HomeMy WebLinkAbout040-1278-00-000 (2)
'Ad.i-onsln Uepar.wenr of Cnrnrrer, PRIVATE SEWAGE SYSTEM r y St. Croix
9:drty :nd BudC ^I] Uwisicn
INSPECTION REPORT dandary Pem t No
fAl IACH TIC PERMIT; 607065
GENERAL INFORMATION Jute Plar "e
Personal informabc- you provldc'nny oe marl to, seconcary pumcses ^vacy -aa' s 1'. Car )or),
Pormt holder Nar:c I.IY village 'awrc:h:c 'orccl-ax No
Matthew Marek TOWN OF TROY 040-1278-00-000
CST 31.1 Ft, Insp BN 5ev Bid C", DI SecLO^TcvvWRnnpr.WN p No.
/Or> o (r d 4L l` 16.28.19.1552
TANK INFORMATION ELEVATION DA IA
TYPE MANUcACTURER CAPACI--Y STATION QS H' FS ELEV
Scollc W; T 1w.. I C Hr~nchmark I Z.I CJ kvim /66
All Hlv
I 66, .tom 7. •6!J
Aeration Hl:ly Sevn r 7 r
ttold;ng u.d Inlol S. q5 q4. 5
S1Ht Oullc'
TANK SETBACK INFORMATION • Z 9 (,o • 2
I ANK To P; Vut__ ESL"J - cm e. !ur s ROAC Lit Inlet
U 6
A- A
Septic '17 Z S / I DI bottom
Dosing "erlavOMar' S 9S. c1
Acla6on _ DISI. Pluc S 95.9
I lolorng - HUI. Svsterrl L
r 7
Final (:ride ~~I/
PUMPISIPHON INFORMATION T t0 17. g
Nlaoutaclure• Demand SI Covet
cNN F11A. 2 - 4
Monet Number
'Dt- L Fnct,or toss. ;i Awlt'wr,c TDH Ft -
°urenmlr Leggth nia. I: :o ;cell
SOIL ABSORPTION SYSTEM
BEDITRENCH 0.":I1- 1 enq:r / `.c 'q Tmn..n. PIT DIMENSIONS No O' PI`` msleo 7la ~cwd CeDC
DIMENSIONS ~J ,U A 7 L 11
SETBACK SYSTFM TO BLDG "W_ LAK:JS I RLAM LEACHING ?.tanufa: :roA,'
INFORMATION _ CHAMBER OR j~+~t e(
` ,r•n '
Q.y -I. OZ N UNIT Id4tleIL C , T
DISTRIBUTION SYSTEM Z 7 Z'7
It 11:Ndcl bl:r'ail'' Dise,owurl \ 4df C+L` A h01e`~'ry ber" to irI InYl15{i
9/ l7! °rPa.;;I S LLB
Le^211' Gr.,_ ,eny:h_~ Ura Soacmn
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
-n:Pih I've, C."ptr .'iv<• xx UCp]P M xr Seeoec'Soatlvd xa: Nulchcc
3e:b"ronr i.e ter '7. 9~] Fur: Tencht Aye:_ _ T0. scil ` -
L Ne Ne
COMMENTS: (Include code discre.pem:Iex, persons uresenl. etc.; Inspection V. Inspection a2
Location: 39' CEDAR 'r.~
1.) WI BIV Description = CEO VV~~ CCC.__MMMCCL~~~
H'dg sewe' length _ 1q6 ,
amount of cove) =
36 F+- Po
Plar revmlor Recluuec" Yes NO
use other side for additional nJumlation V 1 -
Ceti - - No
I::+Ic 1"=ePfY:~`.
ST. CROW COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certi Iv that I have inspected the Cxisting septic and or dose tank
presently serving the following residence:
(Street address)_ 34`7 located
at: itlnJ ''/.1, N-✓'/,, Scction /(v , Toxin 2$ N. Range /7 W,
I'oNN'n of 't Co St. Croix County Wisconsin.
