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Home My WebLink About020-1065-20-000/* `Wisconsin DepartrflentofCommerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1){m)]. Permit Holder's Name: Riesselman, James ^ City ^ Village ^ T n of: Hudson Township CST BM Elev.:- Insp. BM Elev.: BM Description: QO.O` ~ •Or ~ 4w TANK INFORMATION Q TYPE MANUFACTURER CAPACITY Septic ~~S ~~ gtr~ os ~('_ C~a Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septi ~ ~ r .r. S~~ ~ ---- NA Aeration NA Holding PUMP~HON INFORMATION _~ ELEVATION DATA County:., SL Croix Sanitar~~O22 ]No.: State Plan ID No.: Parcel Tax No.: 020-1065-20-000 STATION BS HI FS ELEV. Benchmark . `f Z oo . Z~ ~ Qo .0 Alt. BM Bldg. Sewer ~~ St/Ht Inlet St/ Ht Outlet p 89S ~r Inlet t~ 9• fog • ~-3 r 9-9~ o•~, Header /Man. Dist. Pipe L It ~ 85.89' Bot. System ~ 2 • lS• 4 .~SO Inal Grade S~ ~,~ ~ St cover ~ _ 3'~ 9y~9 ~ c3rf: tr.. a.Z~ 9~•~S` u e~~ 10.32 ~,~p' N ~,,,~- Iv . ~ s 89'. 6 ~ r BEa REN Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN N DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufrac_t_u`e~r: ~ "" g`~ SETBACK T'~` tl~' INFORMATION Type O ~ i , CHAMBER Mo el Num er• System: V , ~'~o ~(o • ^'~ q~ '~~' OR UNIT au DISTRIBUTION SYSTEM "' ~"'°" Header / anif~lcj,/, Distribution Pipes ze x Hole Spacing Vent To Air Intake Length ia. Dia. Spacing '/ ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~ Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched r Bed /Trench Center J •~ + Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No CQMM~NT (Ipclud coded~SCrepan~~5, n ,q~,e52nt~~ tC. lnspecuun r+i: oo, ~,~ioo ~~,~~,~,,t~„~~ ~-.=._~__ Loeat>ton: ~5T Yolen~rive, Hudson, W1 ~4U16 ~~b 1/4 fV~ l!4 24 T29N RI9W) - 24.29.19.249E3 T 1.) Alt BM Description = I1r~/~- 2.) Bldg sewer length = .•• ((, , o' ~ , Z -amount of cover = ~"G~'~ ~*" Plan revision required? ^ Yes ~No ~ ( z / Use other side for additional information. pb 2f oU . ~P SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ~~ii_i,:r"i SANITARY PERMIT APPLICATION Safety and Buildings Division Bureau of Building Water System o,,_~-.._ 201 E. Washington Ave. In accord with ILHR 83.05 Wis. ~ C'ode ~ P.O. Box 7969 • •: ~ Madison, WI 53707-7969 ~; ; ~.._ . • Attach complete plans (to the county copy only) for the syst t~~i'pa er.,t less-- co my ` than 8 v2 x 11 inches in size. ~~ _ ~I+'^r°n,r~` ~~~ (~~ ~~ . C /~D/?~ ~~ ~ ~ • See reverse side for instructions for completing this appl~c t~1 S~aYe a nitary Permit Number -r s r~ E.t ~' .r ~~ ~f The information you provide may be used by other government agency prog ~~ a ~~ k if revision to previous application ~ (Privacy Law, s. 15.04 (1) (m)]. QTY $ `~~ Ian I:D. Number t ~ I. APPLICATION INFORMATION -PLEASE PRINT ALL If»dh~~~ ~ : ` Property Owner Name ~ •S ° ~~ ~ ' ~. Propert Loc ,i~. ~ '~/ - : 1Y ~ T ~ , N, R E (OI(~ SS L a Q /h! Property Owner's M in Add r/ess ' Ldt~AL6L b~ri- Block Number e /~' S O ~ Cit tate Zip Code Phone Number Su v on Name or C M Number ~~ M o~~ (7~s~86-sir S + o ~ o ~h s - F II: TYPE OF BOIL ING: (check one) ^ State Owned ^ ct ^ V Nearest Road- T Public 1 or 2 Famil Dwellin - No. of bedrooms own of u.cQSO D {~~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) a5/, ~9 j9, ay9B 4,Z D - ! 