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HomeMy WebLinkAbout032-1081-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597430 GENERAL INFORMATION 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 DAN MEYERS TOWN OF SOMERSET 032-1081-80-000 CST BM Elev: Insp. BM Elev_ BM Description: SectionfTown/Range/Map No: 28.31.19.393A TANK INFORMATION ELEVATION DA - TYPE MANUFACTURER~ ry ~m CAPACITY STATION BS HI FS ELEV. Septic ,1L, -`G• Benchmark s Alt. BM eration Bldg. Sewer ~j /O + Cj Holding { S t inlet J St Ht Outlet 3 TANK SETBACK INFORMATION ^ i J ✓ 9,7 TANK TO WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing j Header/fti..- •A , j Aeration Dist. Pipe Holding Bot. System Y- 17, Final Grade ;J PUMP/SIPHON INFORMATION Manufacturer De nd St Cover ` ° . M 2• Io3 Model Number TDH Lift Friction Loss S stem Head TDH Ft Forcemain Length Dia. Dist. to well SOIL-ABSORPTION SYSTEM r Lengt No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth BED/TRENCH Width ENSIONS DIM 1l r SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture . r Q INFORMATION CHAMBER OR 7 Ty Of System: UNIT Model mbar: 60v J,4 DISTRIBUTION SYSTEM w e -7i Header/Man'rfold ID istribution x Hole Size x Hole Spaany - Vent to Air Intake ld Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over epth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench ed/Trench Edges Topsoil i es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection # Inspection # Location: No Address Available I, lrv77 LA4, 1.) Alt BM Description= 2.) Bldg sewer length = 1 w * n,~ 1~ C~ 1A - amount of cover 1,14 Z4 !)A Plan revision Required? I`' Yes No J Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor,-% gnature Cert . No County F l1 Safety and Buildings Division Ps„ 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) t;+ S;i t Madison, WI 53707-7162 743 C ~ it Application State Transaction Number $ ~m In accordance with SPS ~ls. Ad. Code, submission of this form to the appropriate govemmental unit A) 4 is required prior to a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Pro ect Address (if different than mailing a6dress) I&e Department of Safety and Professional Servies. Personal information you provide may be used for secondary urposes in accordance with the Privac Law, s. 15.04 1 m , Stats. _/VW 4 I. Application Information - Please Prin I formation roperty O 's Name / Parcel # ratt lo8t-~0-ooc, roperty Owner's Mailing Ad s Property Location of .*31. 11t.313 FE ~;2_t, i7 G' Govt. Lot ity, State Zip Code Phone Number Section circle on ~ Type of Building (check all that apply) Lot # T N; R E W J9 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name Qk Block # ❑ Public/Commercial - Describe Use K.0 0-se, ❑ City of ❑ 1 State Owned - Describe Use CSM Number 76-R AM ❑ Village of h ` 6- CeA.*, L'j ZZ ~Z2- clw'rt, 637 Town of_ i >»rlS r } III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal El Permit Revision 101 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) t Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) 11 Pretreatment Device (explain) V. Dis ersal/f'reat t Area Information: Design Flow (gpd) Design Soil Application e(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed f) System Elevation 17 VI. Tank Info Capacity in Total # of Manufactur r Gallons Gallons Units c y New Tanks Existing Tanks P U A)/ 444 lbk, a U A w C~ P. Septic or Holding Tank S _ At- Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibili or i stalla o of the POWTS shown on the attached plans. Plumb r' ame ri Plumber' Signature /J MP/ IPRS Number Business Phone Number lumber's Address Street, City tate, ip Code) VIII oun el!artment Use Only pproved isapprov $ermit FFeee~j dDa ~Is[su Issuing nE Owner Given Reason for Denial V"• V 7 J 7 IX. Condi WPM easa4$ for pisapproval 1. epti!s tank,ti~ri:1 t+ltii 3 ` Iles` r u sperc:a col must all! b sPfolces !ru ntFi;;e~ f as per ip4rigement plan plu sided by plumbee. 4L fl1.2. Aq ttsfb"re .Ups mems must to maint, lred as per slppbla cads: /,:rdirkimax. Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x I l inches in size SBD-6398 (R. 11/11) - 1 _ r Ile". kN~ 1 / f _ i~ f 7 77 t -_Z2 jey~ '.n CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: L rs„f~~ Owner's Name: <S b Owner's Address: / 4, Legal Description: Township: County: Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat j Attachments: Soil Test & House Plans Designer/Plumber:%~~ License Number: may. Date: 2 Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 1 , j , t i t ~ I -S i Z' T - fi f , f t . j~J /t1 / J /~rc•~~'(J J~ I ~ Grade 4°Sdm-dkd--40 pVC Vent lie wM Vesf (;8P Leaching Chamber Sysletn Elevation Leadk31n9 TFe}7Fe}7f 1~ft Vent or Oxon F1 Chambers f. 4' Ilia. Trer►c h 2 Header cl~~ l~ s~ ~€~t efts Manufacturer And Model EISA Rating ' l' s4 ft per chamber Sr~i7 App}ic~ion Rare r -2 ~ it ~ion RaL X EISA Chambers Agp Sad _ gpcf Design Flaw = -.t,A-- d s~ham~secs each. 2 co vis of page aF n" 