HomeMy WebLinkAbout040-1306-14-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Building Division St. Croix
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 578994
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:
Cichosz, Chad & Kathleen Troy, Town of 040-1306-14-000
CST BM Elev: Insp. BM Elev: BM Description:
Section/Town/Range/Map No:
08.28.19.1841
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER , S CAPACITY STATION BS HI FS ELEV.
Septic
Benchmark 3• ~ 163. Z ~d
Alt. BM C
Aeration r d $ 1611
Bldg. Se er 4~[ o
Holding T' O ~ 8•
St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. en to Air Intake G • 9 7' Z -
TANK Dt Inlet
.A A,
Septic /L ( Dt Bottom
IT s
Dosing Header/Man.
Aeration Dist. Pipe 7-4 95 .2
Holding Bot. System
9
PUMP/SIPHON INFORMATION Final Grade q
Manufacturer 3.S! g
Demand St Cover
GPM Ce J Z • 7 140.5
Model Numb
TDH A Friction Loss System H Ft
Forcemain Leng ia. Dist. to Well
SOIL ABSORPTION YSTEM
BEDITRENCH Width Length ! No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dial Liquid
DIMENSIONS 3
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer
INFORMATION t' t
TypeQf System:. ' 7~ CHAMBER OR
~ ~ r $ A UNIT Model umber
DISTRIBUTION SYSTEM ~ S~"
Header/Manifold Distribution ZZ Z "7 ~JS
Length J Pipe(s) x Hole Size x Hole S acing Vent to Ai Intake
Dia Length Dia Spacing 1\ E e~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth ODepth Over De th Bed/TBed/Trench Edges :S~m
Topsoil Seeded/Sodded xx Mulched
~ Yes ~ No
Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:
Inspection #2: / /
Location: 430 Jordyn Lan H dson, WI 54P16 (SE 1/4 NE 1/4 8 T28N R19W) Su set View Lot 14
/ Parcel No: 08.28.19.1841
1.) Alt BM Description = , t ; v~kJQ. f r2.) Bldg sewer length = a..r w ~d e,K a
27
- amount of cover = 0 77 /66 ^n
~ Plan revision Req
Z d,ti. ~L~L~ W-ignatur
uired? Yes Use other side for additional information.
Date SBD-6710 (R.3/97) Cert. No.
``p¢ Safety and Buildings Divisid
P o ~.OQ/
0,
--I
201 W. Washington Ave., P.O. Box 716 it Number (to be filled in by Co,)
r _ p Madison, W1 53707-7162
p vOIK COUNTY 7
State TraasaetionNpmber
anltary Permit Application
In accordance with SPS 383.21(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 Pro'ect Address (if different than mailing address
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ~36 Jo
u ose,s in accordance with the Privacy Law, s. 15.04(1) ml, Stats.
I. Application. Information -Please Print A f ati n
Property pwrier's Name Pazcel i;
Property Owner's Mailing Address i Property Location
I , /
r
p~ p2 L Govt. Lot
City, State P Code Phone Number S , +i4, Section
p role on
TZ 0 N; RE/
11. Type of Building (check all that app) Lot
Subdivision Name
~~2 Family Dwelling-Number of Bcdr ms _
B J ~17
❑ Pubiic(Commercial-Describe Use 6)`~ ~ ~b~~"
a1 ❑ City of
i
State Owned - Describe Use CSM Number ❑ ge of
❑ O
of
-A6 2.7 , 11I. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
`ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain)
B. I E) Permit Renewal ❑ Permit Revision El Change of Plumber El Permit Transfer to New ;List Previous Permit Number and Date Issued
Before Expiration Owner 1
a ~f q
IV. y e of POAITS System/Component/Device: (Check all that apply)
n- _Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank er ersal Component (explain) ❑ Pretreatment Device (explain) Y
V. Dis ersaVTr tment Area Information:
Design Flow (gpd) Design Soil Application Rate( dsi) Dispersal Arca Required (sn Dispersal Area Proposed (s ystem Elevation /
L/ S' 3, 2 i
VI. Tank Info Capacity in I Total # of Manufacturer 3
mF 10
Gallons Gallons Units o o
J u
15ew Tanks I Existing Tans i 14t
v
Septic or Holdiag Tani,
Dosing Chamba
i
VII. Responsibility Statement- 1, the undersigned, ass r sponsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumb ' attue MP/MPRS Number Business Phone Number
2 z crb 71
Plumber's Address (Street, City; State, Zip Code)
VIII. Countv/De artment Use Only
ate
Approved ❑ S Permit Fee Due~~~~ Lssuin~ , ent Signatur
sapl ~
❑ en Reaso r Denial
I1. Condifi . o S for Dis pproval a+ 4~
1. ''$I' tank, effluen~ filter a~r►d~ J
Dispersal cetl must all fie set .L- 1, ntaitted
as-per management plan provided by plumber.
