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HomeMy WebLinkAbout022-1011-70-025 Wisconsin Department of Commerce Count Safety and Building Division PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT Sanitary Permit No: 453184 0 GENERAL INFORMATiON (ATTACH TO PERMIT) s to Plan ID No: t1 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 90 to d, Permit Holder's Name: I City Village X Township Parcel Tax No: Uetz, 1 ' ' L )1�� Kinnickinnic Township 022 - 1011 -70 -025 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 05.28.18.71 A I m TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark AM k I 2- (. o 2. - 7 163.31 160, 4 Dosing Ir Alt. BM Aeration F Bldg. Sewer Holding SUHtInlet •gD TANK SETBACK INFORMATION St/Ht Outlet 3- 415 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet t 10.33 `�(� • ►`�• Septic Dt Bottom , Z4 N1 12 Dosing , Header /Man. > o� " IIS • I2- o2.3St Aeration Dist. Pipe I f . I 02.32- folding Bot. System o O• Final Grade PUMP /SIPHON INFORMATION �� �,, - U � rz 4 .4 . — o0 Manufaoturer Demand St Cover C �lt_l►�S GPM O � '^ •D O2 - i Model Number �� . /L 4 J6 TDH Lift Friction Loss System Head TDH Ft a sass o s s. (0 cio . ot�.`( 2 9 I 0. orcemain Length Dia. it Dist. to Well SOIL ABSORPTION SYSTEM ('REOW9111ill Width Length No. Of rFeR PIT DIMENSIONS No. Of Pits Inside Dia. MENSIONS 12-C) f U 1 -A— A_ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING nufacturer. INFORMATION Type Of System: 33 ? CHAMBER O S J l UNIT M I Number: DISTRIBUTION SYSTEM d Q ,, �{ Header/Manifold Distribution x Hole Size Hole Spacing ent to Air Intake ' ASP • - t t Pipe(s) r � Length 2.•T Dia�Z I Length 51•zg( �•)Dia l I ! I2- Spacing 2•S S /3z 3.o4 r1 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 VBed/Trench Center Bed/Trench Edges Topsoil I A Yes j No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: g / z / a5 Inspection #2:h"_� *.7 Locatio ✓ n' 1/4 NW 1/4 5 T28N R18W NA Parc I o: 05.28. - ' � 7 ) �l 1.) Alt BM Description = s•T.Iw.o�l►t� 2.) Bldg sewer length = 2 7 - amount of cover = Z 4 f 3.) Contour = n revision Required? Yes Use other side for additional information. Date , - = Insepctor's Signature C �rt SBD -6710 (R.3/97) _ . 1 0. Safety and Buildings Division County 701 W. Washington Ave., P.O. Box 7162 -C7- e ff N isconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (�8) 266 -301� 3' g Sanitary Permit Application See Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 1 may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information - 1 _ on eff4-ss Property Owner's Na me D Parcel # Lot # Block # MAY 0 1 10 A �,11�77 T MM — -7 Property Owner's M ailing Addr Property Location JF 1CF fit% �i!' !k, .y , k/ IA,Section City, State Dip Code Phone Number 7/J - (circle H. Type of Btti ding (check all that apply) T N; R If E - uo �,nn;Cber l�or 2 Family Dwelling - Number of Bedrooms T/ • / ❑ Public /Commercial - Describe Use 7 XV 41, " �� & hh ❑ S to Owned - Describe Use 5 t x ( OA&k -A C.l ", U ° ") 3 ❑City _ ❑Village owns tp o 60 Ut (Check only one box on line A. Complete line B if applicable) 0 10 11 - - OAS A A. R - New System ❑ Replacement System., ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) ,,,/ ❑ Non Pressurized In- Ground ❑ Mound > 24 in. of suitable soil L7 Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsI) I Dispersal Area Required (sf) I Dispersal Area Proposed (sf) System 6 �D . �- o/J dov /I VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel 'ber Plastic Gallons Gallons of Units Concrete Constructed GI New Existing � 1 Tanks Tanks Septic or3tokiing Talc 2 2 t Dosing Chamber �v �,�5 ✓ — VII. Responsibility Statement- I, the undersigned, assume respo ' ' . y for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plum 's Si cure MP/MPRS Number Business Phone Number - 2.2 lloPl- 7V PO t Plumber's Addre ss (Street, City, Stdte, Zip Code) , ��� -.r/ Fogerty Plumbing &Perk Testing < s - O - 3 7 VIII. Co 9 ApprovedS � "0J Sanitary Permit Fee (includes Groundwater Date Issued in gent Signatuip (No Stamps) Surcharge Fee) El Owner Given Reason for Denial �� IX. Conditions pro "-- SYSTEM OWNER: 3� ,V vl� 1 Septic tank, effluent filter and L dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances Attach complete plans (to the County only) for the system on paper not less than SU2 x 11 inches in size r 0 N � y A � ' o M / II Q A o e � O / Cb 5 A � . 