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Home My WebLink About022-1080-80-025 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 582050 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 Township Parcel Tax No: Randall & Theresa Schlotte TOWN OF KINNICKINNIC 022-1080-80-025 CST BM Elev: Insp. BM Elev: . t BM Description: Section/Town/Range/Map No: Cl 8M t" z- 28.28.18.439C-10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1 ~ZGd Benchmark ' /I 2-Z6 Alt. BM Go.~w~Oa S'0 v L6JZA., ~l7• Bldg. Sewer ~ ~ ^ c 9 q Holding R SVHt Inlet C D $5. ZS TANK SETBACK INFORMATION St/Ht Outlet TANK TO P`l. WELL LD(p. ent Air Intake ROAD Dt Inlet Septic } -6 1011 1 ~ Dt Bottom ~s • 97 Dosing 7 56 ,QJ Header/Man. 475.5 -39 Aeration Dist. Pipe 5 Z S Holding Bot. System PUMP/SIPHON INFORMATION Final Grade 3• `3 Z Manufacturer Demand St C ver GPM .1, v ~1 97. ZS Model Number M 154 TDH LifLI_3 Friion~oss 1 System Head /L. TDH'ZV,O ~~JJ SS t* ' it Forcemain LengJJt0 Jia. / Dist. to Well z 1Oz SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS { 7 x 2 ` e X e SETBACK SYSTEM TO `tJ P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR EZ rC~b t,J Type Of System: UNIT Model Number: Ga n-)e"Ha nj 14 3 15a a DISTRIBUTION SYSTEM Z t Z Z Header/Manifo if Distribution Ix Hole Size Ix Hole Spacing Vent to Utakp tJ ~ Pipe(s) ~S JD FJ 1^'';r 11-ength_ 7 Dia Length Dia pacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 7-6 Pit-- Depth Over Depth Over xx Depth of xx Seeded/Sodded jxx Mulched Bed/Trench Center Z _7 Bed/Trench Edges Topsoil \ R, i No No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1117 PINE RIDQE DR 11 ~h 10•x - VjvLle, 1.) Alt BM Description G~.~,... Le r' CD-'t"" 2.) Bldg sewer length C V1 Gi i ~s ' ~G = y - amount of cover A- I~ J 41nsepctor Plan revision Requir ed? ❑ Yes Use other side for additional information. SBD-6710 (R.3/97) Date Cert. No. ~ County v 8@V~'_ r RECEIVE Safety and Buildings Division C/6 1 /Y z , `A S 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) ` Madison, WI 53707-7162 DEC, 07 2095 !5'3, zas coMMU,.Pl+ft Application State Transaction Number accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit / V A equired prior to obtaining a sanitary permit. Note: Application forms for stale-owned POWTS are submitted to Project Address (if different than mailing address) Department of Safety and Professional Servies. Personal information you provide may be used for secondary poses in accordance with the Privacy Law, s. 15.04(1)(m , Slats. 0- A Iication Information - Please Print All Information P PJ P perry Owner's Name Parcel # GL % h re s eJ 22 - 0 0o - -D 2S" Property Owner's Mailing Address Property Location i e jc~j 2 /Z Govt. Lot ✓ City, State Zip Code Phone Number ~ , Section _q J 2, T CU ZZ /S -ZZZ- ZSO (circle one) it/e& T_Z~_N; R /9 EorW H. Type of Building (check all that apply) Lot # ~or 2 Family Dwelling - Number of Bedrooms Subdivision Name j . Block # ❑ Public/Commercial - Describe Use ' le ekm Me 1 ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Z no~ I IZtI z ~IaW t?