HomeMy WebLinkAbout020-1028-20-000
a scor.sin c men c: ni: PRIVATE SEWAGE SYSTEM r ~nr.• S; 7-701;
a1 a in;; Rohe :a DivisrUr
INSPECTION REPORT Sanrar, Lermr. Nc.
GENERAL INFORMATION ~''~=RIAIT' Sate Nair. ID Nc
_r,onal mtormatror VOL orovioe ma, be used to- seconcan numasas r=•n•:acr Ca%r C4 ")im)*
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1:ST BM Eiev tnso 3h1 Erev HM :x_:cnuiior ISt! b,-:ni o.vn.Ranuu,'Mav No.
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TANK INFORMATION ELEVATION DATA
TYPE MANJ=ACTURER ^"APA3I7I' S TA7ION Bc HI FS E~tV.
. 5
t •
t _;eoti;. Bennhman:
I ~eMCr+ _ AL. BM 3, .3 /dz. L
~e~ e~c~. r 3 z.o .~z4
iF+o:at+~ Pa ~ D ~ 57, 31dg Seve•
E~ s
I-toldlnc SUHt inlet
SUHt Cnrtle: I~
TANK SETBACK INFORMATION 7.7(. S'7 - $S
74NK T,)' I P!L 1YE__ B_DG ROAD 15 met-
I eJ ZO 7.VA 97,715
Sept ID' Bottom
.)a inc IHeaoeriM.ar•
Q03 j 9• Z5
St /S X6.3
aeration Dist Pipe qs .71o
i6, 65-
I ,ordinq Bot. System /D • $ y V • Q(
PUMP,'SIPHON INFORMATION Pina Gras=
cm -4~
jtJ;anufactur r Demand 5: ^ove-
GD CIF 1-7 /W.
tA- IModz er
ITD Lrf. Friction L;;ss System: lie- =t I -
IForcemain ~enatn t_ Wel
SOIL ABSORPTION SYSTEM
B=D(TRENCF Wictr Lergtr Nc Dt 1ren:n s PIT DIMENSIONS N, n` ire- Inside D;2.
S jLiuuid Dept
DIMENSIONS h
1
SETBACK SYSTEM TC ?%L BLDG VtrELL LAKE'STREAM LEACHING Mam,=acture-
INFORMATION CHAMBER OR ~Ib
Tyne /6 T UNIT Mooe Numtes
c0 r< 4-- Gt,
DISTRIBUTION SYSTEM t d- . S 4 5
'-ieaaeoPdanitold DistritWor r Hole e ) Ho:e Sua;:nc ve r make
~Pr~e ; 01 ,5 ,O c~-
angtr ~ Dra _ (Leno-r D•. Spa_rre_ It
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ~e,~►4~ )d
I-°ot" .rile' IDeotr, Over irr Uer.'e a xx S > 1;S:,aoar x, Murcnec ;
:ed i renc^ lBec irrrnor Eopest'oesoi -
Nc _ es ND
I -
COMMENTS: driciuae ;ode discrepencies, persons present etc., irspect;or insoe:tior #2
_ocatlon: Farce: No:
G ll~a u►5 ~c~ 1r. 6 6140
Alt BM nesnriptior = ~t GbJ
Rioc sewer Ienatn
arnoun. D' Dove- _
-tar revision Keaaire Yes NC
se other side fo• addhiona info rriatlor. ✓ 1 N
n
ature Car. N::
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( bounty
nnT%i1 LJr
NO "I
Industry Services Divi sl Crcix
D S f 9 2a 1 1400 E Washington S itarv Permit Number (to be filled in by Co.)
\f~\ ` S P.O. Box 716
P
-7ZJ 7
ST, CROIX COUNTY Madison. WI 53707-7 v z4
_Gomm DEVELOPMENT
V c_ ~
5anitai Permit Application State lransaaivn(NuLmber
In accordance faith SPS 393.21(2). Wis. Adm. Code. sub tissior, of this form to the appropriate govemmertal unit A)T1
is required prior tct Obtaining a sauitar% permit- Note. Appli:ation terms fin state-owned POWTS are suhmitted to
the Department of Satcn and Profcs zonal Scr ices. Personal inti rwanon you prov!dc may be used fOr seCLHIJW% Prclect address (if different than mailing address)
purpose> in ac. ordarcc with the Pricacs Lass ; I i (Yl1 I ;':r;. Star; Same
1. Application Infor ' n - Please Print All Information ~IA~ s
Properly O, ICT s \arttc j Parcel a
Margenac. Peggy 02(1-1028-20-000
Propert} Owier's Mailinc Address Propert% Location /Z
551 Spurlirle Circle
Govt Lot
City, State • Zip Code Phone Number - SA NE Section 16
Hudson , W1 54016 (circle one)
I29N R19ForW
II. Type of Building (check all that apply) - -
Q 1 or 2 Fantle Dwelling -Number of l~cdrooms 3 I Subdivision Name
North Line Station Il
❑ Public.,C'ommercial - D.-Scribe lase -06 - Block
❑ city of
❑ Stale 0%% tied Describe Use
C. ~1 Numhcr ❑ Village of
Z p i /_'r ~.llc e.., 174-7 622 O~5 41 4 i~ 759 ❑ Town of Hudson
111. Ty e of Permit: (Check oily one hox on line Complete line 11 if a plicab
A- ❑ \ew System ❑ Rep:acenient System ❑ -1 reatment/I lolding Tank Replacement On % ❑ Other Modification to Existing System (explain)
B ❑ Permit Renewal ❑ Permit Re% isicrt ❑ C':laid=c of ❑ Pcmut I ranstcr to \e%a L. sl Precious Permit Number and Date Issued
Before Expiration Plumber OwneT 49445 5,'29,71984
IV. Type of POWTS S stern;Com onent'Device (Check all that apply)
Von- resJnrrred In- ' ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. it-suitablc sVtl ❑ Mound '14 in. of soitable soil
Holding Tank Other Dispersal Component (,explain) ❑ Pretreatment Device (explain) /a 1!1~2
V. Dis ersaV7'reat nt Area Information:
Design Hoyt igpd) Design Soil AppLeap011 Dispersal Area Req red (sf) Dispersal Area Pro sed (sf) ' System L lcva on
t 0 Rate(epdsfl 643 70i,) 95 ill'
VI. 'l'ank Info Capacity in
Gallon' Total k of ti
R4anufa ur r - v
Gallons Units P c r
New lanks -NisUng ranks i_
lid
Septic or Holding I ank 3201 1000 1320 2 1Pieser Col rl:ic G/ El' Dosine Cnarnber ❑ ❑ ❑
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the PONN I S shown on the attached plans.
