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HomeMy WebLinkAbout032-1004-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 605033 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: Charles & Pamela Couture TOWN OF SOMERSET 032-1004-80-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: YY\ 1 02.31.19.24D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ; r f CAPACITY STATION BS HI FS ELEV. Septic C~ t Benchmark Z.L /6L - ~s~a a~ 04 r Alt. BM /1/1GL~ 04 Z. z 166 ,0.~erattOn ( Bldg. Sewer / r t~ P66 Holding SUHt Inlet st/Ht outlet y ~s gZ TANK SETBACK INFORMATION E„i a~: ^-1 1 TANK TO P/L WELL LD ent t Air Intake ROAD B 4m4et^ 60 ~ - a W ; esa, q, c13 '72. 27 Sept' /6.Z5 Cl"/. C?45 W; 63 Z 14 '7 166 Header/Man. /Z. $ 'P, , 37 Aeration Dist. Pipe /J• ~3 69.0 Holding Bot. System a+ e Final Grade `T PUMP/SIPHON INFORMATION o 5i ll. 3 ~J~. $S Manufacturer GP nand St Cover 1,66 Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Len Dia. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manu?2 urr/6 ~ INFORMATION Type Of System: I CHAMBER E OR Model Number « ~-F 60^ ~e vl 1 i O -75 S 1 /436 4- ~ / DISTRIBUTION SYSTEM Sj A& ec i5 Header/Manifold Distribution x Hole Size x Hole Spacing VAir In ake G Pipe(s) ~ \0 f Length Dia Length Dia Spacing SOIL COVER / x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ove Depth Over Depth Bed/Trench Center Z , 7 Bed/Trench Edge Topsoil Q~ xx Seeded/ dded xx M shed 7 s No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2362 HWY 35 pp JJ G~ ~s 1~~5 e-% 1.) Alt BM Description A ~"'`L CrOJ~ = ` r Q t d( ~f^x W Gt ro4d 2. Bldg sewer length - amount of cover = /I Plan revision Required? ❑ Yes No 7 I Use other side for additional informa ion. Date Insepctor's ignatu Cert. No. SBD-6710 (R.3/97) Safe and Buildings Division 51< / Dil< ED1 Co 'Y AEC a Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) ir Mladson, T70 71 - JUN 05 Z 18 /_d~d33 Sy'~ pliCation StateTrt~umber In accordance with SPS 383 X2(2); tNu:" , su mission if 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 Safety and Professional Servies. Personal information you provide may be used for secondary 0 purposes in accordance with the Privacy Law, s. 15. l)(m), Stats. 7 3t t-, y~ L Application Information - Please Print All Information / , Property Owner's Name j~ Parcel # C A aljej PJJ- ??6 M e% co u- 7~ ~ ~ ~ ~ 32 ' 141 `4 80- 00 C? Property Owner's Mailing Address Property Location o) I r ~3d2- !~w 3s- City State Govt Lot Zip Code Phone Number j 2 Mew 715- ,2 9 y - z sb S /y!N Section 4cucle one II. Type of Building (check all that apply) Lot # Subdivision i! or Ww 1 or 2 Family Dwelling - Number of Be Name ~o•cs►• Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Z ; b 7t-7 1~ a J 19 Town of S!1 /D Q~ 1 C+ r III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) A. ❑ New System ~ Replacement 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 ez IV. T of POWTS System/Component/Device: Check all that apply 'o EA Non-Pressurized In-Ground ❑ 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) V. Dispersal/Treat pent Area Information: Design Flow (gpd) Design Soil Application Rate f) Dispersal Area Required sfj Dispersal Area Pro sfj System Elevation posV "15-0 6.7 6 on • 8,r 700 - 88~ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks 52 R. V Q in rn rn w 0 P. Septic or Holding Tank Q~ s/ 2ooo 2 W j~tr Dosing Chamber I -L VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name ) Plum Si r MP/MPRS Number Business Phone Number ! i CA a me l( 7/S - 2 Y7- 3Zc)3 .1\ 1 6Plumber's Address (Street, City, State, Zip Code) 3 9 q - /9,~ Q,,.c Ybr,-t<,r-~- cv~, s4~zs VIII. Coun IDe artment Use Only Approved Permit Fee Date issued Q Issuin ~errt Sign eu Reason for Denial IX CondiBWiY1AOReasons for Disapproval , 6~n~t s 4r--, t L 1. eptio"tank, etth~srt: tilts erf,i 3 ~ W~- c,tsNer::++ cell must all be s'r~tc. s ' r+± int `r eC G. O Aalw pe giarsgernen! pkn n+o rider! by plu~nbe;. 