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HomeMy WebLinkAbout030-2017-50-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division C INSPECTION REPORT sanitary Permit No: 515186 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Sime, Chad W. & Sarah I St. Joseph, Town of 030 - 2017 -50 -200 CST BM Elev: Insp. BM Elev: I BM Description: Section/Town /Range/Map No: / ! 66-r 1 11 01.29.20.421 B20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 9+ /6). 8 art Septic Benchmark 1 9 14n Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet I/ s TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt In] $• It -71 93, il Septic Dt Bo m X Oft- `S L I1•74 5 Dosing I Header /Man. 1. 13 1 7z • 7/ q. $ /Z. 12,8 Z • 7 Aeration Dist. Pipe �, 13 /S yZ - 6 Holding Bot. System Final Grade d 3 PUMP /SIPHON INFORMATION y• Manufacturer Demand St Cover GPM 1 Model Number j I ro.� 13. Q s + 7l 1 , TbH Li Friction Loss System Head T11H Ft a k, Forcem Length D' Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z �e , �� SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: l - INFORMATION Type Of System: 1 CHAMBER Model Number: BER OR � , 3 Z7 �ob 6 0 b O�► � DISTRIBUTION SYSTEM Z3 f-Z3 Z- 1( Header /Manifold 1+ Distribution x Hole Size x Hole Spacing Vent to Ai ntal� / Pipe(s) \ 2 ,ti a Length_ Dia_ Length_, Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only / h Edges Topsoil Depth Over xx Depth ot xx Seeded /Sodded xx Mulched B Center .✓ / Bed/Trenc \ Yes -] No r Depth Over Yes L] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1179 Cedar Drive Hudson, WI 54016 (NW 1/4 NE 1/4 1 T29N R20W) NA Lot 2 Parcel No: 0 iv 1.) Alt BM Description = • �� t L', Gp�J 2. Bldg sewer length � = < - - amount of cover — - r - -- 7 Plan revision Required? Yes No Use other side for additional information. D 4 - ate Insepctor's Si ature Cent. No. SBD -6710 (R.3/97) I t Safety and Buildings Division IVA 201 W. Washington Ave., P.O. Bo 2 A unt W S'��nS,� Madison, WI 53707 — 7162 W� Number (to be filled in by Co.) Department of Commerce (608)266 -3151 Sanitary Permit Application State Plan I.D. Number / In accord with Comm 83.21, Wis. Adm. Code, personal information you proyjy -� �Iv may be used for secondary purposes Privacy Law, s15.04(1 xm) KG Project Address (if different than mailing address) I. Application Information — Please Print All Information NOY 0 5 200 o3 0, 2 0 17 � o � so• Property Owner's Name � ,vu F µ. I .54,4,1 !9 - 5 ' 1 �� PLANNING & ZONIN O a e lm d n2_ Property Owner's Mailing Address Prope ✓ rty Location City, State Zip C P � P ��ti 1 A Section /MVP fd "J / p �F (circle yo /<i „S • fo � T N, R2& or W ICl/. Type of Building (check all that apply) ' 1 or 2 Family Dwelling - Number of Bedrooms Subdiv / // CS Num /JA Public/Commercial - Describe Use M — / r J ` 3 0 IJ N" !" / ❑State Owned - Describe Use ❑City_❑ViilageXTownshipof S CD III. Type of Permit: (Check only one box on line A. Complete fine B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) /// ✓✓ on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Rec ating Sa id ilterr Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel - less Pipe ElOther(explain )�+�� V. Dis ersaVTreat ent Area Information: Design Flow (gpd) Design Soil Application gpdsf) Dispersal Area Required Dispersal Area Proposed (s System Elevation (0 40 •7 8S � /./ � 9/D Q VI. Tank Info Capacity in ToW Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing ` rS Tanks Tanks / C Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I. the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu 's Signature MP/MPRS Number Business Phone Number o �R7 bey z� 4 3 s` 715. 77a • 3 � Plumber's Address (Street, City, State, Zip Code) VIIEL Countv /De artment Use Onl pproved ❑ � Sani= Permit Fee (includes Groundwater Date su Issuin ent Signer re Stamps) urcge I-) O z: // �! OGS ❑ riven Reason for ' I � �• / IX. Conditions of ApprovaVReasons for Disapproval L L l SYSTEM OWNER: 3 Jy�(SrC tN� M�� � �S a� 1. Septic tank, effluent filter and V G , tt • 0 . � , ` d dispersal cell must all be services / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained k �� Z L-); 14 t1. ye ss per applicable code / Ordinances. r r 'S U r 1;0 t g Attach complete plans (to the County only) for the system on paper not toss than 81/2 x 11 inches in size SBD -6398 (R. 01/03) i X11 / I I I ► ►; ,f x , Xb NJ Cli 2 - M QZ � ,�� � y o b - I Imo_; l ►�� �� I ` I� i I I // ,I► �� O � o L ► Q rq � C 2 \S% � v0 2c CIA 4 v M . �► LA k o CL A w n o b cn T ` T m I` z a O oo �- N �a� �ro;l� C,F/cv kArCv Iff 1 i // / t� M Sol, 51 L y0. �O � r _ ft y Clfo SS SEC T 10A) o1 TIVE It Ile ' Zls�wG- 7e,4 ,5 u ► c S 101A1. 