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HomeMy WebLinkAbout032-2174-02-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600230 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: OEVERING HOMES TOWN OF SOMERSET 032-2174-02-000 CST BM Elev: 7~7 BM Description: Section/town/Range/Map No: 22.31.19.1457 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution Ix Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes L] No C Yes 7~_N, COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2022 57TH ST 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑ No Use other side for additional information. J SBD-671 0 (R.3/97) Date Insepctor's Signature Cert. No. RECEIVED County I - ~ Safety and Buildings Division 1 ~ ~ = K ,'7 4 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be fined in by Co.) u 0 Madison, 53707-7162 ICAAM L1 Yip. _ tOR''WvA1Eo Stale Trnisacti umber In accordance with SPS 383.2.1(2), Wis. Adm. Code, submission of this form to the appropnaco n„. _ is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary oses in accordance with the Pq Law, s. 15.041 m), Stats. _ L Application Information - Please Print All Informatio Property Owner's Name G Parcel # -y Property Owner's ailing Address Property Locabon,)d . Q s r' i7 C/ vT Lot City, Stare Zip Code Phone Number n j~_'f,, Section L~ cle o H. Type of Building (check all that apply Lot T N; R 2 Family Dwelling-Number of Bedroo Subdivision Name Block ❑ Public/Commercial - Describe Use O ❑ City of ❑ State Owned - Describe Use C<M Number ❑ Village of Z III. Type of Permit: (Check only one x on line A. Complete line B if applicable) A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owns r IV. T ofPOWTS System/Component/Device: Check all that apply) C on-Pressurized In-Gro ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: igo Flow (gpd) Design Soil Application t Rate(g) Dispersal Area Required (st) Dispersal G~ propose (sf) System Elev VL Tank Info Capacity in Total # of J w.~ Manufacturer Gallons I Gallons Units F New Tanks Existing Tanks Septic or Holding Tank ► ` Dosing Chamber l } r VII, Responsibility Statemen - I the undersigned, assu esponsibility for installation of the POWTS shown on the attached plans. _ Plumber's Name (Print? Plumb, ' are MP/MPRS Number Business Phone Ntanber j Pl 's Address (Street, City, State, Code VIII. County/De artment Use Only A roved El Permit Fee Date sued pp isapproved ` 1617 ssuing ent Signature I St/ ' 171 eason for Denial IX Condi royal (3sp vui cell r'►t * wtl be smA " ! rl)4 (n~.g 3~ A J b~•~•. r e ass per .7tars&ement plrn prwidert by plumbee. h,o dWr~t,~. 2. Al w%rk rem iremen'6 must.t a ma;nl fired ~~4~/•~ as per ipkctlblss cod! / crdinancm _ l ocra M&IC-4 AA_ A ttach to complete plain for the system and submit - o onlc on-paper not less than 8 12 z 11 inch sin t SBD-6398 (R. 11/11) System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 SW 1/4 SE 1/4s 22 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX SYSTEM ELEVATION 97.7/97.4 2.1' below grade 10/3/17 BEDROOM 3 DATE CONVENTIONAL AT-GRADE CONVENTIONAL LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of EZ-Flowsl 8 BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 69' 10.10 169' B.M.* 100' 111' B-1 3% slope Vents 57th st. 2-3' X 90' cells with >3' spacing 72' 98' B-2 60' B-3 40' Huffcutt combo tank 10' Pro 3 Bedroom House 593' Property Line _ Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 10/3/17 Owner: Oevering Homes Location: SW 1/4 SE 1/4 S 22 T31 N,R19W 2022 57th St. Somerset System type: In-ground absorbtion system (conventional) Manuals Used: In-ground absorbtion system (version 2.0) Pressure Distribution Manual (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. G4a*er Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Set 8. Dose Tank Cross Suction 9. Pump Curve , ~r 1 Signature- License nwfr 6r #226900 System PLOT PLAN PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017 SW 1/4 SE 1/4S 22 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX SYSTEM ELEVATION 97.7/97.4 2.1' below grade 10/3/17 BEDROOM 3 DATE CONVENTIONAL AT-GRADE CONVENTIONAL LIFT X00C HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of EZ-Flowsl 8 BENCHMARK V.R.P. Top of 1" pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE 0 WELL *H.R.P. same as benchmark 69' 169' 10 B.M.