HomeMy WebLinkAbout040-1301-01-000
t ,
Safety and Buildings Division County
N AW 201 W. Washington Ave., P.O. Box 7082 S/ t -Ad
COn in Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce (608) 261-6546 O
Sanitary Permit Application State Pan (.D. Number
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide
maybe used for secondary purposes Privacy Law, sl5.04(1 xm) Project Address (if different than mailing address)
I. Application Information - Please Print All Information t
Property Owner's Name - Parcel N t tE Block #
LIA
dc-.4171-1
O
Property Owner's Mailing Address a I r r r. 3 Property Location
n
9,;W~5- S-41-VIA LA
City, State W Y., Section Awsew- &)l Zip C Phone umber i (circle o ID
T a~A N; R E o
II. Type of Building (check all that apply) Par 5
C Subdivision Name CSM Number
0 1 or 2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial - Describe Use Gaol LL S
❑ State Owned - Describe Use 2 ~ ❑City❑Village STownship of /QO
III. Type of Permit: (Check only one box on line \;k. Complete line B if app ble) -
A. IS New System
❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply)
5 Non -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 ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel-less i ❑ Other plain)
V. Dispersal/Treatment Area Information: - t~
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Propos (sf) System evation
S o, g ~.s' bt39taT
7
tit
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fib Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) 061 's Signature M PRS tuber Business Phone Number
Plumber's Address (Street, City, State, Z' ode)
5bog t:-t e v -
VIII. CountytDepartmen( Use Only
pproved El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing nt Signature (No S s)
Surcharge Fce) ~
❑ Owner Given Reason for Denial (ya /~43
IX. Conditions of Approval/Reasons for Disapproval 3) c•^ ~!!d w1
SYSTEM OWNER: 1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained t n faQ/
as per management plan provided by plumber. ~9~ `1 fo~js
2. All setback requirements must be maintained
as per applicable code/ordinances.
Attach complete plans (to the County only) for the system on paper not less than 91/2 x 11 Inches In size
SBD-6398 (R. 08/02)
Wisconsin Qepartment of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Building Division St. Croix
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 430509
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:
Blaha, Eric Troy Township- 040-1041-10-000
CST BM Elev: Insp. BM Elev: BM Description:
Section/Town/Range/Map No:
V$ u, 09.28.19.137D
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
5+
Aeration Bldg. Sewer
Holding
St/Ht Inlet
Z
TANK SETBACK INFORMATION Za4d A rpp 6HW SUHt Outlet
TANK TO P/L PWELL
ROAD Dt Inlet
Septic BLDG. Vent to Air Intake " 0
7 Dt Bottom
R~ ~ '
Dosing Header/Man. 7 (J _2 7
Aeration Dist. Pipe n~nK B. q2 W 13(o
(G
Holding Bot. System ft-rp ~ 91.33 3S 3;
PUMP/SIPHON INFORMATION Final Grade q
Manufacturer 5'S / •Z
Demand St Cover ~
GPM
Model Numbers
TDH Lift Frict Loss System H a T Ft
Forcemain Length Dia. ist. to well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIO
DLLD_of
IMENSIONS 3 Sb Liquid Depth
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION t~
Type Of System: CHAMBER OR t~l C
IrQ % / taro ° UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution
° s) x Hole Size
Pipe(s) it Intake
Length Dia~ Length Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded
Bed/Trench Center ~j Bed/Trench Edges Topsoil
' Q
-1119 1
Yes E] No 7-Y es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:.5 0,16/ ~ In
Location: 505 Cody Road Hudson, WI 54016 (NW 1/4 SW 1/4 9 T28N R19W) Cody Hills Lot 1 Parcel No: 09.28.19.137D
1.) Alt BM Description = ff--CVA.-\
2.) Bldg sewer length 5to-,_,
- amount of cover = ° Giv-t'i
Wy n,yu lAvr~,
Plan revision Required? Yes / No
Use other side for additional infor Ion. ~ C
- 1
-6710 (R.3/97) Date I sepctor's Signature
SBDCert. Ni~_
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Wisconsin Department of Commerce SOIL EVALUATION REPORT
Division of Safety and Buildings Page of
• in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST-
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. G
Please print all information. Re iewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner pt(-. 2~ Z 3
Property Location 1 p,
IEZQ SLPOP N~-3 1/4 501/4 S T 2' N R 1 ! E(o W
Property Owner's Mailing Address L t# Block # Subd. Name or CSM#
Z 20 S s 'P I A ' 1 - C '%-kl 101 LL S
City State Zip Code Phone umber
S S~ 01 City ❑ Village 2!0 Town Nearest Road
1JI
New Construction Use: Residential / Number of bedrooms
Code derived design flow rate OO GPD
❑ Replacement
❑ Public or commercial -Describe:
Parent material _ C~ ~~fN-a Flood Plain elevation if applicable N
General comments - fL
and recommendations: ttiITIPIt -3 e-AEL.U V,~4-t4 3`x ~L•2-5 'Lux/6 yv U1- tIVr-jL--J fz
Cel-L 'F1
~ ~)Lf,S ~ ~el.{ 3 "x d • 2 S ' ww 6 w I
1 ~ UN ~ ~~Z. L .
