HomeMy WebLinkAbout040-1308-00-155 (2)
oa smDepam-erlof Comme-;e PRIVATE SEWAGE SYSTEM ..ou ry St. Croix
Wet- and Builcing C,micn
INSPECTION REPORT Sn-dmyPermr,NC
GENERAL INFORMATION A-TACH TO Pl-l ~1l Ij 607020
State P an 'U NC
Perscnal in•crmat on nrov Je'"ai ec uscd'c' S2c3rda^i PWVC, S PA:JCy Laa. S.15 4 iI;fm:l
Permit He der'.. Name City Village Ta:: n0 p >a'xI l.rs. No
Ryan and Shelby Kuphal TOWN OF TROY 040-1308-00-155
ST B:! Fe,
1 I^,y Bbl Nev Bt! esC 1 an SCCUCN1owN 4anJ;~=: tr Vp Vo.
l~ <I.1 •2 24.28.20.1974
TANK INFORMATION ELEVATION DATA
TYPE NIANUVAC I UHFR CAPACITY SIAI ION BS HI FS ELEV.
Septio Benchmark -
C t 5`f 5 ~I ~J (1 l~ , 1~ (D
i I -sv.~klA r_ BPA
As:at.oa Bldg Sewer
J v
TANK SETBACK INFORMATION SIHt Orucl
TANK TO PR 'v%EL_ BLDG Vew I, A • Ir lake ROAD Dl Inlet
Sep:c , tj~ I ~..ty=<,;. f Dt Bonon- ,
(Uri (a.jr ~1-•rJ
Donny _ ffeader.'td.an - L too -OD I
Ar.)ah:,r Ols: Pipe
Hoed. rq Bcl. System
PUMPISIPHON INFORMATION Final Grade LAO
Marufactirer _ Demand St Covet-
GPPA
Mcca Nunreer -
TDH L.ft, - r Frict on LOSS SySIvIn Head TDH Ft _
Forcemain Lel gth Dia It Ols-
SOIL ABSORPTION SYSTEM
BED)TRENCH l:'dth Lengl 'k :~f Trenc-.es VIT DVdE I S Nn O`p to Ins dC ❑a. I q,0 Depth
UIMENSIONS 3l j'
i
SETBACK SYSTEM 70 P:L t^, 11 BLDG ~:'FL I. tlk_K +S - P,1 LEACHING Vdan ~IaCldre'.
INFORM1IATION Jam/ CHAMBER OR
Tire Of System l-. UNIT Modcl Numter
1- 0%C n LAI. I e = .;I ~el +I :'Y1.E'
DISTRIBUTION SYSTEM
I lcadc• !'a''uyo 7i,:r Vu:on x HCle S¢e x Hole Spa- ng 'vcnt tV An 1•rtake
Le^;):h_ ILa _cgglh / Cia Spacir.1
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Drp'h 7 e- ! I :)ep'n %i xx Depth of _ xx St'- JJut xx I&IChed
iSeC" er,n Center l L-~ 3cu-ir n.- Edges - Tcosni
i Yrs Nr, - Veg. N:i
COMMENTS: dirdide voce discrepences. persons -resent. etc ! Inspect cr p1 Inspection 0
Location: 318 LINDSAY RD OR -
1.1 Alt BM Description = ? C\~~x
2.1 Bldg sev:e• lengtn = dy I
- amount or cover n _
dL
1
Plan revision Requited? Yes No _ Otte ^ blsepctor nr
Use other side for additional inforrraticr.
SBD-0710 R.3,97: 7 ! Cert No
01
I.(lul L N ,-hln;.rm Ave
FEB 142CIS I<1 lioA4'If> ISa w:uAPrunc un~. Co IIIkJ'n LA i.:l kNja:'7O7 716"
1' ~ 1eD76Z0
~71}ff 1`i y_rj,b} T ~_r dtio Sla[, Irunra1 lion Number
In ♦ Jr aiC<ullh\ \ '!.,'ll 1\ \.II .h. I t r II 'III:nI 1 ,'!cl n AA_
IS Lquircd pnor l+a 6Lm'np la m..l;'pccut.\ 0.. ylh. It.an tali a':e tu.. ..f/ISll;ur ali nnc.l b, Pn lhl:\Jdr:au} JJitasll taa~t.all.ng adJresi
II'r Dgclttm;rt 1 S:ItcIV end Pn tc.e an ~I > I:a . u. 'oi..l :nt ~r"nr.n ~..u rrvlda In., ba u.::f f... ar.....
u I rllr.. LLitl _ _ _
Application lnfounalion Plaur lh nn Ullnfotma n L')5.-k!
