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Home My WebLink About038-1132-60-100 (3)TYPE MANUFACTURER CAPACITY Septic ;S . sing 3 Aeration Holding TANK SETBACK INFr1RMATInAI TANK TO P/L WELL BLDG. t� Vent to Air Intake ROAD Septic Q t 7�b 71 Aeration Holding PUMP/SIPHON INFORFAATInM Pan�ufaTu—rer Demand GPM TD Lifl Fric io LAaHe TDH Ft For ai Length well wawa aidDeP,nmama Co-_ PRIVATE SEWAGE SYSTEM Coao1y sSt. Croix afey,rwevad�n Dwu�r, INSPECTION REPORT SannaryPe—INo GENERAL INFORMATION (ATTACH TO PERMIT) 645486 Personal infonnedon State Plan ID No you provide may Ee used for secondary purposes IPdvxy Law, a. 15 Oa (1)(,)l Permit Holder's Name. CM Village Township Parcel Taa No John & Robin Wilson TOWN OF STAR PRAIRIE 038-1132-60-100 CST BM Elev: InjP BM Elev B s-ptan $etlronRownlRange/Map No ��0 Oar 32.31.18.541F-10 TANK INFORMATION ELEVATION DATA STATION BS HI FS ELEV. Benchmark - O l o �• D BM O�- Bldg, Sewer SVHt Inlet SNHIOutlet CX�S�: / G•S A "� D Inlet 11- % Dt Bottom Header/Man. Dist Pipe Bot. System {q D°yer✓ 3.05 '�, I140.1 C el BED/TRENCH DIMENSIONS Vdth n 1 """Z t No. Of Trongnps fJ. (r7— PIT DIMENSIONS No Or Pds 9 T In d Dia 4pu tN SETBACK INFORMATION SYSTEM TO P/L W BLDG WELL LAKE/STREAM LEACHING M Ty Of System: V l o �rr V y CHAMBER OR UNIT �Yb ✓ Mo flICTRIRI ITInM QVC—is 1 sYV SOIL COVER x Pressure Systems only as VOLWd Or At -Grade Systems Only Depth Over 'i tr o B.d/Trench Center ul Over t BeN �renoh Edg.s opsoPl� o a Seed J Yas ' No CJ __ No COMMENTS: (include Code discrepancies. persons present, etc.) Inspection at Inspection $2, Location: 1804 WINDING TRAIL RD A `1 � S O� f-•-mo S 1 .) Alt BM Descriptions l}i✓�Q- —14 IMF ��5,� �1N�1kw� ' wP 2.) Bldg sewer lengths NI(G51►r{d �� W 0-✓lA U iwit, i" - amount of cover • Xt �/ r^ F�i e� f��tXAi+��lt� IS Olds�d( tASCM�} Plan revision Required? ❑A Yea * No In pc10Ya Siena /`�, Use other side for additional information L I� l 2 I a SOD-8710 (R.3/97) Data -- -- - --- � Cen No 1 21- 2 map NOV ',.LZ Industry Servim WvWw Un Madom Yards Way Mad- 53705 7foix Cc J), Ge W PAW 7162 madmon, WT 53M-7162 "unitary Permit Application Toa-hosalfarb. .A& SPS 39321C21, Ms. Adel of&. farm W &. — •":="=a , I * Holm =iQWTP="-wW.. r1oftmoodscro PesongirdbraradoTao p " onybearod*r-c-lory PFCjCd Ad*4= (jf&fftand Sm aaMnftcar) L rassrow rrm Al hwsty 3-0 G-L LA Zip Code Rose 1hosir. U T N It EL Type ofDoadjog (ebKk an dot ap*) b" 0 �D or 2 F.* D-diog- M.J-aB.&_ Subdi-ion 7iFwi Dw-c-saaa-d-Das—th. 9 of D— OwnW-n -,tic Of f -IRVIamorwoor oW rrohm WN=bk er B. A. Cb.& saw b.. r IZ;']L Compid. 11. C tj MOM-b- 1. IN"all &,SIM O-N-Taak (Qbg�.-d ia&id Sir Desi� �Taw BredBobrs LIRCWW- ofRr6a rrd b Ms. P. P .. k Kbob. sod Dow hwtd j , .V. Kuposparjoars Area Mi Tomak Tabrowedrow- D-V Dcap sa RM-Wd" Am a —77 1 m- Task Isforroubm is Cwkw Toad DsOr irat (may mem6ch- NCW Twil Tab ?a 526; 9 R-1- V. 0 MPAeRS N..b. Bauer PhowNab. -o �715 -,?91s (Seiee4 ,arse. Cede) VT- COMMOM"wartownt the omb 0 =L P ar F. S S, Dab bared S,W— caodrtrar "S�yEmow�NEg"rs`aad 3)-4, a., I. Septic tank, effluent filter and dispersal cell a,(- koxt must be serviced / maintained as per management plan provided by plumber. 9-rst�q All setback requirements must be maintained aS pQ[ applig-nhi, PM, / -An-- SBD-63" (FL 03/21) ! | / | Li | ! MILM L L -'+T I L! CONVENT[ONAL COMPONENT DESIGN PAddoFMAPP&MVon 94)EX AND TfTLE PAGE W� P�ojecttJar� / Sn)% Owne'sNWM /,J 1S �Ul �So„1 owner's nd Legal 0=0* olc !�1- s�rl - s .& . T /A/- 7riP I I Township: C-Kdlr Subdivision Nems 149 l of Number 2 Parcel lD Number_ 33t pips / hds mid 1b Pam y Plot Pbn . Page 3 S)elem akft A CMW-mQ§Dn Page 4 FAm Specs Page 5 Allummame murim♦oo Page MTMV®idPlm Page 7 SL Cmm Clp SOPW Tank MOMMOM Form Paps 9 VVUFnMtr Deed P-gs9 CSOorPbt ArdaO-SoTaS HasePbns _Lkeree Number /n Phone N� oabW 1L--�? — ne�>a...