HomeMy WebLinkAbout016-1004-20-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 589758
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 2723604
Permit Holder's Name: City Village Township Parcel Tax No:
Mark Smith TOWN OF GLENWOOD 016-1004-20-100
CST BM Elev: Insp. BM Elev: Description: Section/Town/Range/Map No:
/00 17 GST 03.30.15.378-10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION R;__ HI FS ELEV.
Septic 3 Mao Benchmark
Dosing Alt. BM
Awetiort
Bldg. Sewer ~Q
ht 1
P6 6 IL 512A
Holding St/Ht Inlet
y3 . q
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG.~tAir take ROAD Dt Inlet
Septic r Dt Bottom
It ~ 7 / ~ IZ 74-'53
Dosing Header/Man. f l `7 7 `J
7 7-1 Aeration Dist. Pipe
Holding Bot. System y 7 g , 17 1~7(,
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover 3. 1~ 3 r-
~V vl~ j GPM- IOI GY SSA ~1~• O
Model Number 0 l
N-4 r ~•Zg ~S. 3'~
TDH Lif Friction Loss System Head TDH ~t
G Z Z 5 4 j f t'
Forcemain Length Dia. I Dist. to Well `
s1C Z ':K7 f
SOIL ABSORPTION SYSTEM 7.5-5
BED/TRENCH Width Length No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~i J F \
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: \
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number: ~a
DISTRIBUTION SYSTEM
Header/Manifold ( Distribution i x Hole Size x Hole Spacing Veto Air Wake
Pipe(s) J 7 Length 3 Dia Length Dia Spacing
Q
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seede Sodded xx Mulched
Bed/Trench Center to / / 7 Bed/Trench Edges Topsoil P4
/ Yes I No es No
COMMENTS: (Include code discrepencies, persons present, tc.) Inspection #1: 9/r9 / 4 Inspection #2:
Location: 3075 180TH AVE /31 ° -r,\
(e
1.) Alt BM Description = ~✓~►r--
~l
2.) Bldg sewer length = Z J
i L
-amount of cover = / C L O
C :"\c i u 0. 7 C.~ l
Plan revision Required? Yes l~o 3
Use other side for additional information.
Date Insepctor'g ignature Cert. No.
SBD-6710 (R.3/97)
RECEIVED
N`rQ~.P.aRTMF,tr(l~
JUN 17 2016 Industry Services Division
i
1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.)
$
pg `ST, CROIX COUNTY P.O. Box 7162 75~
y MUNITY DEVEI.OPME Madison, Wt 53707-7162
Sanitary Permit Application State Transaction Number
2'72- 3& 641
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 forms for state-owned POWTS are submitted to Pro'ect Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 76 7 1
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. ,`j~_ •
I. Application Information - Print All Information parcel #
Property Owner's Name I
M&rK SAA a - Za -300
Property Owner's Mailing Address Property Location
3a 75 ID"." k 4*, Govt. Lot /
City, State /J Zip Zf Phone Number /uW y,, ~vC- Section
of le pidOre 615 -7 circle one
II. Type of Building (check all that apply) Lot #
Subdivision Name
1 or 2 Family Dwelling - Number of Bedrooms
L* Block #
Public/Commercial - Describe Use O City of -
CSM Number O Zr/ Village of
State Owned - Describe Used ( Town of
00 le.4
Co k 76 v 7,3 t)
III. Type of Permit: (Check only one box on line A. Complete line B i ap licable)
A. New S stem t to Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued /I
B. Permit Renewal Permit Revision Change of Plumber Permit Transfer to New
Before Expiration Owner
IV. T of POWTS S stem/Com onent/Device: (Check all that apply)
Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound > 24 in. of suitable soil X Mound < 24 in. of suitable soil
Holding Tank Other Dispersal Component (explain) Pretreatment Device (explain)
V. Dls rsaUTreatm t Area Information: Dispersal Area Pro (sQ System Elevation
Design Flow (gpd) sign Soil Application Rate(gp Dispersal Area Required (sf) pos 7Jj 3
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units u o U v_
^ V
New Tanks Existing Tanks (rJ ~~J V o
V in m yr 'w' C'I a.
