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HomeMy WebLinkAbout042-1057-20-427 a,re.r:crsm DepartroertofComme•ne PRIVATE SEWAGE SYSTEM Cc...'I' St. Croix Salvly' S'iu i4W 9i'jI II'I'ilslon INSPECTION REPORT Sar sari Petm@ Np (ATTACTI TO PFIUo91I) 605003 GENERAL INFORMATION State P.an ID INC PHBO•,a nM,'mark- yon prn'oe may he dsed far secondary p..rpases IPr vacy Law. ; 15 04 (1 i( Permit hr: 7c 's Namc Ody V'lage TOwns-ip. Parttel Tae Nr. Thomas Cody TOWN OF WARREN 042-1057-20-427 CST BY Elev. I-sp. BIA Lle. BM DesC•Ipnon f ~5 ' Seeuonjrmo Rar•ycrlvlan W d~ l o v 20.29.18.319A-42 TANK INFORMATION ELEVATION DATA /11 TYPE MANUFACTURER r r~ CAPACITY STATION HS HI FS I Septic ` y / OT Genrhrnark iz.q //z.o 1 /456 V Ail. 810 Ill 6~- Z. V5 116. bS i t` ` Fl Aerali v Bog 'ev:er 7.1 145.1 Holding Sliest In et 9.0 /a3.$ TANK SETBACK INFORMATION St'l Outlet "1; 3 /d-3 55 TANK TO PrL 'dvELL BLDG. /ort Ic A I'! ike ROAD Dt Inlet .5A .w. seen 4 1 Z I L f Ti Bo tam Dos no Heade.Oi. /0.o 9 Ae'aton Dist PI;Ie /bIa m z 9 Holdlny Bat. System /,b Z- Ell PUMP/SIPHON INFORMATION Final Grade G. P.9anu`aGU•e Demand St Cover /l I GPIA /Q~.$ ~1 7 A4cae'. Nurn:;er TDH I A rri aeon Loss System He Ill Ft - Forcemain l u), !-I 1 Cia. Dist. to vtell SOIL ABSORPTION SYSTEM BFD!TRENCH 4vldtr -encl. I Or Tfe-nhes PIT DIMENSIONS Nc OI ='t IrsJc Liri.,id Depth DIMENSIONS 3 3 'W SETBACK SYSTEM TO P:L BLDG VJH L LAKEsTRFAlo1 LEACHING Marufacturer INFORMATION CHAMBER OR T,.~•••P(~i I I. IyI:,-')I syxl-m UNIT 6tucel Nu^D ~o t ter ` 1 /JET-- ~j ; 11il DISTRIBUTION SYSTEM .54q ~cS HeeJerYdanlfcld 1 ( D st it I n a lru'o S,'e x lnlc Spa:'-ng VE n r t3k 8~-7 Pi„e;;, L^m.Pi I] lip,-y, _ Ora ~pac ng~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ovc' Dentr Over ex Deotn o` xx See:•fed+Scod!•J tx Mul:Ped lie.1'•ar ^h Center I!>enr lr~nch PoGes. 1 luF> _nl * v.._ Np Ves No COMMENTS: (Include code discrepenc es. persons ofeserY, etc t Inspection #1 Inspection #2* Location: 824 106TH ST ! 1_ TyQG.Y(_, O r"tL ~o~a~• (/Illi"a~:~ f . AI: BM Description = r 2.i Bldg sewer length = Z1 - amount of cover Plar revision Required? Yes JyO (J 3a g ~Q (XJ 7 75 Use. other side for addi: ona. intormah n - - - - - - - Date - - - nse Pel' S Si{Trot Cerl I industiy Set vices Division D 140J -V:'ashinglon Ave - Sa'!nan. i'n ini Soo!bcr !te he tilled in hx Ca i P PC Box 7162 v 2 R•ladison. 4s9 53707-719' I 'ranaae ion Nunil~sr Set1)113P) rt.l°t~ )1ICatll)IT + Snc r accol ian c „rzh SINS 83,2 i 1 1 Qn. dAk r , I dh< h nn l1$. tppr ruck cvc : ! u dl t n't ~ ~ i,r auref rriort tha:rim asa.uln p Tat ♦ t ypG, n 'n -m' ! n ;d trP f1 nc 'U!'111 r < to :!u nr m cnl I le l and V'. . nl I r -n I un nraoin , r v n as tit ux d L: s.