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HomeMy WebLinkAbout036-1096-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578942 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: Wallin, Steven I Stanton, Town of 036-1096-20-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: 0O 3 61 1 G5 1 31.31.17.580A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER q CAPACITY STATION BS HI FS ELEV. Septic W r �',.� 1I��o Benchmark 3 7� /O2• /�� 'L LIA. Z 1 �U J Btzsii Alt. BM 1... Po (b l.H, Co Z Aeration Bldg.Sewer Holding St/Ht Inlet 5.z 5-7- 5 TANK SETBACK INFORMATION St/Ht Outlet S• (p `f 7• S TANK TO /L, ( WELL BLDG. Len to Air Intake ROAD Dt Inlet �\ Septic � �/ ,� . ► Dt Bottom Dosing Header/Man. r •7 �4 Aeration Dist. Pipe .70 Holding Bot.System 7.70 S S PUMP/SIPHON INFORMATION Final Grade Z �f�d `1 �G�"�L Manufacturer Demand St Cover/'' ��� -Z-35 Jd a cJ GPM (r�{" Model Number TDH I ift Friction Loss System Hea TDH Ft Forcemain Len ia. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trend f PIT DIMENSIONS No.Of Pits Inside Dia. Liquid De th DIMENSIONS y Z fC �_ SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer: INFORMATION T Of S CHAMBER OR =; Type System' r UNIT Model Nu ber:� 56 LA Gam. DISTRIBUTION SYSTEM /7 ♦-/6 = 3 Header/Manifo Distribution ` x Hole Size x Hole Spacing Vent t'/fir Int ^ Q �j Pipe(s) /dT ( J Length O Dia —1 Length_ Dia Spacing 0 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges �� T 3.7 1 es � No Yes t No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 1897 142nd Street New Richmond,WI 54017(NE 1/4 NW 1/4 3 T31N R1 7W) Westview Lot 3 P cel No: 31.31.17.580A 1.)Alt BM Description= ' (.�t1tJ� �jY'J44A^. �� 2.)Bldg sewer length= VX I5�� 11 6 6 -amount of cover- Plan revision Required? 0 Yes o Use other side for additional information. 1 - Date Insepctor's ignature Cart.No. SBD-6710(R.3/97) CountyC d�� T RECEIVED Safety and Buildings Division J 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) , MAY 0 6 Z01 Madison,WI 53707-7162 I � '5 7' r Osior�et� STS.NCROIX COUN 0 SNIII eI11ll pplication State Transaction^Number accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit / v is required prior to obtaining a sanitary permit. Note:Application forms for 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 ' purpose s in accordance with the Privacy Law,s.15.04 1 (m),Stats. I. Application Information—Please Print All Information Property Owner's Name C t Parcel# S 036 a - oao Property Owner's Mailing Address C 7� Property Location �{ 9 s/ Govt.Lot City, Zip Code Phone Number /U tY, P lt-l'/<, /U LG('/<, Section Nor G S 71-5-- Go-d V/6" circle one) T�N; R Eor II.Type of Building(check all that apply) Lot# 1 or 2 Family Dwelling—Number of Bedrooms Subdivision N e Block# ❑Public/Commercial—Describe Use �Q� ��-��`� ❑ City of ❑State Owned—Describe Use CSM Number ❑ Village of `Town of III.Type of Permit: (Check onl one oox on une A. Complete line B if applicable) 2 OA.V-- ` A. ❑ New System Re lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner �l;( ei Z IV.Type of POWTS System/Component/Device: Check all that apply) Ile- . 'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank er Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis ersal/Tre ment Area Information: Design Flow(gpd) Design Soil Application Rate(gp Dispersal Area Required(sf) Dispersal Area Proposed(s System Elevation `T VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units New Tanks Existing Tanks o 52 aj L S Septic or Holding Tank Qe)O ---- Poo / Dosing Chamber VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. Plumber's Name(Print) Plumb Signatur MP/MPRS Number Business Phone Number Plumb 's Address(Street,City,State,Zip Code) c�c /3ii ''l'l.