)a
Septic or Holding Tank X
Dosing Chamber 50
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of We POWT/MPRS N mbetached Busp Hess Phone Number
Plumber's Name (Print) Plum s Signat
7r5-2~5'l-~/// S p
Plumber's Address (Street, City, State, Zip Code) if - SS 7 ! 7 v
1114 /V
VIII. Coun /De artment Use Only
Permit Fee Date Issued Issuin ent Signatu
Approved., $ 64. c0 7
r ason for Denial
1X. Condi a easfpts for Disapproval
_713
dhoemsu cell-must all r s I na•!tlj~yrK
t ,;W TFw9ernent plan provided by plumber.
2 I nu***rlai*Ined f.1~ r ~id1~ A. WPM r 41WFAd -Dods / Crttinsttoli. 1
Attach to complete plans for the system and submit to a oun o y on paper not less an 8 tiz x 11 inches in size
SBD-6398 (R0313) r
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
SOIL EVALUATION Scale: 1" _ Q SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: 52 DESIGN FLOW: 450 GPD
Mark Smith Attach design flow calculations for commercial plans.
PROJECT ADDRESS: 3075 180th Ave, Glenwood City, WI 54013 Pipe Material / ASTM Standard (Tables 384.30-3 & 384.30-5)
Sanitary Sewer. PVC ASTM D3034
BM Symbol: -$r BM Elevation: 100.0 FT N Force Main: PVC ASTM D2665
II / /
BM Description: 6`0-de 4& ?owtY?6le Gas4o of d fhtr.ewac.t
Indicate north by IMPORTANT:
Slope Gradient 3 Well Symbol (if applicable): p drawing an arrow Show ground elevation contours at suitable intervals.
of Tested Area: on the approprite line.
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35
/ARr r ~ DIVISION OF INDUSTRY SERVICES
10541 N RANCH RD
HAYWARD WI 54843-6462
Contact Through Relay
http://dsps.wi.gov/programs/industry-services
www.wisconsin.gov
vk~~~ ya(CtVPti'~
Scott Walker, Governor
Dave Ross, Secretary
June 10, 2016
CUST ID No. 267985 ATTN POWTS Inspector
MICHAEL J MYERS ZONING OFFICE
NORTHLAND PLUMBING WC ST CROIX COUNTY SPIA
2943 130TH AVE 1101 CAR-MICHAEL RD
GLENWOOD CITY WI 54013 HUDSON WI 54016-7708
CONDITIONAL APPROVAL -
PLAN APPROVAL EXPIRES: 06/10/2018 Identification Numbers
Transaction ID No. 2723604
SITE: Site ID No. 825122
Mark Smith Please refer to both identification numbers,
3075 180TH Ave above, in all correspondence with the agency.
Town of Glenwood
St Croix County
NWI/4, NE1/4, S3, T30N, R15W
FOR:
Object Type: POWTS Component Manual Regulated Object ID No.: 1606715
Maintenance required; 450 GPD Flow rate; 18 in Soil minimum depth to limiting factor from original grade; System(s):
Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual -
Ver. 2.0, SBD-10706-P (N.01/O1, R. 10/12); Effluent Filter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code
requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Please see corrections made to the plan in red. Thanks.
• The building sewer and distribution network piping shall be of material listed in Table 84.30-3 and 84.30-5,
Wis. Adm. Code.
Reminders
• Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of
the POWTS explaining that periodic cleaning of the septic tank outlet filter is required. The access opening
used to service the filter shall terminate at or above finished grade with a watertight cover.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction/instal lation/operation.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
MICHAEL J MYERS Page 2 6/10/20 L6
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 250.00
Fee Received $ 250.00
Balance Due $ 0.00
Carl J Lippert
Wastewater Specialist , Division of Industry Services WiSMART code: 7633
(715)634-5035 , M-f 7AM - 12PM
,wisconsin.gov
carl.lippert(&
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
Northland Plumbing Inc
MICHAEL J MYERS Page 2 6/10/2016
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 250.00
Fee Received $ 250.00
Balance Due $ 0.00
e~~Zwl I
Carl J Lippert
Wastewater Specialist, Division of Industry Services WiSMART code: 7633
(715)6-14-5035, M-f 7AM - 12PM
carl.lippert@wisconsin. gov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484 , Monday - Friday 8:00 am To 4:30 pm
Northland Plumbing Inc
fem.
