HomeMy WebLinkAbout014-1012-60-100
w:scons - necar-mertofCmmni PRIVATE SEWAGE SYSTEM Conti St. Croix
Safety and B. Id ng Dve s on
INSPECTION REPORT sannargrer•- Iva
ATTACH 10PFNMIT` 606930
GENERAL INFORMATION t f state Plan lnNO 3167146
Personal WC.matio•,yuu:Tuvmcitc-scc'a sccu-da^J pu'pcs•s ?,wacyLaw S.-504:1t'^
Pfrebl HG de"s N>me Cry Vdlace luwns"ip Parce. Tax vo.
Andy & Theresa Brantner TOWN OF FOREST 014-1012-60-100
CST 811 Lb_v I I Insp. Sr: Elev BI'l Descrlol al I, J~ Q .cn: a,vn~Ra_.~cvPolap na
I 06.31.15.86B
TANK INFORMATION EVATION DATA
TYPE IAANUIFACILflz~v,.~tl' .411111 CAPH Y STATION BS HI FS CLEV.
Septic v c V7LI Ctu 12 S -S- Q ~j
j- _ rn
Dosing (bifvi 7406 All W-1
Aeration Bldg. Smver l~ L J,
~Id-I g_
TANK SETBACK INFORMATION is/ St.-HI Ouuet !
TANK I) Pi (I I :^JELL BLDG. Vent to A r Intake ROAD DI Irlet
Septic >r _ f Dl 6ollom ,j7
Dosing Hea,Qe ? n. )I. / Wi l
Aeraton~ Dist Pipe (7
Holding Bol. System Il .f (l f IT f
Final Grace V
PUMPISIPHON INFORMATION
Manl.faclurcr 1•
be ru Demand St Cover U
G rt 1 I
Model Number 2 C;V
I UII L.B
r FrictionL s Svslem Ileac TD t ~f~~ >~V~1 {JCQ
fto
Fo•cemair Len - I Dia. 20 Ds1 lo':ae' n
SOIL ABSORPTION SYSTEM ( V
PITDIMENSIO_NS No. O'f'LS I-side Dia. _ IIq,11a :)o-am
BED:TRENCH Ainn, length y No O`Tie•1.;pes~
DIMENSIONS C}l( /~/-l//I(
/
61) 1
SETBACK SYSTEM TO BLDG :^dELL LAKE:SI REAM LEACHING Ma-uraauro,
INFORMATION CHAMBER OR
"(~~51~~/) UNIT MoCul Nv^ee'/
DISTRIBUTJON SYSTEM W! /
~ Vc - t:ur Imar:-
Hea9e.rVdr fulC Ursl it -tor 1x 1 W S ze x I tole Spat -g
LciI'n 7 Oia~, Leng 1~ [iw Spar~r!)__~f ~ r•r
SOIL OVE ossure Systems Only xx Mound Or At-Grade Systems Only
Dear ;?:r Oa.• xx xpth of I xx seedeu socded xx Mu cned
v
Lt d Irc. C< to t ^ pt Bed+Tlcnuh E7yes 7 rf Tooxoil Yes F- No Yes Ne
COMM TS: ;include coee discrepancies persons present 'etc j Inspection #i V~ Inspection 42
Location: No Addross Available nn11
1 1 All BM Descripton ='~1 kt (Witt
2.) Bldg sewer lenyli-
= (~~1 I
- amount of cover = J L
41, iif (ow ~!l 0 0
Plan revision Requiri Yes . NO
Use owner side for additiora! informatioYn~ i - _
Dale Inseoclor's Sicnal;ie Can No
SBD-6710 iR as-;
SAo - 20 m-3t+3
fory on utldinq, Jmssur.
' Ds- r1 J asnln [a 4v Box 7:6' f e
.s 1p 9 (r . witsn 'am[c f.lmlb^ Ito b: fii.:.1 u. by ('n j
~ P _ ~ ~j ZD U tetadsor PJ; 53zG r 1GL ~ ~^q
s rr YV
77
p~CiTllt Appiicallon
L1 O~~d~K 0.'rQ' 11 'Y1 l 1'l- n:bl "ubmT ,Ion tLit, i a-I'Iaq, r ...:C (xl l.L1I 7
rs ¢,mrcd or t. .tartior a .ml Pomu T;In 't„Phu[. c I.nr I'7 stns wv.d VYT- are n.=l nc.: :ur P,:;ie.. 4ddrr>c n " W. Burr ::u lino 1.4L1'ss1
:he .hra"n~ati Sa1CS and ?:°f csstcna: $rvir~ 'cl<vna. m'anvi:~a vnu pepsin nla} be used IM :c:gndar•'
ittTcsc:ma~o :ian.r aidd P r~r_I a: S 4i'FIr4:. s _ > C'
t Application Information Please Pnnt klLka for matiou _ 4~, 2 n
Yr;ltc: lsw'r'v's Tx uc ~ - 1':v:dk
Ojta_
I ~C rv t':w.rr.'s 41;u1mg:1d<kr3> f c:.
