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HomeMy WebLinkAbout040-1152-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578902 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Fraser, John Dufrene I Troy, Town of 040-1152-90-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: '76 9 - L C-15( 23.28.20.596,597,P598A TANK INFORMATION fi ELENATION DATA TYPE MANUFACTURER CAPACIT STATION BS HI FS ELEV. i Septic Z�+ c, Benchmark 7.�+L -7/`-.J —16c.`3 pose I Alt.BM /;�� / � •,f re I (r Cie "t • 3 Aeration Bldg.Sewer �0 Holding St/Ht Inlet /e`7 45 -7.d •9 TANK SETBACK INFORMATION St/Ht Outlet �(J y 7DS• $ TANK TO P/L WELL BLDG. Vent t Air I take ROAD Dt Inlet Septic G „7/6a (40 ,4Z Dt Bottom Dosing D Header/Man. Aeration Dist. Pipe 765 7 Holding Bot.System //•4 3 764 • •g I Final Grade PUMP/SIPHON INFORMATION •`>f 7 Manufacturer Demand St Cover,, GPM �� I C/� li►-- %A/476T-3 Model Number r7k� Friction Loss System He TDH Ft Forcemain Le Dia. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trend PIT DIMENSIONS No.O its Inside Di . Liquid Depth DIMENSIONS ? 3 �J �e SETBACK SYSTEM TO V P/L •BLDG WELL LAKE/STREAM LEACHING Manufacturer: c INFORMATION CHAMBER OR Type oOf^ys�tQem J `/66 / UNIT Model Number: DISTRIBUTION SYSTEM 4 4, Il / Header/Man�iffold/ Distribution x Hole Size x Hole Spacing Vent to Air Intake I Pipgs)� � 9� o�O'J Length Dia Length Dia Spacin SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ,j Depth Over Depth Over xx Dep�of xx Seeded/Sodded xx Mulched Bed/Trench Center f BedlTrench Edges Topsoil \� Yes No Yes [� No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 164 Cove Ct.(Ca fisp Bar)Huds n,WI 54016(Gov't Lot 2 23 T28N R20W) St.Croi)Bea t 11&12 Parcel No: 23.28.20.596,597, t 1.)Alt BM Description= ` ' � Gee (C�Jt 2.)Bldg sewer length= (-amount of cover r Plan revision Required? � Yes No Use other side for additional information. Date Insepct Cert.No. SBD-6710(R.3/97) a County JT . Cr 0 1 e ,., Safety and Bul di t sion Be 01 W s' .45 Box 7162 Sanitary Permit Number(to be filled in by Co.) .iv ``. P I 1. 0 707-7162 �" 57Ts90 Bonita it A ©uNTY State Transaction Number L 1 pp In accordance with SPS 383.21(2),Wis. ode,submissiogp��fq lbylei naFetgental unit is required prior to obtaining a sanitary pe Note:Applicati s Tor state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ``�� L purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. (i`I Co o e. C. • l 1414 scti 1 kit I. Application Information-Pie Print All Information 1 ` Property Owner's Name Parcel# 046• 1/5Z• 96- >C Soh/1 Fra-5ex- 23. 2.4(3. Zo . s q( —s 9 8)A Property Owner's Mailing Address Property Location y©1 kkerfr t.0 00a, 'D'r. 4 -` '/� Govt.Lot 1 City,State ` ' 1' , , Zip Code hone Number Y< 23 CICCkr) \L� i ■ 1 ' S5gl ai4 1 10-001,8 /a( icleion `� (circle on _6 T Z13 N; R 2.6 E 0 W II.Type of Building(check all that apply) Lot# g1 or 2 Family Dwelling-Number of Bedroo / /i 4- ' Z„ Subdivision Name l jr_ Block 5}- Up: V PBD. . ❑Public/Commercial-Describe Use ee,aea Wt e �_ ❑City of ? I CSM Number ❑Village of ❑State Owned-Describe U�^se(n� 3�J' �-O+� p� 2, 0`,. - ( 4J2Q- w E� riot..) 1 LJ Town of ?irOl1. III.Type of Permit: (Check only on box on line A. Complete line B if applicable) 9 A. ❑New S y stem Replacement System ❑Treatment/Holdin g Tank Re p lacement Only CI Other Modification to Existin g System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner I� /'' � f � � �� IV.Type of POWTS