PAGE 1 OF 6
Mound Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10691-P (N.01/01, R. 10/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12)
Pg 1 of 6 Index & Cover Page ,11$Pg 2 of 6 Plot Plan C
Pg 3 of 6 Mound Cross-Section & Plan Vi ✓1~~0
Pg 4 of 6 Distribution Network Specificationvs,9 6'
Pg 5 of 6 Pump Tank Specifications k
Pg 6 of 6 Management Plan 9,4 C
s
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): Mark Smith Phone: 651 _253 _4827
Owner Address: 3073 180th Ave, Glenwood City, WI Zip: 54013
Project Address: 3075 180th Ave, Glenwood City, WI 54013
Govt. Lot: NW 114 of NE 1/4, Section 3 , T 30 N-R 15 E ❑ or W
Township: Glenwood County: St. Croix
Project Parcel ID
Designer Information
Designer Name: Michael Myers p P T, i
_4115
!
Designer Address: 2943 130th Ave, Glenwood City, WI eppR 13
E-mail: mcmyers@centurytel.net r F N AND PROFESSIONAL S,r ES
PTOF S
License Number: 267985 Dy~i SlvN OF INDUSTRY SERVICES
Remarks:
SEE RESi'Oi'3DENLE
Signature: / Date:
Original signature required on each submitted copy.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
SOIL EVALUATION 0 Scale: 1'0 c' WISYSTEM PAGE 2 OF
a& I"
SITE MAP
V, rzz PLOT PLAN
PROJECT NAME: DESIGN FLOW: 450 GPD
Mark Smith Attach design flow calculations for commercial plans.
PROJECT ADDRESS: 3075 180th Ave, Glenwood City, WI 54013 Pipe Material / ASTM Standard (Tables 384.30-3 $ 384.30-5)
Sanitary Sewer: PVC / ASTM D3034
BM Symbol: ! BM Elevation: 100.0 FT Force Main:
N PVC ASTM D2665
BM Description: &"~e 4~?owtY``~~ COt E*,%4ef dr,rv.twc,,r
Slope Gradient Indicate non', by IMPORTANT:
of Tested Area: 13 Well Symbol (if applicable): drawing an arrow
Show ground elevation contours at suitable intervals.
on the 2ppro prite ite li tine.
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PAGE 3 OF 6
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PAGE 5OF6
SEPTIC / PUMP TANK SPECIFICATIONS
4"0 Vent Pipe (No Scale)
> 10 ft from
Building Electrical must comply with
12" Min. or 2.0 ft above SPS 316 and NEC 300
Established Flood Elevation Extend manhole riser as necessary.
(typical) Weatherproof
Approved Junction Box
Vent Cap Approved Locking Manhole
IMPORTANT: with blaming Label Attached
Anchor tank(s) as necessary (typical)
Conduit
pursuant to SPS 383.43(8)(8) 4" Min. or 2.0 ft above
Established Flood Elevation
(typical)
Airtight Seal
Finished Grade
Quick Disconnect
CAPACITIES 17 ° ty Min.
@ gal/in s . - (typical)
Depth (in) Volume (gal)
A 20.9 355.3
Weep ~ Approved Joints with
Hole Approved Pipe 3 ft onto
B 2.0 34 A Solid Ground
(typical)
[C] 5..0 85 LL Alarm
D 10 175.7 B -on
} [c] PUMP-OFF
*Pump Tank Liquid Level = 38 in Pump _off ELEVATION = 88.8 ft
INSIDE BOTTOM
Force Main Diameter = 2 in Concrete
Block ELEVATION = 88 ft
Force Main Length = 80 ft 3" Approved Bedding Material Beneath Tank
Force Main Void Volume = 15.6 gal Vertical Head = 9:59 ft
+ Min. Supply Head = 6.5 ft
[C] Total Dose Volume (TDV) = 78.2 gal/dose
+ FM Friction Loss = 2.59 ft
L (5X total lateral void volume TDV 0.2X design flow)
+ (force main drainback volume) + Fitting Loss" = ft
*(min. supply head x 0.3)~,~,, t~'I
MIN. PUMP DISCHARGE RATE = 39.5 gpm = TOTAL DYNAMIC HEAD ft
PUMP TANK: SEPTIC TANK(S):
Volume = 650 gal Total Volume = 1000 gal
Manufacturer: Wieser Conctrete Manufacturer(s): Wieser Concrete
Pump Manufacturer: Goulds
Install approved effluent filter at the septic tank outlet
Pump Model: PE94P1 hI immediate) upstream of the
(See attached pump curve.) y pump tank inlet.