2 Iff 1 'S a K Tr ec c �V- El A- 13 � S y � WM OVER: See Reverse Side for Vent/ Observation Pipe Details. OWNER's MAINTAANCE 'OF' ­ X_11c SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance of. this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of-this system. The owner is required -by code to submit all necessary - maintenance /inspection reports to the control ling,authorities:. SPECIFIC CONTACT AGENTS *. Governmental authority/ inspectors: _ * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: - 115 -7 � u Z R. ��''_� Pi � 3 `� Zzc�3 � s * Licensed service / Inspection other than installer: ?�IL�I�iCti�" ASSoc * Electrician, for pump, electric controls, wiring units: 6 - 1 44 1 - 'ec IMPORTANT OWNER MAINTENANCE REQUIREMENTS I. Winter traffic (sledding, shove*ing, etc.) across the area shall not be permitted, or frost can /will penetrate into - the cell., freezing up the system. Discontinuos use in the - winter_(a vacaction trip, resulting in no water .use) can also lead to freeze ups. 2• Water c onservation- needs - to be exercised! system can be hydrolically overloaded and destroyed. This svOem was designed for a maximum wastewater flow of g ls. dail a 3. POWTS are not designed to accomodate wastes from a garbage ..., disposal unit, or any other unnatural sources of waste. Any introduction of such waste - materials will overload and destroy this system. 4. If a power outage-occurs, or a pump fails, it may result In a temporary overload of effluent being pumped into'the cell, which may adversely impact the cell (leakhge). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5• Neglect of the vegetative "cover erosion (the cells insulation & Preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system. NECESSARY TO IS REGULARLY WATER THE VEGETATION OVER A It It IS NECESSARY Effluent in the System beneath IS NOT sufficient alone maintain d �i lcovwr. 6• Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated into the system: on the mound basal area inspection pipe), cleanout terminals on thefpressurized laterals, at each tip - for flushing and cleaning the laterals out: The filter system in the tanks ground cover /manhole (via a Locked above person should be ). Only a licensed properly qualiOied & severe safety risks. Evidences ofoeffluent involves health system 's treatment cell shall also be regularrlydinspected. ,._, 1 !!S7 F ' RECEIVED Wisconsin o Dgmftw t of Conn ww SOIL EVALUATION REPORT 3 safety and Br,il ng$ in 0 5 zoo accordance witl, ron � Ca M. ,�,. Code �, s T,. NOV Mach complete site plan on paper not less ten h 8112 x 11 inches in size. Pier must irdude. twt not "tea to vertical and horizor" reference poft (a", director► and Patel I.D. per ©, j 0 • Z 01 S-0 lJ • a cent slope, scale or dim rth ensions, no arrow, and location and distance to nearest road. Please print ail Information. Reviewed by Date POM" 11" Wtron YM pf9VW mW be used for s9=Way pins (ftWacY 4w, c %04 (q (m)l. p c Property Location P i , t S ARA ff J I M E Govt. Lot AJ E 1/4 1l4 S I T N R E( W Property Owner's Ma>l1ng Addrm D Lot # Blodc # Subd. Name or 3 c F h P, R . � e S 7-) 2 - cs (oy7/3 0 V,605 fl. 106 Stye zip Code Raw Number ❑ City ❑ Village 0 Town Nearest Road I TU D SO A.) 1 01 I SY06 ( pis S 1 fj •6f?/ s r• 3osFpH— I ornIQ ©R. ❑ New Ooratnxdion Umfia Residential / Number of bedrooms Code derived design now rate ' GPD - ❑ Public or conwwdal - Describe, A'7"" Parent material Diu,, /c�E.� T ;/t 00&/z Flood Plain elevation If appk *W 1t GeneretoormrerFls AvD 00 rWAS N— . and Area Spot Tested suitable for A oonvolttlottal Inground system (P.O.W.T.S.) ©� # Babog 1 9 - - O Ground surface elay. . R. Depth to Rate Horizon DWM Darrrinec t Redorc Desaiptiott Texture SUuftre Corte r Bo Roots In. MunsN Ou. Sz. Cont Color Gr. Sz Sh. •E1f#1 'Etf#2 Z 5� -F w I AF .7 tife - 7 1 it . � �--- s L sb nNf cs • �f • 7 S 0. q4 C -- /- ..