HomeMy WebLinkAbout182-1028-40-000
"0O r' St. Croix
:.core:~-uepar•meYt orPRIVATE SEWAGE SYSTEM
Safety aro Bsdony 3, Dr
INSPECTION REPORT Sanitary Penn: Nc 615395
GENERAL INFORMATION IATTACt 1 10 PFRdITi sate Pla, ID No
Pe-SOnal irfonnat on yc- Drov Ji: -'ay t+_ jsvJ IDi Sc~inC art p-fG-DSe51FY ro.aGy , aw, s 18.7- ' 1irr01
Per-n f hldci's Narru• C, ti V lage `Yw'nsrip Parcel Tax No'
Matt & Alicia Page VILLAGE OF STAR PRAIRIE 182-1028-40-000
CSI Rrol Flea Insp BM Flea f]V Llcscngl n $P,CtIC 9rTY,WrlRanac ".1ap VC'
311706-31-50-02-01-000
TANK INFORMATION ELEVATION DATA
TYPE I,IANUFA(l URFR CAPACITY STATION BS HI FS EL FV
Se{:.tic Benchmark
Dosing At . BM
Aeration Bldg. Seee'
Heldmg SL'HI 1iiet
TANK SETBACK INFORMATION SUM Outlet
TANK TO P1 V';ELL B_DJ `dent to Hir nta•:r ROAD DI Inlet
Septic Ct Bottorl
DDS no Headerftdar
Au,at on D'. sl. Pipe
Holding Bot System
Fina Gradc
PUMPISIPHON INFORMATION
Nlaruraclu`er Denrano S: C:;ver
GP"
r&ov Numcer
M?i Lift Ftn Ct on_uss Sy's:em Head IDII Ft
Forcerrain Length Dia. Dist :c'W.-ll
SOIL ABSORPTION SYSTEM
Br DrTRENCM d:h I rrr p'n N, O"re-der; PIT DIMENSIONS No. D` P is InSice Oia Lieuic D:pln
DIMENSIONS
SFTBACK SYSTEM TO PtL BLDG VVELL. LAKEiSTRFAM LEACHING tvlanllact-rer
INFORMATION CHAMBER OR
h;c .O' ,te° UNIT MoJel Numcer
DISTRIBUTION SYSTEM
li&3 jr reT•`a-ihiC DIS1nC'Jlin' IIpP_Sre xF.^,eSoacirg Ve-1 is M(lntake
P De15',
le, Uia Lengl~ ?a,. Spac na
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Deot'~ Corr 7cpth C,O xr )P"l-.Yt x: Seecee'SoddP9 xr MWC~ec
Her.~TrenC' CDn:c• BeuTrmnc" EJycs TDp='-'~I Yes Nc Yes No
COMMENTS: (Include code discrepencies. perscrs present, clo.i Inspection #1 Inspection #2
Location: No Address Available
1 } Alt Bid Description =
2) Bldg sewer ~eng:h =
- amount of cover =
Plan revision Recunedo I Yes No
Use other side for additional in`ormation. I - - j
Data Insepcturs sgrwure Cer. No.
S?O.n r I I IR 3 lsi )
~ In lu I Nt nia D[sisiuu t, .I
~a ',I fl li9 141101 A1:nlnn ~pni :1tc
Zp I O 19,s II{' S,:n.h,re l u nd NUnbll In, he i.:.ed in hI (b l
5anitarv Permit nppNicatu Six, IrIn I. :;,.1Nundt•t
In occorcanct x Ih 1, P\ :x. j J:.. A-111 l I, , ,..Erne Ion of thr I " r Io the upf pr .:IC annxn . uuil
1 n IuhtJ p0 o I, r du, 0 0 tt r 1. rn t N,,% Nj t W n I.., r r. ;cd p (M 1 1c w ,noilcd to 4a.je.:t address 111 JIilelcn; than Ilalhn0, aJdlr.a
the Deparll tens II e 1_' art 1 r t .I ti t I ::n d 1 r 1.11,1.1 ..u punldc Ira-, h. Ib1 ,tit nlarv ~O.
