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HomeMy WebLinkAbout038-1203-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579034 0 GENERAL INFORMATION 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: Karastes, Joel Star Prairie, Town of 038-1203-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: / Iv d(~ V\ k 6. 5-( 23.31.18.1088 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER K,'. CAPACITY STATION BS HI FS ELEV. Septic Benchmark d . L( e3-e-T j; ~ f d D ~C. SZ~j Alt. BM, 1 y 7 t a W {~L. J~ R •5 S 3.1 Aeration Bldg. Sewer 93.3 Holding St/Ht Inlet 1 '7 TANK SETBACK INFORMATION St/Ht Outlet 9 • b Z TANK TO P/L WELL BLDG. en o Air Intake ROAD Dt Inlet Wes 9LP,,A&- Septic 77 7 Z Z/ b / Dt Bottom ~ Dosing Header/Man. c/ 7 Aeration Dist. Pipe Holding Bot. System . 7 Final Grade 3-4 PUMP/SIPHON INFORMATION Manufacturer GPM nd St Cover r-1 Gb J QL~ 4, j ~j (y tr Model Numb ' ~ Q • g • 7,~ ~b~• • 4 / 5 TDH LFriction Loss System Head TD Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Len$th o. Of Trenches r- _ ^ PIT DIM SIONS No. Of Pits_ Inside Dia. Liquid Depth DIMENSIONS r~fd 4'j?(~, t1 re 1/1 GV~► SETBACK SYSTEM TO JP/L -l BLDG WELL LAKE/STREAM LEACHING Manufact er: INFORMATION T Of S / CHAMBER OR T,A ( yie yste 1%6 UNIT Model dumber: ~JP.w ro/~ / (y1 ind DISTRIBUTION SYSTEM Z3+-Z3-I- 33 I-33 =!lZ/ mss Header/Manifold / Distribution x Hole Size x Hole Spacing Vent to Air take 4 Pipe(s) N Length Dia Length Dina Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center / edthrOver Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1270 202nd Ave'Ne Ichmond, WI 540r17 (S 1/2 SE 1/4 23 T31 N R1 8W) Wohlers Estates Lot 21 Parcel No: 23.31.18.1088 1.) Alt BM Description = W r"t ~ Cb 0 6 2.) Bldg sewer length = 1 l ti b oo ~l CaY - amount of cover = Z I t I 6A V t,7D ea& '14 " -k Plan revision Required? ® Yes No /D ?CI Use other side for additional information. ` L \Q SBD-6710 (R.3/97) Date Insepctors gnature Cert. No. r 7,3 f lff-~ t rf ~1 ~Iy/oL~ 32s j I t ~v~ AR County . Safety and Building Division 201 W. Washington Ave. 7162 Sanitary Permit Number (to be filled in by Co.) ° ,.t$pS''~G Madison, WI 53 S~ 1 VS~ °~siotz~~G` s.~.~ State Transaction N b it Application In accordance wit-KW313.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit 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 purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. 11-70 o P-AA 1. Application Information - Please Print All Information Property Owner's Name Parcel # f~ 630c- Z263 ~0 - ~ Property Owner's Mailing Address Property Location • I O B 8) 1% 8 r~~ Z-1 S Govt. Lot City, State 4 ode Phone Number 5E 14, Section -J ~10 74, 7©l - oa9 T 3/ N, R lE one II. Type of Building (chec all that apply) Lot # 'j Y1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name QC / Block # ❑ Public/Commercial - Describe Use S //[IU•n~1 ❑ City of P *1A o on CSM Number ❑ Village of El State Owned -Describe Use Town of ,,,S-1r_z . III, Typ heck only one box on line A. Complete line B if applicable) zoneOA A' New System ❑ Replacement System ❑ Treatmeri Holding Tank Replacement OnJy ❑ Other Modification to Existing System (explain) $ 28 28 fl M ~S List Previous Permit Number and Date Issued B. El Permit Renewal ❑ Permit Revision El Change of Plum 4, El Permit Transfer to New Before Expiration Owner e of POrJn--G-rour t /Com onent/Device: Check all that apply) Non-Pressurizen ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil Dispersal Component (explain) ❑ Pretreatment Device (explain) fJ0X7CJV V. Dispersal/Treatment Area Information: Design Flow (gpd Design Soil A licatio ate(gpdsf) Dispersal Area Required (sf) D spersai Area Proposed (sf) ystem Elevation as s~ r 015-0< 9~3 VI. Tank Info Capacity in Total # of Manufacturer _ L U ~ Gallons Gallons Units New Tanks Existing Tanks AV/ o a, U va ~ zn w C7 ~ Septic or Holding Tank IVt Ocj r Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe ignatur 6VWRS Number Business Phone Number 103 7 ?