0 (LO Filters FL 525 EFFLUENT FILTER 7,7 Polylok, Inc is pleased to add its / new commercial filter to its existing I J line of duality effluent filters. The l" t PL--525 is rated for over 10,000 GPD Alarm Accepts PVC (gallons per day) making it one of accessibility extension handle the largest commercial filters in its class. It has 525 linear feet of 1,116 filtration slots. Like the Polylok PL 122, the new Polylok PL-525 has ~t an automatic shut off ball installed 525 linearfeet with every filter. When the filter is of 1/16° filtration slots'"`"-,. r` Rated for over removed for cleaning, the ball will 10,000 GAD float up and temporarily shut off the system so the effl uent won't IW- leave the tank. No other filter on the market can matte that claim! ~ Accepts 4° & 6° SCHD. 40 Pipe f PL-525 Maintenance: The PL--525 Effluent Filter should operate efficiently for several years _ under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs l Gas deflector servicing. Servicing should be done by a certified septic tank Automatic shut-off pumper or installer, ball when filter is removed 1. Locate the outlet of the U.S. Patent No# 6,015,4W septic tank. 5.371,64[1 2. Remove tank cover and pump tank if necessary. PL 5,2 sslatc: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and mercial waste flows up to pump tank if necessary. 4. Pull PL-525 out of the housing. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the 4" or 6" outlet pipe. If the tank, flake sure all solids fall filter is not centered under the back into septic tank, access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter, the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 5. Replace the septic tank cover. 7. Replace septic tank cover. i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pageof FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: El NA Permit # [M Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: O NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: _,S'NA Vertical Distance Tank Bottom(s) to Service Pad. (ft) Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) if horizontal is >150 feet. Specific instructi ns to be provided on back. In Situ Soil Application Rate: (gal/day/ff) Effluent Filter Manufacturer. ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model y__5 Fats, Oil & Grease (FOG) 5_30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA E~NA Total Suspended Solids (TSS) 5_150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: rryte~ (BOD5) >220 mg/L NA ❑ Mechanical Aeration ❑ Peat Filter J~ NA (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BOD5) 5_30 mg/L Soil Absorption System (TSS) 5_30 mg/L NA Fecal Coliform (geometric mean) 5_101 ; In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA ❑ At-Grade ❑ Mound Maximum Effluent Particle Size Y8 in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) IS When combined sludge and scum equals one-third (%3) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA :51 _2 year(s) Inspect dispersal cell(s) At least once every: Y ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA Year Insect um um controls & alarm At least once every ❑ month(s) A NA p p P. p p ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third ('/3) 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 a 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 INST LER POWTS MAINTAINER Name ' Name Phone G Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name - Phone Phone - This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page / of START UP AND OPERATION -IL 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 fines 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 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 INST LER POWTS MAINTAINER Name ,~a Name Phone 7X-5-- 0 _ L Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY i Name Name S•~ 4. Phone Phone 71-5-- 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. ST. CROIX CO € MIT SEPTIC TANT -V,-,AL-Nrf~ . iCE AGREN W AIN-D 11 OWNTERK P CERMCAMN FORM C~wnex~rxtrez~iJ,A~, 2 c,' . lv ai-I;. E Address C ✓~i'~ / r' S. 4b4 Ize-S ~~jr -,3.4, 0 tv Address A- --A I Cvmificatim required ii m Plaffming & Zoning Depeau=t fm new City/State Parcel Identification Number .P I1 Cx_ .L DESCRIPTION P, toerEv Location , '''owr,, of R-~LW Subdivision Plat. a Lot Certified Survey Map - 166049 , Volume Zg Paged 637~ Warranty Deed Ir Fore M07)Volume Page Spec horse C yeso Lot iden'#fiable a to aSTEM MA07MANCE t~} ©WNER C~RT~ICA.'I'ION Improper use and maintenance ofyour septic system could result in its remade maintenance consists of out the premature failure to handle wastes. proper pumping septic tank every three years or sooner, if needed, by a licensed p mrper_ What you put into ze system caz affect the function of the septic tame as a treatment stage in the waste dwPosa.I system. 