HomeMy WebLinkAbout040-1135-10-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 600341
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:
Kevin & Kalen Harmon TOWN OF TROY 040-1135-10-000
CST BM Elev: Insp. BM Elev: BM Description: ^ Section/Town/Range/Map No:
97A P 35.28.19.556P
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~ i /ocl, /fi 66 Benchmark
Z 2(~ 679 - 17. Cp
Dosing Al BM
v San
Aeration P / 0Z Bldg. Sewer
P6
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 Q C)`P
Dosing V ~c , Header/Man.
Aeration Dist. Pipe' J/ 3
P-7 Z ~O
Holding Bot. System
(.9(o qZ •9
Final Grade
PUMP/SIPHON INFORMATION 3.7 9~a
Manufacturer Demand St Cover tt
~OrJ\ GPMJ `F7.,
Model Number 5
TDH Lift Friction 43LOS4 -7 System HeU,4_ TQU7
Forcemain • Length Dial Dist. to Well
50 7 Z
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length C)_Qf Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 (&,,4c.14.46 ~1
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION g CHAMBER OR A 0.
Typ Of System: r g, 11.4 76 A)O+ UNIT Model =r:~~ r
DISTRIBUTION SYSTEM ZZ 41 ZZ 1046
Header/Manifol / Distribution S Ix Hole Size Ix Hole Spaci°ng~ Verb Air I a
Pipe(s) ~ LL+ d\
Length_ Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth f T Seeded/Sodded rIched
uBed/Trench Center 3, Bed/Trench Edges' Topsoil ~
No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 796 B CTY RD
1.) Alt BM Description = ~v A J' / t
2.) Bldg sewer length = y, J~ ~..s ~f~^b fS "~q' 4'S
- amount of cover = its n j A w J G~
6 pt
Plan revision Required? ❑ Yes No Lq ✓ O
Use other side for additional information. JI
Date Insep is Sign e Cert. No.
SBD-6710 (R.3/97)
Safety arid~uitdings b vtslan
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit umber (to be filled in by Co.)
j s i Madison, Wi 53707-7162
NN
State Transaction Number
~ Sanitary Permit Applic~ri gRNIM
in accordance with SPS 383,21(2), Wis. Adm. code, submission of this cF J% ..,,+cntal unit
is required prior to obtaining a sanitary permit. Note: Applicati 6KE~ jwTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal in provide may be used for secondary S
purposes in accordance with the Privacy Law, s. 15.04(1)(m) Stb s. i
1. A liestion Information - Please Print All Information
Property Owner's Name , a " Parcel
u.
x
r -
55
Property Owners Mailing Address Property Location
0 ? b Govt. Lot
City, Sate Zip Code Phone Number Section
w (circle one)
i T N; R Eer W
11. Type of Building (check all that apply) Lot#
+ _y subdsion Name
a
fl 1 or 2 Family Dwelling - Number of Bedrootns4
fr ...<F
Block #
f°el'iJf g., T
Public/Commercial - Describe Use ❑ City of
CSM Number ❑ Village of ;
State Owned -Describe Use D Town of
R. Type of Permit. (Check only one box on line A. Complete line 11 if applicable)
A. 0 New System Q Re lacoment System 0 TreatmentlHolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Ensued
R. ❑ Ponnit Renewal ❑ Permit Revision ❑ Change of Plumber 0 Permit Transfer to New
Before Expiration Owner '
Iv. T e of POWTS System/co m onent/Ibevice: Check elf tbat a l
,,Non-Pressurized ln.Gmund. ❑ Pressurized In-Ground ❑ At-Grade 0 Mound? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
n Hoidrng Tank Q Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Din tsrsal/Troatmettt Area Information: System Elevation
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (5f) Llspe7z! a Pro sad (sf).
VI. Took Info Capacity in Total # of Manufacturer n
Gallons Gallons Units
tt t6h Existing Tanks on 8
i% C7 a.
Septic or Holding Tank
Dosing Cumber
VII. Responsibility Statement- I, the andersigned, assume res ibuity for installation or the POWTS shown on the stttaehed pleas.
