HomeMy WebLinkAbout006-1040-90-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 589749
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:
John Gillis TOWN OF CYLON 006-1040-90-100
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
160 18.31.16.2778
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE90. CAPACITY STATION BS HI FS ELEV.
Septic
Benchmark
r /oa0 q-7 16q,-? /04c~
Rb Lbjr, ~z Alt. BM F`4, 3 a,
Aeration v+~iL~ •
Bldg. Sewer 4;1 •3~ W13
Holding St/Ht Inlet
7. ~ q 7. If
TANK SETBACK INFORMATION St/Ht outlet
7.95 9~•Z
TANK TO I WELL BLDG. ent Air Intake ROAD Dt Inlet
Septic *7 /b/ j~ Dt Bottom `
Dosing Header/Man. 26 94 - 445
Aeration Dist. Pipe
Holding
Bot. System
9.~, ~ S. 1 ak
PUMP/SIPHON INFORMATION Final Grade • 3
Manufacturer Demand St Cover
GPM 3-L /01-(p
Model Number
TDH Li Friction Loss System Head TDH Ft
Forcemain Length Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS it ~7- !e
SETBACK SYSTEM TO P/L BLDG 1 WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: o~/;
UNIT Model Nurub r:
f. ' r v
DISTRIBUTION SYSTEM 1-7 W,&-94-
Header/Manifo~Ci I Distribution x Hole Size Ix Hole Spacing Vent to Air I ake
Len th Dia Len th Dia Spacing ek
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only v J
Depth Over Depth Over xx Dept o ~aa xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges To soil
J P Yeses No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: No Address Avail,§bl G 6 Jar ~ • h!S 4-
1.) Alt BM Description = F+
2.) Bldg sewer length = V7 W QS(~,,
amount of cover = 7 O J b 6
5bi~ WQAL '~a c.awlolt.~ /b
Plan revision Required? Yes
~ ~ 2 3~,~ ► to ~ I III
Use other side for additional information.
~
Date
SBD-6710 (R.3/97) Insepctor' ignatur Cert. No.
a ' V County ` t
Idlq S DlVlsl 201 Box 7162 Samtaiy Permit Number (to
+
be filled in by Co.)
P ` Madison, WI 53E162
JUL 749
Sapi_taj:~f 7~~ 1 iJ(~J•, State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. CCode, submission of this form to e RMIEWernmental unit A
is required prior to obtaining a sanitary permit. Notes Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes oses in accordance with the Privacy Law, s. 15.04(1 (m),
Stats. ~ O /X_ /Al
1. Application Information - Please Print A11,11 n ation v U
Property Owner's Name Parcel #
N A>
Property Owner's Mailing Address
8 1 Property Location
Govt. Lot
City, State 1 1 Zip Code Phone Number
~l 6 . T' '/4, '/4, Section
~U A ~L~~( tCJ l o Y T _3 i N, R ~circlE on
11. Type of Building (check all that apply) Lot #
~1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name
-3
D F ~ Block # I
❑ Public/Commercial - Describe Use
OJ'S.t.. ~ ❑ City of
El State Owned - Describe Use CSM Number Q 265 caz l? ~❑y Village of
17 / 18c, `Town of
III. Type of Permit: (Check only on box on line A. Complete line B if applicable)
A. [)Q
New System
❑ Replacement System ❑ TreatmendIlolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber Transfer to New List Previous Permit Number and Date Issued
❑ Permit
Before Expiration Owner t
!9 2 IV. Type of POWTS System/Component/Device: (Check all that apply) IZA t l
ANon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound> 24 in. of suitable soil ❑ Mound < 24 in. of suitable soi
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treat ent Area Information:
Design Flow (gpd) Design Soil Application Rate pdst) Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o
New Tanks Existing Tanks
U cn cn rs C7 P-
W O ~~tfrr o E!
Septic or Holding Tank C 011
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POW TS own on the attached plans.
Plumber's Name (P int) Plamber'0gnature M~/MPRS Number Business Phone Number
Plum er's Address (S ct, City, State /Zip Code)
5 ,k
VIII oun /De artment Use Onlv
Approved Permit Fee " Date Ts ted Issuing nt Signat e
iv eason for Denial $ 6 00
IX. Conditfp*AWeasons for Disapproval
3) au. w•e
f
@t l Rili3E ~t ~ r - m ,rec
as pK, onap. @m%Bt BRA -1 ~ by pfuntber.