1 t: i►, ask r►quir emery mustnivld.
'as PW~PP
Attach to cumplete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size
SBD-6398 (R. 11/11)
PLOT PLAN
PROJECT Chad Cichosz ADDRESS 2425 Oak Ridoe Circle Hudson Wi 54016
SE 114 NE 1/4S 8 /T 28 N/R 19
W TOWN Troy COUNTY ST. CROIX
SYSTEM ELEVATION 93.2/93.1 5' below grade 6/15/15
DATE BEDROOM 4
CONVENTIONAL XXX IN-GROUND PRESSURE
CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891
# of chambers
BENCHMARK V.R.P. Top of survey iron
ASSUME ELEVATION 100° Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
145' Property Line 85' kale - 1/411 = 10'
B.M.*
10'
<1% Slope, not enough 45, 2-3' X 90' cells
slope to draw contours with >3' spacing -1
Vents
B-3
0'
to be >5'
30' B-2
FPro 4
Bedroom ST
House O
3 0'
All piping shall be ASTM SDR 30/34, within 260' Property Line
10' of tank, piping shall be ASTM F891
fj >6„ uick4 Standard
of Covaching Chamber
th 20.0 ft2 of Area
4' Lft^2/pair of end cap s
34Grade at System Elevation
Jordyn Lane
,Ico
I
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 6/15/15
Owner: Chad Cichosz
Location: SE /4 N E 1 A S8 T28 N,R19 Jordyn Lane Troy
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications Sheet
Signature
License number #226 0
PROJECT Chad Cichosz PLOT PLAN
ADDRESS 2425 Oak Ridae Circle Hudson Wi 54016
SE 114 NE 1/4S 8 /T 28 N/R 19
W TOWN Troy COUNTY ST. CROIX
SYSTEM ELEVATION 93.2/93.1 F below grade
6/15/15
CONVENTIONAL XXX IN-GROUND PRESSURE DATE BEDROOM 4
CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE
DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891
# of chambers
BENCHMARK V.R.P. Top of survey iron
ASSUME ELEVATION 100' Filter Lifetime Filter
BOREHOLE O WELL *H.R.P. sameasbenchmark
145' Property Line 85 Scale = 1/4" = 101
B.M.*
10'
<1% Slope, not enough 45' 2-3' X 90' cells
slope to draw contours Vents with >3' spacing -1
B-3
0'
to be >5'
30' B-2
Pro 4
Bedroom ST
House O
3 0'
All piping shall be ASTM SDR 30/34 within 260' Property Line
10' of tank, piping shall be ASTM F891
Vent
>6" Quick4 Standard
of Cover Leaching Chamber
with 20.0 ft2 of Area
12" 5.6ft^2/pair of end caps
4' Long
34" Grade at System Elevation
Jordyn Lane
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber
5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 98.2'
Vent Grade Vent
3' 411 31
A~-'30/34 Septic Tank
"
5' Long 119 51 S' Long 1 19
3691 Grade at System Elevation Grade at System Elevation
Spacing 5'
2-3' X 90' Cells
Same on other end Observation tubeNent
At end of cell
A
22 chambers per cell B
System elevations: I
93.2'
A-93.2'
B 93.1'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Tank Manufacturer. ❑ NA
Permit # eptic ❑ Dose ❑ Holding Volume:/,_j s- (gal)
DESIGN PARAMETERS Tank Manufacturer: A
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: Vertical Distance Tank Bottom(s) to Service Pad: (ft)
Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad. / (ft)
Specific servicing mechanics must be provided if vertical is >15 feet or
Design (peak) Flow = (estimated x !5270 (gal/day) if horizontal is >150 feet. Specific Instructions to be provided on back.
