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HomeMy WebLinkAbout24-45SINBOUND NOTIFICATION : FAX RECEIVED SUCCESSFULLY TIME RECEIVED REMOTE CSID DURATION PAGES STATUS October 25, 2024 at 7:24:53 AM CDT 7153724159 38 1 Received Oct 25 2024 22:42 HP Faxpolkosk Plumbing 7153724159 page 1 Request for Sanitary Inspection Fax this form to Zoning Dept when you want an inspection — 373.0114 If you do not have a fax and must email the inspection; you must email all staff members Note Time Change fl Discrepancy Other Phone Number 7 13 Fa Plumber: v( oS ?(� 6,-T 7/S 37NumZber L1[S ' Home Owner: J a n+f2 j Sanitary Permit #: Zoning Dept Date: z OK Time: Plumber's Choice Zoning Dept Immediate Phone Number so Zoning � �`3 0OK Dept can call you right back (if needed) ��1 Township: ( 5 Address#& [rro.ttvc` T4 K-2 iC S 1-f z 1 o�nr Road Name: �s� t 6o G r, q..: l7� L4 o or 9 9 ( C != R 4 L o a� 7 y�,�(� .,. c ( te r .� )-} `' -r 5 4 n Directions 6o al'P�Y r.: (e s -r- iZ4 -:`o Gv. ewc)/ To Site: I ret l(pbt(o S4HL ;i( r -k Comments: Reminder: You must confirm any change(s) that have been made prior to or this inspection will not be scheduled and a memo will be sent voiding the inspection. Thank You) ** Plumber must verify any change(s) by fax or no inspection will be scheduled ** informslean itaylrequestfo•inspection ZaNng Dept (09112J04) e August 2021 narerq, ��rnnL Industry Services Division General Information P F 1EANETTE M VILLARIN 20391 FREEDOM DR r REDERIC WI 54837 Tank TYPE MANUFACTURER CAPACITY Prop. Line Well Building Air Intake Road Septic i 2 7 — N/A Dosing _..-' N/A Aeration AG N/A Holding Private Onsite Wastewater Treatment Systems ( POWTS) Inspection Report (Attach to Permit) City U Village .cafhark to-, of: Sanitary PernAt No: State Plan Parcel Tax No: 3g. Sv`/ fl Pump I Siphon Information ump Manufacturer Pump Model Demand GPM Filter Manufacturer Filter Model TDH Lift Friction Loss Head Total Forcemain Length Dia Dist, To Well Disnersal Cell Information DIMENSIONS Width- Lent #of� Its SETBACK FROM Pro Line Building Well OHWM Type of Cell Manufacturer: Model Number. Pretreatment Unit Manufacturer: Model Number. lictribution S stem Header / Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length _ Dia Length 47. Die S Spac! Spacing 0 Yes 0 No Elevation Data STATION BS HI FS ELEV Benchmark a 3', 7 Bldg. Sewer L� 9 2 Tank Inlet , Tank Outlet t , F Dose Tank Inlet Dose Tank Bottom Inst. Contour Header I Manifold f s Distribution Pipe Infiltrative Surface g', Final Grade 4 X Pressure Systems Only Soil Cover Depth Over Depth Over Depth of Seeded! Sodded Mulched Cell Center Cell Edges Topsoil ❑ Yes ❑ No ❑ Yes 0 No COMMENTS: (Include code discrepancies, persons resent etc.) zI i/tn ,IFd te a,tis /4/ckiy1i# Onr,stit9 ('vyy, � r r esce ���� -� Js —O ,r1C/•� `lay w p P6dran nlKi? 7` ) S e Plan revision required? Yes Use other side for additional Inform o . Date POWTS Inspector's Signature License Number CRnS71n ip na/711 Property Owner Information BAYFIELD COUNTY PLANNING & ZONING