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HomeMy WebLinkAbout032-2176-17-000 FF apartment of Commerce PRIVATE SEWAGE SYSTEM county. St. Croix uildin_ Division ' INSPECTION REPORT Sanitary Permit No: 479477 0 r2AL 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: TI Magnuson Enterprises, Inc. ___W_ I Somerset, Town of 032 - 2176 -17 -000 CST BM Elev: Insp. BM Elev: M on: Section/Town /Range/Map No: /'0 Z • Z-I 1 /0 2, 1 4 11•30.19.1502 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / ©D Benchmark ro Y. 1 02,2_ 7 Dosing Alt. BM Aeration Bldg. Sewer C ` , U D;; 3` � Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet r St TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic \ / Dt Bottom -r--1 Dosing / eader/M n. , /� 4 b l ) 9Z• Aeration lP L • D q i!' IZ•� I Holding Bot. System Final Grade PUMP /SIPHON INFORM d:5vs# kw S 1 3, Manufacturer GPM Dema St Cover S I Gt� • �L Model Number 1 TDH Lift Friction Loss S TDH Ft Forcemain Length a. Dist. to well SOIL ABSORPTION SYSTEM 1 BED /TRENCH Width jLengtti. Of Trenchee� PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS �`)� -� SETBACK SYSTEM TO P/L BLUG WELL LAKE /STREA LEACHING Manuf r. INFORMATION CHAMBER O Y Type System:CV ( 1 1 UNIT Model Number. 1 / (U DI IBUTION SYSTEM awy fM- nbsftl Vaderl anifold Distributio x Hole Size x Hole Spacing Vent to Air Intake I Pipes) �i q 3 / (o d ` Dia Len gth cc�� Dia Spacing SOIL COVER 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 Yes No Yes [' No ?1 3 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:�� / </ 6 57 Inspection #2: Location: 1621 83rd Street Somerset, WI 54025 (NE 1/4 SE 1/4 11 T30N R19W) Lakeside Estates Lot Parcel No: 11.30.19.1502 1.) Alt BM Description = Sr '.) Bldg sewer length = 2 15 - amount of cover = f I 'evision Required? Yes c )er side for additional information. -- Date Insepctor's Sign ture Cart. Nr (R.3/97) Vs -hi Safety and Buiklin sion ty Zol W. w -t- consin Madi WI 5 "IICS� � tV ' S nary Permit Number (to be filled in by Co.) Department of Commerce 8) 26 " ' "I -/ 7 Sanitary Permit Application S to Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal inf rovide may be used for secondary purposes you provid Privacy IAw, sl 04(1) �MJJX C O LJIIJT`i ject Address ((iif different than mailing address) I. Application Information — Please Print All Information Z O 3 AD S T �-• . ..L ,c.. .SO �cr �"R StrT — Gv 1 ' Properly Owner's Name Parcel # Owner Lot # Block # SV 4 � ���'1 S dN p — � Property 's Mailing Address a -y /6a 3 R ^/ PmtYLocation City, State J Zip Code Phone Number AX ��' S E 'A Section �!/M�i /� JL �/ • S7� LS �0��• /7� 7�7 �1 (circle T N, R E o W� II. Type of Building (check all that apply) A l or 2 Family Dwelling — Number of Bedrooms ,y�, ��_ � /a � Subdivision Name CS -- ❑ Public(Commercial — Describe Use G � 9 57*7 - ,dFS ❑ State Owned — Describe Use 2 1 ; ) +-� G q,,,,� ❑City ❑Village Township of 51 E 4 S i4' r III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' % New System ❑ R Replacement ep System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System $• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New Lest Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl X ,n — 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 ❑ Red rcuI "ng Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Urip Line ❑ Gravel -less Pipe ❑ Other (explain) t V. Dis ersalUTreatment Area Information: e Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Aria R m s Di � � � � eq� f) �rsai Area Proposed ( System Elevation / VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass NOW Tanks Tanks Septic or Holding Tank O ov — 16 60, Aerobic Treatment Unit W •'LG S Dosing Chamber VII. Responsibility Statement - 1, the undersigned, assume responsibility for installation of the PORTS shown on the attached plans. Plumber's Name Priltt) lumber's gnature MP/MPRS Number Business Phone Number Rt`Z��t3 ��G� zzC�3�S 715'• -3Lf4Z Plumber's Address (Street, City, State, Zip Code) VIII. Conn !De artment Use Onl pproved ❑ v Sanitary Permit Fee (includes Groundwater D Is Issuing t Signatu o ps) ej Surcharge Fee) 2 p© 1 5 Owner Gi carom for - J U K� IX. Conditions of pproval/Reasons for Disapproval .,= 3 \J �JJe, d del ✓'2..s �`�.- +Ile+.r>ll+e 5 6' 1 bye. dim ele';an �r fo per aMl�Illat plan provided trf . mitres. r�, 7 . 