HomeMy WebLinkAbout020-1441-78-000
:'scc^s Dera7 r. '.omme PRIVATE SEWAGE SYSTEM cure" !jr,lk
afe anc huncic n -w;~sien 1 _7
INSPECTION REPORT Sarwary =`wmr. N:
0
GENERAL INFORMATION iI °E?Ml S~T~`3S
IS;ate Plan IC Nc
ersona ir.formatror vnr. nr[r,ioe ma: De uses to- secorjan uu Doses r%m.a~::aA.
I enni Holoe-s Name L; n Oliac X Tovrnsrnr r"are. Tax Nc
J r
o 3N =.Iev Ta Insc BM Hie, BAJ Descnotror. I
Section iowniRanyeRJlap
95. aS Co- L 3 G. 29. lc . zSo
TANK INFORMATION ELEVATION DATA
TYPE MANU=ACTUREFi STATIDN 3S Hi FS
,BPtic h'. x v /4n6 3encnn ali. 2. 1 I -7/ . 4 ':T • 6
5
Al: BM
660 eraUDr. Blac Sewe-
taking (SJH: Inlet
TANK SETBACK INFORMATION "A H* Dutle.
`=,NK TZ, P!. W B_D ven'tc r ur akc r^,,'1AC D! mle:
~0 1:4 L4-
I~eDti_ D ~~Z7 ID: Bottom 7
IDnsinc g O ✓ 5`~
HeaaerRJlan, a 7 c7, 4 1
.r1°, atlDr 7
~ Dist Pide i q
-io:_-ln~
_ I Bot Systerr 9~. 0 8_y, 35
i 8~.3
PUMP/SIPHON INFORMATION =final G-aae
IJlanufaawre• ~ n + ` IVPmanc S. Cove' G
I I
v
Iv, .del NDmbe S 3 -
TDH Lif ' Fr ct on Lc~ 5 Systen tieac TDH
J /~J 7.
(o ~.J S 3d-e r~ r. C0. +
1=oresmalr Lengt s D,Ez it lust tc k'%E: t
16,1 fro Ja
SOIL ABSORPTION SYSTEM 5 s 4-cr,n aj v- ja 1z,
BED'TRENCH vViytr, _G ~Nc -)"7-nches PI? DIMENSIONS Nc O"'i's Insltl<_ D:e. --ilquic DeAn
DIMENSIONS
S`-TRACK SYSTEM TU ?/L 'B-DG tNE~_ L4KE,STP=qPJ LEACHING Manu'aotu r I r
IWORMATION CHAMBER OR
3t0 y I UNIT thous: Nu-De
44 DISTRIBUTION SYSTEM / ~ f 3 Z. Z/MX--
Hca3erllaidoic 11 Ci!AriuurDr x hole SIz~ x. Hoe Soactnc Yell' 1,; Ar IntaKe
x / PlIDets
e-~t- J U Ci,~ _?nctr ~ D;~ Soacm~ ~ 5
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only r~l,Je6r} C.ti
-cot- wer IDeDtr Dver Ya:).-Dtr C., X 5"U_d:SO7aec YJ `hU'. r
I=d iIZ•ncn ent=_r IBeaTren r ❑Dge~-^ ,Di',_ _
~ r'e> Nc. N.:
COMMENTS: it tciuae cdae ols-reden te;. r>arsons present etc. Irspecnor Insractior _ _
Location:
~ar..((~, Parcel No: -
Al*. BM Description ! d ~t1~f ! / aLc
Blda sewer Ienatn = I cJ~ IY- ~o-
- amount of rover G •+T'~
ir ~ I Ve t e,
Plar rev;sior Redulred" ~ Yes x o G, 1 Q ) r / ~3
Use other sine for additional Information ~J l U 1 lQ (Q 5
417
Date Insee;:t Slona;u per. r
1
-VED
~ 1 ,
lei : ti,ti Safety and Buii +
s Givr
E'-I `8 S` ll 1 G 201 W. VJashingtzin P. Eox;L162 Sanitary Permit Number (to be Ued in by CoJ
P- Madison, W. 537! }162 t'
OUNTY 30M VVELOPMENT /
Sanitary Pennit Application 9t-=Trama=on ba-