Plumber's Name (Print) PI ces Signature MPIMPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code) 1 jr
VII Coun 1Dapartment I lie Only
F Permit Fee Date issued Lssuing Agent Signature
Q'Airpwved Q Disapproved ,
e..
$
0 Owner Given Reason for Denial
[X. Condi sasiis fgs Disapproval
E, wrt fni l t.rda' `t ,d e
(il%pem.-at Cellmust dp b%.jltAc s r,WrA&;r 2L
~W per :fw-ye~esent plan o•o tide+t by Plumber.
2. Nl ttetkrl reCLliws!'~A Mutue rat Mt ir.c•i
as ~ 9tpF78Cflblw t ! CrdiltA1M36~.
Attach to complete plain far the system and subunit io On County only on paper not less than a 2x It inches in size
SBD-6398(R. it/11)
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10-
ST. CROIX COUN'T'Y
SI;P'CIC. `DANK MAINTENANCE AGREEMENT l i
~ Zt ~ ~~1 I"!1 ~G
AND f _
OWNERSHIP CERTIFICATION FORM
Ownt - Buver j, %l 11~Ll f!Y~~'i
Mailing Address `L 1,,,x-7
~T
Property Address _ J 1 G f l LLI~c-f
(Verification required from Planning & Zoning Department for new construction.)
City/state Parcel Identification Number
LEGAL DESCRIPTION
Property Location,,-,,---,- /4 Sec. 1' N R W, Town of
Subdivision Lot #
Certified Survey Map # L Volume Page # ~ - -
Warranty Deed # Volume , Page g
Spec house t yes,r,.no Lot lines idcntifable'Vyes 1 no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
~I
Improper use and maintenance of your septic, system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
I
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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning
Zoning Department xvilhin 30 days of the three y r expiration date.
h/we certify that all statements on th form are true to the best of myiour luwwledge. Iiwe arnlare the owner(s) of the
property described above, by virtue of a wa anty deed recorded in Register of Deeds Office.
Number of bedrooms j _
1f L
SIG NA !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 Of=fice and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
rursuant to Comm 83.54, Vis.Ada. Code
• SQCdc Tank
The soPft tw* ShWbe maintained by as W-Ividttal cwMed to Servxx $ ft W ft WWW & 291.48. c The axta 3 of
t11e
. ot4
Mw did be of in at6rd;e~ Tih NR 113. Wis. Adrb. Code. The awsW at Mw easttte Amts ° ! L every 3 years by inspeGion. Tae cutlet of
as a* se* rte wand
M The hen Oe shaiid not be removtd tress pravis fns we arse b retain sours in the tsnk that
O of the Mw w
rternoved facan lee er a. KIN tiger is egged WM an ahlwk the 4i& Shd be 'serviced y
s+eptYc lenit ahal hove its irdiatbe stage fbws a bt intpauilitg twtrt8tprota a1bm. lice
the tatslr. "*OnWft the taMt are omit swan in pie t:rtlt szeaeds 14 the A* vchrme of
tesnoved at Ow bete of s ttfertrthd
V ha dt. 'the adttrtQwswAM r"ds b bs P b IP "I n Jas ftM=MWM
. Jf suet oa dmmicd atiittae b enbaxa sspdc tv* Mbmwza b .
pmduc`s an used they shall be approved for sepfc tardt use by the p of Caaaeoc-, Safer tatd
T '
PRML
The PMP Now tw* sho bepecaad at Jead once every 3 yaers. Al ewes. shrtas. and
eAlttart is irtettaledrtiihit the taakJt3:be dwA be tad b
ktspec~ed and swAcpop
ad os
Al- ad* Com onent and Presae;re Diatribntioa Svatea
o.trees ors s a
be made aroand ,the. plaate or to grow on the component. Plantings ■ay
t Perimeter and the component shall be seeded and mulched as necessary
o prevent eroa14a and to provide some protection from frost penetration. Traffic (other
than for vegetative maintenance) on the component is not allowed. Cold Weather iastal.l-
ations require the component to be heavily mulched far frost protection.
