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HomeMy WebLinkAbout022-1026-70-100 O K W m d <D •• � b C7 0 w 0 O cn � 1� CO N eC i N < C W 7 I > N N Nr C yl l � • CD M W cc O O a O d N N d cr N m 3 O 0 0 (D (L . A CL c c� O O 3 O rr O 0) < i z con C71 !fir o N N o o N O a N a 3 ty a CD CD ° O O O y �• C p < cn z 0 a D v a o h m ° (D ID ID C3 N N I (D IA N zz� o D D o O c cm y I fD I c 3 N m � N Q z 0 CD cn z -1 c0 W m w CL z a ;o o ^' (n N m z N CD ? O p Q C p N Q G O O �a 0 a O QD *, N CD �� 0 �o (° CD N (O m I OT � Q CD A CD Cn O. i O O () O N O 0 O " i 0 � a O o 3 ? v ti N 6.3 b ' m 0 CD a o O o C C) � �, y Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453316 0 (ATTACH TO PERMIT) GENERAL INFORMATION S State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, 5.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Branum, Wayne Kinnickinnic Township 022 - 1026 -70 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map NO: i00.00 t3 fv� CS` 09.28.18.142A10 TANK INFORMATION ELEVATION DATA c� .i�l � 3. E5 0 it H TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S 3 CG Septic Benchmark 1 -S Dosing Alt. BM Aeration F � Bldg. SewerGc n —V $. Z CI Holding St/Ht Inlet Iq ��� f.�F� 9Z•3 / TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ,IUD '-t j 1 I '5 / _ DtBottom sing Do , / Header /Man. _3 Aeration Dist. Pipe �'.yL Paz . Holding Bot. System 0 Z_ 1 6 7 ovose<y Final Grade PUMP /SIPHON INFORMATION L. /6 7.3 7y Manufacturer De St Cover G PM f y rj( Model Number 30 TDH Lift Friction Loss System Head TDH Ft Z-19 1 2- .5 i . ,� 1 \ - 7 , 1A — 7,9 Z 165. 1 - 7 E4 Forcemain Length� Dia. r I Dist. to Well 1_V7 1 Pry SOIL ABSORPTION SYSTEM BEDITRENCH Width Length / No. Of T� chef PIT DIMENSIONS No. Pits Inside Dia. Liquid Depth DIMENSIONS �111,� SETBACK SYSTEM TO PIL BLDG IWELL LAKE /STREAM LEACHI anufacturer. INFORMATION CHAMB OR Type Of System: / of a T' IT Model Nu APB' DISTRIBUTION SYSTEM o r H.!Ie Header /Manifold tribution Size x Hole Spacing / Ven to Air Intake d, Pip ?(s) 7. Length 3. f]fa [ Length Dia ` Spacing �' 3 1 /(" `d v SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over / Depth Over xx Depth of xx Seeded /S dded xx Mulc ed BedlTrench Center Bed/Trench Edges \ Topsoil ` es n No Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: �t ! 7! / O� Inspection #2: Location: 449 Valley View Rd Unknown (NW 1/4 SE 1/4 9 T28N R1 8W) NA Lot 5 mom, Q(r, 40,J Parcel No: 09.28.18.142A10 1.) Alt BM Description = t� 2.) Bldg sewer length = G - 1—`yc :� t t �d�"' � - amount of cover = Go.tag� 5t" �,` 3.) Contour Plan revision Required? l Yes �,' No Use other side for additional information. - SBD -6710 (R.3/97) Date Insepct s Sig re Cert. No. i _ Safety and Buildings Division County s l - C >O / , X j N VAISconsin 201 W. Washington Ave., P.O. Box 7162 7 Madison WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266-3151, I -.T _ 53311a Sanitary Permit Application State Plan / I..D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide �d D C Q 3, ? may be used for secondary purposes Privacy Law Project Address (if different than mailing address) REGE yyy Il«w ,tee. I. Application Information - Please Print All Information I Q� / Property Owner's Na me JUN I t 2004 Parcel # 6 I YU-10 Lot # c Block # WKY,VE j8A4NUM N i , a zz io2 • 70 • i Property Owner's M ailing Address ZO M N G OFFI Pr�operty Location CIO 4 Y 50 • I K .5-7-- .5-7-- / r M) �'A, 54,Section City, State Zip Code Phone Number 54illwAr&__ AV. S s 09)_ 35I o/ .28 / e (circl H Type of Building (check all that apply) c✓ f T N; R E W Z Ll� 1 or 2 Family Dwelling - Number of B oo rms CSM Number r v��`� Soa /o/ ❑ Public /Commercial - Describ7�Q am = C� . 