HomeMy WebLinkAbout040-1203-95-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 600238
GENERAL INFORMATION (ATTACH TO PERMIT) 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:
MITCHELL & RAINE O'KEEFE TOWN OF TROY 040-1203-95-000
CST BM Elev: Insp. BM Elev: BM Description. Section/Town/Range/Map No:
35.28.19.946
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
(
Septic Benchmark
Dosing t Alt. BM
Aeration Bldg. Sewer
J V
Holding St/Ht Inlet
St/Ht Outlet y
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
d
Septic Dt Bottom
/
Dosing Header/Man. J
Aeration ( I Dist. Pipe '
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATIO
XxS T ,j'r f _
a
Manufacturer Demand St Cover
5 GPM
Model WAI, f,
r
TDH Lit- Friction Lois System Head TD4 Ft
i ' • s r
Forcemain Leng5v. % Dia.,+y Dist. to Well .
SOIL ABSORPTION SYSTEM t. T
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pitt Inside Dia. Liquid Deeath
DIMENSIONS ) r
A
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer' f_',.•
INFORMATION CHAMBER OR
Type Of System: UNIT Model Numbg
DIST IBUTION SYSTEM
Header/Manifold Distribution Ix Hole Size x Hole Spacing Vent to Air Intake
l' ~ Pipe(s)
1 1,
Length Dia Length ngth Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over - Depth Over xx Depth of r Seeded/Sodded Yes No xx Mulched
Bed/Trench Center. Bed/Trench Edges Topsoil` - Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 13 DRY RUN RD VP)'~- *Oak 94.
I
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover = L
J
1
:I yy
/'!2 -9)
~ !j ~ n
Plan revision Required? ~ Yes No ~
Use other side for additional information.
Date /Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
A
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) located
at: 1/4, 1/4, Section , Town N, Range W,
Town of , St. Croix County Wisconsin.
Upon inspection, 1 certify that 1 have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 38425, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
r
(Licensed Plumber Signature) (Print Name)
(Title) (License Number) MP/MPRS
(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
OWED
RECE,
Industry Services Division County
i' _ cj~ 1400 E Washington Ave $t• Ddx
P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
~ r
-UNITY DAL MENT iso WI ff 40662.319
Sanitary Permi NE5KQFXGFt4B40 State TrartAiA Numbs
r
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address)
the Department of Safely and Professional Services. Personal inIbunatian you Provide for secondary ^
in accordance with the Privacy Law, s. 15.040 m Stats ShM e A.o
1. Appfintiou Information - Please Print Alt Infwanitioe Property Owner's Name Parcel #
CTCHi=lam. ~'SA\AE A _ G, ~j=~ (~(fv - j 2@ 3 y5 = aol7 r
Property Owner's Mailing Address
Property Location 1 ,
f 3 Ru RDA 0 Govt Lot
City, State Zip Code Phone Number r-
R1 V G K FA LL---, U;TT Section -nos J`LI O LZ T Z , R cirelE or]
N
IL Type of Building (check all that apply) Lot #y
t or 2 Family Dwelling - Number of Bedrooms 3 I Subdivision Name
lock 08R& "Oto- AD Pali
0 Public~ommercial -Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
t k 1 Town of 7K 0
M. Type of Permit: (Check only 9m- z on lien A. Complete line B if appK=bk)
~Z^ IA ti
A. ❑ New System WRtplacemerrt System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date issued
Before Expiration Owner 3 ST 76 IV. Type of POWTS S o at/Device: Check ap Wort a
fi(Non-PressurLead In-Ground ❑ Pressunzed In-Gramd ❑ At-Dade ❑ Mound > 24 ur of suitable soil ❑ Mound < 24 in. of suit oil
❑ Holding Tank ❑ Other Drsp-W Component (explain) ❑ Pretreatment Device (explain)
V. Dior rsaUTrea tildirt Area Information: rw
Design Flow (gpd) Design Soil Appiicatio Dispersal Area Required (si) Dispersal Area Proposed ( Systems Elevation
14!-o 0.6 75t0 7!5Fv 9z or -3 -4 VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units )v $ v
New Toft Tics C>
0.v ar m w t7 0.
s j o 10 co i Aj l ~Ki=C>'t -5T Dos-mg Chamber (rc~
V
VII. Responsibility Statement- 1, the undersigned, asaame respo lily r irsp0ation of the POWTS shown on the attached picas.
