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008-2009-03-000
County: St, Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT sanitary Permit No: 578936 (ATTACH TO PERMIT) State Plan ID No: GENERAL INFORMATION N /~YZ Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Parcel Tax No: Permit Holder's Name: City Village X Township 008-2009-03-000 Ungar, Rick Eau Galle, Town of CST BM Elev: Insp. BM Elev: IBM scription: Section/Town/Range/Map No: os 01.28.16.570 !o I • o P F'FE~cE (~aS`f ~N S~ co16 ~13K STS TANK INFORMATION ELEVATION DATA-"'M TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark -0110 t' •9) 1o 1 ?D l UFFGuTr n1 00 w Alt. BM Dosing " 11.1 FE~~E '/g ado Aeration Bldg. Sewer ~0 ho 0o .70 St/Ht Inlet rZ 5 .3V Holding St/Ht Outlet (Z DO TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet lap Tq- QD _ r gLt! 3~j Septic ~ I I'00' Dt Bottom > IO d' YS Dosing 4A is V a L. Header/Man. O QD ! F0 Dist. Pipe fQ Aeration T~ { Holding Bot. System 1 / 0 If. ~ tf7o~ Q© PUMP/SIPHON INFORMATION Final Grade at 70 Manufacturer t7 Demand St Cover S (oO Zo E GPM Model Number ZD TDH Lift Friction Loss System He TDH~ ~ t 3 JO 7- 70 rs.6r, .30 Forcemain Length Dia. Z Dist. to well } /OD 1P OF L /}A1J SG~ L~ 7o L9IA SOIL ABSORPTION SYSTEM BED/TRENCH Width Length FNNo. PIT DIMENSIONS No. Of Pits Liquid Depth DIMENSIONS 7 SETBACK SYSTEM TO WELL LAKE/STREAM CHAMBER OR Manufacturer: INFORMATION Type Of System: UNIT Model Number: ni ~ loo' tit DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x ~ a Pipe(s) 3/1(b 12 Length y Dia_ Length Dia Spacing 7_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only r![E d Depth Over Depth Over xx Depth of xx Seeded/Sodded Bedrrrench Center > Bedrrrench Edges i to Topsoil / f Yes ®No ~Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: !IL Inspection GA~- p~~ .16.570 Location: 2696 59th Ave WOODVILLE, WI 54028 (NE 1/4 NE 1/4 1 T28N R1 6W) White Pine Meadows Lot 3 Parcel No: 01.28 ~vclc S~~l lodlG~ Gaol ~ LLE~~ 1.) Alt BM Description = 2.) Bldg sewer length = /yep tZ /0, TD RE uN~~fZ CO -amount of cover = S' .(c, !S''2. sW~, IG v ~ /y1EfISGe-E/11xll ?ftl~GW w/ GqP ~ ~ ,IJ M ~ me.r ~/A09- 7i e~nl,I(S Plan revision Required? Yes [ No Use other side for additional information. Date E:~~ In epctor s Signature Cert. No. SBD-6710 (R.3/97) PLOT PLAN PROJECT Rick Unoar ADDRESS 801 South Side Drive Woodville Wi 54028 NE 1/4 Ne 1/4S 1 /T 28 N/R 16 W TOWN Eau Galle COUNTY ST. CROIX SYSTEM ELEVATION 99.4' DATE 4/7/15 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1 .0 ABSORPTION AREA 456 # of chambers none BENCHMARK V.R.P. Top of white wood fence post ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Property Line 2 Acre Lot Tank is to be properly bedded and 270th St. provided with Iockdown covers with approved warning labels Scale = 1/411 = 10' Well I is to meet ` all WDNR setbacks Grading is to be done to divert run-off array from system Pro 3 B-3 House Huffcutt Combo Tank r-I 98.5' N Bedroom ell, ~98' !ov' yO O Area 15' belo y ❑ system is to rerr ai n 97.5' B. M. undisturbed w`B ~.'(OO B- 1 S . LEt,L tD 3% Slope 4 t3uvt 59th Ave OA PAM 11 0:5 County ` Safety and Buildings Division I 201 W. Washington Ave., p.0. Box 7162 Sanitary Permit Number (to be filled in by Co.) x 8 ~ k ~ ~~Y ~ } Madison, Wi 53 7067-7162 ST. Ct~OIX CC7UN b " State Transaction Number Sanitary permit Application 2 5 3 15 42- 1, accordance with SPS 38321(2), Wis. Adm Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permIL 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 ses in accordance with the Privap Law, s. 15. 