HomeMy WebLinkAbout036-1047-30-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 597408
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID N7W
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:
STEVEN VOLKERT TOWN OF STANTON 036-1047-30-200
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
20.31.17.294A-20
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TANK INFORMATION ELEVATION DATA W7 Mi-, C, TYPE MANUFACT CAPACITY STATION BS HI FS ELEV.
i
Septic
i FiLTW,i y•r Benchmark 1O J' V
1
Dosing 7 Alt. BM I
Bldg. Sewer R
n Ht Inlet
.08 3.
NA n ~1 ~q
TANK SETBACK INFORMATION St/ Outlet
Iil~ f ,i ' •7 v
TANK TO P WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic t Dt Bottom
, 1l + r f
90' q
Dosing ead an. 'O
'?9 +
Aerat on Dist. Pipe
Holding Bot. System (1.0
Final Grade 6-,55`17. I~S
PUMP/SIPHON INF MATION
Manufacturer emand St Cover*
GPM Q
Model Num r
TDH Lift Friction Loss Syste ead TDH Ft
Forcemai Length Dia Dist. to Well
SOIL AB N SYSTEM
BED/TRENCH Width Len / No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STIR LEACHING Manufacturer: / a
INFORMATION CHAMBER OR /
~~„f I/~ 1 / UNIT Model Numbe
e W44-1
DISTRI UTION SYSTEM 119 t) lcv
e Id + Distribution x Hole Size x Hole Spacing Ve to it Intake
Pipe(s)
Length Dia Length is pacing _ IV
SOIL OVE x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 1 + xx Depth of
Bed/Trench Center Bed/Trench Edges Yes [ No ]Yes No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1. Inspection #2: ,,yam
Location: 1553 210TH AVE 'Z '✓/J ' 11 Dot ~n `a
1.) Alt BM Description = ,1 v WV `
2.) Bldg sewer length = ~ Pcto- amount of cover Plan revision Required? Yes No
Use other side for additional informatidn.
1] D e r's Signature Cert. o.
SBD-6710 (R. 3/97)
S r~ -a o o~
~rtr County i
T.% boo s T.
S PS l 3 H 813 QAW P 8 G KAC 71 bZ Sanitary Permit Number (to be filled in by Co.)
, JUL 3~#f~~.~ rcRO~x oo-c°y 5'9 7 ~
:,oMMUN anitary Permit Application State Transac omber
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 POINTS 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
/
u ses in accordance with the Privacy Law, s. 15.04(l (m), Slats- 1-14
1. Application Information - Please Print All Informs ' n 1,!5-5-3 I Z-~ -
Property Owner's Name / Parcel #
,S.Z.c.t.~L.. 63 6 " v ) - 3 6 -,266
Property Owner's Mailing Address -d' Property Location ~ V
/5-53 L) A L) Govt. Lot
City, State 1 Zip Code Phone Number AJ Lkt /V C-- Section
one)
6'~sz-l-d-t ~`-L4V1,- C1 1 /-,L. -T ~ ° f trcleEorW
J 7 T ~~__N; R
II. Type of Building (check all that apply) ~ Lot # _
Subdivision Name
AJ or 2 Family Dwelling- /
#
El Public/Commercial -De ❑ City of
❑ State Owned - Describe Use _ / CSM Number El Village of _
4i A 3 -0) 5 Town of
IIL Type of Permit: (Check only one b ix on line A. Comp e e 1 e 1 applicable) .A,
❑ Treatment/Holding Tank Replacement Only D Other Modification to Existing System (explain)
A. ❑ New System' Replacement System Y
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that apply)
e Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 m. of suitable s~ it
El Holding Tank El Other Dispersal Component (explain) El Pretreatment Device (explain) AAP A
d J
V. Dis ersaVTreat nt Area Information:
Design Flow (gpd) Design Soil A lication Rate( dsf) Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation
L/ 63
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units L U
New Tanks Existing Tanks `c
w d ~U~
Septic or Holding Tank
Dosing Chamber J
VI I. Responsibility Statement- 1, the undersigned, assn a responsibility for installation of the POW TS shown on the attached plans.