Plumber's Name i Print) Ptu s ature M11;'v1PRS Number Business Phone Number
John Schmitt 223760 715-760-0496
Plumber's Addre.s i Street. City' Stave, Zip Code)
616 1a0th A\e. Somerset, W1 54025
VIII. ounty/ apartment Use Only
Approved Permit Fee Dar Issu /1 Issuing nl Signature
(lT , \,;n Kea,on It r 1knia; S
IX. Condi&>t!fiaTft(P 1Reasons for Disapproval
1. Septir tank, etlltAnt fine, 2nd
-disper,:ai cell must all be w-n.1ces! nirlnWneec
as per management plan pro tided by plumber.
2. AN ae4N6t* rasup+erewft tstl,rsl W maintained
as per sppticabi* co:l* 1 crdinanua.
ktrach tfi complete plans for the cFstem and ~nhtnit m the ( ounl} only un paper nor lk s than 8 12 X I I inches in cite
ti131)-i.393 s :(i I I i
_ PLOT PLAN
Project Name Margenau 3 Bearoom Replacement Septic System
Leta' Descrintier ISW1/4, NEIiC 516. T29N, R19W =I D 1020-1028-20-000
Sub;a!vision Name. North Line Station Lo. # I1
F~-~- SCALE 1"=40'
Township IHudson Parcel Sze 2.01
Cziunty:ISt. Croix
System Elevation 95.90' Existing 18'x36' Bed
Slope: 13%. T1= 95.50' Proposed 70.00' EZ Flow Trench
NE lot corner 95.50' Proosed 70.00' EZ Flow Trench
A BIv1' Elevaacr, 1100.00' WS11,010~_1iet
Btv12 Eiev5 Existing Ta-iks (S1 i Wieser Concrete 1000 gallon
See Plat Map for complete view of parcel New -ank (S2i Wieser Concrete W320-MR
E`fluent Fi.ter I Polylok 525
r Sc- 4C, -AS-M C266
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CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Margenau 3 Bedroom Replacement Septic System
Owners Name: Peggy Margenau
Owner's Address 551 Spurline Circle
Hudson, WI 54016
Legal Description: SW1/4, NE1/4, S16, T29N, R_9W
Township Hudson
County: St. Croix
Subdivision Name: North Line Station
Lot Number: 1 Block Number
Parcel I.D. Number 020-1028-20-000
Plan Transaction No.
~Iagc 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 Valve Information
Page 6 System Sizing & Cross Section
Page 7 EZ Flow Information
Page 8 & 9 Management and contingency plan
Page 10 Existing Tank Certification
Page 11 Septic Tank Maintenance Agreement
Page 12 Warranty Deed
Page 13 CSM or Plat
Attachment 1 Soil Evaluation Report
Designer: John Schmitt L cnese Number: MPRS 223760
Date: 5/3/2016 Phone Number: 715-760-0486
7 ~tL
Signature: 4 C 10 4
C I!
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1
PLOT PLAN N
Project Name: Margenau 3 Bedroom Replacement Septic System
Legal Description: SW114, NE114. S16, T29N, R19W P.I.D. 020-1028-20-000
Subdivision Name: North Line Station Lot* 1
Townshie Hudson Parcel Size: 2.01 SCALE: 1"=40'
County: St. Croix
System Elevation. 95.90' Existin 18'x36' Bed
Slope: 3% T1= 95.60' Proposed 70.00' EZ Flow Trench
BM1 Elevation: 100.00' To of NE lot corner T2= 95.50' Proposed 70.00' EZ Flow Trench
BM2 E evation: 97.85 S1 outlet
■ Backhoe Pits.
Existing Tanks (S') Wieser Concrete 1000 gallon
See Plat Map for complete view of parcel New Tank (S2'r Wieser Concrete W320-MR
Effluent Filter Polylok 626
4 nch Sch 40 -ASTM D2665
4 3034 ASTti1 D3Q34
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Page 3
PIDIMM M xMlm
govatk,rsin Precast, Drainage Zabel' PL-525 Effluent Filter
!i Wzisfewarer Products A Division c' ?oMok Inc,
111,-525 Filter
The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has
525 linear feet of 1;'16" filtration slots. Like the PolOok PL-122, the Polylok P1,-525 has an automatic shut-off ball
installed with every filter. 1Nhen the filter is removed for cleaning, the hall will float up and temporarily shut off
the system so the effluent ~%on't leave the tank.
1 catures: 1/16" Filtration Slots
• Rated for 10,000 GPI) (gallons per day). - (optional)
• 525 linear feet of 1x%16" filtration. 10000 GPD I
• Acce},ts 4" and 6" SCHD 40 1}- Exte pipe. F%tenssioion 1 " Pvl
Handle
• Built in gas deflector.