�"/� -mss VIII oun /De artment Use Only Approved ❑ prove Permit Fee�j Date s/ue Issuin gent Sign re even Reason for Denial $ 47 s �` /� IX.Condi**T4%&QWNE1JlWReasons for Disapproval 1. septic tank,efflulant fi ternnd' 3� dispersal cell must an 1 r mana meet Ian ro ' ed b lumber ss Pe ge P p Y.P. g. '�I !latc mu�t,q�itl�drtttinid ��� as pK node%crdiral►as. 1 Ott < 57,E �" Attach to complete plans for the system and sub it to the County only on pa er not less than 8 M z 11 inches in size f SBD-6398(R 11/11) )60 ' � r i yo 37 13� CAIV 13- 9cl, 7_5 V -1-b fi=t COPY CONVENTIONAL COMPONENT DESIGN Residential Application /INDEX AND TITLE PAGE Project Name: Owner's Name: dl r p Owner's Address: / 89 7 / Legal Description: _ j�l VJ - /U LAJ - S 3 / — T3/ — l7 L-( Township: County: _ ` Subdivision Name: j Lot Number. 3 Parcel ID Number. 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 Designer/Plumber. %� U7 U7'rfQ- e License Number. o?aa3S`� Date: s— —� Phone Number 76 � Signature ell /e�� ;ee-142— Designed pursuant to the In ound Soil Abso omponent Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 r N 1 N j � qo 32 13- � = T-a �t Soil Absorption System Cross Section 4°S0 Final Grade PV c Wi /� 5-(.ft Leaching --► Chamber /4ft System Elevation 3 ft ( ft Soil Absorptlon S stem Pian View ft 3 ft ft Vent Or Observation Pipe Leaching Trench 1 Chambers 4"Dia. Trench 2 Header Leaching Chamber Soeciftcations FEISARabng urer And Model r ( y sq ft per chamber Soil Ap plication Rate ' gpdfsq ft w T . :,P Soil YApplica'on Rate 16y3 EISA chambers 2 rows of chambers each. 17 Page Page of l µ. "J'" � �Ilr7 TT ti t f II 1111 e j f { } f E 7 4 t { I I k .+ u �:4�i3 �.i... :°�, .a4_ -��.� '�`�z,�.��` x��`. � ' d ��`a'�r,��,.�k"�;�a•,'`_�,.� ..�� �:a _a{krt:�.��+ 4 N M LO Cl) ce i V r- Q r13 m cci LO -- -- I o i --- ' zW CO x Cx = w w l3 J dZ W o � \�___ GO / Y LU ti l� U o d U X O m y - -LU ca -" o cn m , <D V5 LLJ C14 1 LO A Page -21 of y 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 tanks) 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. T aluat a o mg ank be ' a a�a FffzD4.�1-5 nSt1 . �i2-A/6L✓ afj57XClCTID� ❑ 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 2�/}e'o' Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name Name !St. CI?-U( (9U 2D/lllA� Phone Phone 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. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity /©pp gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model �� ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal NA Estimated flow (average) 300 gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) 11- 15-0 gal/day Pump Manufacturer ,�ff NA Soil Application Rate s gal/day/ft2 Pump Model .4K NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 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 A In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <_10' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y$ in dia. ❑ 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: 3 ❑ month(s) (Maximum 3 years) ❑ NA years) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA years) Clean effluent filter At least once every: f(month(s) ❑ NA 3 ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ year(s)month(s) J�`NA Other: At least once every: ❑ month(s) b{NA ❑ year(s) C_ 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<_12 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 Z of 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. The rita-has net bee.,-evaltmted to aluat a o ing�ank be ' e ai e . FffZD+�l15 T,✓� VD PC-A16oJ Co"5M(JCTI D ❑ 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 I POWTS INSTALLER POWTS MAINTAINER Name T Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name Name s-`-, Cf�b ( ou Phone Phone (S— 3 (�_ (0 s 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 Mailing Address Cam- �yd� Property Address S 2 7 (Verification required from Planning&Zoning Department for new construction.) City/State e Parcel Identification Number O 3 6 —/O %6 ` D — 8C5 LEGAL DESCRIPTION Property Location A)4a 1/4 ,�4 1/4 , Sec. , T 3 1 N R 7 W, Town of S Subdivision Plat: f1 -�-�` , Lot# —3 Certified Survey Map# , Volume , Page# Warranty Deed# �?0 70 /-/,3 (before 2007)Volume , Page# Spec house❑yespo Lot lines identifiableXes❑no 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.383.52(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. 