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HomeMy WebLinkAbout018-2011-67-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division ` INSPECTION REPORT GENERAL INFORMATION ~ (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1• Permit Holder's Name: City Village X Township Brown, David Hammond, Town of CST BM Elev: insp. B/M Elev: BM Description: ff , / ~ ~ ~ 1~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic i~ 2 Kati ~ Z~ Dosing ~v `~ . ~ ~ ~ ~ I (J'TC~,d'~. Holding TANK SETBACK INFORMATION TANK TO ~ P/!~. ~,~-- WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ ~ ~ Z.1 ) Z i ~' Dosing ) ~~~ ~' i ~ f ~ Aeration Holding PUMP/SIPHON INFORMATION fC ,F Manufacturer nd GPM Model Number + r~~. ~~ TDH Lif}„'~ SS Frictio~ LoZss$ System ead TDHI ~1 Forcemai n Leng h , p + DiaZii Dist. to well ~~ SOIL ABSORPTION SYSTEM ELEVATION DATAI county: St. Croix Sanitary Permit No: 463469 0 State Ptan ID No: Parcel Tax No: 018-2011-67-000 Section/Town/Range/Map No: 30.29.17.1082 STATION .~ BS ~ .yZ HI io3. FS ELEV. i~ Benchmark `~ iCL + ~~~ AIt.BM ~~`_ r ~" (~ ~ ~~,f ~f ~. Bldg. Sewer a , ~ -1 SUHt Inlet * 9•~ ~ Lj 'I SUHt Outlet ~ '1 Dt Inlet ~ ~~, Dt Bottom ~, ~..1, ~ ~! , ~ Z b Header/Man. ~ I ,~~ ~~ . ~ g Dist. Pipe ', ~ Q~ ~/ ~ ~ g eot. System ~J IO Final Grade , rl~- ~ ~ ~• . L ~z \.o St Cover ~i ,~ ~qmp~ 1 i ~ ~ ~ G -f ~s`i4 Z BED/TRENCH Width r Length ~ ~ o. Of Trenches ' PIT DIMENSIONS ' No. Of Pits Inside Dia. i' Liquid Depth DIMENSIONS 3 hC ~ ~~~ ~ V ~j ~ ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: j~ 'I ~~ ~ INFORMATION CHAMBER OR ~ G Type Of System: ` ~ ~~ ~ ~ _ ),/~ UNIT Model Number: /~ _ ~ ~ DISTRIBUTION SYSTEM Header/Manifold ~y ~ Length ( ~~ ~ Dia Distribution Pipe(s) Length \ Dia Spacing x Hole Size \ x Hole Spac\ SOIL COVER r -r- Y Pracs~~rc± Svsframc (~nlv YY Mnund Or At-Grade SVStems OnIV Depth Over Depth Over xx Depth of xx Seeded/So ded xx Mulched BedlTrench Center Z 7 / Bedrrrench Edges \ Topsoil Yes i _'; No Yes I No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 789 157th Street Hammond, WI 54015 (NW 1/4 NE 1/4 30 T29N R17W) Emerald Acres 1st Add Lot 67 Parcel :30.29.17.1082 1.) Alt BM Description = ~-w\'~"~ ~ve~ ~~~ ~, ~~b1, ~ , 2.) Bldg sewer length = ~ ~ ~ ~~ - amount of cover = 1 ~ ~\ ~ ~'~ .. q ~ ~.~ i Use otherls de for additional in Yes No i ~ ~ ~;83~~5 forma ion. ~ ~~ ~_-- - --- Date Insepctor's Signat re Cert. No. SBD-6710 (R.3/97) /•. 1 ~9 ~1~ Ve o Air Intake p~- ~V Y OY, fl. ~ '.~ p5/1p/2pp5 OB:04 FAX 715 233 p398 Certified Soil Testing i Eau Galle 11001 5af ildings Division County ~ r, 201 W. P.d, Box 71GZ ~~ lv): , T 1152 ~~~~ St. Croix Sanitary Pemtit Nu er {ta be 511ed in by Co } ai (Gp 2ti De artment cat C rce o mme pp + s ~ ry~ ~~fi4\r ~R~~L~~~ ~pr~tiil~ ~ ~ State P LD, um a In accord with Cotrm, $3.2t, Wis. Adm, Code, personal inf tics you provide maybe used for secondary purposes Privacy Caw, 5.{}4[t n 1 2005 Prajec[ Address (if different than mailing addrrss) I. Application I6formaifoa -Please Phut Ali Ioformatipn ~ 7$ ~ ~ 57 ~ S~-~ ~tXC~~N7Y Property Ownt:r's Name ZONING creel # Lot # Black # David E. 8rott~ Q~o`J 67 See. . ~ U S Property Otmcr'S Mailing Address Propt:rty CACatian 3810 Orleans Lane, W. City, Swte Zip Code Phase Number ~- ~. ~ti, Section 3Q Plyrttt~thr MN 55441 7&3-544-4045 (circle anc) II. ype of )guDding (check art that apply) I 1 _ 4 ~ ~ ~ Ubd1V1518R Nsme CSM Number ur 2 Farruty Dwelling -Number of F3odroarns ^ PubiieJCammencial- Describe Use a.w Emerald i~eres, 1St Ai~rl. Q State Awned - t7escribe Ust ~ ~ . ~~~ l..f Z -YZ~ e~n~a, w~VSs~vJ ~ity_^Village B$'awnship of F-~nr-ror-d ITT, Type of Perrriit: (Check ably one box on line A. Complete line >~ if applicable} _ zv ~ '7 _ ~~ A' New S tem ri ~ ReplaCertxnt System ^ TreatmearJHOidng Tattle Replacerncttt Only ^ Other Madificarion to irxis[ing 5ysccm &• ^ Permit ftrnewat ~ permit Revision ^ Change of ^ Permit Transfer to New List Previous Perrm- Number wtd D•rte Issued f3el"ors Expiration Ptutnbor t7wnor iV_ T e of POW'1'S S stars: Check all that a ~, ~'Non-Fressurirtd Tn-Ground ^ Mound 5 24 in. orsuitable sail ^ Mound C 7r4 in. of suitable soil ~ ^ At-Grade ^ Single Pass Sand Fitter [~ Caaswctcd Wetland [] Pressurised In-Craund ^ riolding Tank ^ Peat Filter ^ Aorobic Tr~trrnrtt Unit ^ ReeircuIatiFtg 5attd Ftlxr Q / FLecirculadng Synthetic Media Fitter 1$'Leaching Chamber / ~ Drip Line ^ Gravel-less Pipe ^ pthp' (explain} V. Dis ersAU'I'reatment Arta Ihfdrmation: Design Flow (god) Design Soil Appticarion liate(gpdsfj Dispcrral Area R egelired (stZ Dispersal Area Proposed (sfa System Elevation / 600 / 0.58 / '1000 / 1031.4 .