n. actortaux wift SPS 363.21(2), Wis Adnt Cede, ;ujrnjssioe of this form to the appropriate govt ental unit N
k required pnor to obtaining a smitan, permit Note Appb:ation forms for stattawned PO WTS are submafted LD Project Address 'if different that, matting address)
the Dep c(metit of Safct) and Professional Setvim. ?nwnal information you provide nia~ '-e used for secondary
' yJ
umosm ~ accordance with the Privacy law. s. 1~.C46, ilai, Stan. 65S f w~ 1:) C--(-'
L Application information - PI se Print All Information
Prop' O'raorr. Parse[ i? ~
Property 0%='s Mailmg.gldress Property Loca¢ion 3 . • a `I _ I
CwVL Lot
LRY. rp e Phone Ntunher
M&Z 4, Section
tro,e on
` II. Txne of Build* ati (check all that apply) : of #
or 2 Farnii) Dwellin,-NwTrx of Be Subdivision Nam:
~
Bloek?r O 1.4 1 Or
❑ PubhciCoclmerial - Describe Use tla me -
- City of
❑ State Owned - Describe Use CSM Number 0 Village of -
2- 61s~- ATowa of L Qs~~./
r
Ill. Type of Permit: (Check onl_ one box on line A. Complete line B if applicable)
A.
~j~l~ew Sr3tem a ement S..-stem _ Treatmenu'Holding Tani Rz-p.a_eoent Only ❑ Officr Modification to Ex:, o S
i -nne ystcm (explain
1t
`U Permit Renewal ❑ Permit Revision El Cb2-tge of ?I unhet- f Permit Iransfe, to New List P /P~rmit ~ um ter and Date Lssucd
Befixe Expiration I i_taxer W Z~
IV. Ty
i 'pe of POV1'"I'S S~•stetw'Component,'Device: (Check all that app{v) _
~~vtro-Pressuri;,cd Ir.-Crrnund ~ F'ressuri2ed ln-Ground ❑ !.t-ir.;tde C Mound > 04 in. of suirairlr. ,nil ❑ hlotmd < 2~ m. of suitable soil
❑ Holfluag Tank t >ispersa Com;.ooent (exptain) ❑ Prarca3nent Desire (expiainj
I V. Dis ersaL7rcat t Area Information: f t -y rte
Cksi~n F?ow (~d,~ iksigo Soi] .4pplicarion Rata~f) Dis : al Are:, Rryutrec (;fi D's Area Proposri sit ti~stem Eleca~o _
Y
' d '0 c7
V t Tank Info Capacity in TOW - *of Manu acrurer
Gallons Gallons Units Ir -
Ncw Tanks ?s-- Taal-s
/ w - V ll .C1 n.r
Seprie or
iioldiog Tan:
lX~J ~ tr✓ • jL
S
Dosing Chacuber
za~
VII. Responsibility Statement- L the und
I W.Rj%.j.q
for installation of the YON' TS shown on the attached plans
Pt s ?lame (Print" MP.,'!vIPRS Number BLLSiness Phone Nrapber Plumber's ad&ess (Street, City, Stave, Zip CodeV~_ 1. 'ounri:,De artment Use Only
-
hs.tiug . E Signa:=
pproved f - ?C mn Fee DDa rh s_ue/
eason for ')en ai 1 O I J V
D{. Condi asous for Disapproval
1. 5eptr_ tank, etlfutint fitter and
disper- w cell must all be s9tvtces _r raai_nt r
es per management plan provided by plurnber.