04 co / t0 g ' t1 • O / b t ot 0 0 00 00 IC c n al 00 O P I 00 ti - - - —1— ana.. 10541 N RANCH ROAD I\ HAYWARD WI 54843 VA TDD #: (608) 264 -8777 sconsin www.commerc .wis i www.wisconsonsin.gov n.gov Department of Commerce + Jim Doyle, Governor Cory L. Nettles, Secretary February 09, 2004 CUST ID No.224059 ATTN.• POWTS Inspector ZONING OFFICE KEITH E STONER ST CROIX COUNTY SPIA 23220 WOOD CREEK RD 1101 CARMICHAEL RD SIREN WI 54872 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 02/09/2006 Identification Numbers Transaction ID No. 963170 SITE: Site ID No. 670123 Mark Uetz Please refer to both identification numbers, CTH SS & CTH N above, in all correspondence with the agency. Town of Kinnickinnic St Croix County SWI /4, NW1 /4, S5, T27N, R18W FOR: Description: New mound, 4 bedroom residence Object Type: POWTS Component Manual Regulated Object ID No.: 939397 Maintenance required; 600 GPD Flow rate; 23 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01101) P.I The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes Con and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. A M 1 F DEPARTI No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, DIVIS► OF stats. The following conditions shall be met during construction or installation and prior to occupancy or use: - Ct General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans and with the design manuals noted above. • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. Key Item(s) • The designer proposes to install a state approved effluent filter to achieve the requirement of wastewater particle size. Pursuant to outlet filter product approval stipulations, maintenance information must be given to the owner of the POWTS explaining that periodic cleaning of the effluent filter is required. The access opening used to service the filter shall terminate at or above finished grade with a watertight cover. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. KEITH E STONER Page 2 2/9/04 • Limit activities in the area 15' beyond the dow,0 slope edge of the mound per Mound ComponeAt Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • Maintain well and waterline set backs per COMM 83.43(8)(i). Consult the Department of Natural Resources for well setbacks and exceptions to the setbacks. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installarion/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerel Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 atricia L Shandorf POWTS Plan Reviewer e ' ated v ices WiSMAR1 code :'7633, (715) 634 -7810, Fax: (715) 634-5150, M -f 7:45 am - 4:30 pm pshandorf@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Mark Lletz 4 Bedroom Mound Owner's Name: Mark Lletz Owner's Address: 1600 Namekogen Street Hudson WI 54016 (715) 556 -9656 Legal Description: SW1 /4 -NW1 /4 -Sec. 5 T27N -R1 8W Township: Kinnickinnic County: St. Croix Subdivision Name: CSM Vol. 17 Page 4482 Lot Number: 1 B Block Number: NA Parcel I.D. Number: d R E itio "l Plan Transaction No.: E RENT UILDINGS S Page 1 Index and title Page 2 Data entry NC Page 3 Mound drawings )RRESPO Page 4 Lateral and dose tank Page 5 System maintenance specifications C Page 6 Management and contingency plan Page 7 Pump curve and specifications Page 8 Plot Plan Designer: Keith E. Stoner ° ,14 %S C O nse Number: Designer# 1575 -007 Date: 01/07/04 ., Pie Number: (715) 653 -2324 Signature: to Mound Component Manual for fy j l` .0 SDB- 10691 -P (N. 01/01), and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS (01/81) Version 3.11 (R. 06/01) Page 1 of 8 Mound and Pressure Distribution Component Design Design Worksheet Site Information (r or c) R Residential or Commercial Design Note: Sand fill (D) calculations assume a 400.00 Estimated Wastewater Flow (gpd) Table 83 -44 -3 in -situ soil treatment for fecal 1.50 Peaking Factor (e.g. 1.5 = 150 %) coliform of <= 36 inches. 600.00 Design Flow (gpd) 4.00 Site Slope ( %) 100.40 Contour Line Elevation (ft) 23.00 Depth to Limiting Factor (in) 0.50 In -situ Soil Application Rate (gpd /ft Distribution Cell Information 120.001 Dispersal Cell Length Along Contour (ft) = 5.00 Cell Width (ft) 1.001 Dispersal Cell Design Loading Rate (gpd /ft 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution L�'_� Pressure Disribution Information network? Enter Y or N (c or e) c Center or End Manifold 2.50 Lateral Spacing (ft) If N above, enter the elevation ft) 4 Number of Laterals of the highest point. 