1 co l El State Owned - Describe Use ❑Cit ❑Village Township o 2S' K /;(IA. .f C /,;94V / G III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. Y- New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. El Permit Renewal El Permit Revision 11 Change of El 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 XMound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Fitter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Fitter ❑ 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(gp dsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation q gLj . y (1.0 y S 6 iioi• z S VI. Tank Info Capacity in Total Number ufactur Prefab Site Steel -Fiber Plastic Gallons Gallons of Units �""""` Concrete Constructed Glass New Existing to � e `& � Tanks Tanks J Septic or Holding Tank w•llT� .) Aerobic Treatment Unit Dosing Chamber C� D VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature P /MPRS Number Business Phone umber R. -i /6)e i eA7_ Its 77a 3 1j Plumber � A ddre Z ss (Stree City, State, Zip n • 76 7 VIII. Count /De artment Use Only /C X �l Approved Q Disapproved Sanitary Permit Fee (i c udes Groundwater Date Issued Issuing gent Signature No Stamps) Surcharge Fee) 350 � — J t5" 2a ❑Owner Given Reason for Denial I :ff IX. Conditions of Approval /Reasons for Disapproval 3 SYSTEM OWNER: S� 1 Septic tank, effluent filter and 1 3 / dispersal cell must all be servioed) maintained � T as per management plan provided by plumber. 2. All setback requirements must be maintained) ,y .Rf-t o r¢iZSctp as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size SBD -6398 (R. 01!03) O vi i -- i R� �' NQ CD go cw r � 4 o - - O ♦ O i ego ♦ �s p-m cs m 0U3 ,♦ s \ O M o 0 - 0 \ G }J m 0 �` ` \ ♦ ♦` N i (V -0 -< o a 0 -o U) y �m-q 1 \mom a ,r i 0 C 0D s w -.n i W m 6� (;o PY - _ a � a i Safety and Buildings PO BOX 7162 ,t commercem.gov MADISON WI 53707 -7162 ic TDD #: (608) 264 -8777 sc o n s i n www.commerce.state.wi.us /sb www.wisconsin.gov epartment of Commerce Jim Doyle, Governor Cory L. Nettles, Secretary June 08, 2004 CUST ID No.226375 ATTN.• POWTS Inspector ROBERT W ULBRICHT ZONING OFFICE ULBRICHT & ASSOCIATES CO ST CROIX COUNTY SPIA 2812 10TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/08/2006 Identification Numbers Transaction ID No. 1006389 SITE: Site ID No. 684680 Wayne Branum — Dwelling & Garage Please refer to both identification numbers, 449 Valley View Rd above, in all correspondence with the agency. Town of Kinnickinnic, 54022 St Croix County NW1 14, SE1 14, S9, T28N, R18W Lot: 5, CSM: V9, P2624 FOR: Description: New Mound System / 450 gpd Object Type: POWTS Component Manual Regulated Object ID No.: 962306 Maintenance required; 450 GPD Flow rate; 21 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /01), Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01 101); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes 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. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: P. 1. This system is to be constructed and located in accordance with the approved plans and with the co component manuals listed above. 2. On page 3, Y = 48 inches. AP DIVlDEP E 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 SEE Goa,,, construction /installation/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. r ROBERT W ULBRICHT Page 2 618/04 The above left addressee shall rovide a co of this letter to the owner and an others who are responsible for the P copy Y installation, operation or maintenance of the POWTS. Sincerel , Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 C el Private Sewage P viewer, Integrated Services WiSMART code: 7633 (608)266 -2889,M- , 0630 - 1500 Hrs pepagel@conunerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 ULBRICHT & ASSOCIATES CO. 2812 10th Ave. • Spring Valley, WI 54767 Reg. Designers of Engineedng systems 715- 772 -3442 Prhete sewage Consultants JUN 0 3 2004 PROJECT INDLiAFE T Y & BLDGS. DIN, Plan I.D. # Date 11h'7 36 �'d Owner w ,4VNE, j ?,QqA�jf M • Phone 051.35 i • o�l Address / 0 7 s 0 • ! s S' 0� Z.. Legal Description 407, J CS�y, (f 0 /, y q • Z &2 4 Y Pw 02 s• /026 • 74 Town of It 1 ',VAJ / ?,k4V V1' Count ep — - ---- -- Y S ST � QO t 1L, C.S.T, d EGG � Zza Zs y Installer - U, PiC14 Q - r - Local Authority/ Supervision ;x Cd.vary �- PROJECT DESGRiPTIQN � E`-P 7 i dt &1a4 siy4%-W 4s 4 3 • Rom c 40 /4, A- D E t`�„ /. OA AO/A) 6� e V ew r/ 4L. /10 VV s y s ->~�.Cf 'Us, A-3 &- L S S Nv rill / . kw V SAX-14sle- is