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HomeMy WebLinkAbout002-1035-95-100Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Budding Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law. s is 04 (1)tm)I Permit Holder's Name City Village Township Aaron M. and Heather Kittelson TOWN OF BALDWIN CST BM Elev IInsp SM Elev IBM Description TANK INFORMATION AC TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia Dist to Well bUIL At3bUKI- I IUN SYS 1 EM ELEVATION DATA Bldg. Sewer SUHt Inlet St Cover BS BED/TRENCH Width Length No Of Trenches PIT DIMENSIONS No Of Pits Inside Dia Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG JILL LEACHING Manufacturer INFORMATION CHAMBER OR Type Of System TjjREAM Model Number. ram. n�r..'...�...........��.. UNIT Header/Mandold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing vvr� vv Lf� Y prove ure Svereme n. i -- n. w. r-_,_ e Depth P - Depth Over - - - - --- xx Depth of -------- --, xx SeededrSodded xx Mulched BedRrench Center Bed/Trench Edges Topsoil _ Yes No Yes No i�UmlvltN I b: (Include code discrepencies. persons present. etc.) Inspection #1 Location: 928 240TH ST 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required1i Yes No Use other side for additional information SBO-6710 (R 3197) Date Insepctor's Signature Inspection #2. Cart No - ,. n i _-AM -IA's 1_ ti r 1, 2. _`M,.•hf4l �4-5 = MID E [W.I,vM U - Safety and Buildings( -Division County �-. C Rio i Y 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) AUG 2 3 2�22 t Applica ' Con %gt—ntal State TrmuanionNumber In accordance with 3.21(2), Wis. Adm. Code, submission of this form to the app priatunit Project is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Address I if different than mailing address) purposcsin accordance with the Privacy Law, s. 15.04 I m Stars. � ¢' I. Application Information - Plemst Print All Information Pmperty Owner's Name 1_ _ I 150'V I f { Payrceel p /WZ- 14t r a=rT � 1�. - I Property (Tuner's Mailing Address / q -)ZyD 1-K Si' Property Location Govt. Lot OF-/. �1/4 Section i City, S i I Zip Code Phone Number WS c3gCOZ. -1(5 qM pt q4 T _Z9 N; R 1circle West II. Type of Building (check all that apply) Lot a I or 2 Family Dwelling -Number of Bedrooms 1 Subdivision Public / commercial - Describe use Block a ❑ City of nn -- ` _ 11 State Owned - Described use Na CSM Num )S-4 4 Village of v ! (N 1 �1 D� I. 6 4 3t01 own of III. Type of Permit: (Check only one box on line A Complete line B if applicable) { A. ` New System 11keplacement System Trcafinent(Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plkanber ❑ Permit Transfer to New List Previous Permit Number and Dare Issued Before Expiration owner IV. Type of POWTS System/Component/Device: (Cheek all that apply) Non -Pressurized In -Ground ❑ Pressurized In -Ground At -Grade Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil Holdin Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. DispersaMestment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation _ L 5o 1v NA Nib jU h VI. Tank Info Capacity in Total g of Manufacturer Syb� Gallons Gallons Units i7 New Tanks Existing Tanks �^ Septic Tank Lift Tank VII. Responsibility Statement- 1, the undlersign4litiau,responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI re MP/MPRS Number Business Phone Number Lewis Bork 253976 715-231-7375 Plumber's Address (Street, City, State, Zip Code) ' E7818 County Road E Menomonie, WI 4751 County/Department Use Only ��tVill. yp Approved ❑ Permit Fee S Date Issued Issuing AgrnSignature 'v ��r ` ❑Denial IX. Conditions o pprov 1 3 `J ' 1-_� ( TEM OWNER: t py f1N� d o t�'ut' Septic tank, effluent filter and �L ispersal cell must be serviced / maintained I l g I /g �v7-Z , s per management plan provided by plumber. II setback requirements must be maintained l J� sperappucaoie oaerorainan s. s� `<n � s.I/l,_ p _ t 4sIS t4 8 l�l)t�-� �llfl\ icy r T ales GE I Coelt2 r lr�r Jr�©�� v IIIJJJ v County i71J'�'Cn�v. f7t1�1 ;,• � `/ Safety and Buildings