_ 11411 - 62L-2~3 k4Townof kltin//c4-/AAie- Ill. Type of Permit: (Check my one box on line A. Complete line B if applicable) AL-w- .5 4, e__ A. ❑ New System KReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Mo cation to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner tot IV. Type of POWTS System/Component/Device: Check all that a l t on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) 7# J V. Dis ersaUTreat nt Area Information: .'1 Design Flow (gpd) Design Soil Application Rate(gpdst) ispersal Area Required (st) Dispersal Area Proposed (s System Elevation S5 0 D~S~ /Zof~ .200 ~Fi VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks ~4-- w y v a U rn w U C. 41 A-/ Septic or Holding Tank / i20,Z6) 20Q7 1 /PSPa~- Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number /G 4e L 1, /zce-io I 3 Plumber's Address (Street, City, State, Zip Code) 12 VIII. Coun epartment Use Only Approved (].~isapp Permit Fee Date Issued Issuin ent Signature $ J-1 _5 en Reason orDenial ` « ! Z ✓ IX. Condit easons for Disapproval t S tank, eitluent filter and . dispiersai cell must all be serylees / maintainer as per rrianagement plan provided by piumber. 2. All sic requWem6ntr; mint 0, maintained as per applicable cads / oMinanm. Attach to complete plans for the system and submit to the County only on paper not less than 8 in a 11 inches in size SBD-6398 (R. 11/11) E -I ~Jl ~ZL! rJ e4 K/d1N'iL. IJItr~ r4 S C'mLol r d l < CJ j7 n I w fir? 2 a EZFLOW IN-GROUND SOIL ABSORPTION COMPONENT DESIGN REPLACEMENT FOR A FOUR BEDROOM RESIDENCE Owner's Name Randy Schlotte 1117 Pine Ridge Drive River Falls, WI 54022 Located in the SW 1/4 of the NE 1/4 of Section 28, T28N, R18W. TOWN OF KINNICKINNIC ST CROIX COUNTY WI Parcel # 022-1080-80-25 Lot # 3 CSM 17-4619 022-2003 INDEX Page 1 Index & Title Page 2 Plot Plan Page 3 Soil Absorption System Detail Page 4 Dose Tank Cross Section Page 5 Pump Performance Curve Page 6 Manifold / Diverter Valve Detail Page 7-8 Manual and Management plan Page 9 Septic tank Maintenance Form Page 10 Existing Septic Tank Certification Page 11 Warranty Deed Page 12-13 CSM Attachments: Soil test, As-built, and Aerial Photo Prepared By Michael Rodewald 285 County Road SS River Falls WI, 54022 715- 21-6229 MS931384 Signature Design Pursuant to In-Ground Soil Absorption Component Manual. Version 2.0 S13D-10705-P (N.01/01; R. 10/12) ~~G~cr: t'~ tfC'hrt110iffC. 1hr( i~C. fSa QvaS v~-. p d l <T Z a~ /3 SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page-of Project Name: . d No. of Cells Per Cell 3 ft Cell Width Total No of X20 ft Cell Length ~a sq ft EISA Per Cell T ft Cell Spacing o201j sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: /,y I / //n-/d/L Gravelless Leaching Unit Model: L~ a /213 /9 -A {f Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent - Soil Backfill 3-C-) in ■ Geotextile Fabric ~t ft Infiltrative Surface 12 in (07 91# rt Limiting Factor yA in Slotted and Anchored Vent/ Observation Pipe with Cap @ ® f . 6 ~ Q @ @ @ @ a a a... @ @ ®@ a e a @ ■ . a a o @ . @ . w E ■ s Plumber/Designer Signature: License q313fq Date: Septic-.Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer ! ✓le ~vc- Pump Manufacturer Tank Model Number 2-c7► o e Pump Model Number Total Tank Capacity LI-6 Alarm Manufacturer e c Fri Max.. Bury Depth Alarm Model Number Switch Type F Total Dynamic Head (TDH) - Feet Filter Model Number- te = Elevation Head Distal Pressure W. Network Loss Minimum Pump Performance Required r 5 - Force Main Loss ps+~/ GPM tl Ft TDH Total - t Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. 