2. /-11,WbW,k "F } ~ysi (ailite i E1
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 I inches in size
SBD-6398 (R. 11/11)
qo loi, I'
;l
COPY
9sr r i
D~
Luca f
1 g~
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Proje:;t Name-
Owner's Name:
Owner's Address
S~ 716
Legal Description _ j S r 5 - 7 3
f _C E U
_ y
Township:
County:
Subdivision Name
Lot Number
Parce' 1_~) Nurnber
Page 1 Index and title
Page 2 Plot Plan
Page 3 __.System Sizing & Crass-Section
Page 4 Filter Specs
Page 5 Maintenance information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintena
Page 8 Warranty Deed
Page 9 CSM or Plat
attachments: Soil Test & House Plans
Designer/Plumber License Number: (d
Date: .7- 371 5~f / Phone Number
Signature
Desianec Durs!iant to the fn-Ground Soil Absorption -omponent PJkanual for POWTS Version zC SBD-10705-P (N0 1 /01
1
p3ge
X 13- 3
'70
D~
ACA
JPX
3~,v u v
i
~ ~L)
bs,,r- iiort arasetrrr
~ 4" Schedule 4o G Final Gr;?€ P
PVC Vent Pipe
With Vent cap 516
s
f
(_,r~a¢re~igt' l~rj
S
ft,
f1i
ft AM
it
Vent Or Observation Pipo Leaching ~ Trench 1
Chambers
r R,r
1Y R-1 i
01,
!{each
i
~.eachin Chamber S ecifcations
Manufacturer
And Mode! ` ` O
EISA Rating' ~ sq ft per chamber
Soil Application Raiff ypdJsq It
ypd Design Flout
Soii.Application Rate
SA
H SA 3&2,
/~Vhanibers
F
Page nt
n
i
u
't
18"
cF -CT IV[ LF_NGIW
t1l' t F
~4r~ ~ ~ xY 4
un"
s' v,,t f11
8" INVERT
4 y
rw i f
a
w If
t f
Y ~ 1_ _
r
- -
A I
i ~ c7
Q7
. w"
I -
I~ -
l ~f I
i
- -~i - - -
i
r
- -
O
O
r
<.t F--
C) z °
w
,mss
~w wU W
Y w~
U) LIJ
u; w czn✓~ i i - > C~
~s a >
= U CD o O
V xO my ~.._r
w w F _
LU
co
l = j = - - Z
0- co
/ ie \ \ \ \ 0 LIJ
f Fes- 00
i
L.U c~') C) Qj
_ \ ui ° O C) Qj
LIJ
" LCD
OL CL :17-
-y I
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Tank Manufacturer: ❑ NA
Permit # Septic ❑ Dose ❑ Holding Volume: 9 1G6C3 (gal)
DESIGN PARAMETERS Tank Manufacturer: ❑ NA
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume. (gal)
Number of Public Facility Units: AP"NA Vertical Distance Tank Bottom(s) to Service Pad: (ft)
Estimated (average) Flow : 3C (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft)
Design (peak) Flow - (estimated x 1.5 : ~f i Specific servicing mechanics must be provided if vertical is >15 feet or
_5 (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: (gal/day/ft2) Effluent Filter Manufacturer: /d
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: - ❑ NA
Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BOD5) x220 mg/L NA ❑ NA
Total Suspended Solids (TSS) 5150 mg/L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer:
(BOD5) >220 mg/L[ NA ❑ NA
(TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
Pretreated Effluent Monthly average L1 Disinfection El Wetland
❑ Sand/Gravel Filter ❑ Other:
(BOD5) 530 mg/L Soil Absorption System
(TSS) 5_30 mg/L NA
Fecal Coliform (geometric mean) 5104 X.In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Effluent Particle Size Y8 in dia. El NA El At-Grade El Mound
❑ Drip-Line ❑ Other:
Other: ❑ NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) 1&1 When combined sludge and scum equals one-third of tank volume
❑ When the high water alarm is activated
Inspect condition of tank(s) At least once every: ,3 ❑ month(s) (Maximum 3 years) El NA
Q'Year(h)
Inspect dispersal cell(s) At least once every: 3 I-] month(s) (Maximum 3 years) ❑ NA
ear(s)
Clean effluent filter At least once every: 3 El t(s) El NA
Year(h)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ANA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) NA
❑ year(s)
Other: ❑ month(s)
At least once every: El year(s) El NA
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 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 be taken 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 1,,. Name
Phone 7 6 0 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ,-3.
Phone Phone 7l j ~J
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)&(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code.