L,,Z
Ai I
C - i
m tare Z;p ...:dc Phnnc Numb::
Sc mm
AAA/ 1/11/
L,1I.Jype of Building (ch m:kall chat apply) t Azv
!y"1v hwlly C'ur:u„_t.cm`,or of L'cc.r.;.vttQl~-~ S.inii arms !:ame
EI .::.7
❑ atate [)venal Drs:.otr •JS, i CA nMr vi.F.gr of _
.75
Tf. Type u crmit: (Cheek only one box on line \ Complete ne B F able)
rwSy ter Replacaea: 5v~ZC~ _ ur:nr' .urk Yr„Inemcnt Dalc ZriSlu.:odi5ca:::at. x :un;ISs<telu '.ercpiam;
It. _ Pr.~: Kcuwal J Yrr[m[ l< ,:or. Im-e rr P1 , v 1',=:t fracFt to Rey; List Previous Fcrma Nranher and ]are LwIcd
rictn¢Pxird[W: 'I Uwxa
- - 4
It. 7bire [ f POR CS $vslem C"ornponent. D Ice: tChec6 all that appI y i
ti:m Y:tsu. d L G ,rd 1 1^cs l "_car._ ❑ yt ii. sc. ..taws r, 1 vaL•.nlr. "1 z0 bI err 11!a9e so,l
i dnfl 7Y•1 '._"':1 ~.f^- tel.vs.o I'h r.. maplaxrl"_ _
\ Dispersal Treatment \rtx Info) nuuou _ _ L
rvy ,I Plow v t L: J, s d p; L: aL I>T : r ,..ir 1 Jsp.~..a~l~le~a}RequJei (U) D,11C,r Arcl F : ~...ed uQ rnt aL(L-
V1. "faok Info Ya} rY .n T r,t" ul raurn- ^ 1
..cw T.r.i. >:~ouA 7':+, 11 ° c 1 o
t n
VII. Responsibility S*UMMe 1, der undcrm;"cd, ass rrsponsdnhy I.. hl.laluo"o_of n<1'UN'TS Shugc on the attached plans.
Y umaf "line rtii' ---I i lu h S a^rc
14-4 NIP MALI umbra--.1 dnsra~ Phalle .I'M j//~~ //~Y
mn5er Add; C I S-C Ln 1 Ir l~
613
VIII. Couorv:Departmeot C .r fyul - -r_ _
~ptoved ~ Di fr se I I 'ru "cc l:;;u<c 1 issomg %.e S., a>m
/ p
1 _r C :nY - ruarfrr r_,~n U r.~- - S~ 7 o O m ~a` ~~f'O
11 IA Coodinwl of Approval'Rracr us fur ttapproval 7
r rs I r, _ F.; 3)a~ Co..ce ~~t u-1 a, j etc t
I I] - : i q[~((~
1 )die ill k t L- '.-it h' 1 it
t l rf n u1 1 t 'tt [ u1 r All Tr'grw.. .
it ( r' ..Ci b.: [ R~~~ Wf'"; IR~!. V'aw [u: Ibe ry.leID mIl wbci: w IM [emrY anls .u paper aa: rrc. near. F I^ z [ I iaba m :rue _ -
BILti393~K 11:'11`
DIVISION OF INDUSTRY SER'V,CES
2931 SrLV LUIS PL S?E '.5C
GREEN BAY W1 54304-5211
Contact Though Relay
si P help:ildsps.wi.govtprograms)irdue:ry-seraioes
•'Y` www.w,scens;n.gov
Scott Walker, Governor
Laura Gutierrez, Secretary
October 15, 2018
CUST ID Nu. 226900 ✓ 7-TY: POLM bupector
SHAUN It BIRD ZONING OFFICI? l
131RD SELF STORAGE ST CRO1X COUNTY SPIA
1432 120 FI I ST 1101 CA;L,11CHAE.1. RD
NGWRICHMOND WI 54017-6409 HUDSON W'1 54016-7708
CONDITIONAL APPROVAL
PLAN APPROVAL EXPLRES: 10115,'2020 Identiccation Nwnbcrs _
Transaction 11) No. 3167146
SITE: Site ID No. 854536
Anew Brantner Picnic refer to both idenhhcation numbers,
Lot I Cry Lire Ave above, in all cerre Ioondercc with the agency.
I o%%it of Forest
St Croix County
NW N W I?4, S6, T3 IN, R I5 W
FOR:
Description: Mound SrUent (J Redrnnuts - A'ely CowYructiolo
Object Type: POR'''TS Component Manual Regulated Object ID No.: 1800431
Maintunalce r quire,; 600 GPD Flow rate; 18 in Soil minimum depth to limiting factor ft, in original grade;
System(s): Mowed Component Manual - Ver. 2.0, SBD -10691-P (N.01N I, R. 10,••12), Pressure Distribution Component
Manual - Ver. 2.0, SBD-10106-P (N.0 V01, R. 10112); Effluent Filter
The submittal described above :pas been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submiaul has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with Cie enclosed approved plans and with any component manual(s) referenced above.
'111c owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code
rCG lItCCiilem$.
No person may engage in or wort at plambing in the state unless licensed to do so by the Department per s.145.06,
stars.
'I he following ccrAltions shall be met during cortstruclion or installation and prior to cc up:ntcy or use:
• Preserve dispersal area prior and during construction to avoid disturbance, eompacnon and use of the site.
• Willi new construction, it is recommended not to activate die pmnp in the dose tank until the tanks are puuhped
prior to hontcowner occupancy.
• Wastewater generated front contractors cleaning of equipment and tools andlor tell over construction
products shall not be discharged into the drains discharging to the private onsilc wastewater treatment system
(POW'IS). Waste generated shall be property disposed of on-site or off site.
• Any lad grosses, leaves and shrubs shall be cut short and removed prior to tilling the surface Ibr installation to
prevent nutting under the dispersal area. AI loose organic material to be removed from mound area..
• Divert surface water from POWTS Area.
• Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches.
SmeariA& ard cownrzcling orwet soi! will result in relveing the inlilgelion capac:tv of the soil. Proper soil
moistu:c cuutenC can be deternrned hyroihr.~, a soil smnn;c between the h 1 h rf it rills into a I!4- inch wire,
nc~ siw i_ too wet to nrePale, 1' it ecncb:es, site preparation can proceed If the site ;s too wet to prepare. do not
Droceod until it chic..
All piping sItaA connorm to SI'S 'fable 3S4.30-3 and S!'S Table 334..':;1-5
SHAT K R BIRD Pz6.2 e 18 '
• Insulate building sewer beyond 30 feet per SPS 382.30 (11)(c)
• Well setbacks to meet chs. NR 8116,: 812
• Tank Installation to folow all manufacture's recommendations.
• SPS 383.54(1)(c) The managenteut plar. for a POWTS shall specifically address the servicing mcch:tics of an
aerobic or anaerobic treatment tack or a holding tactic where either of the following conditions exist:
1. TI:c bottom of the tank is located aorc than 15 feet below the elevation where the servicing pad_?s located.
2. The boCOUttf the tank is located more thin 15 Q feel hgrizor.[all from where the senigine pact is locp[ed:.
• Verify property line(s) prior to instaJation.