8 (05~- ~O - 4 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility /Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check my one box on line A. Check box online B, if applicable) A) 1. ^ New 2. eplacement 3. ^ Replacement of 4_ ^ Reconnection of S. ^ Repair of an -_____System ________System_____________TankOnly______________ Existing System _________ExlstingSystem B) ^ A Sanitary Permit was previously issued- Permit Number Date Issued V. TYPE OF SYSTEM:. (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ~epage Trench 22 ^ In-Ground Pressure \ i ~ 42 ^ Pit Privy ~ 3 X 1 p0 43 ^ Vault Priv C~ y , 13 ^ Seepage Pit 14 ^ System-In-Fill ~ ~-~ ~.F.~. r VI. ABSORPTION SYSTEM INF RM TION: l~ C.diDc ~ y a.. r 3~X46'.~.a 7..>~~~{.ss 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate System E~v_ 7. Final Grade s sa . Elgv~at~oy ~ ' Required (sq. ft.) Proposed (sq. ft.) (Galslday/sq. ft.) (Mien./inch) tf: ~ VII. TANK INFORMATION Ca acit in altos g Total ll # of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Ex er. P i i ons Ga Tanks concrete glass A p - New n Ex st strutted Tanks Tanks Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. r's Name: ( nn t ) Plumbe Plum er's Signature: (No Stamps MP P R SW .. r: Business P h one Num b e I I / ~ + ~ y ~j ~j I~ ~ j ~ j 2 Plumber's Address (Str ,City, State, Zip Code}: ~ ~ 7 W ~ IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (IndudesGroundwater ate Issue Issuing Agent Signa ure (NO Stamps) 'Approved ^ Owner Given Initial Surcharge Fee) ~~~~~ ~O`5 '~~ : ___.______ ~~~Q !)-~l.tn Adverse Determination , .,. X CONDITIONS OF APPR VAL./ REASONS FOR [DISAPPROVAL: S8D-6398 (H. OS/94) DISTRIBUTION: Original h). CouNy, One copy To: Safety 8 fluilJings Div,.ion, Owner, PlumtKr INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be 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 pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. 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 tax 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 on system 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; list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for a!/septic, pump/siphon and holding tanks for this system. Check experimental approval only if 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. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 1 1 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 absorption systems; 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 1 15 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~.~ . ~ ~, ~~ ~'~~ N~~ ~ ~ w" `1 ~~ R ~ ~~ ~ ,, V `\V\lI ~~~ C~ ~ 0 '~ Q ~~ ~ o ~- ~ Z ~\~-~1 ~~ ~ ~~ .~ `" -~ i E O o ~, ~~ a ~ .~ ~ > (1D v ~( ? ~o a w \ k X M I 1~~18~ II i~ ~ 1 ~ I! I' I~ ~i `` ~ s ~ I -~. 01 ~ ~ ~I ~~ i~ ~~ ~ ~ ~ ~ ~ ~.! i _~ 00 ~ ` , II ~ ~ d ~. l~ \~ ~~ '~ ba o~y~'t ,. Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page ~ of 3 Labor and Human Relations Division of Safety and Buildings in accordance with s_1LNR 83.09, Wis. Attach com late site Ian on a er not less than 8 1/2 x 11 inches in ~ y'P1an must ~ County T include, but not limit d to: verti al and horizontal reference point (B dr~ction and S / • G~ ~~, x percent slope, scale or dimensions, north arrow, and location and ~ e to n~ parcel LD. # J ~ . ~ ~ • /~ ~ s . L-O • d-~.a APPLICANT INFORMATION -Please print all info ~ ion.: 4 ~E ~ ~~~~ Reviewed by Date Personal infoRnation you provide may be used for secondary purposes (Pri w, s. 15.04'0) ~ - S - 2~}~ Property Owner j~ ~ p6~ion - . ' [ L~ Q p ~(M (\ l != ss~~. ~'1 7g' ~ ~~" -~ -Govt. Lot S;~ 1/4 ~C 1/4,S Z / T Z/ ,N,R / / +!: (or) W Property Owner's Mailing Address ~*.,," Lot # Block# Subd. Name or CSM# , City State Zip Code Phone Number ,~,/ Nearest Road /fv9so~ l ~/ iSyo/~/ ~ (7/5 )~~(p • y067 ^ city villa L"J Town ~17o t EIJ ~ R ^ New Construction Use: Residential / Number of bedrooms 7 Addition to existing building Replacement ~ Public or commercial -Describe: rtJ//~ ' /Vo T /Q6 CD M.~r Ea 4 ~ Recommended desi n loadin rate NF bed, gpd/ft2 • S trench, gpd/ft2 Code derived daily flow gpd J,Cn 9 9 - / Absorption area required~,~.bed, tt2 ~ ~ // " trench, tt2 Maximum design loading rate bed, gpd/ft~~c trench, gpd/fl2 Recommended infiltration surtace elevation(s) 's'ue' ~~ ' '3 tt (as referred to site plan benchmark) Additional designlsite considerations SEE ,3E/DW '~ Parent material -s,s 4U.G~. I ..S' .u Flood plain elevation, if applicable --=~-~-tt S = Suitable for system Cron/ventional rM-,oun~d . In-Grown ressure A I - ~ e aysrem n r rnr/ I r,vi~n ~y ~ a~ ~~ U = Unsuitable for system ~'S ^ U IBS ^ U ^ U S ^ U ^ S (rJ-'U ^ S Boring # Ground e ev. ~3. y ft. Depth to limiting factor 7 /~in. Boring # .. z Ground elev. ~~, ~n. Depth to limiting factor 6 S ; '~(, ;'l o ~ ~ ~~ ~ /l Q_in. Remarks: CST Name (Please Print) ~oQERT ~L~ pj C~~ Signature Address 0111 r1~CrRIPTIt1N REPnRT i H th D Dominant Color Mottles Structure d R t GPD/ft2 or zon ep in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence ary Boun s oo Bed , Trenct ~ o•!P /oyR L 3 ~ /fs~~• ~f/~ w / f •y .. s p.3 /o y,~ 3~ Sim z fs6,~ ~-~~ w ~ , s :. ~ a~ ' '' ~ , Remarks: ~f ~• ~,- Private Sewage Conf 655 O'Neil Rd. -~ Hudson, Wis. 54018 ~i~/~ Tele hone No. 7/S • ,~8~ • S/BS Date CST Number ~ zU. ~ zzG3? S PROPERTY OWNER ~ ~~•E~~/~'r~ PARCEL I.D.M Boring # 3 Ground elev. ~a,~ft. Depth to limiting factor 7 ~/~in. SOIL DESCRIPTION REPORT P ~ ~ Page •Z'" of. Horizon Depth Dominant Color Mottles Structure i C t B d Roots 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ence ons s oun ary Bed ,Trench Z ~•L ~o y~ 3/ s~~ ifs~d,~ ~ ~,e c s - • Z ~ • 3 3 •s /o l R 3 r-- s L / ~ ~-~, ' ~' s -- ~ s 1 /~ /ham ,,,5. ~~ ~ ~' Q . 7 . C~ ,- , ~~- ~ o Y t b , Remarks: Boring # Ground elev. ~y•(~n. Depth to limiting fgact~or 7 ~ ~V in. Boring # Ground elev. __n. Depth to limiting factor in. Boring # Ground elev. ft. . y ~oyr~ ~ o ~-- Sig ~ s z.~ fhb /~ ,-~,fR d~ ~s ~~. - ~ . s ; . G •? ~ • ~ z. r~ Remarks: l r t C i D Mottles Structure d R t PD/ftz Horizon Depth in. o o nan om Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boun ary oo s Bed , Trenc ~ ~ .~ ~~ .