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HomeMy WebLinkAbout032-1027-10-010 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 592156 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)] na Permit Holder's Name: City Village Township Parcel Tax No: Bruce & Erin Baillargeon 7 TOWN OF SOMERSET. 1 032-1027-10-010 CST BM Elev: Insp. BM Elev: BM Description: _ A Section/Town/Range/Map No: 55 lr 1 Z_ 110.31.19.1280 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER /1n7 CAPACITY STATION BS HI FS ELEV. Septic Benchmark 165• /615 F ~~-5/ Z 5a Alt. BM r',.,A_ l Aeration Bldg. Sewer y G . /63, Holding St/Ht Inlet 4.5:5 /d3 ~ Co St/Ht Outlet 36 Z TANK SETBACK INFORMATION TANK TO P/I WELL BLDG. ent t Air I take ROAD Dt Inlet Dt Bottom Septic ~ L 0 Aji+ (0 Dosing 7 Header/Man. .5 C 9w, 4 Aeration Dist. Pipe o • 1 • 4 .5 Holding Bot. System 191 7.05 q3.5 PUMP/SIPHON INFORMATION Final Grade 2743 9-9, Manufacturer Demand St Cover r,~ / L • Q~ /a~ 3 Model Number P h 53 /#j f •]OV S 97 4O TDH lift Friction Loss System Head DH Ft C Forcerf%Q Length st. to Well L SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Li uidq Depth dk, DIMENSIONS 3 .yo Z 'eA SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION T e Of System: CHAMBER OR y I r a ~Q JA- ~ ) UNIT Model Number: Q,,-3. ~6 DISTRIBUTION SYSTEM ZZ4-/_/ #3 Header/Manifol~ Distribution rle Size x Hole Spacing Vent to Air take Pipe(s) S Length Dia_lp Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over jxx Depth of d/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx Seede ti...CL vow No s 11 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: W nab- ti.. Location: No Address Avv~gl~ 1.) Alt BM Description = -t^••a~ O d h 2.) Bldg sewer length = - amount of cover = y /g Q~ ~S Pp rA~, p+`~~, s Plan revision Required? ❑ Yes No I I 3 Use other side for additional informati Date Insepctor's Si ture Cert. No. SBD-6710 (R.3/97) J VA 44 7~t N . 0 1 • 1 c5l v w FyynRn r County , ° Safety and Buildings Division ~3s X 1 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) P S` Madison, WI 53707-7162 ( n IX COUNTY ,ot1~ ST CR® LOPMENT 55 V State Transaction Number Sanitary Permit App1icc-9 pgD nl In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the app, 96/(gq .nit , Y is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS'\atc _ A to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Pdl u oses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. (l• 1. A lication Information - Please Print All Information Property Owner's Name Parcel # 13 4, Property Owner's Mailing Address Property Location I o, T k c 2&r-'7 Govt_ Lot City, State Zip Code Phone Number 1/,, Section /el ' (circle one N; II. Type of Building (check all that apply) Lot # ,~1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name ~C hQ bl, Block # ❑ Public/Commercial -Describe Use ❑ City of CSM Number El Village of ❑ State Owned -Describe Use ^ I n L L ❑ Town of ~L'l Yi 1 -'~S- ST V 606N C aus w Z J♦ Z Z c h~Prm III. Ty e (Check only one box on line A. Complete line B if applicable) A' $New Syste ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain) 2 A 'x SS' List Previous Permit Number and•Date Issued B. El Permit Renewal El Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Ex iranon Owner TV e of POWTS Svs Com onent/Device: Check all that a 1 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 2 {/mf of s~/ /►~s~l f d PlV ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaUTreat t Area Information: Design Flow (gpd) Design Soil Application ate(gpds fl Dispersal Area Required (s Dispersal Area Proposed (sf) System Elevation A/ ) 9 / rZ VTJ' VI. Tank nfo Capacity in Total # of Manufacturer ' F owe n " U a? b Gallons Gallons Units t'bJ1'~Ok ~r New Tanks Existing Tanks h!1 ? o , / r7 Verr{i'/~p Septic or Holding Tank X:' f ~ U ze) bo /i 1 ` Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS s wn on the attached plans. ~n S e Plumber's Name (Print) Plumber's Signature RS Number Business Phone Number /Z~.