1 m , Stats. L Application Information - Please Print All Information Parcel/~# it U 'Property Owner's ame 1 v D " ZO b 9' V 3 1) Iy 1 Property Location "1 Q Property owner's Q v l n ner's MaiC Jr ling Address , Govt. Lot / V o J Zip Code ehono Number '/ti Section City, State , rrcie on V T Z~ N; R E W IL Type of Building check all that apply) Lot Subdivision Name or 2 Family Dwelling-Number of Be / o Block# Gc ❑ Public/Commercial - Describe Use b ❑ City of CSM Number ❑ Village of ❑ State Owned - Describe Use ewn of 1 x 5 D OND C III. Type Permit: (Check only one box on line A. Complete line B if applicable) 0 (~_c A. system, ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New ^ D L Before Expiration Owner TV. T of POWTS System/Component/Device: Check all that a 1 f 11 Non-Pressurized In-Ground 11 Pressurized In-Ground ❑ At ound > 24 in. of suitable soil El Mound <24 in. of suitable sail -Gras - n(~.i~ ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsal/Treatment Area Information: Design Flow Design Soil App Dispersal oposed (sf) El on p f (gpdj ~ , q dsfl Dispersal ~/JAK>\,) R I aired Z(-sf)5 L / LO 111/~ l/J1 l" 7 VL Tank Info Capacity in Total # of Manuf Y S r f ~ U Gallons Gallons Unite i~/ ~Pa L✓ Tt' 1 ! [ rte' u =pp U New Tanks Tanta FxiB a U v s C7 C. Septic or Holding Tank Dosing Chamber yl~ l ~ V VII Responsibility Statement- I• the undersigned, a responsibility for installation of the POWTS shown on the attached plans. Plum s Name (Print) PI Signature MP/MPRS Number Business Phone N , f l Plum 's ass (Street, Ct . State, Zip Cad Z_ i &c ~S County/De artment Use Only o Permit Fee Date Issued Issuing Agent Signatttre 45 Approved Disapp $ _/1 bQ Given Reason for Denial 'w/J L 15 ❑ tx 1 D Conditions of Approval/Reasons for Disapproval SYSTEM OWNER; e 0 /1C{ t`ho n S E 1. Septic; tank, effluent inter and V dispersal cell must be 5eryieed maintained rjfiLlff app I as per management plan provided by p{urrber. 'tn e . All setback requirements must be maintained C 1 Attach to complete plans for the system and sub aWSS12 : 11 inches in size SBD-6398 (R. 11/11) SHAUN R BIRD Page 2 4/29/2015 " is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(i). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. • Insulate building sewer per SPS 382.30(11)(c). A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice, Please Include a Copy With Your Patricia L Shandorf Payment Submittal. POWTS Plan Reviewer, Division of Industry Services Wyment S code: (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. T ' ~~54EP~TVE~ o~ DIVISION OF INDUSTRY SERVICES D off/ 19 10541N RANCH ROAD ~3 ( s P HAYWARD WI 54843 Contact Through Relay 9y S G hftp://dsps.wi.gov/programs/industry-services o A www.wisconsin.gov Scott Walker, Governor Dave Ross, Secretary April 29, 2015 CUST ID No. 226900 ATTN.• PO WTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING INC ST CROIX COUNTY SPIA 1432 120TH ST 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/29/2017 rabove,in ntification Numbers D No. 2531542 SITE: 11743 Rick Ungar o both identification numbers, 2696 59TH Ave correspondence with the agency. Town of Eau Gall e St Croix County NE 1/4, NE 1/4, S1, T28N, R16W FOR: Description: Mound, 3 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 1531900 Maintenance required; 450 GPD Flow rate; 30 in Soil minimum depth to limiting factor from original grade; System(s): CO Mound Component Manu7a--7e-r. 2.0, SBD -1U6M--T (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter DEPT The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes Pr,.OFES and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed i 71~~ ~SION 0 and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.0 SEE stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384.10. No fixture, appliance, appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 4/ 6/15 Owner:Rick Ungar Location: NE1/4 NE1/4 S1 T28 N,R16W 2696 59th Ave Eau Galle Manuals Used: Mound Component Manual Version 2.0 (01/31) Pressure Distribution Manual Version 2.0 (01/31) Page# ')ITIONALLY 1. Cover Page -)PROVED 2. Mound Plot Plan ;F SAFETY AN ES ,oNAL S VICES 3. Mound Cross Section N 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve -ORRESPONDE CE 7-8. Maintance and Contigency plan 9-11. Soil test 12. Filter Specifications and cross section Shaun Bird Signature License numb 6900 PLOT PLAN PROJECT Rick Unaar ADDRESS 801 South Side Drive Woodville Wi 54028 NE 1/4 Ne 1/4S 1 /T 28 N/R 16 W TOWN Eau Galle COUNTY ST. CROIX SYSTEM ELEVATION 99.4' 4/7/15 3 DATE BEDROOM CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 456 # of chambers none BENCHMARK V.R.P. Top of white wood fence post ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Property Line 2 Acre Lot Tank is to be properly bedded and 27r 0th St. provided with lockdown covers with 11 = approved warning labels Scale= 1/4 101 Well is to meet all BNR setbacks Grading is to be done to divert run-off array from syste m Pro 3 B-3 Bedroom House Huffcutt Combo Tank r-I g8 5. w gear -i I+e~ 998 98, Area 15' below ❑ ❑ 97.5, system is to remain B.M. undisturbed B-2 B-1 3' Slope 59th Ave Mound System Cross Section and Plan View Dimension Feet J i A B I i 7 1 D I 1 4 x1.1.1.1.1.1.1.1.1.1.1.1.1 L 1- .1 ~1•.