furp. r, rJI ..,oh the I . I.::t I :,It I Iin X6as -Y/ / ) /a~~~ I
1 Application Inhnnlahon Please I rinl All {{fAAAY ntation 'T
Illuty N1 $a ~~~~(Y~U s
I npa-IV Oa' Al a// addl." I r-pure 1 ar::part
/ G
Govt I'll:
l slat, a /If OXIC
: - 1'ha^c \uathtt Swill,, (cirN our'
II I ple of Bmldiog (check all dual apph ) Irn I `7 / N. H 7 1:00
~ltr>F.IVnLU tli qs Mu.Irv nl l(:'<IOarIL _X N Jr i O.~n Nanc
' lS;.xkk
I of w ('oc nl r is - D,-w 1Ee l sc Ok
I C/d8 ~y 1, ilDrcc rr
[f ti a4 (hsne I Dt,.1 the l7_v SM N_,l-,, o3
IIL'I_ype of l • mil: (('heck only one has on line:\. ('omplete line B if applicable)
Nr:r S,,,tcn. [i f.ep::,e:11, ~cN:-n ❑'Ir.~bmlril In~leiC.:l ..I~JCIIN`11:Only ❑Uthcr Nloti¢irman In Px.vunt, Syslcn lcxpla:nl
Il. n P,:rn . I< . r:1.I. I ❑ I'.:.n t Hr:"an y n i I ut Pr ..ous Penni: Numbcr and Dale Issue
❑llu. gc,a Lcnbn nnl 1):nulcr to ]nu'
Iiclo!c l tl a nO" a
IP'.'I _'OR'fS!q'om tuocoV la'iec: f( hcckall that:reply. _
Non-Pmss. ( Gol hound `,c [n-Gram.; ❑ I I,AI ❑ Mo,ald `J F,
of surablc sad \1.111^d '.Imo' +uraf:tc soil
:m It Ihpcll, lti-Ip".-I!c~pfac.l - ❑I'tt•l: eauacnl DC%WC(ccplaml
\ Dispersal Illall cnl.\rea lnf.rntalion
Uts I Iu•n I... Ik.: d 11 -dr,a K,:cl dv(I I)upersal 1r - lieciw,,'. hll D spLmll Area 1 ro7poscd I, Nsslc . I:Icv-.Ien
\ I. Tank Info Cara, pry i. I tal o nl M;n0luclu:ct
l dl ns (;x00,.1: IF,11,
n t mg I unA. t ~ ~
o 16k 2,:;
SZ '
\ 11. ltcspuiurblhh' Stalemcnl- I, the undo rs....... a+sumc re.pnlr\rhdily for inslallation of the LOSS IN slme'n nn the atlulled plan,
u rFy t N-III-- s y, } 1 a.tbrd .KU / NIP \II R( N n'hrr 8 ...>c I hone Nurher
11 nrrcl
\711. (honk:Ih• at t nlcnl l sc Onlc -
pe,nH:fec• Ihvtc surd h+uin•:-enl Nl ilu
I\.( andil callus fur, Dis:gyrnls nl
filypKry b1 NIIIM aW Of.~l1~!/..Ll1°i'~ ~ '
• (1M i1WV~ phf( pro 4dlrl IN f1h Nw.
2 M tMOM IKLWw.W 111111Md Iw rM*ir.! 4
W W ►ppkfth to61 / d.MM
tn:.cb n.. nnn.1", pun, r... II., - IF F1 a ul 1..11.1..0 F. the < . I...1...nI I an pa pr .1.11 11•, 1h;I s I:. I 1 .ne 11- 111 o,
tillU-(.?',N U2 (IN Ili
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:_-
Owner's Name:
Owner's Address:
Legal Description:
„}n.t r:=>cr R
Township:
County: _ V, ~X
Subdivision Name:
Lot Number.
