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HomeMy WebLinkAbout038-1061-40-250 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 589706 GENERAL INFORMATION (ATTACH TO PERMIT) 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: Kenneth Zeilinger 7 TOWN OF STAR PRAIRIE 038-1061-40-250 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 15.31.18.266C-50 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 1-1~t' Septic Benchmark onC~ Dosing Alt. BM Aeration Bldg. Sewer St/Ht Inlet Holding , St/Ht Outlet 1 TANK SETBACK INFORMATION . i TANK TO P/L WELL BLDG. Ventto Air Intake ROAD Dt Inlet a Septic T, Dt Bottom Dosing Header/Man. I~'~•~ cTY Aeration Dist. Pipe Holding Bot. System F Final Grade S. " PUMP/SIPHON INFORMATION Manufacturer D nd St over GPM ' L{ r ` vC Model Number TDH Lift Fricti oss System Head TDH t / " T~ For In Length[, Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ngth No. Of Trencles PIT DIMENSPNS No. Of Pits Inside Dia-- Liquid Depth DIMENSIONS 71)7 ✓y' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:. _1,~1tf INFORMATION CHAMBER OR Type Of System: I UNIT Model Number: qL4 DISTRIBUTION SYSTEM ` Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ` Pipe(s) Length I Dia s Length Dia Spacing_ I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Yes No Bed/Trench Center r " Bed/Trench Edges / Topsoil E] ygg~❑ No El COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2159 CTY RD CC 1.) Alt BM Description 2.) Bidg sewer length - amount of cover = w~ g Plan revision Required? ❑ Yes ❑ No 9 Use other side for additional information. Date Inssp Cert. No SBD-6710 (R.3/97) RECEIVED Industry Services Drvtslo County , 1400 E Washington A Sanitary Permit Number (to be filled in by Co.) 3 SPS j JUN 0 9 2016 P.O. Box 7162 Madison, WI 53707- ~ 46 9 °~Essro~ati. $T. CROIX cC l1 l `Q co and ary ermit Application Transact Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forts for state-owned POWTS are submitted toy address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1 purposes in accordance with the Privacy Law, s. 15.04(lxm), Slats. I. A lication Information - Please Pr' 11 Information Property O Parcel # 2 s Name Property Owner's Mailing Address Property Location ~adf Govt. Lot jou C•• City, S e Zip Code Phone Number may;! %_/A/ Section At? (circle o T-3/ N R E It. Type of Building (check all that apply) Lot # ❑ I or 2 Family Dwelling - Number of Bedrooms Subdivision Name AA r-_ ❑ Public/Commercial - Describe Use 6 eA D~j, Block # -j Iw O ❑ City of ❑ State Owned -Describe Use Y" ❑ Village of CSM Number Town of 52 5 41 III. T e of Permit: (Check on one box on line A. Complete line B if a licabl A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS System/Component/Device: (Check all that apply) 37 4~w LP-50 21 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mouii < in. o sur le soi ❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsal/Treatment ea Information: Design Flow (gpd) Design Soil Application Dispersal Area Requited (sf) Dispersal Area Proposed (s System Elevation Rate(gpdsf) -71 VI. Tank Info Capacity in Gallons Total # of 2 Manufacturer L U U u y Gallons Units Lo QO 116k 54's New Tanks Existing Tanks s= U vz cn Ls. 0 a Septic or Holding Tank ❑ ❑ ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ ❑ VII. Responsi ity Statement- I, the undersigned, assume respo ,dbility for installation of the POWTS shown on the attached plans Plumber's a (Print Plumber's MP/MPRS Number Business Phone Number Plumber's Address (Street, City, Stat Zip Code) VII oun /De artment Use Only XApproved Permit Fee Dat Issue tt Issuing ent Signature ► i1ii+' Reason Denial S X~g 5. G lD IX. Conditdild$T6flYll ,it/Reasons for Disapproval 3' 1.."1eptia`tank, effluent filter and disperxt,i cell must all be sal ic.s,! rn&in 4 as per management plan pro ridedbyby plumber. 2. 'All-salDick requirements must.be marmtz i6id as per liable rode / ordinance3. Attach to complete plans for the system and submit to the County onh on paper not less than 8 1/2 x I I inches in size any IT, 1 _ Z~N - Nv - , \ 06 0 CONVENTIONAL COMPONENT DESIGN Residential application INDEX AND TITLE PAGE Pa :~x OW77 i Project Name: Lei t Pig - Owner's Name: „~r i~ €rr~2~or Owner's T Address: J Legal Description: Subdivision: Lot , Town: car County: Parcel ID# - License # 2.1%f ~ Designer/Plumb Signature: Date: ~ - i Comments Designed pursuant to the !n-Ground Soil Absorption component manual for POwTS Version !.u fndex4:50e 21212012 l 'VI O ~ fl I'D a e ~ l ~0o~ on s crass $wson c; Ulai Grade 4' schedule 40 2 pVC VenE Pipe ~ i! wa Ved trap ~----1 Leaching Chamber Sjj$ n ©evafion j fE J ft ieacbing Trench 9 f~,z Vent Or Obsen►afion PiP7 Gharr[bers 4' ©13. Trench 2 Header ManufacWrer And Model' sq it per chamber Soil Application Rate gpd/44 it ElsA Rafirtc~~~ Scti1 Apptfcation Rate _ EISA= chambers gpd Design Flow 2 MWS dwambers each. Page ,S - of L " i.. _ f .a.