Controls/Alarm Manufacturer: SJE Rhombus Filter Manufacturer: Polylok
Controls/Alarm Model: S1019300
Filter Model: 525
Float switches containing mercury are prohibited.
PAGE 4 OF G
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow= 450 gpd; BOD5:5 220 mgL"'; TSS :5 150 mgL-'; FOG 30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: Northland Plumbing Inc Phone: 715-265-41 15
Local government unit: St. Croix County Phone: 715-386-4680
Local government unit address: 1 101 Carmichael Road, Hudson, WI ZIP: 54016
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
ITT GOULDS PUMPS
Residential Water Systems
APPLICATIONS MOTOR
Specially designed for the following uses: General:
• Mound Systems • Single phase
• Effluent/Dosing Systems • 60 Hertz
• Low Pressure Pipe Systems • 115 and 230 volts
• Basement Draining • Built-in thermal overload protection with automatic reset.
• Heavy Duty Sump/ • Class B insulation.
Dewatering • Oil-filled design.
• High strength carbon steel shaft.
SPECIFICATIONS PE31 Motor:
Pump - General: • .33 HP 3000 RPM
• Discharge: 11/2" NPT • 115 volts
• Temperature: 1041F (4011C) maximum, continuous when • Shaded pole design
fully submerged. PE41 Motor:
• Solids handling: '/z" maximum sphere. • .40 HP 3400 RPM
• Automatic models include a float switch. • 115 and 230 volts
• Manual models available. • PSC design
• Pumping range: see performance chart or curve, PE51 Motor:
PE31 Pump: • .50 HP 3400 RPM
• Maximum capacity: 53 GPM • 115 and 230 volts
• Maximum head: 25' TDH • PSC design
PE41 Pump:
• Maximum capacity: 61 GPM AGENCY LISTINGS
• Maximum head: 29' TDH
PE51 Pump: c
• Maximum capacity: 70 GPM
• Maximum head: 37' TDH C~p Us
Tested to UL 778 and
CSA 22.2 108 Standards
By Canadian Standards Association
METERS FEE File #LR38549
0
E51 MODELS PE31, PE41, PE51
HP 33, 40, 50
35
10 2 GPM I Goulds Pumps is ISO 9001 Registered.
30 PE41 i r I
w 25 PE31
x
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a 2
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0
15
0
10
5
0 00 10 20 30 50 60 70 GPM 80
0 5 10 15 m /h
CAPACITY
ST. CROIX COUNTY
SH)TIC'IANK MAINTENANCE AGREEMENT
AND
OWNS/RSHIP CERTIFICATION FORM
O\\'ner/Buyer
Mailing Address
Property Address v3d 7,5 1,F0
'~Q~•.e
(Verification required from Planning & Zoning Department for new construction.)
City/State C~ ~,ChtvOOp~~ l ell Parcel Identification Number
LEGAL DESCRIPTION
Property Location /lW Sec. T y1,0 N R (5 W, Town of
Subdivision Plat: Lot # 3
Certified Survev Map # O 3 Volume 2 7 _ Page # CP l/,3
Warranty Deed # (before 2007)Volume Page #
Spec house yes( o Lot lines identifiable yes 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 Comm. 83.52(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 (iFncce,sar\ the septic tank ix
less than 1 /3 full of sludge.
t/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 Commerce 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/v, c certify that all statements on th' 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 a wa -anty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNATURE 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. 08/05)
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P Department of Safety and Professional Services Page 1 of 3
Division of S in accordance with Comm 85,,M Atu~ ~""bCl~o ( Northland Plumbing, Inc.