Parcel ID Number. -
Page 1 index and titic
Page 2 Plot Plan_
Page 3 system Sizing 8_CrossSection
Page 4 Filter Specs
Page 5 Maintenance Information _
Page 6 Management Plan -
Page 7 SL Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
rage g CSM or Plat
Attachments: Soil 7 esl & i iousc Plans
i
Designer/Plumber. License Number.
Date: Phone Number
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS version 20 SBD 10705-P (N.01/Ell).
Pane 1
/ l
~i, ~✓r:
i _
-
G ~j
A f~rAv/ /il'rsRl. 1of~ e~ T/~/.~ ~~G`V G I
`/c =sue
5 C \
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I _
_ _ - ~ s fry' /
- --=~-tt - - - - a"_ ~6- -
- -a -
~ _ it
,~~.~,~i_' ~F:7
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qa
1
Soft Absorption System Cross Section
it
Final Grade
4' Sdiedule 40__..~
PVC Vent Pipe
With Vert Cap
Leaching -
Chamber f - " H
System Elevation
Soil Absorption System Plan View
ft
h {I~IICI11i(Illilflliill111~iI111IlI1II~If1I1II(IIJIIIIIII~IIIII~IIILI~~
':.caching I' [Trench 1 j
Vent Or Observation Pipe Chambers
i 4' Dia.
Header
- Eeaching Chamber Specifications `
Manufacturer And Modeler
EISA Rating sq ft prr chamber Soil Application Rate' _ gpd/sq ft
JL gpd Design Flow ; Soil Application Rate EISA Chambers
- -
- - - - 1-rows of - ==chambers each.
Page _ _ of - -
Mews
PLAN Elf LIAENf (COA CZ-OW
Pnlyiak hec is pleased to add its
now con=KwcW ill to iS e2doti g ~ a
ime of grra6fy aNuent Olem The
Pl_3Zri is fated for over WAGO GFU
ibaiu imr d o n W&V it one of
the ~ fftm in its - atiarroahade
das& it has ~ lrrrear i of 'Ice s
Oftalou dais lien the P dr" a s
PUM the new Pblylok PL-625 has I
an atarrrabcsturtaff hai inst3ied satr.~aot
aE1lrt: s
lifth emmy MEW V Awn the cite is
ranor®d fordeazvK& the het[ wig tirair. ~4 _ t~aelts aver
toot up and lenWora V start off
the sysl mr so tie eat rrar4 €
taetvefhefaf ifbsa4/i~a»eraw -
tiieauietcartiaFCfaem! 4aeirp~e
PL-525 A ak~arms: i
r
ThePtAa5 oEFWardiotdd
opaat3e aflicimwr forsevaat years 3 r
upder normal aorrdiliars before ` 3
re - g daackmi. It is racarn-
nrarded thatthe iipa be cleaned
awary Urns the tots pomspad or
at hest araythms yeas ffibe r . s
i ed"her carr- - anoptiortal r R
alarm theowner wM be
try an clam simm the filkw needs L -
s svkirg servicing shouid he
done htr a aer9Sed sspOCtank C
p®eper ar insEaier_ wrrrorfe ~
t_iora6afheauffet of an rliw.er<,r.FpAW,.aa
s
Lilmrwetantawerandpranp _ -
tak it .rSCOGMary. P1-_9j25 terSCa[jatiQn: I- toCaoa the aetht afthe
3_ Do natuse pkmnbing when sepdctaolc
filar 6 removed. Ideal for rusidenbal and mm- Z PAnx ue rite tardy corer and
4_ RA PLs~. are offha hot®rrg. rnerod waste flows up to pump 1a - itnecessavK
Flaw affiiaaara -the septic WJM Gaiws Pa Day (GPD). 3. [luethe icier hdaeg to the
tank Mdaserve atl sokbfat 4' or W outlet pipe ffffie
back into u*dctanlc titer is not contend under the
access apermg use a Polybtc
the is properly mined and 4L Irrea- the PL-W6 ima mb
omap k%* itrsaaei sa hou*kw
T- Rep(aca septic faint owa: 5_ Replace the septictant cover
W 1=
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of-
FILE INFORMAT N SYSTEM SPECIFICATIONS
d- Tank Manufacturer ((,'/^_'r~C ❑NA
P# _
Sep
tic ❑ nose CI Holding Volume; (gal)
DESIGN PARAMETERS Tank Manufacturer NA
Number of Bedrooms: ❑ NA I I Septic ❑ Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: NA Vertical Distance Tank Bolton(s) to Service Pad: (m)
Fstimated (average) Flow : (gallday) I lorizontal Distance bank(s) to Service Pad (ft)
_
Design (peak) Flow = (estimated x 1.5): (gaway) haizmal's 150 feel ins mast r prouiaee if veer ov is >t 5liter k-
. Spkcdic ' rovided on back.