2. AN stetbdck recluvet Hants must-, & r, l*OiAid
as per apFkabkl code 1,xdirtanC".
.4emch :n mrapktt p':anu cur rue sv:ten: and submit to the County only as paper uut teat than g to z 11 iwIkC' in vtr -
SBL)-6398 (R 1111)
PLOT PLAN
PROJ ulv'r Dave Diemel ADDRESS 655 Marv Jo Court Hudson Wi 54016
S E I, 4 NW 1,14S 36 ; T 24 R 19 W 'r()wN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 89.0!89.0 6' below grade DATE 5!2i16 BEDROOM 3
CONVENTIONAL IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE630 DOSE TANK SIZE
MOUND
HOLDING TANK SIZE LOAD RATE 7 ABSORPTION AREA 651 # of chambers," 2
BENCHMARK V.R.P. Top of manhole cover
Asst!nlt: r;I.I:V.a'rIC>N 95.I►5' Filter Lifetime Filter
❑ BOREHOLE (D WELL *H.R.P, same as benchma-k
All pipingshall be ASTM SDR 30,34, within
10' of tank, piping shall be ASTNI F991
Existing 3
Bedroom
House.
Scal eltl-r 4" = 10'
20'
>6" Quick4 Standard
Leaching Chamber
of Cover with 20.0 ft) of Area B.M-"
5.6ft^,'pair of end caps Huffeurt Comho'fank
4' I:ono 12
Grade at System Elevation
34
2-3' 1 66' cells with >3' spacin2
valve is to 1)e 'l nstalled
B-3
~0-
Please note:
soils will be
field verified
for depth of 40'
system, to be
installed Vents
B-1
at least 6'
below 2rade
B-2
20'
100'
160
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 5/2/16
Owner:Dave Diemel
Location: SE1/4 NW1/4 S36 T29 N,R19W 655 Mary Jo Court Hudson
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Sectio
4-6. Maintanance and C ti gency Plan
7. Existing septic tank f
Signature_ _
J
License number #226900
PLOT PLAN
PROJECT Dave Diemel ADDRESS 655 Marv Jo Court Hudson Wi 54016
SE 114 NW 1145 36 /T 29 N/ R 19 W TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 89.0/89.0 6' below grade 5/2116 3
DATE BEDROOM
CONVENTIONAL IN-GROUND PRESSURE: CONVENTIONAL LIFT XXX HOLDING TANK
WOUND SEPTIC TANK SIZE 1000 gallons LIFTTANK SIZE630 DOSE TANK SIZE:
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of manhole cover ASSUME ELEVATION 95.05' FilteC 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 ASTNI F891
Existing 3
Bedroom
House
'SCal ,elt/4" = 10'
>6 Qu1ck4 Standard 2(~
of Cover Leaching Chamber
with 20.0 ft2 of Area B. N9.
5.6f "2'pair of end caps Huffcutt Combo Tank
4' Long 12
Grade at System Elevation
34„
75'
2-3' X 66' cells with >3' spacing
a valve is to he installed
B-3
50'
Please note: /
soils will be.
field verified
for depth of 40'
system, to be
installed `ills R-1
at least 6'
below grade 10'
B-2
20
100'
160'
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
5.6ftn2 pair of end plates To be >1' above grade
/ Finish grade elevation
Typical installation 95.0'
Vent
Grade Vent
3' 4„
3'
,A~-30/34 Septic Tank
5' Long i 5'
5' Long
36" Grade at System Elevation Grade at System Elevation
Spacing 5
2-3' X 66' Cells
Same on other end Observation tube/Vent
\d of roll
A
16 chambers per cell B
System elevations:
A-89. 0'
B 89.0'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pne cf
ILE INFORMATION SYSTEM SPECIRiCATIONS
Owner 4 r rl Septic Tank Capacity /Cz-~l Gal 13 NA
Permit* Septic Tank Manufacturer 0 NA
IGN PARAMETM Effluent Fiker Manufacturer p NA
Number of Bedrooms 7 o NA Effluent Filter Model ~ ❑ NA
Number of Pul* Facility Units -ANA Pump Tank Capacity , 0 l ❑ NA
Estimated flow (soerage)
Pump Tank Manufacturer NA
galiday
i Design flow (peak), (Estiirttaled x 1.3) t Pump Manufacturer , ❑ NA
Sod Application Ratez Pump Model l"~ 3 (7 O NA
i Standard Influent/Ef mrd 0uality Monthly average Pretreatment Unit
Fats; Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODe) 420 m q& ❑ NA O Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mglL ❑ Disinfection ❑ Other.