— S a # � � Ground surface elev. (�' ! O R DepM to ImMM factor /r Z in. Sall Axkaftn Rate Halton Depth DorvoirwtColov Redox Deso"on Texare Structure Cam Boundary Roots GPM In. Mtrwell Ou. Sz. Ccrn. Color Gr. Sz. Sh. •EW MW 5 110 YMPA 5L_ i f 5biE M f W 2f •z L 3 y ----- q L C 5 CAP i • Elba" #1 a Bt)D > 30 , no m®IL and TSS >30 ^ 150 mg& - E1Ruent #2 = BOD 130 mpyL and TSS = 3o "A. sigrokire Csr Name P L c 4 e4 � (CAT 2� 3�7 5 Aft° Private Sowage Consultants � E cor T Zc.'"�,b�e 2812 1 th 1!S 3 prinq Valley, WI 54767 0 ©MM � / = =� ■ ■ ._ .. MER ■ ..a WA��MMMM mm r��■� �t� mm��� mm��r ��r�■�■�� .1 OMAMWA WAS ®M == i r o a I w i v �'41 Mh �w� a 4 1 o � i ; �� i I 3 � `� I ► ;I M � � \411 lo t o t � 1 o i N(7 L 09-4-4 - , ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANIT PORT Owner Sr Address e--A fR City /State vDIO -v 4//. S yo!!. Legal Description: Lot Z- Block �ision/CSM # �Oy7�3o �0� /S , /�� • y7 Gp /, '/, N '/4 kU) Sec. , T Z f N -R 2- W, Town of ST • Z,� PIN # OJO SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION , Tank manufacturer Size ST/PC / Setback from: House Z . \) ell' Sd Pump manufacturer N /4- Model Alarm location 4 ) (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Wat rte n Meter location Alarm location SOIL ABSORPTION SY STEM Type of system: Width 1 Length ' Number of Trenches Z Setback from: House Well � P/L _ i Vent to fresh air intake ; 32 ' ELEVATIONS ��''''�� C 5r's 8. #2 = 7-0 ' 3!y pvc /pD. FS Description of benchmark ' Elevation Description of alternate benchmark _80 /b•y .te2r t o, /•lc-7;?ei C Elevation / - 9 7 ,4A-),S , J 10Y, Building Sewer g p y� ST/HT Inlet 97 ' y& ST Outlet �L PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover To p �r oif,�usx's Pisttibt*en �6ifl.-@S 96 f Bottom of System ( ) g S• y00 ' ( ) FY 73 ( ) Final Grade ( ) 149 2 • () 1491- o� • zoo i � Date of installation / / Permit numb 3 7 5 10 tate P lan number 22 & 3 7s Plumber's signature License number Date Inspector A Complete plot plan .r • P � 4 i � Y oG god �. ��. of dA 01 -6 To �l P VC • �P s s • I� it q l i it 3 , i Ali vii I M d i l l li II 1 i I I 1 I O' I� ❑ 73 h PP,Al,¢AJ EvuT i 5 7pm G� o r F/.ecyae'� c not 7os,or A) 07F N0 IV 1 : r9S• l 31) /L/ Ulbricht & Associates Private Sewage consultants r,55 O Rd. Hudson, Wis. 54 � l - Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and building Division INSPECTION REPORT Sanitary Permit No: 395106 0 GENERAL INFORMATION, (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Sime, Chad I St. Joseph Township 030 - 201 -50 - CST BM Elev: Insp. BM Elev: 7 Description: Section/Town/Range/Map No: 01.29.20.421 B 0 TANK INFOR TION ELEVATION DATA TYPE ANUFACTURER CAPACITY STATION BS HI FS V. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INF ?I St/Ht Outlet TANK TO P/L WELL BLDG. Vent to A Intake ROAD Dt Inlet Septic t Bottom i Dosing Header/ Aeration is ipe F7- 2:f Holdin CL I �f :\ s ot Fin Grade . System PU P /SIPHON INFORMATION Manu cturer Oand St Cover PM Model umber TDH Lift Friction Loss System TDH Ft Forcemain Len - I Dist . to ell SOIL ABSORPTION SYSTEM BEDITRENCH Width Length I No. Of Trenches PIT DIMENSIONS No. Of Pits nside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO PIL BLDG WELL LAKE /STREAM LEACHING Man cturer. INFORMATION CHAMBER OR Type Of System: UNIT Model Nulller : DISTRIBUTION S TEM Af 6u. I zeo l Header /Manifold Distributio x Hole Size x Hole Spacing nt to Air Intake Pipe(s) Length is Length Dia Spacin SOIL C, ER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil MM Yes ❑ No Fn Yes [E No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1179 Cedar Drive Hudson, WI 54016 (NE 114 NW 1/4 1 T29N R20WW) N_A Lot 2 / Parcel No T 01.29.20.421820 1.) Alt BM Description = - � M kj.� �-� `� 1 "17- O ( a^ '�" CO��,�C� • .y 2.) Bldg sewer length = Q-VQQ,Uw a - $1 `E2 - amount of cover - l - 5 , r Can. Yew Plan revision Required? [] Yes No Use other side for additional inform ion. ( �ate � ' � � In pctcg' ign -- _ Car. No SBD -6710 R.3/97) / J��"�C�'^ �I" e ' 7 [ 1 ' ��4Ct?,rMQwl1� s, S � � 9w. A - s - Safety and Buildings Division County Sil L.