In Situ Soil Application Rate: i 7 (gaUday/ftZ) Effluent Filter Manufacturer' NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model:
Fats, Oil & Grease (FOG) :530-mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA ❑ NA
Total Suspended Solids (TSS) 5150 mg/L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L - Manufacturer:
(BODs) >220 mg/L NA
(TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
❑ Disinfection ❑ Wetland
Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other:
(BOD5) 530 mg/ Soil Absorption System
530 m
Fecal Coliform (geometric mean) 510' n- round (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Effluent Particle Size ya in dia. ❑ NA El At- Lade El Mound
❑ Orip Line ❑ Other:
Other. NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) hen combined sludge and scum equals one-third (X) of tank volume
❑ When the high water alarm is activated
Inspect condition of tank(s) At least once every: ~ ❑ onth(s) (Maximum 3 years) ❑ NA
ear(s)
Inspect dispersal cell(s) At least once every: ❑ nth(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: f ❑ o th(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ month(s) 41 NA
❑ year(s)
Flush laterals and pressure test At least once every:. ❑ month(s) NA
❑ year(s)
Other: At least once every: ❑ month(s) NA
❑ year(s)
Other:
NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifica ions:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pu per).
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 a check for any back up or ponding of effluent on the ground surface. The soil
absorption system 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 treatment tank equals one-third or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code:
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units.
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW-005 (02/05)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are
detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be=discharged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when sal conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the
area within 15 feet down slope of any mound or at-grade sal absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment
tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat
scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge.
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 s. Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems 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 (pumper).
• 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
repl cement 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 the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or sal limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as 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 infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER.
Nam Q5X Name cl-
Phone C J 6 Phone
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name Name 49
Phone t - S Phone v
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
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S' CROIX sC'OUNT""
SEP'1IC TANK 1VIALi`v`11"NANCI? j1GRFEMLNT
AND
OWNFR'SI11P CE,,RT1VK-'/ T1iD N FORM
Owner/Bit er
Mailing Address C ~ nt ~
Property Address J rJ
(Verification requned fiocn 1'la Wing loninlr Department for new consunci'iou.)
~1 b
Parcel Identification N tlt Iher 646
LEGAL DESCRIPTION C/f
Property Location S/= Sec, Q N t-,_._ VV, I'own of
Subdivisioll
- - - - Lot f/
Certified Survey Map #
Itutir. ~ ~
Warranty Deed # l Lt r---
- - - iutne Page it
Spec house yes no 1_ot lino. identifiable vc.s no
SYSTEM MATNTVNAN+C:'1+ AD OWNER CERTIFIICATIO
Trrgxoper use and maintenance of your septic, system could result in its pram iture failure io ]candle wastes. Proper
maintenance consists of pumping, out the septic tank every three years or sooner, ii needed, by a licensed pumper- What you pui into
the systern can affect the function ol'the septic: tank as a treatrne rit stake in the wasre disposal sysi:em. Owner nilinterrancee
responsibilities axe specified in §Connn. 83.52(]) and in Chapter 12 -,"It. t" Dix County Sanitary t}rdinancc.
The property owner agrees to submit to St C come County Naruuril & /01 11111 1)eparoncr it certification form, signu.l bar tltc
owner and by a master plumber journeynran pluncber, restricted plumber or r lrcerssed pumper veritying that (1) the; on_.sii;
wastewater disposal system is in proper operating condition and/or (2) after tnsp(t; ion and pumping (if necessary)., the septic tank is
less than 113 full of sludge.
I/we, the undersigned hznve; read the above; reyuireancnis anci exec to niau?tarn the; Inivaic scwagu disposal sysWril with flit,
Standards set heath, herein, as set b}• the Department of-C cnnntercc and the. Departincnl o1'Natural Re;souraes, ante of Wiscotnsin.
( ertification stating that yotrseptic system has been waintained must be complete l and xetnrned to the St. Croix Couuly Planrrintr &
Coming Department within 30 days; of the three year eapirailon date.