• Automatic shut-off ball when filter is removed.
• :harm accessibility. - rated for
tn,0W GPD
• Accepts PVC extension handle.
P1.-525 Installation:
Ideal for residential and commercial waste flows up to X25 Linear Ft.
Ot 1 / 1b,
10,000 gallons per day (GPD). Hitration Sluts
1. Locate the outlet of the septic tank.
2. Remove the tank cover and pump tank if necessary. Y
Accepts 4" h'" Cl
3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHU 4i: ipe
the filter is not centered under the access opening use a
Polylok Extend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
5. Replace and secure the septic tank cover. Certified d
NSFiANSI Standard 46
PL-525 Maintenance:
The PL-525 Effluent Filters will operate efficiently for "°f *T -,Yr-
several years under normal conditions before requiring
cleaning. It is recortunended that the filter be. cleaned
every time the tank is pumped, or at least every three
years. If the installed filter contains an optional alarm,
the owner will be notified by an alarm when the filter
needs servicing. Servicing should be done by a certified vas Deflector
septic tank pumper or installer. :lutoniatic
Shut-0ff RalI
1, Locate the outlet of the septic tank.
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when titter is removed. T 77N
t.
4. Pull PL-525 cartridge out of the housing.
5. Hose off filter over the septic tank. Make sure all
i6a
solids fall back into septic tank.
L
6. Insert the filter cartridge back into the housing making
Ouhtunr -niir[I ilteri4: Alarm Extend d: Luk `t
sure the filter is properly aligned and completely inserted. Polvlok, Zabel & Best filters accept Fasily installs
7. Replace and secure septic tank cover. the Smartl'ilter ~ switch and alarin. into existing tanks.
Polylok. Inc. 3 I-airfield Blvd. Wallingford, C1' 06492 -lull tree: 877.765.9565 Pax: 203.2$4.8514 w~vvv.polylok.com
Page 4
1'rnerican Manufacturing Company Bull Run Valve Pace 1 43
L L Home About Site Map Order info ~-Training Videos i Contact Drip Systems
Treatment Controls Products Downloads Design Guidance
THE BULB. RUNTM VALVE
'VM1 R-TIOHr
ACCESS CAP
RISER CAP
ACAFTER
RI SER
TUBE
VALVE DIRECTI ON
H%NDLE
The Bull Run Valve" is designed to split flows to septic
fields or systems. In addition to the advantages of 4' QVT PORT
longer life and easier installation it is the most public C OUT PORT
health safe alternating device available for wastewater
disposal applications. The use has absolutely no contact
with wastewater due to the valve's leak-proof and
external operating characteristics. The change over from C IN PORT
one drainage field to another can be accomplished in
less than a minute by simply turning the valve without
digging or contact with wastewater. The Bull Run Valve is available in 4" sch 40 pvc
and is suitable wherever septic disposal systems
are used - in commerc al, industrial, and
residential applications.
OPERATING THE VALVE
Field Fuld V.2 The direction control handle should be rotated
Fief Field Field periodically to direct effluent to one or the ot_hc-r
No. I No. 2 No. I No. of two septic fields. After removing the scre:-,
cap at the top of the riser tube, the valve hard!,--
Valve can be turned with the valve key fu-nisherl
Positioned d
oaNo. 1 BULL RUN VALVE
during during Complete Valve Kit
Odd Years Sep>Fic Septic Even Years Contains
Tank Tank 1. Bull Run Valve bod'..
2. 28" Valve Key
3. Riser Cap Adapter
ITEM DESCRIPTION 4. Watertight Access Cap
BRV4 BULL R!JN VALVE G"
Page 5
file:; //C:/Users,/John%20Schmitt/Desktop/JohniAnnc-rican%20 Manufacturing'N20Companv%20- °'o20Bu11%20... 5:'3/2016
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Peggy Margenau
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
Inf tra:Or EZ1203H-5K 50, 25 0
EZ' 2C3+10f1 0.0' 50.0
System Sizing
EISA Rating per Foot of EZ Flow 5 ft` So J Application Rate' 0.7 gpdfft2
450.0 gpd Design Flow : 0.7 Soil Application Rate = FISA = 128.6 Feet of EZ Flow
=trenches 65 feet long each
2 No. of Cells 7 Per Cell
3 ft Cell Width 14 Total No of 1203H
70 ft Cell Length 350 sq ft EISA Per Cell
3 n Cell Spacing 700 sq ft Total EISA
Typical Cross Section
Finished Grade 99 ft Observation Pipe with
approved cap or vent
Soil Backfill
36 inch Geotextile Fabric
12 inch` II O Slotted and Anchored Vent/Observation Pipe
with Cap
95.50 It Infiltrative Surface
'36 inch
PlumberlDesigner Signature:
License MPRS 223760 Date: 05/03/16
Page 6
Installation Instructions for EZ Ow TM
EZjlon., Systems in Wisconsin byINFILTRATOR
Wiscorsin Departr-ert of Commerce, Safety and Bu Id ngs : 5. The Absorption a-ea (SF; necessary -or a given site shall
D vis or, nas reviewed the specifications ardor plans for ,his be sired based on maximum Gaily sewage flow (GPD) and
product and determined it to :;e in compliance witn chapters : the Permeability for the sire. If cerain criter.a is met, the
Comm 82 through 84, Wscons n Admin. Cede, and Chapters EISA s ,zinc car be used in Wisccnsin, resulting n a 40%
45 and 160, Wisconsin Statutes. A I sites must meet the Site smaller drainfield.