I ryil)`xn: \am -Parcel
I nhy I)wn. AI ulu • AdJ Pr I} IAy'x!1011 j jj q
(rt Sad' Zip CuJc Phone Number ticcliun
II f )ry• of IAulduh (check all that app) y I,e
'_F.:Ind-U'LIhrr~ \uni. Ii:J: /H`~ 1 hinl,lna Name
l
OK l:lo fat ~s< l a[~%
❑ Iih>Ii,:d'un'.m I u. Dsutinc Iac + ~p r
U \lat: U•an:J U's.rrro l ac it n1 - a\uu::;ncr Ll vdla•c
3 s? o llS 1 ~.Y ` r.,w:t or
JAR
I11.'1)pe of Perrnit: (`Check o k one box on line A. Complete line It il'applieable)
N;. 4:anu \ ❑lap:,:a:n I'W >y.:I... ❑ I 11':tinan1 l71Iq :.I I,l -1. .'-men: On.% UI.Ilf".bl:uf li::nll to Fc.s:mg System icxpla:nl
It U cmt, n n •,•:d L7 Pc-.,mr. Rm, I,, U Cf '.tr6: If I-11,111 ,;r L I t -I I,.rr:.a r•: Now Gal Vi,, III, Pe ,.w( NumL:: an'. Uar, Lcsuad
B.f:rcl nla.r..n Utl r. i( fA.F' U/VV
(1-1~Trc7t 1'fT~'~'kIdLI Cnngnmult DaL'lla ((.heck all dint apPl)) a
t~ Non 1, "If I <i un. If H !,t fn:. la fl 21 i:t. or uL ubte scnl U 11.r.tnJ n .rt su):L.I: soil
❑ Ili II; `:u (llta [hp1. ('n:n,t nn.mvp:_mi ❑ Pretrcmmou Dcaic: ictp:am)_
\ Dispersal. TlLt lull Arne lnformahun
D I u I[.,, 1 [)asin 5 I R { I t.' Uir pcaul An I R gctl V J i.Il UI I t 'a PI pox.t' II 1 lull Flcsacm'.
\1.9 aok Info l'::I I LI T IJ I \Luulaumcr 1MhA~ )
V.w I 6. L. Ian I:u:A 'J ~ n r
w lO Szs V L
a m Ill F.
YI1. Rnpun.ihilk) slatetttenl- I, the undersi; ned, assume rcapon0)tIitO lnr illatallminrl n1 Ibe PONN 7s shnrsn on the atuched Plana.
M.. he,*<'N.:u ~i' ~ I Plumb: v •,tWM--i VI' SIPRV \.1 "!m klu nx al un Nambar
lit I tdd AI I, I i 11 I ~h`i I I~ r
\ III Count` Ucpaltmem C v Oul°
y Iua::,i ~ „I L•, I omit 14:c Dar Isu, i 4.A4w
560
~'pwNfifte nun, lot Disapprus11 1. SWi, lark, VIIILcn. lifte- a nl P~Sef`~
ohpe! cell nust EII c.'s r 1.' +(y_ zs I
u permaragement plan ~)w •icell ~v ,,.umt e
Y. All"MRw*Wi,A✓r-onA meal w C:. CI. of
as per PpQkxV It c e.-. I : rd-..a V,r.I-
aunulnungdar.pLu.[,nn•~ aaaln nnA Vdnni: bi lav llr.lnh u:da.nlup< uul lax. rl..rnpl.,. ll in..Lain av.
VI)r )_I~19A Ill-i)A:.-,
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CONVENTIONAL COMPONENT DESIGN
Residenital Appkmfim
RM)M AND TnLE PAGE
Pmjed dame; _ : -
Owner's Warne f -
OwneesAddresM
Legal Descrip6orc = - Y
Township
County
Subdivision Name
Loll f4ranber
Pa rCEd R) Number:
Page 1 _ hMesat,d Bale ff' / ~'Sl 14 ~1K
i
Pagel Plot Plan
Page 3n& &
Page4 Specs
Page 5 Bdlaffdeaamx Q$bmrabon
Page6 rffAm& gsrre~etpaaan
Page 7 SL Cmw Cqr Septic Tar* woe Form
Page 6 Warl-a>ty Deed
Pgge 9 C!M or PW
Attadxnenbr Soi Test & House Plans
limnse NBnbec
Oar Phom Number
7 -
Signabne
pesifflaf pm=mmbthe lO(•ioeo0--;ME sefpiie CbeO=mdYaKelbfpcWm1Asw Z0580.10ms P(RDlemy
Pa 1
11
-..`iii</~x }j✓~~i~4/ f ~ '
/v,4
1 Al
01
r
4 - 1
{
Soil Absorption System Cross Section
ft
4' Schedule 40 Fln'a Grade
PVC Vent Pipe
With Vent Capj _ ft
Leaching ft
Chamber f- System evaUon
d it
Soil Absorption System Plan View
ft
ft 1T(iliiifl(ff(1i11~Ilf1T1i1 ~ ~IIiI~.
i r
Leaching 1 reach 1
_`.'ft Chambers
LLW LLri1J JJitl~ 4" Dia.
Trench 2 Header
Vent Or Observation Pipe
Trench 3
'Leaching Chamber Specifications
Manufacturer And Model
EISA Rating sq ft per chamber Soil Application Rate gpd/sq ft
i
7 --Y; gpd Design Flow _ 1 _Soil Application Rate EISA = T' Chambers
3 rows of chambers each.
