HomeMy WebLinkAbout018-1024-10-100
vnsco,so Depamem of Commi- PRIVATE SEWAGE SYSTEM C"r'ty' St. CfOIX
Solely' and Building Denson
INSPECTION REPORT Sari:a•y Permit No
6069471
GENERAL INFORMATION (ATTACH TO PERMIT) state Plan ID No
Pec.o'al .ride°atir,-. ynu prnvlrn may re used fxseconcarg p.~mnses IP'~cacy Law 5.•5 04 111m)I 3162740
PU'ml: I like,.. Name C I.7 village Towrshio Pavel rax No'
Jeffrey Frank TOWN OF HAMMOND 018-1024-10-100
CST BM Flea Irsa Bfd Elev. SM Des-tiptlon I SectiovT3,vwRange^.l1P No
12.29.17.178
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER 5 CAPACITY STATION BS HI rS ELEV.
Septic Bencnrart
Lj T5
Wo It
Dosng f Alt 13M
Cow Erb ,I (7--) la'•
aalloh r Bldg. Sower
9'ya ~J :r
Holdrg St,*Ht Inlet
SUHt Oll
TANK SETBACK INFORMATION
TANK TO PR. VJF1 I. BLDG .er Au I-take ROAD Dt Inlet
Se-la; - Of Bottom _
ter 7rl Px ~y ro,. 17
Dosing / G Headeri Mar
O s IL I Of 06
Aeration Dist Pipe
~.I MAD
Iro.cing sot. System
Grade J
PUMP/SIPHON INFORMATION Final ~r
tdanufac:urer Demard St Cover
i GPP,n Co 3.33 1(A.~2
Model Nrnbe'
CJ_ti Ira bG d~ G ~tAQ I6 loi (c.>
TDII Lift' { Friction Loss Sys-ter~llea~- TDH Fl n\ l~
c FO 1~ 1
For:wear) Length D.a q Inal r, ,^;au
i1 i
SOIL ABSORPTION SYSTEM z S 3 `,t 3
BEDiTRENCH '.N nth Lengt" No. Of Tern Ts PIT QIMENSIONS Ne Of Pits Irsme D,a - - LaGmd Deg;h
DIMENSIONS
SETBACK SYSTEM TO P1 i. BLDG :"JELL LAKEiSTREAri LEACHING Maru'acte'er
INFORMATION CHAMBER OR
t Ype C' UNIT t.~pce Vr.°her _
- I
DISTRIBUTION SYSTEM
•leaver M.:n Wln DistrioutiCn xIfile Size xHole Spa:: ng Ven: to A.r Intake
_er3'h ~ Gia Len ,tr j - L'a I Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depit' O'oc' IL=p'h over 13,.;G'!P a xx Scucuc. Soeded xx Matched '
Fied,Treroh Center IiSG "erG9l eges 'JpSC j' d Yes No Yc_ No
COMMENTS: (Include code discrepencies. persons present, etc; Inspection #1. 12 t~ /b Inspect.on u2:
Location: 2067 11CTIi AVE
1,r
) All BPA Description = ~ / .d L(jC- "S 6IL
2.) Bldg sewer length = / g
- amount of cover =
Plan revision Required? Yes - No
use other side for additional informa::on - i I~ if
Date hseF=t r s S~g6~ lure Ci t Ni
SBD-ETt0 i;R 0!97:.
~I'~r'~Ll~,;~~~J 5flro-aol8-365 _
_ OCT 2 4, 2018 vy and Buildings Division
0 S _ 2C- W. Washington Ave P.O. Box 1162
P - -cone taryson, VJI 5370(--7162 _ n
S CI:rulrl f'. wl~,. rr r-n' 'I ~~Q 4 1
Sanitan,PermitA lic.atio(
U-I'. I io S.-, i;i 1 i,e.ni:: 1. `het'"
Zoe ~ ~ ~C A 0,E,
L .tppllcall n) Information-Please Print All Infor )
Olg- I OA - 10-100
jo? % 1.'v
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11. PI ~)vu.ir~ll. \'mcba vl Dal::=:ud
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ILd:di -i. [I la:; (evlm.l .1e1,.ah,; tU r i•*palu~ a ~ ~ T
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dispersal tell •n.isl Le I ; `I)n-nta nr,d w,~Go :{tanS ~K S~'Q~C ~QMVte.~ cum [.ti G .c~ wr
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ST. CROIX COUNTY
SEPTIC TANK MALNUNANCE AGREEMENT
AND
OWNERSIEP CERTIFICATION FORM
0wnev23uyer _ ~t~
Mailing Address 7 &C)
Property Address
(Verification required from Planning & Zoning Department for new conswction.)