& Soi Conditions & Locators & so a-ion distances as noted in
ccal regulations. 6. Place EZflow bundle(s) it the EZflow configuration ap-
proved by system desgr permit soecified for the particu-
The approved products are 1203H (3-12' bundles with ppe in lar slle. The :op or center-rrost bundles containing pipe
center bundle in 5' or 10' lengths) and 1203HP (3-12' bundles are joined end to end with an internal pipe coupler. Any
v,- Ih pipe in eacn bundle in 5' or 10 lengths. addit oral aggregate only bundles that may be equired,
should be butted against the other aggregate-only bur-
A single pipe bundle ccn-ains a four inch perfora-ed pipe su•- dles and de not require any /pe of cornectior.
ror.ndec by EPS aggregate and is held together with poly- ;
ehtylene nettirg. A single aggregate bund e ccntains aggregate 7. Tne top of each GEC cylinder coma ins a filter fabric pre-
orl and is held tcgctner with pclyethylene yelling. manufac-ured in between the netting and aggregate. The
• -aonc is nsertec to prevent soil intrusion. The installer
Materials and Equipment Needed shall make sure the the GEO is posNoned upward and is
• EZflow Bundles it cony-act with the fabric: contained in the adjacent cylin-
• EZflow Gectextile Fabric : der before back=iliing.
• EZf ow Internal Pipe Cc,ualers
• Pope -cr Header and Inlet 8 The EZflorl Drainfield Systems should be installed in a
• 6ackhoe.%Lxcavator level trench in all directions (both across and along the
trench bottom) and should follow the contour of the ground
Installation Instructions surface elevaticr (uniform depth), with all continuous
The instructors -cr ins ailatiw of E7flc,v products are given ad oinirg ' 0-foot cyl ndrical bundles paced end tc enc,
below. This product must be irstallec it arcorcarce witn state : with central bundle distribution pipe inte,connectec,
•.,les defined in chapters Comm 82 tnrougn 84, Wisccnsin Ad- : without any dams, stepdowns or other water stops.
•riinistra:ive Code, and Chapters 145 and 160. Wiscons in Stat
tes, as well as tie local health department's c_jrrent design 9. The trench too shall he graded s.,ch that %%atw wi'l not
m_.n al. pond. Backf1l should he seeder r; :;dci m-;i ate }
afte, complet or to reduce erosior.
After the local health department has determired sizing.
eonf.guration, and layout for the -flow systems, stake 10. EZflcw E°S bincles are fe>:i: !r nnri ;:jn "~I i,
or mark with oa.n_ the location of trenches and lines. Be t.,enches as may be necessU t
careful to set co-rect tark.. irver pipe, header line or dis- other obstacles,
.rioution box and trench bcttom elevations bef:xe in.di v-
lation of pipe bundle. 11. EPS agg-egate is lighter -han wate,, mere-cre, i- mir
be expected that natural buoyancy forces would tend
; . Remove pastic EZf ew shippinc bags prior tc p acing cause EZflow assemblies -c float out of ground wh.
bundles in the trench(es). Remove any plastic bags in the pondirg occurs. Field experience has shown, howe:
trench before system is covered. :hat this is not a problem when systems have a mi-
C4) T",
This product must nave ceotextile fabrc that meets re-
quirements of s. Comm 84.30 (6) (g), Wis. Adm. Code,
irstalied directy on top of the product and extending i 20:ii t-GLC)
down along the s des o' the product to a point at least six
irches fro-i the oottom of product. _ c~eotpxnie
Barrier Material
4. When nstAled in a trench, the trerch should be cug *.o . 1, t
a width of 36 inches. This not only saves labor- in excava-%
tion, but also provides better loac-bearing capacity after
back-illing is comolet!. ;
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pzi;e 7..... .
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner. Peggy Marge•tau Tank Manufacturer Wieser Concrete 71 NA
Fermit # Septic Dose ]Holding Volume: 1000 gal
DESIGN PARAMETERS Tark Manufacturer: Wieser Concrete ❑ NA
Number of Bedrooms: 3 ] NA ❑ Septic ❑ Dose ❑iolding Volume: 320 gal
Number of Public Facility Jnits NA Vertical Distance Tank Bottom(s) to Service Pad: ft
Estimated (average) Flow: 300 galiday Honzontal Distance Tank(s) to Service Pad: ft
Design now = estimated x 1.5: 450 gaUday ;pectic ser, cirg mecnanics must oe provide f vertcal s>15 feet o• if
In Situ Soil Applicat cn Rate: galyday/12 rorzontal is > 150 feet. Specdic mstr ccors to to provrdee on tack.
Standard Domestic InfluenUEffluent Monthly average Effluent Filter Manufacturer: POLYLOK NA
=ats Oils .9 crease TOG: <3) rnwL CRuert Filter Model: 525
Bicchem cal Oxygen Demand (CSODs; s220mg1 ] NA Pump ManufaCtUrer
Total Suspended Solids ITSS) S%Orig:L Pump Model.
High Strength InfluenUEffluent Monthly average Petreatment Jmt NA
Fats Oils & G•ease TCO) 530 mg L Manufacturer:
Biochemical Oxygen Demand iSODs; S220mg,L iJernxn'c2 A9raa r Pmt F,!mr
Total Suspended Solids (TSS) <_150mglt ❑ Dsntec on ❑ wetland
Petreated Effluent Monthly average ❑ sand,Gravel F,!er Other
Biccheri cal Oxygen Dernand (BOD5, 130rrg,- of sorption System LIU
Total Suspended Solids (TSS) s3onrl ] NA. L r-Gro nd (g &a n-rrru d rnre>;_re,
Fecal Ccliform (geometric rreanl 5104cfL!t )Gm [ ~.t-Grade ] h1e nd
Maximum Effluent Particle Size: in dia A n ^e o:rr
Other Other NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Niheo cornbrneo with sludge and scurr equals one-third ('G) of tank volume
?ump out contents of tank(s) When the high '.eater alarm is activated
`
°nthiI (Maximun 3 Years) ❑ NA
nspect condition of tank(s) At least once every' 3 mear's'
At least once every: 15 5 monthlsi
rspect dispersal cell(s) (Maxi (tun 3 Years( ❑ NA
'ear s`
At least once every: 1 5 monthlsi NA
Clean effluent filter years ❑
At 'east once every rnortr's.' NA
Inspect purcp, pump controls & alerrr~ l- 'ear's' C
monthlsl ❑ NA
r-
ear's'
monthlsi ❑ NA.