Page of
Q~'. 0 Fib
-~'4°c ] FI , _ alai
PL-525 EMUEM ALTER > ~JMK-2r-°° _1
Pofylok, Inc is pleased to add its r t
new commercial filter to its existing
fine of quality effluent filters, The €
PL-575 is rated for over 10AM GPO Alarm "WIi j A PVC
t
r~alfons per day} making it ones of Accepts
the largest commercial fitters in its j etc0easort 6a°de
dass. h has 525 farear fe-A of ]'lo b
fithatian slots. Like- the Pdylok z $
PL 12Z the new Polyfok PL-525 has
an automatic shut off ball installed ~ 525 Unearteet
with every filter When the after is of t/f~ , K
removed for cleareng, the hall will naafi,. staff timer row aces
z ' texas GPD
float up and temporarily slut off -
the system so the effluent won't
leave the tank go attar Mar on
dw few rrtaA that ~ SCM.40
PL-525 maintenance:
Tho PL--525 Effluent firm should r
operate effiaerdfy for several years t
raider normal cant ifions before i
requiring CLear*xj- It is recom-
mended that the filter be cleared
Ow" time the tank is primped cr f
at least every three years- If the
aesfa[led filter contains an optional
alarm, the owner will be notified _
by art alarm when the filter needs
servicing- Servicing should he _
dare by a certified septic tank_
pumper or installer
1. LOCK10 the outlet of the
Septic batik S87't.VO _-a
Z.'Rerieove tank cover and pump
tank if necessary. PL 525 Installation: 1• Lorain the outlet of the
3. Do not use plumbing when septic tank
filter is removed- ideal fior residential and com- 2. Remove the tank cover and
4. Pull PL-525 out of the housing. rnercial waste flow's up to pump tank if neressary-
5_ t-fase off filter overthe septic 10.000 Gallons Per Day (GPDX 3. Glue the fitter housing in the
tattle Make sure all SoWs fall 4• or G outlet pipe. Ifthe
back iri[a septic tank- filter is not centered under the
access opening use a Polylok
tE Insert dies flter cartridge back 2d end & Lok or piece of pipe
hero the housng mating slue to clatter filter.
the filter is property aligned and 4. Insert the PL-525 filter into
complete inserted- ifs housing.
7- Replace septic tank cover. 5 Replace the septic lank cover-
. ,T Y,t -
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
w Septic Tank Capacity gal O NA
it 'l~ ~ • Septic Tank Manufacturer ❑ NA
1_P0_(Vr'M`
DESIGN PARAMETERS Effluent Filter Manufacturer Lam' ❑ NA
F L1 NA
Number of Bedrooms ' - ❑ NA Effluent Filter Model
Number of Public Facility Units 'ULNA Pump Tank Capacity ~ gal ❑ NA
Estimated flow (average) Blida Pump Tank Manufacturer - ❑ NA
Design flow (peakl. (Estimated x 1.5) - yallday - Pump Manufacturer NA
Soil Application Rate ✓ , q_rlidayrit' Pump N•todel ❑ NA
Standard IntluenuEffluent Quality Monthly average' Pretreatment Unit ONA
rats, Oil R Grease (FOG) -30 mg.1 ❑ Sandi Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand IBODzI =.220 mgil. ❑ NA ❑ Morhanical Aeration ❑ Wetland
Total Suspended Solids (TSSI ( -150 ingil- ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA
Biochemical Oxygen Demand (BOD,,) <30 mg.1 ~d In-Ground (gravityl ❑ In-Ground {pressurized!
Total Suspended Solid. ITSS) <30 mgiL yI NA ❑ At-Grade ❑ Mound
Fecal Colifonn (geometric mean) 104 cfu; 100nt1 O Drip-Line ❑ Other:
Maximum Effluent Particle. Size. in dia. ❑ NA Oth"' ❑ NA
Other: - ❑ NA Omer. ❑ NA
Olhcr. - l 1 NA
"`✓alucs typical for Jonmsl'.c v: as:ce: afar and xeptir. Iznk urtlucnt.
MAINTENANCE SCHEDULE
Service Event Service Frequency
❑ monthls)
Inspect condition of <nk{s; At !cast once every: 21 year(s1 (Maximum 3 years) L NA
Pump out contents of tanks) When combined sludge and scum equals one third (%a) of tank volume ❑ NA
Inspect dispersal cellist At least once every: 0 month(s) (Maximum 3 years) ❑ NA
0 yearls) _
Clean effluent filter At least once every: 0 month(s) ❑ NA
Year(s)
Inspect pump, pump controls R alarm - At least once every: _ ❑ monthls) El NA
? p-1 year(s)
Flush laterals and pressure test Al least once every: ❑ year(s) nonth(s) NA
Other. At bast once every: ❑ month(s) E) NA
❑ year(s)
Oll•.cr. - - - ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licensrs or certifications:
Master Plumhor, Master Plumber Restricted Swvcr, POWTS Inspector, POWTS Maintainer, Septago Servicing Operator. Tank
inspections most include a visual inspection of the tankls) 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 ponding of effluent on the ground surface.
The dispersal shall be visually inspected to check the effluent levels in the. observation pipes and to check for any ponding
of effluent on the ground surface. The pending of effluent on the ground surface may indicate a failing condition and requires tho
immediate notification of the local regulatory authority.
When the combined acrunwlation of sludge and scum in any tank equals one-third 1K-j or more of the.. tank volume, the entire
contents of the tank shall be removed by a Seplage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but riot limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
UMW (4;01)
f '
Page 2-- of
START UP AND OPERATION
For new construction, prior to use of din POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process endior damage the dispersal cellls). 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 highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cellls) 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 dispersal 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 soil absorption area.
Reduction or elimination of the following from the, wastewater stream may inlpruve the performance arid prolong the life of the
POWIS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump puplp) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POW] S fails andlor is permanently taken out of service the, following steps shall be taken to insure that the system is
properly arid safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code,:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• 1 he contents of all tanks and pits shall he removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails arid cannot be repaired the following measures have been, or most be taken, to provide a rode compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks frorn existing and proposed structure, lot lines arid wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and!or soil limitations. Barring advances in POWTS
technology a holding lank 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 locate 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 arid al-grade, soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply With the rules in effect at that time.
< < WARNING > >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS _
POWTS INSTALL POWTS MAINTAINER
Name ;i. Narne
Phone - _ _ Phone _ _
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY. AUTHORITY
Name i - Name
Phone Phone -
This document was drafted in compliance v.•ilh chapter Comm 83.22(211b)(1)1d:81f) and 83.54(1), 171 & 13). Wisconsin Administrative Code.