DEPARTMENT Telephone: (715) 373-6138 Fax: (715) 373-0114 e-mail: zoninp(abayfieldcountV.wi.aov Web Site: www bayfieldcounty wi.gov1147 JEANETTE M VILLARIN 20391 FREEDOM DR FREDERIC WI 54837 Bayfield County Courthouse Post Office Box 58 117 East Fifth Street Washburn, WI 54891 r As you know i/r was contracted by you to install a private onsite wastewater trek ent system on your property described as: Notes: Abandonment of Old System to meet all applicable code requirements: Tank was pumped by: C. Tank was crushed I removed and pipes disconnected by: on at AM/PM On ( //7 7Z 7 at //3® (i!t I PM) the above -mentioned plumber contacted our office to conduct a pre -cover inspection as required under DSPS 383. One of the following applies: System was inspected and appears to meet all applicable code requirements. ❑ System was inspected and appears to meet all applicable code requirements; however, a plan revision is necessary because the installation was substantially different than the original approval. ❑ System could not be inspected because plumber covered prior to scheduled time of inspection. ❑ System could not be inspected because plumber was not ready at scheduled time of inspection. County was unable to return to complete inspection. System could not be inspected because plumber was not ready at scheduled time of inspection. A re -inspection and $50 fee are required. System could not be inspected because County could not respond to plumber's time constraints. Comments: UttormslsanitarypropeRyo ner-input Apr112019 (ZZ/i0'u) 86£9-QHS III sagaul O x 7,1 a ungp na! 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'9'ms16aenud 041 qi!m oauugoaau u! sasodwd P J Paso aq 6uw apinwd no uopauuOJul Ieuosaad •sao,naaS leuo!SSOJwd puu 61yes Jo wauglodo aql q pap!wgns aas SJ.MOd Paumaa)uls .103 suuOJ uopuol,ddy :o1o(y 1pwod 6milous o Smu,algo 01 aopd pannbaa s, 1I°u Isluawwano8 a!u,tdoadde oql of uuo3 slgl jo uoseiwgns'opoo •wpy •sIM'(Z)iZ'ESE SdS oauopjoaae as wn(y0opos uwya181S Yqm u( uoljvoTjddV TIAizod 111 WILILs M)611,N1!w8ad61ulluss lvHyp F votstntq'sa3EAJaSAa;snpuj 'SaatnJaS 77 ,A g �I s luuotssaJoaa Tg :.7 n 7 i n ww 61uno3 A4a3uS Jo lna1JJaaudaQ • •• •_a �li f � ;1l J f — D C� fil Wisconsin Department of Safety and Professional Services Li Li MAY 0 '12024 Page / of 3 Division of Industry Services SOIL EVALUATION REPOR'haYfield Co. Zoning Dept. In accordance with SPS 385, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 1 c;C 2 !) 3 Please print all Information. Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). l"1\ 5 I S• Z!' a�w ' Property Owner...j PropertyLocation ccamt1 j;,,( f d' h Govt. Lot /J %)1/, . % S I S `" T' 7 N R 7 E or ( )U Property Owner's Mailing Address Site Addre sir CSM and Lou: O 3 - •e•e .^ n.z V" Lc �n Z 1 z l' 4p city State Zip Code Phone Number ❑ city 0Village To Nearest Road F e ev''L `i�3-7 (7/Sj S l Ser. c.