• Pump Floats to be set and verified per approved ulau Any changes may result in pump resIzing in nice
TDH and GPM Specifications.
• Areas that are occupied with rock fizLnm.-ats, ace roots, stumps and bo'.ddem reduce the atrraunt of soil
avadablc for proper (reaunent. If tic osier site is available, :reel in the basal area of the mound must be cut off
a[ ground level. A larger fill area is neccs;ary when any of the above conditions are encountered, to provide
su:5c:ant innilruivu area.
Owner Responsibilities
• The c=cnt owner, and each sabscqucut o•wriar, shall receive a copy of this letter including i struciions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate upc:afioct and
nnaintenance manual andlor owner's ma",ual for the POWTS described in this appruva. SPS 383.54(1).
• In the event this soil absorption system or any of is component parts malfunctions so as to create a health
hazard, the property owner mast follow the cuutingency plan as described in the approved plans.
A copy of the approved plans, specifications and Ellis letter shat be un-site during construction and open to
inspection by authorized rcprscutatives of the Department, which may include local inspectors. All permits
required by the state or the local murdcipality shall be obtained prior to commencement of
constmcticm'iastall al i onrbli.-ration.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditicus arise making them nccessa:y:or cede compiianee. As per state stats 101. 12(2), nothing in this review
shall relieve the desi ?ter of the responsibUy for des; iinG a safe building, structure, or component.
Inqui:ie8 con=ning this correspondence may be made to the at the telephone nambcr hied below, or at the address
ou this letterhead.
The above tell addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POW -1 S.
Sincerely, Fee Required S 250.00
CIA This Amount Will Be Invoiced.
O.N. .rA e'!✓!
Wlnen You Receive Tlmt Invoice,
Please Include a Copy With Your
"f hu Vander Leest Payment Submittal.
Privslc Sewage Plan Reviewer, Division of Industry Sen•iccs wj,MART clue ,633.
(520;492.2224 , Man- Fri, 6:00 a.m. - 3:30 p.m. - - - -
tun.vander:eest5iwi.gov
cc: Edwin A Taylor, W'a.tevarer Specialist, 015) 634-3484', 64on-hi, 8:00 A.M. - 4:30 P.M.
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
Now Richmond Wi 54017
715-246-4516
Date: 9/28/18
Owner:Andy Brantner
Location: NW1/4 NW1/4 S6 T31N,R15W Lot 1 Cty Line Ave Forest
Manuals Used: Mound Component Manual Version 2.0 (N.01/01, R. 10/12)
Pressure Distribution Manual Version 2.0 (N.01/01 R. 10/12)
Page#
1. Cover Page
2. Mound Plot Plan
3. Mound Cross Section
4. Pipe Cross Section/Pipe Layout
5. Pump Chamber Cross Section
6. Pump Curve
7-8. Maintance and Contigency plan
9. Filter Specifications and cross section
Attachest
ShauSignaLicen6900
i i!=C~IL!CD
a T - ! ?tl Page 1 of 9
System PLOT PLAN
PRon,'cT Andv Brantner ADDRESS 624 Alice Circle Hudson Wi 54016
f1W I/4 WJ 1145 6 /'1' 31 N/R 15 W TOWN Forest
couNrr ST. CRGIX
SYSTEM RLEVATION 997 1.5' sand lilt 9128118
DATE BEDROOM 4
CONVENTIONAL-_ AT-GRADK CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SITE LOAD RATE 1.0 ABSORPTION AREA 600 N of chambers 1lorlo
BENCHMARK V.R.P. Top 0' 3/4" pipe
ASSUME KLEVAI ION too' Filter Lifetime Filter
❑ BOREHOLE O WFIA. . H.R.p. samo es ben<:hnla,k
Cty Line Avo
Scale = 1/4" = 10,
180'
Well is to meet a!I WDNR setbacks
Grading is to be dono to divert
run-off away from system
08.2
Huffcutt Combo Tank
8 3
Pro 4
❑ Bedroom
House
a-2
3% Slope
Area 15' below system is to remain undisturbed
534' Property Lino
II
I
ao~~
Mound System Cross Section and Plan View
+ -
` Dimension Feet
J
A
I ` f \
A
E -u
t ~D J 1
%5
i t IL
1 t' 't 1
I
_ 777
- - - - - - - i L .
_ a
- - I, L- Slope
- Topsoil (""'l - ASTh,l C-3 Cle:ui aeg to ate
I t cap Mwerihl g ' 4 in. sch. ,ln pvc
_ 3:111d fill to , ri m. iia- observation p.po
Cicotextile - t FI
Pabric
n. ,
~~~Z - 1SS r _
Ft Contour iottc(l~tttfaa55~L~~
Slope L)ireelion
GENERAL INSTALLATION: The mound area is sucked out along the design contour. Existing
vegetation k mowed and raked off the site. Tho motutd basal area (1. x W) is plowed with a moldboard or
chisel plow. Plowing may not proceed if the soil is wet euouh at the plow depth to form a'/, inch soil wire
when a sennple is roiled between the palms of the hands. ASTN C-33 quality sand is placed immediately
after plowing. Sand is placed with a tracked wac?tine keeping 12 or more inches of sand under the tracks or
is placed overhead by a backhoe. Special care must be used when placing sand of less:lltan one foot
thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mowtd
;s seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The
observation pipes are slotted it,. the !ower 6 inches and se u:ed iti place with rebar or a closet flange.
"~r0" lej Page ,>1'_
Pressure Lateral Layout
Two Laterals - End Manifold
- 'T'hreaded
' Cleanout
Lateral Twu•up - ping
Manifold -{TJ~
i
_ y 1 1
X-4
I
Force :'Hain - - - 1. ~ Long
Sweep
90
F3ead
_ Disiributiml NehYorl: SSa) cilications
Pressure System Coustructiun
Latent) Uiameler
Tv4anifnld Diameter- -T Z, _ Int. I Laterals are consrructed of Schedule 4U PVC
_Uriflce Diamlete:r /3 Z In, i I pipe, Orifices are drilled perpendicular to
X (Orifice Srac in L o7 ht. I the pipe with a sharp dri I! bit and face d)wn.