Zaflnent quality into the at- •
30 grade system may not exceed ZZOrrg/L GODS, 150 aglL tSS and
trtg/L 80G. lafluent flov may not exceed the mstwiu design flow SrWIIW the peraic
for thbe *jdjad *It is iaatallation. N=MWAW go
in bi b ud Oft a &N ft Dok at g* and of each Ie wA and itJs
t&12M coder"" 10 "a PIMM hWII p~ g AMM bed
tf aide "9909 tics OCMW and 7 orJfke doming is
wi@vfn bo dspomd oeL
Observation pipes within the die
Poadiag leers mho persal call shall be•checked for effluent
uld be nPorted to the owner and any levels above 4 inches poedin.
considered-
an impeadi= Itydraulfc failure requiring additional, more fro
Sccardaace whir Comm 83.52 (2). quaat moa3corins in
8"tem shall be operated in-accordance
~IAtaiaad in accordance With it•s con with Coma 82-84 tiis.ldm.Code and shall be
state tCVles pea poneat mannal SJJD 10570-t (1.6/99) -and .local and
a talnU8 to system maintenance and maintenance raporting.•
lt10 orte shoot" 1AIK -
POWTS* III J osP+Q+Pltmkslace ft33,WitA~ihn.tbdeMheftft iwooedh Ssp do -
nh. oaoahraprrtd t~oeaee faelta a>~eao longerttad e
Sopfcor
ap
adttpsaMbr* deers wd'ousts s VPAd bed (wwxW8phtheas andsowtd wft AccM
m ba laea~t a~ n afstevtc~-/wyapus<ng deemed
or
- ~y! coding det+it;e b prewartt acddenpd or
k
edlhio a FARM
`oltaa d
~ - p ~d-i
_ - em-Faris aceagipo~ieet s1wD be mind or n~tiCed b beep Ste '
jd'WOd alonaanslModTtpbeaataosdobdiMetMdefi~iNs6elbe
It rthe' a .a~~ogoatafMsataearetpigedoauenoe. Y.
~ ~ vet t"ifls
t to i
aty mPt sKsttlrs: "'fSlisa =a wastewater to
the lifted a►mslaees it
. foplawe as. 7 to last au q►I Pre-irutrst nsl t . or
redditta,' pmt• ~ditiemttl sito amd• ve31-al~tioos aay_ aaaJt•
8sfatl and wr need to bd• prepared and apppovad by tie Department of Corfm@x=.
Qaestioeis .abaiit tLw operatiom~osr uaiate i of this srstaa sham" be "trailed to• .
! The f"h`,- M"t Office at ~l lS - -4-11- b-)t1'7 Pt
"
21e
apt" 3astalbw at `]LS.. t~2.S al4 S7~ W s -
The tank The effluent m~faetarar ac ~~_$40~3ZS_BtIS~, ~t t~1t
neat liltar'rianafecturas at ~-pp - Z21- S74Z. 2-+rC@~TL.
ITAI#r . "~.~,p ' ~ • _ 6 3 O-.8?A-alp p C-yo~s
'/c/
r - _
. 1.'1~' ' rC~~utu". f-T t;~ L.:U\=vlr ~E o r 6
Goulds
Submersible
Effluent Pump
3871 EP04
EP05
■I\~/ II Y/ - - - 1 I 1
APPUCAnOW • Fasteners: 300 series sulsfrie * m dugfr ■ oft llmtt 4: Cast uan
stainless steN. grade tra6ine olifor tw etlidW heat transfer,
Specific* designed forthe Calrable of running lubrcafiior! 6ttd effidertt strertgttr, and duranbikty.
f s ~ to t~ trasrsfet. ■ lMetot Cevet: 7hermoplas-
• Homes tic rates' wIlh integral handle
Avaibt0le for atdottt a ad Motor: and float switdtachrrrerrt
•fauns
tmattrg eItatbq. Att.sAgd6
` Heavy ditty sump • EP04 Single phase: 0.4 HP, models iaelalle Meft" P*ft
• Water ttawfer 115 or 230 V. 60 Hz. 1550 t 3Wft assW*W attd ■ Pawner CoMm Severe duty
• RPM, built in overload with Pad at Yte to d"- rated oil and water nesishaEt.
aowriatic reset. ■ Beviw UPW and lower
CATI9NS ' EP05 Simple phi: 0.5 HP, Ft?/ITtiNES bevy duty ball beanng
115 V. 60 Hz, 1550 RPM, Construction.
Pump: EP84 built in overload with n 004 b"..Thermo-
• SOW Irat►-rig- rwpability: aadwolic rest.