-1 ,/ 1 S• New Construction Use: Residential/Numberof bedrooms -�- Code derived designflow rateGPD l Replacement • ❑ Public or commercial — Describe: Flood Plan elevation If applicable ft. Parent material - 4..s 4 ( 1i f General comments and recommendations: • Li1 Boring # Boring 'Plt Horizon Depth Dominant Color In. Munsell 1 — /eve 3 l 3 [ii] Boring # Ground surface elev. g'• o ft. Depth to limiting factor 7''0in. / elev. ft. Redox Description Texture Structure ' Consistence Boundary Roots Qu. Az. Cont. Color Gr. Sz. Sh. vrvO_ S /fr Cc S a •n c /Ve LS . 2 ii %'h .r ci s Z ty Ne /-ec: 6 K `yt d r -- I �U Soil Application Rate GPD/Ft2 *Eff#1 *Eff#2 '7 !. •7 � []Boring ' r� Wit Ground surface elev.' ft Depth to limiting factor 79/ in. / elev. ft. Horizon Depth In. Dominant Color Munsell I D--3 /C 123 J Z 3 -'1 fliS-3 a Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots pJoM ≤L / 4Y wtv ✓ 4 5 2A °eve S o _1 L cr S o f ys 44 k. t � V, &s jF L.5 <<� k -F v - t v Soil Application Rate GPD/Ft2 *Eff#1 *Eff#2 .4 .7 -7 /. CST iame (Please Print) a `� k-os �j Signature CST Number [ n a sl c� �--- 22. © o,90 Address •? O. j$©r. Ga z. von 121 v er uUJ ≤'ff'(7 Date Evaluation Conducted I - 2 .c - Z V I Telephone Number I * Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 z 150 mg/L * Effluent #2= BOD, s 30 mg/L and TSS s 30 mg/L SBD-833O (R04/21) 1.3 I Boring # ❑ Boring ' Pit Ground surface elev. 10O.0 ft. Page of Depth to limiting factor? in. / elev. ft. ewn A...d .....ftw.. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 i &-3 1oiT3/L /Uo t Sir j44Jk. i4v- c$ .3« .i{ "7 Z 3 -JO c'�r .si r S n yi.r L 4j .7 (. 3 • /D- Ii 7≤ tj/ /-' L-$ c yVl r LS 1L4 I -i p S�� �- N iS y %. ,yi -- v' DBoring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in.! elev. ft. 0-11 Awwliw...Iw.. D..ew Horizon Depth in. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 ❑ Boring # O Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. cwss A..weswwuww o..aw Horizon Depth In. Dominant Color Munseli Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots rr• GPD/Ft2 *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, 5 30 mg/L and TSS S 30 mg/L L 'h Eye P lko„ic; AI✓n�41ny ,�7'c-ttlCc,o LAAr �1 �.in F'e Sr'1G+�C.�,/ Lcn u•en`Fia I Jr'oe� /} IJ 5�3 v'p{-�06I P.O.(rese�z� &.wtp ney7- ot1nnu.a1 USed: N ., tfa�1 ,h,3"�+a p,laa dY14 8,l". 11 rd m 1 X4 7 fl/fl, s U%P= F/ev. F csroo.m(-1a"A6•�� 5!3D -..ln o(�f.�si/4i� 18/d ) d.Zz.mago £ stsn GI'ev,19S S #. j; sxP M,aTw,k 75G�elal(on avi easy Go.+cra%-Sl`i'A L. -Tr 'eE/ and �m^X'SD 38ss� yz Fro wt 6o c,. r tom:: .o lea✓.f`.+e:.11e f am/ C.4,r[•..,vr o' $(+E c.: S'✓'4?A, ^Fh_,:'�'q ci '1'vciau�{b' z� cTah(ci nf;Ifr{arA�;4k'? Tq N8 91 ; 1Z %l¢rghl-�'F�.vua 1.� Ltn r._P h� tild�i�+ tAn°a,!a•e.wawe°wmma•A,,pp/.a/qe .411 5>a53y3 Sept/4 anIc oQr'JPn 1j Amv.e /c/c O. p' .7,cj .c f;c.r,-Pe/y/ekrr oJt/ pLS2C SLb64oPdL 1P�Jay is A5Trr1 D1'195*- Sa.11 So/23c pJC j'.pe..s ASTn'n D33'! appro ucp:pe 7 - 11iO, F, re-Wl4/e'1l/o 5 l.�11. 1l1 �� om� zo, �OWelt l E+• .