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Home My WebLink About012-1071-00-000~ Wisconsi~i Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Dalton, John Erin Prairie Townshi SST BM Elev: /w Insp. B v: BM Descri// ' n: lY (9 IANK INhVKMATION TYPE MANUFACTURER CAPACITY Septic ~~ ~~~ Dosing __ ~_ I Aeration olding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~~~ j ~ ~ ~ ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Ma Demand GP Model Number ~" / TDH Lift Frictio 'ss Syste d TDH Ft i Forcemain Length Dia. Dist. to Well ELEVATION DATA County: St. Croix Sanitary Permit No: 399497 0 State Plan ID No: Parcel Tax No: 012-1071-00-000 STATION BS HI FS ELEV. Benchmark !! lrz Alt. BM .~~ d 3' Bldg. Sewer •~ ~ .S Ht Inlet 9 3 .~~ S t Outlet 9.ss Dt Inlet Dt Bottom Header/Man. p G• Dist. Pipe /d YO e~~ . Bot. System ~~, (~ Q 9~; Yo Final Grade ~ / ~ ! St Cover 3_ ld3 3 B ~ ~. ~ l `~. 0 ~ Sf ,VIL At3~VKl' I IUN 5Y5TEM S~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS '2 ~ ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM L NG Manuf c er. INFORMATION A E OR Type Of System: ~~~~ f"~~i/ ~ ~~ Mod I um er. DISTRIBUTION SYSTEM Header/Manifold ~ i~ Length~_ Dia ~ Distribution pipe(s) Length ~3- ~s Dia / Spacing 1 l~ x Hole Size ~ x Hole Spacing / Vent to Air Intake y ~'S' SOIL COVER x Pressure Systems Only YY MAllflri nr Ot-L+~Af~P Svefcmc Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil Yes No 0 Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_(L/ ~ /~ Inspection #2: / / Location: 1794 County Road E /B~aldwin, WI 54002 (SE 1/4 SE 1/4 33 T30N R17W) NA Lot / 9 S Parcel No: 33.30.17.511 1.) Alt BM Description = `~-~p 0 f ~r~, C~ve rcl1, ~~ 1` ~ I,u' c~ Gu ~~-~A 2.) Bldg sewer length - f'SS' ~, ~ S -amount of cover = ~s r ~ , B~ i ~ ~~ ~0~ `°`- _ / c"~ / 31 dhc~rva/~;,~ P,PP/S ,,- ~ lt/crc ~~~ d~s~i-o~~0 ~uJf 5~.c 6~~,;,7 ~~.y s I L "d C~nweer {rr~,~ G~ riKq V ! 5 r 13 Plan revision Required? ~ Yes [~ No Use other side for additional information. Date Insepctor's Si nature Cert. No. SBD-6710 (R.3/97) ~ V ~ ~ `-~ IVaT~S 8` GaQ'i., QX V~ SySf~ e~PV~~Gt+ GahS,~r~y a/o -3a„ `i ~ f lva 5 ~c ~ w GM'~'G~ r J ~~~ Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 ~'~ ; ~O ~ -~ ~~~ ons~n Madison, WI 53707 - 7162 Site Address Department of Commerce ~" C` Sanitary Permit Ap ration! ~ ~ Sanitary Permi um t~N - In accord with Comm 83.21, Wis. Adm. Code, otman youprovid'e'`,. q G 7 t/q '~ r l r l r ^ Check if Revision ma be used for second ses P w, 5. ) I. Application Information -Please Print All Info on State Plan I.D. Numbe r ~ 1 / ~ ~( . Property Owner's Name ~ ,t1 C t ~ (~ ~QQ~ ' t Parcel Ntuntxr ~ 33. ;p, ~ Z_S l/ Property Owner's Mailing Address ~ Z®Allltf;®FFiC~: o,!/ ~ Pro Location Pent ~7 1 ~.. ~ ~ ~k SL. ~k; S T N.R ~? City, State Zip Code n Lot Number Block Number ~.__-~ Subdivision Name CSM Number 0 5~{Dl j 1 ~- ~~-- II. Type of Building (che k all that apply) ~. 1 or 2 Family Dwelling -Number of Bedrooms ^ ^~~~ Public/Commercial -Describe Use L ^ Township r l -1 State Owned I ~ (_ 2~ ~~ 5 ~I~ huU / I/' 'Y Nearest Road ~t ~~ - . ~~ r III. Type of Permit: (Check only one box on line A (numberm omplete line B i applicable) A' 1 ~ New 2 ^ Replacement System 3 ^ Replacement of 6 ^ Add' on to For County use S stem Tank Onl Existin S stem B• ~ Check if Sanitary Permit Previously Issued Permit Number Date Is ued 3 S zoo N. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44~ Non -Pressurized In-Ground 21^ Mound 47 ^ Sand Filter 50 ^ Constructed Wetland 22 ^ Pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculatin 30 ^ Other V. Dis ersaUTreatment Area Informat ion: ~ Design flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./I nch) 9 /- S / Elevation VI. Tank Info Capacity in Total Number Manufac rer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Heldiag-~T~nk X w Dosin Chamber VII. Responsibility Statement- I, the undersigned, assume res tssibilit for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI 's Signature MP/MPRS Num ber Business Phon e Num ber p '% p C ~ e) ~~ V~CJ ~S~ lum is Address (Street, City, State, p Cod ) `~ l ~ w` J7 ~ ~~ . VIII. Count /De artment Use n Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ^ Owner Given Initial Adverse ~~ ~ / ~_ Determination ~~ ~~ L 1X. Conditions of ApprovaUReasons for Disapproval 1. Effluent filter to be installed and maintatned per manufacturer's recommendations. 