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HomeMy WebLinkAbout032-2059-95-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. C,rOIX Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 600260 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: F City Village Township Parcel Tax No: BRIAN BEAUVAIS TOWN OF SOMERSET 032-2059-95-100 CST BM Elev: Insp. BM Elev: BM Description: . Section/Town/Range/Map No: 17.30.19.738B TANK INFORMATION ELEVA I N DATA TYPE MANUFACTUR r ~ Y` CAPACITY STATION Septic BS HI FS ELEV. Benchmark JI)a 5 i 9@6 1411 IJ Alt. BM Bldg. Sewer A IA 92,5- S t Inlet r Z TANK SETBACK INFORMATION G fII S Ht Outlet ~ / .41 1 TANK TO / WELL BLDG. Vent to Air Intake ROAD Dt Inlet 'f V Septic Dt Bo om - / rw Dosing Header ~ D Q~ Aeratio Dist. Pipe e , hp o-1 olding Bot. System • / (P 5 PUMP/S INFURMAZQ_0N Final Grade +l a U Off: I Man turer D nd St Cover PM L odel Number H Lift Friction Los System Head TD Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM 4_ BED/TRENCH Width 11-en No. Of Trenches PIT DIMENSIONS No. Of Pit Inside ia. Liquid Depth DIMENSIONS Z SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREA LEACHING Manufacturer: INFORMATION T e Of tem CHAMBER OR y I O/ /V UNIT Model N , ;:Ct Sf DISTRIBUT STEM 0V 72> Head anKoId Distribution Ix Hole Size x Hole Spacing V to Air Intake it Pipe(s) v Length Dia Length Dia Spacing J SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched dded Depth Over t Depth Over ` xx Depth of xx Seeded/So Bed/Trench Center Bed Trench Edges ~-T it Topsoil C Yes r-l No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 22 ~ - Inspection #2: .h4 coy 1 k~c~ (M°l Location: 1500 47TH ST Could nab A • ' ~ ~j~ / ~ h~v 1.) Alt BM Description = IllA CQ ! ef~/alA~'1e Id 0-6eQ pe--- ~~~SCQItG. /'l f 2.) Bldg sewer length amount of cover t S~vbbee o AO r~ na . (b w~ - d~ Cnve~ v Plan revision Requir d? E] Yes No / q Use other side for additional informatio ~MD(\ate 1`e nInCse is'Siignature Cert. No. SBD-6710 (R.3/97) ~ ~ll ,t l~na ~fi~~l •vl \ ~ • r ~~S}~I~d ~ ~ ~.5 W` ` ~ G f\~~tn7ar,p~,r` 9~G Count Y f Safety and Buildings Division ~ 201 W. Washington Ave., P. 0. Box 7162 Sanitary Permit Number (to be filled in by Co.) - \~l\? C7 3 Madison, WI 53707--7162 `'utnrsr., c coU pME d 6 Z (v(. -sue -V j-~w4--- `,~,(~1~jit 43I~ Permit .~ppl.1(;~~. ~:.IOI7 - State Tran,cactin Number - ln accordat with S~ 32)(2), Wis. Aden Code, submission of this faun to itac appropriair, I;ovemmental unit i rrcluired prior to obtaining a sanitary Permit, Note; Application forms for state-owned POW I'S are submitted to Project Address (if different than mailing address) thr. I ~r_partmeatt of Safety and Professional Serviea. Personal information yon provide may he nsed for seconds 1,560 J 54- Purposes to tcrordance with the Privacy Law-,q-.15 .04 1 m , Sttt 1 - - - Aptlllc anon Infnrlnatir»t Please, front All fo anon w 1'1-opcrty Owner's Name - -----Parcel V l IG4 ety rL G~1(,l~e r - - - - - /-7, 3 0 l'ropcrtt Owner's Mailing Arldregs 739 t~ Property Location l _ Gf GS -.07r;f 5' Govt. Lot _ E i1y, Stair. 7t - - - - - Code l ~ Zip P bone. Nnmher - ic4l~/~ SL ~(J `3 Section ! 7 C'~v2c` ~l I-Ty^~'~f`e~t (circle ctnel„ _ . - - ~j) T N; R j E n Tl. 