J
eai s`
MAINTENANCE INSTRUCTIONS
inspections, of tanks and dispe•sal cells shall oe made ty an individt.al carrying ore of the following 'xnses or certificaticns Master
P umber, Master Plumber Restricted Sewer. POINTS Insepector POVvTS Vaintairer, Septage Servicing Ope ator ;pumper) Tr i.
nsoectiors must include a visual irspeutcn of the rank(s) to identfy any missirg or broken hardware, identify any cracks or lea'•
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent or g•ound surface. The
dispersal cells; shall be visually hill to check the elfluen: levels in the observation Dipes and to check for any pending -f
or the grcurd surface -ne ponding c'eHlue❑t an the groune surface may indicated a fe ng cordition and requires the immed r
notification of -he local regulatory authelity.
'Arhen the combined accumuattion of sludge and scum it any treatment tank equals cne-third ('/,l or more of the tank volume
conterts of the tank shall be removed by a Septage Servicing Operator and d sposed cf in accordance with chapter NR 113, Vvis,:c
Admirinistratve Code.
All other services. :ndud ng but rot limited to the servicing of effluent `hers, mechanical or pressurized comporen: oe•rea•r-ent
and ary servicing at inter,,als e` 512 morths shall be performed by n ceCif ad l Mai~iairer
Page 8
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(si for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and.ror damage the soil d spersal cell(s) If high concentrations are
detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewate• will
be discharged to the d spersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
eff cent pump or contact a Plumber or POWTS Maintainer to assist in manually operat rg the pump contros to restore normal levels
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of -he following from the wastewater stream may improve the performance and prolong the life of the POWTS
antibiotics; baby wipes; cigarette butts; condoms. cotton swabs. degreasers; dental floss: diape•s; disinfectants; fat foundation drain
(sump pump) discharge fruit and vegetable peelings; gasoline: grease nerblcides; meat scraps; medications; oil, painting products;
pesticides-, sanitary napkins; tampons, and water softener brine.
ABANDONMENT
W-ien the POWTS fails andior is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely
abandoned in compliance with chapter Comm 83.33 Wisconsin Administrative Code.
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed
• The contents of all tanks and pits shall be removed and propery disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shal be excava-ed and re-ro f,.d or their Hovers rarroved and he v^ir space filled with sc I
gravel or another inert solid material
CONTINGENCY PLAN
F the POWTS fails and cannot be repa r-: f r'' I= rrr r~ r :ia >•a~ ry ,,r:
a code compliant replacement system
❑ A suitable replacement area =r r_rl dv - : `1- rr C-" Sy
The replacement area should bt p'utected from clstu-bance and compaction and should not be irtringed upon by requires
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi I result in the roc
and sire evaluation to estab:isl- a suitable replacement area. Replacement systems must comply with the rules in effect tl
perms issuance.
❑ A suitable replacement area is not available due to setback andlor soil limitations If the soi' absorption system carrot n
rehabilitated and barring advances in POWTS technology a holding tank may be installed as a last resort.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site eval-. -
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed +
replace the faded POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed Ir p ace following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE, DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name: John S3hmitt Name. Jcin S&,ritt
Phcie:715-76C-0436 Phone 715.767-C486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Owners C; nice Name S-. Croix County Zoning
Phone Phone 715-386-466C
Tn,s document is intended to meet minimum requirements of Ch Comm 83.22(2),'1b}(1 i(dj&(f; and 83 5411), (2; & (3) Wiscors,r Administrative Code
Use of this dOCUmert does not guarantee the performance o; the POVYTS.
Page 90
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 551 Spurline Circle located
at: SW NE Section 16 , Town 29 N, Range 19 W,
Town of Hudson , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service April 29, 2016
Did llow back occur from absorption system`? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons triiriutes
Tank Capacity: 1000 gallons
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): Wieser Concrete
Age of Tank (if known): 32 years
Permit number (if known) 49445
JJohn Schm tt
(Iy' ensed Plumber Signature) (Print Name
MPRS 223760
(Title) (License Number) MRAIPRS
4129/2016
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
Page 10
ST. CROIX COt, y'I Y
SEPTIC TANK MAINTENANCE AGREENIE:N'1
AND
OWNERSHIP CERTIFICATION FORM
Owner.Buver Peggy M a rg e n a u
Nlailing Address 551 Spurline Circle
PtopetLN'Address 551 Spurline Circle
i VeraScatrm rellit,red ti-nm Planniae & Zoning Department for new construction.)
City?State Hudson, WI Parcel ldeatiticatiott Nuttthet 020-1028-20-000
LEGAL DESCRIPTION
Property Location sW NE See 16 .1. 29 N R 19 W.. T,»vn of Hudson
Subdivision Plat: Northline Station 11 Lot
Certified Survey Flap # _ _ - , Volume . Page #
Warrant} Deed ;V (before 200i)Volume Page':
Spec house ❑yesEto Lot fines identifiWe ElyesOno
SYSTE.t NIAINTENANCE A:.ND OWNER C1:R'I'tFICATION
Improper use and maintenance of ruts septic systen: cOuld resuL in its prCIl]atUrC fiiilUre to itaudle WiiSLCS P- :;r;
maintenance consists of pumping out the sepue tank every three years or sooner, if needed, by a licensed rkinnper.
the system can affect the function of the septic tank as a treatment stage in the waste disposal system.