System/Component/Device: (Check all that apply) 7 (G POw t R 0 Iat Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device V.Dispersal/Treat ent Area Information: Design Flow(gpd) Design Soil Application Rate(ysf) Dispersal Area Required(st) / Dispersal Area Propose st) System Elevation Treoat� ,q 701.0 t /56 .6 /2�`n ✓ 3 b-o Trent A"2 7e4 o' VI.Tank Info Capacity in Total #of Manufacturer Y Gallons Gallons Units .n U ,b, 0 New Tanks Existing Tanks `� o ,; E i w lalt=. S2 I /a U n v 2,6 R Septic or Holding Tank 7z) 75-0 ' 43�!' .s C-C) . N .�esiersiatnmr-- 7 VII.Responsibility Statement-I,the undersigned me responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) P ember' ig ature MP/MPRS Number Business Phone Number cz Sktf lc«/a (I A--- ' ----. 22s y S I (-715)(f a5 -5S 9 Plumber's Address(Street,City,State,Zip Code) 00.82-30 94544^ Slveek ,gwe r 'e s t LI 51OZ2. VII ounty/Department Use Only / / Approved . Disapproved Permit Fee Date Issue Issuing •: nt Signatur- ! -- teen Reason for Denial $ 1175 5 . Si 17 /5 ' • IX.Condit Q easons for Disapproval w� nM< Sep' tank,effluent filter and 3 �'rt '/0 •.s dispersal cell must all be services/maintained /1 as per management plan provided by plumber. G Ce.42a. 2 7Attsetbeck req�1'ements must be maintained �1` f f r II �+ as per code 7 ordinances. -i'1 0.5 t— JM4.utA�T'av\A 1 2_ 61r e6)e-4 O1) . Attach to complete plans for the system and submi to the County only on paper not less thaR 8 1/2X 11 inches in size EZ /aL..> r.-4--5 . SBD-6398(R. 11/11) 0 in Li M 1- 1 Q r T- W`b P I"' Lo .J cog W aix ee W < O O O 3 0 0 I--le u) N u w `` 2 Z / W / WO W00Z O LL W V C • V ~� W NOUN Jm Z W 05 0/ Z I 2� Oz N�1?i-�j o W N J 0 I X t b E2a S Q ul H U lis � z Z � ' 1 � i Cl) 0 W 0 • C LIQ ° 1 01 I ! E co u CO CO c d� cc x V 0 C.) V L till • CI -_II— Ql * :L i- 12. 9, "6 o III C H L p (0310na1SNO0 1ON) *I U. '- Ili Ot Ni-I OVO?I XIOd31NI VS 1- -) • W — — — _ ,sa •oc •oc a z I r I = I N I W I U `_ 1 N �>CV m � � c, i o2,G- — — — — — —_� OL — • Q_-___- CL.o,i,� I 1 - _----_ -------__-- — —__ _sue------ ozc I �J v 1 U _ --- a=== __= CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: LI do LA. Fre4,0e.r' Owner's Address: 174 Coo c,. c 4-- Legal Description: _ Z 3. z.g. ZO• 5-9(4, — 59?!- Township: r County: Sd', o Subdivision Name: Lot Number: 11 d"' !Z Parcel ID Number: 016 • /15z . 9O Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan. Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test& House Plans C Designer/Plumber: Pa,..1( V hC License Number: ZZ.54 5 1 Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 SOIL ABSORPTION SYSTEM DETAIL/GRAVELLESS LEACHING UNIT Page of Project Name: J(,h n Pta s e cQ No.of Cells 3.5 Per Cell �J 3 ft Cell Width Total No of / 3 ,S' ft Cell Length 6 0 sq ft EISA Per Cell (p ft Cell Spacing J y b sq ft Total EISA Mana Model Laying Length EISA Rating Infiltrator 120 5.0' 25.0 EZ1203H-10ft 0.0' 50.0 \, Gravelless Leaching Unit Manufacturer: L 2 fJa03 Gravelless Leaching Unit Model: Typical Cross Section Finished Grade if _ Observation Pipe with approved cap or vent ■ :. n *:::;: :: >':•: :>:> :.a ::':.:.. Soil Backfill ■ ;. . .:.: / -e.GeA !!