't'ype of tiuiiltliaR (cheep all that a - - - - ~ PpIY) Lot # 1 l nr 2 Family Dwelling -Number rtf Bedroo 5 Subdivision Name L - - O~ ` A Aw l3inck /I I'ubliclCnnunercial - Describr, i Fse, Cttyni _ i ~d- - ~ 1 State Chvnerl l k+srrihe Llse Number ❑ Village of Town of ]d[ Type (of 'ernut (Check only one box on line A. Complete line B if applicable) 1 - X-Nrw System [ i Replacement System 1-1 Trvattnent/E-folding Tank Replacc,tnc ul only U Other Modification to Existing System (explain) - - I rrrnit Ike news( i Pc troll .Revision ❑ Change of Plumber List Previous Permit Number and Date Issued 1 1) to New before 1=xlmation Owner rtk IV t ypr of PpW 15 System/Corm otteat/Device: Check all that agpiy) - - - - - - L - d rNou-Pr Gsnrizx ct In Gronnd r Pressurized W-Ground At-Oradr. Mound 24 in of stntable soil [l Mound < 24 in. of Suitable sntl c i l ioldiag tank 1 Other Dispersal Component (explain) Pretreatment Device (explain) I- ~ - - 1 17, Ns er sail I't rat ent Area Infartttxtion. ~ - - - Dc sign ];lrnr (gprl) Drst(n Soil Ap(tl;cation lisle ds tape l{ntR luirec / ) (ta Area Propo (st) System Elevati n 5 l-'lank.info.. - - Capacity in l7rsal ~l of M Gallons tiailons Units inglanks o 'e Sr.(~ur nc ?3nmp ank e-'=--- - )nem 4 Chnmbm VIl Responsibility Statement- 1, the aKill ersigned, assume responsibility for installation of the POMITS shown on the attached plaits. 1 Plnmhrr''s Name;(Ptrnt) P }umbers Srgnawrc. MPfMPRS Number Business Phone Number - f'lumhna s Address (`,trrc.i, City, State, Zip Code) /49~ 'VU1 -oonty/Depar1iment Use Only Pcrmtt Fee pproved approved -Date sued Issuing ent Signature - to per Crven Rcasort for Menial 0 WNE ---i j, I1 t and An - - - t~ Disapproval tiisrzrc i cell roust all be s, :ICS~'ri*in,~n~~ as per mar:agerhent plan plu ridedbyby plumbee. 2 °r~,acll~rk rKsG>~irstsenxs tsualit•t~ wairsk ir.E.~l N per VF ft" w& / zMinalzm. r tine to complete plans for the system sad submit to the County only on paper not has than 8)(2 s I s in I fnehc size ;1117-01M (R. I l /11) r-rca cJ ~ 4A VA- Al 63/4-- l-' /V IT- y X~ C e f I ResidQntiai Applicatlaji INPFX ,PtNP TITI-E PAGI= I Tojent Namf Owner's NarnH: f )tinrnc~r'., r~dcirr !ss: !CGS ~S I eq-,11 Opsr.rlption; T Gr~~~1j/ S' ~ S ~v>. T c± l9' Y'r';lallttir: S~C~F~GSt ➢f ~tahcti~rigir~ll {tame; ~..5'~i-7 1 of NII1Tlbor I~'~~r~:,ef tt~ (rhur►her: rage 1 Index and title gage _ _ Wiest. Plan ('ale 3 ~/stArl71in~ & C:rr.~sa,Sectlan t'agF f`Iltc~r SpPrs I'agt* Mail~teO'anc-e Iiforrtlatian r - Iagw iklfene emPnt i="ian Page 7 ~ k. r::rc lx c1k tlr: tank maintenance Farm Page Warranty Deed_ - _ , Page 9 M or, fiat AttachrnenN: t nil Te t H*a~ l a f'lal~s IMW I ~F'slclrt~ rll'}Y~Il~t~er; GJ , ilv ~~f~ r Sc h dti WL,'~r- 1.Irtense? NY ti~ik~Pr; ,Z ~77 T 'P6 17___...._,._.~ f~i,~l~~ NumtaPr ~Tr• - v i ~ 1 5 iq rtY~tru•r~ J H r,gigrrFC,l Y)rrr:itlAtli to Yltn 111 (~rriill~d toll At~voRijtlnn CnrYiponr.- nt I rnr PO{AF1 ` V"TRion 2_0 :BBD lfl7[3S-t' (N.n9/(11). Pagr; ? fC' y`l~ cG ,v y~ ~ tee, i~ ~"~t % S ~ OG C ~ ~ G~ _ N U~= .SS E✓~ l~ C' L,v 99 ~jpt~s~ v 4,) S~c~y s ~ D i.J 1 Soil Absorption System Cross Section y~~ S ft &4'1C Schedule 40 Final Grade Vent Pipe th Vent Cap ft Leaching Chamber ft System Elevation 3 ft ft Soil Absorption System Plan View ft ft ft Vent Or Observation Pie Leaching Trench Pipe Chambers 4" Die. FTTre 2 Header Leaching Gharnber Specifications I Manufacturer And Model Q" •`c/ Ijs EISA Rating a?Q sq ft per chamber Soil Application Rate gpd/sq ft gPd Design Flow 7 Soil Application - Rate ~a EISA-O-z Chambers 2 rows of 1lr chambers each. Page of I ST. CROIX COUNTY SEPTIC TANK NLAINTENANCE AGREEMENT AND O)AWERSHIP CERTIFICATION FORM Owner/Buyer e c-. v,e c-' s `1v'[ailina Address ~rj, ` Sit"c z s` Property Address S,/ c~. f C.. c: r J<. - (Verification required from Planning & Zoning Department for new construction.) Citv!State