�rmell �. N Sc' o w rJ c' Th7 L. ( � e ua� eU0 fl Va.M4 Caper S&I I7/ /G6 �T4 wwi ovftroe�Caj? ob6eru4 A ion .ges e o p4`@�' k,FG'�P'pes Act' ray, ¢W4 ©wn4W. tl" uC', vm� y LQga� �asevrdaha �rar;� •b� Sari I I Q V I r, )\/w SEl - 4•) 9. Nw a E.adc a� j y SeeJ5T-efl /}4or3P a �,.ls-. pacrtc(oE l4Kd /o ccta-fea in •% s o °�" Zo 3 `j ( rvee l o m Dr 'I ° 2 Gs -ki. a z 1 8Z 9 — G wP: fri fttc: rsc.j Wl. S'fg`�J ql/-jlr9 '^yl 'f,P,AuK�/PIus 0yy�.. May. 5. 201/ 10:41AM BAYFIELD CO PLANNING & ZONI'NG No. 9975 P. 3 PAGE 1 OF 7 SS-o03?5 In -Ground Gravity Plan Index & Cover Sheet Component Manuel Design References. Version 2.0, SBD-10705-P (N.01/01, R. 10/12) U up MAY a12024 Pg 1 of I Index & Cover Sheet "Bayfield Co. Zoning Dept. Pg 2 of'( Plot Plan Pg 3 of i g�pj,Crnk Cvoss Section & Plan View Pg 4 of 7 Management Plan Attachments: Enclosures: S o POWTS Application for Review C rf I Soil Evaluation Report & Site Map Me n.tr &Mce A` vc ew en Project Name / Description ry �2✓✓N �T kF1) Owner Name(s):.rea n €+g /'I I (4 rn Phone: 7/5 u/- sfs≤ Owner Address: zc31 (tee cLe n b✓, c✓ )t2c L0IZip: Sg g 37 Project Address: / is icja S ca.r d 4;/( &e A rcc ✓e --e l c't" 14e J Ivca f ecl-/\(W 1/4 of .St114, Section L S, T `/7 N -R 7 E fl or W Township: i I t Se r, LC4 2- CS'n tin County: 3cyc e Project Parcel ID #: S.SS-5 Designer Information Designer Name: A 1 l,7 n 70/k0 r /c " Phone: 7 / C - 72 - Designer Address: P -O, 3 ©7c Saz y✓o y er LJ Z Zip: S'`f 8r{7 E-mail: --o n y e- b e m v w' eH o r'%'%1 - e- o in Thus space reserved for approval stamp, License Number: 22-0090 Remarks: Signature: Date: Iginal signatures requlr d on each submitted copy. ti Dvanin a Polkasac, 1 ��w,W nr' 11 L r 1 Cone ✓IY Io.% I JCt� AhsoV• �Lc Bye �cul�. I. t' unless vi0 d h' P..0 e9l. Z -^L„ ..f� 1 n l3 rnalen C,HL':•p nt f- A/4� inu4I D5td N Z.1 S. r wit aff47 " gm, JRP=/ev.Dmo,o(=IzA6.Gr.5/3D—to;Yi7a +(N.a/ai;� Itvz) 4t�t hf.. °azooin Sys-t'a E►eJ:955 Cyr n. no sk. s: separc.7-�,LK' '75agaIfon wiessvtcL+cvsle-�"4 '✓ � 'ZD • 30s 'hi' f,ow, b44...., Fa�rr. ,/ , ` •�•� M%' C.j.t•,;i.t.v $ e' -s a .,Y8 Bd �64✓/•ne n 1p.�• 5 p*k.Iar!4 Zn'�t/l'✓G•I S icK? o Iccc4,e�•Fh VtI AelMpi fl . w.. riloni.{F -/ytva�c�6i ' to- SfaL, tiavL /� h:ql, 1@4e/tiny'Crna•a7lta *av¢LLay�esLh /^aN. w, nGH SP5383 Sep/-ic fq,Ac oullief-n.iosr Envi t''r wrl rvri •4fYC.✓•-p./yiok# oQ£l pt --Sys lA Sj14o Pic P% Lis AsTfn •DJifl - SLI% 5Dt23r PJC P.Aae is ASTArol p3a3 l 'tAtorc %S A7 IAN mdC+:•iJe,. Is *1 t/oSIzN�/t;tii� /jC Well r e+, Y`J�e ` ' MAY 01 2024 L (07'oA X p o yL` Bayfield Co. ZytDet. tap nc y,o4cvpJoep Gc4 �y 1 ropep y ©wHer: Lty4l b/tLscrl p#a'en p s_ c' b � e'" ki _ Qlsvi' rl j t-H"evl!1 n Ww*≤E$seUS-rv7NR7wE, off`" Z.039( Freedoni D. /l P4•c'el o� Ac,wtd /OC4 hl eJ, : fl-' Lz'1 asz csn`*z18y o4 g c «LP: L =• a5� d•€J•2rsC.) Nl s7g37 Iowa of ?, ( 5 en A ! yhegtif(!o - p u2,` Co�niyo� l3ay-:•e lJh a'oc�LL,ddyvl+�r •s3 �°� J„gam �A��'T LM O' pm � Y'1_ '•-. ...