0.156 Orifice Diameter (in) (e.g. 0.25) 3.00 Estimated Orifice Spacing (ft) = 7.50 ft /orifice 2.00 Forcemain Diameter (in) 25.00 Forcemain Length (ft) Does the forcemain drain back? Y 93.50 Pump Tank Elevation (ft) Enter Y or N 4.55 System Head (ft) x 1.3 4.08 Forcemain Drainback (gal) 7.65 Vertical Lift (ft) 108.78 5x Void Volume (gal) 0.95 Friction Loss (ft) 112.86 Minimum Dose Volume (gal) 13.15 Total Dynamic Head (ft) 43.08 System Demand (gpm) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 x x 1.25 x 2.00 x 1.50 x x 3.00 2.00 1 x 3.00 1 x Gallons /Inch Calculator (optional) Treatment Tank Information Total Tank Capacity (gal) 1260.001 Septic Tank Capacity (gal) Total Working Liquid Depth (in) Weeks Concrete IManufacturer gal /in (enter result in cell B49) Dose Tank Information Effluent Filter Information 805.121 Dose Tank Capacity (gal) JZabel I Filter Manufacturer 21-761 Dose Tank Volume (gal /in) JA1 00 IFilter Model Number Weeks Concrete Imanufacturer Project: Mark Uetz 4 Bedroom Mound Page 2 of 8 I Mound Plan View 1/10B .. Observation Pipe :::::Q J .... .. ..' l K ' — T w A W . . . . . . . 1. ... .. .. ... .. .. .. ................... LU ................. I ............................... L Mound Component Dimensions A 5.00 ft E A0. in H 1.00 ft K 8.93 ft B 120.00 ft F in I 8.78 ft L 137.85 ft D 13.00 in G ft J 6.36 ft W 20.14 ft 600.00 (ft Dispersal Cell Area 1653.41 (ft Basal Area Available 5.00 (gpd /ft) Linear Loading Rate 1 12.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 103.28 (ft) ---► G I F 101 9 Dispersal Cell a 8 (ft) L ateral 101.48 (ft)--1111- af., } Invert Dispersal Cell «''" 3 : _ t Elevation ' D E :Q:, • _ 1 . A, A A A.�A„ A A l �.I A A 1 1 1 a�A A .' ' 'A �/'., r ' �'' 1 .r l r ' ' .F� 'A s' 1 f 1 1 f ' 1 .F I A, j ' .' �.' 1 1 1 f l„ I A ,« I A 1 1 A A J 1, � �A A s A A A 1 A A A� A A 1 A A A A A A A. a �A J' M e r r . r.., 100.40 (ft) Contour Elevation 4.0 %Site Slope Geotextile Fabric Cover Shading Key -a 2- Dispersal Cell See lateral details on d Topsoil Cap o o- 1.5 ft Page 4 for number, size, "�x g © { { { {{ Subsoil Cap w o 15 w and spacing of laterals. © ASTM C33 Sand ` R" Laterals are equally ® Tilled Layer H 0.5 ft Typical Lateral F spaced from the % distribution cell's Aggregate o centerline in the A distribution cell (AxB). Project: Mark Uetz 4 Bedroom Mound Page 3 of 8 Center Connection Lateral Layout Daigram Force main connection via tee or cross to manifold at any point. Laterals are identical P S AL i= Turn -up wlball valve or I<- X- -)�IEKr7 I 02+ Laterals & force main of PVC Sch 40 cleanoutplug per COW Table 84.30 -5 Hales drilled on the bottom of the lateral. Number of Laterals 4 Orifice Diameter 0.156 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.04 ft Lateral Length (P) 59.28 ft Orifices per Lateral 20 Lateral Spacing (S) 2.50 ft Orifice Density 7.50 ft /orifice Lateral Flow Rate 10.77 gpm Manifold Length 2.50 ft System Flow Rate 43.08 gpm Manifold Diameter 1.50 in Total Dynamic Head 13.15 ft Forcemain Velocity 4.40 ft/sec Dose Tank Information Locking cover with waming label and locking device and sealed watertight Electrical as per NEC 300 and —♦ Comm 16.28 WAC 4 in. min. --t Disconnect _ Tank component is properly vented F— Altemate outlet location Forcemain diameter Weeks Concrete Manufacturer 2 in. Capacit 805.12 Gallons Volume 21.76 gal /inch A Weep hole or anti - Dimension Inches Gallons B siphon device A 19.81 431.14 C B 2.00 43.52 Pump off _e levation (ft) — t C 5.19 112.86 94.33 D 10.00 217.60 D Total 1 37.001 805.12 ` Dose tank elevation (ft) 3" Bedding uncTer tank. �— 93.50 Alarm Manuafacturer IS. J. Electro Alarm Model Number 1101 -01H Pump Manufacturer JGoulds Pump Model Number 13871 EP05 _l Pump Must Deliver 1 43.08 gpm at 13.15 ft TDH Project: Mark Uetz 4 Bedroom Mound Page 4 of 8 Mound System Maintenance and Operation Specifications Service Provider's Name Tri- County Sanitation Phone h((715) 15) 386 -0114 POWTS Regulator's Name St. Croix County Zoning Office Phone 386 -4680 System Flow and Load Parameters Design Flow - Peak 600 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 400 gpd Maximum BOD5 220 mg /L Septic Tank Capacity 1260 gal Maximum TSS 150 mg /L Soil Absorption Component Size 600 ft Maximum FOG 30 mg /L Type of Wastewaterl Domestic Maximum Fecal Coliform I >10E4 cfu /100 mL Service Frequency Septic and Pump Tank Inspect and/or service once every 3 years Effluent Filter Should inspect and clean at least once every 3 years Pump and Controls Test once every 3 years Alarm Should test month) Pressure System Laterals should be flushed and pressure tested every 1.5 years Mound Inspect for ponding and seepage once every 3 years Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn -up Detail Finished ............ Grade 6 -8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box . . Plug or Ball Valve Distribution • • • • • . Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Mark Uetz 4 Bedroom Mound Page 5 of 8 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD- 10691 -P (N.01101) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BOD 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BOD 30 mg/L TSS, 10 mg/L FOG, and 10 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: Mark Uetz 4 Bedroom Mound Page 6 of 8 Page 7 of 8 MGOULDS PUMPS Submersible Effluent Pump EPO4 38 71 EP 5 0 APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower grade turbine oil for tic enclosed design for h eav y du b all bearin Specifically designed for the lubrication and efficient improved performance. construction. following uses: heat transfer. ■ Casing and Base: Rugged • Effluent systems thermoplastic design provides AGENCY LISTING • Homes Available for automatic and • Farms manual operation. Auto- superior strength and corrosion Canadian &andards�aa6on • Heavy duty sump matic models include resistance. • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron (CSA listed model numbers end • Dewatering assembled and preset at the for efficient heat transfer, in "C° or 7".) factory. strength, and durability. SPECIFICATIONS ■ Moto Cover: Thermoplastic Gores Rrnps is ISO soo'l FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. 1 /4" maximum. ■ EPO4 Impeller: Thermoplas- a Power Cable: Severe duty • Capacities: up to 60 GPM. tic Semi -open design with rated oil and water resistant. • Total heads: up to 31 feet. pump out vanes for mechanical • Discharge size: 1' /z" NPT. seal protection. • Mechanical seal: carbon - rotary/ceramic- stationary, BUNA -N elastomers. • Temperature: 104°F (40'C) continuous METERS FEET 140OF (60cC) intermittent. 10 • Fasteners: 300 series stainless steel. 9 30 s G PM • Capable of running dry without damage to a 2 5 rr components. 25 , a n Motor: i • EPO4 Single phase: 0.4 HP, v_ s zo 115 or 230 V, 60 Hz, 1550 1 s RPM, built in overload with o 1 5 automatic reset. a a • EP05 Single phase: 0.5 HP, o EPOS 115 V or 230V, 60 Hz, 1550 3 10 RPM, built in overload with oa automatic reset. z • Power cord: 10 foot 5 standard length, 16/3 1 SJTOW with three prong grounding plug. Optional 20 ° 00 10 20 30 ao so GPM foot length, 16/3 SJTW with three prong grounding plug (standard on EP05). o z a e a 10 12 m3ih CAPACITY G Pumps ® 2001 Goulds Pumps ITT Industries Effective May, 2001 83871 r 0 ► ►� Q u S �ta b n o z 8 b / II / O t I r. p � b ti A b All / H w eo o / `� ►r. b goo p � A e q , 00 m ti Wisconsin Department of Commerce SOIL EVALUATION REPORT Page /_of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2x 11 inches in size: Plan most 57, CARE& include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 2 — p 1 — J " o de Please print all information. R by Date Personal iMornatim you parvide roar Law. s. ,�o 11 L Property Owner S P lion } Tz Govt. Lot a w 114 114 'S �- T N R E (orb Property Owner's Mailing Address M. U f Lot # Block # Subd. Name or CSMS dwZ4, G City State Zip yv , ❑City ❑ Village 21own Nearest Road y Iv� c� 0 6 d s6 Ss - (New Construction Use: [Residential/ Number of bedrooms Code derived design flow rate GPI ❑ Replacement ❑ Public or commercial - Describe: Parent material S.Q;Vzwcd 7S Flood Plain elevation if applicable iP ft General c onwrnernts and rec ninendations: IMAW'D y � �C�t-N ncLE �S 7 3L" d�Locv �G�,[�rst•J�✓ su�cFi�c,E, 4E� .zr SIYmliGO <o� it'�D 4 WP Fisc ry /Z . F / I �g # ❑ Boring Q Pit Ground surface elev. /0/..< ft. Depth to Rmiting factor in. Sail Application Ra Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsefl Ou. Sz. Cont. Color Gr. Sz. Sh. - Eff #1 'EH#2 l 6 Alf p' '4 L L 3 — S— G ac — — Ae b B Boring E LLJ Q p Ground surface elev. ,o% !