City/State C•f.fJt-LLXw\- _ Parcel Identification Number
LEGAL DESCRIPTION (J
Properly Location I-W t/ , NF ,Sec. /,R , T ( N R-J-?W, Town of ~T14 1M.0~ X,
Subdivision Plat:_ Lot
Certified Survey Map # _ Volume Page # _
TVarranh Deed #1? 7 (before 2007)Volume Pa~c ?
Spec house L yes Kno Lot lines identifiabl(Ayes G 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. R•hat you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in iiSPS. 383.52(1) and in Chapter 12 - SL Croix County Sanitary Ordinance.
The property owner agrees to submit to St Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber; restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and'or (2) after inspection and pumping (i f necessary), the septic tank is
less than 1/3 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 SL Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements o this form are true to the best of my/our knowledge. l/ we am are the owner(s) of the
property described above, by virtue of warranty deed recorded in Register of Deeds Office.
7
Number of bedrooms
SIGNATGRE OF AYPLICANI'(S) DATE
'Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded 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)
Vi'11F .
DIVISION OF INDUSTRY SERVICES
\ 10541 N RANCH RD
HAYWARO WI 548436462
P Contact l hrough Relay
http:iidsps.WCgovrprogramsardustry
-services
- W.PN 'NISCOnSin 9ov
Scott Walker, Governor
- Laura Gutierrez. Secretary
September 26, 2018
CUSF ID No. 220357, ATIA /'0;J TS Itopecro,•
BRAOY J UTGARD ZONING OFFICE.
t:TGARD PLUMBING A [ILA I'ING ST C'ROIX COLN" fY SPIA
PO BOX 413 1 101 CARMICHAEL RI)
AMERY WI 54001 fit DSON WI 54016-7708
CONDITIONAL APPROVAL.
PLAN APPROVAL EXPIRES: 09r2W2020 Identilication Numbers
Transaction 11) No. 3162740
SITE: Site ID No. 854128
Jeffrey' Frank Please refer to both identification numbms,--
I L O IN Ave above. in all comes .ondeace with the as ncy.
I oa n of I lammond
St Croix County
\W14. N'L114, S12. T19N, R17W
FOR:
Object hype: POWTS Component %lanaal Regulated Object II) No.: I?98.136
Maintenance required: 450 GPI) Flow rate; System(s): Mound Component Manual - Vcr. 29. SBD -10691-1) (N.01!01.
R. 10 ; 12); Lflluenr filter
The submittal described above has been reviewed for conl''ormance with applicable Wisconsin Administrative Codes
and W isconsin Statutes. fhe submittal has been CONDII IONALLY APPROVED. This system is to he constructed
and located in accordance with the enclosed approved plans and with any component manual(s) Mel--need above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible l6r compliance With ~11 cJQWPT OF SAFE -j .
requirements.
DIVISION pr 1
A copy of the approved plans, specifications and this letter shall be on-Nile during construction and o en to
inspection by authorized representatives of the Dcpanment. which may include local inspectors. All ennits
required by the slate or the local municipality shall be obtained prior to commencement of
construction %instaIlatio Woperation.
In nranting, this approval the Division of Industry Services reserves the ri,,ht to require Changes or auditions sho
conditions arise making them neccssar'y for code compliance. As per %ttrte stats 101. 12(2), nothing in this review COR
shall relieve the de:i_mer of the responsibility for designing a safe building, structure. or component.
Inquiries concernin} this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
I'he above fell addressee shall provide a copy of this letter and the POWTS management plan to the owner and am
others who are respon..iblc fi)r the im!allation, Operation or maintenance of the POWI S.
Sincerch, I'ee Required $ 250,00
I cc Received S 2400
Balance Duc .S 0.00
F. ' i A "I avlor
1Vastew'ater Specialist , Division of industry Services WISMART code 7633
(715)614-1484 , Mon-fri, 8:00 a.m. -4:30 p.m.
edwin.raylon'd:%6.gov Il
MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name- FRANK
Owner's Name. JEFFREY FRANK
Owner's Address: 1079 200TH. ST. BALDWIN WI 54002
110TH. AVE.
BALDWIN WI. 54002
Legal Description. NW / NE / S12 / T29 / R17W
RF„
Township: HAMMOND
County: ST. CROIX In//~ 91n~~
Tr, .
