Loading...
HomeMy WebLinkAbout026-1014-95-000 n N 0 3 T n d 3 m o ID ~1. ~ d # m l o 0 N 0 O ? O .-Z1, A N °C • C:D'- E3 r- 9 CD Sr i~, 9) d Z O. N CD > CD 3 C) - O _ ►h lAl w C 3 O w W N NO a CO O 7 O CD C) ~ n N O C7 O y O a O 7 N N 7 O d Qc w v>CD a CD (n N W s C 0 ° j C - O CD F~ W L C \ \ ? !\i C7 r fJ! co co ~ o0 co 0 0 0 . z z -0 D * * D 0 f 3 v, ca n ca n N N v CD cr 0 CD O d 'O Q° fD 0 = 0 (D Q (a 0 c 3 m :3 a z w ` ~I Z ~ D a j O v o Cl) "A N D N C C CD N (D w m a Z N (D -i lA O O A ? n v a a C 0 Z 03 m W 0 a Z c 9 A A O M 3 m w (D ' A W p~ I I ~ Q N O N C z a 0. m ~ m I a• I A I ~ R A W O N O O I V A ti ti CD ao 0 to O CD Parcel 026-1014-95-000 01/30/2007 04:17 PM PAGE 1 OF 1 Alt. Parcel 4.30.18.51 C 026 - TOWN OF RICHMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - JORGENSON, JAMES O JAMES O JORGENSON 1744 CTY RD A NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1744 CTY RD A SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.460 Plat: N/A-NOT AVAILABLE SEC 4 T30N R1 8W 3 1/2A S 100 FT OF N 330 Block/Condo Bldg: 'OF E 200'OF NE SE Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-30N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07123/1997 730/519 2006 SUMMARY Bill Fair Market Value: Assessed with: 176701 160,600 Valuations: Last Changed: 04/22/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.460 18,000 107,200 125,200 NO Totals for 2006: General Property 0.460 18,000 107,200 125,200 Woodland 0.000 0 0 Totals for 2005: General Property 0.460 18,000 107,200 125,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 215 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ' Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER )i TOWNSHIP SEC. ` T N-RW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION :4 LOT LOT SIZE 711 PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r i 1 _ . :...urn-~_ - ..-sue R ) I' INDICATE NORTH ARttOW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANS: Manufacturer: g; ` rte/ :.Liquid Capacity: Number of rings used: Tank manhole cover elevation:] ' Tank Inlet Elevation: tom` r Tank Outlet Elevation: Number of feet from nearest Road: Front,(D Side10 Rear, O j feet From nearest property line Front,OSide,nRear,O feet ~x Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE: REVERSP: S1 DF PUMP CHAMBER l Manufacturer: Liquid Capacity: Pump Model: _ _ Pump/Siphon Manufacturer: A,~r Pump Size r Elevation of inlet: Bottom of tank elevation: W b5 Pump off switch elevation: Gallons per cycle: fG-' j Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, a Side, Rear, Ft. /Z Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench Width: Z2 Length: Number of Lines: _ Area Built: Fill depth to top of pipe: 7'"'/'// Number of feet from nearest property line: Front, O Side, © Rear, O ht Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevat'ion of inlet: Number`of feet from nearest property line: rront, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Yanufacturer: Inspector: _ Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS DIVISION LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS P.O. BOX 7969 BUREAU OF PLUMBING MADISON WI 53707 [YKCONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number. (lr assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLD ER. INSPECTION DATE Shi,ttey Jolitgenzon R. R. 4, New Richmond, w1 54017 ? "'J0 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: JCST REF. PT. ELEV.. NF SF, Section 4, T30N-R18W, Town o6 Richmond Na- of Plumher. IMP/MPRSW No. JCounty Sanitary Permit Numher: Ca.e Power 1563 St. C/I ix 54899 SEPTIC TANK/HOLDING TANK: MANUFACTURER. , LIQUID CAPACITY: TANK INLET ELEV.'