ivision J' �• C120 1 u 201 W. Washington Ave., P.O. Box 7162 F _ AUG 2 3 2022 Madison, Wf 53707-7162 Sanitary Permit Number (to be filled is by Co.) =V 1� A i 11 �O` ICom t ApjilicaaQ R State Transaction Number In accordance with 3.21(2), Wis. Adm. Code, submission of this forth to the app priatc g tal unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Projcct the Department of Safety and Professional Services. Personal information you provide may be used for secondary Address (if different than mailing address) purposesin accordance with the Privacy Law, s. 15.04 1 m Stats. i I. Application Information — Please Print All Information :SA& Property Owner's Name Parcel M Property timer' Mailing Address Property Location -74nL 21401 ' S� City, state Zip Code Phone Number GosK Lot tA L�inl I,JS `ip" is 01 q& f NF2 ��, —va Section i circle 11. Type of Building (check all that apply) Lot Y T _Z9 N; R t West 1 or 2 Family Dwelling — Number of Bedrooms I Subdivision Public / commercial — Describe use Block N ❑ State owned — Described use Na City of CSM Numb r 15--village of Gn(� t Dbel 6 30 IQ own of III. Type of Permit: (Check only one box online A. Complete line B if applicable) A. New System Replacement System Treaunent/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner Z ype of rvw a a oystemit omponenvuevice: (unecit au that apply) on-Pressurizedla-Ground ❑PressurizedIn-Ground At -Grade Mound? 24 in. of suitable soil Mound < 24 in. of suitable soil ie 713nk Other Dispersal Component (explain) ❑ Pretreatment Device (explain) tCl V. DispersaVrrealmcut Area Informs Design Flow (gpd) I Design Soil Applicati a 450 r%4 te(gpdsf) Dispersal Area Required (so Dispersal Area Proposed Nn NP% in ITotal s of Manufacturer Gallons Units • �� 12 Septic Tank Lift Tank VII. Responsibility Statement- L the undersigno Plumber's Name (Print) Pion Lewis Bork Plumber's Address (Street, City, State, Zip Code) E7818 Countv Road E Menomonie. N 3r VIII. County/Department Use Only \ KApproved ❑ Disapproved Elr Denial IX. Conditions o pprov SY TEM OWNER: 1. Septic tank, effluent filter and cell must be serviced I maintained s per management plan provided by plumber.2.jispersal II setback requirements must be maintains( 751 4 715-231-7375 System Elevation Nh of the POWTB shown on the attached 253976 Agent` F per OppuDe eior°man{zs, - tin r t.4w p�eg2S'II) ee rcotre�t4�t-���' CHECK BOX AS APPLICABLE. SOIL EVALUATION Scale: 10=40' SITE MAP 0 40 60 80 PROJECT NAME: asset IsoeJ 10' �y PROJECT ADDRESS: —Us 2610l �" BM Symbol: $ 6M Elevation: 00 FT N am oeurlpem s&ra o^itt Aae to F, slope Gradient('%) 7 _K, WMI 9 mbd 11 a cebk : �� Indcer noun oy ofTestedAres: —2-6— Y 1 ppK ) Q 1heap(wiving ram arm, opf" � on M appmprY. tIn► P�WV�4i 01`I lrI L41M V41W CHECK BOX AS APPUCABLE_ gco+ • SYSTEM PAGE 2 OF 6 PLOT PLAN DESIGN FLOW: a isr� GPD Attach design flow calculatlons focommercial plans. Pipe Material / ASTM Standard (Tables 384.30-l3�&a �U364,30.5) `a SeMary Sewer ( Ada Force Main:_ / 14 N IMPORTANT: Show ground elovadon contours at sulU"e intervals. by o� o,�� 0 PO L r I17.t �y�, �At ' rocs' �s e� �- 1 IKR Z�S% f�lOe- --- 2 Ltoft-- s{ �c'co�Y +Vo og �s Sir . �s.tirs PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10855-P (N. 03/07; R 01/12) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan Attachments: Enclosures:_ Tank page POWTS Application for Review Soil Evaluation Report & Site Map (if ap Holding Tank Pumping Contract if appi Holding Tank Agreement if applicable) Project Name / Description iplicable) icable) Owner Name(s): n A ro r") y, � -� �- C `So r-�� Phone: S -9a- L 9 Owner Address: %Ze 2t_OA7v% <A. t�U�� " I vSL Zip: ,HCb2 Project Address ME_ Govt. Lot: _NC-, 1/4 of 5E 1/4, Section I� T�qN-R l iG E Uor W L- Township: SA�cu►,�4 County: S4 • Lila�� Project Parcel ID #: 0 Z - to 3s too Designer Information Designer Name: Lewis Bjork Designer Address: E7818 County E Menomonie WI E-mail: lewisbjork@yahoo.com License Number: Master #253976 Remarks: Phone: 