START UP AND OPERATION Page of
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 be taken 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.
lbl~
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER ,p POWTS MAINTAINER
Name 7` 2/~ 1-
Name
A-1 -
Phone ~'Z_: - 0 7 & ~ 0 0 9 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name j
Phone Phone
~l - - 8 CD
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 MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer U tit C' t vj
Mailing Address. Jt~ lJ~\ ~i t _L
Property Address
7,1
(Verification required from Planning & Zoning Department for new co struction.)
City/State AAA k L,~ Parcel Identification Number Tu6 " l U y c~ t C'(-_' o
LEGAL DESCRIPTION
Property Location ~/4 ,Sec. J L, T _aL_N R l,- W, Town of
Subdivision Plat: , Lot #
Certified Survey Map # Volume Page #
Warranty Deed # U4 I (before 2007)Volume , Page #
Spec house ❑ yes ~no Lot lines identifiable Kyes ❑ no
SYSTEM MAINTENANCE AND 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. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) 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.
I/we, 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.
I/we certify that all statements on X form form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of ?"'Tanty deed recorded in Register of Deeds Office.
Number of bedrooms
7 /_z/-LI,
SIGNA LURE OF APPLICANT(S) DATE
* "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)
RECEIVED CS-1- Zd ►S-o7N
NOV 0 2 201b ~ 376 376
Wisconsin Department of I~ OIX COUNTY SOIL EVALUATION REPORT
Division of Safety and BG , k, , a r_,. tr; -'~0 'k4 T° Page of
in accordance with Comm 85, Wis. Adm. Code 0U0 - D - - l
County G" .
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must v
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. I
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. i:'/"C i c
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 412 9
Property Owner Property Location ~7
)4 r• ~G~.~' Govt. Lot.~,,-_- 1/4 1~ 1/4 S T N R (or (w
Property Owners Mail Address Lot # Block # Subd. Name or CSM# Psd/D ICU
U'ry r State Zip Code Phone Number ❑ City ❑ Village own Nearest R d ,
L/ 'e
etEll-kew Construction Llse~esidential /Number of bedrooms% C Code derived design flow rate GPD
❑ Replacement ❑ Public oycommeraal - Describe:
Parent material { ' < _ ( a' / Flood Plain elevation if applicable
ft-
General comments , A ?
and recommendations:
1
System Type +'149✓3./~ ~,-System Elevation ~
A J L o - 4/-0 - 90- Cro
Boring # Boring /
® it Ground surface elev. ' ft. Depth to limiting factor / OJ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. >,t~JMunsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
0-/Z" / .9 n o
L 1 a
1
1
Boring # 0 Bonng
r t Ground surface elev. ft. Depth to limiting factor ~1~2~ in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure E/~ sistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color 12 Gr. Sz. Sh, •Eff# 1 •Eff#2 1
Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 mg/"'"+ • Effluent #2 = BOD. < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Ign CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1432 120th St, New Richmond, WI 54017
~ " ' 715-246-4516
C"
Parcel ID # Page of
Property Owner -
oring
Boring #
0-ft- I Ground surface elev. ~ ft. Depth to limiting factor /~9'~ 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
e
1 -71
F
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth 40 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
El Boring
F-1 Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ pit Soil lication Rate
Horizon ")epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BODS > 30:< 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 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 altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (8.6/00)
Property Owner - E]/Boring Parcel ID # Page of
~
3 Boring #
Ground surface elev. ft. Depth to limiting factor /93 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
A t%
s~ ,
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
Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF
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 (8.60))
Soil Test Plot Plan ,
Project Name John Gillis Shaun., rd
1
Address
2216 200th ave rN~~----
Deer Park Wi 54007
C GI #226900
Lot Subdivision Date 1 /2/15
SE 1/4 SE 1/4S 18 T 31 N/1316 W
Township Cylon
Boring O Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 1.5" pipe
System Elevation 96.1/95.1 *HRpSameasBenchmark
property line Scale is F = 40'
unless otherwise
noted
B-1
9% Slope
3-~ 80'
0
300'
B.M. 20' 10'
101'
98919,100,
180'
6
Qr'~ « ,
Please note: survey was not
completed at the time of testing
210th Ave
SOIL PROFILE DESCRIPTION
Owner:/( Lv~dG/S CST: gl2~ S. - -
System Elev. Proposed: ft Syst. Range 9~O•~ ft to 87 ft Ld Rate:
# Z- Elevation: # f Elevation: lot.( 3 Elevation: f 7_ f
Boring o Boring o Boring
Pit k Pit pit
/oZ
F--
`moo
-
Flo ~ ~ - _ -
~KD~~ sYST~~" GIZV' -
-
sw~ @ .7
-
f iv
icsf ,