2. AM nC46er per * regUw.-Am musts toe r":>airt0r e-1 is ;W rakrbla oack / ,dar.&I. ' Attach to complete plans for the system and submit to the County only on paper not less than S i/2 x 11 inches in size SBD-6398 (R 11/11) OWNER I/ Page 3 of 3 Name Gta~rjeS C~r~CI~ Ca~~r~ Brian Parnell Address CST 231314 Date __b A Benchmark 1 -r© (1lc~ H91e CO- S~~- c ~ z tll~ a Benchmark) J3o fro r~ % r rg a ,i % O/e S'l ~l 'Et, MO, a ~ ❑ Sail Baring J Suitable Area 1" = 40' Scale r T T- - ► # I 1 I I 1( I ( t ~ , I o + I ► t ( ( # # 3 ) # t # , i I ~Z f~,k I .b it Oc At- 61 j C # r q,( + JOL {i ! ! I I i Pilo, # of ! 1 L~~! tI i 1 , I 1~ Ei ~I ~o e ( # CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Q o-7 u /e Owner's Name: Chi /eS r}- /a M c% Co(. Awe Owner's Address: 2 3 6;F_ fwy 2S - yel Legal Description: /V`( Township: f e, County: Sf. }6' Subdivision Name: Lot Number: Parcel ID Number. D ~2 - /00 Y'- ~6- 000 Page 1 Index and title Page 2 Plot Plan Page 3 _ System Sizing Page 4 System Cross-Section Page 5 Filter Specs _ Page 6 Maintenance & Mana ement Plan Page 7 Septic Tank Maintenance Form Page 8 _ Warranty Deed Page 9 CSM or Plat r / Designer/Plumber. 64 fa/-,7 e License Number. Date* Phone Number 71S- Z Y7-_1Zy ~ Signature designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SSO-13705-P (N.01/01). Page 1 OWNER Page 3 of 3 Name 6i~Ce lPS cA ?Mel' Brian Parnell Address CST 231314 Date -/9 A Benchmark l -roe OU44 hole Co~<<S~f. e T z~ t!/~ d k/azs-.-~ j► Benchmark 2 go 96,n an Pole - A-Ad 41, /0, a ~C Soil Boring 1-j i Suitable Area 1 40' Scale 1-- -T--1-_F .1-- i i ! ! ! } J I l ~ a x C 1 1A le, I i i GC iLO i , f 4 .o 10 e ° Cd ~ --l-I.CIL -To ~2, -zcc D l ~ c. ~ lOf r~6t y ~ ~~1 j 7 4 ~ C) SOIL ABSORPTION SYSTEM DETAIL 1 GRAVELLESS LEACHING UNIT Page of Project Name: COCA ~ CA./ e o< No_ of Cells 7 Per Celt / /o • `20 ft Cell Width / Z Total No of -70 ft Cell Length sq ft EISA Per Cell tt Cell Spacing 7Q~ so i{ Total EISA Manufacturer Model Laying Length EISA Rating inMator EZ1203H-5f{ 25.0 FZ1203H-20ft 24.0' 50.0 Graveness Leaching Unit Manufacturer. r'Q Gravelless Leaching Unit Model: / 2 03 - /D Finished Grade Typical Cross Section Observation Pipe with approved cap or vent Soil Backfill :::i~ Geotextfle Fabric - - ~0.2ft infiltrative Surface 12 in 6y lft Limiting Factor in Slatted and Anchored Vent/ Observation Pipe with Cap ~QWOA~~g g;®■D®sa..s .......................c.............................c. Plumber/Designer Signature: laz'ell- License J L'?/e~l Date: C~- 3- Kim INSTALLATION INSTRUCTIONS T° WAAdb PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS centedw" with a¢~erimg ~ _ =cat' ~ - 15 EP r 17 Step 1: Step 2- Ste 3: (A) Locate the outlet of the p septic tank (A) Before installation, place the (A) Glue the fitter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet necessary. (8) Make sure that the housing insert the (B} filter cartridge in the is positioned so the fitter can be Rousing, mating sure the filter removed from the tank for cartridge is PmPedY armed and main6enance and service- compietely inserted in the housing. IVIAINTENAN GE INSTRUC' TiONS C Step 1: step 2: Step 3: I-ocate the outlet of the septic tank (A) Remove tank cover and pump (A) Inert the filter midge back . s • If necessary. into the the housing making sure s , (8) Pull the frier out of the housing. the fitter is property aligned (C) Hose off the filler over the septic twk and completely inserted: USE RiJBBEi Gt w tOVE$ Make sure all sores fall bade into the (B) Replace septic tank cover INN€N_G~EANIItt2 septic tank POINTS OWNER'S MANUAL & MANAGEMENT PLANT page . e FILE INFORMATION SYSTEMSFEC11:1CA7IONS Owner G O Lc f Ga i c Septic Tank Capacity 2 /DUO gal ❑ NA Permit # Cv,~c Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS EfPhiart Fitter Manufacture oc ❑ NA Number of Bedrooms ❑ NA Effhierd Filter Model 0 NA Number of Public Facility Units ❑ NA Pwnp Tank City gal ❑ !VA Estimated flow (averagel ~?Gn Pump Tank Manufacturer ❑ NA Design flow (peak), (Estmated x 1.5) Pwip Manufacturer ❑ NA Soil Application Rate 0,7 d /ftz Pump Model ❑ NA Standard tnftusMlEffluerrt Quality Mond* average' Preneetinen Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter 0 Peat Rker Biochemical Oxygen Demand (BOD5) 5220 mg/L NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection- ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cep(s). NA Biochemical Oxygen Demand (BODs) . 1.530 mg/L ❑ In-Ground (gravity) 13 W-Ground (pressurized) Total Suspended Solids (TSS)- 530 mg/l. ❑ NA ❑ At-Grade ❑ Mound Fecal Cofiform (geometric mean) 5104 cfu1100mi ❑ Drip4 ke ❑ Other: Maxknum Effluent Particle Size Y. in dm ❑ NA Others ❑ NA Odner ❑ NA Other. ❑ NA Values typical for dorn estic wrnwaster and septk tank effiuenL Other: ❑ NA MAINTENANCE SCHEDULE Savke Event Service Frequency Inspect condition of tank(s) At least once every: 0 month(s) (Illlaomixann 3 ❑ NA s) years) Pump out contents of tank(s) When combined skidge and scum equals one-third (i3) of tarok volume ❑ NA Inspect dispersal cell(s) At least once every: ® year(s) 3 ❑ year() 3 ) NA s) Clean effluent filter At least once every: 3 . ❑ month(s) ❑ NA Myear(s) 'aspect pump, pump controls & alarm At least once every: 0 month(s) ❑ NA year(s) 'aterals and ❑ month(s) ❑ NA pressure test At least once .every; 0 year(s) - At feast once every: 13 month(s) ❑ 13 NA year(s) ❑ NA Ctner 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 motion 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 bads up or ponding of effluent on the ground surface. The dispersal cWRs) shall be visually inspected to cheek the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The pondrig of efficient 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 are-third (34) or more of the tank volume, the entire - contents of the tank shall be removed by a Septage Servicing Operator and di of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the serving of effluent fltem mechanical or wed components, pretreatment units, and any servicing at intervals of 512 months, shat be performed by a certified POWTS Maintainer. A service report shy be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painnng products or other chemicals that may impede the treatment process and/or damage the dispersal cog(s). If high cone madorrs are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shalt not occur when sod 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 well be discharged to the dispersal ceff(s) mane large dose, overloads the caNs) and may result in the backup or surface discharge of efflueM. To avoid this situation have the contents of the pump tarok removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Pwumber or POWTS Maintainer to assist in manually operating the pump controls to restore-normal levels within the pump tank. Do not drive or pork vehicles over tanks and dispersal keels. Do not drive or, park over, or otherwise, disturb or compact, the area within 15 feet down slope of any mound or st-grade sal absorption area. Reduction or elimination of the following from the wastewater strearn may improve the performance and prolong the fife of the POWTS: antibiotics, baby wipes: cigarette Mutts; condoms; cotton swabs; degreasers: dental floss; diapers; disinfectants: fat; foundation drain (sump pump) water; fruit and vegetable peelings. 