2. Entire chamber must be installed in natural soil < 32 inches below grade and there shall be > 12 inches of cover over the system. 3. This revision/transfer was submitted to reflect a change in plumber. A ,,....L ....~-,-. r•-•~ ~• •~• ....,...v uu.» wr uw aymcm on paper no[ ius men ai~a s 11 mines to size SBD-6398 (R. OS/O1) E~ ~v~~x ~~ ~~7 T marsh D ~~ l~ ~ ~y n l S Yy 5 ~ Y /v~~v~SG~-n ~ ~ t-1 v~ you, ~_ c _ ~.rvi X " l vt Q~~ -See.-{~~ ~` ~ ~ -- -~ ~, .- our _ ~-:-F~- P~ Qv. .-~ ~ Y ~ _ lain. ~ (;..~ F' / ~~r ~n. - ~~~~~.. j r Contingency Plan: In the event that this POWTS or a component of this POWTS fails and cannot be repaired the following is proposed. Replacement area for absorption cell (per Soil evaluation ), or add an ATU to recover a failing drain field, or other repair or replacement to code. If dosing tank is used -dosing tank, pump, pump controls, alarms or related wiring becomes defective the defective component shall be immediately repaired or replaced with a component that is better or equal too performance. Questions on the operation or maintenance of this POWTS should directed to County Zoning or Health Inspectnr.G~;'(~~ounty Zoning ~-7 I S _~~,(~ - `~la~D ~y! S Tt. ~~~f ~ `-'! a /-p~~ S `'? lo-t-~C I'T4 ~ a-~ 7 C ~ ~-~ -t~ s ~..t~> 1 , r -I ~ ~ ~ ~e.V~~.1 ~~~ ~ ~I I i ~ I.~~i Ala ~ ~ „ i ~I ~± ~ - ~ 113~'+ ~.3 ~„ i , ~ ~„ _ ~~,~ -' / __---- n ~ S. ~ I „ t~~ ~~~90 1 °~ ~`C.V~~o~• ~~~ Conventional System Owner's Manual Sanitary Permit # Owner Name_~(/~,~ Issued Designed wastewater flow (gpd), ~~ Parcel ID # This septic system is designed and approveu .~ meet specific requirements outline in Comm 83 attd 84 WI. Adm. Code so that it will provide safe treatment of wastewater, thereby reducing human health hazards caused by improperly treated wastewater. The longevity of this system depends greatly on proper and timely maintenance and system use within the limits it was designed to handle. The owner of the system is responsible for the operation and maintenance of all components. Following is information [hat will assist you in increasing the life of your systems. Se tic Tank Ins ect and or service once eve three ears Outlet filter Should ins ect once a ear and clean once eve three ears Drain field Ins ect once eve three ears Seatic Tank(s) "The operating condition of tie septic tank and outlet filter shal l be assessed at least once every three years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may sloughs off tie filter when removed from its enclosure. If the filter equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and or sludge in the tank exceeds l/3 of the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to perform to maintain less than the maximum scum and or accumulation. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access opening used for service and assessment shall be sealed watertight upon completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. An effective locking device to prevent accidental qr unauthorized entry to tank shall secure exposed access openings greater than eight inches in diameter. No one should enter a septic or other treatment or holding tank(s) for arry reason without being in full compliance with OSK4 standards for entering a confined space. The atmosphere within the septic or other treatment or holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be dij~cult or impossible. Tank abandonment shall be in accordance with Comm 83.33, WI Adm. Code when tank is no longer used as a POWTS component. Soil absorntion component (Drainfield) The soil absorption component serving this structure to accept domestic wastewater from a residential facility. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption components operation must be assessed by inspection at least once every three years. The inspection shall include recording the level of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, area of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system id prohibited and considered a human health hazard P~e~ 6~ ~i ~ .!......1........... ~.. ~- iej ~~i ..