%e Fabric ^ Infiltrative Su •ce ca.. ft In 12 in 70a i �d - v tp, Limiting Factor in Slotted and Anchored Vent/ v Observation Pipe with Cap ip () ( I _, Plumber/Designer Signature: .,- 1 License#: 012 c L/6-1 Date:` 3/02,6//c.7 Wtrn_�I o f i∎o/siv•■imo∎, O a ••, ----IIMM CO z w 0 o - -I � a_ W . ■S Ilililli= Q N _ N W Cn �.0 m Z O M �I � i� , < ,..5 E � Z Z Z O Q O Q 0 W O a a ..! ����� M�� rrir. ii n 1 1 1 MIn=1■111,OM■3 M U O U e- CO W co u Cu ^ W O U co U J U O O Ch Cr N— cci N u Arr„--.1ww,-- r,,,-‘ hir) i \\,,_46111&‘_,4 \-,' • 1 I 1 I I 1 / P _ . Lq U N u / \_,\ dil .)11 Z � ��W \ 17-Th ..4- ci U O X zco O = «s -- _ W ift O i z W a _= Z W C/) J -..x >-- 0 co O 04 c CL . Ll wz W N a 0 ' Zw _, �- ° O = o Le2cect�I 1111111111111.111 Q > m � "'c.90 .., . / 01■--- _.,,r,,,, .,,,_. ,:,,i.______ II \ ,,,, . , ,___"..,,_,:,, ,.,„ .„ „, . _ . 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F ra .cr Septic Tank Capacity 750 gal ❑ NA Permit# Septic Tank Manufacturer 4 lo-nuesco ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer fl /y lack ❑ NA Number of Bedrooms / ❑ NA Effluent Filter Model 525. ❑ NA Number of Public Facility Units 1:) NA Pump Tank Capacity gal IgNA Estimated flow (average) /00 gal/day Pump Tank Manufacturer A NA Design flow (peak), (Estimated x 1.5) 5-b gal/day Pump Manufacturer %NA Soil Application Rate o (� gal/day/ft2 Pump Model ANA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit P-NA Fats, Oil &Grease (FOG) 5530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) 530 mg/L XIn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size /8 in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event I - Service Frequency Inspect condition of tank(s) At least once every: .3 ❑ month(s) A yearls) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (/3) of tank volume ❑ NA Inspect dispersal cell(s) ❑ month(s) 01 s) At least once every: 3 o year(g) (Maximum 3 years) ❑ NA ❑ month(s) Clean effluent filter At least once every: /a / ❑ year(s) ❑ NA ❑ month(s) Inspect pump, pump controls & alarm At least once every: ❑ year(s) ❑ month(s) J;iNA Flush laterals and pressure test At least once every: ❑ year(s) Other: ❑ month(s) NA At least once every: ❑ year(s) Other: lif 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 (1/3) 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 v START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system:- ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. be .. Fb ,,i� �t jsf-7 UC;rto k •. be'. - -- _ rira'dFT.T3�-e al -. ••�, �gD}-115 1'1�'h• ❑ 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 f� Name .-Bleu►-?✓` P/u. Name J/c//`I t°i' / a.xi of}Il Phone 7/5" — 55" L/ Phone WO"- 554"/ SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name D u n h S p h iE Name STC--eZ (_0(./Kil / Phone 7/ 2otJ/AJ� J��[ Phone — /S— 3Ei(v- �(OSD 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 E.-„ OWNERSHIP CERTIFICATION FORM John Fraser Owner/Buyer z 401 Westwood Drive South, Golden Valley, MN USA 1 Mailing Address l Property Address 7 r .2 ,,,, _ i (Verification required from Planning&Zoning Department for new construction.) i City/State ñ4d5oct, CO I Parcel Identification Number LEGAL DESCRIPTION r-- Property Location 'A 5 kl %Sec.-_ T oZS N R c C) W,Town of �r cy . - Subdivision Plat: p "f", 4 f. S I Cyr.t' 1 4._. Lot if 1i+,i0Z Certified Survey Map# , Volume , Page# Warranty Deed# (before 2007)Volume ,Page# . Spec houseDyeslio Lot lines identifiabieyesDno SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS.38332(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(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. l/we,the,undersigned-_have..read.the above requirements and.agree..to maintain the private sewage disposal system with-the.... _..._._._........._...........