In Situ Sol Application Rate: (gal/dayAl?) Effluent Fitter Manufacturer 7 to be p ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: -
Fats. Oil & Grease (FOG) 530 mgn Punp Manufacturer.
-
Biochemical Oxygest Demand (HODS) 5220 mg/L ❑ NA 13 NA
Total Swym dod Safds (TSS) 1150 mg/L Pump Model:
High Stre gt h IrdluentfEflluent Monthly average Vrelreatment Unit - -
(FOG) >30 mgn_ Manufacturer.
(HODS) >220 mg/L [A NA ❑ mechanical Aeration Lit Peat Filter r NA
(TSST >150 mxyL ❑ Disinfection ❑ wdiard
Pretreated Effluent - Monthly average ❑ Sand/Gravel Filter ❑ Other
(BO%) M mg/L Soil Absorption System
Fecal Cotifmn (TSS) :.30 mglL NA
(geanetric mean) 110' 14ir"3iound (gravity) Tl h;-Qoud (pressure) ❑ NA
[I At-Grade ❑ Maxd
Ma)dmum Effluent Particle Size 36 in dia El NA ❑ prip.une ❑ Omer.
Ofher. - - - - -
❑ NA Otiner' ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump oul contents of tank(s) S1k When combined sludge and stun equals one-third (X) of tank volume
❑ When the high water alarm is activated
Inspect condition of tank least once . - ❑ math(s)
(s) At every: ~ tearts) (Maximum 3 years) ❑ NA
Inspect dspersal cell(s) At least once every: U'nO1tMs1 (Mmndmtm 3 years) ❑ NA
- ®year(s)
Clean effluent fitter At least once every: mordh(s) ❑ NA
_ - Ye(s)
Inspect pump, pump cols & alarm At least once every n ms's) NA
Hush laterals and pressure test Al least once every: - ❑ month(s) El NA
yer(s)
Omn: Al least once every: LI month(s) I I NA
❑ year(s)
bong- - - -
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an irxhvk W carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWYS Inspector. POWYS Maintainer or Septage Servicing Operator (pumper).
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 so m and a deck for any backup or ponding of effluent on the ground surface The soil
absorption system 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 ponding of effluent on the ground surface may indicate a failing condition and requires the immediate
notification of the tonal requfator y authority.
When the combined accumulation of sludge and scam in any treatment tank equals one-third (1'4 or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code
All other services, including but not imted to the servicing of effluent filters, mechanical or pressu®d components, pretreatment unis,
and any servicing at Intervals of 172 months, shall be performed by a certified POWYS Maidaner.
A service report shall be provided to the local regulatory authority within 30 days of completion of arry service event.
GMW-005 (02A5)
START UP AND OPERATION page d _
f-or new oonstrudion, Prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system, If high concentrations are
detected have the rxxhtents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be discharged to the sot
overload that may result in the backup or surface discharge of effluent and damage to the of system in one large dose causing he
contorts of the pump tank removed a Septage To avoid this situation have the
or POWTS Maintainer to assist in Servicing Operator is unfit Priore restoring power to the pump or contact a Plumber
manually operating the pump controls til rhormal effluent levels are restored within the wane tank.
