l add W IS ownrrddlkt ~kty (3==. deer of noNa. kr an event
then owner dos not pri then ceeb wdlhbu any (30) days, s,a ownr spsdkaly agms the dl the maybe paced on 1hs ax
ma a a zpKW aaseernad for as abelemwt of a human Mean hasrd, and the ax ahaa be coMScad a pmvlded by low.
a
4. The runts apron b conbad with a garcon who is I-wd under CIL NR 113, Nis. Adm, Code, to Itaw #0I oldk+g tank ar*ed and to So
■ oW of tin eonbad wdth do ome mnstdd wilt. The ormorfudlur apma b Ace ■ uxrpy of urry ehergse b the tervbs uxtrtlrac6 ore :now sarvtss =*ad, wah tm govanmontei afa waft an (10)
busras days eom No dots of 0110001020 sarfrka 00ntrah t.
i
t
5. The wmw Berea to canted wah a person licensed order Ch. NR 113. Nis. AdflCoda, who shall suanb to the camtll on s sar"Inew-401
L Pam ate g d rife ► Wal ma raiding Mpy kWheuna 1 *1m V40V Wa asrtot being plWdY meek h"L ~ Or County May mtsr 918 PC 10 k"
===t ukv*m whom pu rthpkq rep" rxa
4 Then egheemenl A =1161n In effect only WM the =WW Delos mWmvhb for en reguaaon of WWW onft wasa~ -a syatam
i amass g* Bahr a mwddpd awr r • pdvaa Cutts v twoW Imabsertt eysrm 0fei compose v^ Comm63, WI& Adm. tads erne
dt mawr in gogla rk # a j, moy tlbe lir/a dace Indned enoo a ate tyw~a► rotawfse b eta egnaara In
7. Thla
to to p~ dgp" be bum" upon ds. rid me agriowt sUll be nwrdeed byyttha r' mgad assWww ao den ad the a 20 WIN permit 1do oaf DO
spnamad r bo deamAned by ntfrenoe a the popwV whom ftIuAdlnp tank a massed.
F
PETTA
s) Name(s) . print Pleass Subsedb and swan to me on a dlrw.
O
' 't? 'ISUV Y'NOT
No" PeiAb
~ No s N)
menW UnplIdel 1>lLL IRE145CIV as - ZO 12.
DrdW by;
Lm L
YOU a my be saw sy vaey Lowe, ten.
r
'TNie PAel is PART OF Tile LEM OOCUAMT- 00 NOT RaMM'
Then inkrmagon must be compMbd bysubndgar 09"Wra 0ba such se Ms
oteuass, MW desayhaon, at& may be paced Cn t1Aa Ikd fM doarmud ormeybe plleced on adahton►payea ofOo docwnant I
h 1