a Boring # ❑ Boring
Pit Ground surface elev. -t-) • ft. Depth to limiting factor Z L 8 in,
Roots Soil Application n Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
'Eff#1 'Fff#2
2 3 l - L z~s ~ m ~w l , S . g
Z l1Ab LOy12 ~l3 S l eSbk mV~h C1V ~
b
3 6-108 tp-y 2 Y/,6 _ S G s 1 a
.z , z
a Boring # ❑ Bing ~a 15e~w.{~ RUB 1
pit Ground s rface elev. ft. Depth to limiting factor ~ 48 in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil ApGPD2r, Rata
in. Munsell Qu. Sz. Cont. Color
Gr. Sz. Sh. 'Eff#1 •Eff#2
0--11 blip- 31 ZTs ~ h wl`f~- O-W
z -zg l 0~~--3 ~ ~ - s~ } Zen s ~ k m v`~-r cLU _ .S _ g
3 2~ W1 R-116 s1 1esbk my cLJ ,b
3~'.-~3 toy 2516 `i s o S~ wl- e-S - -S =9
S 6 3 4 10~ 2 `la S 0 S9 M 1, Z
Effluent #1 = BODs > 30 < 220 mg/L an >30 < 150
_ m9n- Effluent #2 = BODs < 30 mg/L and TSS < 30 mg/L .
CST Name (Please Print) Si na.
Arthur L. tde g e r e r
avl;~~c 0~ CST Number
Address 0 3 1 ~j 2 220254
Gde g e r e r $ O 11 T e S t l n¢ & D e S i g ri S e r V 1 C e Date Evaluation Conducted Telephone Number
421 W. Iisin St: River Falls, WI 54022 31,82 ~B3~-06-03
q-S-d3 .715.-425-0165
Property Owner Parcel ID # 7~~ G Page Z of
M Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor u In.
Solt Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont.,Color Gr. Sz. Sh. "Eff#1 'Eff#2
0. l S 1 42 31 z S 1 Z Ts- b 1-r wl GW rd
Z 1S-3g 1D-1 R 3 C3 - S 1eSbIT wl\)tl-
3 -goo l~`12 VL6 - S o sg >M 1 - ~.Z;
F-v] Boring # ❑ Boring p
® pit Ground surface elev. ft. Depth to limiting factor -7 -I in.
Soil Application Rate
Horizon' _ Depth Dominant Color Redox Description i exture Structure Consistence Boundary Roots GPD/ft2
In. - Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 •Eff#2
a -Z I l~-~ R-3 J Z - S 1 Z'Fsb S C(•v l , S ' 8
~o,j tz3~ - s~ 1 Zm s b cw . s sa
3 y ~15~ ) o 1W ) b `S 1 a S~Yz rn eg • -1 Z
-qR 10yRy16 - S C) S5 \M~ - --Z
31, /
❑ 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/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1. 'Eff#2 "
r
Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 BOD6 < 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.6/00)
PLOT PLA~~~~~ Page 3 of 3
Scale 1'=50'
L oT 2
-7A Lz)T
f 9
I - aM*z a~
.~s
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Q-S -0 3 715-425-0165 220254 03 =1 (~Z
CST Signature Date Telephone No. CST No.