94190511; grease; herbicides; meat scraps; medications; oil; Painting Products; pesticides; sandy napkins; ternpors: and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shawl be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsae Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shag be removed and properly disposed of by ai Septage Servicing Operator. • After pumping, all tanks and pits shall. be excavated and removed or thefr covers removed and the void specie felled with soil, gravel or another inert solid matexfad. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant repwaceis system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacernee t eel 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. Fame to protect the replacement arm will result in the need for a new sole and site evaluation to fie- a suitable rephKximent area. Replacement systems must comply with the-riles in effect at that time. O A suitable replacement area is not available due to setback and/or soil Wriketion& Bening advances in POWTS technology a holding tank may be Installed as a fast resort to replace the failed POWTS. © The site has not boor evaluated to identify a suitable repiacement'area. Upon failure of the POWTS a soil and site evaluation must be perfonmed to -a suitable reptacomentarea. If no replacement area is available a holding tank may be installed as a last resort to replace the faded POWTS. 0 Mound and at-grade sod absorption systems may be reconstructed in place following removes of the biomat at the infiltrative surface. Reconstructions of such systems must comply wrath the rules in effect at that time. < <WARNiNG> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR d1iS1)FFIgF~ITT OXYGEN. DO NOT ElffER A SEPTIC. RUMP OR OTHER TREATMENT TANK UNDER ANY CMCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR VWPOSMBLE. ADDITIONAL, CON ML3M POWTS INSTALLER POINTS MAWTAWER Name E Name Phone - Z y7- ,3Z 03 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Narne 14% car v n, Phone Phone Z/5 -3'9(p -44,'90 This document was dri fte_~`- _ -'z:iance with chapter Corium 83.22(2)(b)(1)td MO and 83,54(l),(2) & (31, Wisconsin Adrranistrative Code. Page of ";TART UP AND OPERATION For new construction, prior to use of the POWTS check'tisatmefnt tank(s) for the presence of painting products or.odw 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 hlghwater levels. When power is restored the excess wastewater will be. discharged to the dispersal cell(s) in one large dose, overloading the-celf(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 restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore-normal levels within the pump tank. Do not drive or park vehicles over tanks and disIxessal .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. =a absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the fife 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 peel, gasoline; grease; herbicides; meat soaps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. kBAIIIDONMENT Whenn the F'O'RTS fails ardfor is Perni, er:fty taken out of service the following steps shall be taken to insure that the system is property and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: * AU piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.- i The contents of all tanks and pits shalt be removed and properly disposed of by ai Septage Servicing Operator. After pumping, all tanks and pits shat be excavated and "removed or their covers removed and the void space filled with soil, gravel or another inert solid material. ;ONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or iniist be taken, to provide a code compliant replacement systern: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a re0acement soil absorption system. The replacement area should 'be protected from d'nstvibance and compaction and should not be infringed upon by required. setbacks from-existing-and proposed structure, -lot Ones and wells. Failure-to protect the replacement area will result in the need for a now sou and site evaluation