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordina:r_
The property owner agrees to submit to St. Croix County Planing & Zoning Department a ~r: u: _ ; i,, : •
owner and by a master plumber. Journeyman plumber. restricted plumber or a licensed pumper verifying that (1) the on-site
wasre.warer disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tar'.
less than P3 full of sludge.
Vwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system wid
standards set forth, herein, as set by the Department of Sa=ety And Pro.,essional Services ,ind the Den; tmc it nt"~;~tnn:=1 Resni
State of'Wisconsin. Certification stating that your septic system has been maintained
County Pln nning & Zoning Department tvithin 30 days of the three year expiration dat _
I,'we certify that all statements on t is form are true to the hest of mvdour krnc-•• -
property described above. by virtue of a n
Number of bedrooms 3
SIGNATURE • APPLIC.ANT(S) DATE
",any information that is misrepresented may result in the sanitary permit being revoked by the Planting & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds 02fice and a copy of the certified survey map if
reterence is made in the warranty deed.
(RVV.04/12)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR
P.O. BOX 196
AN RK-ATIONS PERCOLATION TESTS (115) MADISON. WI 53709
(H63.09(1) & Chapter 145.045) I
1 CAA/TI N S Try-T~ y p TOWNSHIP~F-Y OT NO. 1K. NU.SUlROi VIa/ON NAM=/----
~W ~ E 1/ 16 /e` 9 N/R/yB for U/ - ~S /~,.`r/4
srJrJww,. -
COUNTY: WNER'SIBUYEFPS NAME: ,A L MAILING DOR SS:
USE DATES OBSERVATIONS MADE
NO. REOR~K{. COMnn IA E "RIPTIO : - PROWL RIPTIONS: A, I TES(S:
~Rasidarxx - / ,KNew ❑Replaur I 1~ .
L /v fs~psA.cx ~cC.ZT ~ a ( TT
RATING: S- Sne witabla for system U^ Site rsrnsritable for system Sp c r r - S ! e- (O /I- _
ONVE NTIOl'i MOUND: IN-CAWNANT)PTIESS E: S STEM-IN-FIL OLDIN -TANK R LCOMME NULL) SYS (EM-(uptiunall
® s-®s ~u ®s ❑u EIS ~du _ns ®u •cka~tao,,,w~ e r ,9
H Petenlaiion Tests are NO] reulnred DESIGN RATE If any portion of Me tested area is in the /
undln s.H63.08(51(bl, indicate: ~ I, luoitp ,ur, indicate Flawplam elwat on. A11A
P%I E DESCRIPTIONS LLLLLL
BORI GN~TO'iALc PTH GRSU N OWA I E R aMCNLB CHARACTER OF SOIL WITH THICKNESS. COLOR, TEXTURE, AND DEPTH
k*PTH DE NUMBER iR" ELEVATION QBSERVE FR I H TO BEDROCK IF OBSERVED ISFF ABBRV. ON BACK 1
~7 ~7S7 -8
B aZ r ! r Z r itl etc 7 r n S t r S,S A S
B- 3 ' /
B- S UOr r /tedtile 7 • 's-' / { n nS S Y +I ~,~r/"}L~
s q
B 7s sae - CC,-~" ro All. /I If A,
g ~a ~E 7 U•i) r y iE~ N s pS
PERCOLATION TESTS s / 7 f
TEST DEP1 H WATER IN HOLE TEST TIME DROP IN WA EV L4 IiES RATE MINUTES!
NuMoSiR INCITES AFTERSWELLING INTERVAL MIN- p~ Pi INCA
P- z r7', - - - -
G ~ 3 t i t
P -3 F~
P. +
PLOT PLAN: Show locations ut percolation tests, soil borings nod the dimensions of suitable snit areas. Indicate scale or distances. Uescritse what are the hori UL)//
zontal and wrUCal eevation reference points and show their location on the plot plan. Show the wrtam elevation at all borings and the direu lips and percent
SYSTEM ELEVATION 9S 9 ' _ y~ I
~b
o Xfi eo
p,- ~vt ~ \ /lfir:21~'n~f- fasr.`.rcf Af
- --i (,/~ir.Gs:/c~ l wtw+*r+t fyl d Q,cf toe r OF R
IC-21" Oil-
Q ~ 1
I
10
73
-1 IT
1
P-~J3.7' per. .[[~Ei/6F/~rYX[S'f.z hhI
So..r+( sr c~ /./BA' MCj -s
1, the undersigned, hereby certify trim the soil tests reported on this torsi were -redo oy :na m accord with ine pro,xd sees and methods specified in the Wisconsin
Administrative Coda, and that the data recorded and the location of the tests are correct to the host of my knowledge and bi
NAME tpnn~ntJl: / TESTS WERE COMPLETED ON:
A
ADDRESS: 1CERTI FICAT ION %UMRER: PHONF NtIMRFR optinnail:
//6 .(yule l />/1/e' _ sv ~rs , f C'ST
CST SIGNATURE.
0ISTR IBUTION: Original and one copy to Local AutMnty, Property Owner and So,i Tester.