* 100' 111' Vents B-1 3% slope 57th st. 2-3' X 90' cells with >3' spacing 72' 98' B-2 60' B-3 40' Huffcutt combo tank 10' Pro 3 Bedroom House 593' Property Line O U ~ Q O d LL ~ N W (D E ~ y U) 0 O ~ N IL ( co LL Q. L v . ' cam, . ' . . o m ai n C) w C~ N v LL Q > 0-0 T co ~O.O II L CO i- a Q < M O N = is ❑ W E > m 0 CL o LO E a o o .Q 3 _ - z . . a~ o c E E.2 cn O ~ N O co _L. 0 V W CD 4- V.......' _C •V I~r ❑ I N N O V POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner J +r ; , Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ❑ NA 3ESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA i Number of Public Facility Units 5IA Pump Tank Capacity v al NA j Estimated flow (average) Z5 gal/day Pump Tank Manufacturer ❑ NA I 0(--/ I AU/ lflc~ i Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer ❑ NA Soil Application Rate - al/da Nt2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) !120 mg1L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODs) 530 mg/L n-Ground (gravity) ❑ In-Ground (pressurized) /4 loo Total Suspended Solids (TSS) 530 mg/L ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other: iMaximum Effluent Particle Size A in dia. ❑ NA Other. ❑ NA Other: Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent Other ❑ NA IAINTENANCE SCHEDULE Service Event Service Frequency linspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear s (Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA ilnspect dispersal cell(s) At least once every: 0 month(s) (Maximum 3 years) ❑ NA year(s) ❑ onth(s) Clean effluent filter At least once every: , year(s) ❑ NA ) Inspect pump, pump controls & alarm At least once every: qmonth( s .~,~7-year(s) ❑ NA 19ush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) ether. At least once every: ❑ ❑ year(s) month(s) ❑ NA ether: ' ❑ 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 linclude, a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of icembined 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 l-egulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of j:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. Ill other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, land any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authoritywithin 10 days of completion of any service event. Page of START UP AND OPERATION products or other chemicals thF{t For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting detected have the contents of thO may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are 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 nom-ml highwater levels. When power is restored th dexcess ace d ~ will bye will b discharged to the dispersal tea(s) in one large dose, overk%ading the oell(s) and may resuIt in the backup to restoring pewee' to tnt To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior restore normal levels effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contras to within the pump tank. the area within Do not drive or park Vehicles over tanks and dispersal cells, Do not drive or park over, or otherwise disturb or compact, 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 POWT$: butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain antibiotics; baby wipes; cigarette medications, oil; Painting produr .s; (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT shall be taken to insure that the system is propetlY When the POWTS fails and/or is permanently taken out of service the following steps and safety 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 fined with soil, gravel or another inert solid material. CONTINGENCY PLAN code c~npliant If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a replacement system: suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systeim• 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 neied for a new soli and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rute4 in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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. removal of the biomat at the infiitra#ive ❑ Mound and at-grade son absorption systems may be reconstructed the rules in effect following that time. surface. Reconstnxtiions of such systems must comply <<WARNiNG>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE ADDITIONAL COMMENTS POWTS iNST ER POWTS MAINTAINER Name Name Phone E Phone SERVICING OPERATOR MPER LOCAL REGULATORY AUTHORITY EPTAGE S Name Name n..