• 1.1.1.1.1.1.1•L•1.1.1.1.1.1•H4;1 ,1 tr1 1 - i rLr1r1.1~1. 'r4~•r•r•r•r•r•f•r•r•r•r•r + ! r r' 1i~i~i:isr.r.r.r.r.r.r.r.l.r.r.:.r.r.f.r.. •r. r.r.r ' E r1.1•L•M1•Y1.1.1•M1•M1•1 1fif4flf:.M114~1.1:4.1.1.1.1•M1•M1•1.1•L•'••1.1.1.1•M1•1.1•'•• 1.1.1.1•'.1.1• r• r•+•+•r•r•r.r•r•r•!w r•r.r.r r•.••r•r•r•r.r•r•.••r•r•r•r•r.r•r•r•r .l.r.r:r.r.r . A ' f x1:1:1.1 K•1.1.1•L•L•1•t.M1•L•M1•L•L•L•4.1.1.1.1.4f4.1.1•M1••.•1.1.1.•..1••••...1.1.1.1.1.... 1•L•.•1• :iji; r•r•r• .:•:.:vM1ryryrLr•!•r•r•!•r•r•r•!•!•!y •r !•r•!•r•!•f•+•r•r.r•r•r•r•r.r•r•r r r r r r' •l~l~~:J~J:r• 1 1.1.1.1.1.1.1•NL•L. 1 4•L•L•L.1.1.1.1.1.1.1.1.1.1.1.1.1.1.1 _ .'•1f1f.J'J:r•J•r.J•!•l.fM•!.r•r.f•r•r.flr1lM1f~!•r.r.r•r.+•f•rL:41y:;fL:~r4fyr;• f ' •+yJ:f:rM1fY:.:•j.1.1.1.tif111l1jLf1.\.1.4.1.1.1.1.1.1.1.1•• ! r111j111.1.1•L• 1.1.4.4 1 M1 1 L F W r•r•r•r•r•r•r•r.f•r•.••f•!• •r•+•r; r•r•r•r.f; r•+•r•!•:•+•r• r ` _ l l G T " Z ~T H l I J [J J~ I 1{ ~ L W K B Z jO L Slope I - 1 = Topsoil =ASTM C-33 Clean aggregate = 4 in. sch. 40 pvc I I Cap Material LL 0 sand fill '/z to 2 '/2 in. dia. observation pipe L 4~4 4 L - J Geotextile G lip Fabric stir;: f4$4: :~:r~~,::,:,r• F x1.1. .4.1.,.1.1.1.1......... r t D E. r ~ r ~ /~Ft Contour Plowed Surface> Slope Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x W) is plowed with a moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a'/4 inch soil wire when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flange. 10/07lgj Page of Pressure Lateral Layout Two Laterals - End Manifold 4 - Threaded Cleanout Lateral Turn-up ----0 Plug Manifold M X Long Force Main /f Sweep 90 Bend j Distribution Network Specifications Pressure System Construction Lateral Diameter In.~. Manifold Diameter G. In, Laterals are constructed of Schedule 40 PVC Orifice Diameter 311j7 In. pipe. Orifices are drilled perpendicular to X Orifice Spacing) In. the pipe with a sharp drill bit and face down. _ _ Ft. Lateral turn-ups terminate with a threaded L Lateral Length) M (Manifold Len th} rt, cleanout plug and are enclosed in a 6-8 inch Force Main Diameter In. diameter lawn sprinkler valve box accessible Force Main Length G Ft _ from finished grade. Grade C7 6-8 Inch Lawn Sprinkler Valve Box Page _ of 03/05 lgj Septic-Dose Wank Cross Section And Pump Performance Specifications Tank Manufacturer Pump Manufacturer Tank Model Number-r,-~~1 Pump Model Number f Z- Alarm Manufacturer Total Tank Capacity /r Max, Bury a t' Alarm Model Number Type Switch Feet Total DynaX Filter Manufacturer 5 ~ T~-- [Filter Model Number Elevation Head Distal Pressure Net work Loss Minimum Pump Performance Required Force Main Loss 17 GPM Ft TDH Total outlet Manhole Min. 4" Above Grade With Manhole Min. 4" Above Grade Locking Device. Inlet Manhole Securely Mounted With Locking Device < 6" Below Grade Sealed Watertight Weather-proof _ Junction Box Finished Grade Vent Min. 12" Disconnect Above Grade Means With Vent Cap Outlet Filter y - - - - - Inlet met Baffle A 1/4.. Switch Sc*gs and Reserve Capacity Weep GPI Tank Volume Hole B Dimension. Inches Volume Gal. (reserve) A . p Elevation C (alarm) B Ft Bottom (dose) C eY D Elevation (dead) D Ft Total , . , . GENERAL INSTALLATION: amordmce with the TION• The septic/dose tank is bedded and back filled manufacture may of manufacturer's product approval specifications. Maximum d th ofade ha have an specified b ective locking device (padlock) roval. Manhole covers exposed to gr t fittings, and be exceeded without prior app roved material, connected to the tank with watertigh g~> installed. Piping at the inlet and outlet is of app. laid an stable soil to prevent settling or sagging. The force "'is sleeved with 4" Sch. 40 PVC to bridge the tank d the sleeve is sealed watertight., Electrical service complies with NEC 340 and Comm 16.2:1. excavation an Page of 02105 U PER Vil',U`C HEAD ca,PAcit CURVE AND DtwATERINO TY - MOCt! 152/ ? 