~ 95.0194.5 'Vl. 7'a¢k Info Capacity in Tatat Number Manufacturer Prefab Si[e 5tce1 Fiber plastic Gitiions Crallan8 otUniLs (~ Ncw Existin ~"~ Concrete ConstryCtCd Class g ~~~~ ~}~O Tanks Tanks Septit 4r Haldiny Teak Aerobic Treslmen[ u4it dosing CLattilter Wi r - 0 cclmbo X VII- Responsibility Statetneet- I, the ubdersigtred, assume res usibllity instaltpgprr of thx POWTS shown on the attached plant. plumber's l+ramc (Print} PEUmbcr's Signature MP/MPRS Number Business Pharn plumber Oita Hurlburt: ~ MP 422997 )15-283--4851 Plumber's Address (Street, City. State, ~ Code) N 26Ct C1'NUtt Q, Eau Galle, WI 54737 VI . Coun Ne $rltllelat Use Onl Approved Sanitary Pcrrnit Fee [includes Groundwater ' I]atc Issued lssuin gent Signanwe Q S s) owner Giv f enial Surchargo For) ~ , ~ ~ '~ - aO 'S l3 05 a.n.. ~.vuma^~,,. or rr.ppravauaeasons sot ursaPPro~a! ~\ ~ Lb 0 Vim. ~~ L~~o~~` G~?aX~-~a~/~ SYSTEM OWNER: J, t~ J 3~ ~/ SeQtic tank, effluent finer and 51~,atl ~w 1^ ~,Q,~ ~,`,~--g,~ ,ti. ~ dispersal cell must all be services / main~~ ` I as per management plan provided by plurrrlt•r, ~ ~~j,(` a ~ ~,~,~ ~ ~ 3~ ~~ 2. ~ Per kapplicable code / ordirange. . ~ ~ ;'~ SsD-s~~s ~. 0113) D ~~ L~ l0 J~, i /mss plans (Lo ehe County only) for Uk sy^b:m on pacer not 1Ki than 8112 * 1 t Inches is s1z ~~' sat ~ ~av~.`~~--t' 11'x-~5~~`' ~ ~c.~.s~-fto c~ ~~ a r v~,c.~~e~ced~ ~~~, a r ~~. d-t.._ -~ v /~ I`i~.s~tCb} u' ~ ~~p~ U.7/lU/EVUa uo:.U4 rn.a t-ta CJJ lt.tlf6 ~ Ci'L1t1C~Gt JETIl. E~~'&L21I -~ ~s11 4aAttF: ~}~J[~L f ..~ ~-~ apt 2 t~v~~ i~ta~, ~/~. ~ C3 .... _.,_~,,. ~._ ~ ~.. ,~, v,~yY ~~~~ ~ . t ar~cc.'~z'~r+~t4r. s~r~3ee r±~.~ b~.~~, ., n ~ d ~ ~n a ~ ~ _ f . tiro ~ ~~+- ~~'L? co,..lvo ~~ +~ 4: 4~...~1 c,~ S n La w io,,,,. ~f, t{ ~~ ~ Orv.cS~ "~ Q. ~.y .... ~ '1f 05/10/2005 06.04 FAX 715 2~~ Oa88 Certified Soil Testin8 ~ Eau Galle ~ 002 wuwti.~'~' ~ utr~t tq~_t t:t t'AW~~'~ .1ll:t~t:t{tlrClj?M~wi7if~r '~..r~~,t~l.~{,~~~~fOIW . _ _~.~~... __..! .w.. ~A ~~~ -_.__---~-------.,.r-- --~ . .. 7~ - ~ . $ ~~ ``, ` a a ~ t ~..St., .. ~~ ~~~ ~ ~ ~~~-, C ~~ ~~ ~ (~~ ~ ~~ Q'~CJ{it '~w,q+a'~'1 ., .. ~. ~~ {~ ~.a~ ~-4~ ~~+ . ~~ r ~~, ~ 0 ~,~ ~b.'4: .r1 ~ ~,,. s:~ ~..~~ ~-4 M t0 ~+`r _ ` 1 ~~ . ..'K. .,. q5/1gt2gq5 06: q4 FAX 715 233 0398 Certified Soil Testins -~ Eau Galle f~Igg3 J at d-+ o ~+-+!. f$~•d stir?( ~,#,~., ~ ~ ~~~M T ~~~ ~ c~ ~ ~-~ ~~~• ~- ~ ,._, 1 o g.o ~ . Ala, ~t~~~' ~`'~_ 1' ~ a-, ~ i Q, wti ~'^~ ~Mr'r` K ~~'t i^+ ~ ~e~• cs ~~~...,..~ V - ~ 4.s F ~~~~~+ a- ~ o ~.as~ T T ~'"` tZ bb.. O p ~„ g ~ ,~ (] ~ ~ S QJ. M ~ i~.~ D a~ 4~w t.`~ ~ ~a ~". "f'QhF ww +.. 4i,i~Q. `~:M fir` ~{ p5/ip/20p5 p6: p4 FAX 715 2~3 p998 Certified Soil Testia8 3 Eau Gall:e C~j4p4 I ~ ~ kt'r '~ k' T'C~1L Mw~+a w~,-T~ E~P~R LOCKING COVER ,7UMCYIQN f ~IC,K RisGOyyE6T--~` 1 . ~~~ (~`~ PSG s ~ ~"? ~ Pkv~' ~, s+t,/Tp ur~~S~u~~+E So! ~ /~we.~ r ~`tip,~R.vyt~ ~A51i.ET ~~'t"~ :~-•wE~Tkaxs E' ~~~ v ~•5 C ~.~~ .~ g.~ i 1 ~ :.t a ti }r~.s ~.9.~`k bE~ ~-- ON ~~'~ aw ~„ i~~ ~~~ir~jF f~u~ b" ~ VENT .. ~~ _ ~~ ~" wtir No:L ~ ~~~ ~~~ ~ ~~~.~ ~ 3' ono ~ ,,{{ T~,, j G Rauua to+vue~rE . eccc~ ~ f ~ SEPTIC f V PEG-1~1 ~,471 QI~tS i>asc ~ ~~ 7 K5 J _ ~~ nr~ MA- L,-FA•CTLIA~,i~: Altll+ldER OF DobCS~--- ~" _F'EP. awl T~,uK SIZC : E1Y~ -. ~~'~ Glr-t_t.0415 L10SE vaUUME ~~' ~t~.~~~ A L A R 1•'S I'4A~SLI FAGTU its R; o t1~IGl-JDl1.lG OACKrl.oW: ttZ.g4- C. A L L o N 5 nod~ct_ uUl~b~R: ~°t ~`" CAPACfTIESt A~ ~~.o WCNC50R 4~ Gw~LpwS ewlTGlr Tarts M..~...~.. ~.ll, ~ 3z_•~ ~ ~'UMP /1AklUFACTURt11: ~~ Q~wl:c (~ C~~,.,kIJCMC4 07{ Gx~60~.5 1lZ'K~ G ~ ~ ~~ kVCr1E5 ~ pR Lh~.OktiS ~ .,~~~ swl-rCs.~ 7yPE: `w•aw,.,.4 ~.- UQTE: PuMV Ak1D ALARMI aRC TO bt t'iIIJIMUr'1 6lSCNAltGf RATC~_f.~M ~ lhIST/lt.l.EO 0-.! 5~PARATC C~RCU~T~ vtRriC~,t. prFFCKLAi4E'plLTWCCA! PUItiP OFF ANO bIS1~Rlt1lTit>U PIPE.. ~"I~.,~ FEC7 t + r4iuIt1UM k3ETWOitK SUf~Pt.y f11Ef;fiUR~ .. . . .. . ~fl Ft~T + FEET OF PDRCC !"LAlA! X t,~~~p~flttCYtOiJ FACTOR. b,~~ FEET ~. -, ~~ "-' Tt]TAL q~uJ-Mrt ~1C~+b = t'Z`Z~ FEEr ~~ IIJTEFt1JA~ DIMEfl6tCa`!1< OI TAk1K: k.t~1+3fi7H ,~T~WIaTH _ ~ ~.,.._,L14UID D£P7H ~~, 45/10f2005 06:05 FAX 715 233 0398 Certified Soil Testing 3 Eau Galle ~ 005 . ~~ Pumas Chaf~cte~ri~c~t>f i~~~1~ ~ A~-awatic lfe~ 5~~1Ai ~ ~ ~~ ~iTK S110~ ~ Pr } R.rrK. Tss~ -~ a ~ v t~s ~~ ~o femp+nlrr T~0'i A~1~rd NT;ATA D+~ A lass*tlo. dns A Tlssliar 5h+ M-1 /Y" 11-I [3~IgN$ fotids Nnai.y S/4• (19NwN) U~t Watglt - ~0 ~. hwx Csrd T sJ; s1TliG ;!4' sr,L 1~GlOf ~ls~~ Of C15~f110~!'IJCt~QA M.~n. s-~a.>~. s,..t .~ al a Mote Iias C~a Ira r~ ~ ~ M.dra~ sty Sal rrcrs: CarM~t/t~aNr s~~~ e~ r Ik Gsl MMI ~lYi tower R+rw MrN L'EfIMr M1~ ~ 11rM~~~r FestM!