Subdivision Name
Lot Number: Block Number
Parcel I.D. Number: 018-1024-10-100
Plan Transaction No ,
Page 1 Index and title -D `
Page 2 Data entry 'FSSTONAL
Page 3 Mound drawings RY SL-RV.CLs
Page 4 Lateral and dose tank
Page 5 System maintenance specifications
Page 6 Management and contingency plan
Page 7 Pump curve and specifications
Page 8 PLOT PLAN
Page 9 SOIL EVALUATION - ( ;v JL-Id
Designer: BRADY UTGARD License Number: 220357
Date: 08/1 8 Phone Number: 715-760-0946
Signature:
Designed Pursue the
Mound Component M ual for POWTS Version 2.0 SDB-10691-P (N- 01/01), and
SSWMP Publication 9.6 Design of Pressure Distribution Networks for s f-SAS (01/81)
Version 3.11 (R 06/01) Page 1 of 9
Mound and Pressure Distribution Component Design
Site Information
R Residential or commercial Design ( Note Sand fill (D) calculations assume aal
~
300.00 Estimated Wastewater Flow (gpd) (Table 83-44-3 in-sdu soil treatment for fec
1.50 Peaking Factor (e g 1.5 = 150%) cohfom of 36 inches.
450.00 Design Flow (gpd)
1.00 Site Slope
99.06 Contour Line Elevation (ft)
34.00 Depth to Limiting Factor (in)
0.40 In-situ Soil Application Rate (gpd/ft )
Distribution Cell Information
75.00 Dispersal Cell Length Along Contour (ft) = 6.00 Cell Width (ft)
1.00 Dispersal Cell Design Loading Rate (gpd/ft)
1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point
in the distribution Y
Pressure Disribution Information network?
E Center or End Manifold
3 00 Lateral Spacing (ft) If N above, enter the elevation (ft)
2 Number of Laterals of the highest point.
0.125 Orifice Diameter (in) (e.g. 0.25)
3.00 Orifice Spacing (ft) = 9.00 ft1/orifice
2.00 Forcemain Diameter (in)
100.00 Forcemain Length (ft) Does the forcemain drain back? Y
90.00 Pump Tank Elevation (ft)
6.50 System Head (ft) x 1.3 16.31 Forcemain Drainback (gal)
9 56 Vertical Lift (ft) 46.79 5x Void Volume (gal)
0.97 Friction Loss (ft) 63.11 Minimum Dose Volume (gal)
17.03 Total Dynamic Head (ft) 20.60 System Demand (gpm)
y
Lateral Diameter Selection Manifold Diameter Selection
in. dia options choice in. dia options choice
0.75 125 x x
1.00 1.50
1.25 x x 2.00
1.50 x 3.00
2.00 x
3.00 x
Gallons/Inch Calculator
Treatment Tank Information Total Tank Capacity (gal)
1000.00 Septic Tank Capacity (gal) Total Working Liquid Depth (in)
weiser Manufacturer gal/in (enter result in cell B49)
Dose Tank Information Effluent Filter Information
600 00 Dose Tank Capacity (gal) POLYLOK Filter Manufacturer
11.82 Dose Tank Volume (gal/in) 525 Filter Model Number
weiser Manufacturer
Project FRANK Page 2 of 9
Mound Plan View
- -T
1/10B ObSCrvalionPipe -
-K Tl
A
W l y
B rTr _ _
3 I
Mound Component Dimensions
A 6 00 ft E 6.72 in Fl 1.00 It K 6 90 ft
B 75.00 ft F 9.25 in 1 9 00 It L 88 81 ft
D 6.00 in G 0.50 It J 5 16 It W 20,16 ft
450 00 (ft2) Dispersal Cell Area 1125.00 (ft) Basal Area Available
6.00 (gpd/ft) Linear Loading Rate 7 50 (ft) 1110 B Cbs. Pipe Placement
Mound Cross Section View
Aggregate Dispersal Area
Finished Grade 101.33 (ft)
10
10,:., H
2 I
F Dispersal Cell 100.06 (ft) Lateral
99.56 (ft) Invert
Dispersal Cell 3
Flevation E D
I3J .
