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HomeMy WebLinkAbout020-1280-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: • 538747 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 Uetz, Mark I Hudson, Town of 020 - 1280 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No 34.29 19.1344 . TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St /Ht Inlet St /Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer, INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length 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 r �� Yes a No LJ Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 685 Edie Lane Hudson, WI 54016 (NE 1/4 SW 1/4 34 T29N R1 9W) Cherry Hill Addition Lot 9 Parcel No: 34.29.19.1344 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes Z No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No CommerCe.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 i sco Madison, WI 53707 -716 itary Permit Number (to be filled in by Co.) A If Department of Commerce 539 7-/ 7 Sanitary Permit Application a Transaction Number ' V / In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental A unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are roject Ass (if different than mailing address) submitted to the Department of Commerce. Personal information you provide ma be used for secondary L ct purp oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. `" ' / / L A ' Application Information - Please Print All Informa n cl £ 2 v t Property Owner's Name / Parcel # / a/L Z O�c� Property Owner's Mailing Address Property Location 10 f�U ot of J / 2� ST. CROIX COUNTY G t. / City, St ate ,,-- 1 ,_), Zip Code �7 ' , '4, Section 3 �cl bex_45 j L, 3 / 8 / — 7 u 6,1,5 (circle one) T � N; R /T EorW II. Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling - Number of Bedrooms 9 Subdivision Name 9 i 61C as /OCR � A- � Block # \� d1 f . °- El Public /Commercial - Describe Use / �QK- ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of t IR Town of c1Sd 3 `t l- ll,� 20 +-26 t Zb C�� be(S III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. P-New System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. El Permit Renewal ❑Permit Revision El Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that appl W-Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) n V. Dis ersal/Treat ent Area Information: G' f S !( Design Flow (gpd) Design Soil Application R*e (gpdsf) Dispersal Area Required (sf) ispersal Area Propos (sf) System Elevation �4) ✓ 12-60 /Lov 12 ?' VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units n o New Tanks Existing Tanks 6f ,) '� GF ,// 0, U v� y cn s, C7 Pr Septi or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS show an the attached plans. mber's Name (Print) Plumber's Signature MP R Number Business Phone Number CSC kC Wgwr 2 Y72- -ZYL� Plumber's Address (Street, City, State, Zip Code) 2(,5 iv �) , 7.,, C, K LA,� VIII. Coun /De artment Use Onl Approved 4;:w.Tne, Permit Fee Date I tied Issuin ent Signature =ivenason for Den' 1 q�75 • Ob .3 � 1 Z j IX. Condit' ns of A pprovaiVReasons for Disap�{ oval (` SYS EM OWNE / f is n (' 1. eptic tank, fluen tar and JJ � Q � l / P � 1 dispersal II must all be services / maintained ro�(„�a q 167+ as per ma agement plan provided by plumber. t " � ' 2. All setback feauifements must be n *fined / r2 0 N Z- • 6 sB D — 16 76S — PIiv . d 1 cl / ss per sppkable code / ordkwvb s: Attach to complete plans for the system and submit to the County onl on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 Feb -25 -2011 02:23 PM St. Croix County Plan /Zoning 715 -386 -4686 2/2 CONVENTIONAL COMPONENT DESIGN Residential Application ,� INDEX. AND 7171.E PAGE Project Namw / ! ,c- J), 4 Z Owner's Name: U -, 4 z Owner's Address; D K i.. J f?,, Legal Descrtptton! Township; /4 K ),5, County. 3 l�A.v X + SubdMabn Name: Lot Number. _ Par* ID Number. Page 1 Index and ta'tle pago 2 Plot Plan Page 3 System fAN & CtWo-Sedan Page 4 Fiitar gee Page 8 Maintenance inibrmation Pep@ B ManaJEWt ftn _ Page 7 St. Croix Cty SgpW Tank Mpk"nenc Porm Page 8 Wep pt y Peed Page 9 CSM or Plat Attachments: Sell Test & House Plans 0e919nedPlwnber 1 License Number 2- L 2- 8? � Data. U Z - Z �" -1 / phone Number ?L` ` y7 L - z Y z Signature c �� l neglQrad puma Nis 41"GR and Sad Abmv ti ()WnPW ant WNW 15r POWM VWbn 2.0 89C40M* "10J) Pago 1 Cl VII t �o 4 3 w h v Cf 2 V , J .Q V 1 0- �Q O `vim N` r O W � S p � .JA N c � �o r G o h �1 C 31-11 O b i s� � ` G i Soil Absorption System Cross Section ft ft 4" Schedule 40 / q Final Grade PVC Vent Pipe With Vent Cap ft Leaching -► �(,: q - 9� l - qs. j Chamber ft — ' «. - _ System Elevation ft S ft s ft Soil Absorption System Plan View 8o ft 3 f I S ft Leaching Trench 1 Chambers ' 4" Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Model EISA Rating Zo .0 sq ft per chamber Soil Application Rate S gpd /sq ft fe ® J gpd Design Flow - - S Soil Application Rate - 2 - EISA = U Chambers 3 rows of Z d chambers each. Page of t+A I E tW �; v _ Q 0 1 "°' ru L n A 00 y W w E �u ce. rL S, 9 N q W y � °1 y A 4R v d n A A. CIC Cd Q mG w`d d 0 F s �gC3 '.y Q uad • A t s S u A E Vs 0 IL 6� T� S -J O loll .k _ . � � Lb lm 61 0 