/~S'- 5- &(I u Odd A Plumb 's Address (S et, City, State, Zip Code) VIII. Coon /De artment Use Only Permit ``FFeeej Date sued Issuing Agent Signature /Approved d ' g751 ❑ Owner Given Reason or IX. Conditions of OWNER: Approval/Reasons for Disapproval M SYSTEM OWNER: 1. Septic tank, effluent filter and m~ d~~ S ✓f / dispersal cell must be serviced / maintained as per management plan provided by plumber. h 2. All setback requirements must be maintained A ns for the system and submit to the County only on paper not less than 8 12 x 11 inches in size SBD-6398 (R 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: (a~ r Owner's Name: Z,~- Owner's Address: C Legal Description: _ • , j 7 /9 W. Township: sT~ ~/l-Ct~tnt.,2 County: 57`- lit-C9 Subdivision Name: Lot Number: I Parcel ID Number: 639 1203 - C~ -000 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 AttCacchme/ntts: Soil Test & House Plans Designer/Plumber:d4KAP 7 ''L~~cense Number: 7 Date: 7 Phone Number 7/,5~-- 7~ O 0 Signature Designed pursuant to the In-Grow Soil Absorption Co o nt Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 9 N fe All 1 >a I ~ yo l doo IT, / se lal= NC) rho'"-^^-,~ f'►' 13 % 3-5- 133 =~~y7 q3o-y I o®, lo 7~ 5,ted 9-f leop,~J 5T w f Al yloc.IL 7-5 3 - 40 4 Soil Absorption System Cross Section 4° Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 0-7 ft Leaching --b Chamber 90( ' System Elevation ft ft Soil Absorption System Plan View ft I ft Vent Or Observation Leaching YMTrench 1 Pipe Chambers Trench 2 Leaehina Chamber Specifications c Manufacturer And Model EISA Rating Q 0 sq ft per chamber Soil Application Rate s gpd/sq ft ~o gpd Design Flow Soil Application Rate d EISA= W's-Chambers Y ' P-&-,u,5 of -Q2 chambers each. f~oz x o _ as y© a0,oQ ; aa~~ ao Page of o 0 N U') O M O ~ CC5 LO i 00 - co i,. z W L O CID w w LLJ 2f w U ° z = LLJ _ Ucr nCf) > C-) x o m w LL w _ [C co cUn Z W N ~t Q CL O , f l C) m f` ® z W O C-~, (n of M =O~ Z N 1- L LJ i ~ CL ~ 48' (EFFEC 1 NE LENGTH) 34" - I 1 11.2'• "j 13" 8" INVERT 8" INVERT 5.3" INVERT 18.2" I- 33" . ; Q[11CK4 PLUS - ALL-IN-ONE PERISCOPE-- (35(1"SWIVEL 12 7" Ii 6" T ;rt N' /ERT - - LIlCK4 PLUS ALL -IN-ONE 12 Y ENOCAP T 5" - 91, 10-614 Plus Standard Chamber Specifications r" -EiASi, ~fdC~. 57"' NL)ARD f~tFdET£CI k'U ~tkAa,. f INFILTRATOR 800.221.4436 www.infittratorsystems.co POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of Z' FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity / f~D® gal ❑ NA Permit # Septic Tank Manufacturer U.~. AA-4 ' ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model a S ❑ NA Number of Public Facility Units NA Pump Tank Capacity gal i( NA Estimated flow (average) gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5)® gal/day Pump Manufacturer NA Soil Application Rate gal/day/ftz Pump Model ~f NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit , NA Fats, Oil & Grease (FOG) <_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) <_220 mg/L JN 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 Kin-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :530 mg/L if NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :510' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ys 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 8( ear(s) s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑ years (s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: 