.aye ~ of
START UP AND OPERATION
For new construction, prior to use of the POVdTS dw-i; trcattnont tankisi for the presence of painting proeucts or other chemicals
that may impede the, treatment process andior damage the dispersal cellisi. If (ugh 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 fil: above normal highw•ater levels. When power is restored the excess wastewater will be
discharged to the dispersal celllsl in one large dose, ovenoading -he cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation nave the contents of the pump tank removed by a SOptage Servicing Operator prior to restoring
power to the effluent pcrnp or contact a Plumber or POWI-S Maintainer to amst in manually operating the oump controls to
restore normal levels within the pump tan(:.
Do not drive or park vehicles over tanks and dispersal cells. Do riot drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade sell absorption area.
Reduction Or elimination of the followinq from the wastewater stream may improve the performance and prolong the life of the
POwl-S: antibiotics; baby wipes; ciparettc butts; conaoms; cotton swaps: degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (surnp purppf water; trui: and vegetable peelings; gasoline; crease, herbicides; meat scraps; medications; oil;
painting products; pesticides: sanitary napkins: tampons; anc water softener brine.
ABANDONMENT "
when the POWTS fails andior is permanently taken out of service, toe following steps shall be taken to insure that the system is
properly and safety abandoned in compliance with chapter Comm 63.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings scaied.
• The contents of all tanks and pits shall be remove:( and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and rentovod or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, w must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may DO utilized for the location of a replacement soil absorption
system. :'he reolacemeni area should be protected from disturbance and compaction and should riot be infringed upon by
required setbacKs from existing and proposed structure. lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation u: establish a suitahlo replacement area. Replacement systems rnus:
comply with thn rules in effect at that time.
❑ A suitable replacement area is not available due to setback and?or soil limitations. Barring advances in POVJTS
technology a holding tank may be. installed as a last resort to roplace the failed POWTS.
❑ The site has riot been evaluated to identi'y a suitable- replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. It no replacement area is available a hoiding tank
may be installed as a last resort to replace the failed POVvTS.
❑ Mound and a: grade, soil absorption systems may he reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such svstems rust comply vaith 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 SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Nanw Name
Phone I 'r T_• t , - Phonc
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY,.AUTHORITY
Name - - - Name
Phone Phone
Th t. incummnt was drafted in complioocc with chapt.rt Cin r i 33.?7i7rtr.;:l lid;&Ili and 121 & 131, Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer: - -
Mailing Address
j i ,
, J
Property Address _11-- -
(Verification required from Planning & Zoning De pattnteis for new construction.)
City/State r - Parcel Identification Number
LEGAL DESCRIPTION
Property Location J , Sec. - T- N R W, Town of
Subdivision Plat: Lot #
Certified Survey Map # Volume _ Page # _
Warranty Deed # (before 2007)Volume Page #
Spec house 0 yes if!no Lot lines identifiable ~ yes 0 no
SYSTEM MAIN TENANCE 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. What 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 §SPS. 383.52(1) and in Chapter 12 - St 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 (if necessary), the septic tank is
less than 113 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 on Worm are taste to the best of my/our )nowledge- Uwe amlare the owner(s) of the
property described above, by virtue of a warfty deed recorded in Register of Deeds Office.
Number of bedrpoms
/
-SIGN OF APPLICANT(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 it'
reference is made in the warranty deed.
molt n.rnoi
Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer / Mm r'- -imum Pump Performance Required
Tank Model Number CiPM (a) y Pt TDII
Total Tank Capacity
Max. Bury Depth' '
Total Dynamic Head (TDH) - Feet
Pump Manufacturer ; Elevation I lead
Pump Model Number ; Distal Pressure _
Alarm Manufacturer Network Pressure Loss
Alarm Model Number Force Main Pressure Loss
Switch Type Total j
Manhole Mil. 4" Above Grade
_ With Locking Device
Vent Min. 12" Weather-proof \
Above Grade Junction Box J
With Gip
- - - - - - - Finished Grade - - - -
Depth of Cover -7 Ft Disconnect
Means
i
Outlet
Switch Settings and Reserve Capacity I
Inlet Volume = GPI
Dimension Inches Volume Gal. A
(reserve) A J
Weep
(alarm) 13 2 J B hole
(dose) C Off Elev. ( ;
? (dead) D Ft
Total -
Bottom of Tank Elev. , 5'~. _ Ft
GENERAL INSTALLATION: The dose tank is bedded and back tilled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the
manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have
an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved
material, connected to the tank with watertight fillings, and laid on stable soil to prevent settling or
sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the excavation and is sealed
watertight. Electrical service complies with NEC: 300 and Comm 16.28 Wis. Adm. Code.
03/05 lgj Page -I-L- of
(t~ GOULDS PUMPS Submersible
Effluent Pump
3. PE
I ~n I'VHP
SPECIFICATIONS MOTOR FEATURES
Pump - General: General: ■ Corrosion resistant
• Discharge: 1 `h' NPT • Single phase construction.
• Temperature: 1040F (4000 • 60 Hertz ■ Cast iron body.
f maximum, continuous when • 115 volts ■ Thermoplastic impeller and
fully submerged. • Built-in thermal overload pro- cover.
• Solids handling: Y)" tection with automatic reset ■ Upper sleeve and lower
maximum sphere. • Class B insulation. heavy duty ball bearing
• Automatic models include a • Oil-filled design. construction.