�t•r.o....arwe.r..o....�R...rtc. ro.r,s v� zo ago -,mbar pla..�} P— 1 i ,�j, ��,, SoilAbsoroflooCo 8mftn . 4' Sdvmhie 40 F�'r Q1ds PVC Vert Pipe . vwh Vert Cw Leadft Gharrdw �— S"Itgn 8�11 Soil Absorption System Plan V'ww tt 3 ft �ft g Trash 1 rh�an6onb ers Vert Or Ohserwaim Pipe 4' "m Trench 2 11 Header Trench 3 Ghawbwsoecwwaffom Marmfac>W er And Nk dd BSA Raftq = 1// sq it per dmndxw SdAp kaft fLLadtq ft vs _gpdDesipFbw# SaAppicMmRaba ate= BSA=„12J�Charrbm 3 oars of_1� dreaibers eed� Page of lnonaw ie Rant. D-1Wr I Zabel' 4 War~.ROaxtr Amid P*AA PL-525 Effluent Filter PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-12Z the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will Float up and temporarily shut off the system so the effluent won't leave the tank. Features: • Rated for 10,000 GPD (gallons per day). • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. • Built in gas deflector. • Automatic shutoff ball when filter is removed. • Alarm accessibility. • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2 Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2 Remove tank cover and pump tank if necessary. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank, not into filter housing. 6. Insert the filter cartridge back into the housing making sure the filter is property aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filtration Slots �,awEw..;a�sa�.'�. A-"4'&6- SCHD 40 pipe Alarm Switch (Optional) Accepts 1' PVC Extension Handle Rated for 1o.000GPD 525 Linear Ft. of 1/16' Filtntion Slots 1 Cortllled to NSFIANSI Standard 46 Gas Deflector Automatic Shut -OH Ball (i Outduur SniartFilterN Alarm Polylok Zabel & Bent fillers —ept the SmarlFilter® switch and alarm. Fxtend & Lok— Fasfly install. into existing tmiks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, Cr 06492 Toll Free: 877.765.9565 Fax: 203.284.9514 www.polylok.com POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page , of FILE INFORMATION Owner Permit f DESIGN PARAMETERS Number of Bedrooms 3 ❑ NA Number of Public Facility Units RNA Estimated flow (average) gal/day Design flow (peak), (Estimated x 1.5) al/d ay Soil Application Rate al/da /ft= Standard Influent/Effluent Quality Monthly average• Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODa) 5220 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODa) 530 mg/L Total Suspended Solids (TSS) 530 mg/L a NA Fecal Cofdorrn (geometric mean) 510• cfu/100ml Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al ❑ NA Septic Tank Manufacturer _ ❑ NA Effluent Fitter Manufacturers ❑ NA Effluent Fitter Model 104_ — ❑ NA Pump Tank Capacity al ANA Pump Tank Manufacturer 19 NA Pump Manufacturer NA Pump Model eNA Pretreatment Unit 2( NA ❑ Sand/Gravel Filter ❑ Pest Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal Cells) ❑ NA 4 In -Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other. ❑ NA Other: ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tank(s) At least once every:❑ months) ., >� earls) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IYs) of tank volume ❑ NA Inspect dispersal cellist At least once every: ❑ month(s) 0year(sl (Maximum 3 years) ❑ NA Clean effluent fitter At least once every: ❑ month(s) ear(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) JR(NA Flush laterals and pressure test At least once every: ❑ eor(s❑ month(-)l jil NA Other: At bast once every: ❑ month(s) ❑ year(s) ❑ NA 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 tanks) 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 cellist 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 (Ys) 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 shag be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tmk(sl 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 cells) In one large dose, overloading the call(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 perk 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 POINTS: 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. JN 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 AND10R 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 POINTS INSTALLER POWTS MAINTAINER Name Name - I Phone EE�] Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone _ This document was drafted in compliance with chapter Comm 83.22121(b)(11(d)WO and 83.54(1), (2) 6 (3), Wiscotakt AdministratM Cods. 