7'9 f ptaa ti Xfu" n `l a a .-M Z Nsa�� NKs merest be maa;. -d t as iv.ra�lr code / adlrtances. , s i oR�D a%n�r;1.�{'�- � 4a keep �-v 1, l � n. k. Oc (3 _ ( �o�IoQ Attach complete plans (to the County only) for the system on paper t lets 3112 x 11 inch= 9 SBD -6398 (R. 01/03) v I r rod _'_� � Itt "•'yri a ' + as r /14A 611W,X0N c. ca i i 1�i9 4F' 3 233' CP tODtD 00 33 w�- d � s X Z 0 C m x N o` 3 p rl � r 4 _ ® p I II \^ N . V1 1 -° ■ n 3c Q W CA N 'OC 'O �• Cs 6 4 0 r N cr)� = pa � m s T ULBRICHT & ASSOCIATES CO. 2812 1 Oth Ave. • Spring Valley, Wl 54767 Reg. Dwignems of EnginewM Syswme 715 -772 -3442 PMate Sewage Consultants PROJECT INDEX LET 1-7 PLAN ID # DATE _ SE-PT 12. '20 0,�,.,� OWNER `7 /M A ND JU$7 MA4�7N PHONE ADDRESS 11 Y, Sir LEGAL DESCRIPTION LOT -* C--7 _ GAE %Q S 1l 'T '3 N, R-19 - w C 1 TOWN OF $OM�12S�? (✓OIVA -) — rr ®® COUNTY S � • CRaIX CSTM) LOCAL AUTHORITY/ SUPERVISION 57-. C ko f x C � 1/ 2, o Aj f A.)6- PROJECT DESCRIPTION: l ^ ALL. N JZ w NO/V- PRiF SSt4 k1 Zg: Aj- ' kom -� �2ovND S y s r l0 B -7 7� Ulbricht & Associates Private Sewage Consultants 2812 1 Oth Ave. Spring 1�'1ley, W! 54767 THIS POWT SYSTEM SHALL INCORPORATE PER COMM. 83.44(2)c A PROPER ZABEL FILTER MODEL # ( Z _ O S /6 a s i P9•1 INFILTRATOR SIZING WORKSHEET Pg.2 SYSTEM PLOT PLAN P9•3 CROSS SECTION OF'SYSTEM, WITH ELEVATIONS. P9.4 it to It If P9-5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS P9-6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK. PG• (OPTIONAL) PUMP PERFORMANCE SPECS. The attached plans and specifications are based on "In- Ground Absorption Component Manual For Private Onsite Wastewater mrtaa$mor�} Q,� }ome l�TGY4l 7 fly CR - Pfvni /()1 _ 100 67NU--jaW L--o -7 i7 t�A Cis 3 o c 3 R3 Rv S7' 233' tP t�A t•A tab 33wN— � � s m 00 - A v v � r� • 4 kn • � r � DD ® N i R J _a W UJ N 'Q C �- 'R c• S =r (D O �.• ® t0 co • O n n 0 6 O X r tP o � nn IVA �� 3 CD s o y d b 4 � � a NNI � b Z � Ul kA O O ' r W n W N \ _ • - Cif /tv�hTF_ v i - ,..Zr Fri�/rS/f�ED OjA Of A� � � >rl 7xwwooe a .• - _ A C/�D SS SAC �/4� OF T/pL�"itJG��S wry, 1q 11bo*&4P vJ.&7- cam °V /wS �D�'cT /ov 1 IV / "Z_. �� FrivrS�ED TH If Al Z Z F3 �.. s ysT�•� OVER: See Reverse Side for Vent/ Observation Pipe Details. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ./ of Z FILE INFORMATION SYSTEM SPECIFICATIONS EOwn "TIM JU S7 N. MA AI1450^1 Septic Tank Capacity .��-�f gal ❑ N Septic Tank Manufacturer W 18 Sep ❑ N, DESIGN PARAMETERS Effluent Filter Manufacturer Z D� ❑ Nj Numb7of drooms ❑ NA Effluent Filter Model DO ❑N, � I Numbblic Facility Units .t4 NA Pump Tank Capacity [ Estimated flow (average) g �N/ 3 C' d gal /da Pump Tank Manufacturer / Design flow (peak), (Estimated x 1.5) -4 &D gal /day Pump. Manufacturer N.4 Soil Application Rate .7 al /da /ft2 Pump Model . NA Standard Influent /Effluent Quality Monthly average` Pretreatment Unit �l NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD.) 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Weiland Total Suspended Solids (TSS) 1 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cellls) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L Vn- Ground (gravity) ❑ in- Ground (pressurized) Total Suspended Solids (TSS) <30 mg /L N NA 13 At-Grade 13 Mound Fecal CoGform (geometric mean) <104 cfu /100m1 ❑ Drip -Line 0 Other: Maximum Effluent Particle Size Y in dia, ❑ NA Other: Other_ ❑ NA ❑ NA Other. ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency = Y , Inspect condition of tank(s) At least once every: ❑ month(s) 13 year(s) (Maxisnism 3 years) 0 N Pump out contents of tank(s) When combined sludge and scum equals one - third (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) ❑ year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑ month(s) ❑ year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: 0 months) [0 year(s) _ ❑ NA Flush laterals and pressure test At least once every: ❑ month(s) Other: ❑ year(s) ❑ NA At least once every: ❑ month(s) - ❑ NA Other ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. 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 scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in, accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not 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. 