3/l maramum. • Power cad: 10 foot with "M out vanesfor
n
• Capacidw. up tD 55 GPM. standard tergttt,16/3 SJTIJ mectwj cal seal proMction. CNN"3h M * Ida
• Total heads- up to 24 feet with three prong grounding w EPOS Napelter: T#rermo-
• Discharge sizes 1'h NPT. plug. Optional 201" plastic eWosed design for (CM liskd model numbers
• Mechanical seat carbon- WO. 16A UM with impruived perlbrmance- end in 7 a'AC
rotary, three prong Wwd% plug
BUM" elastomers. (stanft%I on EP05). ■ Casing and Bane: Rugged
• ITemperature: } condm m superior strength a thermoplastic design provides
104
140" f (6(°C) Irrterndttent. corrosion resistance.
• fasteners: 300 series METERS . FEET
sminiless steel. 10 ;
• Capadtte of running
drywittoddamage to s 30 GPM
components. I
Purga: EPOS s xsFr
• Solids handling Capad>i1'dy: c r
1'' ma)cimum.
• Capar up ID 60 GPM. o s 20 - - r - - ' - I
• Total heads: up to 31 feet.
• Discharge size: l W NPT. s
• Mechankal seal: Carbon- f
rota~~ykeraof"a bialy. 4
is BtJNG4 I~1 elastorners.
• Temperdbn: 3 10
1f COt~IfNt w ~
1140"f (60°C) irdernrnt. - - - a - EP04 - -
2 5 _t
0 0-
10 20 30 40 s0 am
Y 0 2 4 6 a 10 12 Mqh
' Parcel 040-1135-10-000 04120/2007 04:08 PM
i PAGE 1 OF 1
All:. Parcel 35.28.19.556P 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-owner
O - HARMON INVESTMENTS LLC
HARMON INVESTMENTS LLC
318 JEFFERSON ST
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 796 B CTY RD MM
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH L~
Legal Description: Acres, 1.430 Plat: N/A-NOT AVAILABLE
N 1 Block/Condo Bldg:
O-T E 361 FT OF N 444 1~ Tract(s): (Sec-Twn-Rng 401(4 160114)
C,6 4iyi¢n/1.: p' ~L -L e 35-28N-19W
Nantes: Parcel History:
Date Doc # Vol/Page Type
0711312004 768617 2615/170
0911411998 586964 1356/530 WD
07/23/1997 QSR/177 07/23/1997 596/375 q~~
2007 SUMMARY Bill Fair Market Value: Assesse with f~oynr
_ ° Z~ b
Valuations: Last Changed: /21/20 I'
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.400 42,000 143,900 185,900 NO
Totals for 2007:
General Property 1.400 42,000 143,900 185,900
Woodland 0.000 0 0
Totals for 2006:
General Property 1.400 42,000 143,900 185,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 514854 0
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 X Township Parcel Tax No:
Harmon Investments LLC, C/o Kevin Harmon Troy, Town of 040-1135-10-000
CST BM Elev: Insp. BM lev: BM Description: Section/Town/Range/Map No:
Gb 35.28.19.556P
TANK INFORMATION ELEVATION DATA
TYPE , MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
1406 6-5 AD
Dosing Alt. BM
U Bldg. Sewer K S
Holding St/Ht Itlfet
New-~ ~ 96 , tP
TANK SETBACK INFORMATION St/Ht o`egt o') • ` ` 7
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Dt Bottom
Septic 4p,
6'< f ~ 5ar Z I Z t/ Header/Man. 6S "13. g Z.
Aeration Dist. Pipe D
7.4#-( 9u. a
Holding Bot. System Q
OJ
4L P Final Grade %-7
PUMP/SIPHON INFORMATION
Manufacturer 11 Demand St Co
Sul GPM 21.9 y 7• 4=,-
~oJ
Model Number Ep6 Z^
Q / -7
TDH Lift .'i FrictioLos~s, System AJ Head A- TD~
Forcemain Lengji Dia. i r Dist. to Well
7 5b
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth
DIMENSIONS C,
1
SETBACK SYSTEM TO P/L ,t BLDG WELL LAKE/STREAM LEACHING Manufacturer.