~..-`;yl.`~.. { ep Chia {°Lt_~•`L,.^ + C F-I L.:3 Ix"~ ST, +p~~ ardt5~:1= i t Celt r _ i -2 M 01 :sue` J^ g-4 Of 1 5•'-' ~ R.~.~~ G~~~~<r Yom.. Tl~l W Step 2: step on the yep 1: ~ f oF~ ¢ tank- (A) Before place ft W _ me hot t4 (A) LOC. W Itle atae fflWhousing on fo ft vtAet pipe- Maet pipe- (B) Remove tw* cover and pump tank f Bj €e sure #tat ffm hcrracM9 (B) ~3e ~ tr{ #M ff neceSsarY- is post'ioned so theRter can be housh-tg, fngkkW sun: to ibur arxi emaved fron=t ahe twk for mtklgp is u maintenance and service ~FiSMY kowtad the -4- f F ,qff b 1 , sc -t •,:._-1-, a ' - r ~ f~ ~ f ~ ~ fly'-i ANNE 78 tL,N~ t~...ti-+;.! C.t ~'c,~s•-~•-- M-M Ste Step (A) covey and ~ pump (IFtsa midge Fradc Locate the outlet of ft septic rank. R € fbe the housing mi*Q surz _ me 'is A y e flecassay. (B) putt the ~r ark of ffm housing. aid tAii3P 3 10 t lj° LCD g(gC.)t HOW EJ$,~ ppiece ,per, y L~ie~ Cl~filC t C th* cover M-Z✓~-.-~•~ v ..~-t1Ce 5tt)M~al1 .7Wl1A lClIL 3iCk~l~~ Sepric POWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page _7~~of FILE INFORMATI N SYSTEM SPECIFICATIONS Owner _ Tank Manufacturer: 1/ l-5 ❑ NA Permit # jS Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: NA Number of Bedrooms: ? ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: 2~NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : ~2 (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Moe Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): L (gal/day) if horizontal is >150 feet. Speck instructions to be provided on back. In Situ Soil Application Rate: ' (gal/day/fe) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) 5530 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODS) !5220 mg/L ❑ NA O NA Total Suspended Solids (TSS) !050 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. J NA (BODE) >220 mg/L ~ NA ❑ Mechanical Aeration ❑ Peat Filter (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BOD5) s30 mg/L Soil Absorption System (TSS) 530 mg/L ~I NA Fecal Coliform (geometric mean) 5_10` In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA ❑ At-Grade ❑ Mound Maximum Effluent Particle Size %s in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third (36) of tank volume When the high water alarm is activated Inspect condition of tank(s) At least once every: I~ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cells At least once every: p month(s) (Maximum 3 years) ❑ NA ® year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA J9 year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) [3'NA ❑ year(s) Flush laterals and pressure test At least once every: p month(s) Z NA Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface_ may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third (f6) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 5_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02/05) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall betaken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant 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 must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER, POWTS MAINTAINER Name I.- Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK 1~~4L~TTEI~TANCE AGREEME11\7 AND OWT~ERSHIP CERTIFICATION FORM Owner./Buver 1- I //J1 16 if -Mailing Address _:2//1 Property- Address 0- 7,169 (Verification required from P & Zoning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRIPTION Property Location_Sj;1 1/4 1/4 , Sec. _Zd:- ; T__Z/_N R W, Town of~ .IC _ Subdi\rision Plat: , Lot T Certified Survey Map s , Volume Page 3s Warranty Deed # (before 2007)Volume , Page 4 Spec house yno J Lot lines identifiableAyes ❑ no SYSTEM MAIN7ENANCE AhrD OWNER CERTIFICATION 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 three years or sooner, if needed, by a licensed pumper. Wba! the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner main£enar, responsibilities are specified in §SPS. 383.52(I) and in Chapter 12 - St. Croix County Sanitary Ordinance. 