�D x 1 * 11scons i. 201 W. Washington Ave., P.O. Box 7162 n M adison, WI '53707 - 7162 Site Address Department of Commerce 1179 QeilNA-PL Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code 39 ( C4 ,personal informatitm you provide may be used for secondary Privacy Law, s15. 1 m ❑Check if Revision I. Application Information - Please Print All Information State Plan I.D. Number N/ Property Owner's Name ` Parcel Number p Property Owner's Mailing Address ` Property Location 23 3 CE'f>ifX' ©�2 . 4 / , _ i / yl Nw ii S 1 T N R b d City, State Zip Code Pho tSit �° � lx� ; .� 7 Lot Number Block Number Subdivision Name CSM Number esm &X17/3o vo /. 15 , H. Type of Building (check all that apply) ❑City ) (> Pf 1 or 2 Family Dwelling - Number of Bedrooms ~ El ❑Village Public /Commercial - Describe Use OVilla sT J't�SE El State Owned WTow nship Nearest Road C,ah III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 New 2 ❑Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use 36 - oZ S stem Tank Onl Existin S stem =I ss�ued l B • ❑ Chec k if Sanitary Permit Previously Issued Permit Number IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) — t 44 KNon - Pressurized In- Ground 2111 Mound 47 E] Sand Filter 50 ❑ Constructed Wedand 22 El Pressurized In- Ground 41 El Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other �r V. Dispersal/Treat ent Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Applic Day u rcolation Rate S em a t F' I Grade Required Proposed Rate s. / / ( /Inch) levation 5'W K? VI. Tank Info Capacity in . Total Number Man rer Prefab a Steel Fiber Plastic I Gallons Gallons of Tanks Concrete Constructed Glass New Tanks Tanks Ex Septic or Holding Tank Dosing Chamber " VII. Res onsibilit Statement - I the undersigned, assume 3 p Y r 8n responsibility for Installation of the POWTS shown on We attached plans, Plumber's Name (Print) I Plumber's Signature MP/MPRS Number Business Phone Number ROURT Z(AV uc7" I wbcx 2 26 3'2 S 7!S • 38G • 8! 8S Plumber's Address (Street, City, State, Zip Code Y ' ASS 4 NZi L OP. ov're.tJ VIII. Court /De artment Use Onl Approved ❑Disapproved Samtary Permit Fee (includes Groundwater Date Issued Issu Agent Signature (No Scamps) Surcharge Fee) ❑ Owner Given Initial Adverse - Ito Determination 11 (�(� IX. Con 'ions of A Reons for Disau S`Pt LS Sad � -6a" s_._ ,_k TAIZ tau. -}fl S s 5 — 64v,so S o . 0 ..� w S� I � AmElico. plet. plain o the cognty ) ror a "em on paper not leaf x 11 inches SBD � -6398 (R. 05/01) �S S J 41,11 4o a � • 0 p z � 5 5y<4", 4w"_ p= --�MV_V its �rls � Lo r �-. • 2 3 - - -- - -- o .............. ...... . O 0 CK . /oo S� T ( C h o Cf - � J S3 Q o -� � 1 I � 5 U g ut A /P 50 re&A Shp Ti i g' ys r ffin-its . f I I i 30 oe6v a.... �o a� o Li ' Ta f3 i - r3 -2- /ors UL.MICUIT 8t ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 Reg..Destgners of Fngtneedng Systems 715 -386 -8185 Private Sewage Consultants PROJECT INDEX y PLAN ID # ^/- DATE t� OWNER Q/ PHONE y ADDRESS C/a M. S�' 23 3 4ER f 9 e• LE DESCRIPTION 1 - 0 7 CS Al Co ( 0 Vo l • I S' ' PJ . `/7oC /V N40, SAC. /, T j, ,p 2 cv . TOWN or ST , �'oSE - p �.. COUNTY s TGP_ � CS i'M R . WM1_ * �il T 27-L 4.3 7 7.5 LOCAL AU'TIIORI'TY/ SUPERVISION ST.G� GJ` �D,�,�l,d�j -• _ x y PROJEC DESCRIPTION: , lt v CD.v S772 t1 �7"i o.v � /�DiC' /�/e0 d.I D f A:o. O •+ 1 . ) r t l o rc� f fig rlwtfcrT i v,; - c 7,,reu e�- ...5* IC 4i S 4 Joi/ � ' Gv ;vG- le-4 S � i � Jz. T Ulbricht & Associates Private Sewage Consultants 855 O'Neil Ad. Hudson, wis. 54018 /!PIPS . 2Z40 S S- �o , ORIGINAL Pg.l INFILTRATOR SIZING WORKSHEET P9.2 SYSTEM PLOT PLAN P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. Pg.4 it to it „ of P9.5 OwNER MANAGEMENT PLANS & ZABEL FILTER SPECS P9•6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK. PG•7 (OPTIONAL) PUMP PERFORMANCE SPECS. The attached plans and specifications are based on "In- Ground Absorption Component Manual For Private Onsite Wastewater Treatment Systems." (Version 2.0) SBD- 1075- P(NO1 /01. �o 1 � 0 � y y k _ I L I S o z rr i J o r o - � N L n I� i SAS Go T I ' _ 2 3 /3 4c1a t Pr ? 5 IN 141 oO�z 14 ./00 S �TI h o .,.�"�� SET • �� � �° o � 2� ' 3 p 9 � N D 0 Sa Ito 5 fir- &.4 s r 50 f,PdM 56 P7 - iC g ' i s Y5 T ARtA5 I �I � 30 , j7��V eZ, 96, 0 Li Li - �a S�ST�'!I / U TiDtiS ♦N 4x cle, ' &s 7 69 f3 l3 r . 