4" Above Grade < 6" Below Grade Sealed Watertight Securely Mounted With Locking Device Weather-proof Junction Box - Finished Grade t-.... Depth of Cover Vent Min. 12" Disconnect Ft Above Grade Means - With Vent Cap !t> > Y > S > > 3 r > > r > > > } > > > : r > Y r > > : > > t S t< S< t< S< S S SY< < t<<< S S S< S S< S S S T 3 Outlet Filter-___y Outlet Inlet >i> Inlet Baffle {7< r > i < r t'< A r` >i> Switch Settings and Reserve Capacity Tank Volume = GPI Weep • ~ t>~ { Dimension Inches Volume Gal. B ' Hole (reserve) A / 3 `;s S s ~ < t Y (alarm) B 2 Off Elevation C (dose) C ? Ft > r (dead) D >i Bottom > r~ / < t D 7 Total f t S3< Elevation > 7 Ft t > 't'tS> ' t'`'t't>S'S'{'<'<'<'< S'< i t< S i t t{ i i'S i{< S< t S L S i S S i i i S > > Y > Y 7 S > 7 ! S > Y 7 3 > } , > > Y S } Y S > Y Y Y > ! } > } 7 > 3 ! > > Y 7 3 3 } ) > 7 > Y y > 3 7 GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 LJ Page of _L3 M E40 Series M"M 4/10 HP Effluent and Drain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 77 1 7- 1 40 12 35 10 ~ 30 ~ Z 25 8 7- QO 6 q0 = 20 I z Q ,9 13 15 J O f' 4 !a- 10 S 7 -N O 5 2 0 0 0 10 20 30 40 50 60 70 80 90 100 CAPACITY GALL PER MINUTE 1101 Myers Parkway, Ashland, Ohio 44805-1923 419/289-1144 FAX 419/289-6658 Telex 98-7443 K3326 7/91 Printed In U.S.A. i 50 "ed 5 a INJ V i i 4 ~ U. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page FILE INFORMATION SYSTEM SPECIFICATIONS Owner p V -5 Septic Tank Capacity al ❑ NA Permit # 4~aj0(p3S Septic Tank Manufacturer ~ y ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units 9NA Pump Tank Capacity 6o al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer I Sz ❑ NA Design flow (peak), (Estimated x 1. 6 allda Pump Manufacturer ❑ NA Soil Application Rate r al/da /ftz Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average' Pretreatment Unit ;R~NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODE) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) 530 mg/L .2-in-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ~0 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 ever 11 month(s) (Maximum 3 ears) ❑ NA y' DY ear(s) y Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑ month(s) Inspect dispersal cell(s) At least once every: Z tear(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: / 18 year(s)(s) ❑ N~ Inspect pump, pump controls & alarm At least once even' ❑ irnonth(s) ❑ NA year(s) 13 Flush laterals and pressure test At least once every: ❑ mont ►(s) NA year Other: [ - ❑ month(s) ❑ NA At least once every; la-/ear(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 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of C% START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a Septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should nfsu~~ n by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect t re lacem-e-nt--area ' I result in the need for a new soil and site evaluation to establish a suitable replacement area. Replaceme tt 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. ( AThm si has not b n valuated t de ify a suitable replacement area. Upon fail re of the PO TS a so' ite I v tion ust perfo ed t ocate a uitable r ement are no replac en area is ailab olding tank be inst as a last resort to replace th PO S. ❑ 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 X ke_ O c Name Phone '7 /5-- Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name lt,l r c Name '5-1- C?