Upon inspection, I ce ify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements ofSPS. 384.25, and it (they)
appear(s) to be timctioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No X
(itno, skip next line.)
Approximate volume or length of time: - gallons - minutes
Tank Capacity: _/Sb5
Construction: Pretab Concrete Steel Other
Manufacturer(il'kno%kn): L.J,efe.r
Age of-Tank (ifknown): $
Permit number (if know ) _ SZc{ 17 O
e 'lumber Signature) (Print Name
NIp-S ZZo-z-~(Z
(I iUc) (License Number) MPIMPRS
(Da e)
Form to be completed by licensed plumber (Dept of Salety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
a.. Counts - -S'f~ YV - d rl q ' ofo s
Safety and Buildings Division S R(j 1)
'Y 0 '1 201 W. Washington Ave, P 0 Box 7162 .S,mu:ay Permit Number (m he hued m by Cn.!
SPS I~ I Madifon, WI 53707-7162
L7lli6ry Pcrnut ApplFeatli: SfkteTransaction Number
In accoidmicc with SPS lg3.),II?i, \t is :\dn1. Q?Jc mbmissinn f This limn lu the appmpria s rwtaI unit ~-)~l4-
~s myuircJ prim to obtaining a %vnilmy pcnnil. Note' \pplicalion forms for state-owneJ POWTS arc subn W In Project Address (if different than mailing address)
the Ucpanmcat of Ninety and Professional scn ics. Personal minmiuunn you provide may be used fur secondary
ur -rscs in accordance all the I'nyan`I :rs', s. I i ii7(I I(m Stac. fY 397 C,-L, (-,(4
1. Application Information;- Please Print All 1ation
'rl Properly Owner's Name Parcel g
/~1 ~a r1 E 4✓ ~ d`io - 12--76 - c'c - c^cc`
Propcnv Owner's Mailing pAddress - - - Property I.xalhm ix 0
ZC 1 6 b) V
(invt t.ot
Cov, Slate Zip Odc Phone\mor,,r U! i* y,( Section I{/~
~ (circle one)
U!}SGI~ W~ J `1 CJT, 2l~ N; R ICI ear
11. 'ype of Building (check all that apply) f=ot 4
of 2 Candy Dwelling Nuolhi M llcdrmmts C SaMl:visiun Name
!J PuhliGQrrnnlarnial Dena ibe l5° ~I lily of
I
I I Slate Owned - Des-ribs Use _ _ CSM Numhr Village of -
Z Inwn of T'KOV
III. Type of Permit: (Check on[ - ine A. Complete line B if applicable) ~es•N1-
7 Trralmrnl.+l loldioy. Truk Rephr:en¢nt Only L Omer Modification to Existing System (explain)
\ Nctr Svstcm ' Replacement Svsan
li. Ll Permit Renewal ❑ Permit Rcvision l ❑ Change of Plumber G Penult Transfer to NCw' List Prevalrs Pelnllt Number and Date Issued
L3efint r,ptat inn Owner le~
IV R'mnyonrntrUevice(Check all that apply) _
~`{s Nun V re: xniicrl In-Demean ~f1 V,c,,anrcd I^-enamd CI At-Grade i Mound - 14 in. of suitable .it n Mound `24 in of suitable soil
J Iluldmg' ank Omer lo,pc•saI Component rvsplai ll Pretrcatmcnl Device (cxplainl
Dispersal?Treat rat Area Infonn•Ition V ----f\ f__ v 1- C
-51
)csi u I low (gpd7 W iva Snit \ppbcavurn Ricci- dill Dispersal Area Required (sQ Di gwir it A ea I Ip- d'. System HeNrinon
to-
VI. Tank Into Capacily in Total u of Manufacture
9 _
Gallons Gallons Umts
Yew Tanks L;xisung yanks
t7 a
tiil•t:c or KNdin_e Tank 'C/ C' ~~i I ~I~~~.~ ~ _
(tOSInP l-h,anhrr _ '
VII- Responsibility Statement- 1, the undrrsigneJ, assume responsibility for installation of the POW'7 S shown mr the attached plans-
Plumber's Namc Wrint) PlPumxr's Si - ahire MI 731 Business Phonr Number
1Z>> 2y Z S ~i C/ x`15
F v X I+ 1 -
Plumber's Address (Sine!, City, Scale, Zip Codel I (p
-
VIII. CountylDepartment Cse One
! Pcrnot Fee Date 1 sued Issuin gent Signature I
pro:ncJ ❑yic S
rr /
! (hour rrvcn Keason lia Usual ✓
IX. Condit)( 9\Cr}1MWIReasons for Disapproval
I. SepO-. hare, tMucrit rl'";,n.I
cell null of r:... 1IL . ec
AS per awragement p' , •iueli W plwnoe.•.