APPLICATIONS float switch. • High strength carbon steel ■ Motor is permanently
• Manual models available. shaft lubricated for extended
Specially designed for the . Pumping range: see PE31 Motor. service life.
following uses: performance chart or curve. • .33 HP, 3000 RPM ■ Powered for continuous
• Mound Systems • 12.0 Maximum amps operation.
• Pressure y Pipe Systems Systems • PE31 Maximum Pump: capacity: 50 GPM • Shaded pole design ■ All ratings are within the • Maximum head: 25' TDH PE41 Motor:
working limits of the motor.
• Low ow Pressure
• Heavy Duty Sump/ Draining Pump: • .40 HP, 3400 RPM • Quick disconnect power
• Heavy D
(Mwatering - • Maximum capacity: 60 GPM • 7.5 Maximum amps cord, 20'standard length,
heavy duty 16/3 SJTW with
• Maximum head: 29' TDH • PSC design NEMA 5-15P, three prong,
PE51 Pump: PE51 Motor: 115 volt grounding plug.
• Maximum capacity: 70 GPM • .50 HP, 3400 RPM ■ Complete unit is heavy duty,
• Maximum head: 37' TDH • 9.5 Maximum amps portable and compact.
• PSC design ■ Mechanical seal is carbon,
METERS FEET ceramic, BUNA and stainless
4
Me0rL5. PE31. PE41. PE51 steel.
vts
He .$3_40. so ■ Stainless steel fasteners.
10- ~I ( 2 GPM AGENCY LISTINGS
30 _PMI. 'L 1 1 Ff
25 PE31
o _ Opus
a 20 Tested to UL 778 and
} CSA 22.2108 Standards
By Cana" Standanrs Association
~ 1 s ' - _ Fie atrt38549
0
Goulds Pumps 6 ISO 9001 Registered.
10 5 X/
4
O On - --10 20 - 30-- 40 50 60- 70 GPM Ro
0 s to - - t s m3R1 Goulds Pumps
CAPACrTY n -
Wisconsin Derar~_n;cor-_ saj, SOIL AND SITE EVALUATION REPORT P4y_ of
W bor and i I reran Rel.~xrs _
Division at'Satoty & Builcirvgs in aceord with ILHR 83.05, WIS. Aam. Code
xCJNTY
Attach complete site plan on paper not less than a 1,12x 11 inches in size. Wan must inc:cde, bui ~T' C"\~ LK
not limited to verical and horizontal reference pcirt (Bm). Cirecticn and i, of s:ope, scale cr *N dimensioned, north arrow, and location and distance to cearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION AT-
PROPERTYO'NNER: FRCPElTYL' O~Ai ION
C~DU-i=f\lE"` 1;s E;o W
PROPER Y C NNz9':S WILING ACDRESS. LCT K? SUED t,-mE CR CS'd:
\-L3o1 NZICL .~U~ 0.~. ~ 2.3p i"Ar)ISLCC- I_i ..U`I U:Lt-F.,SF _•'ru
CITY. S?n e ZIP COC% PHO`JE N ti16ER l7^. []b'.LLAGE _k C'RN NEARS RCa1D
Q 1.-K61U r , rn fv
f)4 9Ew Corscuc;icn CSC Reside0al?.Nur-Xr o` tedmcnis `f _ i Ad „fin to existiN biking f r'
(J Replacement [ J Public • Cor•mercal describe ~ '
Code derived daily Bow 60 o gpd Recc'nmenddes'gn loadirg :•a:e _ ~~peed--. g~p~~~d~`~2_8_aench, gpdrft2
AbscrpEcn area recLired bSffi bed, f:2 S13 tench. ;t2 Maximum d~icr lcadine rate ted. CpC;ft2 8 trench, gpd'ft2
RE--Mme ldcd infil7aton surface e'evalion;s; s y A 6 E_~_ -q (as rClCaed to sit= p'an beryl na:k)
Addloora!design ? siteccnsidera5ors S t-JO(ti -M IluSt-RUQZ
Pwonlmaterial ~o sa ovJ~YZ G s~`1RL Ov<tvRSN Flood plaune!=.z;ien,itapplianoie tiA _It
S= suilatle for spstem o.".`.?^,Tlfl`idL V''.,; _ IN 3n^.UNJ F355jUR_ I P--G AO= v°". 9 IV FILL HOLDIN3 LVd{
U- Uns.ri at!C for system I S❑ C~ S U I S G U Ld S❑ U I ICI S O u i O S Ru
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Co or I Vottes I Texture Structure ! I GPD?ft
4u 6n. Pduns27 Cu. Sz. Cant Color I Consistence E r~ Roc , -
_ Gr. Sz. _q h.
Bed 11•
J o lpktz 312.
- ~ ~ >3-L$ IO`IlZ all - S:I I Z'~562 ~ r~S~t cg I b
Ground .5 . 3 1$-UO 3 rr2 3!y -
elev. S a G F It JS J >j
g92.oIt I I I -
Depth to /
bc:org ,
factor
>1l0' ~ Gl
1r---
Remarxs: _
Boaq #
J n' 2z lp M R 3 I Z Isf
B Z zi-53 C i23It, - siI nSSle IKrtr-~--L _ S
3 S3 4(, ~.$Y2 9L y S L Gt O S5
to S _ Z
Ground I- _
elev. t 95-wo' 't:3t-1%,LW
292.8 ft y " 5 O S9 M I _ v1 ' X -n>
- I
Depth tc $ qS,b ua \Uti-2 L!3 LlN1 LGy1S Cj3~~pc GmAng
factor I
I
Remarts:
CBTName: ?.cue Pint F, 9ne:
-
:Arthur L. Wezc_ - rer 715-425-0165
tegerer_Soil Testing & DesignServd.ce-i'.0. Box 74 River
Falls, WI 54022
signature'.