- ft Depth to ru n9 factor in. Sod Apaggtion Rat Ha daw _OVth Dominant Color Redox Description Texdae Struch a Consistence Boundary Roots GPDJW in. Murnsefl Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 �— z L 9 y uJ Z 3 .s — 4AF L le J& c 5 Effluent #1 = BOD, > 30 < 220 mgfL and TSS >30 < 150 mgfL t #2 = BOD < 30 mgfL and TSS < 30 mg&- - PST (Please Print) - CST Number .22 Fogerty Plumbing & Perk T sting Dace Evaluation Conducted Telephone Number / ®3 ��s- Las -919, Property Owner(_ ii6rz- Parcel ID # Page — ;I of _ a� Borin # [� Pit Ground surface elev. _ "4 ft. Depth to tirrrtrrrg #actor in. Sol Horizon Depth Dominant Color Redox Description Texture Structue Consistence Boundary Roots GPDIfF in. Munseg Qu. Sz. Cont. Color Gr. Sz. Sh. *M1 'Eff#2 _ zAp st S&I ads 1 F] am " # �9 Pit Ground surface elev. ft. Depth m- Soi Appilbadon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Ef#1 'Ef#2 i � # a Swing Pit Grou surface elev. ft. b9 factor r-Efff!W1 tion Rate Horizon Depth Dominant Cobr Redox Description Texture Strucltre Consistence Boundary Roots PD/W in. Munsell flu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#2 I Effluent #1 = BOD, > 30 220 mg/L and TSS >30 150 mglL ' Effluent #2 =• BOD 5 30 mglL 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 608jX6*1.f1 or 1- TY 608 -264 -8777. - SOD -8330 (R.6=) S — � • .c \ fib' � 0 � o w \ / fn a p •71 V O p _ OD v � N SAN O� A N x v T ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Bityer Aw "tk 6'W7 .Mailing Address AV .el4el, Property Address 15' 3 c I ZZ (Verification required 60M Planning Department for new construction) City/State Parcel Identification Number (ate- /r/.a- ye Avift 1,4A LEGAL DESCRIPTION Property Location �g, ,) %,, I t/W 1 /., Sec. . T 2P N -R yJ' W, Town of 4w,,� Subdivision — 'A"Xz/o/L ,t - _ ,Lot # Certified Survey Map # 71 A-/ rl i Volume / 7 . Page # yyJU - Warranty Deed # Volume 2 97 er . Page # sus -3 Spec house O yes EYno Lot lines identifiable lil yes 0 no SYSTEM MAINTENANCE Improper use and maintt namxof y septic system could iesult m its premature fadwe to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pndiper. What you put into the system can affect the function of the septa tank as a hteatmant stage in the waste disposal system. The property owner agrees to submit to St. Crone Zoning Department a certification form, signed by the owner and by a masterplumber, jouaneymanpinmba, restricted phw* er or a licensedpumpar verifying that (1) the on -site wastewater ftosal system U 111 proper operating condition and/or (2) after hispection and pig (if may ), 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 Delmrtmew of Commerce and the Depot rent of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and retuned to the SL Croix County Zoning Office within 30 da A AP=' DATE OWNER CERTIFICATION &GNAT rtify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of n abo y virtue of a warranty deed recorded in Register of Deeds Office. - AP DATE - * * * *** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning DeparfimenL "` * * * *• ** Include with this application:_ a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed m p 1 / f U 2470P 553 746614 STATE BAR OF WISCONSIN FORM 1 -1998 KATHLEEN N. REGISTER OF DEEDS DEEDS WARRANTY DEED ST. CROIX Co., MI ` RECEIVED FOR RECORD Document Number 12/09/2003 08:45AM This Deed, made between Frederick G Len ertz as a single Derson WARRANTY DEED Granjtgr, EXEMPT � an 1 hunv-,nnyl (11M 1 G rantee. REC FEE: 13.00 Grantor, for a valuable con1illideration conveys to Grantee the following TRANS FEE: 401.10 described real estate in St. Croix County State of COPY FEE: CC FEE: Wisconsin (the "Property "): PAGES: 2 Recording Are Name and Re turn Address Lnrda-rtl.tE &or + Rwvr� z h 601 W- V" - bmyv 'rod+ M1V 022 1012 80 000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) 022-- 101 I - TO - 02-- 4l�) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except �� Dated this day f aab3 —• (SEAL) (SEAL) e k ZGL,*1r1j (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) w€binY swAT State of Wisconsin, ) 55. -{ p�t PL}gL►�� St. Croix County authenticated this N eat dr ' STATE OF me a me this day of the above named Frederick G. Lenertz. as a single person to me known to be the person who executed the TITLE: MEMBER STATE BAR OF WISCONSIN for in inst rent and acknowl ge the same. (If not, authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Notary Public, Statd of Wisconsin Coldwell Banker Burnet 1301 Coulee Road My commission is nent. (if not, state expiration date: Hudson, WI 54016 3 -61546 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing in any capacity must be typed or printed below their sicinature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. WARRANTY DEED FORM No. 1 -1998 Milwaukee, Wis. U 2470P 554 Parcel One: Lot 4, Certified Survey Map in Vol. 17, page 4616 as Document No. 740870, located in part of the NE % of the SE % of Section 5, Twn 28 N, R 18 W, Town of Kinnickinnic, St. Croix County, Wisconsin. Parcel Two: Lot 4, Certified Survey Map filed in Volume 17, Page 4617 as Document No. 740871, located in part of the NW % of the SE % of Section 5, T 28 N, R 18 W, Town of Kinnickinnic, St. Croix County, Wisconsin. Parcel Three: Lot 1, Certified Survey Map filed in Volume 17, Page 4482 as Document No. 714312 located in part of the NW % of the NW % and part of the SW % of the NW % of Section 5, T 28 N, R 18 W, Town of Kinnickinnic, St. Croix County, WI. CPa_ 96-Db6 D 1d -0(° 000 lbI1 .