0-*miT maintenance :esponsioil es are specified in MS. 383M(I) and za Chapter IZ - St, Croix County Smx tary Urdiuance The property owner agrees to subs to St Crou County Fla g & Zonwg Department a coon ovmer and by a master plumber; journeyman plumbez, restricted plumber or a licensed pumper verifyQ that the sigued by the wastewater disposal system is in proper operating condition andlor (2) after inspection and ianecessary), e onssite less than Ili fall of sludge. nd pumping (~f the septic t Mk is Uwe, the undersigned have read the above requirements and age to maintain the smnda„ds ser frrarh; hrreias, as set by the , p qxrtmenr sewage disposal system with the of ~ And Pro" Srvioes and ~ State of s p 2 .fit went system has been miamftmed must be pmlm= o to thsSt mix days of the the year ap rabou dom. Ywe certify tbat au statements on this fbr3w are true to the best of my/our kuovAedge. Uwe am/are the owner{s} of the property descn'bed above, by trrtxze of a w deed recorded in Register of Deeds Office Number of bedrooms LL -4 G - _ Sf TURE OF APP`LI CAT 1(S), f j DATE my information that is misrepresented may result in ime saaitary permit bed revoked by the PIanuiug gt wing Depaztmez►,t. Include with this applfcation a recorded warranty deed irom the Register of Des Office and a copy of the oertified survey map if reference is made in the warranty did. V. €fL~ n ~s-r-a~►~ - !3~ RECEIVED Wis. Dept of Safety and Professional ervices X13X®C9CZOFY PORT Page of Division of Safety and ffl* l~ 2011 in accorua. ~ mur ar5 385, Wis. Adm. Code IX COUNTY County ~ Attach com le t :tt1u~ d onzontal 0090 jF►an 81/2 x 11 inches in size. Plan must include, b" reference point (BM), direction and Parcel LD. percent slope, scale or dimensions, north arrow, and location and distance to nearest road, Ile' Please print all information. Revi by Date a Personal information you provide may be used for secondary purposes (Privacy taw, s. 75.04 (1) (m)). h/A 7,6 , -F A L1 C Property Owner Property Location / I . Govt. Lot 1/4 5 1/4 S T N R C,; E (or Property Owner's Mailing Address Lot # Block # Subd. Name or_CCM#- ' City State Zip Code Phone Number ❑ City ❑ Village OT arest Road -1 H ® New Construction User Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: ft• Parent material ~c 4 ' s - Flood Plain elevation if applicable Al . General comments / and recommendations: Ike It- 7 etc-S,~n .~y` go,., s 3 or nod"" l ltd ~Se u~lcsflob lint 4 be Pla d 01 Arl off. rc e I ad -on 0 Boling r t~t ft. Depth to limi6n9facto IGl pit Ground surface elev. in Soil ApplicationF4 te Roots GPD/ft Horiz n Depth Dominant Color Redox Description Texture Structure nsistence Boundary in. Munsell Qu. Sz- Cont. Color Gr. Sz. Sh- ff#1 * ff#2 i [l Boring BOn~ Pit Ground surface elev. ft- Depth to limiting factor ~7- i in- Soil Apeliption Rate Horizon Depth Dominant Color Redox Description Texture Structure i.stence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * if#2 * E t #1 = BOD > 30 < 220 mg& and TSS >30 < 150 Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Number CST Na P 1 Sign ~e i Address Date Evaluation Conducted Telephone Number ✓ SBD-8330 fRl )/11) A v Property Owner % Parcel ID Page , i of Q Boning # ❑ 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 2 in. Munsefl Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 ff#2 F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDJft 2 in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. * -=f A" $02 wF ❑ Boring Boring # ❑ Ground surface elev. R Depth to limiting factor in. Pit 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 Effluent #1 = BOD 6 > 30:< 220 rng/L and TSS >30 < 150 mg/L * Effluent #2 = SOD a < 30 mg/L and TSS 30 mg/L 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 605-266-3151 or TTY through Relay. M-8330(R11111) f R ~F. ~ X ~c7~3 i i t , I i i ceIv eo Jut 10 201? CRO ® cap, Property Owner ~I O/ Parcel ID # F Page of Boring # Boring F1 Q! Pit Ground surface elev. ft Depth to limiting factor in. cation Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/fi 2 in. Munsetl Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 * ',,f 02 f 5 r r~ r # ❑ Boring ~Q MNST be Bering Pit Ground surface elev. % Depth to Umiting factor in. Soil Application Rate Horizon -Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPD/ft 2 in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. ff ` ';:f W2 I - , _ ❑ Boring rig # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure 3onsistence TTY Boundary Roots GPD/ft 2 in. Mumail Qu. Sz. Cont Color Gr. Sz. Sh. tf#2 , * Effluent #1 = BOD c > 30 < 220 mgA. and TSS >30 < 150 mg/_ * Effluent #2 = BOD a < 30 mg/L and TSS < 30 mg/L 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. CRiLRi2l1 IR 1 1 /i )1 a / ~ Boa I F t I 4\ f 1 G li,~Ir (212, i ~ Aik s Z 30 1133HS - o ~ dN`dl Q311tfldNfl ,TO.OOL M„TS,9Z.OON _ w EB.L99 co z m^ N ~ ,Z4'Z64 3„90,8Z.Z05 g Z = Z 133a1S ONZV J omi 00 W r o, I W F N N ~ at •z a ag~ 0 0 ?z of L.U 0Z OW W W (7 O g 55 EL z of Z J U r ? 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