HomeMy WebLinkAbout020-1071-00-200
'Ariisconsin Cepartmert of ;o,nrne,re PRIVATE SEWAGE SYSTEM Cc.mty St. Croix
Safety and Builcing Grvws On
INSPECTION REPORT Sanitary Permit No:
582085
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No,
Personal information voc p-ovice may be used for se:xndary pumoses IPri•.acy Law, s.15 34 (1)(m)].
Permit Holders Name: City Village Township narcel Tax No:
Oevering Homes LLC TOWN OF HUDSON 020-1071-00-200
CST Bbl Elev. Insp BM Flee BM Descript on SecticniTownlRange.,Map No:
%,4,74 GS 26.29.19.278B-20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ti~5 CAPACITY STATION BS HI FS ELEV.
Septic ~ J'. 0 Benchmark
& ^ ?.o /ecad IZ.6 G.7 T*'7
r I 1 ~'CJ~~ Alt. BM T 1( C~ 7 1 ih
Aeration Bldg. Sewer y G C
Holding SUHt Inlet •i~ 5.&*
TANK SETBACK INFORMATION Sil outlet p ctb -7 /
TANK TO .L WELL BLDG. Vent to Intake ROAD Dt Inlet T
Septic 7- 1 / Ut Bottom ~
/
Dosing ~O HeaderlMan 779,34T
Aeration Dist. Pipe C
Holding - Bot System 9 -T
16il
PUMP/SIPHON INFORMATION Final Grade ` r
Ot,J
Manufacturer Demand StCove, ~t J 1.7 9-5,0#_
GPM 5 4A_
Model Number 34
TDH 14- Friction Loss System Head TDH pt . i c/r - p 7. 2.q
Forcemain 1 Le - Dist to well Y
bZ 3. , d
SOIL ABSORPTION YSTEM -r. P. 4k T!j
BEDlTRENCH 1^;idlh ength No Oi Trer:xis r PIT DIME SIONS Uo Of ° is Inside Dig Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P!L BLDG Vv=LL LAKEiSTREAM LEACHING Manufactur
T.6;4
INFORMATION CHAMBER OR ' r-7VA p
ypF Of System
s 90' G3 UNIT Mod NurnF. r C /
E6 r^ Q
DISTRIBUTION SYSTEM Sovy1,~ 44 +/1 3 -6A-&L-1
Header;Manifo 11 C strbuton x Hole Size x -cle So e:: ng ve_n~ o Air II take /n]
iLengt,i_ V Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or Al-Grade Systems Only
Deptn Over Depth Over 1"0' Depth of xx Sceded Srr,::ted 1XX ulched
BedlTrench Center r Bed/Trench Edges ` -opso E] No Yes No
COMMENTS: (,Include code discrepencies, persons present. etc.) Inspection #1' Inspection #2:
Location: 798 KINNFY RE) ; Lill O
1.) A
lt BM Description = L00 CA, 2.) R;dg sewer length = s.{ dtr~y~._ it ti 5er d S
-amount of cover = /r J
Plan revision Required? F1 Yes >il ^/7
Use other side for additional information. (r~
Dade Insepctor'/ature Cert . No.
SBD-6710 (R.3;97}
}AA Crnmty
Safety and Buildi ivision
K 209 W. Washington Ave., 79 2 Sarmitary petmrt umber (m be filled in by Co.)
