HomeMy WebLinkAbout032-2185-27-000
Wisconsin Department of Commerce County:
PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605015
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:
Brad & Pamela Wittig TOWN OF SOMERSET 032-2185-27-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
G5 1 12.31.19.1574
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV.
Septic r 't s / D Benchmark
Alt. BM
Vi (df,C. /e z , 1-5
Aeration Bldg. Sewer 974
1
Holding St/Ht Inlet 4) •3 96 • /
TANK SETBACK INFORMATION St/Ht Outlet 1-71 TANK TO P/L WELL BLDG. e to Air Intake ROAD Dt Inlet
Septic l 3 / 8' Dt Bottom
AA-
Dosing 3 10 Header/Man.
Aeration Dist. Pipe A 47Y- 3:5
Holding Bot. System
s. ~ Boa,
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cove
GPM ,L J e0Z !fi
Model Number
TDH Friction Loss Syste d TDH Ft
Forcemal ia. Dist. to Well
SOIL ABSORPTION YSTEM
BED/TRENCH Width Length No. Of Trenctas PIT DIMENSIONS No. Of Pits Inside Di Liquid Depth
DIMENSIONS w I fe~c
SETBACK SYSTEM TO VV P/L 11BLE5 WELL LAKE/STREAM LEACHING Manufactur
INFORMATION Tyy6 Of Jeem O :Z7 CHAMBER OR Model I~{aQibe Qr: l 44 p
DISTRIBUTION SYSTE ~L f- ~0 = 3Z 4J S
Header/Ma Id Distribution x Hole Side x Hole Spacing Ven~Airintake_/
Pipe(s) `~g ` /
Length Dia Length Dia Spaon
SOIL COVER / x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of Teeded/Sodded xx Mulched
Bed/Trench Center u~ Bed/Trench Edge Topsoil -
~o Yes ❑ No Yes F] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 2243 71 ST ST i;a, Coj e.^- G L V~ ta try
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
Plan revision Required? ❑ Yes >No Z`i Q L- r
Use other side for additional information. L~ V J
SBD-6710 (R.3/97) Date Insepctor' Signatur Cert. No.
t.tR r4FF O County
9 S
Industry Services Division
1400 E Washington Ave Sanitary Permit Number (to be filled in by C:o.)
P.O. Box 7162
Vti' MP~ 3 M'lison, #37 71 / I
7 qty {P V
nO17, __11
X State "fransaction Number
St ~ , ~ ermit Applicatlo
In accordance -,vi t SU 2). Wis. Adm. Code. submission of this fnmt to the appropriate governmental unit
is required prior t taining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to project Address (if ditTerent than mailing addre~,,)
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
it Uses in accordance with the Privacy Law, s. 15.04(t)(m), Stets.
1. Application Information -Please Print All Information
Parcel 9
Property Owner's Hanle
-2 , -
Property Owner's Mailing Address Property Location
.J Gott. Lot
City, Stat Zip Code Phone Number Section
w circle o
T~24 NR Eo l'
II. Type of Building (check all that apply) Lot
I or 2 Family Dwelling - `umber of Bedrooms Subdiv siou ? m /
❑ Public/Commercial -Describe Use Block r' lr
El city of
❑ Slate Owned -Describe Use ❑ Village of
CSM \umber ~ Tottn of
ZPNle~ f5
III. Termit: (Cheri: only one boa on line A. Compete line B if applicable) A. System ❑ Replacement System El TreatmenLHolding Tank Replacement Only ❑ Other Modification
to Existing System (explain)
R ❑ Permit Renewal ❑ Permit Ret ision ❑ Change of ❑ Permit Tratlsier to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner • (Naa,
IV. Type of POWYS System/Corn onentfDevice: (Check all that apply)
N - In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound _ 24 in. of suitable soil ❑ b9ound < 24 in_ of atitilblc soil ~aa
titiY"
Holding Tartk ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treatme Area Information:
Design Flow (fgld) Design Soil ;lpplicatiou Dispersal Area Required (st) Dispersal Area Proposed (st) svstem Elevation _
19 3
Rate(gpdst)
Y Tank Info Capacity in
Gallons
Total = of gi miacturer ? ° L L r.
Units
Gallons - =
4ewTanks Existin=Tankso(z
Septic or Holding Tank ❑ ❑ ❑ ❑
Dosing Chamber ❑ ❑ ❑ ❑ ❑
VII. Respo sibUlty Statement- I, the undersigned, assume responsibility f awtatlat' n of the POWTS shown on the attached plans.