L.(Lateral Len 1) _ ~ Pt. Lateral turn-ups terminate with a threaded
M (1 Lvlifotd l,ergth) Ft cleanout plug and are enclosed in a 6-8 inch
Force Main Dian etcr Z` In. diameter lawn snr4iUer valve box accessible {
racv M un LenEtll JI
~e77-2 - Ft. i from finished grade.
• • • 0 00 of* 9
i
' 6-8 Inch 1,a\4I;
Sprinkler\ah,e -L~-l
Box / ~Pai"e e.g
•
Septic-Dose 'f ank Cross Section And Pump Performance Specifications
Tank Manufactured Pump Manufactures _
x9e
Tank Model Number Pump Model Number
A'otal Tank Capacity / -~-Z !J ) Alarm Manufacturer e e
1Max Bury Depth Alarm Model Number
Switch Type °
G ce:
Filter Manufacturer Total Dynamic Head (TDH} - Feet
Filter ki l Number ; Eli evation Head.
Distal Pressure
Network Loss_
Minimum Pump Performance Rze~quiredd Force Main Toss _
- .Q_- GPh1 u , ! Ft TDH f y Total
~1--~
Outler;vtanhole Min. 4" Above Grade With Manholes Mm. 4" Above Grude
Locking Device. Inlet Manhole With Locking Device
< 6" Below Grade Sealui l'Vatertight securely Mounted
Weatherproof
- junction Box
- Finished Grade - - - ` - - ~ ► _
- Vent Min. 12" Disconnect
Above Grade Means
With Vent Cap
Outlet Filter
Inlet IA ` Wet Baffle
A 4:>
rSvritch Settinp and Reserve Capacity Weep
I Tatilc Volume/ GPI B Holt
I I
Dimension; Inches I Volume Gal.
(rest:rve) A~ L
Off Elevation C
k,. (d) C 2~ Z Ft . j Bottom
;i (dead) D D Elev 'on
Total 6 - t:•. -r-~ Et
rr. rrc4wrr-crmr.z??;:7.`.'T.":: zTT •
GENERAL LN5TALLATION: The septicldose tank is bcddoddand back wed in mart dance mwith the
ay of
ruanufacturer's product approval specifications. Maximum depth of bury as. s ifted.by device (padlock) not
be exceeded widiout prior ypproval. Manhole covers exposed to grade have an effective locking (p ) ings and
installed. Piping at the inlet and outlet is of approved material, is edtµ~ the 4 tank
40 PVC o bridge the tank
!aid on stable soil to prevent settling or sagging. The force main lies with NEC .300 and Comm 16.13.
excavation and the sleeve is sealed watertight. EleclriCal gervtc
Page of
02.105 LJ
Mort
Pumps2
,I -
Pump Specifications
290 Series 3/4 hp
Submersible Effluent Pump
LITERS PER MINUTE
P 10C ZJC. 25C 3J0
i
40
i
30
rc
LL i W
2 i I w
o a
a- t i ~ I I e z
J
a W
o a
2C r
0
5 t 4
to
Z
o KI 5C 6C ~ 80 90
GALLONS PER MINUTE
i ~
POWTS OWNER'S MANUAL $ MANAGEMENT PLAN PaOe,~er
FILE INFORMATION SYSI Eh; SPECIFICATIONS
Owner JT _F~: n Septic Tank Capacity a J S
Perm f at DNA
Septic Tank Manufacturer r, NA
DESIGN PARAMETERS Effluent Filter Manufacturer ° - Cl NA
Number of Bedrooms
❑ NA Effluent Filter Model _ I7 NA
Number of Commercial Units z, Pump'Tank Capacity
flat 11 NA
Estimated flax (average) V
naUtla Pump Tank Manufacturer O NA
Design flow (peak), (Estimated x 1.5) f?GG a . Pump Manufacturer
_ ❑ NA
Soil Application Rata jL/ J aUda /fta Pump Model ^ C7 U NA
Influent/EffluentQuality Monthly average* Pretreatment Unit NA
Fats, Oil & Grease (FOG) s30 mglL ❑ Sand/Gravel Filter O Peat Filter
Biochemical Oxygen Dumand (BODJ 420 mglL Mechanical Aeration O Wetland
Total Suspended Solids (TSS) 5150 m 21L ❑ Disinfectlon ❑ Other.
Manufacturer _
Pretreated Effluent Quality O NA' Monltr'y average'' Dispersal co(s) ~T -
Biochemical Oxygen Demand (BODs) i 530 m91L 0 In ground (gravity) OJin-ground (pressurized)
Total Suspended Solids JSS) ,30 mg/L O AI-grade ound
Fecal Coli(orm (geornet the mean) -704 cfu/1001111 O Dr(>dine__ O Other.
Maximum Effluent Particle Sixe a inohdiameter Values lypiul (or Cwneslq(noeconnmr,9aq waslowator one
sopUe tank elnuenL
Va!aes typ"I (if preocaled wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every O months year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum egquals one!tard of tank volume
Inspect dispersal cell(s) - At least once every 3 G months .year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months gar(s)
- - - - -
Inspect
pump, purnp crontrols 8 alano At least once every 3 O monmp. 494ear(s) ❑ NA
Flush laterals and pressure test At Ir., to
once every LI monlht7194ea,1s) r3 NA
- - -
Cthrr.
Al least once every q months FI year(s) J NA
eale(:
At least Dote O months
U year(s) O 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; POWYS Inspector, POWYS 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 pond(ng of effluent on the ground surface. I he dispersal cell(s) shall be visually inspected to check the effluent levels
in the observation pipes and to check for any fending of effluent on the ground surface. The pending 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 scurn In any Link equals one-third (Y,) or more of the tank volume, the
enure contents of the tank shall txr removed by a Septage Servicing Operator and disposed of in a=irdance with ch. NR
113, Wisconsin Administialive Code.