~.. 4 ................... ~ ~ 1_~ ~ -S ~e ! Y ... ... 1 1` 4 :' ~ l Clarence Glotfelty Bnviro-Tech Systems & Services N4955 Sunny Hill Road Weyerhaeuser, WI 54895 °,~5#3~4 ~%1, U /~~ {41~ ~/1 0..I b 1/~ . 2.~ J _ Y~ ~ a ? ~~~`~ ^i Li i cU u~ --- -- 4~ '~ I u ~ ~ •' l ti . I ~. it C'J C. ~ • ~~ (~ ' 1 ~ om- J -~~ ~ I I . ~ N C7.cr~ ~ a I Imo' ' ~ ` ) i`=_.' ' r~ 1ti ~ ~ • ~ ~ v _ , ,;._ t___ v. _ ~ I I~~ n 1 ~ n ~ ~ '~ i ~ ~,I ~~ ~ ~ ~ ~ -~ L~ i << ,, ~ j,l ~'„ I ~ ~ ~' 1=J ~ `" Cry ~ ~ ~ - ` ' ~ ~ n ~~ ,., , ~~' c'~~~ `~ t~' ~ ~ r,~ ~ C- '-~ r .. ~, ~ _ ;C ` ~ ~ f ~~ . ~~ . ~ ~ z_ ~. . ~ ,, <1_ ~ ~ ~ ~~._,~~ I I ~ ~ ~ ~~~~~ ~a ~ ~: f ~ ~1 ? J '~ ~. ~ ~ ~ ~~ T J -~ - \r ,. I r• ~ -~ ~"- _ ~~~ C Q n ~ ~ I - l~i.. 1 o - U 0 _,~ '~a~ ~ ' _ cr 1 , ~ ~~' ~ 1 ? r• ~ I - ~ I 1 ~ y ~, ,~~ ~__ __ ___ __ ~ __ _____ _~______ l ,1:~ ~~ ~r ~~;~ f --;~ ~ C~ r. ~~"~~ ~ ~: 777 .~ fi c~1 c. .a ` --~"~ ~ ~~ .J ..:,~~~,~. ' , j ~~__.._.._~-- ~~- _ ~- . ~ G ,1 i, ~.` '~ ~ .~ 1~• rc:~ / 1, J `~_`- ~ E ~ ! ~ ~; w ~, n ~J .~ t ,. _ ~~ • ~ i O 4i u L f' l} '~ ..~' c_i ro ` ~ '1 M C ~ `~' I , ~ ~ ~ ~ , LL X11 A/ } ~ ~ D ~ ~ '1 ~~ \ ~ V SYSTEM SPECIFICATIONS In-ground Soil Absorption Component SBD - Project Name:~~ ~- - - _ p~~~ Distribution Cell Type Septic Tank ' Aggregate ^, Leaching chambers Min. Septic Tank Volume wZ~~ gal Wastewater Quality Septic Tank Volume ~~ gal. Treated ^ Untreated ^ Manufacturer ~.-~ Number of Bedrooms - Effluent Filter Design Loading Rate (DLR) (Maximum Sod Applicarion Race) Manufacturer 7~C~ L Model ~ Combined wastewater. Number of bedrooms ~ Pump Tank gal/dap/bedroom x 150 Manufacturer Daily Wastewater Flow (DWF) = 5_ Pump Tank Volume gal. Clear and graywater only: Number of bedrooms ~ Diverter valve ^yes ^no gal/day/bedroom ~ Manufacture Daily Wastewater Flow (DWF) _ ~~ Model Blackwater Note :The use of a divercer valve shall be indicated on the management plan indicating how and when the valve Number of bedrooms shall be used. gal/day/bedroom x ~4 Daily Wastewater Flow (DWF) _ Distn~bution Cell Sizing (A ega DWF / DLR = ft~ Distribution Cell Sizing (leaching chambers) Leaching Chamber Manufacture ra. ,' r-~-~r" Model `~ ~i ~c. w i ~ c~• .. 'Adjusted Design Loading Rate / - o~ gpd/ft~ Chamber size,,bottom azea / `7 • ~ y ft= Sys~em sizing = DWF / ADLR /Chamber size (D~ (ELK) (sq.ft.) # of chambers Number of chambers to be used = ~~ ., Page _ ~= of . j Wisconsin Departrnent of Industry, Labor and Numan Relations Division of Safety & Builc~ngs SOIL AND SITE EVALUATION REPORT Page ` of ... <....,v,.....u..~. „ , ...,.., ..,,. , ..........,..., COUNTY ST• ~~~ '~- Plan must irrolude but er not less than 81/2 x 11 inches in size lete site lan on a h com Att , . p p p p ac not limited to vertical and horizontal reference point (B nd qo of sbpe, scale or ^ " PARCEL I.D. # O tZ - l07 ~ -Ob \, Is~r st; rimed. ~~ dimensioned, north arrow, and location and dist a`n I J..,i ~ r1t~. APPLICANT INFORMATION-PLEASE P , fi L INFO~MA710N `:,~ Y ~ D TE R D / PROPERTY OWNER: ~ •~-uL. ,!~~7 '~-p~-~ ~-L'~~ ~f'° ~ / PR~PERTYLOCATION S~ 1/4 St; 1/4,S 33T 30 ,N,R ~-1 E(o~W PROPERTY OWNER':S MAILING ADDRESS • T -~ a tpOB ~,.QT BLOCK # SUED. NAME OR CSM # -` -r CITY STATE ZIP COD ~':.•-'PH TY ~111LLAGE ®fOWN NEAREST ROAD y ~MwiUti~ ~v1 s`to~ :,.~~ ~~ a~ ~Z~N PRA-t2(~ e :, f~b~dr~°~n~, ? (j Addif'IQn to existing building pd New Construction Use [XJ Residential / ro ~ j j Replacement [ ] Public a commeraal des-Z4f17€ Code derived dairy flow ~ gpd Recommended design loading rate - bed, gpd/ft2 • S trench, gpolft2 Absorption area required ~ bed, ft2 trench, ft2 Maximum design loading rate ~_bed, gpd/ft2 ' S trench, Recommended infiltration surface elevation(s) s~ r~uYE?- oh- \~ 4 ft (as referred to site plan benchmark} Additional design I site considerations sK~C~I.J '~ ~.- CAS r~l ~h~ - S~ Mc~T~ dl~ ~~ 4 Parent material S ~ ~..