Pretreated Effluent Quafity MMM average Dispersal Cell(s) ❑ NA
Biocher scat Oxygen Derraxi (SON 530 m0& A-IP-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids CM) Gi0 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coft m (geometric mean) 5104 cful100mi ❑ Drip-lane ❑ Other
iMaximum Effluent Particle Size 36 in dia. p NA Other i ❑ NA
other - ❑ NA Other
_ ❑ NA
'Values typical for don neck wesfevater and septic tank effluent. Other. ❑ NA
NTENANCE SCHEDULE
' Service Event Service Frequency
linspsct condition of tank(s) At least once every. (Maxirmirn 3 years) ❑ NA
(Pump out caontonts of tank(s) When combined sludge and scum equals one-third (Y} of tank voume o NA
Inspect dispersal cell(s) At least once every: y ~)s) (Maximum 3 rears) ❑ NA
clew emuert fitter At least once every: mmo ❑ NA
--1 12 year(s)
Inspect pump, pump owitnals S alarm At least once every: - h(s) ❑ NA
f=lush laterals and pressure test I At least once every. ❑ month(s) - NA
❑ ear(s)
At least once every: ❑ month(s) NA
❑ year(s)
IYIAIKTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certltications: Master
(Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank atspectjpns must
kx kAe a visual inspection of the tank(s) to identity any missing or broken hardware, identify, any cracks or leaks, measure the volume of
Combined sludge and scum and to check for any boa up or ponding of effluent on the ground surface. The dispersal oell(s) shalt be
visually inspected to check the efflueM levels in the observation pipes and to check for any ponding of effluent on the ground surface.
'The por>diing of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local
regulatory authority.
When the combined accumulabon of sludge and scum in any tank equals one-third ('A) or more of the tank volume, the entire contents of
Ike tank shay be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
AdrniNstrative Code.
Ail other services, irxluding but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreafrnent units,
and any servicing at intervals of 512 months, shall be performed by a certified POINTS Maintainer.
A service report shaft be provided to the local regulatory authority within 10 days of completion of any service event
Page of
START UP AND OPERATION or other chemicals tth~{t
For new construction, prior to use of the POWi'S check treatment tank(s) for the presence of painting products
detected have the contents s t t
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are
tank(s) removed by a septage servicing operator prior to use.
System start up shall not o=sr when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fit above normal highwater levels. When power is restored the excess wastewater will bp
discharged to the dispersed cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluenL
To avoid this situation have tine contents of the pump tank removed by a Septage Servicing operator prior to restating power to fide
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.
Reduddon or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POVIM
antibiotics, baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers: disKhfectarhts; fat; foundation dram
(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 propeilY
and safely abandoned in compliance with chapter Comm 133.33, 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 falls and Cannot be repaired the following measures have been, or must be taken, to provide a code compflont
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by reW[*d
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area VAN result in the need
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must corrnply with the rule:) in
effect at that time.