k,~w.4-_b.t lam' 5~27Ce`J'Parcel Identification Number LEGAL DESCRIPTION Property Location _S~4, S~i5 1/4 , Sec. _2`, T 3~ N R W. Town of -S' -AL Subdivision Plat: V6" iyl Lot # Certified Survey Map 9 Volume Page # _ Warranty Deed + _ (before 2007)Volume Page Spec house o ves iQl..no Lot lines identifiable ❑ yes J no SYSTEM lN; XINTENANCIE 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 Ll the waste disposal system. Owner maintenance responsibilities are speci5ed in §SPS. 383.2(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 re urned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on form are true to the best of my/our knowledge. L/we am/are the owner(s) of the ,Pis property described above, by virtue ofa rranty deed recorded in Register of Deeds Office. Number of bedrooms a IGNATURE OF.APPLICANT(S) DATE *`:~ry 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) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page_ ~ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner - « Septic Tank Capacity 16<r d gal ❑ NA emu, r s . Permit Septic Tank Manufacturer <<~ ~r ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer J Q e 7t ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model JC a S" ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gal/dg Pump Manufacturer ❑ NA Soil Application Rate al/daY/W Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Ceil(s) ❑ NA Biochemical Oxygen Demand (BOD51 530 mg/L IM in-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: ❑ year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once even` ❑ month(s) (Maximum 3 years) ❑ NA ❑ year(s) Clean effluent filter T At least once every: ❑ month(s) ❑ NA _ 14 year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA P. P ❑ year(s) Flush laterals and pressure test At least once every; ❑month(s) 13 NA © year(s) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator, Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal ceil(sl shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of s12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page of [-or new ronstructican, prior to use of the POWTS check treatment tonk(s) for the presence of painting products or other chemicals titer ataxy impede the treatment Process and/or darriapd'tha dispersgil cell(s), If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prlnr to use. Syste rn start up shall not occur when soil conditions are fil'0266 at the Infiltrative surface. During power outages pump tanks may fill above normal hiphwgtar I0Vgls, When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, C'yI0e l~ladirig rile i~bllib) and may result in the backup or surface discharge of Pfflr r ,nt. .1.1. avoid this situation have the contents Of ti '0 PP grip filpk rbin,av6d by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Pll,imber Or pOWTS Mslritolner to assist in manually operating the pump controls to restore normal levels within the puma tank. Do not drive or park vehicles over tanks and dispersal cells, Do opt,drlve or park over, or otherwise disturb nr compact, the area Within 15 feet down slope of any mound or at-grade soil abegrpt)on area. Reduction or elimination nt the following from the wastewater ®troalm may improve the performance and prolong the life of the VOWTS: antibiotics; baby wipes; cigarette butts; Apooor7lsl tt4ih,swal? degreasers; dental floss; diapers; disinfectants; fat; foundation drain )sump pump) water; fruit and vegetable poolings; o solirle; grease; herbicides, meet scraps; nledications; nil; Painting