•.nda} Fr, c.1 h:Idre c u tiircnt than mnili:tc addrt,,) Fuq to ac" r~rs nuh Ln 1,. Apklication Informal ion- Please Vt intAll Information - _ • JL•„ -f` J--f q q Q •1 NJ A ~,Jl uts lour l s Jill-F Ad.irrzs 1 ,.ar!•: I„cuuon~-v,. J'f ~L'~~~C~y Let ..Sf iecion 0 t 7 t.IfvlC ❑el /✓~UCISG/J illr - SY~'rL /J 'L/'7°L✓ Ly ,/,9 „r . 11 Tipe of Building Wilick Al that apply) In I r 7 Fnmrl nn re ur.. r n.dr.oms Nuodislsion Na[nt 6k Public Commucial - Dcsc:ibc ;.9.: 131oLk ❑ El Stale Ow::ed - DewrOc a=: Cuy of El jj((~~\\. y, - _ ~S\I Nuntbc[ ✓ %y \!liarc of 3 N` LS1f2L23_ l~~ C'I QSC~~ G To„rr oC - - Cl ~ F ; I11.'I _cpe of Permit (Check onh' on box on line A. ('omplete Imr 13 if applicable) Z~--- 19 New S;,:er: I ❑ Rcpla.:.mun Svmvin ❑ T•ceunn:!I l b Ln,, kink Rcplaecunent Only ❑ ;)Ihc- Alnelh anon to Iixknn~, Syslcrn resplalei Ii it. ❑ 'crnut Rclwual ❑ I'cmit tics rsiua ❑ t hanr.c or ❑ Pcrmil -I ran;ler No Nc% Lim Prcxtcus Pe of \omr. r and Gefc ls1uad li b re rxpl au--n f lu of•< I ot, jlcr ry y ff . J r) 1\ ] x < of POW TS Svstzm Component Dcv1°z (Check all that 411111 yl - _ - - - C T nn I r -.[mz 1 l to"n:d ❑ f rc.-unz d In (r and ❑ tr-I Bade ❑ Ahm i 1 I m of sun t F-s:nl ❑ Moond ]d m. of -linable *od $ [I ur f-trmerr1nl,cr,a: fom ut.m texpl-mi F1lrc-c.:lm nr 1).,ixlcx,laur V. Unpc rsa V'fn atmrnt Area Inlonnalum - r i /IS •3 'X 7L _ ,S c/ 'T Cx ~J - i); nh rl."pJ llas n\-.II ylht.. wn / ).a,: r,.i :.n.l uyuircd lsn Uspu: .:I ti:al«,:,~•,' slt Sc.l•.'m h::c.a!ian f 4V - \l.'fanA Ill f4 Ca in - - t Ilan 1 t ~ ct Alanu:aILI I I ~ t;ah ns (huts ❑ ~ ❑ New'hu*s Ercunng1zncs / . , , f- ~ d U Z err t II I lim. I~mk (.+OC) ~ S ~ No f-I \ll Rt spunsibdtty Statement- 1, the underv ncd, assumr r,puntbilin for imullation of the P0%% TS shown on the anachrd plans. .m a me I n [ lu 'her ~r hn; .1[~] Numta ueincse I rme N'un$:a r 9fAC SZJai !fin/fC:,d:ll 7/j' y%/-,f eg, n Lr Fc truck )t&j lll nut NiDr) trtment t sc Onls rn: rd Lnss}rpo•vodC i'e lit ii .)/ale s*ucd 1--aulr PP Srin;ilu c ~i cn I,.. i) nrtl T TV 7 L•3 IrJDLe/ IX. Cundi r0Mmtttsfnc Dlsappros al 31 ~Ql.Q Q,( e~ (a`1fw:':n cell crust all beCyM1a7./g. Not tnjt:: gf as W .;aarllyeenerr P to n•t. ~japn by dumoe.. 2. All sdhark °eui t,: -an,, tmr.d LC v 71,,' c : en Ppr ?PF ecrb' ° r ~ - : rd r. n ao: . Vrtrh to rnmplrrv Nlnn, L,r thr <yarm and submit m nu• t )mnh olll) on pa lwr nm Ire. B,.o. $ In , I I mJto is .v. 11i:1•. i~!\ tliii~1di y S~ 1~ v_ J o (~r ~ J h o ~ k J l 1 y 0 I~ s~ ~ p 1 v 'C® CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: _ l Cwne,'s Name h i car - i I -..