~,A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWT'S technolagV 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 sail 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 m:sort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstivcted 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 ANDIOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANI{ UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE 0 A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS -
POWTS INSTALLPOWTS MAINTAINER
E Name 1112 Name ` j
Phone ll~ K-;- ~ Phone ~1 - j"
SEPTAGE SERVICING OPERATOR (PAMPER) LOCAL REGULATORY AUTHORITY
Name NamL--
P11-tooe P hone L
This docranentwas drafted in compoance with chapter sPS 383.22(2)(b)(1)(d)&(f) and 383,54(1), (2) & (3), Wisconsin Administrative Code.
S7 (~RoIX C(}UN,PY ZONING OFF'In8
CERTIFICATION STATEMENT
OR UTILIZATTON OF AN EXISTTNG SEPTIC' TANK
'This- is tc, certif
y that I have Zecte,,
SIE ,',-ving the the septic tank
~ /
'
residence 1bCCt~
_ Section a t-
/_the tank y TJp°11 inspections, and baffles to T certify that I have
be.n goad co f(.)ztjlc!
t urict.iol"r-q properly. edition, and it a
ppear.•s to be
tst time serviced:
1; i c3 t low back OcCI ~
L'rOM No absorption system?
Y T's
(If
Apr), no, skip tter,t: i.i ne)
raximat, volume or length of time;
~par_~ ty:~0•'SJ gallons ,
m.ir~ur.t•
'-~nistrurt.ian: Prefab Concrete
Steel Other
(If known)
")'Je Of tur
(x f known;
`
(Name) Please
pry. t
L~-"LL._ - - -
( 1Cense Ntlmbelr•} _
1'un-tit to be completed by licensed
S' atutes) or Licensed Disp (soser NR plumber .
Code 145.06, Wisconsin
113 Wisconsin Administrat.lve
1'Iumber (applying for sanitary permit)` Certification: aon i
t:c~ncl Ig the above statement re g
I certify that the tank tog ing existing septic talk
conforw to the re e best of my knowledge wil..l
qu rementsc,f ILEt g
Adm
i n spect ion openin . Code (excep~for
e " g er outlet batf Is.
N1 all P 7=
Signat MP/Mms ? 66
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.) `
City/State Parcel Identification Ntunber 0ov _ ~;~I
LEGAL DESCRIPTION
Property Locatioua_ Sec. T Z7 N Rg W, Town of 2
l .
Subdivision , Lot #
Certified Survey Map # , Volume - , Page #
Warranty Deed # Volume Page #
Spec house no Lot line;: identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTMCATION
improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every tlnee years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage m the waste disposal system Owner maintenance
responsibilities are specified in §Cormm. 83.52(1) and in Chapter 12 - St Croix Coa my Sanitary (kdinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1 /3 full of sludge.
I/we, the undersigned have read the above requurmeats and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Departruant of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completvAl and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date-
I/we certify that all statements on this form are true to the best of my/our k.aowlcdgc. I/we am/are the owner(s) of the
property described above, by virtue of a7 deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNA O APPLICANT(S) ATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department
Include with this application a recorded warranty deed from the Register of Deeds C)ffice and a copy of the certified survey map if
reference is madt in the warranty deed.
(REV. 08/05)
L
Yq (~Coi1' 9
LOT 76
4.71 AC FIM i!
30s,=6 so. FT
LOT 76
2M ACM
107,917 90. FT
M'
t
wew.s~ae s+isl'
ANSI' 150.OV
l.~t~J ~ U a
LOT 77 a
241 OZM °
104,M so FT
o~
01
~ 4 $ chi
Lcrr
• 3.m ACM
116,347 SQ Fr.
L.8.0. - 1omm I o
zot TO
3.16 ACAM
b,IiESG FT,
~M 11asr ~
° LOT YO
LOT N i I z AC1iM
za Ao~ ; w; 4 12 =0 90, Fr.
Sam? so Fr g ~ t' r
_ LB.O. 1m1,6 p
.ay r
(Nisconsir rbepartmert of Commerce PRIVATE SEWAGE SYSTEM Canty: St. Croix
Safety and 2uildirg Divisior
INSPECTION REPORT san ;ary Per-nit No:
430626 0
GENERAL INFORMATION (ATTACH TO PERMIT) Stale P'.an 10 No
Personal informaton wt. r,vide. nay be used for sewndary purposes (Privacy Levi. s - 5.C4; , I )lm}].