~NL Ycr Plumber's Address (Street, City, State, Zip Code) l- A VIII. CounLt'v/De artment Use Only Permit Fee Date Issued Issuing Agent Si -F~gproved rov 1 O •~I• I ey(~h~?~ / 96k_V, S DO ❑ Owner Given Reason or 5 fyj IX. Conditions of Approval/ Reasons for Disapproval ep acemenf AreA M VST L SYSTEM OWNER: ~ ~ f - ~ 1. Septic tank, effluent file sr and pveserved o A r. *T t p dispersal cell must he sr,ced /Maintained )0.11.11/ CST. as per management plan provided by plumber r L UI-~" 2DI U~" 2. All setback requirements rnutit be rnaintaine l aS per app lCatl LOAt4p IR for the system and submit to the Coun only on paper not less rn atll inches i1 ~i~ in p / j 01 rf i+`^' -Il /1%111 n J J ' a S AM eC~vh~ sBB-6398(R 11/11) S b<~ow YG bt used @ 66 0 67 r CONVENTIONAL COMPONENT DESIGN Residential Application INDEX ANQ TITLE PAGE Project Nam¢: Owner's Name: 4 Owner's Address: I._egal Description: tom= 'l ownshiv .7c3 ►z P-Z -n e -i' County: S CYct iyr Subdivision Name; i_ot Number, lc' Parcel I'D Number: ~ 3 rk Page 1 -----Index and title Page 2 Plot Plan Page 3 SYstem Sizing & Cross Section Page 4 Filter Specs Page 5 Maintenance Information Page g Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM of Plat Attachments: Soil Test & Horse Plans Designer/Plumber; License Nurnber: 2 I9;1G' Cate: Phone Number Signature 8 °a FI)esigroed prrrs14a11 t to tfie In-Ground SOII Absorption Component (Manua! for POVVI'S Version 2.o sap--10705-i' (N.01101). Page 1 ~l 1 g 12 d' ~ y n J c~ 'v i 'FI 1 Wl i ~i Y 1 Soil Absorption Svstem Cross Section .z ft Al- k4'1C Schedule 40 Final Grade Vent Pipe th Vent Cap ft t-- Leaching Chamber System Elevation ft .>1 ft Soil Absorption. Svstem Plan View r~~' ft - ft 1 -~-ft Vent Or Observation Pipa Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model _ e EISA Rating , sq ft per chamber Soil Application Rate --~:7 9pd/sq ft - gpd Design Flow : : 7 Soil Application Rate ~ EISA Chambers 2 raves of -/,-;z chambers each. Wage of POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al 0 NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ' '44"A r ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ~j1.2 S~ ❑ NA Number of Public. Facility Units 0 NA Pump Tank Capacity al ❑ NA Estimated flow (average) o 0 gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) Pump Manufacturer ❑ NA ro ~ Q al/day - Soil Application Rate - gal/day/ft2 Pump Model ~/tll ~Oq,N~ "lix Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ~\V>~ -vS=xFW~I ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filterft~- YJ~ Biochemical Oxygen Demand (BODbl <220 mg/L © NA ❑ Mechanical Aeration ❑ Wetiand YJ Total Suspended Solids (TSS) <_150 mg/L U Disinfection El Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODJ 530 mg/L ❑ In.-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) _<30 mg/L Cl NA © At-Grade ❑ Mound Fecal Coliform (geometric mean) <_10' cfu/100ml Q Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. _-0 NA Other: ~ ❑ NA Other ❑ NA Other: ❑ NA *'lali~es typical for dornestic wastewater and septic, tank effluent. Other; ❑ NA (MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(si At least once every: ❑ month(s) (Maximum 3 years) ❑ NA - - D1 year(s) Pump out contents of tank(s) - When combined sludge and scum equals one-third (1,3) of tank volume ❑ NA Inspect dispersal cell(s)- At least once every; ❑ month(s) Year(s) (Maximum 3 years) ❑ NA Clean