(
INFORMATION TV Of S~tem: CHAMBER OR f"i r 0.f"
UNIT
~.+~rllJ O 162- Model Number.
DISTRIBUTION SYSTEM („~5 ( dV'4AM'_t"4~' Z Z44 . q,7
Header/Manifold ld Distribution x H Size Ix Hole Spacing Ver#p Air Intake
.r pipe(s) ` ` LJ
Length____ Dia 4 Length ` Dia Spacing \ 1 /
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 3.64 Bedfrrench Edges \ Topsoil ` y s [E No
LYes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: \ /
Location: 796 Cty. Rd. MM iver Falls, WI 54022 (NE 1/4 SE 1/4 35 T28N R19W) metes & bounds Lot Parcel No: 35.28.19.556P
1.) Alt BM Description = . 4e-, ~5 ho~S 4
2.) Bldg sewer length
- amount of cover =t` w ,~'l_O~~Kf Q
ell
Plan revision Required? 0 Yes >(No i [
Use other side for additional information. i
Date Insepctor's nature Cert. No.
SSD-6710 (R.197)
J
`
commerce.wi,gov Safety and Buildings Division County
201 W. Washington Ave., P.O- Box 7162
It i sca n s i n Madison, WI ELK" Sanitary Permit Number (to be filled in by Co.)
aepatltneM a/ Commerce 85
Sanitary Permit Applicatio - State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate govemmental 11)4
unit is required prior to obtaining a sanitary permit- Note: Application forms for state-owned POWTS are Project Address (if different than nailing address)
submitted to the Department of Commerce. Personal into s o secondary u ases in accordance with the Privacy Law, s. f 5.04(I)(m), St s. Y G A/11
1. Ai lication Information -Please Print All Inform 'on
Prope~ Owner's Name Parcel # Arm, 6 ;1 APR 2 2 2008 Q v- /3,c' - Property Owner''Aiin ddressProperty Location
~ST, CROIX COUNTY • 5S~
Govt. Lot A
7nNING OFFICE
UU
Ci Sjtat``e Zip Cod -17 one um r 2 ~lF -be tV Section s
r ~V/~ rn J -ta- n'~ trcle on
T O"` S N; REq
IL Type of Building (check all that apply) r4i Lot #
I
? I r1r 7 Famtll, Dwellinv - Number of IlMmom. Subdivision Name Block #
❑ Public/Commercial - Describe Use
❑ city of
❑ State Owned -Describe Use K -Town Number ❑ Village of
K-Town of
ZZ * Z t C .w
111. Type of Permit: (Check my one box on line A. Complete line B if applicable)
A. ❑ New S stem Re lacement System (explain)
y p El Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List
Previous Permit Number and Date Issued
❑ Permit Transfer to New
Before Expiration Owner'
IV.Type of POWTS S stem/Com onentfDevice: Check all that apply)
KNon-Pressurized In-Ground El Pressurized In-Ground 11 At-Grade El Mound > 24 in. of suitable soil El Mound < 24 in of suitable soil
El Holding Tank El Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/I'reatment Area Information: _
Design Flow (gpd) Design Soil Ap lication e(gpdsf) Dispersal Area eDispersal Area Proposed System Elevation
Lit) 3
Vl. 'ank Info Capacity in Total # of Manufacturer
Gallons Gallons Units , S U
New Tanks Existing Tanks U
Septic or Holding Tank V Od x
Dosing Chamber
5 ~S
VII. Responsibility Statement- 1, the undersigned, a responsibility for installation of the POWTS shown on the attached plans.
Plu tier's Name (Prin Plu r Signature MPlMPRS Number BusinPhone u~ be
4 SSA
x r--
Plumlrr's dress (St eet, City, t , Zip Co
~~d 1 s 1~~. 5 v
VIII.. County/Department Use Only
)proved rove Permit Fee ;1;sued Issuing g nt Signature
$ 6 C~o ~
IX.Condition re t V
as per management plan provided by pklrttlfar. w f r rJiQ eIC .