Job NO.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner I~Ple 81-Al-14 Septic Tank Capacity al ❑ NA
Permit Septic Tank Manufacturer C~ 'S ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer z GL ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model _ ❑ NA
Number of Public Facility Units 111111 NA Pump Tank Capacity al ® NA
Estimated flow (average) Q gal/day Pump Tank Manufacturer ® NA
Design flow (peak), (Estimated x 1.5) 1-06 gal/day Pump Manufacturer 8 NA
Soil Application Rate gal/day/ft' Pump Model ® NA
Standard Influent/Effluent Quality Monthly average' Pretreatment Unit O NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD.) 5220 mg/L ❑ NA O Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L O Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD6) 530 mg/L ® In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 510' cfu/100m1 ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. O NA Other: ❑ NA
Other: . ❑ NA 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) O NA
ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
❑ month(s) (Maximum 3 years) O NA
Inspect dispersal cell(s) At least once every: 3 i year(s)
❑ month(s)
Clean effluent filter At least once every: ❑ NA
year(s)
❑ month(s) NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) ®NA
Flush laterals and pressure test At least once every: ❑ year(s)
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 (Y3) 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.
Page of
START UP AND OPERATION
Foy 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 Name e S
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
CAQ / 4- AE_ Name
0 -W i
Phone Phone S 39 6 _ G 90
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
Owner/Buyer I e /3 LOP
Mailing Address 405 S)qL V1 i4 L.A/
Property Address 5 05 COO A6
I I (Verification required from Planning Department for new construction)
City/State R. As oti 1J _T Parcel Identification Number 0 y -I O q 1- 10-00()
LEGAL DESCRIPTION
Properly Location b~l Sec. q . T N-RW, Town of TIZ O Y
Subdivision [ _ O b y gl C LS Lot #
Certified Survey Map # P 1&i of L d„ falls Volume --.,Page
#
Warranty Deed # 736 11q Volume d3 7 7 , Page # 3 48
Spec house ❑ yes ® no Lot lines identifiable ® yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeymanplumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Ywe, 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 Zoning Office within 30
days' f the three y9aj expiration date.
f Iza U 3 OZ
SMATUft'bO A#LICAW :DAB
OWNER CERTIFICATION
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 p pe descn d above, by virtue of a warranty deed recorded in Register of Deeds Office.
A 1~` tF A LTCANT DATE ; r
Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department."""
Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
voi 2377PAGE 349
736114
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
ST. CROIX Co., MI
Document Number
RECEIVED FOR RECORD
i This Deed, made between Maverick Farm, Inc., a 08/18/2003 10:30AM
Wisconsin Corporation WARRANTY DEED
EXEWT #
Grantor. REC FEE: 11.00
and Eric B~ laha, TRANS FEE: 375.00
COPY FEE:
CC FEE:
Grantee. PAGES: 1
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Croix County, State of Wisconsin:
llecr)rdv.,I A", +
Name and Return Address
C'nl At„tpl L itST.e -
~C~AC`G3 l~-3 -
040-1041-10-000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not) -
Lot Plat of Cody Hills in the
Town of Troy, St. Croix County,
Wisconsin.
I:
Exceptions to warranties:
r
S e to Basemen reservations and restrictions of record.
Dated this day of 2003
MAVERICK FARM, INC., a Wisconsin Corporation
(SEAL) By' (SEAL)
i
BARBARA A. GEISSINGER
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State of Wisconsin,
ss.
S
t. C ro' Cou
authenticated this day of e o came before me this day of S go
2. ~Q the above named IF
of Mae Ck Farm, Inc. , a Wisconsin f0
' Corporation, - S !
TITLE: MEMBER STATE BAR OF WISCONSIN to l.'
(If not, me known to be the person who executed the foregoing a
authorized by §706.06, Wis. Slats.) WPubftc. n the same. THIS INSTRUMENT WAS DRAFTED BY Stephen J. Dunlap C(of Wisconsin
Hudson, Wisconsin My c~~gipn~ermanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not _
necessary)
' Names of persons signing _
In any capacity muu be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
FORM No. 2 - 1998 Milwaukee, Wis.
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Wisconsin Department or Commerce SOIL EVALUATION REPORT 3
}Division of Safety and Buildings Page of
E !