Plumber's Name (Print) Plum r' ignatur P ' PRS Number Business Phone Number
"e~~ IQJ~~' llc/~,% 6357 [7157- 766
I~
Plumber' Address (Street City, State, Zip Code)
pif t j3 )x z- 01
VIII. County/Department Use Only
p proved Permit Fee Date ssued Issuing Age ignature
06 Zb
Given Reason for Denial $ gs' 17
IX. Condit' aspns foP Isapproval
Etflt9crt:1"lam F+ili J r
41-6er` si cell n+ust all be s, lrvl 4s
mfk anayemen! plan aed 4. plumber.
a m
AN ll. rect~lwnrnemncs must, be ra:rt, +r ed
2
as per Pff&mWs m tt / ~:.rdinie wra. )
Attach to complete plans for the system and submit to the County only o'n+ per not than 8 1/2 11 inches in size
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, NVEN T =ONAL C-OM 'ONE T DESIGN
Residential Aoplication
INDEX AND TITLE PAGE
Ovvlier's Name:
/ )tQ /~.,.15 / V L 31
5T,
f_ot Number
Parcel 11) Nwnber:
Page 1 ir3ex a, tie
rage 2 P;'P
Page 3 System S:zrrg & Cross-Section
Page 4 Pr Srews -s
Page 5 "a"a ^ e^a-ce r:.Te"on
Page o 1 arae-^ en: Piar.
Page 7 St. Croix Cty Seafc T ar c Maintenance Form
Page B Warranty Deed
Page 9 CSM or Prat
Attachments: Soil Tes; & Howe Plans
Designer/Pfumber. License Number: 6VL
Gate: _ 7 ~ r l ? Pirecne Nur Der 7/ 7~G G ~c
`3 gnatuie
(Designed pursuant to Oita 3rou nd Soi' ASsorptrcr Component Manual toy PQVYT Version 2.0 S8ll-10705-P (N.011o1).
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Soil Absorption System Cross Section
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Final Grade
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Leaching, C
Chamber
System Elevation
Soil Absorption System Plan View
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ft i i { I ,
r II I'?'
J1,
-aching Trench 9
Vert Or Observatc-, _ i
:ambers ~i si f! ~4J
4" Dia.
1 rc Header
Leaching Chamber Specificatio--n
N,Ianxacturer And Model
EISA Rating sq tt per chamber Soil Appiicatic- :7- =--e gpd/sq ft
~gc resign Flow Soil Application Rate = 3C _ SA = v~t ~ Chambers
chambers ea::r-
Page of
48" -
I (EFFECTIVE LENGTH)
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8' INVERT 131 8: INVERT,/- I 1 5.3 INVERT
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POW S OWNER'S IWANUAL & WIANAGENIEN ]'PLAN PagE! d _ o` Z`
FILE INFORMATION SYSTEM SPECIFICATIONS
Ovvner Septic Tank Capacity /R S-C oaf El NA
Permit # Septic Tank Manufacturer, NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ~3^ $e 2f _ ❑ NA Effluent Filter ivlocie'. ❑ NA
Number of Public Facility Units NA rump Tank Capacity gal 1r4NA
Estimated flow (average? LICs O Pump Tank ivlanufacturer ~ NA
7 gai,day _
Design flow (peak), (Estimated x [.J) ~ I t~ 6" Sal day Pump f':ianufac'ura: ANA
Soil Application Rate lump modal A
Standard Influent/Effluent Quality J orthiv a, e 4 Pretreatment Unit -jK NA
Fats, Oil & Grease (FOG) <Kv rrg [ Sand.iGravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD) • =22:: mg-i ivA ❑ Mechanical Aeration ❑ Wetland
i r taf Suspended Solids ;TSS} 50 nig1L ~j Disinfection ❑ Other:
_?retreated Effluent Quality ivfonthiy average Dispersal Cell(si ❑ NA
Biochemical oxygen Demand (E3Giu;} s30 rng: in-Ground (gravity) :_1 In-Ground (pressurized)
Total Suspended Solids (T SS} <33 mg':. NA At-Grade D Nfound
Fecal G'olirorm (geom4uic mean) ; 0` cf C:' 100 m! 1 D: }p-Line ❑ Other:
Maximum Effluent Particle Size '.p in die. E: Nf Other: - ❑ NA
Other. _ . ..-.o. _ . ❑ NA
'Vaiues typical for dnmwllc: waste-,,.,a e- arp _e...ti re" ! NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) A_ ices. once every: :1 month(s)
_ 3 Year(s) (Maximum 3 years) ❑ NA
"ump out contents of tank(s) , er cz)-nnined sludge and scum equals one-third 1 of tank volume !"1. NA
onth(s)
inspect dispersal cell(s) At leas, once every: C yea mntri (Maximum 3 years) 11 NA
( :fear. effluent ff ter AT ma'th(s!
east once eve G
yea s; El NA
a r ,ontnis!