Plumber's Name (Print) Pt i umber Business Phone Number
LIKE F~Dll~iv'!tU~ 3 S 5-g2
Plumber's Address (Street, City, State, zip code) 9
-IS- 8I-
Z.Sa -T,-t{. 55 gXgEK FA US, vjT Sy-ozZ
VI11. un /De rlment use
ed Permit Fee DatrZ3 Issuing Signature
ar Denial S
/ 7
Gwent RQf
0:01
IX. Coe ' pprova
l
t 3 .~i . i^. = cY+^ a
cJbs(er ~~+rxl malt bq ¢picas !w
t1s>per,jW,,agernW.. plan piviided by plumber.
I "Ai ft*llr*WtiirwWM, milabe t;aintr.iad 4tj QV
a per llpp*lbla oodut / crdinarnex.
Attach to eampieie plans for the system sad submit to the Comfy only an paper not teas torn s tQ s 11 ea store A J
Mee4-
SBD-6398 (R. 08114)
PLOT PLAN ;,7- of
Q4o - 1203- 45-aao ,
ScAe, ; 4o
1 ~ ~y Rur~ ~o~
-rows Or- Ta4
•
G MTOF
~~ipnC. YC4 l
C-L• 99.Sa
Of E4.100 vo
63 g5 00
u `T
rot
A/1 D~ 6 - o -To
i TIF
~~i'/1-T~cff t--ILTFje TO F-F ALflE~-t
3-col j~D3 ~Gr~
o~
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Filter Specs Soil Evaluation Report & Site Map
Previous Sanitary Paperwork Septic Tank Maintenance Agreement
Warranty Deed
Project Name / Description
Owner Name(s): MITCHELL V. & RAINE A. O'KEEFE Phone: - -
Owner Address: 13 Dry Run Road, River Falls, WI Zip: 54022
Project Address: (same)
Govt. Lot: NA SW 1/4 of SE 1/4, Section 35 , T 28 N-R 19 E ❑or W Q
Township: TROY County: ST. CROIX
Project Parcel ID 040 - 1203 - 95 - 000
Designer Information
Designer Name: MARY JO HUPPERT Phone: 715 _ 426 - 1775
Designer Address: 28497 King Arthur's Court, Danbury, WI Zip: 54830
E-mail: hollisterdesi9n@outlook.com°''`""""'
License Number: 1859-007
Remarks:
r s
.NGw AAAJA) 1.AJT0 TAAK. HUlERT
Fi END hw W iN TAN K i 1;;9
1-Fl VER FALLS r' 17
DkscoAlAre-cTs 1 WI
40,
SIG iivt
Signature: G~ - Date: 217
Origina ignature required on e c submitted copy.
040 - ►,2a3- gs-ooo PLOT PLAN Pj 2- of
Sc~~e 4n'
1 v RuN ROAD
TOw ~i eF
2
W
arnTo : 9
Ka
EL. 94.86
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19~J~•(~D'~ ~1gyt,Op i
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v 300/
m o PAGE 3 OF 5
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'If 31
Goulds
Submersible
Effluent Pump
EP04
3871
l EP05
APPLICATIONS • Fasteners: 300 series • Fully subme
stainless steel. submerged in high ■ Motor Horsing: Cast iron
Specifically designed for the grade turbine oil for for efficient heat transfer,
following uses: - •-Capab~ of running lubrication and efficient
dry wdhout to heat transfer. strength, and durability.
• Effluent systems ■ Motor Corer: Thermoplas-
Homes components- tic cover with
handle
• Farms Motor Available for automatic and and #0 switch integral h atta attachment
• Heavy duty sump • EP04 Single phase: 0.4 HP, manual operation. Automatic
• Water transfer 115 or 230 V, 60 Hz, 1550 models include Mechanical points.
• Dewatering RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty
automatic reset preset at the factory. rated oil and water resistant.
SPECMTIONS • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower
115 V. 60 Hz, 1550 RPM FEATURES heavy duty ball bearing
Pump: EP04 built in overload with coralxbon.
• Solids handling capability. automatic reset. 0 EP04 Impeller Thermo-
1/4, ma)dmum. • Power cord: 10 foot plastic Semi-open design AGENCY LISTING
• Capacities: up to 55 GPM, standard length, 16/3 SJTO with pump out vanes for
1 • Total heads: up to 24 feet. with three prong grounding mechanical seal protection. canadiaw S>
• Discharge size: 1'h' NPT. plug- Optional 20 toot r EP05 Impeller. Thermo
Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for listed model numbers
rotary/ceramic-stationary, three prong grounding plug improved performance. end in "F" "AC".)
BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104•F (40*Q continuous superior strength and
140•F (600C) intermittent corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10
• Capable of running ' + +
dry without damage to s 30l i - - - -
components. i5, -
Pump: a - - - ' - 1
• Solids handling capability o 25
Y ma3dmum. Q 7
Capacities: up to 60 GPM. _
• - - - - - -
• Total heads: up to 31 feet. s 20
• Discharge size. I W NPT. d - '
- - -
•Mechanical seal: carbon-
15 rotaryceramic-stationaryi a BUNA-N elastomers. - - _ I
0 _ - - z8, a - - - -
• Temperature:
s 10
(4n) continuous 0
14(rF (6t1°C) intermittent. -
r 0 00 - +
f0
30 40 50 GPM
o2 4 6 g
10 12 m3/h
• - combination SeptFic; Tank and
PUMP CHAMBER CROSS SECTIOU AND SPECIFICATIONS ' PAGE OF.
CLIT CAP WEATHER PROOF JWJCTI01J 86X
4'C.I. VE1JT APPROVED LOCKIMG
1O `FROM MANHOLE COVER wr0i
Ji4,
:-IUDOW OR FA~INTAKE f -to tmu.
fiuNlt-X . r I
'LL
IWAIJ
IBwnII4. 'lam - -
y'IUS~orJ P~ - - _
INLET PROVIDE !
AIRTIGHT SEAL t I I
ea~~s I l ~ I
APPROVED JOIM'T A I I APPROVED J01uTS
W/C.1. PIPE 4t Tank construction , III w/C.r. PIPEwxpDc
shall comply pith ALARM
ILHR 133.15 and 83.20 a - t I
1
I t Ou
c -t I
LLEk f T PUMP -_J
OFF
0
COUCKETE
gLEV _ BLOCK
X- RISER EXIT PERMITTED OIJLy IF TANK MANUFACTURER HAS SUCH APPROVAL~3"1WPRflvED
8so0
SEPTIC E SPECIFICATIOUS
0osE tGk1L5
TANK MALIUFACT UKCK' t 'TA'T IJUMBER OF DOSES:_ PER D"
TANK siZC: ~ 1 bs0 GALLONS DOSE VOLUME I
ALARM MAtvIUFACTURCR: QLZC~10 S`ts1t~y1S INCLUDIIJG OAGKILOW:
S S, S3 GALLONS
MODEL NUMBEtt: IZA \aW CAPACITIES: A= 1$ WCHESOIL 30 b GALLOyS
SWITCH TYPE: v_A%-aAJv_>1f 5= Z IUCHES`OR Z4 GI►
_ LLOUS
PUMP MAUUFACTURCK: - ~UL--~S C- 9 IUCHES OR 1S I GALLONS
MODEL NWABER: 35-1t O
D ~ Ct INCHES OR ~ S3 GALLONS
SWITCH TYPE: - ` -W%fv %
NOTE- PUMP AMD ALARM ARE TO ac t°
MILIIMUM D15CKARGE RATE Z_ g-~$ GpM INI TALLED OM SEPARATE CIRCUITS
VERTICAL DIFFERENCE DETWEEU PUMP Off AUO,.DISTRIBUTIOW PIPE.. FEET
+ MIIJIMUM NETWORK SUPPLY PRESSURE ; w'J ECT
~ FEET OF FORCE MAIN X FYI fLFRICTIOM FACTOR.. ~iQ ~ I FEET .77
TOTAL 01 AMIC HEAD = FEET
Pump chamber DIAMETER
IUTERUTAL. DIMEMS.401Jf OF TANK: LEQ&TH -~_;WIDTH -;LIQUID DEPTH
BOTTOM AREA 231= ' - GAL/INCA
i
In-ground p ~'~~r✓~
!Mpo_ R-- T~ Osed-Gravity
The owner of this in_
Management Plan PAGE~~F~-
pursuant to re ground dosed
system requirements of SpS 'gravity system shall be r
shall be considered a hu382-384, responsible f
Furthermore W
Plan. or its pefPetual , all inspection hum 382-384, health isc. Admin. Code.
hazard if not Pursuant to SP
accordance with SPS and maintenance activities shall be maintained in performed by and maintenance
383.52 accordance 83 52 (2) Wisc. Admin.
MBXi (3)' anWisc. d Admin. Cie b with this approved management this
mum Dls er al Area O
gement
e a registered POW TS
Design _ 450 ratin Limits: Maintainer in
9n Flow
ins ect on Ch c glad'
0
type of useklist INSPECT ODs S 220 mgL•~~ T33 S 150 ►ttgL ° age of system EVERY 3 YEARS FOG S 30 ►rigL'
° nuisance fa
° mechani ctors (i.e. odors, user complaints, etc.)