effluent filter - At least once every: _ r - D month(s) I-] NA Inspect pump, pump controls & alarm At (east once every: ❑ month (s) ❑ NA ❑ year(s) Flush laterals and pressure test T At least once every; ED month(sl El NA ❑ year(s) other. ❑ month(s) ❑ NA At least once every: ❑ year(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. The 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 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 M12 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. of START UP AND OPERATION Page 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 cellis) and may result in the backup or surface 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. po 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 POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump purnp) water; fruit and vegetable peelings; gasoline; grease; herbicides; meet 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 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 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 that time, E] 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 as no~en evaluated to identify, a suitable replacement area. Upon failure of the POWTS a soil and site evaluation be performed to locate a suitable replacement area. If no replacement area is available a holding tank may b_i+T afle s 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. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER _Name f 1, i . _ a_ _ C? R YZ Name .U Phone / •..3 f o7. _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name - vbix o vn _ Phone Phone 3 This dorument was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(11, (2) & (3), Wisconsin Administrative Code. ST~ CR€ M COUNTY ii' OWNERS- E P CEREFICATIaN FORM o +~3u~, er r + Zjr v\ f e 0^/ L m-1--eef \Ne iAl CA4 y (rerifi=on mquked fivk Pls mmg & for new coasts action.) City state Q VI/ Parcel 1dcnf&cation Number 0.3 z 7 ~ to - a i V GA L D&S L3 ii5' V, . of Sec. , T N R , D t3 ~ayVi Pr,S'~ --~-L Subdivision Plat: Lot # `)N ~ Certified Survey IV a # ~ Volume J Q .Page.. Z ar-rapa Deed ` ' (fi e 2 r Volume Tr _ Page Spec boust o.. Y'aGA &D rot lines id L able.I(yes 0: ao SYSTEM MAI1`r''''T&NANCE A'-NTD 03R R C~RT`IFICA ICON improper, ause and maintene nce of your septic system could result in its premature failure to handie wastes. Proper maintenance consists of pumcpirtQ out the septic tank every three years or sooner, if needed, by a licensed pumper- ghat you ut into P eke sr~stma can affe a tie fi7Il S1a1 a"k x 1C3cvYL as 21 t' r 'AetSEe d i43 tau S o"'t T. £ics maintenance esponskodes are specited in §SPS. 3 ~2(l) and in C e-» _ St Croix County 5 Ortiunance. The property owner zFees to submit to St Crgbi County Phmoing & ZoWng Depea tment a certc5cation form., signed by the owner aad by a mash plumber journeyman plumber, restricted plumber or a licensed pumper Ym fying that (1) the on-site u-dstewater disposal system is in proper operatng condition and/or (2) after inspection and pumping (if necessary), the septic tank is .ass d= 13 tall of sludge. ttJre_ e - der-Zjp. ha ae_ e^ + the above requi-ements and agree t'o_ma „am the prlv;Aa sewax e disposal system with tL-: s"nd_- s set foci; b as sex by rite Department of &h* And 'gal Ser icm and Etta errs ofl'.attttal'Rescsturces State of A'isconsm. ~m stag dw yours' septic system fins been mamtamed must be compl l and rimed. to the St. Croix Counry Plamung, & Zug Dep em wnhin 3~ of the three Yew expuz dates Uwe certify that all statements on Ibis are tree to the best of my/oar knowledge. Uwe am/= the owner(s) of the property described above, by virtue of a w deed recorded in Register of Deeds Office. Nofb o t7 z~ ATi 0FPLC 1 