7 � o e v v off D P &Item T^ &t&< �' s y S T &M v CRO SS SEC T10 A,) ©/� IA - ) 6- IN i L 7iC 4- Tot('S 5,9 ,rr /f mvvep . l9PjO4&eh I/jEti T c,¢ jd Iff o ' i N OVER: See Reverse Side for Vent/ Observation Pipe Details. An observation pipe may serve as a combination observation/vent pipe providing it terminates in the same manner as required for vent pipes. See Figure 6. Vent cap, Return Mend Cap 12" min. 12" rain. rinal grade I Aggregate Ism milon lateral K k typ. yp. \System elevation Figure 6— Vent and combination observation/vent pipes Leaching chamber tops are at or below the - original grade. Leaching chambers are placed directly on the bottom of the distribution cell. The locations of leaching chambers are in accordance with Table 3 of this manual. Observation pipes are installed in the distribution cells and are provided with a means of anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative surface for stone aggregate systems or from the inside of leaching chambers to a point at or above finish grade. The portion of the observation pipe below the distribution pipe for stone aggregate ' systems is slotted while the portion above the distribution pipe is solid wall. Observation pipes for leaching chamber systems are attached to the chambers in accordance with the chamber manufacturer's printed instructions, extend from a distance >_ 4inches above the infiltrative surface through the top of the leaching chamber up to or above finish grade and terminate with a removable watertight cap. All observation piping has a nominal pipe size of 4 inches. See Figure 5. Water tight cap b r— 4­ min. dia. Top of ' leaching ` Repair couplings chamber Slol� ' 6" min. 6" nrin. Infiltrative surface, min. Water Closet Collar Bar(3)11" min. dia.) Figure 5 - Observation pipes Vent pipes, if installed, connect to the upper half of the gravity flow distribution laterals and extend up to at least 12 inches above finish grade. Vent pipes terminate with the vent opening facing downward by the means of a vent cap or fittings. Vent caps must allow a free flow of air between the distribution lateral and the atmosphere. All vent pipes has a nominal pipe size of 4 inches. f - PAGE 6 REVERSE SIDE OWNER's MAINTAINCE OF SEPTIC SYSTEM POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this system. The owner is required by code to submit all necessary maintenance /inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS ,p * Governmental authority/ inspectors: * Licensed installer, responsible for providing an operation/ maintenance "Users' manual: gljg * Licensed service / inspection agent other than installer: • 3g(o•� -!3a * Electrician, for pump, electric controls, wiring units: IMPORTANT_ OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shoveling, etc.) across the area shall not be permitted, or frost can /will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This system was ' designed for a maximum wastewater flow of &OV gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. ' 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the I cell, which may adversely impact the cell (leakhge). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover erosion preventive) can lead to fail.ure heavy traffic also can destroy t he system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the system beneath IS NOT sufficient alone tO maintain a grass covwr. S 2If-dt& 4 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated into the system: on the mound basal area (effluent level inspection pipes), cleanout terminals on the pressurized laterals, at each tip - for flushing and cleaning the laterals Out. The filter system in the tanks (via a locked above ground cover /manhole). Only a licensed properly quali6ied person should be performing this work which involves health & severe safety risks. Evidence of effluent ponding in the system's tre?tment cell shall also be regularly inspected. 1'11A.