° cal malfunction (i. e., pumps valves, switches fatigue (i.e., leaks, breaks, corrosion, etc.)
° solids volume in anaerobic treatment
0 neglect or im p tank(s) , floats, etc.)
° extent of rOpeC use (i.e., exceeding and any distribution a
o extent Pond'ro in distribution c g design capacities Ppurtenaes, s
dosing irregularities - if ell prior to dosing Prohibited activities, c~ e'' distribution / drop
° electrical components applicable P boxes)
o distribution lateral or lateral orifice (i.e., i pump re-cycling, float switch settings
° surface discharge of effluent or se age back(-up (measure lateral d erne res~ controls, timers,
wage back-up into structure served sure - alarms, etc.)
Maintenance Checklist compare to design specification;
° Se tic and dose 4 MAINTAIN EVERY 3 YEARS
Stats. when the voluk s shall be porn °r When necessary)
as required b me of solids in the t nby a k scertifed se to
y local Ordinance.
exce P e- Servlclng operator licensed ° (fluent filter s Disposal of ads one-third (113) the li under s. 281.48
contents shall be pursuant to N quid volume is.
accumulated solids ll beinspected eve R 113, of the tank(
every 3 years and shall b Wisc. Admin. Code. s) or
months. according
to manufacturers e cleaned when necessa
specifications. A servicing period rY to remove any
Will always be greater than 12
System maintenance reports shall be submitted t
PS 383.55 Wisc.
Admin. Code. Report b o the proper local
ame of individual or company: BET-i• any component failure or government unit in accordance with
ENdORF EXCAVATING/MIKE RODEWALD malfunction to:
oval government unit: St. Croix COtlnt
cal government unit address: HudSO y COMMunit Develo Phone: 715-425-6200
n, wl Y Pment Phone: 715-386-4680
Y defective part of this s
e• Repair or replac Ystof shall be re ZIP: 54016
product for chemicaeo ent er failed or paired, replaced,
rnalfunctionin ar removed pursuant to Sp S
with SPS 384, physi iSc cal restoration 9 components shall com S 383.51 Wisc. Admin. of the Po
(1)
. Wisc. Admin.
Code. WTS may be used unless approved SPS 383, Wise Admin. Code.
=n enc plan
by the department in
tie event that any failed treatment com
an submitted to the appropriate a component of this P
le a ed and replaced b gency for review andOWTS cannot be re
by a code-co persal comproval. p gred, it shall be replaced
mplying dispersal A failed de round dispersal com pursuant to
ponent in apre-determined area of suitab ensoi7s ay be
tern Abandonment
~ of this POW-I°S is discontinued, it shah be abandoned in accordance with SPS 383.33, Wisc. Admin. Cade.
EZflow 1203H - GEO
ESTABLISH NATIVE BACKFILL
VEGETATIVE COVER JX' MIN. COVER
OR PER CODE
FILTER FABRIC
4" PERFORATED
' PIPE
12" EZflow
o BUNDLE (TYP.) 36" MIN.
TRENCH
WIDTH
0
N
3
0
u_
U
O
a.
a. NOTE:
PRODUCT CONFIGURATION AND INSTALLATION
z
z
co
DEPTH MUST COMPLY WITH APPLICABLE
REGULATORY REQUIREMENTS. """A1O4
O INFILTRATOR SYSTEMS INC.