~ , Remarks: Depth to limiting factor in. Remarks: ' SBDW-8330 (R. 08/95) IMPORTANT NOTE TO OWNERS & INSTALLER: All the finer textured soils (loams,silts, etc.) can & will be easily smeared Or compacted even by a backhoe bucket during trench construction. When this occurs premature failure will result. As per ILHR 83.13 w ~, W I N C ~~ ~ ~ ~~ j °.D N - -~ ~ ~ ~ -- o k tit _ cs~ ~ ~ ~~ W Q1 `- ~ ~- W~ _ ~~ ~~ ~ ~ !I~ I I ~ ~ 11 ~. ..o~~ ,, y ~~ ,, 't- y ,, II o Q ,~-=-I , ~ '' ° I I , ~' ~ I I ~ p ~-' i~ II - li II II I I ,~~ I I~ I ~ W ~~~ ~I~ I I K ~.~~~ III ~ ~ o II i~ o ~ II ~ o ~ Z i~ i~ o ~'' I ~ ~~ W ~ ' r I ~ O . . • ~ pm~~ ~ ~ ~~~~ ~Zmp wg-~~ ° ~ `"'°zz v O ~ Q \ ~ ~D~ Z ~ \ -Grp II ~ ~ O~ ' i~ ` m ~ ~ ~. ~~~~~ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the _ ,J i /~'1 i~ ~SS~' ~ /J1GZ~ residence located at: .~ ~ ; , ~~ ; , Section ~ ~ , T~N, R~ Town of Lt~1 S4N Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: i~%"IGLt.~ ~ ~ "-"~ ©~a o-e~ - ~,0.~..-~ Did flow back occur from absorption system? ~~ ,, ~ e ~ skit line) Appro ate,~_v__o~~ume o~ len th of ime: gallons minu es Cap city : ~ . a~.r-/L ~-1r ~r ~. .~~ ~`'c'~( . /oo/o~~ - ~~}}struction: Prefab Con re e Steel Other ~o~~T_- Manufacturer: (If known): t, Age of Tank (If known) : ~ 4 z S ~ `~s~-~ ~~ (Signature) (Title) (Name) Please print (License Number) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). ~~^~_ Name ~~,.,^,,~~rl,~~,~,~,/jZ~ S ignature ~~,zc.c ~ ~w M PRS ? 2 %t 8 ~~Nry /~'~~ ~ v~ ~~E ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owne Buyer ~~~ s /I ~~~~ ~ ~~/~ ~/ T Mailing Address ~ ~ % ~~o `.~ ~ ~ ~ / 7 u cQ..s o /(0 ~ ~`~ ~ ~~ Property Address ~ S/ / a / ~ ~ y~ (Verification required from Planning Department for new construction) City/State ~u,GrSO/!~ ~ ~YD/,( Parcel Identification Number 4.~D --l0% S- ~©.-DOD LEGAL DESCRIPTION Property Location , 1/., ~ '/., Sec. ~~., T~N-R_~zs~ Town of Subdivision /~ ~ ~~~~ f ~~'~ ~~ /a,~1.~ ~~-` Lot # Certified Survey Map # / ,Volume ,Page # Warranty Deed # ~ ~ ~ -~~ 7 .Volume -s-'! ~ ,Page # Z ~ ~ Spec house ^ yes ^ no Lot lines identifiable yes ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. IE 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 licensedpumperverifying 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 Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three ye a tion date. ~` ..~ ~~' / / S ATURE OF LICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (aze) the owner(s) of the property describ bove, by virtue of a warranty deed recorded in Register of Deeds Office. ~- ~ ~/mil /~ 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 ~.---'~ "'~~ k+EALTH AND SOCIAL ~ .~ ,~ Plb 67 ., T„~~ate ~nc~ County State Permit # ~_ F I ~` , . ~ , , ~ Per~~,l~pplwation .T ~. County Permit # ' ` _`~ ~ " ~ for P ivatg mestic Se age Systems ; 4 County ~' ~ _ ~ _ ~~ ~ "DPENOTES;:,STA.~PPROVAL=„REQUIRED~_ ~~~~~~'" ,_e, ~~"~~~ ~_~ ~ ,-u ~'^~~ "° ~„w. State Plan ~~I.D. # ~., Date.ihApproval,,,~R~ceived~`from ,State,a if Required ~ti~' °- f ~, - ~~ m A ~ ~ OWNER OF PROPERTY ~_- Mailing Address ` r ~'" B LOCATION: ; S~ '/4 /1/E''/4, Section ~ N ,R_,..~.(~,~W~-1.pT#I~F~~~i~y~`-"'°"_`_"`."