r y Madison, W1 707-7 ~j
S1: CROU(cou
ransaM on
N ber
Q oPM~ ~3' Permit Application Stale T
CDCC S 38321(2X Wis. Adm Code, submission of this form to the appropriate overnmental
is required prior to obtaining a sari g are submitted unit the Depaztrncut of ~ ~t Note: Application forms for you provide stav-owned POWTS are to Project Address
(if di$eremu than mailing address)
Safety and Professional Servies. Personal information yon may be used for secondary
ores in accordance with the Privacy Law s. 15.041 m Scats. _
L A lication Information -Please Print All Information 1`4 4
Properry Owner's Name
Parcel ii
eJ~
Property Owner's Mailing Address Q a
i 'op 3 l ocation.24--7?. M .2.79 -.76
City We Govt~ot
zip a Phone Number ft
IAv,`t_.(~el) ~-t (/l1 LY..~'f ,f--✓~.'/s Section
CP140
circle
II. pe of Building (check a thatap T N; R E rw) e-- 4 2 Family I)weiiing -Number of Bc _ -3 Subdivision Name
Blo -~7
❑ Public/Commercial -Describe Used
❑ City of
❑ State Owned - Describe Use t CSM Number ❑ *fliage of
Z ` a t C 01 /S q21' Town of
III. Type of Permit: (Check only on ox on line A: Complete line B if applicable) 1011 11,
System ❑ Replacement system ❑ Treafinent/Holding Tank Replacement Only B Other Modification to
Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change ofPlumber 11 Permit T List Previous Permit Number and Date Issued
Before Expiration raursfer to New
Owner
TY. ofPOWTS S stem/Com onent/Device: Check allthat a I
-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of le
Holding Tank Other Dispersal Component (explain)
~ Pretreatment Device (explain)
V. Dis rsaliTrea ent Area Information:
Design Flow (gpd) Design Soil Application
Dispersal Area Required (st) Dispersal Area Pro (st) system
VL Tank Info Capacity in
Total # of Manufhcrixrer
Gallons Gallons Units ru
New Tanks Ex +;,,g Tanta m 0 U
} ~ ~ ~ a~ ~ ar aj m y
Septic or HoIdiag Tack I U rn v~ C~
Dosing Cbamber
VII. Responsibility Statement- I, the undersigned, responsibility for installation of the POWTB shown oa the attached plans.
Pl s Name (Print) Pi ignanmre
r-~ MPt?ORS Number Business Phone N er
Plumber's Address
(Street City, State, Zip
VIII. antv/De artment use Onl f✓
proved Permit Fee Date su Issuing. Signature
en Reason for Dental 85 • 3 AP
IX. Cond` tt~ts f~oor Dis pproval
ink, 1t>fent tiller ah oiNN tt' ,
404 21 Celt Mt* all sw lees ! n
2. All, as per management plan provided by plu 4-a A&.j
' 1 n1'~ st: be MaiM8rt1>
Me par ~ 60& 16rdinanoea,
Aaach to complete plans for the system and sabmir to the County 9* on paper not less than 8 rrt z ] 1 inches in sire
SBD-6398 (R 11/11)
PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NE 1/4S 26 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 91.0/90.0 5'below qrade 3/4/16 3
DATE BEDROOM
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of conduit ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
All piping shall be ASTM SDR 30/34, within
10' of tank, piping shall be ASTM F891 Scale _ 1/4'1 _ 10' Kinney Road
Vent
>6" Quick4 Standard
of Cover Leaching Chamber Please note: borings will be done
with 20.0 ft2 of Area prior to installation.
12" 5.6ft^2/pair of end caps
Long
Grade at System Elevation
34"
98' 96' 94'
B-3
140'
Vents
40'
30' S I 2-3'X 66' Cells with
>3' spacing
Pro 3
Bedroom
Ouse
B-1
77'
74'
B-2
314' Pro e ine 211' B.M.#1 rl- 5 .M.#2 126' 48'
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 3/4/16
Owner:Oevering Homes
Location: NE 1/4 NE 1/4 S26 T29 N,R19W 798 Kinney Road Hudson
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. EZ-Flow Cross section
4-6. Maintanance and Contingency Plan
7Existing Septic tank form
8. Additional soil boring
Signature
License number #226900
PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NE 1/4 NE 1/4S 26 /T 29 N/R 19 W TOWN Hudson
COUNTY ST. CROIX
SYSTEM ELEVATION 91.0/90.0 5'below grade 3/4/16 3
DATE BEDROOM
CONVENTIONAL X00C IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651
# of chambers 32
BENCHMARK V.R.P. Top of conduit
ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. sameasbenchmark
All piping shall be ASTM SDR 30/34, within
10' of tank, piping shall be ASTM F891 cafe _ 1/4" _ 10' Kinney Road
if Quick4 Standard
Leaching Chamber Please note: borings will be done
with 20.0 ft2 of Area prior to installation.
