HomeMy WebLinkAbout042-1057-20-429
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 592283
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village Township Parcel Tax No:
Steve Dalton TOWN OF WARREN 042-1057-20-429
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
IDO 5.r,, a~ Gofn 20.29.18.319A-44
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic / • a C Benchmark q q
t~JW lL... 6 ZSa/~ e~ l~
Alt. BM flu#
i r c iµ~ ;tea,, j 5 i( \
Aeration Bldg. Sewer /Q • 6
S. (P
Holding St/Ht Inlet /d 3 3
TANK SETBACK INFORMATION St/Ht outlet (p. SS w3•
TANK TO P/L WELL BLDG. Vent to it Intake ROAD Dt Inlet
d'CNti
Septic ^ / J! Dt Bottom
Dosing f Header/Man. 7, t
`J /d 2
Aeration Dist. Pipe
7 47 /dZ
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer D
emand St Cover Z J
GPM
Model Number J
TDH ift Friction Loss System He TDH Ft
Forcemain en la. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 7t Z Ire
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR - (
Type Of System: UNIT Model N ber:
r S
GO ~t12 • b :n ~ • 14 ~ 7 M or /1)
~1J ~
DISTRIBUTION SYSTEM ZZ-~ ZZ
Header/Manifold ID st'ibution Hole Size pacing Vent to Air take
J P ipe(s) \ E
/6 4_ Dia_ Length e Dia\ Spacing Ix x Hole S
Length
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of red/Sodded xx Mulched
Bed/Trench Center 3 g Bed/Trench Edges \ Topsoil No
Yes es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: No Address Available
1.) Alt BM Description = k Ga0Ae `V~d~ r h v~
2.) Bldg sewer length = I Z ✓ G z- t - !
-amount of cover
Plan revision Required? F-] Yes ~ 7
o
Use other side for additional information. '
SBD-6710 (R.3/97) Date +1n7sepctor"s Sig ture Cert. No.
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► r Sanitary Permit Number (to be filled in by Co.)
q 1 P.O. Box 7162
1 5J Madison, WI 53707-7162
~~~•~~CNN' Q'tII fdl j11jpli State Transaction N tuber
In accordance v3,21(2), Wis. Adm. Code, submission of this form w N
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned Po vv the Department of Safety and Professional Services. Personal information you provide
may be used for seL, Projed~ddress (if different than mailing address)
purposes in accordance with the Privacy Law, s, 15.04(1)(m), Stats. ~vQQ✓✓~~
I. Application Information - Please Print All Information / o(0 1-1 _
Property Owner's Name Parcel 9'
Property Owner's Mailing Address Property Location oI d q- 19 ~l/ y
3 j- Govt. Lot
City, State y Zip Code Phone Number AAA t/a, Section
J ~^m SS y' }GG9 i . S, T N R/ , ~(cirEcoe one)
II Type of Building (check all that apply) Lot r `rj
~1 or 2 Family Dwelling - Number of Bedroom Subdivision Name
~ ❑Puh&c/Commercial-DescribeL'se Blocky ~
(Z~~nc,~ Svbmi alt
E] State Owned - Describe Use 1 , ~us E Pl"4A(S, 1-1 City of
I
CSM Number I'D Q; 14 ❑ Village of
NSfKbVh'M CPIS K) 224-22 ® Town of
tIJu..,c,.t,i..v
III. Ty heck only one box on line A. Complete line B if a plicable)
A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New I List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
I tem/Com onent/Device: (Check all that apply)
e ri d- ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound> 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil
Holding Tank ❑ Other Dispersal Component explain) ❑ Pretreatment Device (explain)
Dis ersaliTreatment Area Information: c
FDesig,
Flow (gpd) Design Soil Applicati Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
Rate(gpds
f) - - _
- 7-/' -
VI. Tank Info Capacity in
y
Gallons =
Total # of
Manufacturer
Gallons Units c b y
New Tanks Existing Tanks
Septic r Holding Tank K I1 j Ca I j A c; w ❑ ❑ ❑ ❑
Dosing Chamber El ❑ ❑ ❑ I ❑
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
N Name (Print) ; Plumber's Signature MP Number Business Phone Number
J-W
PI fiber'/ Address (Street, City, State, Zip Code)
2 Jt'K jv SYc` i 3
VIII. Count epartment Use Only
Approved t ed Permit Fee Date I ued 7 Issuing Aye Signature
43i even Reason~or Dcnial S Zf~ /
IX. Conditions of App g INtf i%isapproval 9Y~T N '
1. Septic tan , . n+ an 1 1. Septic tank, effluent filter arld
d PtS dlspefs .oi( rill rim iervicad 1R181Rt8r1el
as per r, 1ar:z mber. as ire , Ii et 1. 1vdy Pl4lmber.