3 Clean effluent filter At least once every: month (s) ❑ NA 1,.3 ❑ year(s) Inspect ❑ month(s) kNA pump, pump controls & alarm At least once every: ❑ year(s) Flush laterals and pressure test At least once every: ❑ Yearth(s) NA Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of _<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. START UP AND OPERATION Page li of 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. p~ T . /f'~► aluat' • pn~k be ' e ai a '~R D1dt131T~. FDPC- A16✓ 60"STle(JC-710t* J ❑ 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 I 7G1'9 A 145 Name Phone 7s„ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOC REGULATORY AUTHORITY Name Name C_kZ Q(Jd 20AI l Phone Phone -71f;-- 3a'/Co- q&910 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. -2, of START UP AND OPERATION Page 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 fines 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 aluati MUM 011:,Ct. 11 =Mplace'11011t 231821 it, a o ding ank be i e ai a FRD4(8 nSt, FDR- / 6V J 645 ~ S` 1eUc,-A p>~ ❑ 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 ~ 9 Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOC REGULATORY AUTHORITY / Name Name sue. G~ ( C~UIV ~11f~~ Phone Phone (O O C-D This document was drafted in compliance with chapter Comm 63.22(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 '-)C)ej Mailing Address NW P,--L~w 6 tj w~ S C)l Property AddrP~270 202nd Ave. New Richmond, WI 54017 (Verification required from Planning & Zoning Department for new construction.) City/State New Richmond, WI Parcel Identification Number 038-1203-60-000 LEGAL DESCRIPTION S* SE , 23 31 18 Star Prairie Property Location ~J/., /4 , Sex. , T NR W, Town of Subdivision Plat. Wholers Estates Lot # 21 Certified Survey Map # Volume Page # _ j Warranty Deed # (0 Y)7 5 ~O (before 2007)Volume , Page # a~q Spec house C]yes[Ono Lot lines identifiable ❑ yes[]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. I/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. I/we am/are, the owner(s) of the property described above, by virtue of a arty deed recorded in Register of Deeds Office. Number of bedr oms 3 SIGNATURE OF APPLICANT(S) 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) H. W,L. High Water H.W.E. High Water F.F.E. Minimum F . ~ 12' Wide NORTH R~S89 ,36 _ N 89'28'28*E- - 2,404i89' ORION DO 248.ti' 24 WEST LINE OF THE SE 1 /4 OF THE SE 1 4 ° 2 1. 5 ACRES 1.75 V) i r 4 t i i i r 4 i! r i. i b i t i! i i i i#• i• i i• i i i } y~ # i i i r i r i i i i i• • i i i! i f i#! r r r i i r i s .n!.~.. ..mow... s» w.+............, ....mav_.~.+..~. ..wr+ ~ aaasnv. ...+.wn +a.-+~...:+..+ S 89'28'15" W 811.17' W N 89'28'15' E 811.07' 1 91 i i! i i i i t i i•• i i i s ss *a i t ysi r s• r r r s i r i.r r r r i i r i r r r.! i i i• i r i r i i r i i i r• i r i a EAST LINE OF " THE SW 1/4 OF NNN) THE SE 1/4 , a s f at LOT z 306 ~,,vG® „aL ec 5 Wis. Dept.ZAaj~4d Professional Services = ION REPORT Page Divi09f afety0aNggldings 11~r~~ - of 'T[`~( in accordance with SPS 1PS. 110s. Alm. C(,de ~~^^A0 County G RID 't oe 1r T5 plan on paper not less than 3 1/2x 11 incf- es in size. Plan must 5 but not limited to: vertical and horizontal reference point (BM), direction and Parcel LD. 0 percent slope, scale or dimensions. north arrow, and location and distance to nearest. road. Q 3 01 ADO O Please print all information. Reviewed Date Personal information you provide may be used for secondary purposes rprLaw s. 15.04 (1) (In'7 ?I ~ Property Owner 4 Property Location 01 w _ Gov. Lot S 1/4s 1/? Sa3 T 3 1 N RE (o 1 Property Owners Mailing Ads Vs C j i_ot # Block # Subd. Namle or CSM# r 01~ 4 S a T ►►11 J'f" it O k1 .0- G "fq G City state Zip Code Phone Number -`I L r City U Village Town Nearest Roam I1IP.ty R.