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 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. Uwe certify that all statements on this fo are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a warran deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANTS) DATE ***Any 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) 1 x jw r 0 t t�acs •D 1 , t"s ,�4 '/'�► 1 � r Y� LO 0 CO --- i -J�mo 4> JL .4>"0 S-�cvc� Property Owner L)o Parcel ID# Page 0 of 131 Boring# F] Boring �n Pit Ground surface elev.�� ft. Depth to limiting factor /D D in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/F in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 0-13 �R3 a L, a €5 mFr a F A-31 -7 t5y2q L tl, 41 w `! 14 31-50 51014 S U .-S j- w -- 1 -7 J. 0 ooJa'4PLbl Boring# ❑ Boring r ❑ ❑ Pit Ground surface elev. ft. Depth to limiting factor in. 1—do7ii—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 I *Eff#2 Boring Boring# Ground surface elev. ft. Depth to limiting factor in. F] pit 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 I *Eff#2 Effluent#1 =BODS>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-8330(R.09/00) RECEIVED � MAY d 8 2015 � Wisconsin Department of Commerce §0 EVALUATION REPORT Page ST,CROIX COUNTY` Division of Safety and Buildings-OMMljW' c�A MT 85,Wis. Adm. Code County S Attach complete site plan on paper not less than 81/2 x 11 inches in size.Plan must include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. — a D ba O percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Revi ed by b r /D.. 6 Date Please print all information. All Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner Property Location 1 Ad0I f. r"i Govt.Lot W114NW 1/4 3 T I N R 1 -7 E( W Property Owner's Mailing Address abs Lot# Block# Subd. Name r CSM# Fad R-Sae bc. We5+ v-, e City State Zip de Phone Number ❑City ❑Village ,Town Nearest Road R a v(--c MD (*410'6 (615) )3Y)-lY7 S�' 't'p y� "d S'-F• GPD ❑ New Construction Use:5&Residential!Number of bedrooms _ Code derived design flow rate S p FA Replacement ❑ Public or commercial-Describe: Flood Plain elevation if applicable f{ Parent material General comments �{" .�"ry�y.�,k+ �� I" 'r 'r�' •s �� �� and recommendations: ❑ Boring p n Boring# 1 7.75 ft. Depth to limiting factor /00 in. Q Pit Ground surface elev. Soil A Iication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E GPD/f�Eff#2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. o- ID'IR3� L K Qu2 S/ L10 1 a " ► � y 3 _ -7 silt El Boring Boring# 99 Sb ft. Depth to limiting factor Od in. Pit 'Ground surface elev. P g Soil Applic ation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E GPD/ff ff#2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. o- )D JO r to 9-13 1 ipj as 3 13-35 ,5 0h -,Mf r W ` 16 'Effluent#1 =BOD >30<220 mg/L and TS < 50 mg/L Effluent✓#2�BOD <30 mg/L and TSS<30 mg1L CST Name (Please Print Signature ZT Number q6 cjiie�s C O h 5+� ate Evaluation Conducted Telephone Number `�� LJ-) 3- ar> 5 - 38 � ybi5 5 yak t,, -1 GvcctJ Property Owner Leo i 1 4 �`� Parcel ID# Page of ❑ Boring# '] Boring F31 /� �.pit Ground surface elev. ,75 ft. Depth to limiting factor�'D D in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 - L a r51 k. r�l�r' a F 3-►� R sJ-I i '� 1, r19-31 �,5Y2y1 m� ql 1-50 51 P-glq -5 VVXL Boring# F-1 ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fiz in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 I Boring Boring# Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil lication 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 Effluent#1 =BOD,>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 608-266-3151 or TTY 608-264-8777. SBD-8330(K07/00) --- __—__ __. � - a j � � � � { _ _— ; r---- _. _ .. . i I I _..... _.._r.__._,___... _ _._. � } .. _. -_ I i _. _ - _ ---y--- « ._a i __ _ _}.—_ _. _ _ _ i i a � � i _. _.. ___ _. I i i .. ... .. i -- � � i i + _._.. __.._ __..._._. ._ __... ._. _.... _.. _.. _.. -- __. � � 1 i I i i .. _.__. .. .. -----r—- _ _� _ _. _ .. � ___. ... .___. — __ _. _. ' __ ._ _._. i I I �r _I R I - -- i 1 - I ► , it L -4#,A tiff'- !- J 1 51-1 LL i W I i i ' I t I E r r , _ i - - - - i