2 AN atftm* rtKUllSf vtn,, mynat,u r, airt.'A r:
•per OxftbsM!'!t.rdi. X&L
AuacM1 to Mmplete plain for the agora anJ •ubmll ro the County onh on pa PO. mr In. than a t. x 11 iorhn in size
SHU-6398 (R. I I? I I )
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Pr oiect Name
Owner's Name.
Owner's Address: 0 I .
1-1vu~~~,~; W)
~ ~1 to
Legal Description: VV
1 ownship: -T 1 ll ll
County.
Subdiv!sion Name: f-- 910 LC I;.~
Lot Number: ZC)
Parcel ID Number
Page 1 Index and title
Page 2 Plot Plar
Page 3 System Sizing & Cross-Section
Page 4 Filter Scecs
Pace 5 Maictenarc In'o-mation
Page 6 Manaaemenl Plan
Page 7 S: Croix Ctv Septic Tank Maintenance FD-rr.
Page 8 Warranty Dee-.
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber. License Number: I L L 3 L`f Z
Date 411-7 ' Phone Number -71 5- 'Ell j LI 56
Signature
Designed pursuant to the In-Groind Soil ItiSO'pUOn Cornpor_nl Narwn! b' PJ:NTS Vern^r. ; $3U-10 %~5-? i;K.O Vf?^.:.
Pace 1
-
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Soil Absorption System Cross Section
ft - 4' S c'ie:iuie 4D Final Grade
i PVC Vert; Pipe
Vft Vent Cap f 7.Jft
Leaching -►+!/I
Chamber L (1 /
SYSs e;n Elea:,tinn
Soil Absorption System Plan View
_Zft ll Vent Or Obsarvaac h Pie Leachin
Pip a Chambers Crench i
--z7Ij
ff: Illl l T7,IT'
r 4' Dia,
Trench 2 Header
I Leaching Chamber Spec°fications
Manufacturer And Model rJv+1CTI~FITL'k
EISA Rating u; sq per chamber ~-7
Soil Application Rate - / gpd/sq ft
-LL ; gpd Design Pio~\' Soil Application Rata a 1
L-IS.4= s(f Chambers
L 2 rows of chambers each.
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _of_
FILE INFORMATION SYSTEM SPECIFICATIONS
Lef Tank Manufacturer: U N
#
yd-Septic ❑ Dose ❑ Holding Volume: (Or
DESIGN PARAMETERS Tank Manufacturer: 1211~N
Number of Bedrooms. 5 ❑ NA ❑ Septic n Dose ❑ Holding Volume: (ge
Number of Pubfc Facility Units: ANA Vertrcal Distance Tank Bottom(s) to Service Pad: j( r if
Estimated ;average) Flow: Horizontal Distance Tank(s) to Service Pad: 1 r if
specific servicing mechanics must be provided if vertical is >15 feet o
Design (pack) Flow= (estimated x 1.5): "`7 J ;gal/day) if horizontal is >150 feet. Specific instructions to be. provided on back
In Situ Suil Application Rate. -7 (gagdayfiF) Effluent Filter Manufacturer. L-( 1't \ G ❑
Standard (Domestic) Inttuent/Eflfuent Monthly average Effluent Filter Model
Fats, Oil & Grease (FOG) -30 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (RODS) ,220 mgn. ❑ NA
Total Suspendad Solids (TSS) s150 mgrL Pump Model
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) 130 mg/l. Manufacturer.