~v • r~ Owner's Address: J / ~ C K e 0- Legal Description: 3'w - t 5r( "o v G 8 Township. WvA-A-rN Cointy: ~tis . K Subdivision Narre Lot Number: Parce ID Number: 7 C Y z' i Page ? Index and title Page 2 Plot Plan Page 3 Sys:e-S iro & Cross-Section Page t Fi!ter SpecS Page 5 Maintenance :rformation Page 6 Manaaement Plan Page 7 St. Croix Ctd Seotic Tank' dia:ntena_n_c_e Fo•rr Page b 'A'arrantV Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans 1 Designer,Plumber. CC. %A c /-ra wk, ti License Number. Z Z L f %7- Date: y Phone Number y la/ ` T3C~ S gnature I Desi;ned Pursua~, in the In Rro.,v9 So tA"u-pt C mpor.crt tala•wal FoI PO'✓vi b'e•sion Z L 53C-i ~TCS P fA G:P7'. r":oe ' F y v ~l v r O J l h w Ll 3 3 V cl a N b v 2 C CAL tih ~ ~ I v V a ' X* 'R. h 3 M 3 p V /x'7.0 n 4CI Aiz J - S - Sl - wail Abs•^r±;ticn _ 72, r - III 9 di 17-7 J11 I! ~li li II Tj Iii I II I ~.I... II Leacnirc Chamber Scecifications G ~ Zoo = s_y 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. Step 4 if utilizing a vertical read switch: Insert switch into the hole pre-molded into the top of the filter. Press straight down until it locks into place 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 carridge from the filter case, pull up firmly on the handle of the cartridge dislodging it from the case. (if utilizing a vertical read switch, removal of switch is optional) 3) Usifig an ordinary garden hose, rinse the filter carridge ensuring all visible septage material is removed. 4) Place the filter cartridge back into the filter case pressing down on the car-ridge until it locks into place. S) Place the access lid back onto the tank ensuring it is secure. ufePme titer r.as a lifetime finned warranty: JlvtimefCrrl'. warrants the filter will be free of manufaaurng and workmanship defects during nor mal use for the period of time the original purchaser owns the product. Lifetime filter wil! provide a replacement filter in the event that the onglnal filter was @ not damaged during the installat,on or maintenance process. Cartage to this product ceusua by accident, mi,use or abuse will not be covered under this warranty. improper care or malfun2iuns resulting from product nol be. rig installed, operated or niainta:ned properly will void this warranty. Lifetime filter assumes no responsibility for labor charges, removal -arges, i%tafa;inn or other incidental or corsvivivent;al costs. Contact: mi4r ~nietimn`ilrsrllsmm Phoro:: SC2-724-1231 POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Ianr• P:L^r,~fa~tut?': ,S"/yK ❑ td^, Fe'clit - ,XSaptr: i 11 C'riulc°c Volurlc: 14,00 DESIGN PARAMETERS l-u -k klanu'act_rer. Llr'n ❑ N,", (7 Septic E Dose ] Holding VOILTie. I'_b12 1 is 1Ve-tica; Distance Tank 6ottom~ s!'c Semm Pad(f.} ted 'a've age) %,.v: Hori-onta! Distance TanR(;• to Se-,<ce Pad' lest i•1,.ieG'J e; ic! d r oi Apollo ati:r.r Rate -7 yat iayr i rff1 rc ; Filter re1acufacsurer ❑ N.4 Standard (D me .ic; InYu nt:EffLent ido^.th y ave:acr Ef u n! F:her ;JCde': Fats. O-I 3fCaSn ~30 mya Pulp Mail - P.iochEn:iealOz;renI'e•nand fy0L;,•; _22C ml;rL _I-11A ~[i1Qq Total 5usnended Solids fl SS) x159 m_o:; Pump P.