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S~ e Y7 ~
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.aJ G
Please print a Reviewed by Date
Personal information you provide may be used f r secorl
Law, s 15.04 (1) (m)).
Property Opw.~ner operty Location
1Z\-3 13Q SS) M1- , ZM y 3 ® 200 1/4 /4 S T ? N R l- l r W
Property Owner's Mailing Address E (o of # Block # Subd. Name or CSM#
L4 sc) ST. ~;IX COUN ('y
City GLOStatenz Zip Code Z011 I - p S~~ CU~ l !I ` ULs
❑ City ❑ Village ® Town Nearest Road
S~vJ wl (~iS)386-\31-7 -nZp(_1
New Construction Use: Q Residential / Number of bedrooms Code derived design flow rate
❑ Replacement GPD
❑ Public or commercial -Describe:
Parent material U T1.~J Pit vA,/S Flood Plain elevation if applicable ~0 A
General comments ft.
and recommendations: `t LS D 3 X / Z S L v l ,
C~z:._~ ~ ~E s y ° b~ 0 ~ ~ -
1 ~trZ~ .y t 2 .
Boring # ❑ Boring 7o s` Um
F 144 Pit Ground surface elev. JQ ft. Depth to limiting factor 1 0~ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Con t. Color Gr. Sz. Sh.
'Eff#1 'Eff#2
)ic~ `fCz 31 - ~ ? TSbI-z w). ~'r Cluj ~`lc` ~ S . 8
Z 1~ ~ to`-(GZ313 s 1 1 eSb~ wi U~ ~ ! _ - ~ , b
3 ub-)o$-to~tz~l6
S Us9 v,~i - 1.Z
E Boring # ❑ Boring
pit Ground surface elev. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Eff#1 Eff#2
31 S ! ` r,
ul rz- Z
Z~~>z m \ t- ecv ) -p- 's -8
Z 1~-Z$ 23iy - si I ZrnS61T eL.j - . S - 43
3- 1
z~-38 072 ~~6 s c sb u c - . , b
3 `,63 to`~2s16 - 37 o 1~ ) e S - • S 9
S 63-98 10`l R VA ~ S o S9 - . ~ 11
Z
Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Si ature CST Number
Arthur L. Wegerer -Z-7 I 220254
Address 6,1 e g e r e r S o i l T e s t i n g & D e S i g n S e r v i. C e Date Evaluation Conducted Telephone Number
421 N. Ilain St. River Falls, NI 54022 1-~-03
715-425-0165
Property Owner V s l ~Ij y Parcel ID # Page -Z of 3
F~] Boring # ❑ Boring
Pit Ground surface elev. `O Z - S ft. Depth to limiting factor 7 100 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
0-lS l1)y23/Z - SZ) Z~SbFz ~n`Fh C l't •5 -g
15-38 tQyla 312 - sl eSb `F - y , 6
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. (t. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •E(f#2
Boring # ❑ Boring
F-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/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2
• Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD5 < 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-9330 (R.6/00)
S •
3
Property Owner V S 9 1 ~ 's t Parcel ID # Page Z or 3
5)] Boring # ❑ Boring
❑ Pit Ground surface elev. k O Z-,% ft. Depth to limiting factor 7 1 t)O in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
o-ts io-) 23/z - sty z~sb~ ""fi- c 1--~ •S -8
t 5-38 toy12 3C3 ~ s 1 eSb tit `f c , b
3 3$-loo to~~ y/b - S U S - >`1 Z-
❑ 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/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Boring # ❑ Boring
F-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/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Effluent #1 = GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODS < 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 608-266-31 S 1 or TTY 608-264.8777.
SOD-6330 (R.6/00)
PLOT PLAN Pace 3 of 3
Scale 1' =50'
•
-7~7
L oT Z
LoT}
14
o
9
3ry 14-Z. ~ \
2s
~3 ~b 6 . S t~ k 1 yv kz- - ~sP
D'_ ONJ -I L L; 31 D t R R V j/ L h rf4
-YrOUSE -13J!E~_ -7 S' _FI O)'I O-Elk-5
C~ 1 6-03 715-425-0165 220254 -Z7
oZ 6
CST Signature Date Telephone No. CST No. Job No.