piroducts; pesticides; sanitary napkins; tam0bns and viva}fir saf terror brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of servide the followings saps shall he taken to insure that the sy:atem properly and safely abandoned in compliance with dhaptor Ce mni ",'33i Wisconsin Administrative Code; & Ali piping to tanks and gaits shall be disconnected And the obohtlaned pipe openings sealed. e Fhe r_ontants of all tanks and pits shall be rernoved and properly disposed of by a Septage Servicing Operator. After pl.rmping, all tanks and pits shalt be excaVatso and removed at their covers removed and tho void space filled with sail, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following meaauras have been, or must be taken, to provide a code compliant replacement system: i i A suitable replacement area has been evaluated anti may be utilized for the location of a replacement soil absorption systorn, The replacement area should he pat ad from tlisturp nee and compaction and should not be infringed upon by inquired setbacks from existing and proposed att4dtura, let Ilnioi, mild wells, Failure to protect the replacement area will result in the need for a new soil and site evoluAtioh to betablish to suitable replacement area, Replacement systems must comply with the rules in effect at that time, C..1 A suitable replacement area is not available due to sethook and/or soil limitations. Barring advances in PQVVTS technology a holding tank may be installed as a j,set rosort to raplaca the failed POWTS. p L7 The slta as no~en evaluated to identity, a sultahle e 1) roaht evaluation be performed to locate a %oltabl" rgplaa tt'ilS,It: a area. a no reUpon failure of placement area the avOar able a holding tank may big-issiitalle s a last resort to replace the Nflp[i f*oWTI, fla' 1.1 Mound and at-grade soil absorption systehts ittpy be recopf.strudted in place following removal of the biomat at the infiltrative surface. Reconstructions of such systema must aortlply with the rules in effect at that time. < <WARNINO> > SEPTIC, PUMP AND OTHER TREATMENT TANKS ♦~f1X CO.' T IIy L AL GASSES ANDJOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT T~f I(1 N OR q C"CUMSTANCES, DEATH MAY RESULT, RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE 610010UL on IMP SIdLE. M)DITIONAL COMMENTS oWTS INSTALLER TAINER Cr '=np ial~ FPTAQE SERViCiNQ OPERATOR (PUMPER? t1l TOR Y AUTHORITY Name Phone hieing o:,e- Q 44 its dw-ument was drofted In comfilianco Mth rf,apter Ccmm 83,22(2)(b)(t )14)&(f) gilt! 'o,84(t (2) & (3), Wisconsin Administrative Code. tiV c ~h vw c~~ -°r cU uwoF~-cow " ti JI O 'c z N E~~ I ~I Q E'" D a M c I-1 3 c m E m`om' a~i a~~i c fO corn? 2'- v°', OI 2 I.Ll t~ I` 6 m E E c0 .off c4 w 4) o k W w o W •_p 1..1 c CN to 1 0 o m n c 'o a~ m V-1 ti y C'i o r C3 (may m e oo o y c~ N N o r E c N a~ Q ui f pQ _ o° o E o o o nm~i n ID Q v m w o Z v`~ S aci ° I / 1 I w W -2 d) m 0 0 :E U O tN +a m N M Q) U m U D L E' I / I 00 m o O v = c m c v 0 d 0 o M z w@~ X i a>L> v w , OL 'o S -t5 Q y, .s z 1 how U a - / B __M oa m ? e v Q~./ J 'r J CO N~~w o -o E cu .0 0) U) th Po_ _ N VJ c c c o w o m a ~M E O p N U m a cm o C N N 1 v, U N 2:, u > ° 11 11 45 a ow - CU 0 4 C) 2 ; N V) Cn N s U m N O w d~3 ~0 'p 830 ~~w X0)/, oC3 ti ID a) tx ix - CL 0 _6 -20 43 Lo y N L1 A O > O c 0 / VO / A/ e w L N o m m a AA.,~ ~i ~^P / s 14 2 p v RY cO L o N tv / O} V~ • rj, N io 0 0 E -62 0> (n 8 y~ 4^ O cc6 . S~ o O (^w, ~ w w Imo' ° tr.. 0 4) Lo OM O rc 50 Qo N U m ca -6 m CD /►~.d~ 3 ;s vii w CL . n c .m ° m p " / i c Z tiz I G c a) o 'n 