•tode': 'r ll'nn S*-'engtr. Influen>Efrluent faonthly average PretreatT?nt Unit (FOG; .3C my'L kianjfac; firer. f00D.i %220 r wiL _ El iTSS'~ _ 50 ar7;L ticc fo.ti ;:I mare:i>n ❑ Peat Fide' ❑ DiSlnfe^.[I9f ❑ Wet 7ad P'?treat?d E`Ouect ivtontky a:'e-ago _ S aye;G,a.;_: ~_.lw L Other (PJD;i X30 n:y:L So,: A~ts~orrtiO° System. 30 wj~.. Feoal --dllfornl (pecr io mean) -1o` .Girv:••a:rd (yravityj ❑ In-G-cund (pressit=_J ❑ NA i At- race Fl tdu nd `atexim urrl E%uent Pa''.icle Size in dia. yJA ❑ 1)drdt ne ❑ other Ose': - - Other 0 C! NA MAINTENANCE SCHEDULE Service Event Service Frequency FL 1F ;tut cf:arl;'sl ,:'h?n c 'r'irei Flu I end m eq,:ais cn t '.~c f;;,' tanurla _ C Vin;^c the fiat i> nttivated In l it:aond -e tanKfsi At Ie95t 0:- Lm9ntl ii - =y U ar (Maxlrlnim 3years) ] NA i-spee' dspe'sal cell(s) A! least once every. (Maximum 3 years) 7j NA Clean r roorftsl - effluent filter - _ I At leas) on;-r_• evey: O NA . ~ ~ gea Qtit p C p ^np, FJn• O COntfo!S & a arm A! least Once evefy. C r 3r sh li cre's and u-essure test At least ice e;:.ry: rF 'r.i L-3 D'i MAINTENANCE INSTRUCTIONS Inspections of tacks aim soil ;h5^ :It frn: ..hdl L_ riur- 30- --n 1'10V, J-1. 01'_. I-r 1_1 :Ali f;ins t. Pt. Tb li 'lull R, st i -C- C>:'vTS I G tor, S~.vnr, P( A 'TS 11 :-r dainc- or Scr,vici -q Operator /pun[,eri. Ta iP s o„c:io.l_ n-.1st include a visual im;,e, ko iof the:ank(s, t^ wentfv ar missing or broken fcentify any cracks or eaks. -I eaBu.e the volune of combined Slucge sn;i sown aad a check fcr any back up or po-ci ng of e'Oue•Y, oc the ground surface. Inc. so-i abso-ptio.n sys:em shall de vis.,ally insoec:ed tc cl-ec< the e4i leveis in the observahcn pins and to c'1e;k fcr any uon ing cf effluent 0'. :Ce ground suface. TI'S? pondira pf cffl,.Cnt on ti:e g-o,mc.' 3:Jdace Way indi:ate a `slung ccnditb:: and requires the im:rediate I ctificalion of the loud reg lab9'y au'hory 'Jvhen the colr:b ced aceul,lu.atio': x sludge and sr_!ni in any -,reatile^t tank eq_als one;-t^.ird cr more of tto Wk. vo-uirc- the ectire _o:r>rts of the tank shall be :emc.ed ty a Septace Servicing Operator (pumper;l ann disposed of in acoordance v:itrt chapter NR 13. .,.ycons^P,d:nX!l ratlveCode. F.il othe se'vices, ralud no bu::tut limi'ed to the servici•ig of 2f'h ert `ite's,'l ech.rlcal or press:rized compnrents, oretreatment un ts_ ar6 ar'y serdicfng a' imervn o':=12 ntcrjs, shall he nertonned Ly a rcr. -e9 POb"JTS AJa fita.rer. i,-.u:11' h.n it ime'-"• 'J" START UP AND OPERATION Page of err o. stop,'in cr !e -se a+ the Pp TS chef Irie^t ten' `far re Jresen-e o` Pa r'ting oroduot& solvents cr nth^- htrtigas sr imeni t,^at may impe.e the t amen' prco.