+1�0 7fiVt' 5�V &;Pe y 0 0%e,, ye:- 4-;v — ��� v e-*,� 5 r4,v D ,4#R 11P7 11wy 3S bf / Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ` of 3 bivision of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code _ i �„ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST '�r�C! include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. °�T OF percent slope, state or dimensions, north arrow, and location and distance to nearest road. I riewed ^ 20/7 SO 0,3 2D / 7 ' f/0 S Please print all information. by Date lau Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1)'(m)). / 01 Id do / Property Owner Property Location D I' Govt. Lot 1/4 NE, 1/4 S T N R20 E (or� Lot # Property Owner's Mailing Address Block # Subd. Name or CSM# 196a C��S,vvT ,�iP. Z- c s 13tvOi .76 - City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road '715 ) 3$I 1859 sT XOSEPL, T'z New Construction Use: Residential / Number of bedrooms Code deriv ib r��E GPD ❑ Replacement ❑ Public or commercial Describe: 4 , Parent material /s�sS O(l -�!� Si�A - 017f4 f Flood Plain a on OW General comments ��.,r, / and recommendations: JJ'' c 4 q 1 4� i Boring # ❑Boring Pit Ground surface elev. ft. Depth to IimUmg ✓ =}, t Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 0- / YR 311( s/L s fSAt . s 3Y Y1? Y14 39 /0!/X 516 / fyAe Zt s 52 .2 2 Boring # ❑ Boring / 01 S t7 } P ,Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /f1 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 /� - 51 t_ 2 +S /y►/I die Z f . , 3 OYR G 2 / S •8 - RS/ s. D ► 1 �� I•Z ( 41 t o - L Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number 2-z 6 3 - 7 S Address Date Evaluation Conducted Telephone Number �!S•3 - S Ulbricht & Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL AA r r � Property Owner J �/"�� Parcel ID # Page of Boring 1-31 # ❑ Boring /03-7-5 ` Pit Ground surface elev. ft. Depth to limiting factor /Z in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz In, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 / 0 •g 10W 5/3 L Z /o i e S� z f S h& /W f, c s g cs — z .1.i 2 o �oyl FY-1 Boring # ❑ Boring Y 0 W pit Ground surface elev. 0 t ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure. Consistence Boundary Roots GPO /ftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff #2 7 .S` /� — SL- 1fS � -6e e5 — S 39-110 /o --- S L 2 -A0 Sjf 40 � 4 - c — 5 9 I 7. 5- M /,f hd4t D� F-1 Boring # [] El Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg /L r The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SB0.8JJ0 (R.6I00) O 0 IN � 3 P oi pip 4- g ut I ' w�� II A l i 30 , 2 1 70 i Li fa t, IN T - 13 7z: - 7 s ti � o i 0 cu N N W Z � ° .. t IY W ~Z W � W vi z 3 z J O O O .-. � z J _^ 0 0 2 W W rnQ Q W O (b �_ Z CL w as 0 Q ^� _ Z n- Z 1- O F- C] O d — W z J d , ? ,� w � z �! a • �. S' V 0 1 o a `" > I N o Z z z a v1 A H I w sr ' ¢ W N W �-. I 0 N _J OQ' Q X J . vJ (yJ w I -10 1!7 O z I E , , C, J ¢ ., ... r� to (, I N 1 F-i �J I 1 OZ • O , .R� W j ►,1 o C' ';.. L, C CQ CJ Q o v oo I �/� °• W t.- o E'+ U w � n a N I I CQ I ° , q cl C3 Qo I 00 o C -1 1 z" o W N W (� N .-. C� Z j F Q > Z I j� \_ \_ 0 1 to Q Q W N � O �� � a> a LLJ r N ^1 Ln p? N� m , W O � 1 Z W O Q J tn ui t P z v. 1 0 o rn OD w I Q7 v N �^� I- z N N 1 O H O im O W F w 0 Z I E ° n d � � ��5� N I— M V N N ^ I A � 0 1 W i Wa0 OD N �1 .--4 O O !!'E 37 I •533 8.341.26' �� N F5 cn 'mil I �' >- L w 0 D W E-4 z_. SOB _ v o `°� , W o z� 0 1 U . I ; �' l � T _ { -- r - - - - - - o az hp. 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W 0 / ww A.IC,LG.68S 21438 Ol Q3Wf1SSd 1 I W N M N a W W N N0I133S 30 ti /13N 3H1 30 3NIl HISON z i) ZD XC4> Z 3H1 Ol Q33N383338 388 S'DNI21t13H J y y y 4j NW0 amu ° z °a- ' M ,O J . i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND -- OWNERSHIP CERTIFICATION FORM Owner /Buyer a � 1 ( s / S! .A'l � Mailing Address f �h ess y Pee. 11VRS0 .J Property Address 7 b lr i (Verification required from Planning Department for new construction) City /Staff TT W , 5Z 7 A ) &'/ • Parcel Identification Number 0 R p • 1 D/ 2 • y0 • 0CF • �� • � LEGAL DESCRIPTION 0,30 • a.0/ 7 Property Location Ni '/., N� /,, Sec. 1 , T 2 ( q N -R 2b W, Town of s � • t� Subdivision ,Lot # Certified Survey Map # � l3 b , Volume S , Page # Lft q � Warranty Deed # &5 Y / Volume 1&?3 Page # su s Spec house O es Ano �j p Y Lot lines identifiable / \ yes O no SYSTE MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restticted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1 /we, 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification Slating ( your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this forin are true to the best of my (our) knowledge. I (we) Am (are) the owner(s) of the prope described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNA'I U ICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** i ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 90 Lb 86 ed S L • IOA o ° ti r Er ' f In v O W L7 O W 0=3 u o � ay�N* r �- `' w w p ¢tea H -L, J JJM'. -f7jVI N D 0 N: 2 H z W W U.