1 START UP AND OPERATION Page Of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting. products or other chemical that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content of the tank(s) removed by a septage servicing operator prior to use. System start up shag 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 b discharged to the dispersal cell(s) in one large dose, overloading the cellist and may result in the backup or surface discharge o effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorin+ power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t, 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 are; .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 improve the performance and prolong the life of th( POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat foundation drain (sump pump) 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 POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safety 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. • The contents of all tanks and pits shall be 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 and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: r ❑ 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 from existing and proposed structure, lot lines and welts. 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 eff ect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. , U pon 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. 11 Mound and at -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 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. ADDinONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name (,/LBQtG�y.T Q T GIG Name AME Ag PvMp� Phone vi t5 - X72 - 3d+ 42- Phone " •• SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name I Tej-CO111VIr . TJDA/ Civ Name ,6 ST. C kOIX C'UVNT LPN/ DEPT. Phone IS 3$6'-2 (30- Phone - 7 1.5 - 3$b_ X1680 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. OWNER's MAiNTAINCE - 0F 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 s -E . C,� o x C y. *- Governmental authority/ inspectors: Licensed installer, responsible for providing an operation/ maintenance "Users" manual: - 7`7A �! �--- R , �Q �. ` c �-�-- Pi 3 2--a- -� * Licensed service p / ins ection a other than installer: *Electrician,- for pump, electric controls, wiring units: /XC 7W IMPORTANT OWNER MAINTENANCE RE UIREMENTS 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. Uiscontinuos 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! Or system can be hydrolically overloaded and destroyed. This sys�em was designed for a maximum wastewater flow of 1 1SO 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 result a temporary overl y oad of effluent being pumped into the cell , which may adversely impact the cell (leakbge). 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 {the cells insulation & traffic also can de stroy l t a he t system. It ISmNECESSARYrToeavy REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the- ,gystem beneath IS NOT sufficient alone tO maintain a �L ` cover. a; 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and basal area been incorporated into the system: on the mound b e (effluent level inspection pi laterals p )# cleanout terminals on the pressurized 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 Quaii6iecl person should be Performing this work which involves health 3, severe safety risks. Evidence of effluent pon in th s ystem's treatment cell shall also be regularly P inspected. wsconsin Department of cornrnerce SOIL EVALUATION REP P age of 3 Division of Safety and Buildings in accordance with Comm FsL-e RF C Attach complete site plan an paper not less than 81/2 x 11 inches pmlr9 1 V include. but not limited to: vertical and horizontal reference point (B ction and Parcel tD. perc ent slope. scale or dimenslons, north arrow. and location and d to r rw Mad- i I F Please print all lrrformatlon. te Date Personal information you provide may be used for seoonaaryr purposes ( � � :'�RtS1k _ I ` J W STt lJ M A CAN U SD Govt Lot 1/4 L 1/4 S 11 a N R/ 9 E Property Ownel's MAing Address L me ot # Block # Subd. Na or CSMff City State Code phone Number j o City ❑ Village ❑ Town Neat Road Smoelrse-t I Wt 59025 (10(21 R4b• - 78r+ - 7 Sommsiff? L3r -t Or New Construction use g Residential / Number of bedrooms 3 Code darived design flow race b GPD ❑ Replacernent ❑ Public or conxnerctal - Describe: Pafent material 6 bFF 5 O V V2 50INVY Flood Plain elevation if applicable A R General cony nerMS v!