� Lu O TOP VIEW 4" CAST -A -SEAL WLP750- MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1/2" BOTTOM: 3" COVER: 4" MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: DOME COVER 61" O.D. FLAT COVER 53 1/4" O.D. OUTSIDE DIAMETER: 84" O.D. BELOW INLET: 42" O.D. LIQUID LEVEL: 37" WEIGHT: 6,150 LBS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET, CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 20.28 GAL/IN HOLDING TANK: ACTUAL CAPACITY: 790 GALLONS OUTLET HOLE PLUGGED LOADING DESIGN: 8' 0" UNSATURATED SOIL OPTIONAL FLAT COVER TANK CAN BE USED AS: IS AVAILABLE FOR EXCHANGE SEPTIC/ HOLDING/ PUMP OR SIPHON FOR DOME COVER. COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) OUTLET 'n 1 PUMP PAD SIDE VIEW TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: I) a n z g 2 Q P J Y Q _ O W HIn LU `O O Z 00 -Q n E N M Y� I 0 si' to S SHEET NO. �OF 1 Bayfield County, WI 5/7/2024, 11:36:09 AM 1:1,406 Wetlands Road Type Building Footprint 2015 0 0.02 0.04 0.07m1 I j• I Approximate Parcel Boundary Town • Building 0 0.03 0.06 0.11 km — CFR Bayfield County Land Record, Department Bayri d County Zoning Appb ban hasilmaps.Eayfiekmunt i.gov2oningWAO/ 5/7/24, 11:35AM Real Estate Bayfield County Property Listing Today's Date: 5/7/2024 Novus-Wisconsin Access rev. 12.0206 Property Status: Current Created On: 8/6/2021 2:27:33 PM �a Description Updated: 8/25/2021 Tax ID: 38559 PIN: 04-040-2-47-07-15-4 02-000-21000 Legacy PIN: Map ID: Municipality: (040) TOWN OF PILSEN STR: S15 T47N R07W Description: LOT 2 CSM #2182 IN V.12 P.392 (LOCATED IN NW SE) IN DOC 2021R- 590046 Recorded Acres: 6.920 Calculated Acres: 6.920 Lottery Claims: 0 First Dollar: Yes ESN: 126 I Tax Districts Updated: 8/6/2021 1 STATE 04 COUNTY 040 TOWN OF PILSEN 020170 ASHLAND SCHOOL 001700 TECHNICAL COLLEGE 4 Recorded Documents Updated: 10/19/2011 0 WARRANTY DEED Date Recorded: 7/30/2021 2021R-590046 O CERTIFIED SURVEY MAP Date Recorded: 7/8/2021 2021R-589656 12-392 O WARRANTY DEED Date Recorded: 5/11/2018 2018R-572868 O QUIT CLAIM DEED Date Recorded: 9/28/2011 2011R-540449 1069.224 O QUIT CLAIM DEED Date Recorded: 3/20/2008 2008R-519742 991-735 O CONVERSION Date Recorded: 3/15/2006 476857 727-341;826-659;837-65 48 Ownership Updated: 8/25/2021 JEANETTE M VILLARIN FREDERIC WI Billing Address: Mailing Address: JEANETTE M VILLARIN JEANETTE M VILLARIN 20391 FREEDOM DR 20391 FREEDOM DR FREDERIC WI 54837 FREDERIC WI 54837 P Site Address * indicates Private Road 16640 SAND HILL RD MASON 54856 ® Property Assessment Updated: 9/26/2023 2024 Assessment Detail Code Acres Land Imp. Gl-RESIDENTIAL 0.770 13,100 36,500 G6 -PRODUCTIVE FOREST 6.150 13,800 0 2 -Year Comparison 2023 2024 Change Land: 26,900 26,900 0.0% Improved: 36,500 36,500 0.0% Total: 63,400 63,400 0.0% LV Property History Parent Properties Tax ID 04-040-2-47-07-15-4 02-000-20000 27729 HISTORY O Expand All History White=Current Parcels Pink=Retired Parcels O Tax ID: 27729 Pin: 04-040-2-47-07-15-4 02-000-20000 Leg. Pin: 040103604005 38559 This Parcel t Parents 4 Children https://novus.bayfieldcounty.wi.gov/access/master.asp?paprpid=38559 1/1 C®V\ Jtit ®s1tr o E9E0VE D BAYFIELD COUNTY MAY 0 1 2024 CHECKLIST FOR SANITARY APPLICATONS Bayfieltl Co. Zoning Dept. Submit the Following (Use Permanent Ink) (Title 15, Section 15-1-10(e)) d Check List l9 Original Sanitary Application (Submitted in Deed Holders Name — not prospective buyers) (383.21(1)1.) 