- y= 0 z a o zZ `a? y �� jz I a c V- 0 La C3 Lj N O j Z d Vl o W iO �' . " N W .�. f O N �J U ~ I x J ° Mi w'av Z w O� � • O � I O ti o M., r, MOON . — — — — c m Q W U zz I 0, $ w `` O o 5,' n � a N CrJ E F% zv I g y�/ n o ° h � I co gg ui o U �I a4 9' ° ra w N Co i � ik w cu C a w H I ' ), > A Z , � � I � �U F v� � s • I Z� Za > o M � ♦ wr L�I • V] 0 1 M r-1 �i - -- OI Z o = p` N L i t . . 2 J r m 60 CN in Li LL 44 z I a o ° -.0 r�n v nw_ A ® oq Of E- -q O �--f° yy� UN —, ^I o Iof U w .9 � y� 7 � 1/7 Iv, I J LL m z O U w ` _ E- 376.314- cn�� J u �- 2 .-. I _ w z of ❑n U�O P az co Hw sYrf 7 Fr �{ u 1a `� w � z W r C= O U O a �Lf. ! 1�Q Qr� 1R� A vd w w 2 w w m ° �I -11V o v ww �+ zv Q.�f,7dNn �oo �i66i �O'" 92'21LI �H J ra 03 .90286 t�1 � IXw .�i \ a o IE'b692 ih ri l m m I z c .0 z C%2 W U � Inl �I f (~ (, M..IE.ET.00S P 1 W° 1 tT wa W z 1� w V I •� o �v .p vai a ly 11/13N 3H1 30 b /IAN ^ ° / Qfw 3Hl J0 3N1 193!1 I .� � / O I °� y ri W 2.. 0 1 = o r O; .D f'1 U 2 w U Q 2 moo N li F- / co In o w m z z ww M 'A.IE.46.68S 2143& Ol 03wnSSV '1 �j ro N rz= NOU33S 30 0/13N 3H1 30 3NIl H18ON Lz' m 10 M X W > Z 3H1 01 033N383336 388 SONI21V3H J y y y W Fyo x a tl smc� ° zoa(L I�JIb� � I rn� DOCUMENT NUMBER YOL PAE' 650149 '.,E 51 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD Stanle E. D fi. and wife, Grantor, conveys and 07-03-2001 3:05 PM warrants Ck}ad W. Si a Sarah J. Sim Grantee, the following describe in St. State of Wisconsin: WARRANTY DEED EXEMPT N CERT COPY FEE: Lot Two (2) f Certified survey Map recorded in V olume Fifteen —Ll5 of COPY FEE rvey Maps, Page 4106 as Document Number 647130, filed in TRANSFER FEE 216.00 St. Croix County Register of Deeds Office on June 1, O1, being RECORDING FEE 10.00 located in the Northwest Quarter of the Northeast Quarter (NWlW of NEW) RAGES 1 and the Northeast Quarter of the Northwest Quarter (NEW of NWIA) of Section One (1), Township Twenty Nine (29) North, Range Twenty (20) West, Town of St. Joseph. NAME AND RETURN ADDRESS Leo A. Beskar Rodli, Beskar, Boles & Krueger, S.C. 219 North Main Street PO Box 138 River Falls, WI 54022 030 - 2018 -90 -000; 030 - 2017 -40 -000; w 030 - 2017 -50 -000 Parcel Identification Number This is not homestead property. Exception to warranties: All easements, restrictions and rights -of -way of record, if any. Dated this �+ day of June, 2001. 1 �� SBAL St ey E. (SEAL) Sue E. Dahm (SEAL) (SEAL) ' AUTHENTICATION ACKNOWLEDGMENT Signature(s) of Stanley E. Dahm and STATE OF WISCONSIN ) Sue i ahm. ) ss. COUNTY ) d this 29�iday of une, J 001 Personally came before me this day of 2001 0 // the above named Si nature to me known to be the pe�sons(s) who executed the . Beskar (Name Printed or Typed) foregoing instrument and acknowledge the same. * Leo A • TITLE: MEMBER STATE BAR OF WISCONSIN (sianatus (If not, authorized by 5706.06, Wis. Stats.) + (Name Printed or Typ THIS INSTRUMENT WAS DRAFTED BY: Notary Public County; Wis. Leo A. Beskar My commission is permanent. (If not, expiration date:) Rodli, Beskar, Boles & Krueger, S.C. P.O. Box 138 ' River Falls, WI 54022 0 cu N It N W Z O W A .5; II m 7 � 5`N s U i ` O M— :c w W m U LL- vl z WW ptV�= O Q Z F Z ZZ p p.J N W Z) Z) ZtY J O W O W I Q L) o ti Z N ZW z zrm a F W ..x O N� O fZ) c x m W w -1 a � in o CV) I yJ I N w • 0 f .R o z f r 1 1 �;, w N I I "t 0 !1 67 �� . � I rc z � U ' O W -~ o vI ,L, c0 LLI O OF > ,~ a rn CO E+ O WW Y y �'' M °o 0 I ( I I r >-- rx � �, o — �; w l CO F o LLJ 13 LLI CU A Z Z Z N; , i Z Q a /n/ = W si �> L7 F �� /� , ££8td 0 f E_I I-- W W F v W I j �H O i Z C) _j . �� ' z v. g o I O z :� F- f � Ln I 3 U z LL. N _ OC) W I J1 W E4 a° Cl I 2 v c°n ,, t • `"�u W N I O N o H E-+ I '� z a p O= Ir W A ®¢ A H Q O F p -1 oM ��' ; M �Nm IEej1 FOIzU T- �...,_ I N . O z M z Z Q �c i Z 3 a d , o p O ° N E 376. a � ► N� N --4! LO > W O I S06,53'34��, 31 41.26' c� o `°� o� 0 z J p z I - r J► .naZ o F W a Zs_�_ _ - ago �� Z U W �o �y .