-i lttiflils Siwil Pe$rforfnor-~e Data ~ ~ s 6 ~ ~ s ~ ~ -® i ~rn°~N#4 ~ ~a ~ m ~ ro ~ tftf{ Ili 4 ~ 1 Z f ` ~ 4ri @tM1 N~.} 4~1 ~i ~~ ~i f t 0 D~ff'ietllif+OtfO~ DQ1a -a~a 'y 1. Aliirrreki-d~r «e~ ,~ Ra Inmxld ~ ~a..~an! ~. ;} x cmn ~.~ r.r = TA w~ an •.,n S rN Iw iM.r~w1o ,~. t N~,.d+~.w. eAOrr.~a. ""~ s, a~ddnt~t.~rf d. wnrew~rylroerk. ~Ndr. ^.. piliau ~i~Ar y~ae wdaer nMot ~~ ~ ~ ~ 11' >K G1v~Y ~1~ w~~ "T ~ ~ saR t, } n,~'J~c~., H~i~~V~~! ~~ra !SIOBanerRpdAFldaad,tf~e4ii05 HF.4t4•iBi~~lfi h>G~15~9ataW7 ~ ..- W~ S1pe: wwr.omidtoano,cos fdlES OFi1tfS tN All NtA10p cmK UNIT Ct1U11TRtE5 4im a' w.,SS.e394 ti248 5MS f o~ic' PtimP~. Ashlarni, C~+rt. 41! Rio - Tvw Au~erxad teed Difntbvb+ tWf,.; s. ~,a~ ~r W i~consfi Department of Commerce ' Utvision o(Sefaty arrd Bufldfigs. c ~`tlG® inI Altadr cou to slll~bn~I papal!! r~~rot Icss fidude, hart (hailed to: vertical ant4,1}p~in percent rup scale or I ertyq(oys,`~ t i ~~~le aLp+s e~rrp~~r~~-~~ Per~onel inromr lkxr yov vwi~yy'1!e ~c II~fDpBfly Owner ZQV SOIL EVALUATION REPORT Payo _' _ v<_3 rdarrce wiUl Conun 05, Wis. Arkin. Code - Cowtly • 0 112 x 11 et s iIr size. Plan must ---~ ~~ ~-~- reference p I ), dhection and Paruel LD. nd logll lt~t~e to nearest wad. D~~'~Q!/ -' ~~ ~~ 1 /illaI1011. ~ R rm6'e Uale ary prnpoees (Privacy ,~ ~I (mp. ~~~ ~ I ~/~~~ GrrvLLol U,; 1/~ N~114 S'j0 1~ 2~1 N Ii ~~ E(nr W1C~ ---N-- - - Property Owner's Melling Address Lot >f Bluck # I Sulxl. Name a CSMIf City Sate Zip Ccxle Plrone Number ^ Cily ^ Villaye (~$-town Nearest Ruad t-~ vd tit 5~ ~ 115 ~1- "~31 omrrx~>,-~ ~ C~y . 2d• ~ T ~ew Construc.-liat Use;~(~'Residenl'ral I Nwnber of bedrvutns _~ ~ Crx1e derived desiyn flrmr rate ___~`~_ ~.D .~___ GPU Replacement t ^ Public or cvrnmercial - Describe: _~-_-. -_-_---_-.-_ ~. --- - Parent rnelertel ~_~_---- ----------- Fluod Plain elovation if apldicable __-~~f~--/-Q-,,_- J~X~Cit/ R. ` Uerteral oornmerds ~~sr. Q w'~ .e, e. V ~ -~-~-~e' ~~~-~jA~ *~ s~.S~- arrd recommendalkxts: !Vl ~ ~ • ~ IQ,'"~'.,~_~ ~-~ __ y~~(/I'r-~ ~~~ ~ 3 ~, ~ 1 ~ Boring # ^ Buriny ---- --- - - LLL---JJJ Pit Ground sw(ace elev ~?' ~ IL Ueplh to Ilndliny (actor __~~ _ in. _ -- _ _ _ _ Soil Applic:alion Rate llurizon Ueplh Uominanl Color Redox Description __ Texluro _ Sbuclure Cunsistence [3uundary Rrxtts GP UIIt' in. Munsell Qu. 5z. Cont. Cvbr Gr. Sz. Sh. _ -- _ _ 'Eff#1 'Eff#2 I ~~ 312 -- 5i I 2m~bk ~ _CS Ivy _ 5 •~ Z 12 - Zlo ~ ~ ~{ t k ~~~VVI! 5 L 2 m 5bk ~i r ~ S - , ~ ! . d 3 2tp ~D I~ ~+I • r v _ s s _ m I c S - ~_ 1. 2. ~ - ~ C2.p ~,5 L-I/c~ 5c~1 ~~ - - - ~ - Boring # ~~ Borirty p ~y~ t~-'F'it Ground surface elev. / ~F ` !~_ ft. Depth to limiting factor _ ~~ - in. So~plication Rate Horizon DepUt Uorninartt Color Red~x Description Texture Structure Consistence Boundary Roots GP DltP in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Et(#1 'Etfg2 I b-I 2 10 ~ - Si / ZmSb~.. - _~_ ~ vs . 5 -~ ~- -~ ! ~~ ~.L- 2_ mob k tr~n-~- c ~__ - ~ - I • o 3 3~-~~ r r~ 5 ~L -- - , -7 ~ . 2 - EIIklent tM1 = BOD > 30 < 220 nly/l aril TSS >30 < 15U rrty/L ' EOluent #2 = BOD < 3U my/L and TSS < 30 my/L CST Narne (Please Prinl) Siyn a CST Nuatbcrr __ -"_ _ _ ~5.330~ Address Uate Evaluation Conducted Telephony Number ~a Property Owner 5io~~ Parcel IU t! ,l U ~ ~: " Paye __~ of 3~ J Bo Horizon t Z 3 U Boring rn+g # '~Plt Ground swface elov.~ -7 ~ ~10 tt Deptlt DontinantColor RedoxDescxiplion in. Mansell Qu. Sz. Crn+t. Cvbr o-t2 IU ~I2 ~' 12_30 i ( ~-~ S -- . Deptlt to Grrriting f Texlure Slrudure Gr. 5z. SI+. _ S~ J S ~ M~yr`Y 5 -~- actor Consistence ~i~ ~~ ~n1_ _ i"• SoB n t tlicaGott Rate Boundary Roots GPDIfF 'Ef(1!t 'E(fg2 ~ ~ . ~ ~ _ - --~--- - -~~- 1. d _ _ -~ ~ • Z -- U Boring Boring # - ^ pit :Ground smiace elev. , ft. Uep1h to liu+iliny factor ___ in. gop n I'rcaBon Rate HoriLOn Depth in. Dominant Cvbr Mansell Redox Description Qu. Sz. Cont. Cobr Texture Slrudure Gr. Sz. Sh.. Consistence Boundary RWIs GPDIIF 'Flf#1 'Eft#2 LJ Boring Boring # Ground surface elev. ______ it. Depth to limitiny factor _-_____-.____ in. - ^ pit __ Sorl A tlicalion Rate HOrizon Deptlt Dominant Color Redox Descriptbn Texlure Slrudure Consistence Boundary Rrwls GPDI(F in. Mansell Qu. Sz. Cont. Cobr Gr. Sz Sh. __ 'Eif#1 'Elf#2 'Effluent #1 = BODS> 30 < 220 my/L and TSS >30 < 1511 mylL ' Eiltuent tYL =BUDS < 3U rnylL and TSS < 30 n+ylL 'fUe Ueparttnent of Commerce is an equal opportunity service ptvvider and cngtlvyer. If you need assistance to access services or ncctl material in aft alternate Somtat, picase contact tl+e depatttncttt at GU8-2GG-315 t or 'i"l'Y GU8-2G4-8777. sr+o u3o ra.otroor ~~ V~ Properly Owner ___ I ~ i. page __~ of ~. Parcel ID # _~ (~ J U Boring '~ "~" _ Borhrg # tT~ lir to Grnilin tactur in. -UJ "pit Ground surface etev.