inspect pump, pump controls & alarm At leas: once every: C: year; s;1 NA
ff `ush laterals and pressures test At i636: once every: i~ NA
year(s)
;thee: _ monthfsi
i At ;east once everyy: years; NA
Iii NA
iAINTENANCE INSTRUCTIONS
irispectiwis et aanks art rifspersal calls shall be =r:ade ny an, ind;vidual carrying one of le fo!l,awing licenses or certifications:
lvla ,W Plumber; Master Plumber Restricted Sewer; POPA`TS Inspector,; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visua: inspection of the ank si to Identi`v any missing or broken hardware, identify any cracks or leaks,
measure the VOWITCfi of combined Sitlage and scar,: aria to check Tor any pack lip or ponding of effluent on the ground surface.
The dlscsrsfi ..^eff;S`. r'ltrl. C''„ v:F;tafiy lrlSOe^C.eC'. to check the e'`fl'_!(,n' lo`:re.E in. the ot:servation nipas and to Chpck far any pondinn
Of effluent on the ground surface. The pondinc of affluent on the ground surface may indicate a failing condition and requires the
;mmedia.e notitination of the focal regulatory authority,
i rhea the combinea accumulation of sludge and scurf in any tarik equals one-third or more of the tank volume, the entire
)n-Eenis of the tank steal; be remove-.d by a Septage Servicing Operator and disposed of in accordance with chapter NR i 13,
~,Visconsin Administrative Code.
';,fl other services, including bu. not limited to the servicing of effiuent filters, mechanical or pressurized compoiiants, pretreatment
anr' any cnr.,llC.injj at i11=F."Sc.ia 7f.'~1!. months, ghnf! hp _Qr,r1 Ar 'l 2 ":-rtlfied 13±~4rV S Mlaintainer.
START UP AND OPERATION 7_
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of paintin Page of v
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. 9 Products or other chemicals
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
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge
be
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 of
pump or contact a Plumber or POWTS Maintainer to assist in manually operatin the g
restore normal levels within the pump tank.
A pump controls to
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) prolong the life of the
p pum) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
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 prot the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement areaecReplacement systems must
comply with the rules in effect at that time.
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.
f T
IC"1 aluati : IN!
rQav
be
'last leSult e are a o mg ank
❑ Mound and at-grade soil absorption systems may be r 0NS7RUC n 0n j
infiltrative surface. Reconstructions of such systems must comply wthrthe rules inlieffect at that tlime the biomat at the place wing rem of
< 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
3WTS INSTALLER
ENamee T"POWTS MAINTAINER
Name Phone
PTAGE SERVICING OPERATOR (PUMPER)
Name + LOCAL REGULATORY AUTHORITY
Phone ' Name
r Phone
document was draftad in rnm~l+nnr,c ~n:ith c:htrrt~~; (;r,rY~rr, p};;,2;~( -2)(h),
r 1)(d)&(t) and 8:3.54(73, (2, & (3)Wiccnnsin /administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 1d CS'I'
Mailing Address C/~ , /AJ 12t-ti-
~ I C' /~1,fZ` ~ S ~~l
<
Property Address 5_5 I ~ 3 V'/~=
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number 63w G t/ - 3 C CSC"
LEGAL DESCRIPTION
Property Location Nom'/4 , A~F 'A , Sec. 3 C , T3/ N R W, Town of
Subdivision Plat: , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house Oyesao Lot lines identifiable ftyes❑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 withi 30 days of the three year expiration date.
I/we certify that all statements on is 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 w anty deed recorded in Register of Deeds Office.
Number of edrooms
SIGNAT RE 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
IAlis. Lieut. of S _ innai Page
of
Divis~y~pl~f zaut,f~~ +0 I ! illdinas
J~1~ I jn accrrdance with `'PS ' \A/is /vIn, Code -
County
Ne, ~Ir less ha a 1/2 t 11 inches r _r e P la_r must -S~t~. L
,OMMuN ~Qa, ai and'! ric.., e, arld oalCP.l i.D.