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 serving the following residence: ,�,/� (Street address) /91Dr/ t1 ,,VOi1 N ��./ MJ located at: _,hL'/4, '/4, Section W_, Town__ULN, Rangel9W, Town ofg�,(gi�tir , 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 SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service /J--,W-.-?.—? Did flow back occur from absorption system? Yes_ No z (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: ,/� Construction: Prefab ConcreteSteel Othcr Manufacturer (if known): Age of Tank (if known): Permit n ber (if lmown) (Licensed Plumber Signature) (Print Name) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ST CR iLINTY SANITARY SYSTEM F�� Use Only OWNERSHIP/ADDRESS FORM CraffW212021 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. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. �j OWNER/BUYER INFORMATION Owner/Buyer _� L j ' i I l Mailing Address City/State/Zip _ Phone Number (required) Email Address (required) Parcel Identification Number (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location -Y tv Ys „ th , Sec. -S-,2 T �t-N RAW, Town of _S ! Z 'J f e" J s Subdivision Plat: `' Lot # �. Certified Survey Map #_ 3% T 1`1 -Volume n S� Page # /�/� cr Warranty Deed # (before 2006)Volume Page # Number of bedrooms Spec house O yes 0 no Lot lines identifiable Oyes O no OFFICE USE ONLY New Property Address „44? tff- (Venficat n of new address required from Community Development Department for new construction.) � ,$� Z2Z (staff itials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is mode in the warranty deed. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cddCdsccwi.aov 1101 Carmichael Road, Hudson, WI 54016 wwwsccwi.00v Parcel *: 038-1132-60-200 Valid as of 12/012022 04:12 PM Alt. Parcel ff: 32.31.18.541F-10 TOWN OF STAR PRAIRIE ST. CROIX COUNTY, WISCONSIN Owner and Mailing Address: I Co-Owner(s): JOHN JA ROBIN YATCKOSKE WILSON 1804 WINDING TRAIL RD NEW RICHMOND WI 54017 Physical Property Address(es): - 1804 WINDING TRAIL RD Districts: Parcel History: Dist# Description Date Doc # Vol/Pa aType 5432 SCH DIST OF SOMERSET 05/292001 1646/630 WD 1700 NORTHWOOD TECH 07/23/1997 1187/424 WD 0723/1997 969208 Abbrevlated Acres:0.790 0723/1997 17871446 Description: more... SEC 32 T31N R18W 2.12AC S 12 SW LOT 2 CSM 511469 EXC PT TO ST DOT HWY PROJ 1559-08-23 PARC 018) Plat Tract (S-T-R 40-A 1601A GL) Block/Condo Bldg • 1469-CSM 05-1469 038-84 32-31N-18W I LOT 02 2022 Valuations: pass and Description Acres Land Values Last Changed on 10212019 Imp rova n7t Total Gl RESIDENTIAL 0 790 15,800.001143 200.00 159.000.00 Totals for 2022 General Property 0.7901 15.800.00 143,200.00 159,000.00 Woodland 1 0.0001 0.00 1 0.001 0.00 Totals for 2021 General Property 0.7901 15,800.00 143,200.00 359,000.00 Woodland I 0 000 1 0.001 0.00 1 0.00 2022 Taxes Taxes have not yet been calculated. Key • - Primary �a s�ayao .iq pewo spuel Pa;gaidun a3noaddv "a'Z>,67068S aV3a 01 03N1SStl >/T MS 3H1 d0 3N Il HLOOS 3H1 01 030N3a3d3a 3MV SONINV3a llV I N 3 TT*SSr r SURVEYOR'S CERTIFICATE I,Allen C. Nyhagen, a registered Land Surveyor, hereby certify that by the direction of Bernell Jansen, I have surveyed, described and mapped the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of the S 1/2 