(ROD„ 1220 mg!L NA !
_ iTSS) 1750 mgR L Mechanical AeraUOn ❑ lel: F i
- ❑ Disinfc-fection VjOl
❑ leaand
Pretreated Effluent Monthly average Sanu,Gravel Finer ❑ other:
(BOD') s30 mgiL Soil Absorption System
(TSS) '30mg;1. 4NA
_ Fecal coigorm (germotrlc mean) z10r - Grade (gravity) ❑ Mound nil (pressure) ❑ hi!
Maximum Effluent Particle Sze 1U, in dia. NA A4Grade ❑ Mound
❑ Onp-Line ❑ Uthc+:
Other: A NA Other ❑ N/
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) When combined sludge and scum equals one-third (Xi) of lank volume
U When the high ureter alarm is activated
Inspt condition of tank(s) At least once every: ❑ month(s)
ear (Maximum 3 years) lJ W
Inspect dispersal cell(s) At least once every ❑ month(s)
( A Y ts; (Maximum 3 years) ❑ N<
Clean effluent filter At least once every I ❑ month(s) ❑ NF
Inspect pump, pump controls & alarm At least once every: U month(s) ❑ NF
- _ ❑ Year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NP
❑ year(s) _
Other: ❑month(s)_- _
_ . At least once every: ❑ year(s) ❑ NP
Urh~f:
❑ NP
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shm be made by an individual carrying one of the following licenses or certification
[;taster Plumber, Master Plumber Restricted Sever, POWTS Inspector, PO`ATS Maintainor or Septage Servicing Operator (pumper
Tank inspections must include a visual inspection of the tanks) to identify any missing or broken hardware, identify any cracks or leak
measure the VOlume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The se
absorpfion system shall be:asua'ly inspected to check the effluent levers in the observation pipes and to check for any ponding of effluel
on the ground surface, The ponding of effluent on the ground surface may indicate a failing condition and requires the immedial
notification of the local regulatory authority
When the combined accumulation of sludge and scum in any treatment tank equals one-third (35) or more of the tank volume, the entir
contents of the tank shall be removed by a Septage Servicing Operator (pumper) and dispo.;ed of in accordance with chapter NR 11:
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent titters, mechanical or pressurized components, pretreatment unit:
and arry servicing at intervals of f02 months, shall be performed by a certificxf POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
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Page _ d
START UP AND OPERATION
For new construction, prior to use of the POINTS check treatment tank(s) for the presence of painting products, solvents of
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrate
detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use.
Pump tanks may fill above nonma! highwater levels prior to startup or due to pump failures, Start up or restoration of power under
conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose caul
overload that may result in the backup o- surface discharge of effluent and damage to the system. To avoid this situation ha
contents of the pump tank removed by a Septage Servicing Operator Ipumper,. pncr to res inq power tg the pump or contact a PI
or POINTS Mairtainer to assist in manually operating the pump comfort; until norms` effluent leves are restored within the pump tai
System start up stoll not occur when soil conditions are frozen at the infiltrative surfao-e
;k not drive or park vehides over tanks or the soil absorption system. Do not drive or park over, of otherwise disturt or compz
area within 4.5 feet down slope of any mound o• a:-grade soil adsorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the tre
tanks and sell absorption system. acids, antibiotics, baby wipes, cigarette butts, condoms, cadon swabs, degreasers, denta.
diapers, dsinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides
scraps, medications, oils, painting products, pesticides. sanitary napkins, solvents, tampons, and water softener brine discharge
ABANDONMENT
When the POWTS fails andfor is permanently taken out of service the following steps shall be taken to insure that the system is p
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 dsconnacted and the abandoned pipe openings sealed.
• Tne contents of ail tanks and pits shall be removed and property disposal of by a Septage Servicing Operator (pumper;.