~ Z ~ ~l~ it. ~J~ep 9 Sod A ica6ar Rate , horizon 1 Z 3 Deptlt in. p-l2 12-3D 3a-`~ Dominant Color Murtseii IU t3 2 ~ S Redox Desaiplbn Qu. Sz. Cont. Cobr ~' - Textuf•e _ S ~ 5 Slructme Gc 5z. Sh. C SA Consistence rn~'r ~- Buundary _~ -~ _c~ - Roots _ - GPD 'Eliltt j~ • ? IftT 'E(fQQ#2 - 1. d ~~ LJ Boring Boring # ^ Pft Ground surface elev. ~ ft. Depth to limiliny factor __ in' Sad A licatlvrt Rate liorizar Depth in. Dominant Color Munseti Redox Descriptbn Qu. Sz. Cont. Cobr Texture 5lrudwe Gr. Sz. Sh. , Consistence Boundary Rovls GPDItF _ 'EI(#1 'ER#2 L] Boring Boring # Ground surface elev. ____ tt. Depth to lirnitiny factor _._ _______ in. _ ^ Pit _ _ Sod Application Rate Horizon Deptlr in. Dominant Color Munsell Redox Despiptbn Qu. Sz. ConL Cobr Texture Structure Gr. Sz Sir. Consistence Boundary Rrwfs GPD/fF 'Eft#1 'Eff#2 • Effluent #1 = BODS > 30 < 220 rnylL and TSS >3U < 15t) nry)L " Etiluent lf2 =BUDS < 3U my1L and TSS < 30 nry1L 'ftte Deparitttent of Commerce is an equal npporiunity service provider and en-ploycr. tf you aced assistance to access services or need material in att alternate format, please contact the depatUnent at Gq8-2GG-3151 ur "i'1'Y G118-2G4-8777. SPD--IU301R.01I0r11 . 1'nc~ 3 orb NAfvtG: s~v~-------[_urs ~_'~_I,-ir~nl,l~rs~'-clt'r-r~tl:(~u~ii~WEU~-,`~~.1Zq.N,-t,l~_I(~,r~ SCALE: 1' °___- "/_~----- -- -- _ _- ------- - -- -- - _ - ~ 1 Y • .. DNI 1 DL'•SCltll' I~IOrI: -b~~ _o-~_l _ p~~L- ~` ~~----_- [3M 2 GLLVn'I IC1N: ___ q ~, ~ Q _. _ fee ~. -3 O __- .-_-_ _. _ __~_ _ - - --- ,- , d SYS'CL'ti[ LLIiVn'I"li )rJ: _ _ 9~' S __ _ SVS'1'I~.M'1'ti'I'li: ~c~n Ue/~-~. ~na.~ __ -_ __ - 9~ ~a SIGNATUR[:; 7~r~ ~ UA"I'L: '~ = ~"-~ ~AV~ 04i29i2005 12:10 ~f t {JW-STOLiT*SERVICE CEhJTER ~ 8171`i2$348fi1 -. .„~ ~, ~+. .~ ~ ~~ ,~ z ~ ~~ . ..-._- ~- X~ ~ \ _ r ~ ~ a _ ~ y .~ J l i ~/~ ^ ~ ~ j p q, ~ ~I,9f I.~ tlF ~ Md 119 nn1 ~l G f /~`n ~y V' \~ i e. ~ s. i ~ `~ -• ~~ ~~ '` ~ f~ F.~ 7 ~~. r~ ~ I ~.1 ~4 5'i ~; .~+ h~10.319 1702 05!10/2005 06:05 FA% 71.5 233 0398 Certified Soil Testing -~ Eau Galls u. ~ - . ~ dWNER'S MANUAI, MANAGLMEIYT FI.AlV - , .._.,,.....r~_ ... FILE 1<NFQItMATiUJY ~ _G: rf,,~atrrt.,~. • . .,..~...._~.. _ r_ ~` n ~-g. i... .. Rt~c+mtat ~ - - - - Owner ~ ~, bt Pemrit # DESIGN PAI~.AMETER~ Number of Bedrooms 100ppd Nurr,bcr of Cnmrr'tcrcial Units ESEirr~ted flaw {averaarr+ Design flow (peak), estimated x 1.5~ So;l Application Rate IntlventlEffluent Quality {NAp} Fats. Qir & Grease {FpG} Bioehcrtvtal Oxygen Demand {B.ODs) Total Suspended Solids (7'SS) Ivlodcl b~ ` elide rum tvianutacturer ~r,.1. alldti ft pa Model Monthly Average" Pretreatment Unit ` 30 mglL f f-7 Sand/Gravel Filter d Mechanical Aeration S 224 mg/L "~ D laisittfection ~ ~4n.,....: ,/' Manufacturer.. Prctrcated Effluent lily ~] MonthlyAverag Biochenvca? oxygen d ($dDs} ~ 30 mg/Z. Total Suspen 'ds (TSS} Fecal Cotifa gcametr !man) ~ 34 mg/I,, 14'cfu/l OOmI Maximum Ffllucnt particle Size 1/$ inch diatsret 'Wastewater Flow Verification an and calculatiocts: (other than bedroorrt based) " Values typical for domestic (nan~cornmercial wastewater and sep[rc tartk effluent, '"'Valves t teal for rt:treatcd wastewater. l~In-ground (gravity} ^ At-grade tz~ ~ Q~a~~ a1t<--~ 4 ~"~ LRt, ~ w CMS see trF ~ ICJ 006 Page ~ of _ gdr a NA p NA i tx [} ?~„ awl pNA ~^ NA ~G [J ryA ~ ^ NA_ Ct NA at Filter ctland d Q In-ground {pressurized) O Mound m Leaching CFtamber Manufacturer •. .~ .k Model ~"'"~` ~ APProvai 5tipula[ian Soil Application Rateo.Stf gpolftt Arca Req. }~ iron a Absorption Area Credit per unit ft~ Minimum Number of Chambers ~ 4 Q A e ate Desi Flow2aa tee ~- nun Materials: al! materials must comply with W3 Adm. Cade COMM84 and be installed per manufaenrrers speeif'icattarls and ap rQoval letters. /' ~, W ~sconsin at-grade Sail Absorption System, Siting, Design & Constnretran Metros!" (Converse et.a1.1994} ^ "W iscansin Mound Sai! Absorption System: Siting,. Design & Cansiruction Manual" Cattvcrse, 7.C. and E.l. Tyler. Publication IS,2Z ^ "Design of Pressure Distribution Networks for Septic. Tattle-Soil Absorption Systems" Publications 9.6 p "Design of Canventiorral Soi} Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 atttl "Design Manual - CJnsite Wastewater 1'riatmerrt and Disposal Systems". EPA 62511-80-412 dctaber 1984 d SBD - 1 t)57t~-p (tt.6199) "At-Grade Carr~ontnt Manua! Using Pressure Distribution" l~SBD , 14567-P (R-6f99} "trt Ground Absorption Gotnpanent Manual" D SBD - t0705-P {N.tllf4l) "In Graturd Soil Absorption