----- antic der iaee the soil absJro!ior. system. It high CJncenuation, rye detoured ' ve f..e contr-as cf :r. ta~t<(sj removed L;, a SeP:ace Servicing Operator;o_jnPerj prior to use. Pump tans may f11 elope purple hig'v;a:er lovs,s Prior';, start-o or due tc pump'ailures Start ip o- rests stio of pcvrer wider th=e concitcns is Ct reCc-inmended, as the excess vas r r of \ 'I h to rt-e -,,I so'otto-i rvs:-cm Inc-f- la,oe dose ausw rn la aver caC' tna nav result in the L ckup or s rt m o scha. a o eff,.-ent n,. J... age, to ,,e sy ri To a vend this sltu_",on have t-.^ cJ:de'IlS Of the oultp tank fenovc" - Soptap< Se v r.i-g Or ate• ;punp ri prop restoring pCVer to Zile pjctp or Co-.:act a Pl;.mcer cr P(XVT: 19iintainer ;o assist in r,an al,y operating the pump ortrc's nil norr,al effl-e it.,eels are rest:,rei %~i thin th, pump !ark, SysteT stay. LP Shal: not OCCUr •A*hen soil conditions we fro-en at rte Infiltrative s:jrfaoe- 11"I not drive or park 'oehincs over tanks o' 'the soli absarpt.c- system. Do -ot d-.'Je or oark ever, or OF:e-v:Se dlsturc or compact, the r.rca within 15 feet down slope of any mound c- nt-grade sGl' abs,op! on area. I icduetion or elimination of the for os4ng from the •„astealater strear-t may irip'o`rn ire aer`ormance and p-olonc the life c=tae treatment leas and soil absofr) on system acids an-tiotics .:ab.v wipes, ni:,arette b:r.. conJoms- cotter se'ahs, dex-ase-s. Cen1a 3oss, . an,. s, d.slnf ctah!s, fats found_tor crai° {s rap p I t I scharee 11 fruit a -,d vegctatle peelings, gasoline, g-eases, erboid~s, real - ns, hied' cations, o:c rt~.'.It ;g pred~.Cts, pesti„ ales. sBnita y napr;ins sa vents, tampons, and •v:ater so"e..er urine dlscharge.- ABANDONMENT A-en the PO'e'd rS fails , ndror is permaneraly taken out of service !tie to iov;lrg steps shal' be taken to insu-e [oat the system is properly and safely atmndonaf in compliance ml[n s. Comm 63.:3 V'i'ro-s!n Adntin:strative Code • All pipng to tanks: pts ana other soil atsok:; on systems sha!I De disconnected and the abandons-J pine openings sealed. • T,-e contents of ail tanks and pits scar' Le removed and properly dispCSed of by a Septage Servicing Operator (punpe,; • After pumping. all tanks and Pits shall be excavate" and ren•oved o- their oovers removed and P'e void space filed wim soil, g-am•;cI o< another inert said material. CONTINGENCY PLAN V UIe PO TS fails and cannot Le repaired the follomrig neasures `ravo been, or must be taken, to provide a code oampliant re~~laeenent systorri: l!~m A suitable replacement area bas been cval„a:ed and may be u-i~ized for the loca]on of a reclacemen: soil atsorptlon sys:cam,. The replacement a-Ca s'-cuid be pro'ec:ed'rom -i5'.urta^ee :.no compacton and should not be in; ringed upon by rcowed se:backs from existing any nrcoose,' =structure, lo: tines are v;.ells. Fail-,re to orotezt the replagemen: area will resua in the need Cr a prow so;[ and site cvalJation to csia_-Ilsh a su. table replacement area. PePlaccm&-t systems must comply R".fit the rules in ctfc-tit at t e time O` their permit issuanoe. ❑ s.