� v �- I 1 �I J N W W SU Q N U -- --- - - - - -- MI / O W W W F z (4 Q�f,Jr�7dNn o Lf ° a o � : CO, 66 _ �O ._ . ,92'21Li O So'266 cl) t` �'' W I a ,I E'b69Z % 1 W:D C/]i I s u z E - 4 CQ E-4 M „tE.Ei.00S z iw V i ��v d' CL z �i wl O`r v 6 ,Ir WC4 b /t3N 3H1 30 6 /IMN i I ' �?. Ma ? ',Z, 3H1 3❑ 3NIl 1S3M O CSI �Di .�°J. C t,ci 1 I •,►I .'� Oho H v .o Cl) U Q S Cl) W F - 1 " moo O O / W W 3 LJ V) f/1 N m m N m W H F- (' as z z F- -p M �p W W M.IE.LS.68S 2N a of a3wnSSd I N M N {') N0I133S 30 t► /13N 3H1 30 3NI3 HiNON z M zo ih XC4> 1 f 3H1 O1 a33N32J33321 321d Sc]NI21'd3S J y y y F Fyn a <) am0 Z °°af r ♦ wiscxnsin Department of Commerce SOIL EVALUATION'REPORT p l of 3 Division of Palely and Buildings in accordance with Co►m1.85 Wis. Adf& Code Attach complete site plan on paper not less than 81/2 x 11 indres in size. Plan must County S4. Cro I include, but not limited to: vertical and horizontal reference point (BM), direction. and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all in 4' Reviewed by Dade Personal information you provide may be used for y par'(P"y taw, s. 15.04 (1) (m))- Property 1 Owner PmpertyLocation q S + e ' n 12� V a.h rvl ..c? r ' i Lot £-- 1/4 n 0/4 S � T - ! N R1 � E (or) W Property Owner's Mailing Address -_ �, Block# Subd. Name or CSMff H ia 35' fj 3(� 3 CRY stye Zip S j1X % i fte own Nearest Road S"T:JOSEPH New Construction useFf Residential tiir rpf Code derived design flow rate 4) 5" GPD n Replacernent Pubic or Parent material 10 - c ar Flood Plain elevation if applicable ft. General comments and recorr lions: I lI Boring # U Boring ( � I-1 Q Pit Ground surface elev. -`I ♦ 57 fL Depth to imil, Ihdor 9 in. Horizon Dept: Dominant C- Redcx Description Texture Structure Con=sistence Boundary RuotJS GPDW in. Munsell Qu. Sz. Cont. Color GL Sz. Sh. '111 `Eft I 0� Id z SI umsb MVr Co 2 r sl 14 MA k r 'W ,5 •6 3 -�1 7.� r -" S � -� — 7 • � I I I I I I I I I I i j pi ng Ground swiace elev. 5, 5 � a C1 �° Depth to fruiting fado in. Sail Application Rabe Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rook GPDW In. I Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `EfI1#1 1 - EfW2 1 0- 9 6 1b r3 A a f` sbK r �(J ,Z 15 Z 8 -20 1 64 I S 11 s K -'r- i'v 3 30 -9� 1 -7.5 �- ` Effluent #1 = BOD > 30 2M mglL and TSG >30 < 450 iV& ' fifluent f1;2 = BOD < 30 nV& and TW < 30 no& Nam CST Na (Please Prim - - Signature CST Number t. a Y) d --i`— A.7 3 8 7 i 1 9 - I o {-� S+ e 4� (� r e x� r�1 o h cJ? c.� ( Dade Evalu �Corduded • Property Owner U- 1 M Parcel ID # Page of Fil Boring # Boring �2 61 pit Ground surface elev. '� 2 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -� i o r3 - L 51 -S0 I i r 4f4 S11 AmsbK MEr 3 0 - 7's Irk — s rh -- y - r� Boring # ❑ Boring V Pit Ground surface elev. '9 ft. Depth to limiting factor 7 b in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f1? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 O- I b I o r Y Z — 5 a 3 U� M Zr tJ Z� I S , 2, 10- 10 r'{ /A j MS 1•' r I ` - �' 3 )R-q0 TS rM — S dS rnj `" , 7 e Boring a Boring # 1:1 Pit Ground surface elev. o• 1 ft. Depth to limiting factor 2 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 - Eff#2 15- 2 7. S r� — S U — — ► � '� ' Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (8.6/00) Wisconsin Department of Commerce SOIL EVALUATION REPORT P Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Pam I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location ah Govt. Lot 1/4 1/4 S T N R E (or) W Property Owner's Mail Lot # I Block # Subd. Name or CSKW 1190 35 City State Zip Code Phone Number ❑ City ❑ Village fjaTown Nearest Road " a I WI j sqpi JIS )SU -,2 I St , Jo S+ 35 It New Construction Use: ['Residential I Number of bedrooms Code derived design flow rate S�O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable fl. General comments and recommendations: a Boring # ❑ Boring Pit Ground surface elev. _ ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 I 0- '1 51 Vo Vr z - S1 IF F -1 Boring Boring # Pit Ground surface elev. tt. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 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