of the SW 1/4 of section 32, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin, described as Certified Survey Map volume 1, page 160, as recorded in the office of the St. Croix County Register of Deeds; further described as follows: Commencing at the SW corner of said section 32; thence S89049142E, along the south line of said SW 1/4 of section 32,670.88 feat; thence N01008'13"E, 119.43 feet to the northerly right-of-way of S.T.H. "64" and the point of beginning of this description; thence S88050'40"E, along said right-of-way, 757.75 feet to the centerline of a 66 foot Town Road; thence N27042'43"W, along said centerline, 87.98 feet; thence N44025132"W, along said centerline, 229.49 feet; thence N88049112"W, 551.44 feet; thence S01 08113"W, 237.90 feet to the point of beginning. Above described parcel is subject to an easement for Town Road purposes and all other easements of reco--c. That this Certified Survey Map is a correct representation of the exterior boundary surveyed and described; That I have fully complied with the current provisions of Chapter 236.34 Wisconsin Revised Statutes, and the Land Subdivision ordinance of the County of St. Croix in surveying and mapping same. Valune 5 ylye 1L69 r C. 6YU... 4 i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Ti450t POL4.0 h-er ADDRESS SUBDIVISION / CSM/ AJIA p LOT # IQ- SECTION T 3/ N-R Y W, Town of iyar `raI r 32.31. IS. 5`�1 r ST. CROIX COUNTY, WISCONSIN Alt - I jPLAN VIEW SHOW VERYTHING WITHIN 100 FEET OF SYSTEM .l fi s�� 1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: /1lu1 �pynyl Sfti k e Q / /� ALTERNATE BM: SEPTIC TANK / RMATION Manufacturer: 1.J, Liquid Capacity: / �y Setback from: Well rjG ■3 House Other __Eump--MaTMacturer Modelq Size Float senPration- Gallons/cycle: A SOIL ABSORPTION SYSTEM Width: S Length SU Number of trenches oZ Distance & Direction to nearest prop. line: W it 0 Setback from: well:ywl l House other _ ELEVATIONS o Building Sewer 5f,95� ST Inlet.1D ST outlet /3 PC inlet 4Z-L PC bottom Pump off 7 Header/Manifold 9.3.81 Bottom of systemp sf/d' 7 9D�/ Existing Grade 7i Final grade DATE OF INSTALLATION: / PLUMBER ON JOB: LICENSE NUMBER: �S6 INSPECTOR: 3/93:jt Wisconsin Department of and F16�aeIDl��afNOaa Page d �J Division of Industry Services St. Croix CounUATION REPORT COMMunit Develop in aotxrdrloswiM SPS 385, Ws. Adm. Coda C—* % Attach complete site plan w paper not lass Man 81/2 x 11 inches in size. Plan must Include. .. xd rat limited to: vedk:W and hor¢on(BMA direction reference point (Bdirection and Percent slope, Pacal I.D. stele or dimensions, north arrow. and location and distance to nearest road. — Please print all information. I� Date Personal nlorrnstlon Provide may be used for 86=00widery purposes Law s. 15 1 at Property O" , Property Location ❑ [� fiwl ti A S' T N R E (or) W Property Ownefe a^g Ad6ese Will, Mock S 8tbd. Name ar qgw I 29p Phone Number ❑ City ❑ vage, f ❑ New ConsfitrLm Use: Ed Reeldent W/M i..tbetroamr Z Code delved design Dow rate GPD ❑Replacement ❑ Public or commercial —p/errwe: Parent material r'T� L"- —a LY1d� Q—J'Ni17J Flood Plan eievation IfapplicatleA�— R General comments and recommendations: 41 ,x t/ Baring, ❑ Baring C&PM Ground surface d".Aa t Depth to 11 *b larlor. h e � �A0 W-M , Boring y Boring � ® • v Ground surface eby. = 8. Depth m limiting facmr'((Q In. Sri Application Rate Florimn Depth DomYrra Calar Redox Desr�lpllon Texbre Sauchre Cauhurnos Bound"— GPDlFt' ti. AAumM Ghn. Ai Coral Color Gr. S2 Sh. .�.., MM Property 0� parcel to s F, -Ge --/60 Papa -L�2 of 1771 ❑ Boft ® pit cro,nd wrraoa alp, . %S, >' e. Dean to "ng factor _ ,E In. Efirera 01 - BOD , > 30 < 220 mgft. and TSS >30 < 150 m9k ' EnMieru N2 • BOD , < 30 mg& and TSS 130 ffVL The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. saoawra—O 3 w 2 it 4 R i I I