t 7) DATE ssy information that is misrepresented may resuk in the sanitary permit being revoked by the Planning & Zoning Departmwt include wA this apphc=on a recorded w=anty deed ;rom the Reaisrsa of Deeds Office and a copy of the wed survey map if referesm is made in the wan wty deed. r TV. 04/1,2) (G)...... Draw.ng R,oort.. LC 2?o 6 i - -1 p f tJt _kf i ~ I L Ill I 1 ~ L i ~f JAL t m I__ 1 ~F1 f ~<i I i `J O ( , `z f I i I T o f FH ~Q. 1 ~ i P L lain s Prow" Room P~RUCE & ERA PAILLARGEON I All 0 a , XXXX GOU/VTY ROAD I,fOMMER/ET WL 54025 OC laln's Drawmq Room. aC 201 0 z q------- 1-~ V I I; i I i 1 I 7 ' I 4AT I I L i fi i I ! I L i i ,V > I ~ _ j ' f I S a N N c~ .-,x-e rrr 1 I ~ ! lain' P) Dravin Room. 9 R1CE & ERIN PAILLARGEOA s rk O al XXXX COUNTY ROAD I, fOMMUR tT WI. 54025 LLLL- © Iain's Drawlna RGOm. LLC 201 G I , ( r I ~ I tiPJ Z I J P P, P .-.Ill p, 1 n P I. _J ~ P ~ I ~ ~ I V I ~ ~ vI ~ r- re IV re 1 till re , re ~ ~ P ~a I N f L rY t . 1 BRUCE & ERIN B,AILLARGEON loin's Drawing Room I~ $ 1 O~ I XXXX COUn7Y ROAD I„/'OMMERJET W1. 54025 1_, I > rain's D; aMna Room, f -C 201 6 Mij - ~lf ho i hu ~ i i ~li II l ( i L - X r--------------- -i u 0 I i lu i i ' ii n a c P)RUCE & ERIA P~AILLARGEOPI bin's Droving Room O XXXX COLOTX ROAD I, -ET lA. 5402/OMMER 5 1'r w.. ©Izlr'S Drawing Doom. LLC 2016 a AL' _ a i , 71 I I 1 I sal II / L _ t - ~ - _ l F ~ fi II t ~ 1 - 1 1i 1 ~ ~ Y a f i r . `l , I I I , x 5 ~~-j~'2 lain's DrowinRoom r I_I P~RUCE & ERIA P~AILLARGO/4 9 O XXXX COUATY ROAD IJOMMEWE W1.54025 ~ ut~de a a I` G~ larn's Drawing Room. LLC 20 6 1 i n i I ~ - r tl ~ a i' Iain's Droving Room . P)RUCE & ERIN P)AILLAR6E0/4 l~Z Q XXXX COUATY ROAD I,./'OMMEWET WI. 54025 ' z d c r t w+. rs _ ng Roo 2010 i i 5 f+ ' ~ ~ AI . i. ~o t I s ~ 4 i i i~ a` 0 3 D I Ija z ` - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Q Cl O Z N ~~-~D C1 oooo~^In J ~ D V Z? N p v n t a G5 z_ PORTAL MAfRED WALL ¢ I4 I r ¢ ~r rn rU s I I I, r ~.cwr na , PIRUCE & ERIN PIAILL+ARGI=O/V loin's Drawing Room . "Jil XXXX COU/iTY ROAD I,fOMMERfET WI.54025 utC~}r a I Wis. Dept of Safe s SOIL EVALUATION REPC s, Yy Division of Safety a uildings ' 890N60F1A762R ,~qe~ of n W'l tin accordance with SPS 385, Wis. Adm. Code OCI ~ County J C'/ m r~ Jam' Attach complete site plan on R'San-Towand han 8 1/2 x 11 inches in size. Plan must ` include, but not limi - -=eference point (BM), direction and Parcel I.D. percent slope, s(location and distance to nearest road. 032- /0Z-r- /O- 0/0 Please print all information. Review Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). p• • /n Property Owner Property Location W 611-4,C 2 Govt Lot ~F 1/4 /1,GG1/4 S 16) T 9/ N R 1(~ 7 A (o W ' C, Property Owner's Mailing Address Lot Block # Subd. Name or CSM# I Al City State Zip Code Phone Number ❑ City ❑ village [Town Nearest Road aMe~S-c~ CvT SYoEx (71S ) 2y7-C'IVO/ ~'D~t~JCT C-/let) ® New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate G GPD ❑ Replacement ❑ Public or commercial - Descnbe: ft. Parent material Flood Plain elevation if applicable Ls General comments 6U (S and recommendations: 11~ a~ y' bt16w rud~2. Per phone eonvrvsa+hon wl'44h a i~5 efta&4- hAvt *&tw PtLe 05 5A Boring 11 Boring # F 6 [3 pit Ground surface elev. S ft. Depth to limiting factor z 91 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 '2 s~ 2msak rr<L~~ /M 4.6 /'0 , ? - V yA L S M c c., /a A 0, -7 Y y8- I2 /0 a / IV A rn s O=E /'z - 0,-7 1.6 F*7-1 0 Boring # F1 Boring Q Pit Ground surface elev. j Depth to limiting factor ~Z8 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2 / YR•'Ll k / rz v~'~ c21 Im 0, 0,4 z %I-1o /07/j %y &A- S/L ^4,4 /n~'~ c /n-t Q, 6 4,8 3 30-37 '7 TA C S rL-2 1.6 rn S o Effluent #1 = BOD > PM:Zww&anckSS >30 < 150 mg/L ` Effluent #2 BOD ,:S 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number frra4 Fat 2-11-71 Address Date Evaluation Conducted Telephone Number 0 C. a~ S©n, e~s-ef t,~ /v-/8 /G 77is-Zv7 J?zof SBD-81-10 (R] 1/11) Property Owner Parcel ID # Page of 1:1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft m in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 *f#2 ❑ Boring ❑ Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Z in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. * ff#1 *02 ❑ Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 * ff#2 E * Effluent #1 = BOD 5 > 30 5 220 mg/L and TSS >30 1150 mg/L * Effluent #2 = BOD g < 30 mg/L and TSS < 30 mg& The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-5330 (R11/11) OWNER Page 3 of 3 Name gP u c1C. Brian Parnell Address Z 2 9/ - C , /1cQ CST 23) 314 Date /g- ® Benchmark 1 70Co Sf~,~< <C. ~O6' oo IV `I O Benchmark 2 ❑ Soil Boring Suitable Area 1 40' Scale , 1i i j y = 1 1 , 't L f i j ~ t I t 1 t ! y ; ~ -F 7 I I I oyI ! Z 1 ' j i 0d ~i i i ) ) , 6 S y I 1 s ) i 211,14 i s t 1 scor~ sin- Labor and Humartm elaof Industry, SOIL AND SITE EVALUATION REPORT Page ~ Of 2 Divisio .-orSafety & Buildings in aCCOfd with ILHR .QS, Wis. Ad ode . ' s i Attach complete site plan on paper not less than 8 1/2 x 11 inches inYze. IP a~st clude but not limited to vertical and horizontal reference point (BM), direction and % of slop ,scale or PARCEL .D. # dimensioned, north arrow, and location and distance to nearest road. /''D-7- APPLICANT INFO RMATION-PLEAS-E`PRINT ALL INFORMATION jry. S` 'tx'~Z R f _ DATE PROPE TY OWNER: a PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T ~ N,R C'(or A6C PROPERTY NER':S MAILING ADDREtS LOT # BLOC # S BD. NAME OR CSM # _ CI STATE ZIP`CODE PHONE NUMBER ❑CITY ❑VILLAGE QfOWN NEAREST ROAD 1A New Construction Use Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe G j. Code derived daily flow gpd Recommended design loading rate '7 bed, gp ft2_trench, gpd/ft2 Absorption area required bed, ft2,:~4-,,? trench, ft2 Maximum design loading rate , 7 bed, gpd/ft2 -trench, gpd/ft2 Recommended infiltration surface elevation(s) P ft (as referred to site plan benchmark) Additional design / site considerations Parent material 1- 2 f) I/j 2Ali 4e Flood plain elevation, if applicable ft F itable for system CONVENTIONAL MOUND 71N-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK suitable fors stem EIS ❑U as ❑U ®S ❑U ®S ❑l1 ❑S ®U ❑S oil SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Clu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench 1 ' < 3 /Z~ 5e A, Z Ground elev. " ft - - Depth to , S limiting factor > ~l s Remarks: .E~/L's Boring # s .S 7 Ground elev. ft. Depth to i limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: L PROPERTY OWNER SOIL DESCRIPTION REPORT Page. of PARCEL I.D. # T' Depth Dominant Color Mottles Texture GrStructuSh Szre Consistence Boundary Roots Bed TM Boring # Horizon in. Munsell Qu. Sz. Cont. Color . . . Bed Trer n -tj /z5 31-2 Al Ground _ 16 1 -wj elev. ~Zj ft. s ~f 27 Depth to - - - 7 limiting factor Remarks: Boring # AIZ Ground elev. 7 y ft. Depth to limiting factor Remarks: Boring # 1 S 5 , /Id Ground elev. c Al i ' ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PROPERTY OWNER SOIL DESCRIPTION REPORT Page,,,,~ of S PARCEL I.D. # yT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench > G Ground _ elev. -7 Z ft. Z5je -eI4 "//ol s vt _ Depth to /z> wo limiting _ 7 factor Remarks: Boring # Ground elev. 5 ft. Depth to - - limiting factor Remarks: Boring # 1 -S MA -429d Ground elev. Allo ft. Depth to limiting factor >>9 Remarks: Boring # MEMO Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) i' C/ I i