~itable replacement :-ea is not a'va:Iaole ax to setoack ari soil limitations. If 'lie soi' aL'sor_+tion system cannot be rehahi1itated and barrir>.;1 advances in PJ'N7S :ethnology, a ho d nc tank may be installed as a last resort I The s::e has nc: t..-eon avalaato- to identih• a su:lable reolaxment a-ea. Upon faiiu•e of the POVeTS a spa and site evaluation m s! be ecru rope to locale a s,:itable renlaoe tent sea If nc replaceine^.t area is ava :able a holding tank may be instailed as a last resor. to replace :mc failed POVeTS- ❑ t,UJUnd and at-grade soil absc-ot,on systems may oe reCocst'u_ted in place follom4hg r=_ncva' o` trip b,cmat at :tie rfJ:t'ative s::raae. ?egons7urw'On" a'sUCh Systems n.-s' comply'„t-'nn'_~les in ef`ect at t'tat tirre. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK .1„ SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. v ADDITIONAL INSTRUCTIONS: POWTS IN TALLER POWTS MAINTAINER Plane tame 1 SEPTAGE SERIhCING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY f, a:rr. a Jl~:s Nart" S~ !/ti u,-K ~ Th's < : i n n r0 - 1 by II I' n' t7 : n' a 1 L_l,t t ..rho J rC% f-C . i; :.a,tl o:o , : r'ri~ r pld s t ar a tai 1 iA,wti --ci ` _4.1'..,.:., r i 1 r.i ch~ ,,..s - _ wry ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGRF.L ANT AND OWNERSHIP CERTIFICATION FORM U«neriBupcr / ~7 c.-y» v 3 p rl `.ailing Address ? i ~Y c.t~ ~l 111l t~Jo. 1 t~, S~ d i L Property Address /11V9 --`S. p (VeTIttL ion required from Planning & Zoning Department for new construction.) City'State iL, ~f,cf3 Parcel Identification Number /L_ /o ? Zc-- YZ' LEGAL DESCRIPTION e t f Property Location A-l ' Sec. L o I Z'3 N R 1'f3_&1" To-AM of W,;, Subdivision Plat: A &I I.ot ? 1 _ Certified Survey Map Volume Page ?S Warranty Deed # (before 2007)Voiume , Page Spec house :3 yes no Lot lines identifiable i(yes Li 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. "'hat you put into the svstem can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 38352(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The propem 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 pamper verifying that (1) the on-site w :stewatcr disposal system is in proper operating condition and.or (2) after inspection and pumping (if necessary), the septic tank is I-ss .han 1.', full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 & 7•onmg Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of myiour knowledge. Uwe amiare the owner(s) of the property described above, by virtue of a v,•ayanty decd recorded in Register of Deeds Office. Number of bedrooms -/~1-G ~ y!ayis SIGNATURE APPLICANT(S) DATE .