j q - Z 9 WT Numbee
YT r r.rc 220254
PROPERTY OWNER CtKMQI: VQVcr..SOIL DESCRIPTION REPORT Page -7of~
PARCEL I.D. a L ti>pl lv G
# ure
Boric Horizon eplh Dominant Color Moltes Ft-
n. fv:unsull Ou.Sz.Conl.Color Fexluro Conssten~BOUxiary Roots GPD/ft
Sh. Bed Tet., sblz M.Ar cS - S .6
Ground 3 - i6-lo$ ~.S UZ'~[y _ S 8 6> v Sg M - $
elev. - ~
Ueplh ;o - - -
firming
factor ~ - - - _
1 O$ -
I
Ilemarks:
E3o29 tfi
I o-? r!,'nz 31i `.i I _•='fSl,yc__ c~t~~t ~w . S ,6
~ ~ K-~S t'J `1R 3[6 _ _ - s i I _Z.vrrsbFi -wt`~'r c ~ • 5 ~.6
3 tS-lfo 1•SItm 31y _ S Gti o -
Ground - - S9 MI elev.
S9S_$ fl. _1-
r,,u nn -
>L !u
:
Ficmarks:
Do[" •19 H - - - - - - - -
n 0 to rr 31z - sit Z`f5bn &S)r)
' !O Y2 3/6
: - l0 1 - Sit _'i'sbtc Cn'fH ry _ .S `.b
-).S y1z 31-y S ~i 6H O s
Gloorld
elev. - -
h~3J fl. - -
Depth to - - -
!irniing
`act-r LLL d I.
7110" - - --.__i_
- 3
Remarks _
3onng ffi -
sbk -A-
IV - s 6
t= -L zr-6Y1 1O`ttZ 316 _ srf 2^t S1>1z m1~ eS
S
648~/ 1.$yR 3lY -S4
,round 3- _ _ U S9 M1 cEw - •Z ~ •t;
- S 106 Ill
)epth to FS 39 - M I - N fJP
wiling T
WS < SO°/o L!rv1
STo>J ~N`~✓TS
a-lor E
Flemarks:.-_
PROPERTY OWNER CUKMIJQ-k)M-
PARCEL I.D. k Dcl,, SOIL DESCRIPTION REPORT Page_Zol-Y
- S°L /l.r~l rv to
florin Horizon Depth DominaniCotor Iv'ollies Structure GPD/Il-
i~lr in. Plunsr,ll T'exh,re Ou. Sz. Cont. Color lCons,I)once &x,rrkuY Roots
Gr. Sz. Sh. Bed Tee
C'.. I 0~9 l~y-ik 31L _
- si4_ Z 4 sb~cc~ - S -h
-z b Io `1v 3/6
- ;,1 sblz Grcurd y S d GV• 0 ,3 Def,l;l tU wiling _
fn°Inr -
Remarks:-
- - - s,I Z.~,sbk m41- cs S..t
31
Ground - - Y - - S 4 GV• 0 Sg rh 4 . S
elna. - -
R•1S.SIt -I j
Dep:hto - - -
fniur - - -1 -
l iemarks:
Ho~iby t! - -
Io'-r¢ 511 - s,'t Z`fSbk r~tSh cw !
Ct Z ,O -Z
_ 10 y2 316 _ S11 7.~131AL LW
ITti- t S I.U
Ground 3 ?2_~to- 1-S YR 3!y 5 of6h U S5 Vvl1 _ ~
elev. - - -
Depth to
limiting -
factor - - _ _ - _ i.
>IIU" -
Remarks:
'Al >r
10
t ~ _ ° -Zy_I 4 U`•12 3 l L - - _ r 1 2'~ S bR r~ "I ~ " 5
x ~ ` Z 2 6 1o`nz 316
3 d 4-8y I -l . S'Y Iz 3 fl. 6l- .
around - II O S9 -M1 cl.w - •~t
;lev.
oDDII. 4 - - _ _ S OS~ M~ ~W 1
)e(:Jh ;U - - - I- 'f S U 99 M 1 N~P
inning U~
actor r~7uS < Sooto LI,hE5TD1J _ F GI>Lk~ S
Remarks:
tcr and dL !iv"Fart"°la"r-os!•
L,itcrman P-Iaoce SOIL AND SITE EVALUATION REPO
La REPORT Pare l ci
Drii,ion of Sarcry &
in ar,CC•d r::;h ILI l::i =3.Cti, :"1's. Adrn. Code
CCt,fiiY
Attach corrplete site plan. cn paper not less than d 1;2 x 11 inches in size. Plan .Trust induce, bu: ~~T' ~-b10 LK
not limited to vertical and horizontal reference pcint (Bfd), c;rection and 1- of slope, scale cr PARCEL LD. S pt~p ,v 6..
dimonsionod, north arrow, and location and cis:arco to nearest road. '
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION ~ED83Y G TE
PROPERTY GTifiERt 3C-E41't_ CA-. CN (
C0k.1Z11'1 trxr%ttt -`t~~l U\?wl~\vT CatLC C"*^=>T S E 1:: v4,S2y T 2 L N.9 0 ETC
P..;C=EP.'v CvVNER':S !.1A LNG A.CO RESS.
\Z?, p 1 e.~.JG•t2l?t. - U..'J'A•41" OR GS~N U
1 ti0 _~'Zo , t ` t~.