715 _231 _7375 Zip: 54751 I iu. .i,,t,k rrycn�d ik); aI,proval Ntany. Signature: Date: (0 -l5 -20Z2. final signature required on each submitted copy. CHECK BOX AS APPLICABLE. SOIL EVALUATION sca►e: t• • 401 SITE MAP I 40 60 B0 PROJECT NAME: _ & AAi tT31 `�y 110, PROJECT ADDRESS: 926Z610i" yl. N SM Syni $ BM Elw&Wn: 00 FT Slope Oradil" It61 CJM� InAkane noon Pi or Tested Area: We" Syrtk7d lMappMcaCN ): Q atw 4ppnarrokw CHECK BOX AS APPLICABLE. g:of • 3 SYSTEM PAGE 2 OF 6 PLOT PLAN DESI3N FLOW: aOPD Attach design now eaicuombons for commercial plans. Pipe Material I ASTM Standard (Ts)lm 384.30-3 8 364.30.5) Sentry Sewer /se Lft So Ford Main _ / M M IMPORTANT: Show ground elevation contours at suttaCk intervals. / Fy�'�'' WAMA �y 4,40 - o S4,cw� :0 zsa 9-7� ter'' am cieka L O O4 Y� 9' � to z•S � Caw , f 1 ► 0 yr %fb�� -- 2 Lott.. s{ viii D 6 PIG 517 T WC14. T*6wv5 PAGE 3 OF 4 Electrical must comply with SPS 316 and NEC 300 HOLDING TANK SPECIFICATIONS ( (No Scale) 4'0 Vent Pipe p Weatherproof >70 ft from Junction and Alarm Box Approved Buildehg Approved Locking Manhole Vet cap 12' Min. or 2.0 ft above Established Flood Elevation with Wsmirhg Label Attached �— / (typ cof) (typical) NIV Airbght Seel Finished Grade 18' Min. N InW Inlet Invert Approved Joints wth Approved Ape 3 ft onto Max. 12' or 90% of total volume Solid Ground h1 ^n o^e farhk (typical) Alarm -On y Compartment 1 Vol • Z� gel Compertrtxent 2 Vd = � I t TOTAL HOLD?bG TANK 3 ! VOLUME = 1 000 gal 3' Approved Bedding Melerial Beneath Tank 4' Min. or 2.0 ft above Established Flood Elevation / (typical) L �" TANK MANUFACTURER: 1/ ,i666 0 < 00 a Anchor tank as necessary V ( pursuant to SPS 383.43(Bxg) q O Ballast Weight = [(cu.ft.tank.voi x 62.4 lbs/cu.ft) - Ibs.tank.wt] x 1.5 Ballast Weight = [( 3l Z cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1.5 A v� Plug 191468 `$ 0 PAGE 4 OF 4 Holding Tank Management Plan IMPORTANT: The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s) shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Estimated Daily Wastewater Flow = N5o gpd Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o surface discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Slats. when the wastewater in the tank(s) reaches a level of one foot below the inlet Invent of the tank(s). Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis. Admin. Code. Report any component failure or malfunction to: Name of individual or companny:�, 1 ��r h,�; /� �AV'V'�Lu -WW1"fk Phone. 711� 232r��/375U'' Local government unit: • C tic �/ Ir-1 �' Phone: _ 1 15-" 3% - YCj C Local government unit address: C �� f ICI t A � I J _ ��i� � a ZIP: Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Continuency Plan In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agecy for review and approval. System Abandonment If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently sening the following resid nee: (Street address) q2A Z4y �. located at: _146 1/4, S+E '/4, Section , Town 29 N, Range 16 W, Town of 13&4Lo W , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? (if no, skip next line.) Approximate volume or length of time: Tank Capacity: Construction: Prefab Concrete Steel Manufacturer (if known): Age of Tank (if known): Permit number (if known) Yes No _ gallons _ Other (Licensed Plumber Signature) ) (Print Name) (Title) (Date) minutes (License Number) MP/MPRS Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 . ________________ II I' 4" CAST -A -SEAL I ii I a 1 � IIII V �I I �y I Y/ "Pill 1 l FILTER OR I BAFFLE Ili I —________________ I111 __________�� c _ �. r I U TANKS ARE MANUF r4" CAST -A -SEAL 4" VENT PUMP PAD WLP1200/800-MR TANK SPECIFICATIONS o a a i DIMENSIONS: o WALL: 3" a a BOTTOM: 3" COVER: 6" MANHOLE: 24" I.D. PRECAST CONCRETE RISER o HEIGHT: 53" LENGTH: 13'-8" > WIDTH: 8'-0" BELOW INLET: 41" E LIQUID LEVEL: 36" WEIGHT: BOTTOM 14,800 LBS. - a g m COVER 8,170 LBS. S o a INLET AND OUTLET: ~ m o 0 0 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: 4 < o F o W WISCONSIN, SEE DETAIL #10 Lu (OTHER STATES SEE CHART) 2 LIQUID CAPACITY: 33.46 GAL/IN (SEPTIC) ? 