Id Cdv,ve - e - 0 - W t` #_ 6 Y STerm , o :`v�` g Ulbricht & Associates vT' ll, Private Sewage Consultants 0� 2812 10th Ave. q o O Spring Valley, WI 54767 ,�, .S,� tie <oN ���'S # zz��3 W U -7 s oti ��3� -�a�y o z.. Pg.1 PLOT PLAN VIEWS Z Pg.2 SYSTEM CROSS SECTIONS & SYSTEM P A (REVERSE SIDE == ETAILS INSPECTION PIPES & FABRIC /TOP FILL DETAILS) (P&.3 PE LATERAL LAYOUT (REVERSE SIDE SHOWS DETAILS OF LATERAL c� CLEAN OUTS) LU U Pg.4 DOSING CHAMBER CROSS SECTION & SPECS. O ... Pg.5 PUMP PERFORMANCE SPECS (REVERSE SIDE SHOWS PUMP DETAILS) �� v Pg.6.OPERATIPN, MAINTENANCE REQUIREMENTS (REVERSE SIDE SHOWS SITE & SPECIFIC PROJECT DETAILED INFORMATION,UNIQUE TO LOCALE AND GOVERNMENTAL UNIT AREA) The attached plans and specifications are based on the following approved manuals: "Mound Component Manual For Private Onsite Wastewater Treatment Systems " (Version 2.0 SBD- 10691- P(N.01 /01) and "Pressure Distribution Component Manual For Private Onsite Wastewater Treatment Systems" (version2.0) SBD- 10706- P(NO1 /01). • J F o r kA - C Y � � a � �� � o zq CIO C O ._ ` ._.___,_ _ _____v_ : � , � � ` •A � �, e " \ COO. C3, co c ;, O ♦ _ 4= . co l - 11 ao 9 \ — tn O 33 \ \ X m >m ` N � i \ m 33 m m d E ^ 4 o D O2 r ca > ® W .0 o U P "to s n o o N � Pd. 2 of Lcpc)ss SEc o T' d� F Moues D w i r tt 'f3e0 i3ftn °F % " ro DtST� i{3tiT�a� A35ec5ATE Cs pi Pto�- °F W/ S Y-4 TEN! C�p'S- \ � E'1EV1l1'io V M i Fo g M To 4 0 E RATIO MEL). I SAMI , F'iowEe7 'r 4D ..R- r oR« uu � F °RM 51 aPE UA3 Of MAW 1l 2 5 Fr 15 ESEvArl o,.1 S F, yl` IF r. • IMVF OF z, IAT�RA(S /G 1, F = .g3 FT . , 5 Fr. + T ° F Rock ��.Z • 0 H /� 0 T � T °P °� 1 Z- IATERAIS / D�. ?Q F PLA M VIE OF Mou -- wi r vi 13 E r _ FpRcE MA;� G F L -_.__ __-___ D 7,5' Fr IT K `z- Fr Q ---- - -�_ -•-_ c i ! t� Fr `1� Utz Fr [3Ei7 OF PVC- cAPQED T° ! i" Al 4 � dC3SE+�vhrio,v -�1; Pip E 5 P EA MApiE,aT MAQ KERS (P)OS d Glgrg v owl swtc - isP; RvQufRED BASAL AReN v a���y �/lsrE'�to y✓ Q ll �-- i' So � hC iTy1RhT}�E s p `7 a. Fr PR-oposeD BASM ARL-4 (A t - 75� A 6r r Observation pipe -� r— Distribution cell Fill material ICI$ Coiner material (ASTM C33, fine `` Via • aggregate) , Tilled area E•�Slope / %0 Force main Figure 6. Cross- section of a Mound System Water tight cap Top of 4" min. dia. leaching Repair cauptings chambe � Siot 6" min. min. d in.. Inflltrativre surface Water Closet Co liar tisr(3B" 7'la-) Figure 8 — Observation Pipes COA'A4. A ro p 000 . 1 1 � ' ,, /f7- �isTF' P ips - I-Ayou P ono M A 0 -� P 72 Fr R • 5 F Fo Rce M A xi FF f , 4ro" 20 Fr. o f P c � ru cN f %; VRRi'4 TO TAL. V(gtD UbIL)A �� • � G A� 5 • Pf ST ^a i H R roc p �5 p8t_ �� r �,.� i IN t}ES M rNCt�� FopcE- MAIxi ru�Nt;s .�. °F NUIES / pi PE 'LOOP -RT E LEV AT#oK or LATEIN S SEE ��UE�SE - 51DE F OP , /O Tl-' P -t i ",kL clo b 6 T_4( L foR DF _F _ • d PrTE p Pi pa PER FaR . • R� MovEE X41{ �Ril � l BU RR5 y Noi�S IC)CATEO o,j BoTroM ECi2v�tlty 5 ACED , r�N • p T)( S TRi (3t rro" DISChAR b•E RATE Fo I c 1 - R A h LA t_ �-� & 14L�Mi�.1. T c)rAL 17 +STRiBOTro o D ^ R GE R ATE PoR NETWORK 2 7 � G� a •� f M I'M I' M0 AA OF L 4T iii L 9��4pE \� i Vf /Aw SIX1,vi z " m/at '' 130 Gv � �i ff' �C�"S s .. �•. _ r� ��� /�� I�Q ° S LUE o 4 2 c/D Clf1a w , 1� 14 104'x`- "f2 PE 4 7''�p BUG 131111 vA /PAE- f; Z-) PA NO f 545pic % .5*AAI/ 144x, 2 y' 1 wA A 0u �--- co 1Ae'L. ov ��2 i�� •4t_s SEP TIC TK r; PUMP CHAMBER- CR SECT ION A SPECIFICATIONS 116W A) h 4" CI VENT PIPE 12" MIN. ABOVE GRADE Z ; !WEATHER PROOF 2 "t ?" LD' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR jTAKE WITH CONDUIT MANHOLE S D W1 PAD LO 6 "E ' A; _ � WARNING E' Tiov 4 MI - 40L INLET I `+ GAS- TIGHT \ 1 C� A SEAL SGA. V i tTm �_ , APPROVED PVG PiP B ' ALM JOINTS W, M019 L A "/(1Z7 I DN PIPE 3' t 3 " 16 SOLID - f- 3.3 � SOLID S0 SOIL PUMP OFF ELEV p . + -- t— i I OFF RISER 3n�Qt" )" D PERMITTET IF TANK � � ip .O MANU FAC TL 3" APPROVED BEDDING UNDER TANK HAS APPRC CONCRETE PAD SPECIFICATION SEPTIC / DOSE Gt9�ESe-/2 TANK MANUFACTURER: C*,0�CUf� NUMBER DOSES PER DAY: TANK SIZES SEPTIC /0 90 - -- GAL. DOSE VOLUME INCLUDING G /� DOSE ( D GAL. 1q FLOWBACK: ! -/ GAL. ALARM MANUFACTURER: /t 11, d A/ CAPACITIES: A = INCHES= 3 6 MODEL NUMBER: V; 3WITCIi TYPE: B = 2 INCHES = PUMP 'MANUFACTURER: ZDZ145A C = 7 8 INCHES = t MODEL NUMBER: 7 y IT • SWITCH TYPE: D = 1 3,7 INCHES= t REQUIRED DISCHARGE RATE 30 GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 7 5 + MINIMUM NETWORK SUPPLY PRESSURE . FEET + � FEET FORCEMAIN X 1 ,9q FT/ 100 �FT. • FRICTION FACTOR • , FEET -i— f; � FEET TOTAL DYNAMIC HEAD = p (� EET INTERNAL DIMENSIONS OF PUMP `TANK: LENGTH % 'J U WIDTH - _ ; DIAMETER LIQUID DEPTH SIGNED: LICENSE NUMBER: DATE: Plc SPECS 4 THIS P WT O SYSTEM- SHALL �'1�Cf,�, � ©� INCORPORATE PER COMM. _ 83.44(2)c A PROPER ZABEL '^ /6, 2- -5 FILTER MODEL # A X 20 " SEPTIC TANK, per Comm-83.44 (2) (c) shall be eq uipped outlet attached a 9 PPed with an � (liter). Tank shall an a ppr o ved device {Zabel ground locking manhole cover for o regular v (ever y 12 months or less) inspection & servicing by a 1 7 r.Pricdd cnr :ri -- ..,.....,,.� P�. 1 HEAD / I4�•1 115 34 „g CA PACITY 32 105 30 100 CURVE g5 EFFLUENT 24 so MODEL — and 75 MODEL 188 DEWATER/NG x 70 155 � g5" Z 18 60 p 55 O 18 MODEL MODEL H 14 7 12 �4O 35 10 DEL � =MODEL 137, 39 188 SEWAGE and e DEWATER/NG 6 MODEL 15 OO 181 4 10 sp MODEL 2 5 53, 55, AL 57.59 0 GALLONS 10 1 0 40 SO iz 0 9 0 100 110 24 g0 LITERS 0 8o 160 240 320 400 75 22 FLOW PER MINUTE 70 20 � p 18 80_ -MODEL V 50 14 MODEL Z 2� >• p . 12 40- MODEL F 10 293 MODEL F 30 2a4 - i g 2S MODEL 8 20. 262 i 4 1s 10 MODEL OELLE/P O. 2 5 267,260 g I 3M Old Mi1iN w Lane GALLONS 10 20 30 40 50 e0 70 80 90 100 110 120 130 140 i50 180 170 180 190 P.O. Box 1047 LoulhvAk, Kentuoky 40216 LITERS 0 so 180 240 320 400 490 560 840 720 (502) 778 -2731 FLOW PER MINUTE 1s1 - t i ron n series "13 " Bro Vedes HEAD CAPACITY UNITS /MIN Feet Meters Gal. Ltrs. •Automatic or Non - Automatic. 5 1.52 1oa 3sa • 'h H.P., 1 Ph., 115V, 200 -208V or 230V. 10 3.oa �s 300 • 1 h H.P., 3 Ph., 200 -208V or 230V. ..z20 6.10 36 136 _ • Non - clogging vortex impeller design. 25 7.62 - 30 • Passes % inch solids (sphere). Lock Valve: 26• • 1'h" NPT discharge. • Float op erated, U Canadian Standards p submersible list e NEMA listed ( 6) 2 pole © mechanical switch. Assoc. Approvel available • Automatic reset thermal overload protection. • Stainless steel screws, bolts, guard, handle and i3e s.iss se -l arm and seal assembly. 'Bronze motor and pump housing, switch NOTE: N case, base and impeller. o UL listing for 200- 208V/1 Ph. pumps. Mercury float switches are available for non - automatic models. EMS . Yg. b Of b Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shalt 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 fitter shalt 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 wilh 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, Safety and Buildings Division. 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 penetrption. Cold weather Installations (October - February) dictate that the mound be heavily mulched for frost protection. ' Influent quality into the mound system may not exceed 220 mg /L BOD5, 150 mg/L TSS, and 30 mg /L FOG. 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 feast 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 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its component manual [SBD-10572-P (R. 6/99)j 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. Oontingencv 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 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 bioiogicaily clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions on the operation or maintenance of this system should be directed to your county zoning or health inspector. i SEE. REVERSE SIDE Pg.6 FOR MAINTENANCE REQUIREMENTS SPECIFIC TO 'I'llIS SITE, DESIGN, AND COMPONENTS MAINTAINCE OF."SEPTIC SYSTErr , , POWTS (landowner) is reponsible for maintenance of_this system. Regular proper operation -and servicing is necessary for the safe health ic inspections and SYstel. The owner is required b Y operation of. this maintenance /inspection re orts.tocode to submit all necessary p the controlling ,authorities. SPECIFIC CONTACT AGENTS * Governmental authority/ inspectors: S C ?61 'X "I . 