Cortrponent Manual" Version 2.Q D SBD - 14G2$-p (N.6199} `'Recirculating Sand Filter Sysum Component Manual" (~ SBD ~ t465t~P (N_6199} "Split Sad Recirculating Sand Filter System Component Manual" Q 513D - 14S72~Q (R_t5/99) "Mound Component Manual" ^ S8D • 1t}fi41-P (t~t,41/t]I)'*Maund Component Manua}" Version 2.0 D SBp - 14595-P {R,6/99} "Single Pass Sand Filter Component Manual" ^ SBD - 14557-P (R.b/99) "Drip-tirn Zffluent Dispose! Component Manual" ^ SSb - 10573-F {R 6!99} "P~sa[rrc DlstribuHarr Compor[e:nt Manual„ D S>3D • 1470b-P (N.Olipl) "Fttssure Distribution Component Manual" Version 2.0 p Drip-line 8ffluent llispersal Gorrtponerti Manual for Multi-flo Onsite Wastewater Treatment Units D t~ . ~_..-,_~-- ---~ - -- MAINTENANCE MONIxpRI1YG SC~TEDULE --- ~.- V .~.~ ..*•-•"~v~j•;~~~1 Service Event Ins ecr condition of tank s At least price eve Service Fre uenc Pum out contents of to s ` ^ months When combined stud a and scum c uals anc thi d ca s Maxtmurri } s.1 V3 ens rct dl s real colts At least once eve - r of t ank volume +~ C'tcart effluent titter At Icast once the / / ~ mend's ~ yc~~) (Maxunum 3 yes 1 !ns ecr um , nm controls 8c alarm . At least. ome ev ~ ~ months ^ mpACbB d Year(s) ' filush laterals and ressUrc test At least once e D months p ~ s d NA Valves Other. At lass! once eve Q ttionths b ar s ears NA ~ NA At least once eve ^ months ^ ear s ~' ?rt-a Q5l10/2Q05 06:05 FA% 715 233 0398 Certified Soil Testing ~ Eau Gallo (~jt}07 .. .. ...~ . -~--- page ~ o[ ~ 1'or new construction, prior to,uae of the POWTS check tt~tatrttent tasilc(s) far the presence of painting products or odter chemicals chat may impede the treatment process aadJor damage the dispersal cell(s). if high concentrations arc detected have the contents of the tanks? removed by'a septage servicing apcratot' prior to use. ~' . Systcrrt start up shall iKtf occur w}sezi ~i2 conditions are fioketi~at the infiitFative surface. / The property Cwrrer is responsfble~ for the apt~sdofl' atl"d'rstiiittetta»ce of tlio~PpWTS tiriC~-sutitttission of required reports. The quantity ,and quality of tilt wastewater stream will affat;t~the ptrfbr>zi$rtCe~am) larigei+ity ot'your P4'IiVTS. The instaitadort of water~savtng appliances and fixtcues along with prorrtpt repair oi` tasks reduces the wastewater volume. Ajso the brine ar waste from. water softeners, 'trap removal units, other clear water trgattnent devices and fourtdadott drains s'tiotild be discharged to the ground surface whenever possible. Note: this does not include lattndiy waste;'showers, dishwater, etc., This system is designed to handle domestic strength wastewater, however the disposal of food based greases and ails, vegetablelfruct peels and seeds, bones, and food solids such as ihos~ produced by a garbage dispoaaJ should be minimized. Toilet tissue rs the only pspfr that should be discharged into the system, ether non-biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs should trot enter the aystttn. Chemieats such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not bt fltis}~d into the system as they can striausly damage your POWTS and contattunate your drinking water supply. ,,,~ Maintain a regular study flow by spreading taundrpc tMashing throughout the week. Avoid vthiete traffic aver all system campanents. Compaction of snow over the dislursal unit may cause it to &eeat up. ! - ^ Valves Valves shall be operated in the fallowing ~Alarrns ~ Alarms should be tested on a regular basis by the home owner, If an sierra sounds, contact an individual licensed to setvrct POWTS, There is normally a 1 day reserve under regular operating conditions, however water should bt conserved until any ~ problems with the systcrn~ arc corrected to prtvtnf back-tip of sewage into-the dwelling ar surfacing. , [nspet:tian shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, tvlaster Flumber Restricted Sewer, POWTS Maintainer of Septage Servicing Operator {per the attached Maintenance Schedule}- optic Tardcs Campancnt U Tank i»spectians must includr m visual inspection of the tank to identrfy any missing or broken hardware, idtntify any cracks or leaks, measure the volume of combined sludge acid scum and to check for any baektip ar surfacing of cfftuem . Access openings used for serviet or assessment shall be sealed and/or lacked upon completion of service. Any defects shall be promptly corrected. Exposed opersings greater th,sa $ inches in diameter sixall be secured with an cffcctivc locking device to prevent accidental or unautharizcsd entry into the tarok. ~ , . When the combination of sludge and scum in any tank