1 1 _
FA]
99.06 (ft) Contour Elevation
1.0 % Site Slope
Geotextile Fabric Cover
I Shading Key m o, * Dispersal Cell See lateral details on
1J E_ J Topsoil Cap o C 1.5 ft t Page 4 for number, size,
10 Subsoil Cap ~ o I and spacing of laterals.
[3~ ASTM C33 Sand v Z U / F Laterals are equally
W L~ Tilled Layer N 0 5 ft Typical Lateral spaced from the
❑5 Aggregate e o ~s distribution cell's
centerline in the
- A - ` distribution cell (AxB)-
Project. FRANK Page 3 of 9
End Connection Lateral Layout Diagram
Lafetals,:..rre•ed ovef the AiEdimensr"r. turn uC "n'Gell valvn nr rzieun~•utpluy
•All 4tc•ralc are idenae..ln Ifx~I 1-L~Ip~dnlled nth. GOrtom of [heletpnl
paced _ -1.
i
Force main cpnnPC[ICn lid [oa of Clu.gr maLlloid it ~n9 !xn[
.I Lateral e: r:r rran orl i'.:~ri dtl
(Per i_r Rdfd'd'ales Ft .u. 51
Number of Laterals 2 Onhce Diameter 0.125 is
I.ateral Diameter 125 n Orifice Spacing (X) 3 06 ft
Lateral Length (P) 73 44 It Orifices per Lateral 25
Lateral Spacing (S) Aft ft Orifice Density 9.00 W/orifice
Lateral Flow Rate gpm Manifold Length 3-00 ft
System Flow Rate gpm Manifold Diameter 1.25 in
Total Dynamic Head Forcemain Velocity 2.10 ft/sec
Dose Tank Information l nicking cover with waming
label and locking deve;e ar'd
sealed watertight
I-lertccal as per NFC -I-0 auf _r -
Comm 16 2a WAC ~4 in. min
Disconnect
Tark componcrt is properly vii E. F- Altemate outiei
location
_ Forcernaln d ametor
wciser Manufacturer 2 in
Capacit 600.00 Gallons t
Volume ^ 1.62 gal!mch A
_ • Weep hole or anti
Dimension Inches Gallons I B siphon device
A 37.42 4423
3 C -
B 20 0 23 64 Pump off elevation (N)
C 5 34 63.? 1 1 90 50
D 6.00 70 97_ D
Total 50.76 600.00
Dose tank elevation (h)
J 3" Bedding un er tank 90.00
Alarm Manuafacturer LLVEL
Alarm Model Number DLV
Pump Manufacturer GOUL DS
Pump Model Number EP05
Pump Must Deliver 20.60 gpm at 17,03 ft TDH
Project FRANK Page 4 of 9
Mound System Maintenance and Operation Specifications
Service Provider's Name UTGARD Phone 715-760-0946
POWTS Regulator's Name ST CROIX Phone 715-386-4680
System Flow and Load Parameters
Design Flow -Peak 450 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow - Average 300 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity1000 gal Maximum TSS 150 mg/L
Soil Absorption Component Size 450 ft2 Maximum FOG 30 mg/L
Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL
Service Frequency
Septic and Pump Tank Inspect and/or service once eve 3 ears
Effluent Filter Should inspect and clean at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test month)
Pressure System Laterals should be flushed and pressure tested eve 1.5 ears
Mound inspect for ponding and seepage once every 3 years
INSPECT FILTER ONCE A YEAR
Miscellaneous Construction and Materials Standards
Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap,
and are secured in as shown in the mound component manual.
2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code
3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code.
4 Tillage of the basal area is accomplished with a mold board or chisel plow.
5 The mound structure and other disturbed areas will be seeded and mulched to prevent Soil erosion
and help reduce frost penetration.
Lateral Turn-up Detail
Finished
Grade
6-8" Diameter Lawn - f:_ Threaded Cleanout
Sprinkler Valve Box Plug or Ball Valve
Distribution
Lateral
Long Sweep 90 or Two
45 Degree Bends Same
Diameter as Lateral
Project: FRANK Page 5 of 9
Mound System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its'
component manuals ISRD 10691-P IN 01101) and SSWMP Publication 9.6 (01/81)) and local or state rules pertaining to system
maintenance and maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death.
Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access
openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound,
defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an
effective locking device to prevent accidental or unauthorized entry into a tank or component.
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281 48, Slats. The contents of the septic
tank shall be disposed of in accordance with NR 113. Wis. Adm. Code The operating condition of the septic tank and outlet fitter shall be
assessed at least once every 3 years by inspection.