22.24 GAL/IN (PUMP) c2 0 LOADING DESIGN: B'-Ow UNSATURATED SOIL O Z CEO Lo I TANK CAN BE USED AS: < N SEPTIC / HOLDING / PUMP OR SIPHON o COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN /9 (SMALL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE 3 � � J i Q o Z ro I p < M L) BY IREVIEWED REVIEW DATE N a. ix DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: SHEET N0. APPROVAL DATE: i Z PRODUCTS NEEDED BY: / OF 1 SEPTIC or HOLDING TANK SERVICING CONTRACT (O I C) I -n This contract is made between the Tank Owner(s) Name(s) and Pumper's Name (A �a%� lr/lr�� r� H eat her K gt6or� M a rK yl o S-rpb,c, � We acknowledge the installation of (a) septic/holding tank(s) on the following property: (Provide legal description): 1. The owner agrees to file a copy of this contract with the local governmental unit (St. Croix County Planning & Zoning Department) to document maintenance by a certified septage servicing operator as required in SPS 383.52(1)(c)2. Wis. Adm. Code and the approved Component Manual. 2. The owner agrees to have the septic/holding tank(s) serviced by the undersigned pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the septic/holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the septic/holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the septic/holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the servicing of the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the monthly report: a. The name and address of the person responsible for servicing the septic/holding tank; b. The name of the owner of the septic/holding tank; c. The location of the property on which the septic/holding tank is installed; d. The sanitary permit number issued for the septic/holding tank (if known); e. The dates on which the septic/holding tank was serviced; f. The volume in gallons of the contents pumped from the septiclholding tank for each servicing; g. The disposal sites to which the contents from the septic/holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) lOwners Signature(s) Subscribed and sworn to me on Hea+vler 1b'f-H1a&nWxC"vv- a-►'t A /3 7 Pumper's Name (Print) Pumper's Matt 14-ertn k Pumper's Registration Number Signature Date Parcel #: 002-1035-95-100 Valid as of 09/06/2022 01:11 PM Alt. Parcel #: 16.29.16.244A-10 Owner and Mailing Address: AARON M & HEATHER KITTELSON 928 240TH ST BALDWIN WI 54002 Districts: Dist# Description 0231 SCH D BALDWIN-WDVILLE 1700 1 NORTHWOOD TECH Abbreviated Acres: 10.000 Description: SEC 16 T29N R16W PT NE SE BEING CSM 15/4069 LOT 1 10.000AC TOWN OF BALDWIN ST. CROIX COUNTY, WISCONSIN Co-Owner(s): Physical Property Address(es): * 928 240TH ST Parcel History: Date Doc # Vol/Page Type 07/05/2001 1673/1616 WD 04/09/2001 §42296 1614/563 WD 05/31/1990 459108 872/174 LC 04/11/1988 436105 807/381 1 QC more... Plat Tract (S-T-R 401/4 1601/4 GL) Block/Condo Bldg * 4069-CSM 15-4069 002-2001 16-29N-16W NE SE I LOT 1 2022 Valuations: Values Last Changed on 03/07/2022 Class and Description Acres Land Improvement Total G7-OTHER Woodland 2022 Taxes Taxes have not yet been calculated. Key * - Primary ST. CRO i1JNTY SANITARY SYSTEM File Office use only OWNERSHIP/ADDRESS FORM Cremed212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. OWNER/BUYER INFORMATION Owner/Buyer Aaron Kittelson Mailing Address 928 240th St City/State/Zip Baldwin, WI 54002 Phone Number (required)715-977-0494 Email Address (required) Parcel Identification Number 002-1035-95-100 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location NE t/e SE 1/, ,Sec. 16 . T 29 N R 16 W, Town of Baldwin Subdivision Plat: r Lot # Certified Survey Map # (4'43(D Volume J Page # 466cr Warranty Deed # 650200 (before 2006)Volume 1673 page #616 Number of bedrooms 3 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no New Property Address (Staff Initials) OFFICE USE ONLY (Verification of new addres( required from Community Development Department for new construction.) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form o recorded warranty deed from the Register of Deeds Once and a copy of the certified survey map if reference is made in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.00v i t. 1 G3C�M[ED Wisconsin Department Division of safety and ComCmercCe Ildings AUG 2 3 2022 IL!=.I,page � or 3 In accordance Comm 85, Wis. Adm. Code County /' /f 1 Attach complete site n on p�j3err(b1'�a�a91i�� 1/2 x 1 Inches in size. Plan must `^D include, but not limited : G4Allt>il point (BM), direction and percent slope, scale or imensions, north arrow, and location and distance to clearest read Parcel I.D. c2a(O35 15r 100 Please pdnt all Inforrnadon. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) (m)). 6 Z Property Owner I _ 11 V1 Property Location p nJ ` JO^r Gout. Lot QE, 1/4 $E 114 S 16 T Z I N R E❑(ora Property Owner's Mailing Address l Zl'EO,♦4i ST. Lot # Block # Subd. Name or CSW State Zip Code Phone Number City Village Town Nearest Road W L 5410 115) 4 24D ElNew Construction llse[D Residential / Number of bedrooms Code derived design flow rate LlqoGPD Replacement ❑ Public or mmercial - Describe: Parent material QJn. INfA Hood Plain elevation if applicable NIA It General comments and recommendations: -£40,� 6rt th �—AL4j A 1 � D Boring eorirg # Q ElPit Grourid surface elev. 97, + p ft. Depth to limiting factor 0orin. BABoring# U Boring ❑ Pit Ground surface elev. al- ft. Depth to limiting factor in. Redox Description Qu. Sz. Cont. Color i / MO& WO 1 ®®� • 1 f #oIa! 0r/ 19011M Mwml rm=SM� - tmuem Al = tsvu > 30 < 11u ng/L and T55 >30 < IV rng/L 3 qfluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Point) re CST Number Lewis B'otlk BJo* 253976 Address Date Evel5abon Conducted Telephone Number E7818 County E Menomonie WI 54751 kj"2q � 2.00!2— 715-231-7375 M P%Ac J Property Owner -1 7 t L 50" " Parcel ID #�Z ' V� j' Page B 3 Boring # El Boring /(��[[�� r1 pir Ground surfaceelev. gq'Sft. Depth to limiting factor 0 in. 2 3 of c-;j Redox Description E 00M. - RMM®©M�� Bing # n Boring Q Q Pit Ground surface elev. 7 'S R. Depth to limiting factor In. Soil AeoLLrat{on Rate ■W A M i IA YIMM— M-- �,g # Born M Pit Ground surface elev. �_ ft. Depth to limiting factor �_ In. 4Z,J1 s.,nliratiryi Rate Qu Sz. Cont. Color Ft me o RA cI7� MMI M���� IMM ' Effluent #1 = SOD, a 30 < 220 mglL and TSS >30 :5 150 mglL ' Effluent #2 = SOD. < 30 mglL and TSS 5 30 mglL 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. Sa6U30Twt(KQ7A , CHECK BOX AS APPLICABLE. SOIL EVALUATION Scale: 1' = 40' SITE MAP I <O 60 80 PROJECT NAME: �/ll �4L SAi Y'�lTp!' �J 10 PROJECTADDRESS: 92S SM SymDd. F BM Elevatioonn.10V FTC• SM DeWAPtMn: —. Sall Q otj �4 o E N Slope Grader) (16) CMS lr,@Mng noon h or Tasted Anti.: • WNW Symbol ltl appacatXe r. 0 Cr,w+np rwho - m e ,ppropil• Iro. O Wku(4c�a- W#M/tam. y7lw`,1•, I CHECK BOX AS APPLICABLE. g:b+ • 3a►4 3 SYSTEM PAGE 2 OF 6 PLOT PLAN DESIGN FLOW: uM GPO Attach design flow calculations for commercial plans. Pipe Material ! ASTM Standard (Tables 3``8--,4..3--0-3 & 384.30.5) .][ SaMary Sewer f Jr Lib Fact Mdn f 96 M IMPORTANT: Show ground elevation contours at sultable intervals. 1 R"O> 0 0 � t -� 0 0 0 0 C ] 0 3 + 99 w L 0-0 o�o dti 9 ' f,z '2- pkO* a.z Y � tj '� `11D as k-�- o Z.S /a 4pr-- -- 2 LW it. Si • - �5(SAPM counTv rvo. 645406 STATE SANITARY PERMIT OWNER COT*69 Y-inacpj PLUMBER L60K 936it1. LIC.# 2.5317 6 e TOWN OF A) SECT_20:tN, R_& _Vjn AND/OR LOT BLOCK - up SUBDIVISION CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit Is valid and maybe renewed fora specified period. in) Changed regulations will not impair the validity of a sanitary permit (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may Impede renewal. (f) The sanitary permit Is transferable. History: 1977 c. 168;1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. AAAk A ZED ISSUING OFFICER - DATE % S PERMIT EXPIRES O UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)