**Any information that is :misrepresented may result in the sanitary per-nit being revoked by the Planning & Zoning Department. include with this application a recorded warranty 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) woos GuinWd suinl xjo-D vnv.t,? n -i, G 77 r F- [1 ~ I I i ' L Cpl O i t ~ ~ I _ J O o ty; LI~ LJ , ~ t I I l i,!, I` i it Iqi 11 I I i~ .Its I woob Guino.i4 r,uioj - CV 7 O c cz IF El 9 f R1 8 I~ .~y~voprZu~ _ woob 6uinoJd s,uio~ ~ - .0407 WivP? 27~1it1 O i C G ~I L u- ~ r C] > Yom- R• V _ :S :F ' f) ~t~a3's~iin? t~ X607 VdVj-? d7]-IXi L00021 GuinoJd s umj - Z - O'N Z O ' O I III LL- O O - - U LL- Z I I i v I i rCSI ~ r z V v } i . 1n w:~ ~ y.~rsopwva _ x„ AJO'D vn f? nay cl woos Guinni~~ in 7 F- Li ~n L LL i V -71 A 'I - woob 6wnni(I s,uiul \~9arvp►~ - - ~C Z U J 'I Imo. Z H I 77 Z C) - C-1 0 m LL I. O , z I I I I I I I I I I v I I I I I I I L 'I I I LJ, I Q I I l I I I I I I 1 ~ - I F I I_:. J.r[1. of Saf 217 1 si~.•r~l3AP)Nes SO SPORT Page y- o' .j ~)w s :,n of Safi id Du Id ng-s acce'dOcC,- with SPS-,85. 'rPhs. irdm. CcCe r; f nt I Cooly 3' > Alt dl compleleisttefHri 'paper ffi?fB 12 x 11 inches it s'zo. Plan rnusl l LD X but not tied b. vertical and t'orizontal reference point (Fi if. ai•ection and Pa ocl LID. n en.ent slope, ssala rr dimersiers, north arrow. and localicn and disance to neares' road. y T - /a,y j D - yz Please print all information. Reeled by ca: PerSr M1fl '(r: r. yp_ pn :J'i bV a-B <OBC;~:r'L ~U-7CS?f (Vi, vdc~ _a li 1] OC ;i; f-q}. !'•epertO:ncr ) Property f ocalion , j //~u.r'+', !•.S C. dCly Goo. !o(tiw 14yf 14 SZ T L9 N R F{rn;&`) 'ropor-ty Gv: we, S e(aill nri i~d^rCSS r n, r„ / / Let # Mock Su :.d Nom.; City Stall 7c: Cede Phone 'J-ember ❑C.Ip ❑r ilago QTorvn Nearest Roar djii to, J"Ye/~ tires /4 ah Jf- ® Nnsv Constriction Use: B RcsiC.en7i;al' Vznbcr of beerooms J Coco dwivcc: design flow rate BPD ❑ Rcplecernen' ❑ °ublie er corrrercal Describe. _ 'arent material Fli Plain elevation if applicable. fl. General convncnis :-nd recommendations. 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Sh, ~f Ffi mg L and TSS >3n _ 15: n9r- ' E-iJent.2 = 60:) SS 21:) 'T n°"ionalSe.rvicesisanegt.aloptot~eirdsctt,-eproci,~e'aldemplexcr.Ifyoune:d;a,r,ce:rec!n ~..'I'l;,.itl('CCiI!ilnl r:C:I❑1I+'Ii;.IC f;'n'I'r!1. art 1 'Cta tl-. -i'.:n7-i 9d f f'r )1` I f i1 7• s Y .i - - ~ ~ i ~ f J T ~ 1 h _J y \ p ~ ~ J - ~ ~ ~ ~ ~ ~ ~ IIG- ~v A ~ ~ v •J N ~ 1 J ~J~ ~ ~ ti ~ ~ H N h ~ h ~ t1 i~ /J iC h ~ a -c ? _ - - 4---- ~o r ~ r~ r Y J O, I T ~ ° ~ ~ v .V ~ - ~ 3 i r~ S h t v S ~ ti~ C~ it RECEIVES csr-its- all FF, 0320iTo s> a_ ue :.r>rsafec fea7e L„~ SOIL EVALUATION REPORT Cilasnn o`3a1~I i. t fNDE/ E~~P4R6At#adance'.o-hSRS:i3b,'v';c; AG•i. 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