/lw�l5►fi and rr �•�� ORTGI r AI Boring # o ® Pit Ground surface elev. 9 811 tt. Depth to limiting factor ) 9� in. Sol Rate Horizon Depth Dominant Color Redox Description Texture Struchre Consistence Boundary Roots GPDAtm In, Munsea Uu. Sz. Cont Color Gr. Sz. Sh. •E1f/11 'EtT#2 - IDYR 3 / -' �- 2 3 16.11 10 T `+/ - S CI v j .0 4 �}I-50 OYR C sYR`�/ Sicl aw 2V-F �+ •(o 5 50-97 10 YsL Me IVf rl �.� 5 JLA.� Boring # ❑ , ® Pit Ground surface elev. 1 / • O 1 ft. Depth to tin & g factor ? 9y' in. Rate Horizon Depth Dominant Color Redox Description Texture Stukttue Cormsistence Boundary Roots GPDAP in. Munseti flu. Sz. Cont. cow Gr. Sz. Sh. •011#1 *1211#2 0 10 Yls 3 12- - t m b M -F r $ 2 5 1 0 YF ' A, - ; I 2 bK rh�-i a. '�►' • b 3 7 - 0Y2 sly — S 05A d. I — J of I • •� • Eftm t #1 = BOD > 30 < ZM nV L and TSS >30 1150 nV L ' Mart #2 = BM 1 30 ffQL and TSS :E 30 nVL CST (Please pnm CST 5993ly J c 4 n/ Y LA � f3 r2 l 4 r1 -7 Address Evaluation Conducted Telephone Number 2812 1 r-~ AAve c Snit c7 J*kw'E" -j Lj( ,SEPT 7200.5 715 - 772•'- Ulbricht & Associates Private Sewage Consultants 2812 14th Ave. Spring Valley, WI 54767 F ate.. 1 Susr/A propertyowner f Vl A (rAj V S � � Parcel 10 # Pa p - 2 or 3 9 # ❑n8 ® Pit Ground surface elev. �3 R Depth to kMM fador } 52 n• Sop � Horizon Depth Dominant Redox Description Texhue Structure Consistence Boundary Roots GPDIIf IM MunceN Ou. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 l -l0 /0YR /2 - r fr 5 3� $ 2 (� i 4 .4 .6 3 7 -22 3 1 pYa 5 srR'V►% i cl f b K M f i u, W v-� .4 (vr 2 I 0 Ya. s — s 0 55 a - ✓f 1 F ' # O Bo ❑ Pit Ground surface elev. R Depth to WWft factor in. Sol! A Role Horizon Doh port*wM Color Redox Description Texture Structu a Consistence Boundary Roots GPM IM Murwei tlu. Sz Cork. Color Gr. Sz Sh. *M1 *EM F - 1 ❑ Bor 80*V # rrrg ❑ Pit Gnxxrd suface elev. R Depth to Nrrdtirrg tac6or in. Solt ApplicAm Rate tforizoo Depth Domir rt Color Redox Description. Toclure Strums Consistence Boundary Roots GPOW In. Mursel Qu. Sz Cont Color Gr. Sz. Sh. 'Ef!#1 'E10i2 Eflluerrt #1 = BOE `> 305 220 ROIL and TSS >30 5150 molt. ' Effluerrt #2 = BCC , _< 30 ROIL and TSS _< 30 MWL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or nerd material in an altanate format, please contact the department at 608-266-3151 or TTY 608- 264 -8777. aaoujotarsroo> l►r! N1 Nc��D� L07 ! P4&Er 3 o c 3 �93 Z33' 0 OD tD 00 w t^ r'_ +�N u o 'too w�s • ■► c � o x � o o� � m 00 �` p r �v c r� ' NJ ► C V3 D 4 IC io N °1 ° v ■ O Q `� o® � N Q CD C: r t� cnS� r cD �2cn `< > :E � vi mCD 8 d cn n Si 0 O rn �N e ° v u> s x N r . �► 1n rEA '0 ° 6 , CD m ell I i t / r • i r. v - d A � \ \ \ \���• a\\\\\\\\\�\\\\\w\\\�\\\\���\\� \ \ \ \ \\ `� ` \ \\ \`�� • 0� ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/BU er U 1 l� - ri m SQ /A /�°� /y. Cr�to 11 Owner/Buyer � Mailing Address 1& 3 � r^ Property Address I b - f (Verification required from Planning & Zoning Department for new construction.) City /State Same s �- ��. Parcel Identification Number 6 3 Z z 1 _ 17 - cbo LEGAL DESCRIPTION Property Location Al 1 /4 , :51 �' 1 / a , Sec. l r , T N R /� W, Town of Subdivision , L # 1 Certified Survey Map # , Volume , Page # / Warranty Deed # 7 3 v C js , Volume Z J� , Page # Spec house y s no Lot lines identifiabl yes no SYSTEM MAINTENANCE 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 §Comm 83.52(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 1/3 full of sludge. I/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 stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bed ours SIGNA F APPLICANTS) 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 if reference is made in the warranty deed. (REV. 08/05) to ' 736985 _ v�± 2Q 85 Fr.