Number
Plumb i'ama (P n 771 Pluitlber s Signet re MP/MPRS Number Business Phone
/2 I
~22_1
Plumber's Address (Street, City. State. Zi Code)
1
-r-- r ~
VIII. untv/Department Use Only
roved Pprovc Permit Fee Dat Issu Issui Agent Signa ire
S / (J , 46
El Oltner en Reason for Denial Q-/
lake
i !WRS f Disapproval
4p
rondi
uiswerr3ai sill must all bgset`.it?s..•r r'tt m~ g5 I
es per i erAgement plan pro ridert by plumber.
2. All mfth+ir':k rerq iwmenm mlx t,tie trantcii e
so per eK*mbl1.t wde I C.rdinaxtFa
Atbich to compleie plans for the system and submit to the Counts only on paper not less than 8 11Z x t I inches in size
i
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1
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: l/
Owner's Name: - -
-'V
Owner's Address:
Legal Description
Township: ~~''s r 1
County:
Subdivision Name:
Lot Number.
Parcel ID Number.
Page 9 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page b Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page S Warranty Deed
Pzkge 9 CSM or Plat
j Attachments: Soil Test & House Plans
Designer/Plumber License Number. 7 5
Date: - - T Phone Number
~r
Signature
Designed pursuant to the in-Ground Soil Absorption Component Manuai for PoWrS Version 2.0 SBD-10705-P (molim
Page 1
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Soft Absorption System Cross- Section
-Z'! .T ft
4° Schedule 40 inr al Grade
PVC Vent Pipe
With Vent cap
Leaching
Chamber
System Elevation
ft ft
Soil Absorption-System Plan View
ft
' Vent Or Observation Pipe Leaching Trench 1
Chambers
4° Dia.
Trench 2 Header
Leachin Chamber S cifi ations
Manufacturer
And Model
EISARating,-SZ- ~ sqft
_ per chamber Soil Application Rafe /7 gpolsq ft
gpd Design Flow : - Soil Application Rate fns ?
r EISA = = Chambers
2 rows of chambers each.
Page of
E flu
PL x`25 EFFLUENT RLTER
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent fitters. The
I-~
PL-525 is rated for over 10,000 GPD Alarm
Aece PVC !
(gallons per days making it one of accessibility rr
extension handlie F
the largest commercial filters in its ,
class. It has 5255 linear feet of 1/16'
IW~~
filtration slots. Like the Polylok MW
PL-122, the new Polylok PL-525 has
an automatic shut off ball installed 525 Imear feet
with every filter. When the filter of 9116"
removed for cleaning, the ball Will Y ftration slots Rated for over
10,000 GPI
~
-float up and temporarily shut off , 3 g° r
the system so the effl uent won`t- z
leave the tank. Alo other filter on the matket can make that claim! ~ Accepts ¢ Pipe'
y
PL-525 Maintenance:
The PL-626 Effluent Filter should `
operate efficiently for several years 3
tinder normal conditions before
requiring cleaning- It is recom-
31
mended that the fitter be cleaned 14
every time the tank is pumped or = N
at least every three years. If the , , ' _
installed filter contains an optional N c k
L
alarm, the :owner will be notified
by an alarm when the filter needs FU f
Gas deflector
servicing. Servicing should be
done by a certified septic tank J Automatic shut-off }
ball when filter
pumper or installer,
is removed
1. Locate the outset of the U ;Patent Nwe sjis aas
septic tank. 5.53 (,640 1
2.'Remove tank cover and pump
tank if necessary. PL-5'24-15- i f seal le ti on : 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
4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
6. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Make sure all solids fall 4 or 6 outlet pipe. If the
filter is not entered 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 property aligned and 4 Insert the PL-525 filter into
completely inserted. its housing.
- Replace septic tank cover. 12 j S. Replace the septic tank cover.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Tank Manufacturer: Liz, &2
L; ~LEl NA
Permit ❑ Septic ❑ Dose ❑ Holding Volume: ld'~TiG' (gal)
DESIGN PARAMETERS Tank Manufacturer: /El NA
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: JD~(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): .j (gal/day) if horizontal is >150 feet. Specific instr ctions t be provided on back.
In Situ Soil Application Rate: (gal/day/ft) Effluent Filter Manufacturer.- ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: S "
Fats, Oil & Grease (FOG) <30 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BOD5) x220 mg/L ❑ NA ONA
Total Suspended Solids (TSS) 5150 mg/L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer:
(BOD5) >220 mg/L_ NA NA
(TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
❑ Disinfection ❑ Wetland
Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other:
(BOD5) 530 mg/L Soil Absorption System
(TSS) _530 mg/L NA
Fecal Coliform (geometric mean) 5104 P~ In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Effluent Particle Size in dia. El NA El At-Grade ❑ Mound
❑ Drip-Line ❑ Other:
Other: ❑ NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume
❑ When the high water alarm is activated
Inspect condition of tank(s) At least once every: I? ❑ month(s) (Maximum 3 years) ❑ NA
0 year(s)
Inspect dispersal cell(s) At least once every: El month(s) ? 'year(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: J ❑ month(s) ❑ NA
.f year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ANA
❑ year(s)
Flush laterals and pressure test At least once eve ❑ month(s) NA
every: ❑ 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 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 _512 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)
START UP AND OPERATION Page-/--, of
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
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 INS A ER POWTS MAINTAINER
Name Name
~K/ 7 4Z /2 Phone S Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name LNa e~~
Phone e _
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.