The servicing of effluent fillers. medl niral or pressud7ed POWTS components, pretroaltmenl components, and any
oUrer maintenance or monitoring at irJervals of -12 months or loss shall be performed by a mrtififd POWYS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START UP AND OPERATION
For new construction. prior to use of the PO W I S check treatment tank(s) for the prosenco of painting products or other
diemim(s that may impede the treatment process and/or damage the dispersal cer(c). If high cortuvgtralions area
ddede;i have the contents of the tank(s) (emoved by a sePlage servicing operator prior to use.
Page Of
START UP AND OPERATION
, prior to use of the PObVTS chock treatment le. for tie prosenta of painting products a ether chemicals tFur m new pe edoensl the ructfon treatment process ondfor damage the
dispe
rsal cell(s). It high wncentrat ens are detected have the contents of the
impede
may
tank(s) removed by a septage servicing operator prior to use.
System start Lip shall not occur when soil condition are frozen at hie ini ttral(ve surface.
Durinq pourer outages pump tanks may ill acova normal laghwater levels. Vvhen power is restored the excess wastewater will be,
dis(ilarged to the disperser cell(s) In one large dose, overload-,ng the w'I(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 ti*
effluent pump or contact a Plumber or POWTS Nlaintainer to assist in manually operating the pump controls to estare normal love's
within the pup tank.
UO not drive or park vehicles Over tanks and dispersal cells. Do not dove 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 e!L•ninalion of the following from the wastewater stream may Improve the performance anidlP edegithe llif fof the
ion d Iii
entibiot(cs; baoy wines; cigarette butts; condoms; cotton swabs; degreesers; dental floss; diapers;
(st,mp pump) water; Ooh and vegetable pee!ings; caso1ne; grease; herbicides; meat scraps; medications; o1; painting products:
pesticides; sanitary napkins; tampons; and water sroGener b:lre.
ABANDONMENT
Vlhen t"o PGvVT3 fails and'oi Is pemianenny taken out of service the follcvdng steps shall be taken to insure that the sysler, is propel y
and safely abandoned in compiianoe with chaptar Comm 93.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnocted arid As abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septago Servicing Operator.
• After pumping, al( tanks and pits shall no excavated and emoveo or their covers removed and the void space filled with stilt.
g-svoi or another Inert solid malarial.
CONTINGENCY PLAN
If the POVVTS falls and cannot be iepetaod the following measures have been, or must he taken, to provide a code wrap pl
replacement system:
❑ A suaabla replacement area has been evaluated and may be uhlized for the location of a reptaccmunt soil absorption system.
The replacement area should be protected from dLWturbance and compaction and should not be infringed upon by reputed
for a now soil and alive evaluation to s ebllsh a isulltablerepfa beln'ent area. t Replacement ystems must co pl'y with nuen the r, lit
affect at that time.
❑ A suhabe replacement area is nct available due to Setback and/or soil limitations. Harting advances In POWTS lechrw'l&jy a
holding tank may be Installed as a last resort to replace the failed F0%,N S.
-The site has no! aoen evaluated to identify a suitable replacement area. Upon fuilure of the POWTS a sail and site evaluation
must be performed to locate a suitable, replacement area. 'if no replacemem area s available a holding tart( may be Instaltedl as
a last resort to neplace the failed POWTS.
Mound and at-Grade soil absorpton systems may be reconstructed (n place following removal of the biomes at the Infiltrative
surface. Recorrv.ictans of such systems must comply vd!h the roles in effect al that tine.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADCITIONAL COMMENTS _
POWTS INSTALLER POWTSMAINTAINER
/ Name / `
Narn;
--Phanc Phone / d La e `
SFPTAGE SERVICING OPERATOR P MPERLLOCAL REGULATO Y AUTHOR Y
Name?(~ v Name ~O/~_ ~Fr+J
t _
Phone [ Phone ~~,J
Tnis eagrriarn urea droned In cam'41•uncn with ehnplur SPS 38322(2)lb)(1)(d)Etr} ar.d 3033y54(t), (2) & IAMs.:anln Admin&IrnlMe Code.
O
~•E 1E
\ a `
1
-'v,+- ~ I ' VIII
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1 C , ,y
Jill
O n
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y
v e,'~n ~ rn
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i
1
Wc«wn ~cpurtrnert of ccmTwrW SOIL EVALUATION REPORT
O:.r•iva of Saforyand RWtdaps Pape of
n accc:aance wiU) C_mm S:, lTS. ;Am. Code
Al a.h a , eto s:e Ian on pope- Crwnly
P alan lhanD tl2x 111n;hof m3'~za. Flan must
'11 n
rdcdp,oul nwtlimited ;u:seN al and norz h«tcnalraleronceus:(BA),droG nono Pava LD.
petten'A4Pa, efAlU Or dimenslona,r1al71eapw,M~:A'dlUO and di6fanCY to nop]p5trf)11J. ~1.,. rI ~ ~~~~_/R/rat ~/1. ~1
Please grin( all m/ormariell. R~ uY UNafVtl;,/-_`(y„`sG[ ! L~ 7t
l Det(9' 1
~a•ono yometmn you poviaa,e.+y0<cgar«.r.ma•ry Pauwr(Pm'•ry l.rx,. 1e.u (+J;r,
Pmp" ONner
Propurry Lampon A
Sb T
Propady OwTN(e S1ai::y God W
I Let a ' u.~;.x a ;Sand N vrw or CSf.,
L'J •S l P -~P GOGa F.'1(M1C NL.TbBf L: Ciri Names! Road
/ C U,tape Uwr. Neaws: Rcaa
n'w CuuUacprn L'su Ra~:_atil:d/Numbwofpedfarnr C,fd ooltled dpm'n flow rata U
-1 11J O G
Q Repijco.na.lt I] Pub"er 0.~mn;arPa1-:Jr.$Sibo:
rood Plan elsrab" a OW ab!c y
Gorwrxl o«mymts , e.
arN roaprlvnendaton•:
_ r
System TiPe zryI •yC [lt _
S r~ Syxlent Ele:•alloa.J.1.