3 y ,96 g4go � N w � * Licensed installer maintenance • responsible for providin Users manual: g an operation/ * Licensed serv&ce / inspect.ion agent other than " G 7" f • ,,S f ' T-- installer *.. Electrician, for pump, electric controls, wiring units: IMPORTANT OWNTER MAINTENANCE RE UIREMENTS 1. Winter area shall not (sledding, shovelrin be permitted, or o e across the frost can /will the cell, freezin g up the ro penetrate into winter . e system. Discontinuos use (a vacaction trip, resulting in the lead to €reeze ups. - in no water use can - 'also 2 - Water _ conservation needs tb be exercised! hydrolically overloaded and destroyed. Or s ©r system can be designed for a maximum wastewater flow ofvs d iem was ysd gals. daily. 3. POWTS are not designed to accomodate wastes or an es from disposal unit, Any introduction of Y other unnatural sources of waste ge. destroy this Such waste materials will overload.and system. 4- If a power ol.atage occurs in a temporar , or a pump fails, it ma y overload of effluent ben- Y result veil, which may adversel g pumped into the recommended that a licensedmputhmctll {leakage), It is allowing the Pump to return to peer e p Y the dosing tank, a Your installer immediately do sing the correct amounts. Consult Y for advice. 5. Neglect of the ve erosi getative cover (the cells insulation & P can lead to traffic also can destro failure. Compaction or h eavy REGULARLY WATER THE V EGETATION S OVER m_ It I S NECESSARY the system beneath IS A SYSTEM!! t To i ` cover. NOT sufficient alone Effluent in to maintain a b. Periodic inspections by the owner necessary. Inspection gents, i into the system: on the mou . or his a and ports have been incorporated inspection p ), cthe moundebairatl area laterals Pipe {effluent level at each tip - far flushin the pressurized out. The filter system in the tanks and cleaning ground cover the laterals /manhole). Only via a locked above Person should be Performing a licensed properly qualiOied Y risks. Eviden & severe safet d this work which system's ce o g in f effluent involves health tre?tme re nt cell shall also be regularly the g ulal Y i n spected. I,I Wisconsi.; Department of Commerce SOIL EVALUATION REPORT 3 Division of Safety and Buildings Page 1 of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size Plan must P T include, but not limited to: vertical and horizontal refer ence point (BPA), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Personal information you provide may be used for seconds ( Date ry purposes Privacy Law, s. 15.04 (1) (m)). Property Owner �p _ Property Location � t:tt PV 1id S� 1/4 S q Property Owners Malting 1- + T Z N R ) E io �j p10 ( r S j � Lq �� Sr Lots Block # I Su same or CSM# C 'ty `t State Zip Code Phone Number v OV- � P� ' ❑City ❑Village ®Town Nearest Road 1 N sso9,Z (ts )3S1 -0961 �l rvrvtiC 1 IVI��1 VI 2 FGeneral uction Use: (� Residential / Number of be drooms _ Code derived design flow rate !,I �7 GPD t ❑ Public or commercial - Describe: cable app Flood Plain elevation if li nts ft and recommendations: LV b �1 ST�L�`tZU�,� �L `S" 01 =-. FILL, yea Boring # ❑ Boring r [2 Pit Ground surface elev. C) 6 . 3 ft. Depth to limiting factor �_ in. a Ylp Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounder Reots Soil AFGticatien Rare in, Munsell Qu. Sz. Cont. Color c . c y GP Dlft° `g Gr. „h. ----- S v u` R 3t6 S1L1 Z�Sr`z ) 3 S 1 ©-1 tz 6 12 ro+ N a Boring # ❑ Boring n. ® pit Ground surface elev. _t a ft_ Depth to limiting factor Z Z n. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bounds Roots Soil Application Rafe i in. Munsell Qu. Sz. Conolor �' GPD /fF . Sh. 