. TANK OUTLET ELEV.. WARN( LABEL LOCKI GC VIER t11 J^ PR OVID. PROM ED, C l 't/ti -f L~ ❑S~ ES ❑ NO S° ❑ BEDDING . NO VENT DIA.. VENT MATE HIGH WATER NUMB R OF ROAD: P OPERTY W . BUILDING JVENT TO FRESH J ALARM FEET FROM t LINE e' AIR INLET ❑YES ❑NO l C E ❑YES ❑NO NEAREST I 1 ` 2~ DOSING CHAMBER: G COVER MAf),7ACTURER 7ING L IQUID CAPACITY PUMP MODEL PUMP/SIPHON MANACTURE{R WA ;'RNING LABEL LVDED J~ PROVIDEDES ❑NO `,C GL Z YES ❑NO ES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING IV ENT TO FRESH (DIFFERENCE BETWEEN FEET FROM uNE~ rT AIR INLET PUMP ON AND OFF) ES ❑NO NEAREST L 1 SOIL ABSORPTION SYSTEM. Check the soil moisture at the th of plowing LENGTH JDIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, constructio shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF DISTR. PIPE SPA CyN COVER INSIUE D I A tt PI TS LIQUID BED/TRENCH TRENCHES / rv7nTEHIAI,* PIT DEPTH DIMENSIONS GRAVE I_UEP !T H F±L~D EP HDISTHPI PF DISTR PIPE DISTR. PIPE MATERIALNOSTNUMBER OF PROPERTY W LL BUILDINGVENT TO FRESH BELOW PIPESA . VER ELEV. INLF1iT ELEV U PIPES LINE AIR INLET'. t rl t I I "Z- i. ry ( FEET FROM / v NEAREST-~- ~ ~ !J 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 ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH'BED DEPTH OVER TRENCH,BEU DEPTH OF TOPSOIL SODDEU SEEDED MULCHED CENTER EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL. NO. DISTH. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA. ELEV, PIPES DIA.'. ELEVATION AND DISTRIBUI ION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: TNUMIT BER OF PROPERTY JWELL: BUILDING: FROM LINE ❑YES ❑NO ❑YES ❑NO REST e'er ~ A Sketch System on XZRetain in county file for audit. ' Reverse Side. DILHR SBD 6710 (R. 01/82) [ITLE w~smnsm APPLICATION FOR SANITARY PERMIT . DILHR COUNTY (PLB 67) UNIFORM SANITARY PERMIT # OEPRRTTT1EnT OF ~ InOUSTRV,LRBOR6HUM-RELRTIOnS x}29 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER / MAI ING ADDRESS PR PERTY L ATION CITY: VILLAGE: _h 1/ i= 1/4, S , T~ N, R (or) W TOWN OF: ~i 1 LOT NUMBER BLOCKZf MBER ISUBDIVI,SI¢N NAME NEAREST f~OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER Y JcL' i ti TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity 1,1906) Lift Pump Tank/Siphon Chamber / Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint ❑ Public Qhe undersigned, hereby assume responsibility for installation-b'f` he private sewage system shown on the attached plans. Na of Plumber (Prin Signature: MP/MPRSW No.: Phone Number:: Plumber's dress: 7 Name of Designer: Ad' ji COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent:. Fee: Date: El Disapproved ❑ Owner Given Initial ~41 Approved Adverse Determination r Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number o square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (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 between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building 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, DILHR, State of Wisconsin. APPLLCATION FOR SANLTARY PERMIT STC - 100 't'his application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ell" Location of Property . ,Sjr_55- I4 S Section T ~Q N - R W 'T'ownship ` Mailing Address Subdivision Name. Lot Number Previous Owner of Property Total. Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes Ar" No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPnICATTON ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays "t the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPFRTV OWNER CFRTIFICA TION I (We) caNk6y that A 6tat mevtts on this Jonm ane_ cue to the best o4 my (out Nawfedge;that I (we) am (ate) the own en e ~na~e desentbed in tlus t.njoamation Aonm, by vi ttue o{ a waina deed veeoaded in he 014ice o4 th.e, County RegiM oA Deed, as Document and that I (we) pne~senNy own the. pnopo6ed site lot the 6 . e 71 s system VA I (we) have. obtained an easement, to tun with the above descAbed poopeltty, loft the consthuct on Q said system, and ,the same, has boon duty movonded in the OjAice o{ the County Re#s.ten oA Deeds, as Docume-of No. ) . SIGNATURF, F OWNER ¢ SIGNATURE OF CO-OWNER (IF APPLICABLE) DA`I'F. SICNF`D DATE SIGNED H Y S T C - 105 r y H SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County d 9 A OWNER/BUYERt ROUTE/BOX NUMBER- Fire Number Ci'rY/STATE CA-) -zip- T N, R 1k W, pROPER'IY LOCATION: SF_ Z, SCE' Section , Town of ~c.NMu^x-c]1 St. Croix County, Subdivision Lot number------. I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pum er. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents maw he eligible to receive a grant lot- a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement th.:L owners of all new stems agree to keep their systems properly maintained 'l'ire property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) of-ter inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I/WE, the undersigned, have read the above requirements and agree cn to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- _j ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 1 SIGNED, D ATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-:>_239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (1151 P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: - SEC ION: p TOWNSyIIP/MUNICIPALITY: LOT 0.:BLK.ifVO.: SUBDIVISION NAME: 114 --1 ~ /L;pN/R (or) W / Z 1 COU NTY: OWNERS/B,UYER'S N ME: MAID l~VG ADDRE~S: 2tL~k el USE NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE LryResidence 17 ROFILEDESCRIPTIQNS: PERCOLATION TESTS: ❑New Replace ` _ / RATING: S= Site suitable for system U= Site unsuitable for system ' t` CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYST EM-IN-FILL HOLDING TANK: ECOMMENDED SYSTEM: (optional) CAS ❑U CIS ❑U GAS ❑U OS EU OS RU If Percolation Tests are NOT required DESIGN RATE: under s.H63.09(5)(b), indicate: / If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: r PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUN)WATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH tl, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B jc~ B- t ; k' i T 7 r B- y B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMBER -kNCHES- AFTER SWELLING INTERVAL-MIN. RATE MINUTES r PED PERIO 2 PER1003 PER INCH P- J. P- - l P- P - P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION ? P .'?I1f 3 M tt-- f~c~~a~S 4-1 - sI 33'" _ _TN ' E - - - 21 E -r E E [ • ti - i of I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in thi Wiscpnsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, NAME,(~rint): TESTS WERE COMPLETED ON: - D _ P e ADDR SS CERTIFICATION NUMBER: PHONE NUMBER(optional) CSI~ NATURE: ) 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER A F ~ as ,a t~ r'vC._'~«. .3ff~ ~M ,i 3 a.... S_I t 13 c-,itk.{ v it ( t_ r, a att0' s31 i„ ~'t?~r, ;,t t. , ~ _2t k', p`:7i trr „ati , a _ t t b r. t t z2 E ,t Lr ( ~a .,.,c ! tion t0, c 4t1, v;EH s~ Sa -6 t =cSy F Eix~lF c i P c e cjiJ r d n Fsor1t t YE^t'°rtEest r` t?f f~ 3 L`ts.t; PAGE OF CruSS S`~ i()1 cl`~ Fresh Air InIe14 And Obcervatlon Pipe C Approved Vent Cap Minimum 12" Above Final Grade ZO- 42" Above Pipe _ 4'Cael Iron Ta Final Grade Vent Pipe Moreh Hay Or SynlMllc Covering Min A ggregale Over pipe OletribulIon Pipe 0 0 o 0 0 Tee - b Aggregate Beneath Pipe 0 Pertoraled pips 8e10w 0 Coupling Terminating At V Bollom Of Syvlem 1 / ton SOIL FILL DIS7kIBUT10~I PIPE APPV.S'jjJjHETiC 1 OVER 2 OFgGGREGAT~-~'~ r o 'MATF-RI^G- DPP q" OF STRAW OR f~ARSN HAS D `ti (o OF %2` 2AGGREGATE ELEV. OF o~8 n FEET-_ LIML DISTRIF3UT10U PIPE To BE AT LEAST 3 ~ IIJCHES BELOW ORIGIAJAL GRADE AUL) AT LEASTZO INCHES BUT 1.10 MORE THAI) HL IMCHES BELOW FIAJAL GRADE M AX'MuM OWN OF F-XcAVA1100 FXUM OWINA4 6KADF- WILL BE S~2 INCHES MIdIMUM ®EP" OF FACs1VATIOM WiA. C4~161114AL 694PE WILL BE INCHES SIGAIEb LICEUSE AUWABEIR: i~) fry DATE: FRUMP CHAMBER CROSS SFCTION AND SPECIFICATIONS Vent Cap Weather Proof Junction Box Approved Locking ?Manhole Cover 12" Min ' 4" C.I. Vent Pipe Final ; ' Grade 4" Min } Conduit I 18 Min - 18" Min i Inlet Approved Joint w/ Approved A Joints w/ C.I. Pipe C • I • Pine Extending 3' Onto Extending i ®Alarm 3' Onto Solid On B Solid Ground , Ground C Pump- Of f Concrete Block D SPECIFICATIONS TANK PUMP Manufacturer :~"St Danufacturer: F![s;jT~. 4 Tank Material: Model Number: h242 3414 Tank Size: Gallons Switch TvDe P. Total Dynamic Head: FT CAPACITIES Pump Discharge Rate: Total Daily Effluent: Gall-GPM ons A =or Gallons Number of Doses: _ _ Per Day B = or b; Gallons Dose Volume: 71 -,,S ~v6ic,C Gallons C or Gallons Notes: 1. See pump curve for D = or Gallons additional performance Total Tank information. Capacity Required = ~QL°) Gallons 2. Pump and alarm are to be installed separate circuits ALARM as `per ILH .19 WAC. Manufacturer: SIGNED:,., - Model Number: LICENSE NUMBER: Switch Type DATE: , ~f I I > i - f~'-~3 / rte. cC - rS®~'-~i-f1~ i a - T i r I