to establish- a suitable replacement area. Replacement -system must comply with the-rules-in effect at that time. ❑ A suitable. replant area is not available due to setback arxVor 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 bcate-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. ❑ Mound and at-grade =8 absorption systems- may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems racist comply with the rules in effect at that time. <WARNiNG» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SOYTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DFRCULT-OR-IMPOSSIBLE WDITIONAL COPAME TTS 'OWES VWrALLER POWTS MAINTAAWR _ Name Bi,1 ar. I E Itiame Phone 7/j~ Z 5'7- ~z ©3 Phone 1EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name -Nacre ~iCA e X ~ Phone Phone. 7p:5 3Sto - his document was draf =rrp!iance with chapter Conirn 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), WF n Adatirisuative Code. ST. CROIX COUNTY ZONING OFFICE II 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) '57, 362 h/w~.- mss- located at: SF V4, N w 1/4, Section 2 , Town 3 N, Range_Z_? _W, Town of so , 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 Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes NTO _ (if no, skip next line.) Approximate volume or length of time: gallons Minutes Tank Capacity: /Od er. Construction: Prefab Concrete X Steel Other Manufacturer (if known): Age of Tank (if known): yo-~ Permit number (if known) r (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS - -7 - /,,F' (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 ST. CROICK COUNTY SEPTIC TANK A AND OWNERSW cmMcAnaN FORM Own~rBuye~r C/1 /es vL 011;ilnelCe - o C -1_CA_.e naffing Address ,2 ~b 2 141 /alecv cat o-~.~ Gc~2 S yO/7 Propm-ty Address 5 cc A&.Q, (Vetificat%ort requited ft m Phwing & Zoning Depwft east fir new eonaftuetion.) )o 7 _ Oa0 City/swe _,5 M emer 10l Parcel identification Number 03Z A LEGAL DESCRIMON Property Location S V. kv i/ , 'Seo_ , `P- / 1'q It. 119, '6 Town of S©Me'lr gr6diirision CerttMed Survey Map # Volume ,Page # Warranty Deed* Volmne , Page # Spec hove yes ® Lot des idenfisabie ~ no SYSTEM AAWAJD 'ENAIYCE ADM OWNER CERTIl~IC~i TION Im4xoPeruse and of yow septic sysirnnarnld xcwkinits pM aUme fa = to bmM wastes Propor maintenance consists ofpnmping outthe septic tank everyi~nm yes cwsoonw, ifneeded, bya p~ What;you pat iabo the system can affectiho fnnt w offt st fc tank as aticatmet u stageja ft wasw disposai sysma t. ownermahanLuce: responsxbies are sped is §Comm. 8332(1) and in Choper 12 - St Qmim Coutty Sa Awy Ord. 'fie paopmiy owner agrees to submit to St. C rom Comaty Pianooo og & Znmmag Deparanemt a fOCKI; signed by the ow.-.w=. d by a master pImnbm iott n mast plmobq resricteI Pbmberor a iiceosed ptsinpet verifying that (1) the on sift disposal system is in proper oparatmg condition and/or (2) aft won mad. Pu=PmS (rfuw=arY), the septic tank is stewater less than 113 full of sledge- 1(we the wed have read the above reqamemenft and agree t+a "W"Oln hepnVM sewage disposal. system w fife set forth, herein. as set by th"ce DW&= e►t ofC.onm2crca and theme ofNamtal RMUMmM SM of W Cer-tifica ;ant stating that your septic sys bas been maintained must be completed and rebummd t D the St. Cvoia Comity Pb=ing & zoo €Depa. witbin 30 days of the three year eaphation datre- Iiwe certify tbat allsurn f -on this f=are tree to tip best ofmyAm r kmowledge. f1we amAwe the owner(s) of the property described above; by vntue of a wanwAy decd recorded JARegister ofDt cds Office. Number of bedrooms 3 14 SIGNATURE OF APPLICANT(S) DATE t** ny onthatis~sentedmayrwltbtftsam;aypcunkbeing zevd1wdbydwFlannittg&Zoning Departa=t ..de wi=•b this application a recorded vzoraatydeed fmm the Reginer aMeeds Office and a coon of t3irre c artified sw vey map if - ,cepis made in the wmm-dnty deal