~ Phone = Phone This docurr"twas drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. I I \ Ali ~.J ._1 I \ - t D C I S ~ t D Co ,1 s n A I - r I v ' I' f ~I... I o -g r I O I 1 d 1 A I~ iI lilj - l~. tt' ie" I ~ I 1 ~I I ~ I i•r ~ii I ~ I 7 1 1 ' I, It !1 N t ~ I i I i Septic-Dose `dank Cross Section And Pump Performance Specifications Tank Manufacturer ' Pump Manufacturer Tank Model Number J o Z) Pump Model Number Total Tank Capacity Alarm Manufacturer ntin Max. Bury Depth Alarm Model Number G- Switch Type , _ -2 c~Z , G cc Total Dynamic Head (TDH) -Feet Filter Manufacturer ti Filter Model Number ? Elevation Head Distal Pressure Network Loss Minimum Pump Derformance Required Force Main Loss o S GPMf L7~ .S Ft TDH Total y outlet Manhole thin. 4" Above Grade With Manhole Min. 4" Above Grade Locking Deg ice- Inlet Manhole Securely Mounted With Locking Device < 6" Below Grade Sealed Watertight Weather-proof Junction Box ~ - Finished Grade Vent Min. 12" Disconnect Above Grade Means With Vent Cap outlet Filter ---~,y - lnlet Baffle ' Inlet A 14" Switch Sett%ugs and Reserve Capacity weep B Hole Tank Volume GPI Volume Gat. Dimension Inches S 6 (reserve) A. oz f! Off Elevation C > 2 B: alarm) t F I ( r Bottom Ya, S {dose) ! j D Elevation (dead) D r" Ft > > s Total . . s a ::a • < s < a i s i ><i Y<>i ><ra,<><> Y : i :::a i>:: a • . • f with the < bedded and back filled in accordance The 'c/dose tack is a N. Th not y GENERAL INSTALLA►TTO th of bury as specified- by the manufactuner ma roval specifications . Maximum dep device (Padlock) manufacturer s product app exposed to grade have an effective locking be exceeded without p&r 4pproval. Manhole covers expo waterti t fittings, and installed. Piping at the id et and outlet is of approved material, connected to the tank Sch. 4o with PVC to bridge the tank sleeved with 4?* f orce maw is laid on stable soil to prevent settling or sagging. The l1ES with NEC 300 and Comm 16.218- excavation and thesleeve is sealed watertight. Electrical. service comp . Page of 02/05 U TOTAL DYNAMIC H'=AD/CAPACITY w w HEAD CAPACITY CURVE PER MINUTE g MODELS 53/55/57/59 EFFLUENT AND DEWATtR!NG j 25 r Model 53/55/57/59 6 20 c I =t. Meters I Gol. _trs. Q 5 5 43 '63 29 a G 3.1 3/- z 4 15 4.6 19 72 o 1,0 j S"at-off Hecd 19.25 ft. (5.9rr. 2 -a 5 15/166 5/32{ j 4 5/8 --III 0- "/2 -1' 12 NFT I I , U.S. GALLCNS 1 2 30 40 50 i 15 10 LITERS 80 160 / 0'I i _ FLCUV PER MINUTE 009897 / 4 ',/16 Variable level float switches available. Variable level long cycle systems available. Available with special cord lengths of 15', 25', 35' and 50'. t - Alarm systems available. - Duplex systems available. y 3 3,732 _,_'_,^ylnni SK858 Single Seal Control Selection Listings Model Volts Phase Mode j Amps Simplex Duplex CSA UL 1. Integral float operated mechanical switch, no external control required. M53/55 & M57/59 115 1 Auto 9.7 1 Y Y 1 2. Single piggyback variable level float switch or double piggyback variable level N53/55 & N57/59 115 1 Non 9.7 2 3 or 4 & 5 Y Y float switch. Refer to FM0477. BN53 115 1 Auto 9.7 Y Y BN57 115 ' 1 Auto 9.7 N Y 3. Mechanical alternator "M -Pak' 10-0072 or 10-0075. BE53/57 230 1 Auto 4.8 Y Y_; 4. See FM0712 for correct model of Electrical Alternator. D53/55 & D57159 230 1 Auto 4.8 1 Y Y 5. Variable level control switch 10-0225 used as a control activator, with Electrical E53155 & E57/59 230 1 Non 4.8 2 3 or 4 & 5 Y Y Alternator (3) or (4) float system. Single piggyback switch included. O CAUTION For information on additional Zoeller products refer to catalog on Piggyback Variable Level Float Switches, FM0477; Electrical Alternator, FM0486; Mechanical Alternator, FM0495: Sump/Sewage Basins, FM0487; and Single Phase ie t _ Simplex Pump Control/Alarm Systems, FM0732. _ _ For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. - - 1~ - - MAIL TO: P.O. BOX :'R247 - Z Louisville, KY 40250-9 Manufacturers of.. z SHIP T0: 3649 Cane Run Road ® Louisville, KY 40211-1961 Qj~gUT7'Pu~trPS,,//NCE ~,~L7,7 -2731 - 1 httpJ/www.zoeller.com PUMP M. (502) 778 FAX (502) (740) 3624 PUMP © Copyright 2002 Zoeller Co. All rights reserved. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Q2ver1,, - Mailing Address Property Ad(jr~ (Verification required from Planning & Zoning D nt for new construction.) City/State _ Parcel Identification Number Jtl- 6,5) J 071 LEGAL DESCRIPTION Property Locatiot.LL, Y4 t,5~~ %a , SecpZZ , T3/ N R W, Town of Subdivision r, Lot # O~ Certified Survey Map Volume Page # Warranty Deed # Volume Page # _ Spec house yes no Lot lines identifiable yes no SYS'EM 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 yeazs or sooner, if needed, b a licensed the system can affect the function of the septic tank as a treatment stage in the waste disposal system. OwnerttearmWhat eon put into responsibilities are specified in §Comin. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance The property owner agrees to submit to St. Croix County Planning owner & Zoning Department a certification form, signed by the by plumber, journeyman plumber, restricted plumber or a licensed wastewater disposal system is in proper operating condition and/or (2) after i p~ verifying that the on-site less than 1 /3 full of sludge. nspection and pining (if necessary), the septic tank is 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 Certification stating that your septic system has been ma eedcm~a the co~~ed and of Natural returned to the St- Croix Coun 1 Zoning Department within 30 days of the three year expiration date. Planning I/we certify that all statements rm are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a W14 deed recorded in Register of Deeds Office, Number of bedrooms r IGNA OF APPLICANT(S) / DA TE ***Ajay information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. fnclude 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) NOR rH 1 14 CORNER z SEC. 2.7-31-19 1 0 (FOUND A[ UYINUM I . L; MONUM£n/ T) LA NORTH LINE OF THE SW 1/4 OF THE SE 1/4 OF SEC- 22 u ~ ~.r..1 N 88°45'49" E 1320.61' 7~9.T0' -r 66M -774 M9 - \ $O' RADIUS TEMPORARY (-V -DE-SAC EASEMENT (TO BE EXANWISH£D NOR n, 5 S as°as 49^ w 115.3 UPON £XTENS/ON OF R040) f rNt = . LOT X \ \ W \ 195,724 sq. ft. 4.49 acres b w LOT 1 a y J O2at acres h ice' {s. TO O. H. W. tit. LOT 2 3y \ O 3.151 acres r. rO O.H. W M. a1 ,7t-~ ati'~' \ \ a 6 k' LOT 3 3.02t acres Shy' \ \ A rs TO 0. 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I I - - - I I I I I ~ I 1 I I I I I I I I I I I I - - - - - - - - - - - - - - - - - - - - - - - - - - - - rn ern aHnaiaM zA - - - - - - - - - - - - - - - - - - - - - - - - - - - - B8 Y Wisconsin Department of Commerce E ALUATION REPORT Page of j' Division of Safety and Buildings in accordance with Comm 8 Wis. Adm. Code )u .N'T"Y County Attach complete site plan on Papeg-AOLIe& l i/2,k 4l ifaches in !ze. Plan must - r ~ fH~1r1B ' include, but not limited to: vertical and horizorital referenca`poirM direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. R Date c` Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). /7 d 7 Property Owner Property Location Govt. Lot 1 /4 1 /4 T N R C E (or Property O er's Mailing Address Lot # BI Subd. Name or CSM# c State Y Zip Code Phone Number ❑ City ❑ Village Town Nearest Road j New Construction Use: Residential / Number of bedrooms ;'I- Code derived design flow rate ' = G GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable General commentsG l/ oil 5/ Stern 2. 7 LJ ' and recommendations: Boring # ❑ Boring Ground surface elev. ® pit ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. . ff#1 'Eff#2 -ate I e 1 Boring # Boring U Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff#1 •Eff#2 Effluent #1 = BOD > 30:< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print), 7Sig ture CST Number Address Date Evaluation ? E7valuation Conducted /TelephocnneTNumber 4 / r Property Owner - Parcel ID # Page of i Boring # ❑ Boring C JAJ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 e ZZ2 s~ s _ C S iJ. _ IW-IrA Cbanee~ 41,4 lh j ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Cj Boring ~ # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Effluent #1 = BODS > 30:S 220 mg/L and TSS >30 < 150 mgA. ' Effluent #2 = BODS < 30 mgA. and TSS < 30 mg/L The Department of Commerce is an equal opportunity wervice provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6'00) Page 3of3 ame Brian Parnell =~dciress CST 231314 Date /V U, U Soil Tl3orIML _ _I SLiitabI r 1 =-~rV~ ~S~al SOS ~~0 . ~l, n-P ' i 1 I i i , - - - - - - - - - -r - - IZ I K ~ \ , , 1 i I I 1 . ~ I i , r i e , - 'r U I i 1 ; , ; , 1 I I