HomeMy WebLinkAbout032-1075-95-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 584716
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 Township Parcel Tax No:
Troy Landry TOWN OF SOMERSET 032-1075-95-100
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No
/6Z . ~ - Z G ~T 27.31.19.377A-10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER . h~ CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ~6- 161 14Z 7
a l a ~zS Alt. BM i 11.x.,.. a,", 3.5 /0 - g
Aeration Bldg. Sewer
3.7 A . S 4d op 0010
Holding St/Ht Inlet
S4 ASZ.7
TANK SETBACK INFORMATION St/Ht Outlet 5 R5 /6Z • y
TANK TO P/I~ WELL BLDG. ent it inta e ROAD Dt Inlet
Septic 6J - z ( Dt Bottom -7 I(SL
Dosing N Header/Man. 971
Aeration Dist. Pipe p
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade /QD ,
Manufacturer GPMand St Cover / CV1J~+ 3_5 Model Num
T Lift Friction Loss System Hea TDH Ft
Forcem th Dist. to Well
SOIL ABSORPTION YSTEM Z •3 i-
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 1
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: /'7'
INFORMATION Type Of System: CHAMBER OR f~~ 4fj
UNIT Model Number:
Ca ~J.e ..3~'i d 57 Z -7 S
DISTRIBUTION SYSTEM ~d /(,o
Header/Manifoll Distribution a x Hole Siz re Spacing Ve t to ilnta
Pipe(s) `
Length ~ Dia Length \ Dia acing Q N
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over x(Depth of r Seeded/S dded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil `
• 3 es ~ No Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1945 CTY RD I G~~ (~J•cJ.. C~, Ml ~ L d
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover = 4-b 6#_ GOo{,- V
Plan revision Required? ❑ Yes to Z/3 ' ~
Use other side for additional informati n. ~v
SBD-6710 (R.3/97) Date Insepctor's nature Cert. No.
ECEIVED
~ County Safety and Buildings Division S ~~o /
D
So, i 201 W. Washington Av P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
'S; APR 18 2016 Madison, WI 5 71
N 3T. CROIX COUNTY ~8~ 7l
N Iry low NA ~uto.p
ermit Application s State Transaction Number
ani ary
"P 7
In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmen t /r
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to LProject Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secon /
purposes in accordance with the Privacy Law, s. 15.04{1} m), Stats.
I. Application Information - Please Print AINnformation
Property Owner's Name
Parcel #
n
III Property Owne s Mailing Address - c
g _ ~ Property Location C a - It 5 _ -
~L c ~'l Gv~ Govt. Lot r a7, 31~ I~1. 3774-j6
City, State Zip Code Phone Number y., Section L 7
S Z Cf~ircie on
II. Type of Building (check all that apply) Lot # /C I -S T ~ l N; R Ent~~
~rl or 2 Family Dwelling-Number of Bedrooms Subdivision Name _ 4- ok c:.,! Block #
❑ Public/Commercial -Describe Use T_ ❑ City of
.`i~._
❑ State Owned - Describe Use P CSM Number 72-1 (PAiO ❑ Village of
Z -74E f! Ow J 4ot 1 -7 Ph 4515 W Town of
III. Type of Permit: (Check o y one box on line A. Complete line B if applicable)
New System ❑ Replacement System ❑ Treatnrent/Holding Tank Replacement Only ❑ Other Modification 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
IV. Type of POWTS System/Component/Device: Check all that apply)
R,Non-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)
V. Dis ersal/Treat at Area Information:
Design Flo d) Design Soil Application Rate(gp Dis al Area Repired (st) Dispersal Area Proposed ( System Elevation
VI. Tank Info Capacity in Total # of Manufacturer ,
Gallons Gallons Units p c
New Tanks Existing Tanks Y, io
a a, U vm Z a2 i.; V pr
Septic or Holding Tank l Dc
- .
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POSVTS shown on the attached plans.