'Eff #1 t C tic Sz 'Eff#2 S11 Z g_zZ �o�R 3�6 1 CA !Q- Z�Sbk �, , e IV-1 R G L3 - - ,p .D Effluent #1 = BOD > 30 CST Name (Please Print) < 220 mg/L and TSS >30 < 150 'Effluent #2 = BOD s < 30 - _ Mg/l. and TSS 00 mg/l. ; ... Arthur L :. We g e r e r'gnature CS ,Number Address Wegerer Soil Testing & Design Service 220254 Date Evaluation Conducted Telephone Number 421 N. Main St- River calls, HI 54022 i_.l_S_pl, 715 -425 -0165 Property Owner �--1� NU VA Parcel ID # O Z Z - Z - - 7 b . )b lj Page Z of Boring # f❑Ct Boring r1J Q U z Pit Ground surface elev. �_ ft. Depth to limiting factor `4--� in. Soil Application Rate IWizon Depth Dominant Color Redox Description Texture — structure — Consistence Boundary Roots GPD/ft .� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 7- 317- s? 1 z`f�S blz W) Cl,, z-- ` , S . Z 2) R 316 a Boring, f❑ Boring , � AAIS ® Pit Ground surface elev. �l - ft. Depth to limiting factor —� - on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil ApplicaGPD /titi In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 I 0-8 10 -1 2 31 Z _ s; S Z b 1z wf c-w - Z"p • S •8 Z - �i 10`1 R 31 S 1,C) Z S 12 }>' " C LLJ �'� • 4( • (, 3 23- AY1V Ga - � �� _ _ _ • U • d. i Boring # ❑ Boring Ground surface elev. ft pit G Depth to limiting factor P g c or in. Soil Application Rate Horizon Depth Dominant Color 1 Redox Description Texture Structure Consistence Boundary F Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 I r i I i • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L ' Effluent #2 = 130D < 30 mg/L and TSS < 30 mg/L 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 (R.6/00) ' PLOT PLAN Page of Scale 1'= SO' L-oT L) y,-c— ! p T rn1�FsC C 1, ` a n �- I C01J ��ti 2 - �Z�1 loo o ' 2 v of L� N1C�J 1 p1.2S' �Ib 4 5i it &q �3 1\ Ro p e►� +� L� r , o ' &, , 7:, 3 `m�c F �I ';r- L4 (4 v X i )! s "Ir � J v�u��j o PC'ty Q �I 0 I =3UO+ . 715 - 425 -016 y 5 '220254 Qq _3 3 CST Signature Date Telephone ' p LJo . CST No. Job NO. 06/11/2004 09:20 6513517327 SALA ARCHITECTS STIL PAGE 02 06/11/2004 08:05 17157723442 RpBERTULBRICHT PAGE 02 F 715.39 ST CRO mi ;. Gasawr AM T f 'fj Sgp'T1C "SANK OWNIMSM w m FORM M �,51- 3 51 ' OW so�z Oaacx/Buy� j�t/Ay .! whT /�'/�- S y 7 11A PMPCM Addceas (verifwadon leqWxed *wn Planmaft D 'r°m°°t far D Z L /OLCp • 70 • !d pawl Ident&0100 a Number G�tY/State - * sr� •t DFSf"RIP'�.'IQI� � y► �B /� W, Tom SubdivitdOn ,� loge # Z Cyr e5m 50V1,91 Ccttifled survey MP # J700 Volaane _�� Runty Deed # Spec house O yes PCnv Lot lines idendfksblz )kycqs n no of ov�d xes+dt � its piematl� ,: to ha van - 7 t o the Sydow �gp�Cnoe. ndcfYoaraePtiway� ,�Aeededb�►aLceased�st�. Wbat3►aal� 000a� of p sot fire sew tack evmY throe yea= ion Go Waste dis� a]►°°DQ'- oc� Md a. of the � Unk as a Stage IL ��i�oatidlr tomr, si� by *0 °� and by 4 The PUMaw pevpaty owner agrees t o Su b m it p St Croat that (1) the as -Gite ffi >�R° is +o p�oP� bPe�"°B ynm=pj at p oa sad VgMO 6 ('f am * Elie tank is k" than 1/3 X11 cludSo. to age disposal � � w d° i4adatds t/� the =MkC geed leave rand the 00" � and as" to mam &° State Of Wisaamia. ad forth, Wale, u sat by tbo Department Of Comnaesc* and the flopaAiaeat of Nattrt>~l 1�aioU3aFS, Zoe ofnee within 30 Mists that yea t aeptto syetom has bow mai Mdn d must - e�leod �d tztamed to fhp SR C4ek Coan� days of *8 throe year ww'raticnn daft DATE ffiM A Olr APPLIt�ANT OEM CMTMC I (we) = t7� that all, atatc w== va this f6 mr ate ttua to fire best of my (ca) lcao�t ed8o, I (, no (am) ��s) of $w apeaiy d al eve, by vit[w of a warranty deed =a X*d k Astor of Deods a DATE Sl�'3ltiAT[Emlr OF APPLICANT * r+•.. +w•w•• Amy iatosmation eSiR is spin- capsaaeti►ted may roW ft �' I� t is jmk heft t!et►t"d by rho ZMO D Iodade *111 this appeatlon: a clamped w o aavy deed ftom the 1Registie9 of Deeeis calm a copy of rho asstified RaArey map if Mft is mads is the w ==ty deed, ? URN ST CROIX COUNTY Fi x 715 3 *6 • %6 Q 6, s �• �,�� SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer wAy 13R^A)UM &51 3 5t OW G Mailing Address g� 50 U M, S r • Property Address y� 1114 Pte`. (Verification required from Planning Department for new construction) /� �� //s 61 2, 2- - ioZCv • 70 • City/State K / U Parcel Identification Number W - LEGAL DESCRIPTION ,VU) �`G 9 y� /d 1� /ASV/ G� /N.0 / Property Location i/4, i /4, Sec. . T N -R W, Town of Subdivision 0511 S Da /D� . Lot # s Certified Survey Map# , Volume 9 . Page # W arran ty Z 4Zy Deed # J � o (e 3 S Volume I y , Page # Spec house ❑ yes Kno Lot lines identifiable) yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin, Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. y / / SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** 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 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2 -1YS2 THIS SPACE RESERVED FOR RECORDING DAY A WARRANTY DEED r: C 1STER'S OFFI 506.3x6 , 1QJ7PAGE 54� • jl.