9 Index Page / Title Sheet (Signed by Plumber) (383.22(2)69(c)) 9 Original Plot Plan (383.22(2)2. 3. & 4.a) d Cross Section, Over -Head Profile of the System nd Schematic of Tank from Manufacturer ❑ Pump Tank Diagram, Alarm and Pump Curve (when applicable) S Contingency Plan / Management Plan (383.22-3(2)(b)1.f.) G7 Maintenance Agreement (Owner's Original Signature) (383.21(2)(c)(5),(6) (Recorded at Reg. of Deeds) ❑ Holding Tank Agreement (383.21(2)(c)(5) (Recorded at Reg. of Deeds) ❑ Holding Tank Service Contract (Original Signature of Pumper and Property Owner) (383.21(2)(c)S) ❑ ATU Servicing Agreement (Recorded at Reg. of Deeds) G7 Fee (Make Check Payable to Bayfield County Zoning) (383.21(2)(c)7) R . Complete Set of Plans (383.22(2)(2.) (Note: Snjtr.ySppllction and Maintenance Agreements are to be attached to all copies) L7 Soil and Site Evaluation Report (383.22-3(2)(b)1.e.) ❑ State Plan Review (when applicable) ❑ Copy of Warranty/Quit Claim Deed (Optional) Sanitary Application: (Include the following Information) d I Application Information must include: 0 23 digit Parcel ID# -- (do not use 12 digits anymore --obsolete) 0 Project Address or Road Name where driveway is/will come off of) g11 Type of Building El III Type of Permit l9 IV Type of POWTS System S V Dispersal / Treatment Area Information [0 VI Tank Information ES VII Responsibility Statement (Plumber's Information) ❑ *Date Stamp* Plot Plan: (To Scale or To Dimension) 0 Signature and Plumber Information p Surface Elevation of Body of Water El Direction and Percent Land Slope Rr Tank and Filter Information and Location fa7 Wetlands / Navigable Bodies of Water fv7 Absorption Area (Proposed and Existing) R Bench Mark (Location, Elevation and Description) (9 Component Manual Version at Legal Descriptions Piping Material Information (conveyance line, building sewer line, material type and diameter) El (Owners Phone Number) O' Address Number and Road ES North Arrow S Contour Lines El Structures and Driveways El Boring Locations El Property Lines © Well Locations Turn Over ► :Aq Pajooid(3P-ZTOZ/Z/S®)(ZTOZ/Z®).'(TTOZ/L®)f(600Z/0T) sdde/i uesioAslNl3ag3/ pp p/ wu j/n (spesa 10 6aa oo;no spew s)losyo) 000£ $ 4 s;ueweei6y eoueue;ulell g 0005 $ uol;oedsul uin;ell ❑ Jo;deoioiul a;eAIJd pue 0005 $ uofloauuooea weis is e6emes a;enNd O 00'SZ $ suoislA9 I AGeIlueS ❑ 00'00S $ ;uaw4eaal-aad 6upinbai swalsAS ao spunow ❑ 00'0017 $ (s�luel 6ulploH) walsAS e6em9S a�WAPd ❑ 000017 $ (s�luel ol;deS) we;sAS e6eMeg MAIM JM ag (Aux sAH /yaadoJd smogs A:p doJd) 5-f-7—Zwllds uaaq Aiiadojd siy1 seH O r ' Zpuel jo paled sly uo aq aietp film suaa'fsAs Auew MOH 0 UoEinwiojui Aiiwd Ilan yea uI sslun jegweyJo JagwnN V IapoW 'a)1eW A sq daa pue suolsuawla J sadid IuaA pue uofeMMasgo jo uoplsod pl uolUena13 wat5 pue 3DejinS �l a s ayjo ado d eaH-aano p e u. as-ssoao