• After pumping, all tanks and pits shal" be excavated and removed or their coves removed and the void space filled wi
Oravej nr anri her }ncpf cnliri math'
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code car
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement sod absorption s
The replacement area should be protected from disturbance and compaction and should not be infringed upon by re
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in th/
for a new sal and site evaluation to establish a suitable replacement area. Replacement systems must comply with the r
effect at the time of their permit issuance.
'J A suitable replacement area is not available due to setback anaror soil limitations. If the soil absorption system can
rehabilitated and barring advances in POWTS technaogy. a holding tank may be installed as a last resod.
,j The site has not been evaluateo to identify a sikable replacefilwlt area. Upon failure of the POWTS a soil and site eva
must be performed to locale a suitable replacement area. If no replacement area is available a holding tank may be instalte
iast resod to replace the failed POWTS.
❑ Mound and at-graoe soil absorption systems may be reconstructed in blade following removal of the biornat at the infi
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 L
SUFFICIENT OXYGEN TO SUSTAIN LIFE NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE DEATH
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POINTS MAINTAINER
Name_r."r---'r= Namc
Phone Lj ~I I G; Phone - - - -
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name Name I
Phone Phone ` -7 (5~- 3SL - `71~ C
flits documerit was rtrafted by the staffs a the Green Lake. Marquette and Warshara Cuunty PQWrS regulatory agencies in compliance with s,
Comm 63.22(2)(b)(t)(d)R(f) and 83.,5/4(1), (2) & (3), Wisconsin Administrative Code.
N 1 /4 CORNER '
'_TE_D _L AND T28TK10RR 19W
58059'00" E 2616.30' NORTH LINE OF THE NW 1 /4
t 4 _30.00'
1308.15'
S• DEDICATED TO THE \
PUBLIC FOR PARK
0.400 ACRES
;g
• \ 20 17.411 S.F.
2.546 ACRES
1 10.899 SF.
S • 30' ~ 'Q
N
v .7 ~ N dO•~f
R=W
' Q
21 ' N 20'
2.169 ACRES N
C0 94.485 S.F. u • jo i
eS _ ! RFW'34 MARK-
.cunsm Department of Commerce PRIVATE SEWAGE SYSTEM county ty perms No St. Croix
Seidl, and Building Division INSPECTION REPORT 574390 0
(ATTACH TO PERMIT) Saba Pan 10 NO
GENERAL INFORMATION
Personal intortnallon you provide may be used for samndary purposes Ir'*'8CY law, 5-15 04 (tl;m)). Parcel Tax No. I1.7
Peme Hdders Name city village Tavnsnip 040- B-00-000
Marek, Matthew & Shannon TrD Town of
SecaWTowMlangalM+D Nu:
CST 8M Ele¢ Insp. BM Elev. lHa p~-iiplb¢ 16.28.19.1552
~fyZ.~L7
ELEVATION DATA
TANK INFORMATION CAPACITY STATION BS HI FS ELEV.
TYPE MANUFACTURER
Benchmark 67'-f x154, 9yZ `F
Septic 5 (0 5 aft
W es~ F:IL . z'
An BM d
re O~•rsu~.~ a 7
I /r Bldg. Sevier 9 SS . 5
Aeration
SUM Inlet
Holding
SVHt Outlet cil, Z, >J
TANK SETBACK INFORMATION
TANK TO 1 P/ll,, WELL BLDG- Vent Air intake ROAD Dt Inlet
of Bottom
Septic Je AA it s
HeaderlMan. g•O ~~g, a
Dosing , o qJ8•
Dist Pipe /o.