-CfK. Cs+x-OTY - tJ/Al Phone ~ ! ,2 Phone ' ~5. 396, 6~ 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. 4~ N I AMIX COUNTY TANK MAfIf TNAJ4CB AGICMMI NT I'.ND O NrsEUMP CI'R1111CATION I101W 57CJJ_L a 7- 7-G Mailisig Address - 7L/~z_ a d 1t/l (`yl ✓ClL ~/~i~ S lku/ S o Z 2 1 opcity A,tdress r"`1 C` ~i fO C ~2~✓ - '~r~r 2 ~ S ~,vl ~cf0 Z (Vuitica(ioa required from Planning Dqa mcnt for new eonstiuction) Pared McnGttcation Nwnber 1 %:C~~11,_i)IS(``IZII''iT~r1 I'rapa ty Location S Ill V✓ yt, Sm a g T~ g N-g I W, Towuu o f _r l 1 ('-,K I ~v u 1 . Sut~divisrotz _ .Lot - Cc4fiod Sarvcy hlip f ~j L I volume Pace !t 4 `v,LtT-ata(y nccd (j U a 4 3 n P LO) s volume j 7 Page it (0 spec house ❑ arcs no Lot t= idcutifiable,1 ycs ❑ no :~x'ST~Vr~4Lg~~A~ICE zcpeta oaty~ rpstcaz oocld tcsali is fts pcr;~r: to bandit aras.I'ro~cr mix masists vt o can tirraci the tundioa of the SqW4 bak cr-sy ti,zex Y= or soma, ff noodai b?' t Ti oarsed parq ct, Whit yon put. into the Cyst= tanfcu, a tratzcra fa ex waste dit}. lb~ cua xr ty owaa scr= to mi ni: to SL Croix Zoaing Dcp~ i< ax6fisxtion fccm, rivncd by tho ,O ~ nd bT a tLcsrodrtcnbcrort paMrx.txifyiagfW(i)dcoucitywastcwatcr&voulcpstcm PiOPa opcMtWz cunditioa tndlor (Z) u2cr iaspcc ian tad pamging.(cf 000asuy), dic scptia,Ual is I= don U3 fM of ldadgc. f (h^ ..uo3cr-~ bAyt toad the tbon rcqakaucats tod q= to tmiftlin dc peintc vMv di posal rystcm WA Me MDdards . otbythr- ofI~ttrrraSper, Sttc ofWisaiaGitiC&Ucuz catig Ql:t }roaecrtic system has bocceM,tar~ a,L~c be oouVXW aoct rttanQ to dz St Cmix.Cocmty Zcainr ()trice~viihin 3G 6)'t of dx ~ Yru aviation date. iao,o 3 MRIM : Or. ArrclC~xT L/ DA1~E fR7'IWCAII0N I (wc) octiify that tII ctatrQU~tc on US form tm ttnr to the bat of my (ow) kuovAc*. I (wc) em (arc) We oa%aW of 6, proPaty dl s,-M d above„ by virtue of it wrmcn(y flood Moa4~d in Rmisfa of Docds OM,. 0 3 ~itfATZI r OF ArrI1CANT I)till; • • • • • • A "y inforniation tUt is snit-tgms od may m -A is the ani (nY Iermi(being ttvokod by et~r, 7.onin Derartmatt. ' • InclciQc tritir iLfs at,Idica(iolt: t ctimpod w,mn(y dood fMM the Rcchtccoi'Docds otTioc a copy of ti,c cc OV-d MIYCy map if rcfcocaoc Is made In the x:artanty dcrd ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the followiAWe- residence: Street address)__ ( 1J7 _ located - at: '/4, /ls br '/4, Section , Town ZO N ,Range _ 161 W Town of tU~~txl~s~_ St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes__ No_ (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: _ l a - Construction: Prefab Concrete .X Steel Other Manufacturer (if known): Age of Tank (if known): PermOsedPlumber (if known) j - -~h o-ce- 2d o',~ -,icSignature) (Print Name) --_31300` (Title) (License Number) MP/ PRS (Date Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 r~e 16 ~ ~ 'Alsconsin Department of Commerce SOIL EVALUATION REPORT page of - 'Division'of Safety and Buildings in accordance