Permit Holders Name city village X Township Parcel Tax Ne.
Bast, Kernon Hudson Townshi 020-1441-78 000
CST BM E ev Insp BfA Elev: BM Descnptinn: Seci on/rcwntRange'Map No
17 S.& U c/ , 36.29.19.2804
TANK INFORMATION ELEVATION ATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
,1, ?S t-, k
Septic B r nrn rk ~X"o 'iI o~ZS 9S iq
Dosing G~~ Alt. BM Ca V1512 Aeration Bldg. Sewer ~SG/L/ 0
He ding SUHt Inlet 13/
r
TANK SETBACK INFORMATION SLrHt Gullet
TANK TO P !L WELL BLDG, Von! to Air Intake. ROAD Of Inlet
Septic , 1 1 lQ1f / 'S Dc ~Q
Dosing He4an. ~i S
Aeration Dis P pe
S .9 sy
Holding _ 13ot. System r
PUMP/SIPHON INFORMATION FinalGrad43 1,7
Manu`acturer Demand St Cover
7
GPM / ' I~+'n , 2 9S D S
Model Number
S 3 G 2'~ wog ►7
TDH Lift Friction Lest 'Ste Head TDH F:
5 E7.t~ c17~ j. Z
For .ma 1Len to Dia. D t to'Ne i S
in 2 " jJ
SOIL AB ORPTION SYSTEM /17 -aA-cbt -Z-Z~ -
BED/TRENCH [..'tllh encdth No Cf reaches PIT DIMENSIONS `Je of Pits Inside Ow Lcuid Depth
DIMENSIONS 2 '
J
SETBACK SYSTEM TO P/L BLUG_ WELL LAKE!STREAM LEACHING ►.4a - t
~(a✓ u~~ k
INFORMATION CHAMBER OR
Typ 'f System 1 X r N 0 `y i i UNIT Mcdel Njr-her
r
15 T~ / ~J i
DISTRIBUTION SYSTEM ~j olAd C-Llls~ri6QJli
HaadQr~ tar fc d Distributior x Hale Size x He e'pnci ng !eat Io All IntaKe
~ ~ !r Pipe.;sl ~
L).7 1
ength_~ Cia Length / 7i2 ~ Spacing_ ,LL
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only S
Cepth C.'er 7epih Over xx Depth of x_x Sanded Sod:fed xx h"~khed
Ha 1rI each Center ` 1 1Q~yy Bed/Trench Edges Tcp`ui; "es Jo 'Ies No
COMMENTS: (Inaude co e disrrepenc es, persons present, etc) Insper.tinn #1 _ . 2 Insoection #2: _ r
R dpe 1st Mot,
Location: 655 Mary Jo Court Hudson, SwI 54016 (SE V4 NW 114 26 T29M R174) Cottonwood
fi Parcel No: 36.29.19.,2-80_4, /
1.) A t BM Descr'pticn = ST' CO Vi~M
2.) B.dg sewer leng'h - Zc>'A kw,
amount of cover = ? g Z~, G1X~'~
~~{jti ' So r r q +
Plan revision Requ red? Yes
Use other side for additional riforriabon.