I , I fa«ulp a Q 8-nd
Pit Ground su•aw nlm:10 --D, 11. Dutch to lln'.'~q fauw.y!•r~
"WUett Depth Dcxrvrwnl Cd« Nrxx,x Deeo:pUun Toxtuo Sa': Ilczbv Owe
Sw~1we Ccna.slu::co Bcurwary Raota GP .w
N. MurazM DU. Sz. Conl, Cola I
Gr. St Sn 'Feat I •FBe"
Pj _3 5
I
I
au:rg
SP.I GVllnd awl ea elav.l1l_ 0-n Oepm to r•nlenp!aQl IIn.
rHcdenn .^,eel D«rt ANCIXa Rp Sell AUC~•te7an Rate
II h+x De=(;,tan Tax1Ure oUUM'o ^p•ayialonu Fioul,;;a•Y Rwu GPC.M,
in Munsell N SL Co,v. Color
' Gr. St SI. IT 'ENi •EI12
Z , -f 3
-r n l , NI f
_ r 'DDWefup1 tlCO.>30 «2,j myl ern TSS >:oJ5150 --•Efnucc~u2=BCD. <3Dbras-a^,] TSS<S(; mplL,
CST (lame (Please Prlnq - lure CST Nu
Bird Plumbin , Inc. Shaun Bird 22 Nu
4r,C:use - Gn:o Lvahmlton C«wucad Tn:npncno Number
1432 1201h St, New Richmond, WI 54
..01 -7 /15-246.4511)
1--l~
~P~.+Wdy OnMr n Parcel lGx
1 I B N CQJl RGirq Pains cl, _
f raPil Grprr4 wWce atov.~•~ R. Dupci to :rn:ry} law _ LL In..
Vrarr~n Depat Domim.MColor Redox Dour bw Teaaaa Saucyre Car Rx:0
fn. M.w4a;i Cr. Sz. Cam IT autanoa Bcorviny Roots Gp"
Gc Sz. $n. 'ERaI •EIIx2
S -,N-^ ti N
Oa1ry N D
Q PII OlUer{dal.^taGe clev, tt, DUO lu Sm7np ra<rcr _
_ v.
Ffyiun WPM LLStinanl ' Redox f)arrr! Jcn 7 - _ Ste; PP .7icatiun Re's
Mura : P oxlwa BRwuro Cuu:atancu
h' CV 5-* Cant. Gx« Cry Sz Sh Ounulery Rx's Gi+C,TC
•ENNS •ESx2
O
Balrq N 8aroq
❑ Pit Orou.alwface elev. R,
Dope, U tlnfvy NcUr _ ya
Nadran NO,
Sol :md Cork eee, Teuton Struc4u6 G Iortao Sar."Idar/ Room GP,M Wrte
cu. SL SL . Cork Cam or. SL Sh
'EAxI •ER02
i
L-_
'Ei•vrrl Nl• eco. 130 !920. nµl aRl TSS»0.'60 my7. 'E'ha+a N2
(iOD~ <;+a rnpyt un0 TSS < 50 nq1.
The Depavrent of Commerce is an equal oppor4micy service provider end em;rloye:. ifyou aced assiaraow to acceus auvieea or
need material in an alreznate format, Please contact the depannent u 608-266.3151 w TTY 6fi8.2648:77.
uoazru:um+
Protect Name Andy erantnar Soil Test Plot Ran
~ 611 Bird
Address 624 ircla _l
Hudson son Wi 54016 y~---~ ?.f,L
C7sM 2..6900
Lot Subdivlslon Datq 6130/16
NW 1/4 NW 1/4S 6 T 31 N/R15 VV TownsfiiplForest
Boring Q Well t'L Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 3./4" pipe
System Elevation TBD •HRPSamea$Benchmark
County Line Ave
Scale is V = 40'
I unless othel-N ise
noted
99'
919,
40' B-3
97'
sir 15' B-2
B-1
- o
5' 10'
3% Slope
Poor suits
Soils snrror frog the tested area had
spots of A+0 soils, tested area
w2s clearly flagged and system must
he installed in that area only.
The survey was not completed at Line
Pro Property Line of testing
CST-~D
I'Itil
ZGIB
WSCOrrSin Department o+c(~IMere2 5 SOIL EVALUATION REPORT Page _o' 2
Division of Safety and Buwldings y
111118coordan4e with Comm 85. Ws. Palm- Code County t 1~ .
Attach complete Nlep{d+ron pa r-not less Than 8 112 x 11 inches m sue. Plan must y-
include. but not limited-ro.'whi al and horizontal reference point (BM), direr ion and Parcel I D , n
percent slope, scale or dimensions. norm arrow, and location and distance to nearest roan.
Please print all information. Rev,ew- y Date
Wnonn inronnermn you nmvide mey De Used rot sec xrenry P,npnees(Prnacy L" a Is M(II Inl)
('i •/(Q /
Property Owner , Property Location 10,
_ - 10
Govt. Lot 114/l/ / A S V T N R /J E (or, w\'
Property Orrtler's Mailing ss , Lot III Block N Subd. Name or CSMu
/ (-rZi (C19i 11
City , Slate Zip Cate Phone Number ❑ City ❑ Village own Nearest Road
New Construction Usejd_Residenhel / Number of bedrooms Code derived design flour rate ' ;_4~ GPD
❑ Replacement _ ^ ❑ PubliG or canmeroal - Descoue.
Parent material 'Q,i(~(C/./16/Q- FIa1d Plain elevation if aWp garble ~~'Z 1,~C ft. j
General comments
and recommendations*
~Sys!am TrpC ~C[.r ~ Slr'r..c' trt/f r Si'~: rn FN,;atn':r ~ ~ ~ - -
' I Bourg # Boring
t 1 I pit Ground surface elev - R. Depth to limiting lades Vm.