with Comm 85, Wis. Adm X10 County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan t include, but not limited to: vertical and horizontal reference point (BM), direction a Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest PkEK-A~~> IIL/ G Please print all information. Re iewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~x 2 ~ Property Owner , operty location i Sovt tpt 1 /4 1~~t}l A S Z-8T Z- ~ N R L E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1 l lpk),j L 1~ t. aE U 21 u C~ DtH'j (3 C3 )^-1 Cih State Zip Code Phone Number City Village 0 Town Nearest Road SZIU j s ~L SyotZ (~tS) 107 '7LIJ"j,j\,Z\,(z..1>j),jLC New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: Parent naterial Vf`'_l oU 1 l J f4S'~ Flood Plain elevation if applicable ry ft. General comments Z v S~ and recommendations: X 1.Z.S r LLIJIV G 1n.1 l `n~ Z~ VhJ l T.s O F o`er -o U F c s 3~'~ ~7 ~U Ujv °t S . 0 Boring # r❑~ Boring Q y~ r 9i_ i 63 FBI pit Ground surface elev. v h. Depth to limiting factor 7 4 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 ! o_C7 ~.S~li 31.3 l~~ 1 b0 nil of,- 3 0 10 2 S) - U SQ rat } 5 2s- z/ c g- Bonin # ❑ Boring 8F g lei - pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure jConsIstence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cant. Color Gr. Sz. Sh. 'Eff#1 •Eff3#2 -t ~ ~•S I [Z- - 1 1 cs b ~v ct'j . S . 3 Ub_q~ to~-~~ S1 ~S CD I _ , S 9 Z-(o ' Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 150 mcVL ' Effluent #2 = BOD6 < 30 mg& and TSS < 30 w411 - CST Name (Please Print) Si natu CST Number Arthur L. We Rerer ou~c~ '4 03-1ZFj-3 220254 Address W e g e r e r S o i l T e s t i n o & Design Service Date Evaluation Conducted Telephone Number 421 i1. !lain St. River calls, UI 54022 `1 -Z~- p3 715-425-0165 Property Owner Parcel ID# r/JG Boring #❑-y Boring Page of It---~JI SKI Pit Ground surface elev. • j ft. 7 cl Z -J, V? Depth to limiting factor In, Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Soli Application Rato In, Munseli Qu Color . Sz. Cont. ` Gr. Sz`. (Sfh. Roots GPD/ft2 O S `lR 3 1 Prc - al"j 'Eff#1 'Eff#2 ) j U f j n U Ste, h } t ~s Oil Boring # ❑ Boring J ❑ Pit Ground surface elev. 1t. Depth to limiting factor Horizon;. Depth Dominant Color Redox Description Texture in Structure Consistence Boundary S. Roots GPD/ft2 Gr. Sz. Sh. Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor iorizon Depth Dominant Color in Redox Description Texture Structure Consistence Bounda Soil Applicatt Rate In. Munsell Qu. Sz, Cont. Color rY Roots GPD/ft2 Gr, Sz. Sh. 'Eff#1 •Eff#2 'Effluent #1 = GODS > 30 < 220 mg/L and TSS >30 < 150 mg/t. ' Effluent #2 = BODe < 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 0.8330 (R6/00) PLOT PLAN Page ~ of Scale 1'= SO' DoT l..l eve ~?tY..J` 1Z1 ~G:. ~ . c-uL~ UE_S f~C I. ~ ~4 q :11 3 I 3°/0 ? 1 _ I` N I ~(C- P, wry 1 rv 1~"L A L l~r"n..~J l ~ u7 ~ I I ,1 s1 B,3` 3` ~ W~. ar1'Ei-z - ~L.. q~3 • ~f , o,v 31c! (z~-~3~ ~ _ OM~~f 1-~-03 715-425-0165 220254 Q3_\Z6 _ 3 CST Signature Date Telephone 1-To. CST No. Job NO. S c a l e AA Gk- (c11 p a o 1--~--~ Pl,,1(- , l-vl s14 OZ z ~ 01 h' ~J 1NSTS1ll_ "Z Do ~ elf ~'x 1Z5' LuKj 7L 1, ~O lUAJL 1--5 Ol^ I N iz I L`~ly. 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