Plumber's Name (Prinrtj Plumber's Signature
MP/MPRS Number Business Phone Number
1-3 y
Plutrii3er's A~d/dress (Street, City, State, Zip Code) °
A
VIII. un epartment Use Only
pproved 9Disapprove Permit Fee Date sued Issuin went Signa
ner Given Reason f Denial '
IX. Condi easons for Disapproval
k, eftlt*nt f fte• turd
dispem-31 Cell must all Pi, ~tC9 t rna~n J
"aS;per management plan provided by plumber.
2 0-ietbdck regidretaenls must be mainttinad
as per applicable coda / ordinaWA3, '
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD-6398 (R. 11/11)
Paae 3 of 3
.-vane C~r`lJ y
B ri an P a rn e l l
7c J''L CST 231314
:'Dale ~/-17 /
Benclzi~zari: 1 ~D~ ~ ~f° f 0
/>e c lz,--e.1 C'f /oc>J' L f~ 7 L~
S'Oll hOrM0
~ ~~lllCl~lc r~I'CCl -
1 40' Scale
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:_ ,~L.2k~✓~
Owner's Name:
Owner's Address: T~ ~
Legal Description. -
6e c- _27 196e_;
Township: op,
County: ~Subdivision Name:
Lot Number:
Parcel ID Number: _ 210 3 Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing
Page 4 System Cross-Section
Page 5 Filter Specs
Page 6 Maintenance & Management Plan
Page 7 Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
11Z /I e
Designer/Plumber: /
License Number: ~ ~ ✓
Date: Phone Number 7/_! Z -e- 7 -326
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 S13D-10705-P (N.01/01).
Page 1
v NE : Page 3 of 3
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:=add cSrr 23 1314
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SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page of_
Project Name: ✓ Z~~~
i
No. of Cells _7 Per Cell
ft Cell Width Total No of
_ ft Cell Length ~Q sq ft EISA Per Cell
J ft Cell Spacing sq ft Total EISA
Manufacturer Model Laying Length EISA Rating
Infiflrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
Graveiless Leaching Unit Manufacturer; I
Graveiless Leaching Unit Model:
Typical Cross Section
Finished Grade
Observation Pipe with
approved cap or vent
%:•::.::::•:::::;__--Soil Backfll
-37in
..a:::::>::> Geotextile Fabric
J~ 'ft Infiltrative Surface
72 in
^ ft Limiting Factor
Slotted and Anchored Vent1
Oin
Observation Pipe with Cap
• . ■ ■ ■ ■ ■ ■ ■ \ s f . r r t i . • s ■
Plumber/Designer Signature: z
License 2.31
/y Date:
r
i
PJ31 VFAFLOX- INSTALLATION INSTRUCTIONS
A 1w.
(ic=Drainaye Zabe1°
& Ads PL-525/PL-625 FILTER
INSTALLATION INSTRUCTIONS
Center fitter
with opening i
-
j
_ r
PEPSI
281-
'M V-4; 1-~'
Addrf~o W pipe or r
Poly~kExfend& LoTc blue
forcenfenng
Step 1: Step 2: Step 3:
(A) Locate the outlet of the septic tank (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
is positioned so the filter can be housing, making sure the filter
removed from the tank for cartridge is property aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS
i
I
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t .Y
RN,
max. . ter- ~ F
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Step 1: Step 2: Step 3:
Locate, the outlet of the septic tank (A) Remove tank cover and pump (A) insert the filter cartridge back
if necessary into the the housing making sure
DO NOT USE PLUM
M' I (B) Pull the filter out of the housing. the fitter is properly alighed
WHEN FILTER IS RE
(C) Hose off the filter over the septic flank and completely inserted.