10 ' F- 0 FEE =I I_ V: y 00 1-1 0 Q a ® W F CN Z 3 - Q~ h V, Ln 7, LL do tn (D cu (a V) O I f') ~j r ¢ Q 1 F'~' Q co d w N 1 ~~tiiilttlil ~i z C2 co z a I J p IT O S Y- o _ 01 } i cr C, Q, x U V i F- = rn uLI v aM 3 cfl Q' +wa ,Z CL N 1 i Avolfit ..i of ) h 1 tU ,aw 1 opt" C-7/OS - 7/4MS 31411 1SV3 H11M 1311V'IV,-- LL .sue 1;'0'6EE 3 ,6Z, kFov® S s1 w o a a o,o, 41 o ~n m lU aNtfl Q31LY1dN(1 ~ T ~ ~ T N Wis. Dept. of Safety and Professional Services X IL EVALUATION REPORT Division of Safety and Buildings •3 i1 q,4` Page of -5 iri raAnce with SIB 385, Wis. Adm. Code County f Attach complete site plan on paper not~~@sltt ! x'f;1160c e~''in size. Plan must include, but not limited to: vertical and AV cl`tef&ence point (BM), direction and P reel J.D. percent slope, scale or dimensions,;4%lnlw, and location and distance to nearest road. ) 11,- 205`1- q1 Please print all information. a ewes, by Dad Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location s Govt. Lot 1/4 S T ; N R ; E (or G/' Property Owner's Mailing Address Lot # Bloc Subd. Name or CSM# City State l Zip Code Phone Number ❑ City ❑ Village ®Town Nearest Road New Construction Use: ® Residential / Number of bedrooms ' Code derived design flow rate ~ D zZ,Z, GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material ~s~--, Flood Plain elevation if applicable ft. General comments q r4 7L"k and recommendations: Jt-..,~ - S ~S rtm~r - Ga►t. ~ y~ - 7 . leer ►,,,2~-~,~ Boring Boring # F-/1 ® Pit Ground surface elev. 7 ft. Depth to limiting factor/f. - > in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 G i 'tole t Boring # ❑ Boring ® Pit Ground surface elev. 0 F-- S ft. ~th to limiting factorin. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 ~ - r i- S~ ~r * Effluent 1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (P e Prin Signatu CST Num ber Address ~124tLeEt'-- luation Conducted Telephone Number r Z7 2L 7 SBD-8330 (RI I /11) Parcel ID # Page ^7 of Property Owner Boring # Fj Boring E] pit Ground surface elev. '16 S~ ft. Depth to limiting factor in. Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 I/ Z c G P ~ l' r ❑ Boring # F1 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. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 Boring F-1 Boring # Ground surface elev. ft. Depth to limiting factor in. pit =Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 * ff#2 L * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 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. SBD-8330 (RI 1/11) E, 2iJ 7 9 .27AM r. Cr,IX Co Goat Crr:i N 4564 r'. 2 Property Owner - Parcel 10 # Page -:;2-of _ Boring # ❑ Boring E ® Pit Ground surface elev. Ft- Depth to limiting factor- in. Soil Applicatlon Rate Horizon Depth Dominant Color Redox Descrlptlon Texture Structure onsistence Boundary Roots GPM Y in. Munsell Qu. Sz. Cont. Color Or, Sz Sh. " ff#1 ff#2 r a o Q a k /I 'X F1 Boring # 0 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 OPo/ft in. Munsell Qu. Sz. Con[. Color Gr. Sz. Sh. ff#1 02 Boring # ❑ goring u ❑ Pit Ground surface elev. ft; Depth to limitiho Fgctpr in. Soil Application Rate Horizon Depth Dominant Color Rado% DeWintlon Texture Structure onelstence oundary Roots in, Munsell Qu, Sz. Cont. Color Gr, Sz. Sh. 01 *42 * Effluent #1 = SOD , >30 <220 mg1L and TSS >30 < 150 mg1L ' Effluent #2 - BOD E < 30 m t 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 111aterial in an alternate format, contact the department at 608-266-3151 or TTY through Relay. Si+i~-H33u (xr r1t rl 1 i Hof ~ ~3, ~~3~~ TG ~y A IV, I/