`~ ayts2 G ~..tt'C_t t1'L `S'11. L Flood plain elevation, if appl"rcable N • A ~ ft S =Suitable for system U = Unsui~ble for s stem CONVENTIONAL ®S ^ U MOUND (~'S ^ U IN-GROUND PRESSURE l~ S ^ U AT-GRADE ®S ^ U SYSTEM IN F~L ^ S I~ U FIOLDMG TANK ^ S ® U SOIL DESCRIPTION REPORT Boring # kvhY:ti l\..ti\ri`::i >.;:. x•~ ' i i^• ~;_v v!4~\tti'z::iJ Ground elev. \Ob•~ ft. Depth to limiting fac~a,, Boring # x~~ ,~> ~~;~ 2 h ~y~~~~.. ~~~ Ground elev. 99-Z fL ~~ Depth to 31- limiting `~ ~ 68' H i Depth Dominant Color Mottles Texture Structure ~~~ Roots GPD/ft or zon in. Munsell Qu. Sz. Cont. Color' Gr. Sz. Sh. y Bed rends 1 0 -L ~ l O`-), R- 313 - S ~ Zwi b~ `n't U '~r Gt.v ~ ~ • S ` ~, z ~1 39 ~O`~\i 31(, ~ 1~s 1 ~ sb~ rn v~F~- c t.~., - . s < ~ 3 39-68 ~o`~t 2s1~ - ~s 1 ~-sbk ~, u~-~. - - s , b Remarks: ~ o-to ~0`1\~31z ~ s~i -z.,~bn +~'~~- ~, 1'4' ~S €~~ Z -~ zz ~o~, cz .~ C e - s ~ ( Z wt Sbk ~n'~4- e-S - • S ~ ~ 3 zz.- 6~, ~ ~`-c cz_s ~ 6 t'FS ~ ~ s b~, >~ v'Fc. - S ~ ~ ~ Q ~$, Remarks: STName:-Please Print Arthur L. W e~ e r e r Phona. 715 - 4 2 5- 016 5 ~~e~erer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022' signature: ~; Date: c" CST Nrunber: ~-,C•~ y.y~. ~~-1. ~~s'1- °1 ~3 - Q 1 ~ - Z--1 ~ M00 5 7 6 PROPERTY OWNER ~'P~L-`CON SOIL. DESCRIPTION REPORT PARCEL I.D. #t . O ~`Z..- l 01 I -OD r Page ~` of Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourr~r Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerid~ 1 0 ~FI l oti R- 3 1 i. - s i ` Z. ~- s ~~ vr1-~ ~. ~w 1 ~ • S • ~ Z• II-2,4 , lv~tZ316 - s,~I Zrnsbk v~`~~• ~ ~ • S • 6 3 Z~f-6~ to ~ ti s l ~ l ~s ~ e~ b~ m v'~- - • S ~ b Remarks: I o-8 ~O~R 3I 2 -- S I I z-~'Sb Yh~r ~-w ~~ , s • ~ Z 8-z~ ~o~~z ~l~ - ~r-91 I Zrnsbk vrJ ~-~ ~s ~ • S • ~ ~ zb 3s ~o ~ tzs ! 6 - L`~s 1 ~.s1~k IM v ~-I- Cs • `' • b 3 s ~ S LO `1,~ S1 z s c Z~`~-b~ -vf ~~ c S ~ ~( ~ ~ 5 .. S. us-~•~ ~u`'l R. s ~ L - \`~s 1 e-Sbk m v `~ ~ • S ~ Remarks: O-l I L O`'11Z 3! 2 ~ St ~ Z`~-s1~12 h'1~1-• C..t,~,_, 1 'F • S -1, Z II 29 10`1123(0 - Grs~ - Z~ sbk h~~~- ~ 5 ~ . 5 - L 3 Z9 ~0 10~-t RS~6 - ~~s 1c.sb>~ mv~~- ~ , s ~ .1_ o.. .i... o~ ~ ~ 101, 2.. 3 ! Z ~ s 1 1 Z,'~s~1-c ~'F>'- e,~., I ~ • 5 • t, Z t.1 38 Lo`•t1Z. 31 ~ s i ~J Z-n S bk wr ~(.. ~ S _ . s . ~ 38 -6~, ~ 0`112 S Z 6 1`~S t e-S~1~c Ins U`~'~. - . 5 •6 a Remarks: SBD-8330(8.05/92) • PROPERTY~0INNER ~~-~~ SOIL DESCRIPTION REPORT ., ~:,, v..:,~ ~ .. PARCEL LD ~ O LZ-- l ll'11- VO Boring # Ground elev. X7.5 f(, Depth to limiting factor ? -?3'' Boring # :S Ground elev. ~~ Depth to smiting factor >65• Boring # Ground elev. Depth to limiting factor Page 3 - of rizon H Depth Dominant Color Motites Texture Structure Consistence Bouxtar Roots GPD/ft o in. Munsetl Ciu. Sz. Cont Cobs Gr. Sz. Sh. y Bed ~ 0-~1 Loy-I,SZ 3J3 ~ S1 ~, ~.~b H'tU '`~ C 1 ~ ~ ~l • S Z l1-sy . ~e~QSI~ "' 1`Fs > e_sbk mV`E'i- cs , S . ~ ~ S$ 13 lo`1,LZSL ` ~ l`~s ~, ~°-Sbl~t ~ U`~'t~ - - S . L Remarks: ~ o-tD 1b~-t`z ~1Z - Sll ~Z~-S~k ~'~r- ~k. ~~ ~ s ,~ 2 ~0 Z.z til~~ ~-316 -- Gr s~ I Zm Sbl~ yv~ ~~ ~~ - • 5 - ~ ., 3 z._-zg ~o`-tt~-31 ~ - s 1 Zw~ s bk m v~- ~- _ - S - ~ z~~b ~ off, 2 sJ ~ ~~-s 1 ~ Uk v~ v ~.. ~s ~ . s . L S . b o-6s L o`-t tz ~l~ - v ~ s 1 a~ -~ v `~-~ - - 3 € • ~( Remarks: Remarks: Boring # ground stay. ft Depth to limiting factor I f Remarks: SBD-8330(R.05/92) ~~ PLOT PLAN SCALE 1"= 30' S d~~ Page LJ of zSo f ~- a6 °- T3W11#-1 -U!2. LOU.p ON - , 8'`N'16H, 31~"pl~ Pic ~~a``i ~ L pe wl(.t~-f~ n"~ ' ~~. _ s v cT~$~ R~sA ~CiR X1.,953_ '1 "- i g 3 ~ ~-~ZEo~/ C~ i /~ i ~ i 'z.. a°1o'~ SIAP~ uh'1~~' ~ \ °~~ ~ Ste- ~.LVr~'rlu-~ s 1 _ b Sul i l -' _ .~~~ _ $ •z. s~' nS ~l.~t 3 S ~ ~ ~,°r°i Z a•6 ~~~ ? I ~ ~ 1 ~ - $,~ ~~- t~-toot' L ___ -'-- • 6" ti-tG ff, 3lyY D-R, Puy. ~ t P E w /u~`j7.1 3~ '~ 4-7 w ~~-~ S ~`~ = ~~w3r. 1'0 `e'X'r." ~'i` Lt~ST ~.S' Flzu~-1 `11ZC~v C~ . w~TtrL ~ ~ Spy .. ~, , 1!~ h~ i `ro _~ C`R~ Est _r~o`ce- To 1 ~v sum, c~ ~~ `1~~et~S `N1'R-x. Z~l~ O~ ~'f" ~'6 Dllwu S l.,t.lP~ r~ 6 E ~lI`51't1 f`.- `~}}~ _ Sit 1'KA~-` h'~ S'H'rW*~ . ~~1zM.t-~Ls ~~~c14 Liu ~t~fi7U1uS PY~J _ - ~-~v gfia~~ ~~t- 1~ 17wi~ o~ ec~~vsYR-v~~n~,, --- CST Signatu~e~~ ~ 1 ~?