01LHR1;6D-63A5 (R. 02(62) OVER
0-102- t~ - 2- a -rov
L)~_-PAH I MEN 1 UE INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
_ABOH & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P U. HUX 1969 BUREAU OF PLUMBING
MAL)ISUN• WI b310/
,'U CONVENTIONAL -ALTERNATIVE s.+r PI,., D N r cJe
111 .»iyir;l
• L. Holding Tank 1~1 In-Ground Pressure Mound L
`J.AL'E 0= PEFNIT HOLCEH 1171 ..it1 PLFJMIt n(rL_IzR NSPLCIIUN DA IE
J. She`cman PeteAzon 311 Gateahad Rd, N. Hud3on, W1 -~~-Ll
3ENCH MAR- IP=---,r -1....,.c1' p~,ru uF:.!:Il ilu r cd! I I FLN' - V FL•:^J Z~~~11/ REF. PTELEV Usl HLI PtELEv
SW NE, Sec. 16, T29N-R19W, Lo.t 01, ,Town o~ Nudb n
f
17cugta5 S.tlcahbeert ' 5432 St. cuix 44445
SEPTIC TANK/HOLDING TANK:
~.NJEACTURER JILICiso CAPACITY TANr: IN-ET ELCY . T NL: OU?LET ELEV' AI •I'J':•. ABEL Irtcih:~::U': )(N
~ S F 1 FO P Ir:Fn
-L / J J YES NO YFS O
BEDDING vNTUTA/ e•_v MA! L nl:,rlwr.rEF NUMBER OF ROAD FRi1FLHI" nLLI [IIIIulv., JVFNT - -RFSFf
1' AI ..R•.1 _ FEET FROM 1NI AIH INLET
__YES NO 1 LYES NO [NEAREST
DOSING CHAMBER:
r.rv r, F nE P BEDUIN; uILr1 dFA(;ITv PUMP MGCEI - IP "IP 1.-r)', \.;'JUE ~._"..+RL~• Y5 LABLL _UCKI%U CUVLH
PROVIDED. PHU'JICEU
i _IYES NO ❑YES ❑NO YES F~] NO
GALLONS PER CYCLE. CONTRO_SOPERA- ONAt NUMBER OF FR:JFFRTY WELL BUI_D1NG ENT TD EHESI
IDIFFERENCE BETWEEN FEET FROM aIRINLEI
PUMP ON AND OFFi 77 YES .__.NO NEAREST
SOIL ABSORPTION SYSTEM. Chunk thL wil mDlsture at the depth of plowing I- A •1 1 r -FR1Al avn .+AHKIN,
cr excavatior. (If soil can be -oiled into a wire, constrtiction shall cease until FORCE
MAIN
the soil I=. dry Pncnlyh to continue.)
CONVENTIONAL SYSTEM:
'rlu-`I I Nt.T-f 1NN If PI=E ~PAr'.rJC
BEDITRENCH f r,iFNI I F° / r FPIT I cFPTH
DIMENSIONS ll t~ 3 .
F%T + ILL rEPTII 'IST + f l-[ J ,T 1 'Irl nIS-R PIPE .:.TER Al 1 1 1 r•.•1 NUMBER OF PROPERTY '.YELL BJILDING VENT TO FRESH
! F'_y~ Aa tr, f. `j ap LINE ~j AR INLET
FEET
1 ?2 lit ` 1SL 1T,1
p l
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ENO
SOIL COVER rExrLRE - PERMANI_`JI i.1A IFFS vEtl
L:] YES L] NU LJYES --NO
~I:FPT-A (IN ER TRENCH BED 1JFPTH nl;FR THENCP BEL a F•n. GF tOF SOIL SUUULU SEEDED MULCHED
fr•TEH F-JI'ES
I JYFS FJNO L_IYES L_ NO -YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: _
.vt.:III LLN:., 1.1 I'.D OF JILAILN41- SFACI`JG c, F'"LL DEPTH BE_Ow PIPE FILL DEPTH ABOVE COVER
BED/TRENCH HLNr_HFs
DIMENSIONS
^4?1 FOLD P+,MP '.IAN FOLD UIS'It 1'l l•F [1AWCILD MA7FHI!1_ NG DI STH CISTR. Pill DISTRIBI_- ON PIPE MATERIAL & MARKING
F LF`i. LE,., DIA LLr V. 'FE'S GIA.
ELEVATION AND
DISTRIBUT ION
INFORMATION 11 Cl LE S17F HOt F SPA-:IV DRILLED D,13RFCTt Y (7.nVFR MATFFIAI VERTICAL III T CORRESPONDS TD APPROVED
PLA•.!
❑YES___ ENO -YES _.NO
COMMENTS: P~nMANFNT MAliK nS JaSERVATION HELLS NUMBER OF `PROPER7Y KELL BUILDING
FEET FROM LINE
CYF NO _JY -I NO NEAREST-- _
f
F
Sketch Systern on county file for audit.
reverse Side. . J _
pp ~IC;NA'URE / TIT[ F ~ "
DILHRSBD6710iR.01r82) C~3..J (~UL = f _
~'~,S~onS" DILHR APPLICATION FOR SANITARY PERMIT -
4 -COUNTY
'
rgwaTrnc n. cc (PLB 67)
UNIFORM SANITARY PERMIT #
rr uu~ r av. grlClq r. ~.umcan gE~glion5 /y_/4_
-Attach complete plans in accurd with s. H 63.05, SVis. Adm. Code for the system, on paper not less than 8;zx 11 inches in size.