[1SE f2UBBER GLOVE Make sure all solids fall back into the (B) Replace septic tank cover
WH)=N CE_EAIVIIV Flly ER septic tank.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of _
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner ..1. Septic Tank Capacity rC~!"i0, al D N1 n l
Permit N Septic Tank Manufacturer ( e_-' ❑ rv
Effluent Filter manufacturer pc ~ 4 C- O N,,
DESIGN PARAMETERS
Number of Bedrooms O NA Effluent Filter Model r' ❑ N"
❑ NA Pump Tank Capacity AI D N-
Number of Public Facility Units -
Estimated flow (average) 3 6) O gal/day Pump Tank Manufacturer ❑ P"'
Design flow (peak), (Estimated x 1.5) v Pump Manufacturer ❑ N
gal/day
Soil Application Rate 2 Pump Model ❑ NF`.
gal/day/ft
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ Ni,
Fats, Oil & Grease (FOG) 530 mg/L D Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODE) 5220 mg/L ❑ NA O Mechanical Aeration O Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ N` `
Biochemical Oxygen Demand (BOD,) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA O At-Grade ❑ Mound
Focal Coliform (geometric mean) 510° cfu/tOOml ❑ Drip-Line Z) Other;
M Particle Size Y, in dia. ❑ NA Other; D Nf.
Maximum Effluent P
Other; ❑ NA Other; ❑ NA
Other: ❑ Ni'.
"Values typical for domestic wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
Service Event Service Frequency
nth(s) (Maximum 3 years) ❑ NA_j
Inspect condition of tank(s) At least once every: 0 moear(s) : - !
Pump out contents of tank(s) When combined sludge and scum equals one-third (YS) of tank volume O NA,
❑ month(s) ` (Maximum 3 years} ❑ Nh
Inspect dispersal cell(s) At least once every: year(s) I
❑ month(s) ❑ N;:.,
Clean effluent filter At least once every: .Iyear(s) _
❑ month(s) ❑ Ni
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) c
Flush laterals and pressure test At least once every: El Nb
p ear(s)
Other: At least once every: ❑ month(s) O NA
O 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.
he 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 Administratlva 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.
(3MW (4/01
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 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 oeli(s) and may result in the backup or surfa0® 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 arv<o
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 systerrt i
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 rnatorial.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following rnuasures 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 rnus:
comply with the rules in effect at that time.
0 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.-.. -
❑ 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 systerns may be reconstructed in place following removal of the biarttat 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
...aft
POWTS INSTALLER POWTS MAINTAINER
Names Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
`his document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Page 01
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 bu
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surfeoe 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 grub
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 systern s
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.
. r' W
• 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.
'ONTINGENCY 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 location4 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 mus;
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,-------
❑ 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> >
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, RE&CUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
,DDITIONAL COMMENTS
OWTS INSTALLER POWTS MAINTAINER
Name Name
Phone f~ Phone
EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name( Name
Phone Phone
us oocument was drafted in compliance with chapter Comm 83,22(2)(b)(1)(d)&(f) and 83.6401, (2) & (3), Wisconsin Administrative Code,
ST. CROIX COUNTY
SEPTIC TANK MAIZgT.ENANCE AGREE /TENT
AND
OWNERSHIP CERTIFICATION FORM
Ow-m,/Buyer
Mailing Address ~f `72 -7 C f ✓ l C%r ~ J G ~n ~ ~ ~f ~
gee
Property Address I
(Verification regm red from Planning & Zoning Deparment for new construction)
Cif/State ►yn Parcel Identification Number 03-2 / 0 7 59-
LEGAL DESCRII'~T/ION
Property Location / r ,V V,, Sec. 2- -7T.31 N R r/( , Town of In e J- e
SiAbdiuision 7,0~ r
Certified Survey Map # , Volume , Page #
Warranty Deed l Volume , Page #
Spec house yes no Lot lines identifiable no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its prernumre fame to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumpm What you putt into
the system can affect the function of the septic tank as a treatmeat stage in the waste disposal system. Owner = atiben m
responsibilities arc specified in Women. 83.52(1) and in Chapter 12 - St Crone County Sanitary Ordinance.