f 1 :., -tea 1 w • O •- 1 Q a 5 .1d © v ° J 1 a I. 1 is 1 w rl N v' N t vii ow m w no INGROUND SOIL ABSORPTION MANAGEMENT PLAN PURSUANT TO COMM. 83.54, WIS. ADM. CODE General This system shall be operated in accordance with Comm.82 -84 Wis Adm. Code and shall be maintained in accordance with its component manual [In- ground Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (n.01/01) and SSWMP publication 9.6 (01/81) and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic tank or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm. 83.33, Wis Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed and watertight upon the completion of service. Any opening deemed unsound ,defective, or subject to failure must be replaced, Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis Adm Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of the triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maxium scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. however, if such products are used they shall be approved for septic tank use by the Dept. of Commerce. Pump Tank The pump tank shall be inspected at once every 3 years. All switches, alarms and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Soil Absorption System No trees or shrubs should be planted on the absorption area. Plantings may be made away from the cell's perimeter, and the area shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than foot or for vegetative maintenance) on the area is not recommended since soil compaction may hinder aeration of the infiltrative surface within the system and snow compaction in the winter will promote frost penetration. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired of replaced with a component of the same or equal performance. If the dispersal area fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Replacement in a suitable area nearby is also an option at which point a diversion valve will be installed between the old and new systems to allow dispersal cell rotation at a schedule to be determined at the time of cell replacement. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of - FILE INFORMATION SYSTEM SPECIFICATIONS Owner �� t -} Septic Tank Capacity Z YO ga l ❑ NA Permit # Septic Tank Manufacturer c� u „� ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer � f " ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model l- /(O ❑ NA Number of Public Facility Units B31qA Pump Tank Capacity gal A Estimated flow (average) 60 gal /day Pump Tank Manufacturer 0 Design flow (peak), (Estimated x 1.5) y Z D gal /day Pump Manufacturer afiA Soil Application Rate . S_ gal/day/ft' Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit G-NA Fats, Oil & Grease (FOG) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD <_220 mg /L SWA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD :530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L �IA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100mi ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. g.mA Other: ❑ NA Other: [�-rv`A Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 19-year(s) 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: 'N ❑ months) (Maximum 3 years) ❑ NA c- 19 year(s) months) Clean effluent filter At least once every: l ❑ year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA 9 Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA 2- _Z ears) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ 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 <_12 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. GMW (4/01) -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 chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall 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 be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to 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 area 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 If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ 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. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a 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 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. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name G4 +ti �J A- Name Phone 7 2— _ Z tJ Z I' Phone y �17� -- zyz_ ( SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name � Name ' T , �ti0 , X Phone — 7 j YJW Phone 3 8 L This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 7" Owner /Buyer / ! ct LIZ Z_ Mailing Address 10 70 eo y 3 Property Address Q (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number 02-(> l L S o LEGAL DESCRIPTION Property Location '/4 , ' /4 , Sec. 3 `� , T Z'� N R I `� W, Town of Hu use A,. Subdivision Plat: C�- r- ,c,t..� �-a.�, r , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house yes (9 Lot lines identifiable es i'i 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 system s Y em 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 ( I ) 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. 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 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. I /we am /are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms /" a4 l/.