53 :1rJG~L z Ww wlw z5 ,j ~y• 23, 2 40 4 5 J 152 j 44 ice- - L y U 30 1- l I i _ 8 it ii - =G _ i 20 -j ! t I . - t ,4,ca , i ~ II i o 20 40 EO 80 too I j GALLONS .~LITERS o 16 7240 2C - 5j8 n F LOW RY FOR SPECIAL APPLICATIONS CONSULT FACTO Timed dosing panels available. e Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are availab e for controlling single phase systems. Double piggyback variable level float switches are available for variable level long and short cycle controls. - S Sealed Qwik-Box available for outdoor ins'.allations. See FM1420 • Over 130"F. (54°C.) special quotation required. 152J153 Series ~,ntrol Selection 1521153 MODELS Model Volts_^Ph l Mode Amgs Simnj,lex r Dupfex_ Nt$2 x115 t Non ! B.S _ 2 or 3 ~i_ r a ~u u SK2os4 j 6.5 t Inctuted-_r___2or3 t BN152 115 1 Ruto- i Et 52 230 1 Non 4-3 t 12 or 3 Autc 4.3 ` tnclu=ed_d- -2or3 I BE152l 230 _ --h-- - - -i t4 53531 t1515 t Non 1 10.5 1 2or3 -j SELECTION GUIDE t0.5 mclu'e0 2 or 3 99 piggyback 1N huto i --i ~ Et63 -1 230 1 Non i 5.3 i 1_ 2 or 3 _ 1. Single pi yback variaole level float switch ordouble variable level float `BE1 531 230 Auto 53 Included 2 or switch. Refer to FM0477. FA CAUTION 2. See 'FW0712 for correct model of Electrical Alternator E-Pak. All installation of controls, protection devices and wiring should be done by a qualified 3, variable level control switch 10-0225 used as a control activator, specify duplex (3; licensed electrician, Alt electrical and safety codes should be followed including the most or (41 float system. recent NaGonat Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual ccnditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL 70: P.G. sox,, 6347 Louisville KY 402560347 man.ltacturersor. 1L~ • SNIP 7v 3649 Cane Run Read ~ ~i~,fs + a Louisv,ce Kr40211ts6t QuvUrr~un~asSiNCE /~9~9„ y ® (502) 778-2731 • t (800) 923-PUMP Zo s 4 t UM.P' FAX (5G2) 774-3624 http;//www,zoeller.com U Copyright 2000 Zoeller Co. All rights reserved. I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page or FILE INFORMATION SYSTEM SPECIFICATIONS Owner C'~n Septic Tank Capacity L~ al ❑ NA Permit # Septic Tank Manufacturer NA 'DESIGN PARAMETERS Effluent Filter Manufacturers ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Commercial Units A Pump Tank Capacity 7 al ❑ NA Estimated flow (average) __5-- aVda Pump Tank Manufacturer ❑ NA Deslgn flow (peak), (Estimated x 1.5) 411 J gal/day . Pump Manufacturer NA Soil Application Rate /L? aVda /ftz Pump Model ❑ NA Influent/Effluent Quality Monthly average' Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/GMvel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BOD5) 420 mg/. ❑ Disinfection ❑ Other. Total Suspended Solids (TSS) 5150 m /L Manufacturer Pretreated Effluent Quality A Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BODs) S30 mg/L ❑ In-ground (gravity) ❑ In-ground (pressurized) Total Suspended Solids (TSS) s30 mg/L ❑ At-grade ound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-line ❑ Other. Maximum Effluent Particle Size Y. inch diameter • Values typical for domestic (non-commerclao wastewater and septic tank effluent. " Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume Inspect dispersal cell(s) At least once every ❑ months year(s) (Maximum 3 yrs.) Clean effluent filter At least once every ❑ month ear(s) Inspect pump, pump controls & alarm At least once every ❑ months ,aiear(s 11 NA Flush laterals and pressure test At least once every ❑ months year(s) NA other. At least once every ❑ months ❑ year(s) NA Other At least once every ❑ months ❑ year(s) 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 (Y,) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatVment components, and any other maintenance or monitoring at irkervals of 12 months or less shall be performed by a certified POWTS Maintainer. A servicrc report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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. Page of START UP'AND OPERATION products or other chemicals the-',t