- Wisconsin Department of Commerce SOIL EVALUATION REPORT �� Page tof� Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County � Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must cow, include, but not limited to: vertical and horizontal reference point .. 'on and Parcel I.D. percent slope, scale or dimensions, north a ant�a'tance nearest road. Z 2 / 7� ' OZ Please print on. �' Re ' wed by Date Pe rsonal information you provide may be used taw. 15.04 (1) (m)). 3 Property Owner P operty Location F /tGQ o,- L—en COUN (v +t. Lot 1/4 WA,64 S T L fr N R f (or)l, Property Owner's Mailing Address ZONIN t # Block # Subd. N me or CSM# ( ` O r /t r� r' / �- ( It�Z �/7 c ity - State Zip Code Phone lqumbcTr ❑ City ❑ Vllage ® Town Nearest Road M 1 SSO? (rosy) y - I 'A -X C ® New Construction Use-Q Residential / Number of bedrooms 3 _ y Code derived design flow rate Y O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material r Flood Plain elevation if applicable General comments S yS f p e -e ✓ . and recommendations: �On e je V . 7 p f" Boring # ❑ Boring [� pi{ Ground surface elev. fq• gd ft. Depth to limiting factor Z O in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1ft in. Munsell Qu. Sz. Q� -Rh 'Eff#1 •Eff#2 3/ z Boring # ❑ Boring Pit Ground surface e.- --_ in. Soil Application Rate Horizon Depth Dominant Color Redo: Boundary Roots GPD/ft in. Munsell Qu. S. _.___ _ _ _ _ _....Y_�_w __ n. _..._ _ •Eff#1 •Eff#2 ra -I Z Iz -Z/ a / - S,•c/ rnSb � C 5 - • G I- y/ . s YZ4 Sr- L en sb i: Effluent #1 = BOD > 30 c 220 mg/L and TSS >30 _< 150 mg /L ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L CST Name (Please Print) Signature CST Number S3 0 Address Date Evaluation Conducted Telephone Number l -VI Z s - zo _ o Z 7/5 - y 7 -,el,*? 1 Property Owner _ L erll e#-4z Parcel ID . # Page of Boring # ❑ Boring Pit Ground surface.elev. , Y4 R Depth to limiting factor I in. Soif Application Rat Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz In. Munsell Ou. Sz. Cont. Color Ge. Sz Sh. `Eff#1 ... •Eff#2 /o `/r / S' � zm sb rn 4 r- f -Z 7S r F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application RatE Horizon Depth . Dominant Color Redox Description._.... _Texture _Structure Consistence Boundary Roots GPD /ftz In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff #1 'Eff #2 ❑ Boring # ❑ Boring Ground surface elev, ❑ Pit- ft Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD /ftt in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff #2 - ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/l. and TSS < 30 mg /L The Department of Commerce is an ecpral 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 1330 (R07100) • PAGE 3 OF NAME L n r z LOT# / ' LEGAL DESCRIPTIONSw %vW 1 4 ,S S T Z g' ,N,R, J $� Elor� SCALE: I"= BM I ELEVATION IV Q. O BM I DESCRIPTION �nD �� /�U .�4•_p 2 �-- —' BM 2 ELEVATION BM 2 DESCRIPTION SYSTEM ELEVATION O SYSTEM TYPE fAatie, el CONTOUR ELEVATION fir. 9 - 0 El b• Z A y� �o z re SIGNATURE DATE PAGE 3 OF NAM E LOT# L LEGA DESCRIPTIONSPY X -JAU Y ,S S T L f N.R. , I glf btM SCALE: I"= !�/D BM I ELEVATION �o c> • O BM 1 DESCRIPTION D Q-F • �Uc _ �� &7- —' BM 2 ELEVATION !F iT , /D BM 2 DESCRIPTION c . • - - - - -! -- S ee-. '� - -- SYSTEM ELEVATION d IQ2 . O SYSTEM TYPE rAou el CONTOUR ELEVATION tg': T N C , Q�oo D. I 60 SIGNATURE E__ DATE t '" 431C VOL 17 PAGE 4482 KAT91=9 M. V7CL5R -- REGISTER OF DEEDS NW coR. -� _ -- - . —._ -- _ - -_ -- ST. CROIX CO. MI SEC. CERTIFIED SURVEY MAP 03/24/2093 91 96pH LOCATED IN PART OF THE NW1 /4 OF THE NW1 /4 AND PART OF THE SW1 /4 OF THE NW1 /4 OF SECTION 5, T28N, R18W, CERTIFIED SURVEY MAP `.4 3.35, TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN. REC FEES 13.00 COPY F PAGES: 2 " I NOTE: DRAINAGE EASEMENT SHOWN HEREON IS CREATED TO MAINTAIN EXISTING SURFACE DRAINAGE. IT IS THE RESPONSIBILITY OF LOT OWNER TO STABILIZE AND MAINTAIN APPROPRIATE VEGETATION ON SAID EASEMENT. CFNr PREPARED FOR: FREDERICK LENERTZ 220 LIVESTOCK \ N I `N >r0\ of EXCHANGE BUILDING \ r) r _pppSNA E 34\+ 55075 I Vv ° N I EASEME , . • + /� SURVEYOR: 'b4'E THOMAS M. HEALY S & N LAND SURVEYING, INC. In 2920 ENLOE STREET Z .y— LOT i 9CK( /N HUDSON, WI 54016 I Om 3.00ACR F I GON I 0 I I T / .) INC. RAN r 1 _ 2.43 ACRES N i MJ m y (105,745 SO. FT.) EXC. RAN P ,op I s> 463 Y N I E 5p ? r3 UOSON, ice° _ w 100' - NW 1 /4 OF T HENWI /4 .9� WI J ��O Iro4 1 m ; SW1 /40FTHENW1i4 e SUR z C LOT 2 jcry 0 Z: 2.50 ACRES No cn: (113,044 SQ. FT.) INC. RAN = i 111 l o— ?] 