~w~Dn~ ! _ ! ~y017 i 1 s )7 $ bD q~~._~•tct.r a`, O Ar New Construction Use: Residential / Number of bedroorrrs Code derived design flow rate y so GPD ❑ Replacement El Public or commercial - Descrinr,: Parent material loess Vey. t'°od Plait, elel'ation if applicable General comments land ecommendations= Su$g~~-~ S 14t Sra~~ mc\)Vat,p rso+ ~-t• 9~, r,~ ~ bu+ b•cavi c cF t'~+c lack o~ 4„y M4++1.q ~ t rna yb t Vet k-G;--- ~ F] Boring I'~ Boring # ~ Pit Ground Su' face elev. W.. 35 Denih to limitinig actor I~ _ in, A4 1/ f Horizon Depth Dominant Color Redcx Descr ar A I a te Structure onsistence oundary Poots GPD/ft n. Mansell a5z_ lor - I Gr. S7. Sh. _ ffl?1 ff#7_ O -g I /OQ3✓ - L S, 1~^?Ia-s b _ rr, f r a,.c~ F V _ I- a - y l p r 3 a Via' yJ,/ ' - !C w . g y - -S F y0a} yA%! cw 14 ® Boring # ❑ Boring U .be FA Pit Ground surface elev /b.be icI Dteptb to limitirn~ factor-1 ao in. Honon aDepth Dominant Color Pec'oa' Desch ion T--- Soil Application Rate P' ^xtrn Structure n n/I onsistence oundary Roots ( GPD/ft 2 (nseilu. S7 C-ont. Color d . S ff#1 ff#2 to LJ1 Fr 3 -Re-yR~--- Y ~ 3o I ' Effluent = ROD 30 < 20 .iq/l _t d _ and TSS -10 7~ Ft;luent #2 = BOD r CS"i Nam 'Please Print < 3G my/L and T,~S < 30 mg/L '~q~ P~ 1 a ( ire I- ~.3LQ •T 4.~ '1~ a, CST Number Add a1i to C~ D~ Date Evaluation . Conducted _ry'~,--T Q Telephone Number SRD-8330 (RI 1/11 ) Property Owner ILIA) 1, ~ Mcetj Page ir_~ of,3-_ Raring Boring l J A Pit Ground surface elev. 7S•4_/ r. =)eptl "o limiting factor aD in. Soil A lication Rate Horizon Depth Dominant Color Redox Description a xtur^ g c~ir uciur onsistence Boundary Roots GPD/ft in. Munsell Cu. Sz. Cont. Color F Gr. Sz. Sh ff#1 ff#2 s Q F_ ~ 1 a w i F 3 p" y R y s S I FS bX r G v~7 J F _ 7 1. .._O P?7-1 -f P-1 Roving i Boring # Ground sui ace elev. C?epiit io lin q factoi in. L_~ Fit Soil A lication Rate Horizon Depth Dominant Color RedoxDescription tiirr rP 'onsistence Boundary Roofs GPD/ft in. UlrmsellCu. Sz Cont. C'ofu' ------I--i. `_h. ff#'1 ff#2 I r1 i Boring i I Boring # Ground surface elev. i)epth tc'11;,itlnt3 fa.caor._ in. I- Pit - TSoil A lication Rate F7onzon !depth Dominant Color; ,edox Description a rl^ onsistence oundary RootGPD/ft Gi tif;ff#2 Munsell Or Sz. Cool Corm .-fit' - - l I y 9 w i j 1 p t 9 ~ f > 30 < 220 mg/Land >3Ci ,r) mg/I_ ` Fifluenf #2 ROD : 30 ma%I_ and TSS _ 30 mg/L iIc 13t h'. C:{ STic.l ~.i",.! D,( ~ al ~.'rS cf~ is Nil ~?T C„i C 1~1'('tc_iC'' a,n,l C'tl'1hiOj~Ct'. 1f yOtl nCGCI i1SSI t9JlC(= t:0 c..-. ,'111('J l-x;ic 1, nn ml a1 61), 6--' i i, or i tY thro,.i2h Relay. I I f Page of,, Property Owner Qtf L., e t2:2 ce ar ei D - 1 Boring I Boring Y Ground sw.ace elev. q5 .q i~ep:, Iimitina factor in. Soil Application Rate Pit z I Horizon Depth f Dominant Color I Redox Description -axtuse E Siructrrre ~-onsistence oundary Roots GPD(ft ' r. Munsell Ou. Sz. Cont. Color - ,r. S7- Sh. ff#1 ff#2 r 1 , • Boring # Ground Surace elev Ppt! ic,imiting factor- in. TSo,IAca ~Horizon Depth ~Dominant Color l Redox.Descnp`ion xiurr -,t ,ire consistence oundary Roots n. t 1lrLinsell Qu. Sz. Cont_ CoElc: g'-F. Sz_. Sh- I , I s i r - r Boring I 1 Boi'inr # . Ground surface elev. JPpth (C-,',!; iihng fact-)' In. L ---1 Pit Soil A lication Rate i ionza': i r ; Dominant Colo; ! =edox Description SIFU~Ire,, , FAnsistence (Boundary Roots GPD/ft ff# "i s Mansell Oc- Co^i. Coi; S ! ff1 z. Sh. I ~ i 4 i I 1 r " p 1 1 -t1uer ' ; _ ::D 3u < 2 0 !nail and 3G ! r- g Effluen' #2 = 30D t < 30 mc.,L and TSS < 30 mn/L The 71.}(`1)1. (i i.:C.°. lid : 811.' 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