For new construction, prior to use of the POWTS check treatment tank( s) for the presence of painting ent rocess and/or damage the dispersal cell(s). If high concentrations are detected have the contents of thi. may impede the treatm p 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. pales is restored the excess wastewater will be cower outages pump tanks may fill above normal highwater levels. When p During p result in the backup or surface discharge werff~oel~e discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may controls to restore normal /eve's -ptae anually operating the pump erator prior to restoring p To avoid this situation have the contents of the pump p tank assist in a S m effluent pump or contact a Plumber or POWTe Maintainer to within the pump tank. ark over, or otherwise disturb or compact, the area within Do not drive or park vehicles over tanks and dispersal cells. Do not drive or p 15 feet down slope of any mound or at-grade soil absorption area. the performance and prolong the life of the PDWT Reduction or elimination of the following from the wastewater stream may improve p rnd rals; antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation dralin (sump pump) water; fruit and vegetable peelings; gasolrne grease; herbicides; meat scraps; medications; oil; painting p , pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS fails and/or is permanently taken out of service the folll Aing steps ealll be taken to insure that the system is propel y and safely abandoned in compliance with chapter Comm 83.33, Wiscons Code: • Ail 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code comp itiln replacement system: ement absorp ❑ A suitable replacement area has b from diist bane and utilized compaction and should nottcbe infri ged upontby quer,ec The replacement area should be protected a will result the setbacks from existing and proposed replacement Failure Replacement systems mustgcomply with the rule,er o establish lot lines and for a new soil and site evaluation effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN holding tank may be installed as a last resort to replace the failed POWTS. WTS replacment area. soil and The site has not been evaluated to idenfy a if no replacement reaaisuavail ble aOho d ng tank may be installed'a suitable suitable must be performed to locate 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 infiltraliv urface, 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 NI ENTER A SEPTIC, PUMP OR OTHER TANK MAY BE DIFFICULT NUNDER OR IMPOSSIBLE. CIRCUMSTANCES. DEATH MAY RESULT. RESCUE p`= PERSON FROM THE INTERIOR OF A ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER - E Name E Name fF 1 Phone Phone ~f '-~-SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGUL,-A~TORYAUTHORITY Name Name ) J -~~7 i / r C Phone Phone This document was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code minty 1 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ` ' ' L ( Date Please print all information. Reviewed by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location A~ r Govt. Lot i/. 114 L~= 1/4 S T N R E (or - w Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# L) 2 "1 c4ty State Zip Code Phone Number ❑ City ❑ Village own Nearest Rgad , New Construction Use: Residential I Number of bedrooms - Code derived design flow rate GPD - - - - ❑ Replacement ublic or commercial -Describe: Parent material .~..~-x Flood Plain elevation if applicable ft. General comments and recornrnendations: System Type~~ _ System Elevation ❑ Boring / 7 Boring FF1 # P-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. Munsetl Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 / 7 r, ❑ Boring , a 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 GPDHf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 -Eff#2 n r. ' i • Effluent #1 = BOD. > 30 5220 mg/L and TSS >30 ` 150 mgll. Effluent #2 BOD. < 30 ffxA and TSS < 30 mg1L CST Number CST Name (Please Print) Si 226900 Bird Plumbing, Inc. Shaun Bird , Date Evaluation Conducted Telephone Number Address ~--/F - 715-246-4516 11432 120th St, New Richmond, WI 54017 / -/s~~ f • Parcel ID # Page of Property Owner