W 4 Business Park Rd. Old Saybrook, CT 06475
(800) 221-4436
J
Q
U
Z EZflow 1203H - GEO
z
U
W Drae W EMB Dale: 0 810 7/2 0 1 3
H
C7 Scale: ~T ro sca a G ded bY: DFH ShW: 1 of 1
R)
w
00
DO
H
1r
mm~
1 1
W W
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D -0
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NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
r~
Y
~O
M
t
cli
INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IX
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (f)(m)]. 3 3 8 9 7 0
Per MEYER ~ N T lei City,[3_vYage Town of: State Plan ID No.:
CST BM Elev.: Insp. Be-- M ElBM Description: BZ Parcel Tax No.:
040-1203-95-000
X10 -910
i - 80
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_
Septic
pe Gyk"' ~ppp bs7lO Benchmark
Dosing
Aeration Bldg. Sewer
Holdin St/ Ht Inlet /a~b3 99• Y3
TANK SETBACK INFORMATION
St I Ht CA -Us&--
TANKTO P/L WELL BLDG. ventto ROAD D
Air Intake
Septic >3p 3 ` 1 NA Dt Bottom
lS9f3 V. l~3
T. to-
Dosing NA Header/Man. rt',
L ~f (o tO
Aeration NA Dist. Pipe
Holding Bot_ System
PUMP / SIPHON INFORMATIO nal Grade F. jVo "13 0 '
Manufactur nd 7• 2 -2. SZ
Model Number GPM
TDH Lift 10%,-k< T
f-ft
F
Force in Length Z.1 Dia_ N Dist. To Well
SOIL ABSORPTION SYSTEM q
BE$ TRENCH Width Length No f renches PIT No. Of Pits Inside Dia. Liquid Depth
1 •2r 4 I N1 N
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manu tur r:
SETBACK
INFORMATION Sypem: O ( S~ >~0• OR UNIBTER Model Num r:
DISTRIBUTION SYSTEM
Header I ani of Distribution Pipes Ax Hole Size x Hole Spacing vent To Air intake
Length eL Dia (may! Length 7~p0/
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
Bed /Trench Center Bed/Trench Edges Topsoil E] Yes 1 E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCI~TION: TROY 35.28. 9_1~946,5w,SE X13 D Y RUN ROAD
mow.-
=
Plan revision required? ❑ Yes VNo
use other side for additional information.
f
I il t3 CR3 1-71
I
r
C SBD-6710 (R.3197) Date nspector's Signature Cert No.
SWdy and B &Wvs Mvtmn
*96onsin SANITARY PERMIT APPLICATION 201 E. WeshinglonAve.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 79M
department of Commerce Medison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County c7T G ~O
than 8 1/2 x 11 inches in size- r
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it r evisM previous application
(Privacy Law, s_ 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT L INF MATION .,I
Property Qer Nam Proq j « i is 5 3 T , N, R E (orj~g)
p
Property w Maili g ress Lot Number Block Number
C, state r( Zip e~~ Phone Number Subdivision Name or CSM Num r r
BUILDING: 11. TYPE OF (check one) ❑ State Owned o ! Nearest Road.
l age
3 Town of rt7 brr lib
Public 1 or2 Family Dwelling- No. of bedrooms ❑ Vi
Ill. BUILDING USE: (11 building type is public, check all that apply) Parcel Taax~Number(s) *-is .1°I9
1 ❑ Apartment/ Condo " Vo 3 Y-oooo
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 only one box on line A. Check box on line B, if applicable)
A) 1. F New 2_ ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
-----System .System ----Tank Only- ExistinQSystem Existing System
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 410 Holding Tank
12 Seepage Trench h 22 ❑ In-Ground Pressure / 42 ❑ Pit Privy
13 ❑ Seepage Pit I tv>~ y , a/' • Z 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION-
1. Gallons Per Day 2_ Absorp. Area 3. Absorp. Ar a 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
-1 Elevation
A Requir ( ft.) Proposed sq. ft.) (Gals/da /sq. ft.) (Min. inch) t) e 90 ~
41- l
t ter*41 Leet S4 ^%P Feet
161 1
it y
TANK in all'ins Total # Of Prefab. Site Fiber- Exper
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Ply" App-
1 New Exstin strutted
I Tanks T nks `
❑ ❑ ❑ ❑
Septic Tan Q r S /r CfQS-7 ®
0 - H
Lift Pump Tank ❑ ❑ ❑ ❑ ❑ ❑
VIII. MSPA SIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s hown on the attached plans.
Plumber's Name: (Print) Plu r' Signature: (N S lamps) MP/ RSW No Business Phone m
a5--~
Plumber's Address (Stre t Zip Code).,t iU S G✓' 5, LjC2
IX. COUNTY! DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (iWucimGroundwater ate ssue Issuing gen i ature (No Stamps)
s~,.cnargerce)
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Approved ❑ Owner Given Initial
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Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVA
S80,6396 (8.11196) DISUOUTM: OrW" to County. One a" To: ssfaty a ou"ngs Division. Ow+er, rkmbor
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Confirmation Report--Memory Send
Time : Nay-11-99 08:06M
Tel line : 7152475031
Name FIRST NATIONAL BANK
Job number ; 925
Date Nay-11 08:04am
To 16512916250
Document pages 01
Start time Nay-11 08:04am
End time may-11 08:06am
Pages sent 01
Status OK
Job number 925 SEND SUCCESSFUL. *~t
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