-See reverse side for instructions for completing this appiication. PLEASE PRINT
PROPERTY OWNER rS l er"A e er kYL MAILING ADDRESS i I c o_i, r' _
I1 _ -I. I ~,~Cfk ~'S _ yam/ L
PROPERTY LOCATION e1TY-_
17A
G I-
1 _1/4, S N, R Q{or TowN OF:
LOT NUMB n BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED 3/)') -
1 or 2 Family Number of Bedruirns. Public (Specify):
THIS PERMIT IS FOR A:
Ne,ni System Tank Replacement Repair
Replacement Soil Absorption System L✓ Revision Privy
Alternate System I Reconnection L Petition for Modification
IF THIS H IS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed = Seepage T•erlch Seepage Pit U Holding Tank
System-In-Fill In-Ground Pressure Vault Privy Fj Pit Privy
n Existing, For Which A Previous Permit Is On File, Permit # issuea
❑ An Existing Sysio,-n That Has Been Inspected And Is Compl ant As Far As Soil Conditions.
total # Of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Corc•ete Constructed
Smuc Tank Capacity
L ft Pump Tank,'Siphnn Cnarrber
Holding Tank capac ty
Manufacture-:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound In-Ground Pressure
Total # o` Prefab. Site Steel Fiberglass Plastic
//W Gallons Tanks Concrete Constructea
Septic TanK Capacity
[r,13 ift Pump,'Sipmon Chramber
nufacturer
PERCOLATION RATE ABSORPI ION AREA ARSORPTION AREA WATER SUPPLY:
(Minutes per inch l: REQUIRED ;Square Fee-1 PROPOSED (Square Feetl:
Private _ Joint - Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumbe (Pr nti: S gnature: klP'MPRSW No.: Phone Number:
_Dor~Gla S 5tr ~h62Q L ` L ~
y4j ~'st/3Z (2471-32_
Plumpber' Adfdres/s~:~ / Na/~me of Design/er;
_5 Z1 - ~s `/75 069
COUNTY/DEPARTMENT USE ONLY
Signature of ssunul Agent: Foe: Date: Disapproved
V cZ~f C El Owner Given Initial
Approve] Adverse Determination
Reason for Disapprove --u
A'ternate course(s) of Action Available:
DILHR ~Bn-6398 1p. 5:621 DISTRIF.U ION. U,,iri3l to Coun-y, Otte Copy To; Bu•eau of Plumbing, Owrier. Plummer
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
1 n he c..nmplete and a c rate the permit application •rnu;t inc'u -I e:
1. P operty owner's name nor complete legal ci .sc intinn, ple,ae ci cle the appropr a-e municipal governmen* unit, (:rd~et er this is in
a city, village or tov,,nI:
2. Indicate snecitically what tyre o` u.u i~, ivec, ` puhl c is chic,ed inc:icate ty:7e o' use 10 unit apartment, 30 seat restai.ant,
e-(-., ;
3. Curnplete the block for conventions or 21ter -.ate system depending on system -ype, check all appropriate poxes or blanks.
4. Indicate the design perculail rate listed on the 115 soil test report, :he number of square feet required by code and the )ur!il of
s~luare feet to be installed;
5. Complete the section on vvatei supply;
h. PRINT the name of the master plumher or master plurttbcr restricted vvho ,:ill install the system, circle th ac~prooriate I cense cla_s -
ficatinn, place your license number in the space provided and sicn the permit m the signature block;
7. Please place the p unhers business phore number in : e hlarik proviocd, i* thenc i-. a problem of question th 5 „ill speed rrvi'"v of the
permit;
8. Change of ownership or plumber requires a Sar•itaiy Permit Transfer Form (67 TI to be s_,hn-itto,d tc the coun.v p'ior to installat on.
Failure to comply Will void the sanitary permit.
9. This permit may be renewed, and at the time of eriw,val any new criteria in the V`1 s. Ad ii. Code v,ill '02 apl:licahle.
10. A new permit Will be needed if there is a change in, estimated wastewater tlova, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances betv,een beds if appropriate, tank locations, effluent line trom tank(s)
to system, building seVver and vent observation pipe(s).
15. The permit issuing agent may rectcire a cross section dradding of the eftl_:ent disposal sys-em.
TO THE OVVNER: This is valid for two years. Changes in your budding plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained, Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHft, State of Wisconsin.
I'lINP ClirlriGLR ~i
Mauufac:turc-r: Y Liquid Cap.cr iLy:
Pwap Model-: Pump/Siphon ManLIFI'CUrC-r Pump Size
Elevation of inlet: Bottom of lank elevation:
Pump 01t switch el evatinn : ^ - Gallons ,)(2r cy.Ie:
Alarm Manufacturer: Alarm Switch 'T'ype:
Number of teet from nearest property line: FronL, C side, 0Rear, 0 lL.---
Ncmlber l) f I cre f rom w,,I
NLIMbtr of teet frk buildinr;:
(I.rnc Jude distances on plot plan).
SWL ABSOItI_TION SYSTEM
Bed Tr CIiC11 : -
Width: (y _ Length:- Number of Lines: Area Built:
Pi I I depth Lu Lop of pipe:
Number of ieet [rum nearest property line: Frolit, 0Side, Rear, Ft
1. 0
Number of feet from well:
Number of feet from building: - _
(Llclluie distances un plor plan).
Size: fJ T Number of pIt_s: llianicter:
Liquid depth: Bottom of Seepage pit elevation:
Aj-ca Built:
11as either a drop boxy or distribuliun box0been u:-,,2d uit any of the above soil
absurbllon sytems"? (Check uue) .
iIUI AA NG TANK / 1-
Manufacturer r-.. _,.~c• i rv:
Number of rings u5ecl: G1evaLion of bottom of tank:
Elevation of 6tu.let
Number of feet Lrnm ii(2a esl property llnP: Fron( , O Side, 0 Rear, 0 rt._
Number of feet trom well:
NLIIIA,or oT fpeL I ri)w building:
NwAur of feet from nearest road:
Alarm Manufacturer:
Inspector' -f- - -~j-~'
Dated: - - - - Plumber on job :y~!,
License Ntcmhc_r: -
614 :111 ]