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 1/we certify that all statements o this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a ,arranty deed recorded in Register of Deeds Office. Number of bedrooms SIGN_ OF AP IC_ANT(S) DATE C_ *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 Office and a copy of the certified survey map if reference is made in the warranty deed. REV. 04/12) 'SpIlL k Wisconsin Department of Commeke IE VALUATION REPORT Page _ of Division of Safety and Buildings Jok OFFt mm 85, Wis. Adm. Code Nt`5\N~ County Attach complete site plan on pape 4 g an 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. _ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O (o TV Please print all information. ew Y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property r Property Location Govt. Lot 114 S S T N R(or) W Prope Owner's Mailing Address Lot # BI Subd. Name or CSM# -DLA S Zip Code Phone Number ❑ City ❑ Vl~ge JE Town Nearest R ad New Construction User Residential ! Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: _ Parent material Flood Plain elevation if applicable ft• General comments and recommendations: /~f~~~~.ska .i~s~ - l~'• `1~ F 71 Boring # Boring Pit Ground surface elev. y,, 7 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Clu. Sz. C nt. Color Gr. Sz. Sh. "Eff#1 'Eff#2 -2 _1 9 / GZ. r - s - ra i{ a k Boring # E] Boring ki U jN 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/ff in. Munsell Clu. Sz. nt. Color Gr. Sz. Sh. `Eff#1 `Eff#2 _ ; XV/ 4 t- - 47. N ~ Efflue t #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' ET *t BOD < and TSS < 30 mg/L CST Name se ) Signature CST Number Address Date Evaluation Conducted Telephone Number _-z 1- ~ _ ZZIZ' I Property Owner Lc Parcel ID # Page of Boring # ❑ Boring c 5 Pit Ground surface elev. 1. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 •Eff#2 1/1, j - - F-1 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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 *Eff#2 ❑ Boring F-1 Boring # El 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/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff##1 *Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mgA- ` Effluent #2 = BOD5 < 30 mg& 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 (8.6100) Property Owner i - Parcel ID # Page of Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots :GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -E-Eff#2 ~r ly~ ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F-1 ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cor Color Gr. Sz. Sh. `Eff#1 'Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg& ` 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 (8.6/00) PAID Wisconsin Department of Comme Fe u~ I~E VALUATION REPORT Page of Division of Safety and Buildings i) UFF\ ifi bc` oroi ~ mm 85, Wis. Adm. Code Ntv1h~' County Attach complete site plan on papel` 6 Iran 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). property 7,t:~-v/ r Property Location Govt. Lot 1/4 1/4 S'16- T N R X(or) W -Properfy Owner's Mailing Address 7 Lot # BI Subd. Name or CSM# /./11-1- A Sta Zip Code Phone Number [I City [j Village f~Town Nearest R ad City l ~ 17 ( ) New Construction User Residential / Number of bedrooms Code derived design flow rate - 5 d GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material FY1~ Flood Plain elevation if applicable 4VI4- tt. General comments and recommendations: 1 f- 6'e'o Boring ❑ Boring # Pit Ground surface elev. pp~1- L - ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 19-19 T-- a 4 Boring # El Boring 0 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/ff in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 h 4- ¢ 4 ' Efflu _ t #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effl t BOD < g/L and TSS < 30 mg/L CST Name ) Signature CST Number Address ate Evaluation Conducted Telephone Number - 1 . ' \ ~ ~ - ~ o 1 ~ ~ ~ ~ r ~ ~ ~ ~ ~ a N ~ ~ ~ - ~ r. ~ n~ ~ ~ \ ~ . ~ j ~ ~ ~ _ 1__ ~ ~ ~ ~ / l 1 / / ~ j ,3 / _ ~ ~ ~ a ~'J _ ~n / ~ ~ ~ J k k ~Q i \ ~ N \V~~ b% I ~ ~ ~ J~ _ 1j ^~u ~ ~ ~ ~ Q ~c a ~ ~ ~ M ~ ~ o ~ ~ ~ ~ ,;y ~ ~ r ~ i~ Fi C p J G U 'l ( t h„ T -3 t ,r r TI C. CJ r~ TJ C 1 n (n ~ U 1 Irl ~ S l I T G ~ 1 r. 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Z> IT ' T n r U) :Y> U, J rN r- 3 FL7 ; x r) it -1 C t- ) tn C f) ~.frjZ r,`f rrt ~.ct k o~ t~ c~ r (Tl 7j n-1 l:) 0 l f T" f -1-1 . l 1 Y7 -I t 1 n u3 cu 77 r~ G <.4 l T7 _ U w w r Vl; m r_ - .L F I Y n'l F- F- CI) C. - (.J ;A L ,y ~ --1 7) l "n r -n t C) C C Tf n LI) -a• C7 - - C. C) C C_ C) v f l 7 I° i• C~ I n u7 T~ { I i IT U- C 7 - rn Q T Z C ) J tC ft co z n U) s --n 71 rn yj fl! n a` r - 28 - - - f f ;~v Ti C z (q _ j $ L: .F lJ C 0 G TT, ti ' rrf > > C) C7 ; C; "Al II 177 ' HOME TEC DESIGNERS & BUILDERS, j Kenneth and f.. eerie eilir~=;er fi~< INC. ~ P.O. Box 48 New Richmond WI 54017 rT; ,,ihrrE1filri 715.246-4343 Office 715.760-0871 Cell www.hometecbuilders.com 7 J