Boring # Boring j Ground surface elev. _ ft. Depth to limiting factor L in• Pit Soil lication Rate 1 Horizons Depth Dominant Coiorj Redox Description Texture Stricture Consistence Boundary Roots GPOIff .EEff#2 i n. Munseil cu. Sz. Cont. Color Gr. 5z. Sh. J / / 5. # t i f i--' Boring Boring # pit Ground surface elev. ft. Depth to limiting factor - sn Soil Ariolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKf in. Munseil Qu. Sz. Cont. Color Gr. Sz. SK 'Eff#1 'Eff#2 4 i j ' Boring F-I Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil lication Rate GPDfif Horizon ')epth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs Eff#2 in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 ' i r t Effluent #1 = BOD, > 30 < 220 mg1L and TSS >30 < 150 mgtL ' Effluent #2 = BOD, < 30 mgtL and TSS < 30 mWL The [department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need maternal in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (A.6=) L 4 fi Soil Test Plot Plan Project Name RickUngar Shaun rd Address $01 South Side Dr. Woodville Wi 54028 C TM #226900 Lot 3 Subdivision White Pine Meadows Date 4;4/7/15 NE 1/4 NE 1/4S 1 T 28 N/R16 W Township EauGalle Well PL Property Line County ST. CROIX Boring Q BM or VRP Assume Elevation 100 ft. Top of white wood post System Elevation 99.4' *HRPSame as Benchmark Scale is 1" = 40' unless otherwise noted Property Line 270th St. 1.5 Acre Lot Scale = 1/4" = 10' B-3 ❑ 98.5' 98` ❑ ❑ 97.5` B. M. B-2 3% Slope B -1 59th Ave U1y FILTER CARTRIDGE INSTRUCTIONS Installation k" STEP 1 Dry fit the filter case onto the end of the outlet pipe to ensure it is c , r :L e into the ' - centered under the access opening. If not, then either insert more pipe tank through the outlet or solvent weld (glue) additional pipe onto the outlet I`~r 7 pipe STEP 2 While the case is still dry fitted on the outlet pipe, measure the length i4 x o of 3/4-inch pipe needed to brace the filter to the tank end wall if utilizing the 4 optional supplemental side support. If side support method is not utilized, proceed to step four. r' STEP 3 For installations utilizing the optional supplemental side support: 77 solvent weld the 3/4-inch pipe onto the filter case. If side support method is not ,'x, f r ~ti utilized, proceed to step four. T STEP 4 Solvent weld the filter case onto the outlet pipe. Insert the filter cartridge into it the filter locks into the bottom of , the case, pressing down until , the case. + ;f STEP 5 If a VRS switch is utilized: insert into the filter and lock by turning Zi Iti.iy clockwise 90°. Maintenance 1. The effluent filter should be cleaned every time the septic tank is serviced. 3 2. Open the outlet access opening to inspect the tank and filter, 3. Pump the septic tank completely, making sure to remove the sludge layer on the bottom of the tank and not just the scum and effluent. 4. Once the effluent level has been lowered below the invert of the , outlet pipe, firmly pull up on the filter handle to dislodge the cartridge from the case. 5. Slide the cartridge up and out of the case for cleaning. 6. If a VRS switch connected to an alarm is present, the switch should be removed by turning counterclockwise 901 and cleaned with water only. 7. While holding the cartridge on its side (large flat surface facing down) over the access opening, rinse off the cartridge with water only, making sure all septage material is rinsed back into the tank. 8. If VRS switch is utilized, replace by inserting into filter and # turning clockwise 90°. 9. Insert the filter cartridge back into the case, pressing down until the filter locks into the bottom of the case. 10. Replace and secure the access opening on the tank. BEAR ONSZTE"' FILTER CARTRIDGE - FIVEYEAR LIMITED WARRANTY BEAR ONSITE" Fitter case -Lifetime Limited Wa an Y KI R: e , vtWifi~bea'ousite.com 877IA +FILTERS 6534483) . , ST. CROIX COUNTY SEP'T'IC T1, ,K MAIN TENANCE (GREFMYKI' /kND OWNE'RSIi1P ClFJU1FK'A_TIf_ N FORM Owner/Buyer R r Mailing Address Property Addre aco -10-- crrfication required Flom Planning Zoning, i)c;pdtt.nellt for new corts11actio:n ) City/State LEGAL DESCRIPTION Property Location r , Sec. 