System start the shah not occur when sell conditions are frozen at the infi"ve surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or oft3wise, disturb or compact. the
area within 15 feet down slope of any mound or at-grade sell absorption area.
Reduction or elimination of the following from the wastewater stream may improve the
tanks and soil absorption system: acids, antibiotics, baby wipes, performance and prolong the life of the treatment
diapers, disinfectants, fats, foundation drain , cigarette butts, condoms, cotton swabs, degreasers dental loss,
scraps, (sump pump) discharge, frail and vegetable peelings. gasoline, greases, herbicides, meat
mediratrons, oils, painting products, pesticides. sanitary napkins, solvents, tampons,, and water r softener brine discharge.
ABANDONMENT
When the POW TS faits and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and dher soil at>_seplion systems shall be disconnected and the abandoned pipe openings sealed
• The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator (pumper).
' After purnping, al tanks and pits shall be excavated and removed or their doves removed and the void space filled with soil,
gradd or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code comp!ia;11
replacement svstem:
❑ A suitable replacement area has been evaluated and may be utilved for the location of a replacement soil absorption syshurn
The replacement area should be protected from disturbance and compaction and should nol be infringed upon by requirF l
setbacks from existing and proposed structure, tit fines and wells. Failure to protect the replacement area will result in the necd
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at the bme of their permit issuance
.
U A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in 1'OWTS technology, a holding tank may be installed as a last resort
❑ 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 folding tank may be installed as a
last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomal at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING ENT T SUFATMENT OXYGEN TO SUSTAIN LIFENNEVER ENTER ANYSTAMAY CONTAIN POINOUS NK UNDER ANY CIIRRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POW(S INSTgrL,tR
POWTS MAINTAINER
Name _ -
Name
Phone - - - - - -
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
Name ~ - -
This doaanent was dratted by the staffs of the Green Lake. Marquette -
Comm 8322(2)(tixlxd)&(t) and 83,Wl), (2) d (3), Wisconsin Adminis ratiw Cod thaa County POW IS regulatory agencies in compkarhex• with sections
t~!.nr OF r+t:w sntzATvr;A sRx:N'~;~;
A.L1, PARCEL qS UFC, I N WITH M'706-31 50
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Ryan Yarrington
From: starpv(alfrontiernet.net
Sent: Friday, July 26, 2019 10:24 AM
To: Ryan Yarrington
Subject: Shoreland
Ryan,
The Village does have its own Shoreland regs. I'll forward to our engineer for review. Please have the new address sent
over once assigned.
Thanks!
Amanda
Amanda Engesether
Village of Star Prairie, Clerk-Treasurer
P.O. Box 13, Star Prairie, WI 54026
0: 715.248.7131 1 F: 715.248.7501
FT TI l dr l:.i if i,- -qii
1
ST. CROLL C€)T ~dTY
SF,_p' TC TA.r-z, a2,.4XI r CE AGRZ.EMEVT
.4
.1%7D
WXER~ET CPXTIFICAnON FORy
•ae_ drirass l ([1 ~~t + ca
t czziicanon tvquierd imp G1nm9 & Zoning Depais nt inr new wmtuclioa)
L =.'Siaze Parcel Identification Numbsr e
L G_e DESCRIPTION
AJ6 1/4.61A-) t'rope'tg crcaaat ,Sec. ~P . T c31 'vT R 7 1V, ~ovmvr"^- ti
Subdivision_ Piar
_T- TAIL T
Certified Survey Map n Volume -z
~ page #
Io~2S
T°arv Deed., o0 (beore 31)Qivo use Pie g -
Spec -house D yes Lino lkt Ines identia'able r] yc3 3 no
SYSTEM ~NA_INCE AND OWNER CERTmcATION
in=ovuri we find maintenance of your septic system
maintcnance co nsists of C0121d I4gpit in tC4 brCII1Ma ](t; j~jl WC i0 band'-- ~yg5~~j. Propel
pumping out the sc~tic tank eve»-y three years or sooner; if need, by z
Iiceased pumper. pibat you put into
i 1e Sys'nt can affect the fiwcaon of LSz S- oec iaak as a trcar~ee^t s in the wash dsaosz syxtEZn Owaarmainzeaanca
responszbilkieS arc soeciued in §SPS. 38352(l) and in Chapnr 12 - $r. C:O Cotmty Sant I Ordinanm
T6o masse Own= agrees zo Submit o St Crgi county Plaant,w a
o m Zoning Department, a cattaca(ion fa m» signed by the
z and by master plmnber, journeyman plumber, restricted pln giber or a Iieensed pumper verhyma ' (I) the as site
wpstcv,•a? disposal system is is proper oP-ating condition and,'or (2) afar inspection and pumping Ctfgot at sary), the -spec taek is
less than Iii Pali ofsiuage.