Date Insepctor s S _Inattrre Celt No
SBD-671C ;R 3 97'I
_ J
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of
Division of Safety and Buildings
in accordance w•th Comm 85, Wis. Ad m. Code
County e
Attach complete site plan on paper not less than B 1f2 x 11 inches in size. Plan must
Include, but not limited to: vertical and horizontal reference point (BM), direction and Pam I.D
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 7 -00
a
Plea print a wed by Da
TC
Personal iMorrnatbn you PiGe y be used for sewn ary purpaee (Prr Y Lew. S. 15.04 (t) (m)). Q
Property Owner Property location
k rr"\ar, & -Lb 1 6 2004 Govt W s 114i(fuj 1/4 S T N R E(or
Property ownees Mailing Address T i:RO X C ()1. I., ~ # Block # Subd. Name or CSK"
df~YC T •i.
f NING C FBI 7 a oo r n
State ❑ City ❑ Village ® Town Nearest Roab
vcts6 wl al ( ) Al e~
® New Construction Use: ® Residential! Number of bedrooms -y Code derived design flow rate Y5016 OU GPD
❑ Replacement ❑ Public or commercial - Describe: rI
Parent material -1L! FkM Plain elevation f appicable 'W A tL
`,ems motions: sy~~ Ql ~v. fo, op
F IBoring Bo'ring
Pit Ground surface r 0 ft. Depth to ll n&Q factor , in.
Soy kallon Rats
HOri M Depth Dominant Col Redox Texture StnMn Consistence Boundary Roots
In. Munsell Chi. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 TOP
3 0 r! 2 .6 SL Z,~ K t C.5 S-17
a~ Z
~ 4a •v'
L __j
a Boring # ❑ Boring
Pit Ground surface v. Qft. » o lirr>iting fa~ in
Sol ication Rate
Horizon Depth Dominant Color R oc Descriptio Texture Stnidure Consistence Boundary Roots GPDM
in. Munsell Qu. S . Color Gr. Sz. Sh. 'Eff#1 'Eff#2
t l Z - C r .O
y
Z
(D - l -
r'rZo 7 ~ • ~
Effluent #1 = BOO > 30 < 720 mg& and TSS >30 < 150 mg1L ' Muent #2 = BM ,'j 30 mg& and TSS 130 mglL
CST Name (Phase Print) S' ture / CST Number
4M w. Q 33~
Address Date Evaluation Conducted Telephone Number
i OZ 2- -0 7/S- 7Ga a2
Property Owner Parcel ID q _ Pago 3
F3 Bcft # C] Boring ! O
l~S Pit Ground surface v. 1 ~D • d Depth to limiting factor in. Sop 34ication Rate
Horizon Depth Dornktant Color Redox Descnpbon Texture Structure Consistence Bou
rtdary Roots GPDIPp
In. Munsell Gu. Sz. Cont. Color Gr. Sz- Sh. •Eff#1 'Etf#2
3 - SL e5 1~~. .s
2 - yyVk cs ,
Ir `
ClC7 0 L 113 C ~ SL r ~
8Y. 6 .6
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. _9WAppk_ab7w_ Rate
Horfaw Depth Dominant Color Radox Description Texture Structure Conwstenoe Boundary Roots GPD/ff
In. Munsell Ou. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2
F1 # ❑ &xiV
Ground surface elev. n.
❑ pit it Depth to linrting factor in.
Sol Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPOM
tit. Murzo Ou. Sz. Cant. Color Gr. Sz Sh. 'EM1 'Et1#2
Effluent #1 = BOD, > 30 < 220 mgtL and TSS >301 150 mg& • Erttuertt #2 2 BODr ! 30 nV& and TSS < 30 mglL
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 dcpartment at 608-266-3151 or TTY 608-264-8777.
SBD-U D(RAM)
PAGE_Z_OFa
NAME: S~ LOT#1_ 78 LEGAL DESCRIPTION:I/4 vwl/4,SaTLy,N,R,E(or &
SCALE: 1"° %6
d►n~ ELEVATION: /0 4• d
BM I DESCRIPTION: e~d a4xr__ am r--
BM 2 ELEVATION:
BM 2 DESCRIPTION:
SYSTEM ELEVATION: ?0, a d
SYSTEM'IYPE:
C.t~ a d CC :la c~
.r
1 f U a
p ~
~ y
NATURE: DATE.---
S'(