exceeds one-thud (1l3} or more of tht tank volume, the entire cantrncs of the tank shall be rerrxtved by a Stptage Servicing Operator and disposed of in accordance with chapter iVitl 13, Wiscans~n Administrative Code. The cutlet filter(s) shalt be inspeettd and cleaned to remove any sccumulated solids according. to manufacturer's speciftcatians. Provisions art to tat made to retain solids in the tank. Filter cleaning rlsay be necessary at more frequent intervals than stated in the maintenance schedule to keep lira system operating. Pump ChambertTnatment Tanks Compancnt The irfspcctipn must include s test of alt electrical equipment such as putr~rs, alarms and floats. a visual check must be rrtade for leaks, bat:kups, stufacitig;'fnissing or 6iro!'Cen scturity devices and ether hardware and the condition of fire fi}tcr Any service needs ar repairs shalt be,promptly taken cars of. t)5/iQ/20G5 QB:OB FAX 715 233 0398 Certified Soii Testin8 ~ Eatt Gape f~jODB ' Y ra e ~ or ~ ~ln-Ground Gravity Ct7rttpatte#tt Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation tubes and. a visual inspection for any evidence of surface seepage ar discharge. Any discharge to the grvutul surface must bt promptly reported to the regulatory authority. Ponding a[ depths greater than 75Y4 of the height of the component may indicate overloading or impending hydraulic failure necessitating tt'-ore fregytnf monitoring. G] Mound, At-Grade, In-Ground Pressure The inspection shall include recording the vela afponding, if any i observation tubas and a visual inspection fur any evidence of surface seepage or discharge. An "scharge to the. d surface must be promptly reported to the regulatory authvriry. Ponding greater than 75%0 of the bright the ca Went may indicate overloading or impending hydraulic failure necessitating mare frequent monitoring. The prtssure distt7butidtt system is provided with apenin t the end of each lateral to ba used fen flushing. The laterals should be flttshcd at least ones every three (3) _ Pressure c ks of systems with multiple laterals should be done to ensure that equal distribution of effluent is earring to promote the longevity of the system. Reports far maintenance, inspection, and monitoring shad be submitted in accordance whit C014tI41$3.55 Wisconsin Adrrdnistrative Code. When the PQWTS fails andtar is permanently taken out of service the following steps shall be taken to ensure that the system is Rroperfy and safely abandoned in compliance with Ch. COMM 53.33, Wiscor~cin Administrative Code. . AIt piping to tanks and pits shall bt disconnected and the abandoned pipe openings scaled. ""~ - The contents of al! tanks and pits shall be removed and properly disposed of by a Septagt Servicing Operator. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space Flled with soil, gravel or other inert solid material, CONTIIVGEIVCY PLAN 1 f the PQWTS Faits and cannot be repaired the following measures have been, or must be taken, to provide a Cade compliant replacement system: *~' A suitable replacetrsent arcs has been evaluated and may 6t utilized fbr the Location of a replaccrnertt sail absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by rrquired setbacks from existing and proposed structure, lot lima and wells. Failure to protect the replacement area will result in the need far a new soil from existing and proposed structure, lot lines. and wells. Failure to protect the replacement area vnll result in the need for a new sail and sits cvaluaticm to establish a suitable replacement area. Replacement systems must comply with the rules in eE~'ect at that tithe, O A suitable rep}acement area is hat available due to setback and/or sail limitations. Barring advances in POWTS technology a holding tank maybe installed as a Last resort to rcptace the failed PC}WTS. ^ The site has not been evaluated to identify a suitable replacement arts. Upon failure of the Pt7WT$ a soil and site cvaluatipr! must be performed to locate a suitable replacement area. Ifno replacement area is available a balding tank tray be installed as a last rtsart to replace the #'ailed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place fallowing rerl7ovat of the biamat at the i~ltrative surface. Reconstructions of such systetrB must comply with the rules in effect at that time. ~t W ARNING>3 SFsPTIC, PUMP AND QTIII3R TREA?MENT TANKS MAY GDNTAIN LETHAL, GASES ANDlQR INSU)F2rICIEIYT OXYC1gN. DO NQT EiVTER A SEPTIC, PUMP OR EYl YYE>l;'I'REAT1VfEN'T TA~tK UIr(QER A~IX CIRCUMS7APlC~S. DEATT~ MR,X RESULT. RESCUE OF A PERSON p'ROM THE. INTERIOR OF A TANK MAY BE DIFEYCtJLT OR IMPOSSIHI.E. ADl)ITIOIVAI„ CQMMEIVTS POW'r5 INSTALLER PD'WT5 MALI~ITAINER Name *.R'L L .r.. Fs•.. ~ ..,~ r Name Phone ~5'• Z$S• SiSr~ ~ Phant $EpTAG)v SERVICING OPERATUR Pu r I,.t)C'AL REGULATORY AUTHORITY Name A one t.Jrra:S, C.o... ~++..: ' Phone Phase ~~~' Ji~'tt+ •4r.