'Ii~ l~ _1 t0 W Y Tovvn. a ( ~r.LC.v q Subdilrisioll - - - - - - - ,Lot /r Certified Siti-vey Map # Warranty Deed # - - t---- -C) VcAunre w Page Tr, Spec house yes n 1 of line,: identifiable ono SYSTEM MAINTENANCE AND OWNER CERTIJACATION improper use and inainwilance of'your septic system could result jr), its pr.mlature faihue to handle wastes. Proper maintenance consists of purnpirng out the septic tank every three years or sooner, tj needed, by a licensed pumper. What you pun into the system can affect the function of die septic lank as a ireatrnerrt stage in the wasre disposal syst:errr. Owner nuzintenance responsibilities are specified in §conun. 83.`iL(i} afrd in Chapter 12 - St. Cioix county sanitary Ordinance. The property owner agrc ~.°.s to submit to St. Croix County Planning d' `Lon ait,, Dcq)arrrnent it ccrtificaiion tonic, signed by the owner and by a master pltunbet, journeyman plumber, iestrictrd plumber of- a licensed pumper verilyiug that (1) the oil site wastewater disposal system is in proper operating condition and/or (2) after inspct-ion and pumping (if necessary), the septic tarn; is less than 1 /3 full of sludge. I/eve, the undersigned have read the above requirenrc'uts and grv to nxtrntain life private sc wage' disposal system with the standards set forth, herein, as set by the Department Of C-0lrlrnerCU and the C)epartn,cnt ofNattrral Resources, State of WiSGOnsin Certification stating that your septic system has been rnaintairred must be complete, hind,:eturned to the St. Croix County 111anninir c ~ Zoning Department within 30 da):`; of the three year exp.1ratiort date. I/we certify that all statements on this form ane, true to the best of fny/om k ¢owledge. 1/we arrriare the owrner(s) 01,111C property described above, by value of a w' runty deed recorded in lleg;ister of I)eet is Office. Number f Brooms STCr.. A' OF AP LIC.A 1(:;) I:~/~'I ***Any infibrination that is misrepresented may result in the saintary perrnit bcing wvol ed by the Planning & .zoning i)epaitiriew. Include with this application a recorded warranty deed from the Register of Duelds fice and a copy ofthe certified survey reap IF reference is made in the warranty (REV. 08/05) b rEr ■ 39 ER r d 1 ~ 16 AMM AN'S r a S~tl 6~y d If-is . d w 1 N~ i Aff-Aw AT i 00 # 0 Ac, ~ 1140.43 4 '2 1142.43...., i T CN 1 I LO T 3 c:) rn 87122". SJI"'~ Lo Ln c..0 C~N / r 0 } r'" f LO Ln ` .~."'t .k .,""r•.+° I ~,r.) 0 fv~ r r~ te II r Property Owner _ Parcel ID # Page of Boring # El a ❑ Boring Pit Ground surface elev. a' ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 o-11 A,3z- /8 2 11- !V 7 17 v (ZeF D s - - r ❑ 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 ❑ Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon ')epth Dominant Color Redox Description- Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'EfT#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS 130 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. SBD4330 (RAM) i Wisconsin Department of Commerce ~ SOIL EVALUATION REPORT Page of Division of Safety and Buildings ~'s in aitce with Comm 85, Wis. Adm. Code _ Q Courr' Attach complete site plan d4Q t"34 11 inches in size. Plan must include, but not limited to. hol 6rital reference point (BM), direction and Parcel I.D. percent slope, scale or~i Fr s, north arrow, and location and distance to nearest road. I p~ 0 - ZW- Please print all information. Revie Date - Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S Property Owner Property Location ,C Govt. Lot 1 /4 % 1 /4 S T Z N R 6 E (or Property Owner's Mailing Address To-t# Block # Subd. Name or CSM# city State Zip Code Phone Number ❑ City ❑ Village own Nearest R d ~/vn Cv/ 0~ ) 08-.:8/ New Construction Use: P6Residential / Number of bedrooms -3 Code derived design flow rate 5 ~SZ~ GPD ❑ Replacement ublic or commercial - Describe: Parent material Flood Plain elevation if applicable / / ft. General comments and reconwnendations: System Type System Elevation Boring # ❑ Boring 7 F] pit Ground surface elev. ` - ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Boring # ❑ 77II ~ boring ® [a 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 6 - 0 3 oU- , 1/0-30'. - zfzef :Z