2.33 ACRES w O i u rn m (101,494 SO. FT.) EXC. R/W w j i N C > x; SCALE IN FEET 1" = 100' ` V i in m z I VII N M. 1 0 8.50' 0 100 ao v i m o o > I� 6.7' ? �!` IO° ��m N89 °35'25 "E 475.26 a i I 0 1 APPROVED CD Z m U ST. CROIX COUNTY ' i z' m ' LOT 3 Pfannlnn 7n "Im and Parks COMM .� i o A z l� z o 2.17 ACRES MAR 2 4 2003 w ; S o ° ' (94,312 SO. FT.) INC. RNV N m 'a rn 2.02 ACRES 0 I C� ) EXC FT 874 SQ (87,. .. A V i 0 I I M faWltlad WMIn 30 days of, z m o approval loss apMvM shall be _ null void and � uo j 3 37. m I c m 444.03' I S84 °78'12•E 481.41' 33' 133, 6 6 , FOUND ALUMINUM Grd ST. CROIX COUNTY m LOT 4 SECTION CORNER N Z Im 2.23 ACRES MONUMENT D tD (97,038 SO. FT.) INC. R/W w SET 1" OUTSIDE 2.04 ACRES DIAMETER BY 18" I I m � (88,832 SO. FT.) EXC. R/W Q O LONG IRON PIPE, I WEIGHING 1.13 LBS, PER LINEAR FOOT 37 7 i DIRECTION OF 444.27' / DRAINAGE A cz S88 ° 42'12•E 4$1x99' _ 66' WIDE JOINT Mfrvl(�(1 ��!'G[�� I r �p) D G Lr;L7Wi DRIVEWAY EASEMEN - - -- - --- - ---- - --- - -- - (n W1/4 COR. THIS INSTRUMENT DRAFTED BY: WILLIAM KANE SEC. 5 I JOB NO. 6000 -17 DATE: 09/19/2002 REVISED: 12/12/2002 SHEET 1 OF 2 SHEETS Vol. 17 Page 4482 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER -- - r 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 • Fax (715) 386 -4686 s EROSION & SEDIMENT CONTROL, PLAN Parcel #05.28.18. end For Lot 4E, 1093 Cty. Rd. N. (Kinnickinnic ) — owner(s) Tom Uetz Under St. Croix County Zoning Code 17.70(3)(b)5: "The (Zoning) Administrator may attach reasonable erosion prevention conditions to a permit approved for issuance." Comm. 21.125 also requires the building permit applicant and /or landowner to follow erosion control procedures and maintain them until the site has been stabilized. The owner is responsible for notifying all contractors performing construction on this site that an Erosion Control Plan is in effect and the following activities will be required in order to maintain compliance with the plan: 1. The primary source for construction site runoff will be the house foundation excavation, driveway, and any soil stockpiled until final grading and stabilization is complete. Septic system excavation/installation adds to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Plan to apply seed and mulch as recommended in #5. Maintain existing vegetation wherever possible to minimize sediment movement off site. Surface drainage is to the north, with >175 ft. to a road ditch on County Rd. N. 2. Create temporary diversions graded ALONG CONTOUR between excavation areas and any potential receiving waters (this includes road ditches) by routing contaminated runoff into vegetated buffer areas on owner's property. Do not allow diverted runoff to be directed onto neighboring properties. (Refer to specification sheet for Temporary Diversions provided by Zoning Dept.) 3. If builder /excavator grades the site to create temporary diversions (see #2) to contain sediment and leaves adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt fence or other approved sediment control products will be required if sediment cannot be contained on owner's property with diversions and vegetative buffers. The POWTS inspector and/or building inspector will evaluate ESC plan effectiveness and make recommendations to owner for any action required to comply with applicable regulations. 4. Construction equipment and vehicles must utilize a stabilized driveway access off public road for heavy equipment; this includes cement trucks, well drillers, and other contractor's vehicles that access the property during construction. This helps avoid muddy, rutted conditions that may allow contaminated runoff to reach waterways and/or drainage ditches. Property owner must repair damage to ditches resulting from multiple access points and sediment tracked on public roadways must be removed at the end of each workday. 