The property owner a,,arees to submit to SL Crvia 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
wastevrater disposal us--em is m proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 fu11 of sludge.
v
Vv,re, the undersisaed have read the above requirements and agree to maintain the private sewage disposal system with the
_a-2dz7s set forth, herein` as set by the Depa t of Commerce and the Department of -lIatmaI Resau rees, State of Wisconsin.
Cex L. zcztioii stating that your septic system has been maintained most be completed and retu med to fire St Crone County Planning &
Go_ n.a Dear i, ear v'ithin 30 days of the tflree year expiration date-
Vvve certify that all statements on " form are true to the best of my/our knowledge. Uwe amlam the owner(s) of the
property described above, by virtue of a deed recorded in Register of Deeds Office.
Number of bedrooms .5
_~Llt -7 11 (J
SSIGNATME OF APP CANT(S) DATE
may information drat is misrepresented may result is the sanitary permit being revoked by the Planning & Zoning Department.
ode nzfn this application a recorded wm=nty creed from the Register of Deeds Office and a copy of the certified survey map if
-en.e is made in the warranty deed.
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of 5a~.3ty and Buildings Page -of--,
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County r, I
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # L
0 3
APPLICANT INFORMATION - Please print all information. Reviewed Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Prope Owner Property Location 7
7 Zajl Govt. Lot kf bll 1/415 bV114,S Z T N,R 0 (or W
Prope/rty/ Owner's Mailing Addre Lot # Block# Subd. Name r CSM#
City State Zip Code Phone Number _
El City El Village ® Town Nearest Road
0. New Construction Use: D Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow ( ~✓1 ~pd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required 15_7 71 bed, ft2 T _c:% trench, ft 2 Maximum design loading rate bed, gpd/fit 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations p
Parent material _ A~J l ~~'Gf~] 7 ~c..`.a1 Flood plain elevation, if applicable ft
S = Suitable for system T Conventional Mound In Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U EIS ❑ U 0 S El U S El U ❑ S U El S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground 7 }
VTV
Depth to
limiting I~
factor
in.
Remarks:
Boring #
,~.-2.1
Ground
. , elev.
6 7`ft. ,
11 ~
Depth to
limiting
,factor
in. Remarks:
CST Name (Please Print) Signature _ Telephone No. - a -y
Addressg Date CST Nu'ber
ll~`' L ~~C
SOIL DESCRIPTION REPORT
PROPERTY OWNER y I y Page 2 f
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
a C~
Ground .7
elev
Depth to -
limiting
factor
in.
Remarks:
Boring #
j % ~/✓4 -
9
Ground P S (7159 f`,72 Z'
elev. d
C/ ft.
Depth to
limiting
factor
in. Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. ~Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # p /C'jf~ 1~t L ;~/~1S riot / ~y' ~M S_
Ground /Lli* : t rc=a MZ-
y7 . ,
elev.
ft.
Depth to
limiting
factor
16f8 in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD-8330 (R. 07/96)
SOIL DESCRIPTION REPORT 2
PROFERTY OWNER r-may Page of `
--mss
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
2 Il-Z Z 7w Sys (s A%- 8
Ground M-5
e o
7
elev 144 Depth to
limiting
factor
0 in.
Remarks:
Boring #
I b -/s //4 SL f6~r~~~ c G- o o s
Z Z_ Z M.s k
3 3e- yi 7s
Ground y `1y/lD ~C~//( ~i ~S QSc /-,72 Z_
elev.
Depth to -
limiting
factor
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
2 a- zl /Dl/~ si Ql/,~ S Zrnsb~ s~ S 1 s ,
Zl 7sf~N' ~iy /A~//A/ / ds5 m c 4, Jv~ .7 .8
Ground &14 M L- r , O
elev. -
Depth to
limiting
factor
108 'n. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
- Remarks:
SBD-8330 (R. 07/96)
0W ER Page 3 of 3
i~ ame 'r/(j~/ Lu✓y Brian Parnell
Address'
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