__4__ of
START UP AND OPERATION Page
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
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 INSTALL/ER ^ POWTS MAINTAINER
Name - Name
Phone S 57 _ Phone
'_2 - I 1~1/ ~7 7 ~j I
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
FName Name ~ a
I Phone Phone - J '/Z k l/
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)(1b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUN'TS'
SEPT7C TA'xX MALNMR-4_1"CE'.i GREMW EN`I
AN
OWNERSHIP CC TTON FORM
Owaer~uyerC~~ 7 Si- a o~
per V
(Vert%'mon regmred fre PlaM & zot g D%xuuwmt ft new anent uodm)
City l Stame Parcel Identification Number x_2,7 s::2
DESORTION,
Propart~r L_ i/< a 5 yzL V4, Se;c.~ T,;L/rN R W,'ovyrc o;~~ T
Subdivision Plat: LL%~°~1r,~ , Lot*:::
7
Certified Survey Map # , Volume , Pane
Wanvnty Deed (Wore 2007)Volum . Page #
Spec b m o yes bno brat Ihm i&mtii e a 3e i z€o
SYSTEM MAUaTNANCE AND OWNER CERTIR`ICA'ION
improper use and maintenance of your septic system could resnh in its prema=m faume to hancUe wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper- ghat you pit into
nee system can &Aem the function of tho. septic tank as a treatment; stage m the waste disposal systems. Owner magiftance
Fespoust' es are specified is §SPS. 383.52(l) and in Chapter 12 - St Croix County Sanitary Ordiua =
The property owner ads to submit to St. Croix Com2tyPlaming & Zo=s Dgmtm t a c oat form, sWed by the
owster and by a master pltmaber, journeyman phunbeKr, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is im proper operating edition mWor (2) after istspection and pumping (mfnexesmy), the septic tank is
less than 1/3 fall of sled ;e.
ilwe, the 3mdwsigned have read the above requirements and agree to maintain the private sewage disposal system with the
stand--cs = ftt4 bervi as set by !be Depatnew of icy And -Pr=- MOMW Sa races and tttc Departtn= of3 1 Rte,
State Of W-rc stag t your scode system bas be= " . must be comp1cftd and reftmad to the St. Croix mumftmed Couny P & Zug Departmew willb 30 dws of the
J daw.
I/we certify that all st ems on tb$ form are true to the best of my/our knowledge. Uwe am/are the ow er(s) of the
property descnbed above, by virtue of a r deed rec mzle d in Register of Deeds Office.
Number of bedrooms
laWA ' OF APPLICANT (S), VATS
*.Any information that is mmepreseated may result in the sanitary permit being revoked by tree Planning & Department.
Include whim this agpho tion a recorded warranry titer iiom the Ra of Deeds Office and a copy of the certified survey map if
reference is made in the wy deed.
LOT 10 ~II>I I _LOT
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SOIL EVALUATION REPORT Page of
Wisconsin Department of Commerce
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County `
5+1 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. / t~~
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. G '
Re i wed by Date
Please print all information. ~j
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (t) (m)). Lv7
Property OwpA Property Location
Govt. Lol) 1/4- / 1 /4 S T-3/ N R E (o W
Props er s Mailing Address Lot # Block # Subd: Na for CS /
oa
i~ State Zip Code Phone Number ❑ City ❑ Village Nearest R~
GPD
New Construction use' Residential / Number of bedrooms Code derived design flow rate
❑ Replacement ❑ Public or ce merclal -Describe:
Parent material -
h, Flood Plain elevation if applicable ft'
i, ' -
General comments ~j
and recommendations 5-` 1 1
~
F-11 ~ # ~ Boring in.
Pit Ground surface elev. ~ft Depth to limiting factor m Soil Application Horizon Depth Dominant Color Redox Description Texture Structure Consistence
Boundary Roots GPD/in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
'Eff#1 f 1
,-1
Boring # Boring f~ 7
Ground surface ele/-.4 O,✓ ff. Depth to limiting factor in
Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •EGPD/fgEff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
a
i
' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:< 1 `Effluent #2 = BOD < 30 mgL and TSS 30 mg/L
CST Number
CST Name (Please Print) lure 2T
Bird Plumbing, Inc. Shaun Bird Telephone Number
Address Date Evaluation Conducted
O` 715-246-4516
1008 192nd Ave, New Richmond, WI 54017
r
Z
of
.