� SIGNATURE OF APPL ANT(S) 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) 8013201 STATE BAR OF WISCONSIN FORM 2 - 2000 TX :4010098 Document Number WARRANTY DEED 927285 THIS DEED, made between Glenn R. Zillmer and Barbara J. Zillmer, BETH PABST husband and wife, Grantor, and Mark T. Uetz and Karl N. Uetz, husband REGISTER OF DEEDS and wife, as Survivorship Marital Property, Grantee. ST. CROIX CO., WI Grantor for a valuable consideration, conveys and warrants to Grantee the RECEIVED FOR RECORD following described real estate in St. Croix County, Wisconsin: 11/19/2010 11:37 AM SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF EXEMPT #: N/A REC FEE: 30.00 TRANS FEE: 225.00 PAGES: 2 Recording Area Name and Return Address: Edina Realty Title, Inc. 400 South Second Street, Suite 115 Hudson, WI 54016 965766 Exceptions to warranties: 020- 1280 -60 -000 Easements, restrictions and rights -of -way of record if any. Parcel Identification Number (PIN) This is not homestead property. Dated this 2nd day of November, 2010 U Glenn R. Zillmer Barbara J. Zillm AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF 1A COUNTY OF authenticated this 2nd day of November, 2010 Snuox Personally came before me this � � �b the above Glenn R. Zillmer and Barbara J. Zillm r, h sband and wife to me TITLE: MEMBER STATE BAR OF WISCONSIN known to be the person or persons who executed the foregoing (If not, instrument and acknowledged the same. authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Martin D. Henschel Cheri Brown 6800 France Avenue South, Suite 410 Notary Public, State of Wisconsin Edina, MN 55435 My commission is permanent. (If not, state the expiration date: (Signatures may be authenticated or acknowledged. Both are 0212712011) not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 2000 1 of 2 ,00 I to F- w w U) o N LL m ❑ F- w w z to z w ❑ N °m c Z a 0 3 v . to L6 go C3 LL cv n o 00 . L; N - t0 tol m " m ❑ m t0 w I m t0 ❑ N a1 w CD J I LL to N N cn U I ir F-1 ❑ I m al 3 3 U �► j I I- o . a to w N O t0 OD f L S in 9 N C3 o o N •o N N p Z z lD 0 ~ a: to _ N Q F- so w Z R. 3 00 — o T m to O 60'LL9 3 nOb,95,68 N T'9bT y2_ -' 0 z 0: _ o y3; -' ENV I Cl 565." F- O - 85 M .0 .95 69 S . 6E' GOT 1O w U) F- 3 ui o '�' 3 „Ob 95,68N N ' 1 m .90'V929 m T- m 9 C3 rn o in o >- z • O ~ p (3 I a o Z to p O a z m i I I Q 3 f CL z Q F- J O I O tp coin U tL Fw 3 0 mo O a m I H .99 / N m o oN ti to a W o N v m W to / Z N L O1 60'6TE 3 „Ob,95 68 N O / ,zz'EC L8'S5z O v d) 2g X62 3 / cd to .lZ LO sC 41 ,6L • 992 3 I o 0 3 ,Ob,95,68 N lL1 o n o d z O N N - 0- ,t J a ° . o 1 2 S ►, I N t0 c) w to g i I o / I N 3 2 / n � O � m o N 0 L I ei = a N w O O to z tD O o m . o � o I .o m I o cu �Zo I O N v co m Q u) to m a c0 cu Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County �• f , D : X 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 Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 -61— j Z h " � U — 0 J0 Please print all info tl A Revi ed by Date *� M Personal information you provide may be used for second rposes , s. 15. (1) (m)). Property Owner Prope Location �f x k l./ £ Z + o vt. L 1/4 114 V T L N R/ E (or) W Property Owner's Mailing dress Lot # Block # Subd. Nam or CS /C) 76 Mailing J - J)ti . INN L 7 `1 f'ti't h 4 •v £ C State lip Code Pho Number C Rp �� ❑ Village LMTowrl Nearest Road ew Construction Use: ff Residential / Number of bedrooms T Code derived design flow rate CPO 0 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments - — 7 c c � � _ r! and recommendations: �i9 ` ' 1 , Boring # E] Boring F ® pit Ground surface elev. l� ft. Depth to limiting factor > in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDN in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 cs - / ,c �/ S / bK ✓ fc as IW O Boring # ❑ Boring Q rj' r ❑ Pit Ground surface elev. ! ft. Depth to limiting factor ! J 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 ` C-, I S �?�• ✓fti C.C.S 17P `l • 7 /o .i 0..; r� * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CS Name (Please Print) Signature _ CST Number 4L L Address I ) f Date Evaluation Conducted Telephone Number ' M � Property Owner Parcel ID # Page of ❑ ❑ Boring # Boring 7 (+ ®Pit Ground surface elev. ` ft. Depth toTit�i)iting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/fF } in. Munsell Qu. Sz. Cont. Color Gf.'Sz. Sh. *Eff#1 *Eff#2 / Z Y4 Z- 1 ' F-1 Boring # ❑ Boring ❑ 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/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 F-1 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application 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 * 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 (R.07 /00) Property Owner Parcel ID # Page of ' a Boring # E) Boring C, ® Pit Ground surface elev. ft. .. Depth to fimftin� factor (` in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color NGf: Sz:'Sh. *Eff#1 I *Eff#2 L dti'�iy --- 0 J � F-1 Boring # ❑ Boring ❑ 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # El Boring 1:1 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/fF in. Munsell Qu. Sz. Cont. 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