Aeration
Bot. System
Holding
Final Grade 5, 4~7 5 / . Z
PUMPISIPHON INFORMATION
Demand sit cover / 1 Z
Manufacturer S
GPM
Model Nu
TDH Ft
TD Lift Faction Loss System H
Forcernam Length Die. ust. to was - - '
SOIL ABSORPTION SYSTEM PIT DIMENSIONS No Of Pig- Inside oia. Lrqud Depth
a OrTRENCH VAdth / Length mo. Or Trenches -
DIMENSIONS 3 Z, 14"(. o
E/STRFAM LEACHING Menulscturer. in a
SETBACK SYSTEM TO P1L BLDG WELL LAK CHAMBER OR r /
INFORMATION Type of System. ^ rA ./A UNIT Mood NumDeC_✓' (,r- 4 51".
l8 ,7b /V Pr ~I/fT" CJ
Co'./cr,.. L 7
ION SYSTEM UT(d zHoleSpxing VenttoAklmalio
Disoltwtlon z Hde Slze~--__ _ _ Ew b~_ g S
lleaderrMBnilOtd r/ _
/ Plpels)
Length _l0 Dla 4 Length Dla Spacing- _
SOIL COVER x Pressure Systems only xx Mound Of At4rede Systems Only Mtsdi
xx Depth-. tae Sceded'Soddod _
Depth Over Depth Over Topsoil Yea Lil No trt.y ;el No
BedRrerxh Center N Bed,Treneh Edges
Inspection #1.Inspection #2'_1_1_
COMMENTS: (Include code discrepancies. persons present, eta) Parcel No: 16.28.19.1552
Location: 397 Ceder Court tludssoon`. Will ~a016 (NW 114 NW 114 166 28N R191M Eagle Bluff Lot 20/
F GoOC,. //4-~ 1e(t~11 C L II (r~~•
f s'~dJ~dt rvx"'ib~ a•...,~ b~Y~~
1.) Aft BM Desuiption /N AI
2.) Bldg sewer length = 14 1l ` '-6 ('e. N• U 4-' %CS
- amount of cover = y/ 1 -
Plan revision Required? iTJ Yes No 1271 7I J (.f _ - L - -
~'s7,~~ nelure CI No
Use other side for additional inkrmaWn• ~ DM Insspdors g - - - -
SBD-8110 (R.9197)
CST-;) 01 ct - of -7
'Ntswnsin Department of Slai and Prolrss. oral Se-viccs Paga_of-
Division of Industry Sor:icCll
SOIL EVAIIUAT '
In ara:ordance with SPS 31 'Xis. Adm. Axle Cor.nly r'/ ~
Attach complele sto plan on paocr not less than H V2 x 11 'r'rhes in swe. Plan must'nclude, but not limited to'vertinal and horizonta: re`cre•tco point (Bhfi di•ec;og :and ;:e:ccw
slope. Parcel 10
scae or d mensions• north arrnv:• and locab::•I a'id d stance to reerest road
Please print all information. Rene d by Dat q
Per%onal Irtorma:ion you provide may be used lot suwndmypurposes Wovary t aa., s 15.I14(1)irn' 1.
11reperty O.vrer Prwc4y Location
Guilt. Lot : •sl ny ~ A S N R E {or) W
rn: erly Ova rer's f.lailing Address Lot f+ Block G Subd, Nar. a or CSbI#
i D A~~ Q L Ll F c
City State Zip Code Phone Number ❑ Cily ❑ v llage ® town Nearest Road
' 1 .U.,? I `.''ice', ';t (~,2 1S5jd~': - T~~OY -~_lCl7L L•~"
U Merv Conslruchun Me. ® Rosidenlial: Numberof bedrooms Codo derived design flow rase 7 jU GPD
U Replacement ❑ Pr.bllo of commerool - Describe'
'arenl malonal rlood Plan ele.alion i1 applicable- It.
Gcnral comments and reco,amendaua'u.
I
Horiny H ❑ Boring
l I ® Pit Ground surface elev. Depth to limiting facto•)/OD in
I _ Serf Applica:.or Rase
N)llLon Depth Doninant Color Redcx Dcu:tifku r TCxtu'e Slr.whire Consistence Boundary Roots GPDiFI`
In. Mansell Od. Az. Con. Color Gr- Sz. Sh. 'Effdl 'P+h:2
M _ C7 1 z M i
Boring # Lj Gering 4 7
ril Gre'.Irld surface CICv.' T?] It Depth to limiting factor 1 Q ir.