Attach complete site plan on paper not less than 8% x 11 inches in si . P County
r,~0UN St. Croix
include, but not limited to: vertical and horizontal reference point (BM , air
percent slope, scale or dimensions, north arrow, and location an,30WWNkTWe61&TZW I.D.
Please print all information. Rev ed By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). /
Property Owner Property Location
Mark Smith Govt. Lot NW1 NE1/4, S3, T30N, 715W
Property Owner's Mailing Address Lot # Block # Subd. N e or CSM#
3073 180th Ave
- 2
City State Zip Code Phone Number City Village Town Nearest Road
Glenwood City WI 54013 651-253-4827 Glenwood 180Th Ave
New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement Public or commercial - Describe:
Parent material Glacial till Flood plain elevation, if applicable ft.
General comments
and recommendations:
❑ Boring # Boring
Pit Ground surface elev. 96.84 ft. Depth to limiting factor 21 in. Soil Application Rate
Horizon f Depth Dominant Color Redox Description Texture Structure Consistenc Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color i Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-11 ! 10YR3/2 I sil 3sbk mvfr cs if .6 .8
2 11-17 10YR5/4 sil 3sbk mvfr cs if .6 .8
3 17-21 10YR5/6 scl 2abk mfi cs .4 .6
4 21-37 10YR6/8 7.5YR6/8 fld spots s Osg mfi cs .7 1.6
5 37-49 i 10YR5/8 i 7.5YR6/8 fld spots sc~ Om mvfi cs 0.0 0.0
Boring
2 Boring #
Pit Ground surface elev. 9435 - ft. Depth to limiting factor 18 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence' Boundary ; Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 Eff#z
1 0-10 10YR3/2 sil 3sbk mvfr cs if .6 .8
2 10-18 10YR5/4 sil 3sbk mvfr cs if .6 .8
3 18-23 10YR5/6 7.5YR6/8 fld spots scl Om mfi cs 0.0 0.0
- -
4 23-28 10YR5/8 7.5YR6/8 fid spots! sc 2sbk mfi cs .2 .3
5 28-32 10YR4/6 s Osg mfi cs .7 1.6
6 32-48 ! 10YR5/8 7.5YR6/8 f1d spots' sc 1sbk mvfr cs 0.0 0.0
Effluent #1 = BOD 5> 30 < 220 mg/L nd TSS >30 < 150 mg/L ' Effluent #2 = BODS 30 mg/L and TSS < 30 mg/L
CST me (Please Pint) Sign ure: CST Number
AAt Al
2G77,!75
- -
Address Northland Plumbing, Inc. Date al tion Conducted Telephone Number
2943 130th Ave Glenwood City, WI 54013 C Z 20/4 715-265-4115
SBD-8330 (R.1 1/11)
Prcr~rty Owner Mark Smith- Parcel ID # ORIGII` ; L
~ f Page _-_2 _of 3
-
Boring C 3
3 ]Boring # Pit Ground surface elev. - 94.56___ ft. Depth to limiting factor 21 in.
- Soil Application Rate
Horizon Depth Dominant Color ! Redox Description Texture Structure iConsistence Boundary Roots GPD/ft
z
in. Munsell Qu. Sz. Cont. Color Gr- Sz. Sh. `Eff#1 Eff#2
1 0-8 10YR3/2 sil 3sbk mvfr cs if .6 .8-
2
8-110YR5/4 sil 3sbk mvfr ~cs 1f 6 8
3 13-21 10YR5/6 scl 2sbk mvfr cs 4 6
4 21-26 10YR4/6 7.5YR6/8 fld spots' fs Osg mfr cs .7 1.6
5 26-46 10YR5/8 7.5YR6/8 f1d spots sc Om mefi cs 0.0 0.0
i
F Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture i Structure iConsistence Boundary Roots GPD/W
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#l -Eff#2
~ i
I
i
I
L-J
Boring
Jr Boring # Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon I Depth Dominant Color Redox Descri tion Texture Structure Consistence Bounda Roots GPD/ft2
p ry in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2
I
I
I
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 Safety and Professional Servicese 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-8330Test (RA 1/11) Northland Plumbing, Inc.
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