�= 3 3 ' STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., WI This Deed, made between Jeffrey S. Boardman and Karen RfiCEIYfiD FOR RECORD Boardman, husband and wife, 08/22/2003 09:00A)! WARRANTY DEED EXEWT # Grantor, and TI Magnus Ent. In REC FEE: 15.00 TRANS FEE: 930.00 COPY FEE: CC FEE: Grantee. PAGES: 3 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix _ County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area (See Attached Exhibit "A") Name and Return Address B ,-. ✓nq-t` - Ff ,15p •emu e S t) 5� - 35 6 3 a Sv 60.0 032 - 2043 -10 -000 Parcel Identification Number (PIN) This is homestead property. (is) MXOO Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this &14/1, day of June 2003 • + Je S. Boardman • + Kar Boardman AUTHENTICATION ACKNOWLEDGMENT Signature(s) c} S `rte} STATE OF WISCONSIN ) ) ss. { St. Croix County � ) authenticated this ! day of Personal) came before me this day of Y Y June 1 2003 the above named # �� S ( /^, l✓ Jeffrey S. Boardman and Karen Boardman, husband and wife, TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY + _ Attorney Kristina Ogland j — Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) , ) ' Names of persons signing in any capacity must be typed or printed below their signature. Information araeas;onais company. Fond du Lac, W STATE BAR OF WISCONSIN 800 -655 - 2021 WARRANTY DEED FORM No. 2 - 1999 I vo 2385 w% , J384 EXHIBIT "A" Legal Description File No. 3 -42642 Lot 1 of Certified Survey Map filed in Vol. 10, Page 295 of Certified Survey Maps as Document No. 530892 except: Part of SE % of SE % of Section 11- 30 -19, being a part of Lot 1 of Certified Survey Map in Vol. "10 ", page 2951, described as follows: Commencing at the SE comer of Section 11; thence N 89° 24' 04" W, along the South line of the SE' /. also being the South line of Certified Survey Map recorded in Vol. 11 10 11 , page 2951, at the St. Croix County Register of Deeds Office, 1323.86 feet to the SW comer of Lot 2 of Certified Survey Map; thence N 00 27' 15" E, along the West line of said Lot 2, 660.00 feet to the NW comer of said Lot 2 also being the point of beginning; thence continuing N00° 27' 15" E, along the West line of Lot 1 of said Certified Survey Map, 658.31 feet to the NW comer of said Lot 1; thence S 89 38' 43" E, along the North line of said Lot 1, 660.00 feet; thence S 00° 27' 15" W, 661.12 feet to the NE corner of Lot 2; thence N 89 24' 04" W, along the North line of said Lot 2, 660.00 feet to the point of beginning. Also except Easement granted to Dairyland Power Cooperative as shown in Vol. 1404, Page 297 Document No. 597998 described as being 40 feet on each side of the following centerline: Beginning at a point on the East line of a parcel of land located in the SE %-SE %, Section 11, T 30 N, R 19 W, and further described as Lot 1 of Certified Survey Map flied July 5, 1995 as Document Number 530892 In Volume 10 on Page 2951, said point being approximately 16.12 feet North of the Southeast comer of said Lot 2; thence in a Westerly direction a distance of approximately 663.86 feet to a point on the East tine of Lot 2 of Certified Survey Map flied July 5,1995 as Document Number 530892 in Volume 10 on Page 2951, said point being approximately 22.10 feet North of the Southeast corner of said Lot 2 and there terminating. Also except a parcel of land located in the SE % of the SE % of Section 11, T30N, RI 9W, Town of Somerset, St. Croix County, Wisconsin described as follows: Commencing at the E % corner of Section 11; thence S00° 27' 04 " E along the east line of the SE % of said Section, 1323.90 feet to the north line of the SE % of the SE' /. of said Section and the point of beginning; thence S89 40'13"W, along said north line 658.66 feet to the east tine of a parcel of land recorded In Volume 1141, Page 571 at the St. Croix County Register of Deeds office; thence S00° 13' 35 "E along said east line, 120.00 feet to the south line of the north 120.00 feet of said SE % of the SE %; thence N89 40' 13 11 E, along said south line, 659.13 feet to said east line of the SE %; thence N00° 27' 04 "W, along said east line, 120.00 feet to the point of beginning. And: A parcel of land located in the SW % of the SW % of Section 12, Township 30 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin; described as follows: Beginning at the SW corner of said Section; thence N 89 14' 08" E along the south line of the SW' /. line of said section, 285.79 feet; thence N 00 45' 52" W 165.47 feet; thence N 35 15' 13" W VO 385 101.43 feet; thence N 58 51' 18" W 219.64 feet; thence N 02 36' 46" W 315.02 feet; thence S 87 23' 14" W 28.05 feet to the west line of said SW ' /,; thence S 00 27" 04" E along said west line, 679.12 feet to the point of beginning. Parcel #: 032 - 2176 -17 -000 09/15/2005 04:23 PM PAGE 1 OF 1 Alt. Parcel #: ' 1x.30.19.1502 032 - TOWN OF SOMERSET Current X \ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 01/28/2004 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - TI MAGNUSON ENT INC TI MAGNUSON ENT INC C - COPAR DEVELOPMENT LLC COPAR DEVELOPMENT LLC 15211 113TH ST N STILLWATER MN 55082 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1621 83RD ST SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 3.070 Plat: 09 /99- LAKESIDE ESTATES 1/22 032/04 SEC 12 T30N R19W PT SW SW LAKESIDE Block/Condo Bldg: LOT 17 ESTATES '04 LOT 17 (3.07AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 12- 30N -19W SW SW Notes: Parcel History: Date Doc # Vol /Page Type 01128/2004 752813 9/99 PLAT 08/22/2003 736985 2385/383 WD 0912712002 692047 1991 /540 QC 09/27/2002 692045 1991/537 QC 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.070 60,300 0 60,300 NO Totals for 2005: General Property 3.070 60,300 0 60,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I ULBRICHT & ASSOCIATES CO. 2812 10th Ave. • Spring Valley, WI 54767 Reg. Designers of Engineering Systems 715 -772 - 3442 Private Sewage Consultants PROJECT INDEX L o T 1 PLAN ID # DATE SEpT 1 2 - 20 05 OWNER - TIM A N p , JUST /N MACS N kSW PHONE ADDRESS 1 (o39 �'3' &/ Y r 5c>me1%�ct, wi 4 e 5 LEGAL DESCRIPTION LOT # 1 LfJ/ S %DE S I/ 'T 3 o N RI 9- w TOWN OF SOMEkSe? ) COUNTY S _ � - CRoix CSTM LOCAL AUTHORITY/ SUPERVISION 5 Cpo ` X ZQ 00 1 lJ&_- PROJECT DESCRIPTION: INSiaLL IV r2: VV N0N- AR�ssLr�ei2Ea JAI_ L 7 r<'ovND /40 Apt C � Es ` &Aj w� s_rE �( Ulbricht & Associates Private Sewage Consultants 2812 1 Oth Ave. Spring Valley, Wl 54767 THIS POWT SYSTEM SHALL _ INCORPORATE PER COMM. 83.44(2)c A PROPER ZABEL FILTER MODEL # /b ( 1 ^' O S c ;24 f P9.1 INFILTRATOR SIZING WORKSHEET P9.2 SYSTEM PLOT PLAN P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. Pg . 4 It of it to it 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 '1'rcafmcn�- CvcFamc � (ZTcrainn 7 o CRT)_1n7ri_A(N()1 /(11 o � d r•. � V O . b � � � b Ao fw Ak `s. z S Ul tA kA s r c� n � 1 L..o`7 /7 ' /V! A' G7 N tlaD�✓ PA• 3 o c 3 g3 pp s - 233' 3 c�t�t� t j w r' p a N c o 0 x = m r Ooo �` p av o v o vi .� r . •� vo ..a A N O 3 N (ANC -L�'� z ro N =' C e q1 cu > * D CD 0 O C' 0 p, SD cn p .P. M m O 4 �� e ° � LA n� N r V` M V ® it r V, _ O -0 rq �.� U N NV � m � m C,FI v Fl7 U� ► .. i9Pl�i�Dlrc�1> Usti 7 C.�4/° jA a� IAI -VIE - T/d v f7� or q% "z-. �INiS�ED Rio SS S�cTioA.) 0 Tip�w�s' Q ic.K ZK CAJ 4crry U Cam, �fcl Ji SeC 7 190AJ ► ,• /9J U�w 7" Cam/° .Etiv, i"Z,'' Mfr t TH r F3 G,� Mel_ iE' T it°t �t•Y.! �r�` OVER: See Reverse Side for vent/ Observation Pipe Details. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa . / of FiLE tNFORMA770N — SYSTEM SPECIFICATIONS JU57JN MA N Capacit U90^1 FEffluent ptic Tank C .�, Permit � I"V ga l ❑ N, ptic Tank Manu #acturer 1 � 14e yER ❑ N, DESIGN PARAMETERS Filter Manufacturer Z� L.— 13 N, Number of Bedrooms �£ 3 ❑ NA Effluent Filter Model 10 0 ❑ N, Number of Public Facility Units NA Pump Tank Capacity Estimated flow f average) al �Na 3 b b gal ay Pump Tank Manufacturer J�,'N Design flow (peak), (Estimated x 1.5) ��jp gal /day Pump. Manufacturer V N1 Soil Application Rate .'7 aflda W Pump Model Standard Influent /Effluent Quality NA tY Monthly average Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Fiher ❑ Peat Filter Biochemical Oxygen Demand (BOD 5 220 mg /L 0 NA 0 Mechanical Aeration ❑ Wetland Total Suspended Solids ITSS) 5150 mg /L ❑ Disinfection Pretreated Effluent Qualit ther: t1' Mon thly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ,Wn- Ground (gravity) ❑ 1n- Ground (pressurized) Total Suspended Solids ITSS) 530 mg /L NA ❑ At -Grade D Mound Fecal Coliform (geometric mean) 510 cfuf100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia, ❑ NA Other: Other ❑ NA ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effiGent. Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: ❑ month(s) Pump out contents of tankts) {Maximum 3 years} El NA Q earts} When combined sludge and scum equals one -third (�) of tank volume p NA Inspect dispersal celt(s) At least once every: 0 month(s) (Maximum 3 Yom) ❑ NA i ❑ year(s) 1i Clean effluent filter At least once every: 0 month(s) ❑ year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: Q months) 171 year(s) ❑ NA Flush laterals and pressure test At least once every: 0 month(s) Other: 0 year(s) 0 NA At feast once every: d months) Other: ❑ year(s) ❑ NA ❑ NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer; Septage Servicing Operator. Tan' 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 scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third %) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in. accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not 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. i START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting . products or othe# chemical that may impede the treatment process and /or damage the dispersal celf(s). If high concentrations are detected have the content of the tanks) removed by a septage servicing operator prior to use. System start up shalt 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 b discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge o effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorint power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls b 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 are; .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 improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat foundation drain (sump pump) 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 POWTS fails 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 chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be 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 It the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system; r. ❑ 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 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 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 tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. AJ(Pon failure of the POWTS a sot( 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 and at -grade soil absorption systems may be reconstructed in place following removal of th 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 AND /OR INSUFFlC1ENT 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 Name U1. jM, T T GIG Name Ate+£ , q.s DvM pgi2 Phone -1 772_ 3- Phone �' • SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name TRi /TY $ /DA/ 686,V Name � $�. cQoix f vvNT L ave DEp�; Phone `Z )5. 386 'a ($C? Phone 15. 3$b- This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Admiriistrative Code. OWNER MAIN'PAiNCE - OF SEPTIC SYSTETf 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 con trolling ,authorities. - SPECIFIC CONTACT AGENTS *. _54. c(20i C7` Governmental authority/ inspectors: _ 3 9 - 6 SO Licensed installer, responsible for providing an operation/ maintenance "Users" manual: J"1 P, S �- °* Licensed service / inspection agent other than installer: Electrician, -for pump, electric controls, wiring units: jM r� <5' N IMPORTANT ©WNER MAIAITENANCE RE UIREME . 1- Winter traffic (sledding, shove*ing, etc.) across the area shall not be permitted, or frost can /gill penetrate into the cell, freezing up the system. Discontinuos use in the . winter vacaction trip, resulting in no water .use) can also lead to freeze ups. 2. Water conservation to be exercised! Car system can be hydrolically overloaded and destroyed. This sys�em was designed for a maximum wastewater flow of ysO gals. dairy. 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, I t may result in a temporary overload of effluent bein cell, which may adversely impact the cell (leakkge),It recommended that a licensed pumper empty the dosing tank, allowing the pump to return to d osing n the come Consult your installer immediate) cor ' amount s . y f o r advice. 5. Neglect of the vegetative - cover erosion (the cells insulation Preventive) can lead to failur traffic also can destroy t he system. e. Compaction or heavy It IS NECESSARY TO REGULARLY WATER THE. VEGETATION OVER A SYSTEM!! Effluent in the„gystem beneath IS NOT suf ` kCOvwr. ficient alone t0 maintain a � C. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and Por Into the system on the mound basalareaVe been incorporated 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 coverfmanhole). Person Only a licensed properly qualiCi.ed should be performing this :cork which involves health Severe safety risks. Evidence of effluent ponding in the system's treatment Ceti shall also be regularly inspected. _ I l'o Pi9R 79&vn4op.4i 7 -- coo 72vef ry,Q,vs ¢ O& Wfl,v S7- �jv SSoGG (os/• 388 • /Good Wisconsin Department of commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings In accordance with Comm 85, - Wis. -A w. 07!� g �� �+ ,.. ST C�90/ X Attach complete site plan on paper not less than 8 1/2 x 111 s in sl¢�iPfbfm'r11us1 - Include, but not limited to: vertical and horizontal reference poin (BM), direction and p I.D. percent slope, scale or dimensions, north arrow, and location a distance to ne rent 7 Please print all Information. J U' - /� 11 Re wed b Date Personal information you provide maybe used for se000dary purposes ! aay I,dtrr, F, (ryyn)p:• Property Owner trr _ 61144 Jeff 3aARPigr1AJ Govt. Lot 114 1/4 S Ie2 T 30 N R /57 ti (or) W Pro ry owner Subd Owner's Mailing Address Lot # Block # . Name or MY Z /(Oct w-, 14 U.e • 1-7 P ,vPi.uG- 1"J'491P CRY State State Zip Code Phone Number ❑City ,4 ❑ Yllage (a Town Nearest Road �iGlr�yo•v� W1 Syol7 ( 7/S •-S34eG Sa,, - 1 /lvo)A 4V . 04 New Construction Use .A Residential / Number of bedrooms - 3 Code derived design flow rate lr0 o GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicabl General comments A fO,4 7'ES 7&,P �P �!'v�'�P�S o v vv s and recommendations: ZlS /N(r /,;L /11 F /I # p Boring Boring Pit Ground surface elev. 7 � 2 � Depth to Hmov factor 3 3 in. Sad icafiort Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Mu nsefl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 •/l 10 31 s� 14",f . y . 4. z //-/J 10 0 y/ _ Gs ; W f cis es -- • - 7 2- • s Al YtP s/ ° rs S/G s nm � • 4 ti• — . 2 3, Z • 75 /d Y S/ o,c s / f 4 4.1' f ioyR Yly z a e M6 r 5/ t- / f Sh,� �, �i • 4,c' — • Z • 3 F2- � C3 Boring / .2 k / S'S . S . J Pit Ground surface elev. _ ft. Depth to limiting factor in. So(1 Rate Horizon Depth Dominant Color Redox Description Texture Strurcture consistence Boundary Roots GPD/(! In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Ef#/1 'Eff#2 z /40031 - � fs ,� � -w w z - 17.S Af y SG 2 fsbk /4119%9 a,G /o Si Q )0 s/cL S bk nil V61' • Z 3 to yie Orz Effluent 111 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg& ' Effluent #2 = BOD < 30 mg& and TSS 1 30 nlWL / CST Name (Please Print) — Signature CST Number e R 7_ Z/ /� /'i iC� j' - 2 Z & 3 7.5 R o%3 Address Date Evaluation Conducted Telephone Number Ulbricht & Associates J U 4 , . t 16, , 7 I • 77.2- <3 Y?12- 2812 10th Ave. 0 e Z- 20 q.1 V -0 • "0 Spring Valle 71 � S / p s y, WI 54�I �� 5e .se For issuance of permits and designing _ o 3 Z - Z 0 SO. 0 2 - S Contact: Ulbricht & Associates ,s j rS� SF / L- Registered private wastewater consultant al plumbers / _ p 3 • oaa 2812 10th Ave. Np l�'' /UGl��SL[� SEC• � Spring Valley, WI 54767 715- 772 3442 ill Gv f 5 w S 10 1N w c. Z 3p,oZ ORIGINAL i 4 L. b •T' i 7 E . 1 3 o f ?P , '1 AJ Property Owner Parcel ID # Page .Z of F -31 S.S. � # .pit Ground surface elev. �• 7 d ft Depth to limiting factor / In, sa Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD f In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 'EB#2 0-/ v z —- S /iSl ' � f,P w 3 f . 6 z / / s A" / 7• s — 54- i f At nit � ' cS — • S .. � 114'4 / ) O-rr F] Boring # C] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Appl ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #t 'EfF#2 ❑ Boring F] Boring # [� Pit Ground surface elev. ft. Depth �ng factor In. Sol N Horizon . Depth Dominant Color Redox Description. Texture truchure Consistence Boundary Roots jGP i n. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'El Ong # ❑ Boring ❑ Ground surface elev. ft. Depth to limiting factor In. ❑ Pit son icatiort Rate Horizon Depth Dominant Color Redox ption. Texture St Consistence Boundary Roots GPDfff t In. Munsell Qu. Sz. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = SOD, > 30 5 220 nxA and TSS >30:S 150 mglL ' Effluent #2 = BOD, < 30 mq& and TSS 1 30 nVL 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. seaa»o tR -doo) �m � CiN It ky\ 'b 7z ti kA 31 � o Arl - � 3 �j c mi l, • o V° o n c o N J w - �G E? as �S1 as `n y Q � c cn L '. CD- CD C i