The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions
are made to retain solids m the tank that may slough off the fitter when removed from its enclosure. If the fitter is equipped with an alarm,
the fitter shall be serviced I the alarm is activated continuously. Intermittent fitter alarms may indicate surge flows or an impending
cdntinuous alarm
The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the
tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of
when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not required. However. if such
products are used they shall be approved for septic tank use by the Department of Commerce
.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be. tested to verify proper
operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary
.
Mound and Pressure Distribution System
No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be
seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration Traffic (other than for
vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the
rnound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the
mound be heavily mulched as protection from freezing.
Influent quality into the mound system may not exceed 220 mgrL BODz, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30
mg/L BOD;, 30 mg/L TSS. 10 mg/L FOG. and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design
flow specified in the permit for this installation.
The pressure distribution system is provided with a flushing point at the end of each lateral. and it is recommended that each lateral be
flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test
when the system was installed to determine if onfice clogging has occurred and if orifice cleaning is required to maintain equal distnbubon
within the dispersal cell.
Observation pipes within the dispersal cell shall be checked for effluent pending. Pending levels shall be reported to the owner, and any
levels above 6 inches considered as an impending hydraulic failure requiring addttional, more frequent monitoring
Continency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in
proper operating condition
If the dosing lank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately
repaired or replaced with a component of the same or equal performance
.
If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or
replaced in its* present location by increasing basal area if lee leakage occurs or by removing biologically clogged absorption and dispersal
media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition
See Page S of this plan for the name and telephone number of your local POWTS regulator and service provider
Project. FRANK Page 6 of 9
GOULDS PUMPS
ITT Wastewater
PERFORMANCE RATINGS COMPONENTS
To -ta I H e ad
ift. of water) [iNoo Deunpvo~
Bese
ic 46 62. 3 %mpca",q
1; 36 5~ - ulseli
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7
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25
6 1 20
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4 6 8 10 12
CAPAMY
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• - B3
SEPTIC or HOLDING TANK SERVICING CONTRACT
Contrail Date
LA - This contract is made between the
Tank Owner(s) Name(s) and
Z-je;-FP Pumpafs Name
FR ~N~ iZe,~ S 5 ea Sbna.~
We acknowledge the Instasatton of a s
eptidhdding tank(s) on the toAowing property:
_rovidele~aldescriptionr_ 2p~~_ \\o~'"` pvE
1. Tae owner agrees to file a copy of this Contract with the local govern ntcvtal emit (St Croix _ _ - - _ - ` - _ _
Plaunmg Zoning Depa tmem) to dom mem maintenance by a certified County
me aanual- operator as
required in Comm 8352(1)(c)2• Wis. Adtu Code and the sepmicing
approved Component Manual
2. The owner agrees to have the septidholdivg tank(s) serviced by the undersign
permit the pumper to have access and to enter upon the property for the purpose of pumper and he to
septidbolding tank(s). The owner agrees to maintain t n t servicing the
service the s diet he access row or dove so that the pumper can
pumper for all ding tank(s) with the pumping equipment The owner farther agrees to Pay the
owner and pumper. charges the septic/holding tanlt(s) as mutually agreed upon, by the
3. The pumper agrees to submit to the local governmental unit (St Cmnc County) a report for the servicing of
olding tank(s) on a monthly basis. The pumper further agrees to include the following in the
the scptic/boort
monthly re
a. The name and address oP the person responsible for servicing the septiolholding ttmk;
b. The name of the owner of the septidholding tank;
c. The location of the property on which the scptic/boldmg tank is installed;
d- The sanitary pest mtmber issued for the septic/holdtag tank (if known); I
e- The dares on which the septicAolding tank was serviced;
f. The volume in gallons of the contents pumped from the septic/Iwldmg tank for each servicing;
g. The disposal srtes to which the contents from the septicAolding tank were delivered
4. This agreement will remain in effect until the owner or pumper terminates this cootma In the event of a
change in this eoahact, the owner agrees to file a copy of any changes to this service contract or a copy of a
new service contract with the local governmental unit named above within ten (10) bi sme ss days from the
date of change to this service contract
Owner(rs)~Name(s) (Prirrt) Owner s(s Subscribed and swore to me on this date:
J c I '1 ~ru,~r
.1I~ - - - - Tadeys Date
Pumpefs Name (Print) 'Pumpafs Sign ahhre
(Notary Public Signattm3
Merrc Meyer
Pumper tionNumber - -
- - - Commtstion Expiration
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'41 54 1 FRANK r!-l,-or''.'. RANCH
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