~a ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ y~ ~-- ~ ~ s~ t3 iZt,,~,•~/ Mailing Address Property Address ~~ 1 y ~~ti ~.~ Pc,~•~c:,TFf S S~4r `7g`1 ~~- M.V (Verification required from Planning Department for new wnstruction.) City/State t.lgv-,ti~„ri~? w] Parcel Identification Number LEGAL DESCRIPTION Property Location ~y+,J '/a , N ~ `/a ,Sec. 3(~ , T Z `l N R I ~ (V~Town of HA•~•~,, G,vp Subdivision ~ME~~o AcfLES lsT A~n~r~c,-v ,Lot# ~7. Certified Survey Map # ,Volume ,Page # Warranty Deed # ~`~~ ~ ~ 5 ,Volume Z~_, Page # 3 ~~ Spec house ^ yes ^ no Lot lines identifiable ^ yes ^ no SYSTEM MAINTENANCE U" ~ c~,~ ~ 7g z $~S 1 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 County Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, 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 Department within 3 days of the three year expiration date. ~~.~ o o ~ ~- 5 ,~, , SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT vS / I(/ oT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** y~ s Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. 794 1 95 l~ U; 2't97 P 310 STATE BAR OF WISCONSIN FORM 2- 2000 WARRANTY DEED THIS DEED, made between Kernon J. Bast, a married person and Richard O. Stout, a married person, tenants in common, Grantor, and David E. Brown and Lisa M. Brown, husband and wife, as Survivorship Marital Property, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: Lot 67 Emerald Acres I51 Addition, St. Croix County, Wisconsin. Recording Area KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO. , WI RECEIVED FOR RECORD 05/05/2005 10:S0AK WARRANTY DEED EXEMPT ~ REC FEE: 11.00 TRANS FEE: 179.70 COPY FEE: CG FEE: PAGES: 1 Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Richard~t B * Robert S e A e in Fact for Richard O. Stout of ~- Zol i'- 6~-oao Parce( Identification Number (PIN) This is not homestead property. 2'~ c~s~ AUTHENTICATION Signature(s) authenticated this TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Peterson, Fram & Bergman -Steven H. Brtuts 50 East Fifth Street, St. Paul, MN 55101 (Signatures may be authenticated or aclrnowledged. Both are not necessary.) •Names of persons signing in any capacity must be typed or printed below their signature to and Retum Address: is Realty Ti c. S. 2nd 5 -Suite 115 son 154016 _ ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this ~ .~ day of fyl ~ 0 DS the above named Kernon J. Bast, married person and Robert Speer, Attorney in Fact for Richard O. Stout, a married person to me lrnown to be the person(s) who executed the foregoing instrument and ac ledged the same. G. w *Pamela A. Willman Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: 2/25/2007 WARRANTY DEED STATE BAR OF WISCONSIN Pamela A. Willman Notary Public State of Wisconsin FORM No.2-21100 Parcel #: 0~~-2U11-67-~~0 05/13/2005 09:33 AM PAGE10F1 Alt. Parcel #: 30.29.17.1082 018 -TOWN OF HAMMOND Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 12/17/2004 00 0 Tax Address: Owner(s): * =Current Owner * BAST, KERNON J KERNON J BAST STOUT RICHARD O STOUT RICHARD O 948 LABARGE RD HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description * 789 157TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.020 Plat: 10/42-EMERALD ACRES 1ST 018/04 LOTS 36/86 SEC 30 T29N R17W PT NW NE BEING EMERALD Block/Condo Bldg: LOT 67 ' ACRES 1ST ( 04) LOT 67 (2.02AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 30-29N-17W NW NE Notes: Parcel History: Date Doc # Vol/Page Type 12/17/2004 782881 10/42 PLAT 06/16/2004 766092 2597/300 WD ~nn~ ci innnneQV Bill #: Fair Market Value: Assessed with: 0 Valuations: Description Class Totals for 2005: General Property Woodland Acres 0.000 0.000 Land Improve 0 0 0 Last Changed: 03/25/2005 Total State Reason 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ~ o M ~ 0> ti a w C h O O N b O d ~D w O4i '~ 3 ~pp t •~ N }~ v .~ •~ O `~ n W Z ~ v Z rn M ~ Z II c t9 .• o Z ~ ~ ~ N H r ti a Q m w~ m a to J V L' r o 0 ~ O O ~ r ~ N O r, o H ~ '~ ~ C W ~ ~ ~ O ~ ~ ry N t ~ ~ ~ O M S CO ..fir RS at ~ m .1p ~ ~ a a m '~ ~ ,r ~ ~ c Ac°~ a ~ 'CS C 7 LL 3 v a~ Z O L a m v c 0 N N ~ C L y U ~ m ~ c a ~ U tq Z J Z H ~ .. R ~ y d i D O a ~ N N f~ H ~~~a~ o ~ ~ N ! = M N ~ w O L ~ d f0 N 1~p ~ ~ W C i ~ I ~> i ~ m 3 ~ m ~ o i .~ d m a a ~ ~~~, c O N U °o O ~ NI C N N O Z td O :6 Q y C Q1 N .