~~ Date Signed ~ Telephone No 5 -(11 F, 5 I400ST # ST CROIX~ COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address (Verification required from Planning Department for new a City/State ~ ~~•5 , Parcel Identification Number l3! Z ~ / ~" 7/ ' Q ~ LEGAL DESCRIPTION Property Location ~ f '/a, ~S ~ %., Sec. ~ 3 , Ts~N-R~~ ,~',~V Town of ~,C; ,~ ~ ; `L ,~ Subdivision ,Lot # Certified Survey Map # ,Volume /, ,Page # Warranty Deed # 2. ~ ~~ ~ ,Volume `~ ~) ~ .Page # ~~. Spec house ^ yes ~ no Lot lines identifiable ^ yes !8d 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 masterplumber, journeymanplumber, restrictedplumber or a licensedpumper 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. Uwe, 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 Natu.al Reso•,:rces, 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. SIG TURF 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. / / SI ATURE OF APPLICANT 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 5 ~~ l ,- ~ n s ~ ~~~~ f ~~ ~j ~ ~ d,8 -loci-~6-ion (.~~Z~,.a~-c~AP-~ I Ul8- Imo? ~zo-' ooc~ -~vJ r 0 33.30. l7 •SI~ ~,~? CODC~ LGD--~.; c~lZ.-tomb-~o~~ ~ ~3~ rs~ ~"` ~ S~ ~ 3Gf'~,D eC-e.g ~ li-/off I-oo~cxx~ ~ 33 30~~ ~ 20 d c`e rc.~ ~~ ~~ ~~_ Ckr rvr~ ~ y ~~ld r f: 1: :a i~ :~ ..... %^i ~ . - - ~ - - - - ..... (~' V.~. :-~ic ''}S: :`~,: T ~ ~ j Y.M~ z~ ~~ 0 z CQ CL G Q ~~ v L M - - - ~~~; ~M ~~_ "'4 f'` 1 ~[ :jj: '3S 4305 t ~' • • T M `~6~x~ i• ~ o -~ ~J 0 ~~ ~ i~ i ,. .9 N _ ~~ ~~ ~~~ ~ ~~ -e .~ '~ /~` ~~~ ~~ ±' U ~ ~ 4 .` / ~ I v ~ ~ cS ~ ~r4 .J ; 9 4i o p U r ~~~~~ ~ ~ ~ ~ ~ f s, ~ ~ ~~ ~~ ,~ ~ ~ -,~ ~ ~ ~~ ~ c~ 7 ~ l ,, s of ,_S~o/ V .~ <- - - a~' --- - } t~ 0 J ~~ f q ,~'a,.~'' Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 `~sconsin See reverse side for instructions for completing this application WI 53707-7302 Madison Department of Commerce Personal information you provide may be used for secondary purposes [privacy Law, s. 15.04(1)(m)] , (Submi ompleted form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 1 ches in size. Coun State Sanitary Permit Number ^ Check if revision to previous application State an I. D. Number ~~ C',~~ -~ ~ s I. Application Informat -Please Print all Information ocation: Property Owner Name N L / ~ l d~ Property Location ~~ 3 f d , / ~N, R E (or) 1/4, S~3 T f 1/4S Property Owner's Mailing Address Lot Number Block Number ~~g~ r to ~`` ~ r `~ City, State Zip a Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) a ^ City ^ 1 or 2 Family Dwelling - No. of Bedrooms : c> ^ Village ~'fown of . ^ Public/Commercial (describe use):_ ~ ~ N Nearest Road ~ ~ ~ , ~. a Pazcel Tax Number(s) ~ ~ 2 - O - 0 D ' i Type of Permit: (Check onl ne box on line A. eck box o ine B if applicable) 3 3. ~ . I , S" A ew 2. placement 3. ^ Repl ement 4. 5. 6. ^ Addition to ystem Tank Onl Existing System g) Pe umber Date I ued A Sanitary Permit was previously issued ~ 9 IV. pe of POWT System: (Check all that apply) ,Non-pressurized In-ground ~~91,~ L+'~~~~~ ~ f- ^ M d ^ Sand Filter ^ Constructed Wetland Line le Pass ^ Dri Tank ^ Sin ' y ^ din ^ P i d I d / p g g n-groun ressur ze ~~l '7' ~~"ZLfo "~ ~ ^ erobic Treatme Unit ^ Recircplating ^ Other: ^ At-grade " V. Dispersal/Treatment Area Information: I. Design Flow (gpd) 2. Dispersal Area 3. Dispers Area 4. Soil ApplicaU 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals./day/s .) (Min./inch) Elevation VII. Tank Capacity in otal # of Manufacture Prefab Site Steel Fiber- Plastic Information Gallons allons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks ~"~" ~ C x ~00 ~ / ~ ~- ~!i cdV/ ^ ^ ^ ^ ^ ^ ^ ^ ^ VIII. Responsibility Stateme I, the undersigned, assume re nsibility for installation of the POWTS shown on ched plan P tuber's Name (print) Plumber's Signature (nos ps): MP PRS Business Phone Number Q~ u~ ~~, ~s ~~~ ~7 `f '7z ~Y~ PI tuber's Address (Street, Ci ,State, Zip Cod l~l~S 4~ti v£ ~ ~i~ IX. County/Department Use Only O Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ^ Owner Given Initial Adverse Surchazge~e) ~ Detennination Q (J ~ ~ O val: Reasons for Disappro X. Cond i tions o f Ap pr oval / / / ~ / ~ / -/ ( / r / Il YI ~F~(- ~C~e ltir 'F~ ~I~Cv I ~P ih 5 ~R ~~d G~4 j4tQ ~h Phi n 20~ ~Oe r lvl.4h k,`0. G`+~ r~r 5 /GGafM n~N.OI LL I I~GY~, S. ~ ~ o .~ / ~ ~t/P r,J Cade rey u ~ v-5 Q~ ~ ~~ ~. SBD-6398 (R. 07/00) d Li ~v ~ ~ l~d n~ / 7 9 y //o fti av ~ ~~~~~~- ~ I~ ~ L-3o2e 8 N ~y ~ 3i ~~ ~~- r,~~ /~ ~~~„~'~" g-?_oi ~~ s~ t t ~,a ~ 1 g oY 1 0 1 1/ ~~ ,~~: ~~ ~, ~~~~:~ i~o ,s F boo ~t r _~ ~~~ 1 ~' M ~~ ° • ion o ~d/ ~~.~.r.