Sal Application Rate
Hwzorl Depth Dominant Cola Rodox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsea Ov. Sz. Cont Color Gr. Sz. Sh, •Effa1 •EffN2
<1 /YC
r. Boring # ❑ Boring
SPit Ground sunace elev 23-1f- fl. Depth to limiting factor in.
SOd Application Rata
Horizon Depth Dominant Color Redox Description Texture Structure Consistence BoundaryRoots GPD1tF
In. Munsell Cu. Sz. Cont. Cola Gr. Sz Sh. •Effft1 'Efrp2
Effluent a1 = BOO. > 30 < 220 ngrL and TSS >30< 150 • Effluent 02 = BOD, < 30 mq4 and TSS < 30 rrx
CST Name (Please Print - lure CST Number
Rird Plumbing. Inc. Shaun Bird 226900
n1d.nas rata Fvaluation Conourted Telephone Nurr,w.r
432 120th St, New Hichmond. W1 5401 /--Y-Z 715-246-4516
J ~ l
Property Owner__-_ Parcel lD#__
- Page -`~-ot
a Boring # ❑.r77 Bong (t , _ -
&pit Gmumd surface elev h. Depth to limiting factor in.
Soil ica6cxt Rate
Haimn Depth Dominant COW Redox Description Texture Structure Consistence Boundary Roots GPD,ff
in. Munsell Qu Sz Cont. Cola Gr. Sz. Sh •Eff#1 •EH#2
I
❑ Boring# ❑ Boring
❑ pit Ground surface elev ft. Depth to lim,6ng factor in.
Soil 'iWt%xl Rate.
Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Rods GPD,'ff
in. Munsell Qu. Sz. Cont. Colo Gr. Sz. Sh. •Elt#1 •Eff#2
a Boring # ❑ Boring
❑ Pit Ground surface elev. It. Depthto limiting factor --m. Soil Application Rate
Horizon 'lepth Dorrunant Colo Redox Description. Texture Structure Consistence BoundaryRoots GPM
m. Munsetl Ou. Sz. Cont Color Gr. Sz. Sh. •ER#1 'Eff#2
Effluent #t = DOOM > 30 < 220 mgt and TSS >30 < 150 mgt ' Effluent 92 = BOD, < 30 nV& and TSS < 30 rigt
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
~JT
Soil Test Plot P n
Project Name Andy Brantner Sl atttt Bird
Address 624 AliceCircle
Hudson Wi 54016 (.S _6900
Lot Subdivision Date 6/30/18
NW 1/4 NW 1/4S 6 T 31 N/R15 W Township) Forest
Boring Q Well Pl. Property Line County ST. CROIX
BAt or VRp Assume Elevation 100 ft. Top of 3/4" pipe
System Elevation TBD *HRPSame as Benchmark
County Line Ave
Scale is 1" = 40'
unless otherwise
noted
99.
9s'
,10• B-3
97'
HO' 45' B-2
B-120
5' 10'
SO'
i'
39< Slope
B.M.'
Poor soils
Soils surrounding Lhe tested area had
spots of A+o soils, tested area
was clear"1y ilJv;ed and system must
be installed in that area only.
The survey was not completed at time
of testing
Pro Property line
I IIII)VAIFSLOCATIONOF )p
SOIL 11=51 ROAD 11011: ;
CERTIFIED SURVEY MAP ORICI~'
1ARAIEOI\'I11FIRA( I ONALN\4!;,()I- HIFNW,01 SI`f
f31 N, RC+W'. IOVVN OP PORI:SI, S I CROIX CO(IN C), W'ISC'ONSIN.
IF-.G7 SHOiNN f~EkI L`pil5 r;t1HJL!:I 10514 11
6ENCRAI.NOTICE5TATCMEN7
C!?U7JTV M•: Li TO'hTJ iI1P LASp'< RJL~S AND RCC ULq I I(1N5 r_, AU:r_5S IU VAR('LL,
MINI M.!7N.!V~ SI /I_, ty:_I,ANL Iii_e.'41C11UN :1. HLFUR~Pt/RCHA ;!'dS CR
bF1•'fI_CR7 N/. ANV `a!!I'Fu IV ((ONIAC' :HIS! CROIX COONIVCON.M AI1V
(+VFIOPN.F'JI0FFT0 Alit, 'HCA'`:ROPPIAIF Tf-?WP:;OAR0'r:GAII I('F.
N89"56'55"E ''•IF IJ F F F I
Ira (tF rrtir- fRAC11OFiALNI ,QF H
F UOPih IINF RFAR~NBg ~T•F sI ' . IAA
ri rr NORIHIINFOF 1HF FRAC TIONAI. 34?5.45'
$IN" 1A,nv cocP;d NATF SYIFFM NVV(.I OF SECIION6
N89°56'55"E 767.69'
N89056'55"E POLK ST. CROIX ROAD I N89"56'55"F 4
131917 N89°56'55"E 767.69' Lr 133859'
o
m m N{t COPNC), SEC .6
NW CORNER SEC. 6
(I' STEEL SURVEY (2 25" IROIJ nPE W/
MARY NAIL FOUND) P.Y. NATL FOUND)
J
It LOT 1
435,663 SC,). FT. (10001 ACRES)
r'h INCLUDTNG RTCHT-OF-WAY Q ? n
.11 'o
tOO OD 410,329 SCE FF. (9420 ACRES) u
Ii,-
,III W T FXCLUDTNGRIGHT-OF-WAY = T m
M
1'to [j
d L
If) W~
ll .'_~1~ Q Z 0 f
ROR.I I iQLF Lu
I_OCA 1 1,1 N5
I
589056'55"W 767.69'
I
DESCRIPTION:
I'AHCFI I )F 14101 f?t -.AIFD IN THL WAC 11f lON- N•N I, OF I HF NW,'t, OF SFCI ION 6, 1 3lN R15W, 1 OWN OF FORFS' , J~I CLcI " ' it if
Y,
4'•9SC0'iSBV FUR I I IFR UFS!'P.IeE[' A= °OI I CA4'S
a. !Ivl :'FPICIN(: A' THE tJW CORIJFR (:F &ND SEC 11!JN 6: R16NCL N8Wb6'55"E 1319.17' ALONG II IE NUR 111 LINE Of H IL I RAC HONAL MA'
~ T F:AIF: SCGT'C;N f. TC) -HF POINT Of RB3~(`7fLNG; D~EPJCF CO'J I INUING CON11NLiNG ALON!i SAIp NOI2111 LINE PI89"E8'S5"E 757.89 f0
I IF FAST I INF CIF THE r RAC:-IONAI_ fd'aV C>I- 111E NIA", 01 SAID SE ' ON 6, I'!ENCE SUO"5o'42'1V 58/ yg ALONG `SAIU EASI LINE,
THPfT1;F Sfl9 f 5"';; '47 fu' THEN: f N00"r9'4t E 56759 :U `iAU NOIOH LINL UI IIIL l lb\:J Ik_»inL "r'vV Yn AND I I1L PUIN7 UL gEd'P!^;I`.'.;
t'AAlrIilF 14 il r-3 S'j:IARF FFF' 110 001 ACRES 1 MORC OR LFSR AND REING SUP3 CTT(I A%Y CASCMIFWS RESTRICTIONS OR
1', C'IA,tJT5 OF RCCeRD.