2. All setbaci, r.. v.~~ d 2. AI! s r P Itllntained
as era iiGaWU w~i turUillratl S.
a Mt o- a p ete plans for the s}stem and submit to the County only on paper not less than S 12 x 11 inches in size
SBD-6398 (R03/14)
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: f~,~ , pJ
Owner's Address: '%J c? A,o
Legal Description: r . Z
Township: A-,
County
Subdivision Name:
Lot Number:
i
Parcel ID Number: C% 7, Z_
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
I
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 -St. Croix Cty Septic Tank Maintenance Form
I
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: lei jj 7
License Number:
. _ yr
Date: /-/L/-/ ? Phone Number
Signatures.
Designed pursAnt to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
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POP
Soil Absorption System Cross Section
n r-
Io
4" Schedule 40 Final Grade
PVC Vent Pipe ,
With Vent Cap G ' r r
Leaching
Chamber
E- '
Svstem Elevation
3 ft L
f
Soil Absorption Svstem Pica View
~gv
ft
ry
Y ~ ~ ~ II IIII. II II I II II VIII IIIIII I. I I I II ~II II e ~
Vent Or Observation Pipe Leaching Trench 1
Chambers
I I I I ~ ~ I~ I I
III I ~I I IIII I I I
4" Dia.
Trench 2 Header
Leaching Chamber Soecificafions
Manufacturer And Model,
7REISA atin gL~'
sq ft per chamber Soil Application Rate 7 gpd/sq ft
d Design Flow _ 1 a, d
7 _ y y
9P Soil AppGca;ion Rave _ t- EIS" - Chambers
2 rows of Z- chambers each.
Page of
Installation and Maintenance Instructions
Installation
Step 1 Dry fit the filter case onto the outlet pipe going to the drain field. Ensure it is centered directly under the
access opening. (if outlet pipe is already in a fixed position, additional pipe may need to be added)
Step 2 If utilizing the additional single side support and the two bottom supports: While the case
is still dry fit to the outlet pipe, measure and cut 1"schedule 40 pvc pipe to the length needed to extend from the
hubs that are pre-molded into the case to the side wall and the inside floor of tank. solvent weld pipe into the
hubs that are pre-molded onto the case.
Step 3 Solvent weld the case to the outlet pipe. Insert the filter cartridge into the case pressing down on the
cartridge until it locks into place at the bottom of case.
Maintenance
1) Remove the access lid of the tank. Note: To ensure undesirable solids do not exit the tank and into the
drain field, the tank should be pumped out until the level of effluent is below the outlet level of the tank.
2) To remove the filter cartridge from the filter case, pull up firmly on the handle of the cartridge dislodging
it from the case.
3) Using an ordinary garden hose, rinse the filter cartridge ensuring all visible septage material is removed.
4) Place the filter cartridge back into the filter case pressing down on the cartridge until it locks into place.
5) Place the access lid back onto the tank ensuring it is secure.
Lifetime filter has a lifetime limited warranty:
Lifetime filter LLC warrants the filter will be free of manufacturing and workmanship defects during normal use for the period of
time the original purchaser owns the product. Lifetime filter will provide a replacement filter in the event that the original filter was
not damaged during the installation or maintenance process. Damage to this product caused by accident, misuse or abuse will not
be covered under this warranty. Improper care or malfunctions resulting from product not being installed, operated or maintained
properly will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal charges, installation or other
incidental or consequential costs.
Contact: mike(cDlifetimefilterllc com Phone: 502 724-2231
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner ~LiLL// 4 k, t J Septic Tank Capacity I- J 'Z7 gal El NA
Permit r Septic Tank Manufacturer SA1_ G1 11 NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms q ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units - C _NA Pump Tank Capacity gal ANA
I
Estimated flow (average)„ gal/day Pump Tank Manufacturer A
Design flow (peak), (Estimated x 1.5) (moo gal/day Pump Manufacturer _..g"NA
Soil Application Rate 7 9al/daY/ft2 Pump Model LT`lA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit +-'NA
Fats, Oil & Grease (FOG) <30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODS) 5220 mg/L L~`NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) _<150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODS) _<30 mg/L &In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L lA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) _<10' cfu/100ml ❑ Drip-Line ❑ Other:
Other. ❑ NA
Maximum Effluent Particle Size % in dia. ;:NA
Other: ❑ NA Other: ❑ NA
Other: 11 NA
*Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
Service Event I Service Frequency
Inspect condition of tank(s) At least once every: 11 month(s) (Maximum 3 years) 11 NA
$year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (%s) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: fl -year nth(s) (Maximum 3 years) [I NA
❑ month(s) ❑ NA
Clean effluent filter At least once every: _11 year(s)
El month(s) -2-NA
Inspect pump, pump controls & alarm At least once every: El year(s)
` El month(s) ANA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) N
At least once every: ❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent or, the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (%3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of <_12 months, 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.