� J C � f. Q..� Cio.s tit Reed Aw Raw 14 w+ MA r2et x�. �rsa4 c — SEP 2 9 1993 flr peed! conveys and warrants to RETURN TO the'ollowing described real estate In County. I State of Wisconsin: Tax Parcel No: Loc.� -3 /N Tom, Nw % of rge SE 5 CGr� ifi7� y' i' �✓� jz / 8' w, T o w,v sip, k or k ti A/' r2 YV�1 A4-14P )r,QL� Alp a T�' s. a T A-1 � 40r A y T v t This )1 T - - homestead property. E (is) (is not) ( Exception to Warranties: C D V 7- " 29 th day of (SEAL) • (SEAL) r4 cL tc tz- rn� -, (SEAL) (SEAL) • Mar � �h ari S AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN sE. St♦ Croix County. authenticated this day of tS Personally came before me this 29th day of September ig 9 3 the above named Mark 14, and Ma MA Pharis _ s TITLE: MEMBER STATE BAR OF WISCONSIN 1 �1 (If not, to nown to $e the prrso . I executed the 1: authorized by § 701.1)1, Wig. State.) for THIS INSTRUMENT WAS DRAFTED BY of g instrument ledg me. .! i �� ., • Y J es O'CooreF2 'e r t' 'CL tG. rt4n, S Notary Public ' " County. Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permagaato (11 not, state expiration are not necessary.) date: April - 20, 19 97_. ► -Names of persons s.yn,nq m any capacity should Oe typed of printed wow their vpnalurse. $81 NN 0021 p WARRANTY DEED STATE EAR OF WISCONSIN FIaICO Tax Forms. P.O. Ow 10201L Oren ay. B WI SC107 -0201 "7 Form No .7 — 1962 Cpl FILED 6 JUN 0 19931r 3 JAMES O'CONNELL ca Register of Deeo St. Croix CO-- Wt 500101 C0 CERTIFIED SURVEY MAP t_OCATED IN THE NW 1 /4 OF THE SE 1/4 THE SW I /4 CF THE NE I /4 AND THE SEI /4 OF THE NE 1/4'4 ALL IN SECTION 9, T28N, R18W, TOWNSHIP OF' KINNICKINNIC, ST, CROtXrCO., WI. (BEING LOT I OF THE C17 RT1FIE0 SURVEY MAP VOLUME 7 , PAGE 181 5,00C. NO. 425589 ). 'If ALSO THE NE 1/4 OF THE SE 1/4 OWNEO BY MARK AND MARCIA PHARIS W 1/4 CORNER OF SECTION 9. 1166 COULEE TRAIL q... (2" IRON PIPE FOUND), POSePtS, WI 54023. to N o� s-A - 4 x FENCE a= SET I "*24 PIPE`WEIGJtING 1.13 LB S. PER LINEAR FOOT. ab: I 0 1" IRON PIPE FOUND. LESS THAN 20'Y. UNP l.ATTED L iV D W E f SLOPE. S1 °3a , „ 48 E 28,00' s j t N87 °35,41 "E 599.96` ,I S9°30'l7 "E 754.51' s7! S9' ...... .. 4 'l•� tF NE COR. NW - / ' 120 •/• OR a 1 ( !"`� T LESS THAN 1. 288.62' GREATER ACRES b b !k' 4 GREATER ! 229.638 SO•FT4t� ) 2 SLOPE L APP f •8,20AC.EXC.R.OT l ItN SLOPE 6,226,462SQ.1 ° �^ ry i � M ' r t00`F'+4 OUILDING SE78ACII , 780.90 .� ,i IO f 3>dt.34.' 394. 90 ' t i Ji CO } � �. St3':"30 t7 N 396.00 es °3o f. •� •__-. i� �,iJiiff�! 1 , .M .._... C7" ..: .1. n .,� � t� I 1R1Z't ft v w 9.70 A Zo ning and _ aClr VOL. 7 2 a P G. 5 5 3. a 9,3 S O. Fr. parks Colnmit a� C N r9. AC.EXC.R.O.W, to � I - 835,307 SQ.FT.I �~ -. It not recorded ; ° Q. kl WELL �j .. \ . ............................. within 30 days of -���"' + H O U S E approval " N Z approval 00 be nut( X void S89 °53 00 W 397.08; I S89 °5.3 "W a f PARCEL REC. IN 0%* !tS NP8b46`40`�E °j 21 93 L 2 j V0t..42! PS. 566 W - J, 3 b. Ta' CL: .t^ Z, ° I N37•22' 2 "`p_ -� BttILDtNG N 3 7' 2 2 ` 10 .. W '2 2' 10 - sErBaclC ° - C • 268.07 V) O M ' x 1 *53'00 � ., W 4 2 7.1 0' Ntt ►1 r+ttlto� 14 1 58. C4, 1 -T— - r ��,dN r � i �`_ S89 ` 0 0 W 4 44, ti F/ 10 I,I o JAMES M.(, S UN LANDS WEBER i S • 8W { SP G VALLEY rM� S ' /4 CORNER OF SECTION 9. NOTE, BEyAt7*bS AREREFERENCED ! COUNTY MONUMENT FOUND). TO THE N +.S Qt1ARTER L,fNE. I RECORD - S i�e 0�, „ ED SEARIING.''' SCALE t :200 �It,�fQ $IJRV , � �rbl ttt�M��� ✓` "' 0' 100' 200' 400' VOIr' MF 9 PAGE 2524 - '�aru SHEET 1 2 .w•r JAMES M. WEBER S -1800 THI S INSTRUMENT DRAFTED BY �.