5. Stabilize new topsoil cover over septic system with seed and mulch immediately after installation — do not wait for final stabilization and/or landscaping of entire site to cover exposed soils on the system. If weather will not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can get established. Erosion control matting can be applied any time of year and if installed properly, will provide protection even if seed germination is delayed. The owner of record during site construction will be responsible for compliance with the ESC Plan. Please feel free to contact me with questions regarding erosion &,sodinwnt co of i lation. , Prepared by: Pamela Quinn, Soil Erosion Inspector #665054 A Owner acknowledgement of ESC Plan requireme 1/ 2003 C) ('s C-Q-� Q C c1Q FOGERTY PLUMBING & P ERK TESTI 28288 McKenzie Rd. Spooner, WI 54801 �. (715) 15) 63 63 5 Fax (7 -5286 15) 63-5286 / 1 j'09Gr�V -w br Mr 6V ce,Ik Ty /iltT (� /` 3107 3 .. �� p i s gr�sSf�e�rE : Lft�Ea -�l .� - D �'" riYs sma'L 'ff'y* eAOv MM/ TUTU " rc�w7Dv�c r E'rr�BL,rs"d 8, �Xd�n- urll �YOr sumtk D�r/E�/ r�f6 6e�tiv� F�clJj¢y- -2w,V5 �l a w.f i CEAeIC5 �.s: i �3��iG n Tw .� -x�+2T 5EC AA f1W ��u as ;e ov.�rs 9- N� . _ '� ��✓ ��r E� w,rr�n fZES�ON�� Ta A4,o=7g4f rte• h14497 .f sivlrir-LG .#r A. /3 sa�• I z- d ow I awnid x IN3903 dz O :60 60 21 nO W W:;consinOeparlmentofcommerce SOIL EVALUATION REPORT Page of f]ivision of Safety and Buildings in accordance with Comm 55, Wis. Adm. Code Count' �+ /mil Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must C AW( include, but not limited to: vertical and horizontal reference poW ' •on and Parcel I.D. percent slope, scale or dimensions, north a pce nearest road. Reviewed, by Date please print ft inr a on. Persorol infomrarion you provide may be used secondary Law. Property Owner Location Y Lot s(/v 1/4 � S T Z. N R J ior)� Property Ownefs Mailing Address ZUNII`l F t # Block # Subd. Name or CSM# r ✓e R r/ r' / 6 ity State Zip Code Phone Numbdr ❑ City ❑ Village ® Town Nearest Road �• Sly v ( - • h'1 mi SS o 7 ( Co5/ ) YA - 26 20 s • •ri hJ L C ® New Construction User Residential / Number of bedrooms __2L— Code derived design Row rate Y O 0 90 GPO Q Replacement ❑ Public or commercial - Describe: Flood Plain elevation if applicable ft- Parent material If General comments S y S f P n1 G { t/ , '&)0.0 and recommendations: e- 1 f V. F T1 Boring # Baring Pit Ground surface elev. ft Depth to limiting factor L � in. Soii Application Rate Horizon Depth Dominant Color Redox Description Texture structure Consistence .Boundary Roots .E GPD/ttzEff#2 in. Munsell au. Sz Cant Color Gr. Sz Sh. 3/L r► �,.� r ' C S 1 . S 7 ' Boring # Boring _ J+ pit Ground surface elev. 99 � d ft. Depth to limiting factor �L in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots -Eff#1 I Eff#2 in. Munsell Qu. Sz Cont. Color I Gr. Sz. Sh. wy l- y� , s 6 S� G I. Sb 6 - - , Effluent #1 = BOD, > 30 < 220 mg1L and TSS >30 c 150 mg/L ' Effluent #2 = BOD 30 mg/L and TSS < 30 m9 - CST Name (Please Print) Signature , CST Number S3 a Address Date Evaluation Conducted Telephone Number �- 7 2 cl 9BZSSE95 t L i JN I HWf11d AIN390A da 0 :60 60 2 1 ^0N Properly Owner L ert Z Parcel ID # Page of _ Boring # ❑ Boring = • Pit Ground surface.clev. 1-7, '/D fL Depth to limiting facto in. Soil Application Rat Horizon Depth Dominant Color Redox Description Texture Struclum Consistence Boundary Roots GPD/t(= In. Munsell Ou. Sz Conl Color Ge. Sz_ Sh. "" •Elf#1 •EIf112 WO s z Sb c - • Y - e .G. r — . 6 a Boring # ❑ Boring ❑ pit Ground surface elev. ft_ Depth to limiting factor in. Sail Application Rai, Horizon Depth Dominant Color Redox DescripUon.._ .. .Texture - Structure Consistence Boundary Roots GPD /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sr Sh. 'EfIN1 'EffN2 F--1 Boring # ❑ Boring - ❑ Pit ' Ground surface elev. ft. Depth to limiting factof In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /f(= in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Etf#1 'EffN2 Effluent #1 = BOD: > 30 < 220 rng/L and TSS >30 < 150 mgA- ` Effluent ff2 = BOD < 30 mg/1 and TSS < 30 mg/L r The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access scrvices or need material in an alternate format, ,please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBDr))O (ROLOO) E - d 9BZSSE9S i G I 9W I awnlcl ,x IM3903 d20:60 60 al AoW • PAGE 3 OF N AME i OT# � � i FGAL DES` TTr i^i: S^f Y4A*J X S S T L C _N_R_ E[oil�l SCALE: I "= �D BM I ELEVATION O V • O BM I DESCRIPTION D Q4 l Ave � e d95 BM 2 ELEVATION q8 /D , BM 2 DESCRIPTIO —�� - - - -- -- - - -- SYSTEM ELEVATION eO • D SYSTEM TYPE /Yl o u n el CONTOUR ELEVATION tf : 9 - q� ° r1 d• Z A VA �o 1*1 D� 3 SIGNATURE DATE Gam' - d 9BZSSE9S I L l 9W I awnid AIN390A Jao = 60 ED al ^ow