GMW (4/01)
Page of
START UP AND OPERATION
For new construction, prior to use of the POW T S check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal 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 power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result 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 trotsi go
power to the effluent pump or contact a Plumber or POINTS Maintainer to assist in manually operating the pump o
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 the 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, diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or 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 and pits shall be disconnected and the abandoned pipe openings sealed.
s The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
e After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
j A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
th at time. the ':riemat at ,he
❑ Mound and at-grade soil absorption systems may be reconstructedhi the placesfollowing in effect at removal
infiltrative surface. Reconstructions of such systems must comply
< <WARNING> >
SEPTIC, PIiMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NO-i
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM'TIIE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
L Name
Name
i n
Phone Phoe
75- " ✓ / - ~i P
LOCAL REGULATORY AUTHORITY
SEPTAGE SERVICING OPERATOR (PUMPER)
Name C~tie,x ~~,a.v~~ A
Name
Phone Phone f ,3P ~ &,o o
'1 i ~ l cl r' <
This document was drafted in compliance with chapter Comm 83.22(2)(bM)(d)&(f) and 83.540), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer L A << ~J
Mailing Address
Property Address p
(Verification required from Planning & Zoning Department for new construction.)
City/State alD ~i Parcel Identification Number /05 7- -
y~
LEGAL DESCRIPTION
Property Location 451A) I/4 , 1/4 , Sec. 2 J , T Z `3 N R W, Town of
Subdivision Plat: Lot 4
Certified Survey Map # $ Z S Volume Z7 Page # CQ .
Warranty Deed # (before 2007)Volume Page #
Spec house yes no Lot lines identifiable K-yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal 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.
I/we, 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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date.
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.
Number of bedrooms
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warrann< deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
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Wis. Dept. o a~i services SOIL EVALUATION REPORT /
Division of S Buildings Page of J
O' I in accordance with SPS 385, Wis. Adm. Code '~'aq'~~' fA' 4`/
~QR ~ ~ ~ County
Attach completeRel plane on t les than 8 1/2 x 11 inches in size. Plan must
include, but not I" ntal r gint (E A), direction and
percent slope M s, north arrow, ~_-1 Parcel I.D.
ce to nearest road. n Y2-l 6J i~L ~a- yz
i
Please print all inru,,,,_ Review by Date
Personal information you provide may be used for secondary purposes (Privacy
Property Owner Property Loca ion S J `i, GQ
1 ~ a P~ • ~ ~ rl"
Govt. Lot N w 1 /4 J F 1 /4 S 2~ T N R E (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# pp
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
) ~A- 1✓ G.'1 L}
New Construction Use: [ Residential / Number of bedrooms
Code derived design flow rate
FGeneraf Replacement ❑ Public or commercial -Describe: GPD
ent material Flood Plain elevation if applicable
comments ft.
and recommendations:
® Boring # Boring
® Pit Ground surface elev. ft. Depth to limiting factor > V? in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
_ ff#1 ff#2
r'
a+
`Z 2, cal sf~
pot Y
Z - _
7
Y/'{ /
/J -2• AV
1 l9
L_ Boring # El Boring
((--JJ ® Pit Ground surface elev. r'r~ % • j ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
0 ff#1 ff#2
l L L 1 L, y y A
,3 1Y
Y/ Y
•9~ `may
* Effluent #1 = BOD 5 > 30:< 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 30 mg/L and TSS 30 mg/L
CST a e(Pleasee , Signature
r CST Number
dres
-71
Date Evaluation Conducted Telephone Number
SBD-83-10 (R 1 1 A 1)
Property Owner E 2 d Parcel ID # V q -Z- 105 7 -(may % Z q Page d of 3
F ❑ Boring
f ~ I Boring # f~
l1~ Pit Ground surface elev.~L'~ ft. Depth to limiting factor
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Rcots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
a
-71
1
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
F-1 Boring
Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD s < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD-5330 (RI 11/11)
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