1/we certify that all statements on tins foam c. 5uc to rhea besi of,Ill)""our knowledge.. 11;we arrr/are the wwncr(s) ol'ilie
property described above, by v' a warrant
eed recorded in Register of Deeds Office-
Number of bedrooms
V1 N.A' 1441 OF APPLICAM I (S) --1) A
'°''r*Any information that is misrepresented may result in the sanitary permit beinb o vok.ed by the ]Tanninf, . Zoning Y
c`st I)epacnnrr7c,
Include with this application a recorded warranty deed tiom the Register of lac ends .-office and a copy of'tlrc certiliecl surrrey rnap it
reference: is made in the warranty deed.
(RI;V. 08/OS)
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Wisconsin Departme r~el vSO SOIL EVALUATION REPORT
Division of Safety d Bu, Page ` of
n 2 ~corda ce with Comm 85, Wis. Adm. Code
County S ~
` Attach complete Si plan w0pe`~ At less than 8 1 x 11 inches in size. Plan must C
include, but not limi d to: Vertical and irph~al refe ence point (BM), direction and
percent slope, scale r dim L s'gG Qi Parcel I.D.
G. fr6w cation and distance to nearest road.
P! \N
mt all information. Rev' wed by "Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
1 IS
Property Owner Z-
_ Property Location
3 ~~v'~ U7 d! HJ` SC 1/4.)V~'1/4- S F • T Z.8 N R
Property Owners Mailing Address E (d) W
Lot # TBlock # Subd. Name or CSM#
P o, Sox 3 3 J
City State Zip Code Phone Number UVV Ste'
❑ City ❑ Village 1~1 Town Nearest Road
3 R~r~ ~RI-L~ vv t 5 8'1p I S) ~l$S _33 5 I T 1Z-0`1'
~ New Construction
Use: ® Residential / Number of bedrooms
3 -Code derived design flow rate (4 S Q - (}0GPD I
❑ Replacement ❑ Public or commercial - Describe:
Parent material G Lie) L y~y~~
Flood Plain elevation if applicable PQ
General comments ftand recommendations:
~ ~t~~ 3 ►N1 tilt C~~S k J11MF
Boring # ❑ Boring !
® Pit Ground surface elev. ft. Depth to limiting factor ~ 9 8 . in. 42-
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roots Soil Applic;2 tion Rate
in. Munsell Qu. Sz. Cont. Color ry GPD/ft
Gr. Sz. Sh. 'Eff#1 'Eff#2
I o-~3 to~~z3Lz
Z 13-~(~ lU"llf~3l6 S) -1ko _S I•~
I
a Boring # ❑ Boring
® Pit Ground surface elev. 9 S - ft. Depth to limiting factor 4
in.
Horizon Depth Dominant Color Redox Descri lion Soil Application Rate
p Texture Structure Consistence Boundary Roots GPDlftz
in. Munsell Qu. Sz. Cont. Color
Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-\`1 I0`1SZ3Iz. - St ! Z`(-s6k hn' Ctv ,S -9
1l -U 1p`'1 R 316
sit Zen sbk ►n`A-- Cg - .5 . ~
3 ~-Liq to~l~l~ - S c) s~
' Effluent 91 = BODs > 30 < 220 mg/L and TSS >30 < 150 Effluent #2'= 8 )D < 30 m mg/L
CST Name (Please Print) - s _ 9/L and TSS < 30 r
Arthur L, tdegerer Sign ture CST Number
Address °e~p- O 3 2 1 S- y 2 2 0 2 5 4
4d e g e r e r Soil T e s t i n g & Design Service Date Evaluation Conducted Number
421 w. Main St. River Falls, WI 54022 1Z_zo3 715 -42 5 5--0 Telephone-0 16 5
65
A
1
Pro ertI
p y Owner
Parcel ID # `j Pa
n . 9e of
a Boring # ❑ Boring 9
® Pit Ground surface elev. 9 b' Z fl. Depth to limiting factor 7 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
.0- t oI R_ 31Z
s j) z`Fs b w7`F1~ e w Z-~ s
13 Z lug R 31G S i I Z ~i s b k m. ~s - • 5 g
-2 7.
n ~1
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 GPO/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
F-1 Boring # ❑ Pit Boring
❑ Ground surface elev. ft. Depth to limiting factor In.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
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 = BODE < 30 mg/L and TSS < 30 mg/L
'I7ie Department of Connnerce 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.