C;Tr.S_.1Tc - 21P000E PiiCNEENUMEEa .n_PCT T.
e . 1
L.rcT ni c , r-L rv `=.:'-try c 1 n C~ow, a~_~T aoAr,
Two`( n-'h 3N` L ¢ot~p
(kj New CocsbL^5cn Use Resider.tal lkrnoer cl tedrorms U Addis r to exist'r. w d rr
[ ] Replacemert (]Public ^r am Handal desa'ce -
Coce der:aed daily Pow• Loo cpd Rec^ nmeMM d=<icn:MCirg :a e _bed, e°z'R2_' 8 ter, h cpu,~2 -
AbserPlion area rc-au:red `,S~ bcd. t.2_7So tench, i? !,1ax17L- design icadinr r:e tcd. gpdifl2_ g 1e.7ch, t
god,:f2
R acmr, ended infii7aEon sut'ace e'C':etier(^ rF_ F= P~F.- L/ ft fas wE-Cd P^ Site Plan benchmark)
Aaditcnal design! site ocis derabors NJOTI 7ZI N Srntl.L~ ~P G I`. _ -
Pa•entraterial_ L.Ot?t5a oQ~M G\ft\CiftL Ov~tu~S4 -coCplain ele:a!';,r.,i'apFrtte_ -1A tt
S=Scitat:efersys:em C \';_\il!T•d-l O'J`,C N3n,2LVp=.r.,Ea"L;E i^'rCc <YSTF!A "PILL HDlCIN3 ;R
U=Crsuiet!aforSVStem I RS Liu I ZS na I S ❑U bSS UU I k5 ❑J I ❑S RJ
SOIL DESCRIPTION REPORT
Dept` Dominant Color Motes ~ ~ Structure I GPDrft~
Boring # Horizon' Cc1 luIn. Mur.Sell cu.Sz.D:.r.tColcr axture ser~D y Roots
M~ X 8 i 16 4 i'z 3 (Z 5:1 ~2 Z S 'rt L~ _ S _ Bed ; rcrc
11
Z b-l8 loticZ 3I6 - I sll I Z't~56k~~S}~ J cS I .5 ~.b
Ground 3 18-\l0 , S to 3!y - ~SGGI 05 I cal .-1 J .5
elev. - r
s4.oft i i i-
Depth to I I I f
filnitirg
fwtr
> 1 lo' -
1
Remarks:
Bonin n
lV~ o-ZZ lp~t2 312 _ p t
B c S
z •Lz c3 lC 1lZ 2,16 - sil ss' `5 s .6
M
S3AL 7,S`iR~ly I _ IS36s L~S9 MI c3 1
` - -1_
Ground
- -
elec. <>ti-too ,~,~,tz y(y _ ?
' ,v
a9_a rL - s g3 M I NP ~
Depth 0,6W S S o \ D`t R t /3 Lu-1 4e 'vT4 c
I e~4a
liiintng
factor
Remarks:
CSTNante: P'easePrinl - n••, -
Arthur L. W.Ferer e 715-625-0165
,f C,a re.r SOil Testing Design Service-P.,. Box 74 River Pa1ls,id1 54022
SiPna:urc X47 - I -
CST Number:
\72_ll-49 22025+
Ncpr~yTY owtiER ~uFJR QEkXt-l- ~tV SOIL DESCRIPTION [7EPORT
PARCEL I.D. a--pL,lrp)1vv Page 3 013
Br ~g # 40ri7011 De V1 Dominant Cobr tAaltes Structure
iyo n. I ?,lunsell U:r.SZ.Conl.CCcr Texture Gr. Sz. ShConsistence F3curciay Roots GPO/fl
. E3ed T~ -
2 Il-t-"A l(341? 3/L,
Greur9 3 3L-wzd 1.Sye Sly I -
(I I C- v,
Depth to- I 1 - -
limiting
factor
I ~ -
Remarks: _ -
y ~_-!o tot>zjlt _ - ,+t (2{sblZsl~ _ g 1.6
~a wr
to zs 1r,,~ Zsb>z--~-
- Y~t~r c s S !A
3 1S-tort '~.S `12 31 y I , c[ 6!- O S9 ~ Jrt ~
r iemurkS:
Vl l~ I ''i'Za t~ tl~ it.
i--
~t4 t:~oh mot Z~j
L Z -~-3'u`tt- DIY Sr1 3~'3bh - _ S{.6
wt't ~ e S
•:;und 3 F~3 -S3 _C', Ll rZ- 3 - s F l F;r y Uk
_ 1*1~~ C S 5 ' • 6
836.01, y S3-90 1.S`1R Sly - Sr~Gti UY9 jNI
-1
Depth to - I
Remarks:
FilW5y
~~rat t. - s ~8= )o4 R 6t~ -tsar _ rva rum
' ry
f?err arks
PLOT PLAN Page of 4
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CST Signature Date Signed Telephone No. CST #
PLOT PLAN gage a'
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a
~i 0j. f' 1 ~v 1170.
