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eery.' AAid 1e oixenn INSPECTION REPORT Lq enilx
GENERAL INFORMATION RTTACH TO PERMIT) State on mien SAN-2019-170
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Alex 8 Kal Williams TOWN OF KINNICKINNIC 022-1096-20-025
eMa., unded serve sx ovewl� e.uxtrte.na.M.Mrw
33.28 18 519A-25
TANKINFORMATION ELEVATION DATA
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TANK SETBACK INFORMATION
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Report of Existing POWTS
Current POWIS located at 110B county Road K River Falls, WI bebnging to Alex & Kadlm Williams is.
al Capable of handling the proposed wastewater Flaw and contaminant load
structure to be served. Initials e�
bl functioning properly and is not failing Initials
Ci Ingoodmndition Including the 1250 Gallon Wieser Concrete holding tank, 75p gallon
Wieser Concrete dosing chamber, manhole covers, and baffles. ' ®/
Initials n/C///
di Going to meet the setback requirements. Initials �,�// ZA
�,C /�C
Signature
Date:
plumbers Name: Robert Kolashmso KIPW 226207
ii!iiiiiiu iii
f.,�*KEUM
St. Croix County
1083658
Affidavit for a single POWTSru
WITH
`EREGISTER
servicing Two Structures via Private-lulcreepWr M1iain
OF Eor
111ex A 1 oWK
reeeeo MR RECOrao
Name —(Owner) Typed orpremedoaliano.vmo,
ea AN
being duly swum, states, under oath, that'UN 27
RXEnIlw5he
2019
Li
cow
n the ownemmovmer of the hollowing"melaG3mBr.Onrx
PAGES,Itoo
Cowry,W omm,wordedmvolume — Page
/O / / St Crou Cormry Rmister of morel, Office
Name aotl Remm AS"ren
A parcel of luWlomlN mNe$1.14. of We /%U'/.of5ecnou 3�},TANAIMI, Rw Willlrrt
Twor of k:,wdrJ�..l „a. Goo. Colon. Modems, hems duty dewlxeu 10t T
fellows Include lot ad/orer' and xa ilmoimi SM or dmillrlMpl
lend aounmm a u+ E:a, is ryaei
IZ543o PUe, 619 022-/096-rbo
Jelawe.27 (PIN)
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pen nferbumumnml Amuxmaof IS occuporm mpe e rmmM, rfine number a ucuupent, eud
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"Goadiwer l PlM4jrnwmpWoome, in DO future
13J IunaersMetureryGasura of Nix mlormum will to madebmy punt
mruesrm m Wrehuins Itrxgopeay in Jd fumrt
txrmaix 11'—'mrof zoi%.
Il
AUTHENTICATION
SrpduMfl
Ofno,
— — nammrua by; Ta oe, Wn SO[,) *: `
THIS NSTROMENT WASORAI•1PD aVry oOF
64. u.:w C' „1.Q 64tJ Ill �
(eigdNm. der beanmenheMaoraannwroagen noNea
am nummsr.)
ACKNOWLEDGMENT
STAIUOP WISCONSIN )
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