~„'-~~~°-.,~ ~~,~, ~b i~;fsign a ;.~nearg~t ~r~qa~ ak, or,~lan ar QIk#y~' ~ _ ;/t~lJ~t~a~ {~~r~~ -~'~ ~/~ /'• ' M~ bR W~ ..~ t~-AL/~ ~ /.~ ~ /} •'/~,y ~y^ J F ~Sa F.: b.. '~'A",`~. •! -t.,.~ `'. ~.'F~~~p'rSC~lM.o+"~r t fJ/ It/ ~ Rx u ~ +s ,iii"a*'~ i ^~ s'1 ~ 4i ~~J / ! G _ ', ry "kG'k. ~`., ^"~,r Rl'!~ i ~, .? _ T ; '~~. yti-~. - - .., .. ,~ .. ~" ~p CUP ~'commercial•~~ n ~ rral ~\ . j -a ~„° w Othe ,(specify) ~'~' '~ ~ ariance: • . ,., • i l ~ .~, .~; ~ ~ ~; ~*~,~,;,~ ~ ~` Pro . f~;,~ m .8 •. _.. u le No. of d o s '~~ t ,,.< ~, ~, ~,.A~ _, ~ . . "- . `~t•TY{D. OF~AP ANCyIC-S ,Dishwasher ~Y S , 2 NQ Food :Waite Gnnde YE ~ ath ~ ~ ~ .h Y> Y", ~ ` J~'y, Y ~E ~~' J ' • ~ IPA W - ~ c^^'~.,. ., l ~• A . Y k ~... ~ - ~-.`~ .~` ~~~v ~tgrtfc, Wast~,~~~/ ~~~~S f TNO, Other~,_~s _~ ~ ~ .~ ~ ~,-.. ,~ ~~- Srt, a ' -r r F ~~" t ~ ~.. -;',€~ "'-':. -C~"fi. ~'3 ;~o-:~.i...n d i ~ : I~.,;~''. ~'l~;~ii ~;r ~ .f~... _ ~1ons ~ '`Np q#.'° tanks; ~ :' -~,,~~"k! ing tapk~.~caAacrty ~~~ ~ '~`~ Total gallons No of tanks, '"`' ~ _ r_~ ~ ;~ ~~ ~ r~~ . ~,, ~ ', j - ~ 7 ew lnstallat~on ~ Addition '' ~ ~ " replace ent~ r ~ :Prefab; C ~ r :. , ~ ~ "Poured ~In~:Place °-~ .Steel ~'"•~ "~ ~fOther~('specify) a~ ~~~'~ ,.>`.-~ - ~ a •N~~,~~ F :.: EFFLUE DISPOSAL SYSTEM: Percolation .Rate 1) ~ 2)~3) Total: Absorb~fArea ~'sq ":ft. -` NewAdditi w Replacement '~ `Fill 'System~~ ' ~'~~~' ~ xtir '; Seepage Trench ~~NQ n Feet=~~ Width ~'~` &Depth ~7•~Je~~,Depth ; e No ~ ' >~ch~s'~-"`~'' ~ f ~ - epage Bed , Length ~~Width - Qepih `'r. ' Tile Depth" No of, Linesn '.. ~ ''~''~"~ ~„ ."` Seepage Pit:'` Inside diameter 7 `Liquids Depth `'''~ `- ~ y •;'~ Tile'~Size~ ~*~~^'~~°~~°-°-~'_ s r ~ ~- ~ ~a.P [celope- of• land ` /t~ % Nom':, ~ ,~,~ ,~,_ ' Distance 'from.~~[iti'" l e« ~ :-~-,~ ' I tiie~~ujldersigned,~~Q,,uhereby ;,certify that the _ information I have :reported :is in.accord with, ~e~~j~n~;`-1-{62 20, _ ' ~ ~` s ops~n~~~dministraSi~g ;aCode and,.zhat L have sized .,the ,effluent dispg$al ., System ~„from the' ~ ~ {~r~ared~: ~~ ~by the Certifi d `Soil' Tester, - - ,~ ~, ~' ` -' ~~~~`~ r~' .NAME ~!JF~-`~ ~r/.E~/'~r.IQ~/ C.S:T, # ~~-3 and~,,other.. nform~att= ~,. bbtainedl from ~ _-5 , ~ ss ' ~' ~ ..r--- (owner/builder , ~ o ~ _ ~,,,~~-~ ~s ~~ f Plumber ~ Si~naturer Mp/'~'R~"#~ ~ ~' ' `PLAiV "V.IEW "~Prgv>~d skefch belo~~,,.of ~system~,(mclud,~r di[~ection~ of -` slope''a~d all distances ' + its' .~"' -= I - - H62.20; including ~ welO. _ ~ ~ ' j` ~ •' ~ ~ ~ "~ (tip' S"C'i4~', r ' + `,,.~~ ~~ ~ ~ ; ~ ~ i f r ~~ •'n' ,« `~ ~. ~y err`:. r. F ~~~. ~ • , 4 -.~.~ ~ r ~____"~---_~ _~ ~ _~ _,__ ~ - - ~ ~ ~ .,a ~ ~@ ~, .E ~- J , _ ,. -r -'~--- ~-- - _ ~ ._ - ~- - -- _- _ __ ~ ~ I ~: 4 . ' ~ ~.~ .. ~ - ~ }........-„-_._.__+,_._. ~ ,.~~~~ +,~,;:y ~ a, . ,Y: ,~ e~;w ~.j j- ~",l '~~ ._..-.fit ,•" `~ I I ~ i~t ~ ~ P~ t ^r -. ~ r, kY -L~- a S-~y~ • l4 •„~ '.~ vt ~o. ,~~;`~ i : >~ r _ ~ ~.ti.' «-•,- I 1 .~ • _ ' ~. ~i ~.~~"~ - w ,; ~k- ~;~ _ r I p.r ~ ~. ~ ~.,~ _ ~ , . ~. ~. ., i ~; . A s» ~ * -a ~y4 ~, x~ t Y:~ ~ i'4.~ ~ 4 y i ~ r a - .... - .. - - , I - - ., ~ ~ ~ ~~ ~ r ~~ ~,~ ~ _. r w ~ ~ `rti : t i - -~ ~ `` µ, yr ~ 'ti ' E F. 4. 'z. ~, .