� -+ �;, r , GATED a' x"' ,` REVISED 8 -19-91 W R €NTOi + REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS Y, DIVISION LABOR HUMAN A ND MADISON PERCOLATION TESTS (115) MADISON W 7 (H63.090) & Chapter 145.045) i LOCATION: SECTION: TOWNSHIf ICIPALITY: OT NO.: BLK. NO.: SUBDIVISION E: N W - 4 t/ q IT �,� I,.»J � c t�.ti r yU �. - �� �Pase� c. S • �'! Do COUNTY: OWNER'S UYER'S NAME: MAILING ADDRESS: ST c.��x wool �w �v��- SL�►oJ �o�E�2TS w� s��z3 USE DATES OBSERVATIONS MADE NO.BEDRMS•: COMMERCIAL DESCRIPTION: PROFILE DE CRI TIONS: ATION TESTS: Residence -� RNew ❑Replace I 5_ 1 ` 8 ( S _ RATING: S= Site suitable for system U= Site unsuitable for system — _ "� r b I -I `I' CONVENTIONAL: MOUND: IN_ - GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) EIS ZU I ZS ❑ S ZU I EIS ®U I EIS ZU I If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Iv under s.H63.09(5)(b), indicate: • k. Floodplain, i n di c a te Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATERI '� CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH M. ELEVATION OBSERVED EST. IGH TO BEDROCK IF OB SERVED (SEE ABBRV. ON BACK.) 1 z. S' oo. � ' > z. %I 0.6' Lek Bh si I TS; vi l 3h s i 1 ; LS lg� B" Z. 7­ 5' \o b.8' -7 2.Sr o.6' i 30,0/ �, ; VC t� 7 3,S O•F- `{ ;V 1 1 v B- 2.V t0ia-S' ,1 7 Z_ Z' O. 6' It O•a' '� 0• t t S Z.o' X08.9 ' `+ > z• p' d. 6' It j o g ', ; o. 6' 1 B- ( a. NO'7.9' 73•Z' O•"7' t� i `. '� �+ I� 7 3_S' \091. tt 3.5 ' o• 6' 't i 1• °l' ; �•c�r u B- B" �` 1►�al �S � 1rJ6S SU 1. uv B PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES ! NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD PER10153 PER INCH P_ ► Z 2 Svo 3D ` /t6 'Sl �b 3 Z loss P_ 2 Z.2 NO 30 I! I/g l! Z.'7 Ida.I/ P_ 3/ 3/ y p o9•0' P -_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. _ M) OF 8SA CZ oF-SA/uQ) prp� - 7 S ItilttAU�r� S l SYSTEM ELEVATION '1 (3 g' 0 i P1 r MotU1.1� • iT ZA I (� i i Sk'tl�uE;I ;t Z w/ A I C/ l7 MFr L _ S I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: 'PR vR L,wi�i - (:,- 'S -Z8 -86 ADDRESS: L/ BOX -ZZ6 CERTIFICATION NUMBER: IPHONE NUMBER (optional): wo ) S76 113_4 Zs. o) 6t{ CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report_ must include: 1. Complete legal description; 2. The rase section must clearly indicate whether this is a residence or commercial project; 3, MAX number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 5, PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram aMlratelY locating Your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8� Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to elates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 19. If the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 11. Sinn the form and place your current address and your certification number; 12. Make legible: copies and distribute as rec.luired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols i st — St one (aver 10 ") BR Bedrock cob - Cobble (3 - 10 ") SS - Sandstone gr — Gravel (under 3 ") LS Limestone *S — Sand HGVV - High GIOLH Water cs -" Coarse Sand Pere Percolation Rate med s — Medium Sand Ulf - U1eII fs — Fine Satin! Bide Building Is — Loamy Santa > - Greater Than sl Sandy Loan-, < - -- Less Than 1 -._- Lo i3 ni t.'a .._. 131 "'Clvi1n siI Silt Loam 81 Black si Silt Cry — Cray c — Clay Loam Y -- Yellr>w sci — Sandy Clay Loam R Reel sicl - Silty Clay Loam nrot -- Mottles s €_ Sandy Clay vv -- vlith sic - Stfty Clay f fe"'v, lino-e" faint c -- Clay e;r; -- c«rarna€;ra t r,ar;e pt — Peat _ N"k- ty, naa •.l UM m -. Muck d d stinct p — prorninf rot HUI1L — High vvatc?' hovel, Six rleneral soil textures urtaco °aster for liquid waste disposal RM — Bench Mark � VRP - -- Veitical R perence Point TO THE OWNER: This soy' tes`_ repoo is the first ste'r) in iccearisac v swlil a y perrnrt, f'he toot. €roy on the D;.ap<artmew may t ecir.rest e'l <afloo ('J rhis :-soi €.ca3; in, the field i r:or to cr =rr. '4'> %tar }t,b A ct:mipk) tE -,el of plans iw the private S system and a pern)il applica6FIn mus be "o trr c local aw tority in order tes )bt?!in ca d eri'y0i' . ke a.rnafary p" rrrlit rnut ' be t)"'! Int d jc''l rlos'te l:' f "O trt :;)girt Ul" awp +'rYla`t.(ti Cti23? "r.