5.6ft^2/pair of
end caps
3 4" Grade at System Elevation
B-3 98' 96' 94'
140'
Vents
40'
30' 2-3' X 66' Cells with
ST >3' spacing
Pro 3
Bedroom
ouse
B-1
74' 77'
B-2
5'
314' Pro ert ine 1~ 211' B.M.#1 M•#2
126'
48'
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
Vent Typical Installation 96.0'
Grade Vent
3' 4"
.A~30/34 Septic Tank 3'
5' Long 199 5' S' Long 119
3699 Grade at System Elevation Grade at System Elevation
Spacing 5'
2-3' X 66' Cells
Same on other end Observation tubeNent
At end of cell
A
16 chambers per cell B
System elevations:
A_91.0'
B_90.0'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Polls of
Ll NFORMATION
er SYSTEM SPECIFICATIONS
it # >1 ' S eptic Tank Capacity ( 0 NA
Septic Tank Manufacturer D NA
hCOIGNPAPiNETERS Effluent Filter Manufacturer /
Number of Bedrooms D NA
❑ NA Effluent Filter Model DNA
Number of Public Fxility Units .
Estimated flow ~A "Pump Tank Capacity
(a. "rage) NA
Ud Pump Tank Manufacturer
i Design flow (peak), (Estirnated x 1.5) NA
. ' Soil Application Rate aU Pump Manufacturer
NA
i Standard Influent/Effluent Qua) aU Ift Pump Model
by Monthly average NA
Fats; OA & Grease Pretreatment Unit
(FOG) 530 mg& D Sand/Gravel Filter
Biochemical Oxygen Demand (BOOS) 5220 D Peat Filter
MCI ❑ NA D Mechanical Aeration O Wetland
Total Suspended Solids (TSS) s9 s0 mg/L i7 Disinfection
i Pretreated Eftluerg Quality D Other
Brod cati Oxygen Demand (HODS) Monthly average :gw mgn KD Cell(s) O NA
Tote! Suspended Solids ( round (gra vity) D In-Ground (pressurixed)
530 mglL ;B~A .10 rade
Fecal Co6fonn {geometric mean} 5104 cful1 OOmI 13 Mound
iMwdmum Effluent Partids Size Drip-, 13 Other.
36. in dia. D NA r103
her.
A her DNA
*Values tlrPicai for domestic xrastsrv and septic tank efliuern her. D NA
NTENANCE SCHEDULE ❑
~ Service Event
" Service Fn3qusrcy
Ilnsped condition of tank(s) At least once every: ` nth s)
P out contents of tank(s) s {Hhucirttuat 3 years) D NA
When combined sludge and scum equals one-third of
Ilnspect dispersal cep(s) tank volume DNA
At least once every: D (s)
Glean effluent fliter )s (Maximum 3 years) D NA
least once every: month(s)
Inspect pump. Pump controls & arm s) D NA
" At least once every: month(s)
19usfr laterals and pressure tit D s NA
least once every: D month(s)
D year(s) NA
At least once every: DD monthjs}
r. NA
MIAINTENANCE INSTRUCTIONS NA
!Plunons of tanks and dispersal cells shall be madeby an individual car
Master Plumber Restricted Sewer; POyy1-S In Mn9 one of the following licenses or certifications- Mister
a visual inspection of the tank(s) to identify any ms gr or broken Mainteftmr Sedge Servicing Operator. Tank in any rlni lCludude de -sedge and scum and to sthe
o volume must
check for any back up or ponding of effluent on s the ground for teaks, measure the volume of
Visually inspected to c~k the effluent levels in the observation pipes and to check fora The dispersal cell(s) shall be
The Ponding of effluent. on the ground surface may, indicate 'a fail' m! ess the of a on the round su .