=
Ywe. We untie cig °d ve read the above requir __ts and afire to maintai, Le nrieate sei.2ge dsposal system with the
sans. ds se fo:~h heran, as sex by ere D 5rmeat of Sau L~ And Pmfessionrl Sc v r~s and the
Stetaos'A%r CeraScaoons tithe ywirseflticsyse~has ,a Dzpartm= ofNaII¢slRsou,ccs,
CcrWey P"2'enng & Zoning De;w- nt %-t&, 30 day, Ojtbe th-ez d m'.= be completed and reamed to the St Crcic
Ilwe carnfy that all' statemenu on tbi; f07m an true to dhe bet Ofmy/our knowledge, Mve am/are the owner(s) of toe
property described above, by virtue of a w/aria y deed recorded in Reristx of Deeds oticc.
,Number of bedrooms
- Uf<r
y nfo~arioa fret is misrepresen~ ]may result n tine saniimy permi bung revoked by the PIMM Dg & Zoning DepartmeaL
include wire tlris aapticaeon a recorded warnmty deed £rom the Register of Deeds Office and a copy of the csii5ed survey mV ii
reference is made in die wa1*-znty deed
(RETV. )D+!Il)
(f 5-7 -do lq _ /77
'+Iscn•rsin Ll(Wnn'ehl of SafOryand Pmfoesionai Services - - ?11
7.:•isirv U' Inc„SU•/ S.=rv!GC. _AV Page of
SqL EVALUATION TORT
In amordance with SPS 38ti.:4'Is. Ad") Code County
llac n comp clr, sde elan on P
peg not le 'than 8 7 x 1 7 inc m site. Plan roust c. , _._j_..---A -
cj~ -
e.t limi'ed lu, e•tiCal and horizonla reOrull;:e poml (HP~) dre
, ~rcdinn and purcerl sloope, Parcel LD
,::ale weir em ors north 4•rchv and k^'•911nn and d•s!xrre! to noarem road.
C
Please pant all information. Rvme• • by Dale
P r ..ial iniomlvlwr: you ruvi,l , may Uc u .d `OI xeamC PLTOSOS {Privac'y Lav .15 04i 1 I(rn))
.
Properly Owner I - ~
Pfcperty Location ❑ ❑
1 1: ~ r
" Govt Lot i, T N R __Z1 F iorj
Property Owners PI Addre•,w Lnt # ~Bloa # Suad- Nam, or CSWI#
C{>',/ State Lip Codc Phone Number v
//villago Q vm ' Nearest Road
A L' 1 I I ❑ (,i,y
.LrL25.fF~l~'l~l~a':lc~_
Q New Construalon U:w:~ReSidenliall Nurnherofh[:dmrnnS_ Cnde Uclivw.!aesicl~'lav rate- LGPD
❑ Replacenlent ❑ PLblx ur commuraial Describe /
Parent material Flood P:an elcvaUon if appfiWblr.: h,.
General comments and recon:mendatons.
Boring # ❑ Boring - -
Pit Gic.eld surfooc elev.. ft. Depth :o limiting faCtur in.
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