Property Owner _ Parcel ID # Page
F3-~ Boring # Boring J
Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots •EGPD/fFEff#2
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh.,
~f
~a rr f7~
2- L4 Sc - o'0 ~1
1 L2 6-3
r `l
e
I
I
~t
Boring # p Boring
❑
pit Ground surface elev. ft. Depth to limiting factor in. Soil ~Rplication 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
F-I 0 Boring # Boring Ground surface elev. ft. Depth to limiting factor in.
pit soil PDIfFn Rate
Horizon Depth Dominant color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
Gr. Sz. Sh. `Eff#1 `Eff#2
in. Munseli Qu. Sz. Cont. Color
Effluent #1 = BOD; > 3o:5 220 nVL and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL
The 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.
SBD-8330 (8.6/00)
i
Soil Test Plot Plan
Project-Name P.C. Collova Blyds. Inc. Shau rd
Address P.O. Box 489
Somerset Wi 54025 TM #226900
Lot 27 Subdivision Wild Turkey Retreat II Date 11/18/04
NW 1/4 SW 1/4S 12 T 31 N/R19 W Township Somerset
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Survey Iron ^ g wt
System Elevation 95.8/95.9 *HRpSameasBenchmark
Alternate Benchmark Top of 1/2" pipe @ 100.3'
535' Scale is 1" = 40'
Property unless otherwise
Line
noted
B-3
90'
0% Slope
5'
10'
30'
B-1
200
Please note: Lot lines were not
adequately staked at the time of
testing. Installer must verify all lot
lines and setbacks before installation!
B. M.
365' Property Line
B.M. TOP OF 3/4' 6o RAUws
IRON PIN ELEVATION 1EMP CRARY
967 24' CUL-DE-SAC
EASEMENT. TO BE
. W 1/4 CORNER OF SECTION 12, PEUOVED OPON
FOUND 3" ALUMINUM MONUMENT NORTH LINE OF THE NORTHWEST 1/4 OF THE SOUTHWEST 1/4 Ex'E soa1Y OF
S 89'06'44" E 1339.17' ROADWAY
361.86'
360.26 I l 66 0 ry 551.05'
/ -722 .12'- I I~ 12557117"1 /
/ TO CENTER OF
E 5EVENT
LOT 30
0p
N
LOT O,
28
ao' RADIUS 131362 SO. FT. °J V /
7E!.1POR ARV M I / LBO = 9848x.00'
CUL-DE-SAC w 3,01 AC, 131058 SO. FT. o
EASELI NT, 0 BE m 3.00 AC.
REMOVED UPON O
rrSTERLY LOT 29 j I
Ex TENSION OF
ROAD'NAY ry 131754 SO. FT. 89'21'04" W 599.04'
0 3.02 AC_ / W
- - - - - - Z / I / / 279.20' 319.84'
S67'33'0I•/
86.54' p>
TO CENTER OF B.M. TOP EL }/TI m
E ASEE`AENT IRON PIN ELEVATON
996.04'
-5 89'57'58"
m 193.98' , 224TH - CS\~~
93.98' n AVENUE LOT 27 0 LOT 25
N 89'57'58" E C6 x502 `O
~
w 1068 SO FT.
3.08 AC. AC* o
B.M. STOP OF 3/4"
N PIN ELEVATION
997.77'
1 6 2..
C O N 83'20
Z z z O 1 / / V ~ O3' ~/J
o o m O - /
O n? w eM4 - 99000 ' / 1 I / \ \ - - -
p N ° LOT 31 LBO. 99200'
N = '
m 137273 So. FT. I ( \ LOT 26 /
I~ N N 3.15 AC. / ' -1 I 131230 S0. FT.
0 nF,N I 1 / _ --N 89'33W .p
C W e.M. TOP OF 3/4'./ ~aSF,ti11 I N t \ \ 3.01 AC.
I> p = O IRON PIN ELEVATION / 1 2 'Y N 108.33' m m
Z rn 947.90'
1 cmn N 9A
lo8 -o'
-S 89'3317" E
a N 0240 / / '\c?\~~ \ \ ~~CT 6Y9 vt i~~ N
Co
LOT 32
/ 6°' /140495 SO. FT. \ / z
/ 3.22 AC.
o LOT 35 LOT 36
130965 S0. FL 130921 S0. FT. y
LOT 33 w, 3.00 Ac_ 3.00 AC.
° o
130918 SO. FT. LOT 34
3.00 AC. c~ a
130834 S0. FT.
2 3.00 AC.~
428.08' 455.12' 220.69' 236.06'
z N 89'06'44" W 1339.95'
o UNPLATTED LANDS
N N -
O CO
N z [HHUM