l~egula#ory authority. ~ failing condition and requrrs the Immediate iate t Immediate ►rotiflc~tion of the local
When the combined accumulation of
the tank shah removed by a sludge and scum in any tank equals one-third (4) or more of the tank volume the
Adm
the tarstrative Code. Servicing Operator and disposed of in accordance with entire contents of
chapter NR 113, Wisconsin
All other services, inducting but not limited to the servicing of effluent fkara
Ond any servicing at intervals of 512 months, shall be performed merit T8 pressurized c'om ts. pretreatment units,
A service report shall be by a cerWW POWTS Maintainer.
provided t0 the local regulatory authority within 10 days of completion of any service eyed,
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS deck treatment tank(s) for the presence of painting products or other chemicals th*t
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of thO
tank(s) removed by a sage servicing operator prior to use.
System start up shall not occur when son conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. Wherh power is restored the excess wastewater will ble
discharged to the dispersal cell(s) in one large dose, overloading the Dell(s) and may result in the backup or surface discharge of effluent.
To avoid this situation have the contents of to 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 POW
antibiotics; baby wipes., cigarette butts; -condoms; cotton swabs; degreasers; dental floss; diapers diswdbcWrhts; fat; fowndation drain
(sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting produc 0s;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS falls 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 sued.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, an tanks and pits shalt be excavated and removed or their comers removed and the void space fined with son,
. 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 compfant
replacement system:
suitable replacement area has been evaluated and may be utilized for the location of a replacement son absorption system.
>!,Ae replacement area should be protected from distiubance and compaction and should not be infringed upon by requirled
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the nAe4 in
effect at that time.
itsble replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologic a
holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sal and site evaiuaion
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 foilowing removal of the bionat at the infiltrative
surface. Reoonstruclions Of such systems must comply with the rules in effect at that time.
<tWARNiNG»
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE 0 A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Nana J Name c r
Phone
SEPTAGE SERVICING OPERAT (PUMPER) LOCAL. REGULATOR AUTHORITY
Name Name f O
Phone Phone L~
This docxerherrt was drafted in compliance with chapter M 383.22(2)(b)(1)(d)W and 383.54(11 (2) 8 (3), Wisconsin Adminisfrebm Code.
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer (52e ue f ),q
Mailing Address
Property Addre2l
(Verification r v
equired fro fanning & Zoning Department for construction.)
-
City/State
Parcel Identification Number ®o26 -
LEGAL DESCRIPTION l - DD -02 cTZ7
Property Location j _ Y4 , t^ %4 , Sec, / T~
b ~IV It~w, Town of
Subdivision
Lot
Cerfifed Survey Map
Volume-/--) page #
Warranty Deed # -
Volume , Page #
Spec house 'yes no
Lot lines identifiabl Dye no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its re
maintenance consists of pumping out the septic tank every three Pre mature failure to
the system can affect the function of the s years or sooner, if needed, b handle wastes. Proper you put
tic resPonsabilities are s eP tank as a treatment stage in the waste disposal s stem. Owner maintenance
auto
specified in Wonma. 8,3,52(1) and in Chapter 12 - St. Croix Co y
unty Sanitary The property owner agrees to submit to St. Croix Coon Ordinance.
owner and by a master plumber, journeyrnan ty Planning & Zonin
wastewater disposal system is in Plmnber, restricted plumber or a licensedpt vv t a ng t at (1) form, signed by the
less than l/3 full of s e, proper operating condition and/or (2) after inspection and verifying that (l) the on-site
pumping (if necessary), the septic tank is
I/we, the undersigned have read the above
standards set forth, herein, as set b requirements and agree to main
by the Department of teen the
private sewage disposalsystem
Certification stating that your se tics tem Commerce and the Department of Natural with the
Zoe D P ys has been maintained must be co Resources, State of Wisconsin.