500.8330 (W6/00) ,
Property Owner
Parcel ID
Boring # t❑t Boring G Page of
ref Pit Ground surface elev. C) b, ? ft, Depth to limiting factor - 1~
Horizon Depth Dominant Color Redox Descri lion in
p Texture Structure Consistence Boundary Roots Soil Application Rate
In. Munsell Qu. Sz. Cont. Color GPD/ft
Gr. Sz. Sh. •Eff#1
O l JZ- t z - w 'Eff#2
s~ I z`Fs b
►3
Z S
Z ►u~l R 3~~ s i I e
3 VZ-°~a )ova y~(, s bk m`P~- es _ ,5 , ~
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor. Horizon Depth Dominant Color Redox Descri lion In
p Texture Structure Consistence Boundary Roots Soil Applieatton Rate
in. Munsell Qu. Sz. Cont. Color GPD/ft
Gr. Sz. Sh. •Eff#1 •Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Soil Application Rate
in. Munsell Qu. Sz. Cont. Color n' Roots GPD/its
Gr. Sz. Sh. •Eff#1 •Eff#2
Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L
' Effluent #2 = BODs < 30 mg/L and TSS < 30 mg/L
Tlie Department of Commerce is an equal opportunity service provider and employer. If you need assistance
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777, services or
SUD-8370 (R.6/00)
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page \ of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County S - e~ o
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 IccaUcn and distance to nearest road.
. Please print all information. Review b 'Date
Personal information you provide may be used for secondary purposes (Privacy Law, s: 15.04 (1) (m)).
Property Owner Property Location ~Q
$ L ~~v Q~ dv N NJ` SC 1/4.V 1/4• S .S • T Z.F N R E (d) VV
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
P-o. Sox 33 19 I - slJYQ sZ- qIZ Lj v,
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
t3f~ r~1 ~Rh ; ~Lv 5 ~1 tl0 1 L4as -33 5 1 T tZ O`1'
21 New Construction Use: ® Residential / Number of bedroomsT Code derived design flow rate _U S C) - `j Ub _ GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material G LP.\ C1 Y: t. ~2u1 k, f~ ~4 Flood Plain elevation if applicable N ft,
General comments
and recommendations: 12ELp~..1~ 3 rwt1~~ ~ S %J/NCI
)3b,r yr t Or- CQI-QS ~~N s4 r~rw 60
"
Boring # ❑ Boring
® pit Ground surface elev. ft. Depth to limiting factor ? 9 in.
Soil Application Rat=
Horizon Depth Dominant Color Redox Description ( Texture' Structure I Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-\3 ro'-l `z2 cL
Z ~3 -v_~ t~vlrz-3!b - s i 1 z~, s m'~r^ ~S. - ~ •5
3 UPI-~4 I v-1 rz alb ( S v s~ m 1 - - Z
Boring # ❑ Boring
Z ® pit Ground surface elev. 9 S - ft. Depth to limiting factor Q in.
Soil Application Rate !
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I 'Eff#1 'Eff#t2
1 0-~7 ~o~tsz3~z - si 1 z,`F-sb~ nn`~t-• ci,v z~F •s -9 j
Z ll -y,~ ~b`'1'(z_ 31 ~ - S 1 ~ Z~'►'i S b k ►n`A- Cg - • S • ~
1ZHfL 141~ - S USA vn ( _ .Z t,z
Effluent #1 = SOD, > 30 < 220 mg/L and TSS >30 150 mglL ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L .
CST Name (Please Print) Sign lure CST Number
rlrthur'L•.-Wegerer CAD. 03 Z1S - )y 220254
Add' Wegerer Soil Testing & Design Service Date Evaluation Conducted Telephone Number
421 I1. Hain St. River Falls, WI 54022 1Z.-Z.Z_O3 715-425-0165
PLOT PLAIT Page 3 of 3
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CST Signature Date Telephone No. CST No.
Job NO.