~ N r 0 ~ 7 ~ ~ ~_ 'a = O Z .-~ ~ ~ [0 C Q Z !n C O d y ~ '~O Z ~ Z ~~ ~~ ~~ ,a f .. _ ~ Wi~consinDep®rtmenloiCommerce SOIL EVALUATION REPORT paye_ ~ ~ 3 Ulvisiort of Safety snd Bulkf'nr s c® in a rdarrce wiUr Conran 85, Wis. Arlrn. Cute ('~~`v 6 Cour-ly ~ Altadr con le sR~n~7n paper rrot toss U- 0 1/2 x 11 nr s h- size. Plan muRt ~ ~ ~ indude, hid llmlted to: vertigl an' ~~izonta reference p r ), direcibn and Perael LU. percent ~rup scale or i er s,~~irarruw, nd locatl e W nearest road. D~8'~~1~ -- ~~ ~~ v _~ O~~[e(~pQf~(~a'[/ ill 11118[!0//. ~ O R revue Uale Peraonel Inform lion yov v~iV U~Jor eec ary purposos (Privacy , n. A r (m)-. ~ y ~ (~ Properly Owner ZQ Pr ocalfon GuvL Lul _~U,,j 1/~ 1V ~111_S 3D 1' 2.~I N Il ~ 1 E (or~l Property Owner's MailingAddress Lvt # Block # Sulxl. Name a CSMfF 13~ ~ukee tr . (,~1 J~[d ~cr~5 I ~ ~rL City Sate Zip Carle Phone Number [J City ^ Villaye ~1own Nearest Road 1--~ ucd t~l ~ i 1~5 ~-~I - ~~3 ,mom ~', . Rd. c T ~Rew Construdiar Use:~Ftesidenl'ral /Number of bedrooms _~ ~ Code derived desiyn Iluw rate __~. ~2_ LO .~___ GPD Replacement ~ ^ Public or cormnercial -Describe: ____ _ ____ ____ _ Parent rneleriai ~~___ __________ Flood Plain elevation if apfrlic;able __ ~ ___ __~_~}~_~ ,_ R. ~ General cornrnerrts / - ., ~ ~~ ~~~[~[/ ~~sr ~ ~ 2,~ 2. V ` ~ll~fiCi~ ~~~ (J arrd recornmendeliorrs: Borlnp # ~ Bunny --II ~Plt Ground swface elev. _________ ft. Uepllr Iv Ilnriliny factor ___tO____ In. - _ _ _ __ Soil A lir;alion Rate Horizon Uepyr Uon-inant Color Redox Uescriplion Texture Shucture Consistence Boundary Rrxds GPUfit' _ hr. Munsell Qu. Sz. Coral. Cobr Gr. Sz. Sh. •Eff#i 'Eftg2 ~ I t© 312 -- si [ 2m~bk ,~ __ cs - _ Iv.~ .5 •~ 2 12 - Zlo y- ~y ~T~fi'V~T _ S ~- 2 m5bk ~ ~ S - . (Q 1. d 3 2to~10 10 ~I -" s s _ rn( c~_ r 1~ 2 D Boring ~ Uy ~ `" 2 Boring # ®--pit Ground surface elev. _ ft. Depth b limiting factor _~(~_ in. Sob Application Rate Horizon Ueptlr Uaninarri Color Redpx Description Texture Slruduie Consistence Boundary Roots ~ GP DIftT irr. Munsell Qu. Sz. (:ord. Cobr Gr. Sz. Slr. 'Eff#1 'Eff#2 Z 12~ ~ ~~~ ~_ Zm b k r~-~'r- c.~_ - ~v ~ . o 3 3~-`~~ I r~ S ~ -- - -7 1.2 - crrnrern a r = nvv ~ ~u ~ zzu nrgn_ afro r ~ t1;-tF~= • ERluerrt N2 = BUU < 3U my/L ar-d TSS < 3U mylL CST Narne (Please Prk-t) Siyn CST Number _ ~___ _ x..53 3~ Address Uale Evaluation Conducted -telephone Number ' '~~ ~ ~d '`e ,~ hG ~2 . ~~ ( II' Properly Owner ~ ___ Parcel ID tl _L~( `~ Page __~ of _~ ~~ f~~------ U Boring ~ r ~ - "~ . ~_-~'"-'~s Babrg # -pit Ground surface ele it. s,6aepUrto dnriling:~actur . Horizon Deptlr Dominant Color Redox Description Texlu~.e~ Slrudure Consistence in. Mansell Qu. Sz. Carl Cobr _ (3c Sz. Sh. 1 in- Sod A icaUon Rale Bvundary Roots GPDIfP 'Eillit 'Elf#2 i Z 12-~ ~ - - S L ~o1~r' ~ -` _~_ 1. d f ~ L-J Boring # ^ Boring ^ pii Ground surface elev. it. Depth to IimiGny factor __ irr• Soll A lica8on Rate Fl i th De Dominant Cvior Redox Description Texture Slrudure Consistence Boundary Roofs GPDIfF or zorr p In. Mansell Qu. Sz. CorrL Cobr Gr. Sz. Slr.. 'Elf#1 'ER#2 Boring Boring # Ground surface elev. ____ il. Depth to limitiny (actor ___.__.___ in. - ^ Pit _ Sori n licalion Rale Horizon tlr Oe Dominant Color Redox Despiptbn Texture Slrudure Consislenr~ Boundary Rrwts GP D/tF p in. Mansell Qu. Sz. Cont. Cobr Gr. Sz St-. 'Elf#t •Eff#2 'Effluent #1 = BODS> 30 < 220 mglL and TSS >3U < 150 rnylL ' E(Iluent #2 =BUDS < 30 my1L and TSS <_ 30 nrglL 'Cite Department of Commerce is an equal opportunity service provider and employer. If you aced assistance to access services or need material io an alternate fomrat, please contact tLe deparUnent at GU8-2GG-3151 ur "1"1'Y GUS-2G4-8777. ti sao-auo re.oNVOr ,~ . f'AGG J_OI~~ _~ ( - t cill.l)t.Sc~-ttl'i'Ic)r~,:QW-~~t,Ut=_t~~t,s~~1~Zq.l`,,It,)~f:(t~r~ NA1VtL: ~ vT---_LU['11 ~.~-- '' SCALE: I' _ ~O -------- _ ----- - --- O ---- ---- .... _,.,„ ,.; ,, ... f~ wv.\CLLVA'I'ION: l~~ ~~~• ~~ - .:. 4 1 ~~ Dht t DGSCItl1'~I~IOhI:~_~~__pJ~L_.~s~~ __ 1 DM 2)/LL'•VA'iluN: _ -_~ ~~._~ ~ .._____ __ -__ _---~ce~__3_d. _._. ---- y-- .:.- DM 2 DL•SCltll' 1't(~~I: ~~_~ ~-_ ~-~~_w_.c-_~~'~ 2.__ ~' o ,:: . SY5'rLivtLLLVn~rr~,r,:____9°~•S. __-__-__ ._ . _ SYS'I'L•Nt'1'ti'l'li: ~'c>nUe•~1~~:~,naa.~ -. __ _ . _. 3 3, -~ SIGNA'i'UIZL;: ~. ~.. '" ~ L .... g~ c b4~'~i~ 1 ~ : 1ka UW-8 t UU [ ~ ~RU I (:E eEPITER ~ 817152834861 ~ ~'. -,~ ~, -. ~.,. , '~ ~. ~+ ~ - .~ .; ~_ ~ ~` '`~....rr . ~~ ~ ~ ~ ,. '•._ ~ ~ • _ -, ~ . _ I IL~6~~~~'Q'IIW 1~~~~ 1 ~l a ~.. v- ~'~ t.~.._ ~ . I.Il~ GF ,~nnyr! R OF 1-~ ~ ItR, ,~~' 1y ~~ ~ ~~ ~~ G A `~' ~ ~~ ., , ~ ~ ~ ~~ `~ Z 3 .Z ~ ~ ~- ~ ~~ ~,~ ~., n N0.319 9~2 r