Sol Auplicaaon Rate
Rn:inm Depth Dominant Color Redox Do%m ption Toxture Slnrclur , Consistence Bouncary Roots GPDiCI` _
In. Mansell Qu. A7. Ccm. C(Ita• Gr. Sz. Sh. •Eff#l •L'1142
2-
T,3•~~1< - s S -f
Ciro
-
'L
Effluent o l - ROD, > 30, 220 asg!L and_ I SS > 30<_ 15011 ' Effluent #2 - DOD, 30 s 220 ntg1L and TSS > 3011501
CST Name (Please Print) S' azure f CST Number
Add es. Date Evalu ion Conducted telephone Number
SHD °330 M415i
~S 2 ~j
Rorinp # ❑ Hocng
® Pit Grcmnc surface clo•✓.10a h. Depth to limillng factor/1 30 in.
Soil Apulicatior Rate
I toff<on Depth i)nminanl Color Rcdox Descr piton texture StruGUre Consisterre D•~umtary Roos GPIJiFI' _
In. fdunsell Ou. Ai. Cont Color I Gr. S<. SShh 'Fff# Fl f2
2 A-120 to yR9/& o mS ml - - 7
Ronng # ❑ Boring
❑ Pd Gra.ind sudare elev. _ II. Depth to limiting factor _ in.
_ Sal Aeplicnon Rate
I lnnl nm I:eplh Domiranl Co!er I Rodex De c•iot on I rxh.re Slr,iclure I G.msmlerce Boundary Roots GPD+I'
In. Mursell (J.r. Ai Cont. Gelar G. Sz. Sit.
- -
'Ef1#1 'Eff#2
Renng ❑ Boring
❑ Pit Gn:.md surface elev- -fl. Depth to limiting fade, ri.
_ o,1 Acp irahor. Rate
Horn°n D.01 Cr:ntn rl C', :'T P~dcx Dezcoal on Texture I Structure (i>nsisterce 7candary Roos GPD:H'
L In r, nll i. Az. Cont. Color Gir S<. Sh, Fff#1 'Fff42
I
' 6III.rent 41 -ROD. > 30 _ 220 mgN_ and TSS 30"150 mgr:. ' Cllluerl h2 = ROD r SO < 220 nvg1 wrl -S5 30 < 1.y) ten'I
1
8 W: Grcand surface elev.l h. Depth to limiting facial, 'Din
_ _ _ Soil AO licauor Rate
Horizon Deptn Dolm and r Rodcz Desc-iai on Texn,re Stricture CAnSisten0e Bodntlary' Roots GP7l=F
I In. FAursel Uu. Az. cont. Caor Gr. Sz Sri
I I 'Fff#1 •EtF#2
-'20 r Vk - a m.54 m~ - - 7
- i
I
jig
3c'rnq k ❑ Satiric
❑ Pi: Gro.md saga: e elev. t. Depth to Irmiting'ar w i~
_ Sal No hrx,or Rate
ioraor Daptrr Dnmmant color Redox Dos:rlpao'r Iezlu'e SIn1G1n'.. Consistence Saunoary Roots GP7!--t'
Ir:. M1lunsell Qu kz. Cunt. Color Gr. Sz Sh. 'Eff#1 'Eff42
I
I I i
Bc•iny k ❑ Gunny
❑ pi: G¢und sudacz elev. _ It. Depth to Inni:ing factor _ in.
Soil Awmu hor Rale
-wr.zor UC51n Ua:nireinl Clola- Radcx Desclm or Texture Straoturc• Consistenco 30ulcary Reo:s G~DrFt'
In FAur sel Oa. Az- cont. Caor G. Sz. Sri. •Effkt 'Eff#2
FMuent #1 = BOO, 30 228 n@A one TSS > 30 1 Y' mp:L ' Elllaent #2 = SOD. > 30 5 220 mg.L and TSS ? 38 150 mgt
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