. U t-
Z. All setback requirements must be makttaiflad
as
Paf / ordmWices, g $ . Z • 27
r
< Attach o mple plans for the system and sub it o the Countv only on paper not less than t 1 i hes in size
/ ;7 17 ~t~6,1~ Kc~~ a1`/ v~1 CGS
SBD-6 (R. 01/07) Valid thru 01/09
i
L -
SOIL EVALUATION REPORT Page of
Wisconsin Department of Commerce 3
Division of Safety and Buildings
in accordance with Comm 85. Wis. Adm. Code
County St- Cr v X
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point ( dire n a Parcel I.D. _ 113~ _ - Q 00
percent slope, scale or dimensions, north arrow, and location and nc ea t print all information. Re ' Date
Personal information you provide maybe used for secondary purposes (P 112,,Z G
Property Owner RECEIVED Pro rtyLocation
K e n f a E y„ o Go Lot "4 1/4 SF 1/4 S.-L~- T .Z N R 9 ftor) W
Prope3rty - ress- s APR 1 6 2007 Lot BI- C9eDt+-P1emeV Z6P /70
-T P- I City State t Zip Code hone Number ❑ ttY O Village IZ Town Nearest Road
ST. CR X OU T
M M
n User Residential / Number of bedrooms Code derived design flow rate 6' OO GPD
'~R!! Oement Public or commercial - Describe: ` ~Re-
Flood Plain elevation if appl Ie /V ft.
/
General comments T ti G 3 fi s. s t r e c-f of sS i s 7 9 G CH MM
and recommendations: V ~ L OHflhfll r~ 0. C o/ H Yevy ?i "oh) I SrT e`en, u s • /ed1- A cr~rd e., ei f S 4c~* ~s
;.r CA, 4 ,`f
i i•! /-~-i a7~'iJNS yj- ~ t7'!wt O~Y~I Cdl f SP'f' CLt 1n. 7rL'_'~--r
yEJy -41-d a(F,",c:(4 wrw le be -ryx~te.-a -e/. rif'• dM~ 9~ d g.t' f• t• ni S t~~ ~~ntj lt'I~ v} j
I ❑ Boring C- "C
Cl Boring # Td- a
J E] pit Ground surface elev. ft. Depth to limiting factor y in• Soil ication 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
3 Z; S" 4&- 1 S r~ a 1`~ ~~r r- 0.7 1-6
3~-R2~ 7_S X,G;A s ~ s d I j 6'
I
50
Boni # F-5-) I ❑ Boring
pit Ground surface elev. '76--6 ft. Depth to limiting factor b Soli Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/l?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2
04+ I" ct 4+ Ir" Tim
3-~ -/0 7s 6- _ / - C~- 7 f-1a~
it A*
L6 V 'I
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Number
CST Name (Please Print) 101 Si ature
C~l~ler e~sne- Z~a6Z~
Address Date Evaluation Conducted Telephone Number
73
!1~5%3FS ~ EE/sst.~ ~ 'Z
4011 30,r~.
e v/ //3S'-/~ -DOC7 3
Property Owner K e ~7 d 4 o h Parcel ID # CS~ O - Page of
❑
7 Bonng # Boring
~ pit Ground surface elev. 6• 3 ft. Depth to limiting factor /dQ in.
Soil lication 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
-9 04 0. 9
/b eid .f! ! r S' O- v 0' -2 ard AK in P 3 26-3/ ZS R,f - / r s v ~e s - 0.7
4 31 7
7SY/P 6~ s c rr -
l
I 'T
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to tirrnting factor in.
Soil Rate
Horizon Depth Dominant Color Redox Description Texture Strumre Consistence Boundary Roots GPD1fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
❑ Boring
Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Sal Appication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlff°
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2
i
' Effluent 01 = BOD, > 30 < 220 mglL and TSS >30:< 150 mg(L ' Efouent #2 BOO, < 30 mg/L and TSS < 30 mglL
T'he Department of Commerce is an equal opportunity service 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.
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SBD•8330 (R.07/00)
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