g ePartInent within 30 days of the three year t aupleted and returned to the St. Cr
expianon date. oix County Planning &
Uwe certify that all statements on this form are true of my/our
ProPerty described above, by virtue of a 7Dy the best ster of De r ofDeeds Office,
fds Office, I/we am/we the owner(s) of the
deed recorded in Register
Number of bedrooms
TGNA OF APPLICANT(S)
DATE
***Any information that is misrepresented may result in the sanitary Permit being revoked by the Planning & Zoning D artme
Include with this application a recorded warran eP nt_
reference is made in the warranty deed.' deed from the Register of Deeds Office and a
copy of the certified survey map if
(REV. 08/05)
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Parcel 020-1071-00-200 02/27/2008 08:07 AM
PAGE 1 OF 1
Alt. Parcel 26.29.19.278B-20 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
KRISTINE S KNOEBEL O - KNOEBEL, KRISTINE S
601 WEST ST
STOUGHTON WI 53589
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 798 KINNEY RD
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 2.240 Plat: 4211-CSM 15-4211 020-01
SEC 26 T29N R1 9W PT NE NE BEING CSM Block/Condo Bldg: LOT 03
15/4211 LOT 3 2.240AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
26-29N-19W NE NE
Notes: Parcel History:
Date Doc # Vol/Page Type
01/11/2002 667971 1812/613 WD
07/23/1997 434/557
2008 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.240 70,400 0 70,400 NO
Totals for 2008:
General Property 2.240 70,400 0 70,400
Woodland 0.000 0 0
Totals for 2007:
General Property 2.240 70,400 0 70,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00
0.00
io -/F-of
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of •J
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
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.
Please print all information. Re ' w Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). / Ltr
Pr erty Owner Property Location
' ►1 . ne Govt. Lot 1/4~ 114 S Z T 21 N R I j -E fey W
Property Owner's Mai ng Address Lot Block # Subd. Name o CSM#'
Ktnn fs ~!I
City State Zip Code Phone Number City E] Village ~ Town Nearest Road
1- wl SDI) (71S 31XPP525 I s?S
Nf New Construction Use: Residential / Number of bedrooms Code derivedd -flow rate L So o t'- G 6 o GPD
❑ Replacement ❑ Public or commer 'al - Descr'be: 1 I
Parent material Flood P tion if applicable' ft
General comments
and recommendations:
CID N
Boring # ❑ Boring
a X Pit Ground surface elev. ft. Depth t lirhl 'ng factor ii"
j , - Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structur -•t Consisteric ° -Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
a-10 r Z/z... s, I sblC M P r e s z , 5 1
2 to-44 ►o r 51(,0 s zrni l' rr1 r- c t"-) i . S ! 6
® Boring # ❑ Boring
R Pit Ground surface elev. . 13 ft. Depth to limiting factor > I I g 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. r~ *Eff#1 *Eff#2
laa 9 t o r 3 2 t I ! 5 yj
~~r t
eQ -5
3 -1 t ~i, r s S ~ ~ • a.. - .7 t
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CS~e (Please Print) Signature CST Number
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Address
Date Evaluation Conducted Telephone Number
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SBD-8330 (R07/00)
Property Owner 1 In Parcel ID # Page of
❑ Boring
ff Boring # E I Pit Ground surface elev.l b 1, 9 S ft. Depth to limiting factor ~12- 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. *Eff#1 *Eff#2
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Boring # Boring
F-1 ❑ 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/ft2
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 Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
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.
SBD-8330 (R.07100)
Property Owner r) t-\ Parcel ID # Page of S
Boring # ❑ Boring
[K] Pit Ground surface elev. , 9 S ft. Depth to limiting factor ~71 P-o 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. *Eff#1 *Eff#2
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❑ 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/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
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❑ 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/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.07/00)
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