1 \1
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4-2q~_ltl0
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CST S,grature (715 ) 475-n1s,;
Da,e Sigr.ea Telephone No. CST
P:~oP:fiTY O'P+F1ER WRtT1u~.~Tt;t Dt~, SOIL DESCRIPTIOt,l REPORT
'AACELI.D.>r_.- n't.~~llrvru,- - Page 3 0!H
1 rng # Horizon) DCPth Dominant Color t'O;yes
11% o, in. F.1r,csell Ou.Sz.Cont.Color foxture Structure Consistence E3prrr~ Rcotsl GPD/!t
Gr. Sz. Sh. +Y
iZ 31i _ Bed IT'Eildi
Grand 3 36-tlt l. S 1L
I
- I- -I ye - - - ~ S A'G4 f) 39bk ~~`~1 CS -
rv
e?o✓p la I I - ~ - - I-
Iciiliry - -.l-.-I-`-.--I-
Remarks:
iy l0 L1Q`.IQ 31Z _ >II
- - - _ 2{sbt~sll ek, - s 6
H 10-ZS tofri/f, Sr'I -I- I
~zs-ID9 ~.s `/R Sty - S9 -
cr,;.nd 3 - - s 'y G> r, 1
ept :0
~Imting -
>7I09 - r - - -i - - - - L-- - - - -
i -t t- t
r~,nmarks:- -
tyv. ~__zZ tO-Icz~Izl - -
s I l ~'Csbk
mph rw .s.[,
L'' zz-33( Lu`tt )1y -
s .
a -S3 to ttz s/6 JI sr l `trr Sb4c rt~t
efev. S&6_qL 53=90 ( ~.S `tR 3tyl- - Sit Gr U sq -
Depth to - I l- i
limding - _ _
`zctar - i
Remarks:-- -
I I o-I$ I Igytit 9!2
yy-S z! S I23/Y SsC6} USg rh~- cs
;round I
P SI. ~l SznB )b4lI (/A
1-
iepll! ;o S - 8 - 1 toy rz 6/ - LS 8SZ l _ -
imiti'IrJ ~ N~ N~
uCICr
Remarks'
SOIL VALUATION REPORT 'age_
'MSWnvn Oapartmenl 'w:Emen;e t
-
71V111c:1 OI $BION 30C HUM Ns
In xcardarue vnth Comm dS,Alm, CodO
'
AnDal CAmp ole site p•an on capM not tens than d ~tz x • 1 Inc Os 11 s{a~EP/ E D P• I D 1 30f, _ 6;6 - / S-6
lace, L'ut.sKllr tod lO .amWl Ntd nam,lal ao,,uo Ot (,istdP.A 10 OeaIe11 LDd
;,tarco(e siooe. scale or d,M,WUl os• 1Or10 GROW dn Jf10t0W110nO~d ;llSl. - Dale
I ~ Ha~Mw00 by~
Please print all information.
vve r.a.. r. t50n I ~<l ,J,✓h G3 ,
V~nonu mtom'auon Ycv worm m>Y muE lnr uco^-E~ry uw DOrex
--'PfnDa(rylVCaaO+~ i
PropaM rJebor ` _ •r '.3 ?l) -o(i'!I
p J .A. r.'-ca c,~. __vd Sr "a 4 2+~ Z8
'CU~IVENS _ C`_E LGfannEM CDr\1.
~Vt o .:IUO U swo vame« ~e
ProperrypvrnOrs Meding ACCre11 u1TE ID6 55 TRO`( U{1_IJ~G6 (,-"•j~DUN~
11 e 0 h(3FXDT~NJ STT.E1 Wile a own noarusl HCOa
j Clq huge Lp Code 'hme NumOer I C'.:v L.-''' 9
.t-r-75~8 -~~OV ~Ltr.ioSAY KD_
ILL A j.>JE :x14A1 $544
haw (:«19INCtIOM1 !JSO:~ Hefdef•11DI! NUmee! JI bpo(OOm$ '..Ode dented design WOW (.110 _ V' =Q_- ,
ROPawrnOrt /1~[T~ A.~ F'vDllc 7r ; IeMal - ~AsulbJ
P3IVnItNfBnal.y~[,aIWLY ~l10VIAL FIVW flail a'.eVaacn 11 OP--WLL.
'ienerJl JORJnOM4
anO rec«nmerdauonS. LOIU D@JJ~CON AL LJJ-01RDUNC7 TREtI~'.HE"
O,7 LOAOJ/s' KATE
~ I
coring n q45. _ Depth 10 Am"nq cr cuuon Hale
irnuna sunace elov , = ,
n,
Hontor "`apln Dominan!C«« .Babox Descnp:ion -oxture ;tructve IDu+sutanca. 3c;+ndar•,+ our-ls rrpZ
r.~~nunsel _ 0:,. Sz. Cnnt Cc••^.r i ---1 -
I_ I i 0-!~Y~z ~ r sl l i 3f-LxlaC a~:~vF~!~~-~-{ ;
.7
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t77~2JJ, ~y ir•, I
~ p,; :roun0 •adece etav J-n v . " Depth fo Ilrry Ong IDCar 7 _O wit :.p ~GDtlC.1 -late
Homo.) 0010 I Corrnnant (0404 ROOOx Des«tpvbn ~extu(a olrmture : Ca%Mslerwu Joundaryl Rf%>I ~~'MRR^O2
it _'ALnsOJ Oo. BZ. Con: CaOr ,r St Sh..
1
o I ov zf~~J~.
tiff_I r I ~.Y 4-~ '1
IL _U uK 13 ` m~
7
'LL 3 X-24 o .441, ds ~s ~uLf 0_7 t.z }
Li 26 -40 4 D -
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t:'flLanl et = 9OD -10 1120 mp+L Jrd rSS >30 • mryt ' ET•:ant r<I • 3CU, = -0 rnq•'L v1O TSS < 30 nxyL
SlgnaturO to>T No. nnei
:ST tidrnB IPteale Pnntl
rY}i Y .j0 H."+l L'v~F'. t:- 'uwuror»N.Mm r '
~dj- - Data Ewtueoon OrKlucsad
w'S75 ~o'1, AVE. ' :yEti T Att: '.j7 5402Z