~~-~~ ~ ~/G~l ~ a~~ /~ w Z b r / (/ c~7~-1 ~ - ~-- - .~ dam,-~.~ ~~""~ ~~,c ~ z z z ~ 7 ~ q-7--a~ ~ S.(~, (lit/ 1M, U S f a'`w' f 8 rr~G.~s Get ~ ~ ~~~ l~~h, ~79~ ~ • ~~ISCO/1S%11 S NITARY PERMtT ;~.:_ Department of Commerce In accord with ILHR 83. I . dm. Cod ~-.,.`!,! ; Safety and Buildings Division 201 W. Washington Avenue P O Box 7302 Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the s st , on pa[~~~ss h vC ty ,,I ~ " t an 8 v2 x 11 inches in size. h ; 1~~jri ~ ~ ,iGd i ,~ • See reverse side for instructions for completing this appli ~~;on s Xg ~9 c ~e r ~.,~ Sanitary Per _i1;N r a . ~ ~ Personal information you provide may be used for secondary purposes ~~ ZON~~NT1~ GO eck if revision to previous a(iplication [Privacy Law, s. 15.04 (1) (m)]. FFlG~ to Plan LD. Number I. APPLI ATION INF RMATI N -PLEASE PRINT ALL I Property er Name / d< ~D ,,J r ion ~ t /a, S 3 3 T a p, N, R /7 E (or) Property O ner's M ~ng Address q y' c~ ~''' dv~' lot Number Block Number City, State t~ d Zip Code / Sa ~ Phone Number (7~~ > - ~ 9z Subdivision Name or CS Number ~-Y-~d~ o . . 7 ~ 11. PE F IL IN (check one) ^ State Owned 3 ~ It~ E'~,• - ' ~ Vil age Nearest Road , Public 1 or 2 F it Dwellin - No. of bedrooms c. ~~, K, C Town OF ~ ~y Parcel Tax Nu er(s) ~~ 2O, I~• ~1) 111. BUILDING USE: (Ifbuil gtypeispublic,checkallthatapply 4 1 ^ Apartment /Condo 1~~9 ~ Z ` /O "'~ / - G O 2 ^ Assembly Hall Medical Facility/ Nursing Home 10 ^ Outdoor Recreations] Facility 3 ^ Campground 7 Merchandise: Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 obile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ fice /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one x on line A. Check bo n line B, if applicable) q) 1. New 2. ^ Replacement 3, ^ Replace nt of 4. ^ Reconnection of 5. ^ RepaiFof an _______ stem ________System_______ TankO __ Existing System ________ Extsttnc~S~stem B) ^ A Sanitary Permit was previously issu Permi umber Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Dl ibution Experimental Other 11 ^ Seepage Bed 21 ^ Moun 30 ^ Specify Type 41 ^ Holding Tank 12~Seepage Trench 22 ^ In- and Pr ure 42 ^ Pit Privy ~~ 13 ^ Seepage Pit ~ ~' ~ ~ Z ''~~ 43 ^ Vault Privy ~ 14 ^ System-In-Fill a j! ZN i f~ ~,,,,, ~ ~ _ ~ ," ~. ~ VI. ABSORPTION SYSTEM INFORMA ON: 1. Gallons Per Day 2. Absorp. Area .Absorp. Area 4. Load Rate 5. Pert. Rate 6. System Elev. 7. Final Grade y~ Required (sq. ft. Proposed (sq. ft.) (Gals/da q. ft.) (Min./inch) Elevation ~(f 3 9(0.4 Feet 9B ~ O Feet VII. TANK Ca act INFORMATION in gall s Total # Of Manufacturer ame Prefab. Site C Fiber- plastic Exper. New xistin Gallons Tanks concrete on- Steel glass App. Tanks Tanks strutted Septic Tank ng a X ~i'-f0 cJ d ^ ^ ^ ^ ^ Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ VIII. RESPONSIBILITY S TEMENT I, the undersigned, as me responsibility for installation of the onsite sewage syste hown on the attached plans. tuber's Name: (Print) Plumber's Signature: No Stamps) MP/ PRS o.: Business Phone Number. a~`'~~ d;,," ;,mss ~ ~1~ -Y7z-~~/yG PI be 's Address (Stre City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue tssu~ nt 5~ nature (No Stamps) Approved ^ Owner Given Initial ~~ Surcharge Fee) ~~~ 9 f~ s Adverse Determination /~ X. COND TIONS OF APPROVAL /REASONS FOR DISAPPROVAL: ~ n t~-~-s' ja~~ on y~! ~ ~J ~51 ~) co ~ ~ ~-°~ - ~IR~G ~ ~o~', Sao, SII , ~9A' SL) ~-~- ~~. ~ G~~.~-- ~ SBD- 6398 (R.11I97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t r ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in.ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pu er whenever necessary, usual ly every 2 to 3 years. 6. If you-have questions concerning yqur onsite sewage system, contact your local code administrator o~~[he State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tali number(s) of where the system is to be installed. II. Type of building being served. Check only one~and complete # of bedrooms if 1 or 2~ Family Dwelling. III. Building use. If building type is public, check all~~appropriate boxes that apply. -''~ IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending orbsystem type. VI. Absorption system information. Provide all information-requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or. existing tank, lKt the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and~~ank rhaterial. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval on1Y~t`tanks received experimental product approval from DILHR. ~" VIII. Responsibility statement. Installing plumber is to fill in name;~license,number with appropriate prefix (e.g. MP, etc.), address and phone number.° Plumbermust sign application form. IX. County/ Department Use Only. X. County /Department Use Only. ~w Complete plans and specifications not smaller.~#~ian 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot-plan, drawn to scale or with complete dimensions,.location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorptio-tsystems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) .cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; a-~i F) all sizing information. ~. GROUNDWATER SURCHARGE ~ 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices w~ch can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. .~ d ~~ ~~ ~~ \'~'~ ,,~ ~s .e a~~~ ~~ ~n/~/~ -~ ill Gov t ~U ~,,,,~. .~ i sb t L ~~ I~ / / ~3 / o ~ 1 a 1 ~, ~ 1 a 1~ ~ ~ 7~ ~ ~ ~,,l~W 1M,U sf ~~ d ~.~. ~ ~ /~~~ / 7 9 y //o fh ~v ~ ~~~~1~- I~ ~ l~a~ ~ /`~' ~l 8" ~ ~- y , ~ , Vii. ~z ~~ ~~ w .^ ~ J POWTS OWNER'S MANl1AL 8t MANAGEMENT PLAN BILE INFO MATION Owner _ ~~,/ ~~ ~~ Permit # neer~v DeDAMCTCDC rNumber of Be ooms ~ ^ ~• Number of Co dal Llnits ,1~ NA Estimated flow (avers ) ~/,rU gal/day Design flow (peak), (Es sled x 1.5) gal/day Soil Application Rate 9 gal/day/ft2 Influent/Effluent Quality Monthly average* Fats, Oil 8t Gre (FOG) X30 mg/L Biochemical Oxygen Demand ODs) <_220 mg/L Total Suspended Solids SS) 5150 mg/L Pretreated Effluent Quality ' ^ NA Monthly average* * Biochemical Oxygen Demand (BODs _<30 mg/L Total Suspended Solids (TSS) <_30 mg/L Fecal Coliform (geometric mean) <_ 10' cfu/ l OOmI Maximum Effluent Particle Size inch diameter MAINTENANCE SCHEDULE Service Event Inspect condition of tank(s) Pump out contents of tank(s) inspect dispersal cell(s) Clean effluent filter inspect pump, pump controls 8t:alarm Flush laterals and pressure test Other: At least When a At least At leas At le At ast rage of SYSTEM SPEGIFIGATIC7NS Septic Tank Capacity 0 O p al ^ ~+ Septic Tank Manufacturer ~ d ~,,~ ^ NA Effluent Filter Manufacturer b~ ^ NA Effluent Filter Model ~ o o ^ ~' Pump Tank Capacity ~ gal ^ NA Pump Tank Manufacturer .~ ^ NA Pump Manufacturer ~- ^ NA Pump Mode! ~-- ^ NA Pretreatment llni ^ Sand/Gravel lter ^ Mechanical eration ^ Disinfecti Manufactu r ^ Peat Filter ^ Wetland ^ Other: ^ NA D' persal ell(s) n-gr and (gravity) ^ At ade ^ p-line ^ !n-ground (pressurized) ^ Mound ^ Other: Values typical for domestic (non-commercial) wastewater and septic tank effluent. * Values typical for pretreated wastewater. ,ry ^ months !~ year(s) (Maxiimum 3 yrs. ) sludge and scum equals one-third (Ys) of tank volume Service Frequency ^ months !~] year(s) (Maximum 3 yrs.) once every once every once every least once every At least once every ^ months d] year(s) ^ months ^ year(s) NA ^ months ^ year(s) I~NA ^ months ^ year(s) ^ NA ^ months ^ year(s) ^ NA MAINTENANCE INSTRlICT10NS Inspectioru of tanks and dispersal cells shal a made by an individual carrying one of following licenses or certifications: Mast Plumber; Master Plumber Restricted Sew ; POWTS Inspector; POWTS Maintainer; Sep ge Servicing Operator. Tank inspectior must include a visual inspection of the k(s) to identify any missing or broken hardware, entify any cracks or leaks, measure tt volume of combined sludge and scum d to check for any back up or ponding of effluent the ground surface. The dispersal cell(s) shall be visually inspected to c k the effluent levels in the observation pipes and to c ck for any ponding of effluent on the ground surface. The ponding o effluent on the ground surface may indicate a failing condr on and requires the immediate notification of the local regulatory uthority. When the combined accumula of sludge and scum in any tank equals one-third (Ys) or more o e tank volume, the entire contents of the tank shall be moved by a Septage Servicing Operator and disposed of in accordan a with ch. NR 113, Wiscons