__.. standards set forth,herein,as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix County Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. 1/we am/are the owner(s)of the property described above,by virtue of a warranty deed recorded in Register of Deeds Office. N ber o ;rooms 4 6 15• j — .._ ....`_ / /_ SIGNATURE OF APPLICANTS) DATE ""•v information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department."" Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.04/12) Wisconsin Department oS,��I•, SOIL EVALUATION REPORT Page 1 of 3 ,,.., Division of Safety an. : 1 . ,� gr0 in accordance with Comm 85,Wis. Adm. Code County s� , Attach complete site pli pgper c e -∎: '81/2 x 11 inches in size.Plan must ty �"` . include,but not limited erti.«. . . ontal reference point(BM),direction and Parcel I.D. c� percent slope,scale or dim+•s° *.rth arrow,and location and distance to nearest road. CT Gi //5 2 J_) `(_.L_-6 , b�a a print all information. Reviewed b 1 Date / 1jPersonal information y�i�rovide may be used for secondary purposes( y Law,s.15.04(1)(m)). �----:'f�r t C��,.��ryvfa I /0/7 Property Owner Property Location JoA n Fr(Ltder Govt.Lot 1/4 1/4 S4,73 T 4,11 N R.4 ti 4 Property Owner's Mailing Address Lot# Block# Subd. Name or CSM# LUIS . vJe 4-w0( 0 Dr. ,ll `iz _ -I- G—o44 f City State Zip Code Phone Number 0 City ❑Village 0.Town Nearest Road Mi011. .., .vt1'rr MN 554 RO (7U- )qs t -- 37 r 5/ Ciq,1 :, / e y ❑ New Construction Use 'Residential/Number of bedrooms Code derived design flow rate 3 01) GPD Replacement ❑ Public or commercial-Describe: Parent material Flood Plain elevation if applicable ft. General comments • and recommendations '1 ( 5 t Yf t e Iv-? L,-`•e-e.0 3 /i, ^:'t�y, r'Y.� L f 6)A bi,'CLL JG=-1-62 Boring 7 �r,... ✓ / Boring# pit Ground surface elev. /64. r p ft. Depth to limiting factor#'-"' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 0 !a D R3 e s ' ! wen w 4 C /,0 02 -070 1€ r ,. M (9A 4t r 640 y t f , 4 / b 3 ,o-, 0: .'t IIIIP M P4- r e 4 , , / II 02Boring# Boring np Co .... ❑ Pit Ground surface elev.709,3 ft. Depth to limiting factory( q in. ( Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 *Eff#2 6 -/o lb Y2 3h, ,t1a« e s i t M sbk Ai r.re Cs.) 3,/ f r 06 1,0 42 /o-/9 kir ley si/ _�2 hlt cbk hofr c4._/ Iv I , .6 /. 0 3 /7-61 /O f R 0 s i i pZ ht 8),/, in it — (J /a 0 Effluent#1 =BOD5>30<220 mg/L and TSS>30<150 mg/L 'Efflue t# =BODE<30 mg/L and TSS<30 mg/L CST Name r ease Print) - Signatur: / / CST Number lc& ( C J Sle//1e _ j w «` "Sf Address D.S Evaluation Conducted Telephone Number N. 'e `1' 5 f A/vev fa lls , GU_T . 7/�=yl�=,f5'/q r • Property Owner e)hn Fra$e( Parcel ID# Page of CkBoring 3 Boring# /t „ ❑ Pit Ground surface elev. 71 0 ft. Depth to limiting fact e> 72 /in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fr in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 'Eff#2 1 0-sil. Jo }14/z . , r 5,'/ 02 A s C Alec' c.0 3i4 4 , !a 1 1 2 S -/7 AD Y/R 64 5 1 ,, Atsbk / o 'y CL Jvcf 4 4 6 3 /7-A /n ' 4 5/1 ..Z Ai 51* i r — — . A /.4 1 /o tit) ti4 I Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. 1 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. • *EMI` 'Eff#2 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 Effluent#1 =BODE>30<220 mg/L and TSS>30<150 mg/L `Effluent#2=BOD5<30 mg/L and TSS<30 mg/L The Department of p Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.07/00)