EXI Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30:5 150 mg/L ' Effluent #2 = BOD. < 30 mg& and TSS < 30 mg/L CST Name (Please Print) CST Number Bird Plumbing, Inc. Shaun Bird Si 226900 Address Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 54017 715-246-4516 ~I Property Owner Parcel ID # Page of Boring # ❑ Boring a pit Ground surface elev. 7 ft. Depth to limiting factor ZXJ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 2 v D s - - r Al ❑ 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 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 `Eff#2 L Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < 150 mgA- • Effluent #2 = BODS < 30 mg/- 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 608-2648777. SBD-8330 (RAW) 1 Soil Test Plot Plan o -F .3 Project Name RickUngar Shaun Ud Address 801 South Side Dr. Woodville Wi 54028 C #226900 Lot 3 Subdivision White Pine Meadows Date r17115 NE 1/4 NE 1/4S 1 T 28 N/R16 W Township EauGalle Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of white wood post System Elevation 99.4' *HRpSameas Benchmark Scale is 1" = 40' unless otherwise noted Property Line 1.5 Acre Lot 270th St. Scale = 1/4" = 10' B-3 ❑ 98.5' 98' ❑ ❑ 97.5' B. M. B-2 B-1 3% Slope 59th Ave Property Owner c,_ \ d\ 11 ~SOl~ Parcel ID # Page Q of 1-37 Ea Boring # ❑ Boring 7 Pit Ground surface elev. , Depth to limiting factor 32 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Mu{n~sell Qu. Sz. Cont. Color Gr. Sz. Sh. *Effff#1 *Eff#2 3 -`E O R ~3d .5Y/ZS ~IU t S~ ~ e2 ~ 6v V~~,' rr Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate I 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 I F-1 i Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 i I i I f" i Effluent #1 = BODS > 30 < 220 mg/L and TSS >30:5 150 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. S 131).8330 (R.07/00) P: Wisconsin Department of Commerce /SOIb' VA'6kT4ON REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code` County S C~Q~ Attach complete site plan on pap r~ Nn 1 inches in size. Plan must include, but not limited to: vertical poigt (8M), direction and Parcel I.D. ~y`Y! ~~,•n~ percent slope, scale or dimensions, nor nddista nee to nearest road. M or V Please print all information. view Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Z G Cd Property Owner Property Location Pa J ke4 o j, Govt. Lot A)~- 1/4 1/4 S T~ ~ N R f ro E (or (W Property Owner's M 'ling Address Lot # Block # Subd. Name or CSM# -2 ~os Rj , -3 ~t 4 e M eu ~Qoc~s City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road WbCj Vt ( 15-) 09- ~yv-3 t,,,, .~1 e~ a o ~f~ New Construction Use: esidential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material L d ~S S D U CY / Flood Plain elevation if applicable fL General comments A l and recommendations: uSE C~ 156: kA C,c.OAd-2lr~JQ pe e C 0 C 6&t ~6 Uk- y f mound S S -i F -[et). 9 Y, S l n Boring Boring # / l / I ❑ Pit Ground surface elev. / y i ft. Depth to limiting factor 7u~ 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-I~ Y ~ s t~ .6 ~ lo-I W toy Q ~O~I~ S f C .2 C J VI L,) b- U 1 ~y h - ( (4 Boring # ❑ Boring I I Pit Ground surface elev. ft. Depth to limiting factor ' (A~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft? in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 /3 fzr I t C). Vft o G,- y - ~ lU Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L IName (Please Print) Signature CST Number Address / Date Evaluation Conducted Telephone Number 7701, nne~ n+wn TnA Mn\ 'roperty Owner Ri w Parcel ID # Raged of ❑ ' Boring # Boring 7 U-P-it Ground surface elev. ~7 , ( ft. Depth to limiting factor 3 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 l i~ c~~in s ~-sdk w 7- cs~ 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/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 _777 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit 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 = BODS > 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. S I3 D•8330 (R.07/00) ' may, I r Plot Plat ~~~r 3 OT n~ o r ~~6Sow , 5, e v.r+~ e on F~ y ~ i i ,3.M. 9e, . S l t,"'l. Cnc►~~U -roe ®f 14 ti 6°UC f'I~e Ew` ~~o sr f- qy oo-~ SU, b ~e '73.0, 0 &3 a~ s i qa~ a' f