Administrative Code. The servicing of effluent fi lets, mechanical or pressurized POWTS components, precreatement components, and any other maintenance or monitoring at intervals of l 2 months or less shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START VP AND OPERATION For new construction, prior tot srocess and0/or da age the d persalacell(s)fol high oncentrations are detected have the conteir that may impede the [realm p nr rho ranlr(s~ ramovPd by z Sent~e servicing operator prior to use. ar «- System start up shall not occur when loll condltJons art frozen at the Infiltrative surface. Fate _, vf„ During power outages pump tanks may fill above nomul higfiwatex levels. When power tt r+estond the excess wastewater will be discharge4 to the dispersal cell(s) in one large dose, over(oadlr~ the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situarjon have the contents of the pump tank removed by a Sepa>te Servking Operator.prior to restoring power to the affluent pump or contact a Plumber or POWTS Maintainer to assist In manually operatln¢ the pump controls co restore ncrtnal levels w~lthln the pump lank. / Reduction or eilmin ion of the following from the wastewater itrearn may Improve the performance d prolong the lik of c~-e POWTS: antlbiotlcx; aby wipes; cigarette butts; condoms; cottots swabs; degreasers; dental Ross; pars; dlslnfectants; fat; foundation drain (sump urnp) water; (Writ and vegetable peelings; gasoAne; Lrease; herbiddes; at scraps; medications; oil; wlntlna t;roducu: aesticl ;sanitary napkins: tampons; and water sofuner brine. Do not drive or park vehicles over unks and dispersal cells. Do not drive or park over, or otherwise dlswrb compact, the area within 15 feet do slope of any mound or at-grade soU absorption area. A$ANDONEMENT When the POWTS fails and/or is mtanently taken out of service the following sups s 1 be taken to Insure that the system is property and safely abandoned In pifance with ch. Comm 83.33, Wisconsin Ad tstrative Code: • All pipln¢ to tanks and plus II be disconnected and the abandoned pipe Wings sealed. • The contenu of aft tanks and shall ba removed and prc+perly dtspo of by a Septa¢e Servicing Operator. • After purnpinY, all tanks and pl hall be excavated and removed or lr covers removed and the void space filled with soil, ~+~avel or another Inert solid aerial. O Mound and at•gradr soft absorpc systems may bt veto cted in place following removal of the biomat ac the infJluadve surface. Reconsw ns of such rysterru must.co fY with tht rules In effect at that time. < < WARNING > > SEPTIC, PUMP AND OTKE REATMENT TANKS MAY CONTAI LETHAL GASSES AND/OR iNSUFFIGiENT OXYGEN. DO NOT ELATE ASEPTIC, Pl1MP OR OTHER TRIEA NT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT, R GUE OF A PERSON FROM TKE INTERI OF A TANK MAY RE OIFFlCUIT OR IMpf1CCIRl i. CONTINGENCY PLAN !f the POWTS falls an<i cannot be repaired the lowing measures h e been, or must be uken, tv provl4e a code compliant replac meat rystem: ~,A suitable replacement area has been evalu ed and m be udJlzed for the location of a replacement soil absorption system. The replacement area should be pr cted disturbance and compaction and should nat bt infringed upon by required setbacks from extsdng and proposed n, lot fines and wells. Failure W protrct the replacement area will result in the Head for a new soli and site evalua co estab4lsh a suitable replacement area. Rsplacement systems rnust comply with the rules In effect at that t1me. Q A suitable repiacenxnt area is not available a to ack andlor soli ifmltations. Ban•In>z advances in POWTS technology a holding tank may ba lnstaUed u a last to re the failed POWTY. O The site has not been evaluated to Iden a suitable lit area. Upon failure of the POWTS a sol( and site evaluation must be performed to lot a suitable ropla ens aced. !f n0 roplacement area is available a holding tank may be installed as a last resort W reel the failed POWTS. ADDITIt7NAL COMMEDR'S POWTS INSTALLER Name ' Phone ~ Z _ POWTS MAINTAINER -.Name ~Pnone 4 z-~yyl~ SEPTAGE TERVICING OPERATOR (PUMPER Name ~~ ,' c~ ~G ~ ~v ~'r}," ~ Phnnv ~Z "7 - ~ ~d 8 tACA1 R>rGULATORY AUTHORITY Aaie~Y ~f: ~K o ~ ~o k ~. ~" z J ,., ; .~, n ~ d