'?ercent slope. Scale or dimensions. il. h =,rr obi
f r. 9,-Id' icca~io:, a, _ . rant r i1.^~aresC road. L)
°e~~e r^rFa t f ~F za~Fn#, !i Review by Dalee~ y~
Property O~riner Location
Lo', tj . 11? 1 J4 S O T I N P. ( (or) VV i
Property Chvner's Mailing ndare s 'I Block # Subd. Name of CSWt#
C
Iss 4a
ity Staic p Code °hor rIunCe iitr ❑Villaae1Tr,vvn Nearest Road
F[,- ~.le~nr Construction Use: P.. sides i-~ , Num~ ei of b dloo is -'odo, derived design flOW rate GPID
➢~.'~eplacamPrr ❑ -'ublic ~ ~ r,e a- i7esr.iil~c`
Parent tateria r Ir o(; Phin elevation 1f applicable General comments
9 and recommen0niions S `aV a-~ r I i1Y~~ 1 c :•F d ~'r " t~?,
-Ti tv
9 ,So
s! Boring
Boring
Pit Grounds i`ace ele\~. aJ f~ D n t~ to liniiting `actor ! Soil Application Rate
Ilorizon Denth Dominant Color cox uPS,-iotior ,multi e Insistence oundary Roots _ GPD/ft ~
R mIlsell
7z- (,oi~t. Coic ~C . 3, Sh. 1 _ ff#1 ff#2
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f _
~Lg 3b .1
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76 C;~
-in4
f3orinq #
to
i Dit Ground _I ~a elev _ 7j tr_-'t );h to linnitino factor, in
e
S
oii p ii,atiors Rate
Horizon of Depth Doi~u~antOoir~ doK e ei~u'iir ~,a cure onsistPncF, Boundary Roots GPf~/ft `
in. MunSell f Sz C Cols i (-,r )z Sh.~-„ 1I- fft#1 lff#2
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19
5
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Effluent #1 BOO 30 ;-'2 7"L ar I SS r 5: I'l lent .92 = BOD < 30 mg/L and TSS < 30 ma/1-.
CS- Name Prm, it CST Ni-ember
l i., 3 ? `acs _
6 %djcts -t 3 . T"y+ c Evair anon -ond_icteci Telephone Numhsr
00 1
Propertv Owner
zereiID
Boring # Boring page of
Pit GFOUnd surface elev. %-,z) , Derih to limiting factor l ~
in.
Horizon Dep h Dominant Color r -
Redox I-Desci ptioir SoilA lication Rate
Tex,ure
n. Munsell ~irtiiciure onsistence ot.mdary Roots
S;_ Cor.t. Coo rt. GPD/ft
1 t
x: 1 D Y w 1 - a- fr#I fr#2-
-
n Boring
I ring, Pii C''cl Si]-face elev. lep;h to limiting factor
_ in.
Horizon Depth Domina rt Color ;edcx Description - Soil Application Rate
in guns° n uin Structure onsistence ounda
i . 1
u - Coy] 01or G-1, N Roots GPD/ft
- _ . Sz. Sh.
ff#1 ff#2
Boring 5oring
#
i
t ounave elev.
_ . o li niting factor in.
Horton 1 Decih
PoninanQ Color; - Soil A lication Rate
p Desrnotion wre )urc'ure
in. 1 onsistence oundary Roots GPD/ft
tUunseli -fir .
J_ f%oi i CO101
i _ - _ _ _ ff#? 1 ff#2
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4-.iiiUeni= =BOD ~30;ZSS '.3~~<9;
- Ffitlent 412 = BOD < 30 mg/L and T SS < 30 mg/L
Tho i)cht. of 57ieiv d
j n c t „ 'I 1uLi ~crvt~t hlnr,td<randemnlo~;er.
1[ C CtiR SL I~ ICCS O ljoc3 it '8) in ,117 ,]17.01 l nC - t f rYou nEed a.ssigance t0
' c~ ~'~t'~ rho dc; ;'N]"cM it 60,-566-3 151 ()r "1'TY through Rc1av.
•"vim. ~1...-...~ ..t`~
PrOpEr~i ~WIIE -
t rE l D' x PaaE
j i Bo,ina Morino
I P Gs'%. '!i So, -V. ~t .Gi.'° -r'-
t i iin"in, ~actor in.
Horizon n ~ _ i' Soil Application Rate i
J scrimlon EXiL
Structure ~;orsisI enc E ~3pundary
unset Roots GPD/ft I
S on ' pip
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F-'11 Borinc ~ f ho'inc i
uno su'=ace Elegy.
:...~tI- i-iliiinc ta~io'
Horizon I Dept" D - 1 Soil Aooiicatior Rate I
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p [ructure oosisience (3oundan~ Roots
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orizon =~2 ~f C fo
Soil Ap lication Pate
Domiranf - s o „u;-e f. uchare l.,onsisie;~ce punch PooIs o
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f- f k t f l ~
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ffiluem --!~2 - BOC - 30 mg/L and _ _ 3' , ma/L
I; you nccd assistance -to'
a 60,>-266-- 51 or TTY ihrouah P,cla;
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