SURVEYOR'S CERTIFICATE
?6EPI I'ud. 44ANR L I Z i 3 . Pf(0TE9SIONA!- LAND SURVFYOR HFRFRY CF R TI FY IHAI BY THE DIRFCIION OF 'HE OPonIFRS,PFTFR A`:
.NL 1 ARCAfIi i• I i iA.!F S!IRVEYLD ANL) CIVID6U IH!- (ANUS SI IOVVPI lit-RFON IN A(.,:ORIIANCF VM Ili OFFICIAI RFCORDS CI IAF i FR
;3r,1401` 71 IF V19SC;1fiS1(J S1A I!1I FS, I HF ST CROIX COUPI7V SI_RCIVISICIN ORDIPlANCE APJD TI IE TONM OF fUREST SURDIVISIO^.
'KUINANCE AND TI IA( W IS MAP AND ULSCRIP;IOPI ARF A 1 RLIF AND CCIRRFC RFPRFSFNfAII0N tO SCA.1 F OF 1HAI SIIRVFY
J!?`?Cf H GRAtJRERG DA -r.
?RSIANDSOII.ITI!iriS; ]It,
' I T-1 1-'4IH AVI 701
',F::'PJCIIV1f. ''Al `,41'
Sl'. (IMIX COUNT',
SI~PIK, ]'iVNK NLAINTf:NAV'CF.:tGl
ANID
011 NF.[~SHII' Ctih'1'tllC;\71(,NI-ORM
Owncr,`13uyer
~n
Mat ling tA.(i(Jje%
Ila
Property Ad(bcss _ - - - - -L -
(Voilic:aion rcquved (ixnn PhL-mine & Zouing Department lot new construction j- -
CI(yr:;Slalc
- - - - I'arae Ideutific:ationNut 7ber
LEGAL DESCRIPTION ~ / j - - - -
Property Location/-✓to'," Town of -
Subdivision ^ )
- - - - - - Lot # /
Cet9i13ed Survey 'Flap !i Vr lunlc '14 Page . 5 - -
-21 -7 t, 6 _ S
Warranty Deed ri - _ / J
~'c h me Page ,
Spc, house }e u I ,.rt hn iduLL;fiahlco' no ~ -
Sl'ST•FM MAINTENANCE AND OWNER CERTIFICATION
Iralnoaer use and Inahuax>anse o!'vol r c1 ,ic. cyst ni ::ouid lesul! m Its ptnmamre faihnr to handlt wastcs. Propar
mainteriunec consists of pumpi ig out !hc scp*i lat ever} IJ ter vcacc or sooner, t needed, ov a hceused pumper. Whal you puI :rl!G
die system can a[lbet flit Junction ul'die septc CIA a, it treatment sat.,; tit the waste disposal system ()Wm'r maint,nmr:,e
i ,sponsibiliues are spcufivd in §Comnt 83 2(1) and in tlmprcr 1:! ';I Crolx C'ounrv Sato affil (?rlinaucr
T'ite property wsavi antes lo subatii to St. CtOLC c.c m(; Pi;:nul i2 R•- Zon rill 1)eparlmcnc a ccttiiicatimi four. sirncd by Wr
outir r and iry it inamm 1 Iumbcr, u'nrncynran pltanh i, re.Ln itd phunbor o a lisnsed pumper vet ilying that (1) the on-sac -
wi,stewater disposal syslem is in proper operannt t;wmf lion aw;. or (2) after inspo! ion and Inmtping (it necessary), the septic tank is
Ws s than 1;.i Iidl of-sludgc.
Iiw.., th.- Imdcr'ieu d na'c Icad tla; ajwo ' ICdu I I eun n.5 ano al rcC. to lnal UU: the prl\air `:cwa}!r drsposal system with me
srmdards set forth, term us :cr by t1w Uepannrcut o; ( oinowt. c and Ce• Lit:panir ent of Natuiai Rcsoncc's, date or Wisconsin
Cer tihcation swung (hat yotu .phi,. SWite n has bci.o trvunamed must he compictell and iounted to the St. Croix Coann, Pi imnly
/omng Department within 30 days of tilt- tJ•rce a ar expiration (fall
I' wv cectrfy that all statcmr_nts on this form .rc o-in- ro h: hest of iny:otu 6 rol Il,i ~r_ 1~ we autlair the owuor(s) of the
property described above, by vulue of a w' arty dccr. tv.oulcd it. Rise.lel A* Dm Is Office.
Nu/trio ruhbedlroons =
UATF.
*-Asy intorma.ion that is inisrepresented n:av Insult tit the s:utdal y wn'~!( b;-me, r-voi;ed b'; the Phmniug & 7,unurg Depamnrnc.
(nalude with this application a recorded earrani.v deed hon n kctpstei .rt I hods C mitt and a col;,, of the certified smicy natp if
icfercnce. is made in the waeranty decd. -
0810$)
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