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HomeMy WebLinkAbout026-1143-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 405193 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 Permit Holder's Name: City Village X Township Parcel Tax No: Mickelson, John I Richmond Township 026- 1143 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: # .° Ebb ,a Cs" ew► v / TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t \ Benchmark 1W V Dosing Alt. BM Zo Aeration Bldg. Sewer -o Holding St/Ht Inlet �.� ( qS -( V/ TANK SETBACK INFORMATION St/Ht Outlet J TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic S 5� 1 �! Dt Bottom Dosing Header /Man. p•Z�J Z Aeration a ) l � °1 3• �� XN n_0 41 Holding Bot. Sy to �• V �, (� / I • • PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Nu er TDH Li Loss System Head TDH Ft Forceibain Length Dia. Dist. to Well SOIL S TION SYSTE RENCH h Length o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME �� (p8.� CZ SETBACK SYSTEM TO P/L DG IWELL LAKE /STREAM LEACHING M f3ctu r INFORMATION Type Of System: CHA MB OR Model Numbe 1A ' � o . ZO A - ) .---- DISTRIBUTION SYSTEM Header /Manifold 1A Distribution I x Hole Size Ix Hole Spacing Vent to Air Intake Pipe(s) go Length Di a Length Dia pacing ~ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth es ITopsoil � ' Yes No th Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center BedlTrench Ed 9 � 1jil Yes 1 r No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #11 z� J (.w2 - "" Inspection #2: - - --- r — Location: 1039 144th Avenue New Richmond, WI 54017 (NW 1/4 SE 1/4 20 T30N R18W) Waldroff Meadows Lot 4 Parcel No: 20.30.18.1045 1.) Alt BM Description = `� 2. Bldg ewer length = 9 9 7. - amount of cover = ~ P 20 Zoo Use other revis l No side for additional inform lon. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division City 201 W. Washington Ave., P.O. Box 7162 _11 - Cho / x N visc ' vnsin Madison, WI 53707 - 7162 Site Address. Department of Commerce 7 -d3 -{� Z SJZ/ S p3 /� ' �9d•Q- Sanitary Permit Application Sanitar Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 4a 9 �/ " 3 may be used for secondary purposes Privacy Law, a15. 1 m ❑ Check if Revision I. Application Information - Please Print All Information --�� State Plan I.D. Number Property Owner's Name Parcel Number 20 . 30 /0% s 3 Property Owner's Mailing Address Property Location ST. Cf rO COUNTY 'A S T e 30 N, R 1 City, State �, �` Zip Code Lot Number Block Number ,� vG � � �- " Subdivision Name CSM Number V II. ype of Building (check all that apply) ❑City 1 or 2 Family Dwelling - Number of Bedrooms 3 ,❑v�illage ❑ Public /Commercial - Describe Use ifJ7ownship , �� ❑ State Owned Nearest Road III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B If applicable) A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use System Talk Only Existin System B • ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check nil that apply)(numbering scheme is for Internal use) 44 Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. Dispersal/Treat ent Area Information: Design Flow (gpd) Dispersal ea Dispersal Area Soil Application Percolation Rate / System Elevation Final Grade Requited (bg3 � Proposed Rate(Gals. /Days /Sq.Ft.) (Min.11nch) µ, S+;2 h U Elevation 96 -� SZ? 75 ,© /� �. _ov 3 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass t New Existing Tanks Tanks Septic or Holding Tank �i t ^ Al Chamber W VII. Responsibility Statement- I, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plant. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number: Plumber's Address (Street, City, Slate, Zip Code) 7 11 VIII. Count /De artment Use Onl Approved Disapproved ' Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) , ❑ Owner Given Initial Adverse � zz S � zw0 _ Determination IX. Conditions of ApprovalfReasons for Disapproval Ic rn¢e oe_ µ 1 . - �e +0 - 6. PeI 1 �, , � is 6 Attach complete plans (tO the Coaery outs) for the n system �oe paper� IM than 8113 x It leehges le�aahs- � � � r � J • -,, �' SB 5 /Ol)� ' 4j F r le6,c._. -+z'L. N� t , r " :r f +� H 1 J f � i S,�' ,�rlLl sa I • Q r r r i �%`.4 %�$t. �i Zia "T '" '1' 1 ,. � � 1 'Ir✓— rOd ri t o r• a S i. .. WWWW " ". `� ," 9 r ' I Ile s^ 4VC a 7.r�pf i Y � q n � �• , ri T 1� ,,pper� d A ; ` y 4 e ; 2r 'tzl+a- 9 Bi h fY x �r }0 food n ` ! �� a PI/V5 oN PlAT : D X& • / o (o /• 30 • o So • OV Wisconsin Department of Commerce SOIL EVALUATION REPORT / )IvIsIon of Safety and Buildings Page of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper riot less than 8 1/2 x 11 inches in size. Plan must County J !. 7' ; CRO Include, but not limited lo: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. Rev wed by Date Personal information you provide may be used for secondary purposes (Privacy roperty Location ZTV IFN Law, s. 15.04 (1) (m)). Property Owner RECEIVED 2� /,/ � 1 p o j�AE s0/� ovt. Lot NW 1/4 51 1/4 S 2*� T3 N R /o E (or) W Property Owner's Mailing Address of !1 Block # Subd. Name or CSMN I/3 /yo- sT'• Jul 0 2002 (�� City �EW Slate Zip Code Phi �RpWCOUNTY MCAPOW5 ❑ City ❑ Village (L) Town Nearest R ad R6I•G.M oti �/, SPI7 F S t•G a,v /�/�l X /jv� [� New Construction Use: 0. Residential / Number of bedrooms Code derived design now rate _��`d GPD El Replacement E] Public or commercial - Describe: Parent material _ y o ( lifq. Flood Plain elevation if applicable General comments n • and recommendations: e 5/'7-,6r /� /Q� vsl► AC COWS G �'Nfi / 7�,Q"i - a �p �j3iD Di �FvS�i25 U Boring # Boring q& g S > Pit Ground surface elev. I! fl. Depth to limiting factor / 4? in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. '041 •E/f#2 a� • Sit. s 3 o /o SiG � C — . s • 8 r S Boring ill! ❑Boring ? C p [I pit Ground surface elev. 0 J ft. Depth to limiting factor In. Soil Application Rate Horizon bepth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *E11#11 'Etf#2 d ' & /a YR 3 / y �o yR _ c • Z 3 S/ cs , s . Foy V. 2 Effluent Ni = BOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Prtnt) Signature �O 4 7— CST Number Address �' Date Evaluation Conducted Telephone Number flC 8 • J j-� '715 386 8/8 S Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 l,�A�OoRr Po4v3 - G Property Owner Parcel ID # ❑ g Page Z of Porin Boring # S Pit Ground surface efev. fl. Depth to limiting factor �y In. H ry orizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Roots Soil Application Rate In. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. T I GPO /ft Eff#2 l 4• S� /o y 3/3 L /o — 3 �s /1" ,e c . 7 A z /o s ed- s o z q 8 ❑ Boring # ❑ goring ❑ Pit Ground surface efev. fl. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil A GPO / Rate In. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'Eft #1 'E0 ..... ..... I IJA � ❑Boring # ❑ Borin ❑ Pit Ground surface elev. ft. Depth to limiting factor In. fforizon Depth Dominant Color Redox Description Texture Structure Consistence Bounda Soil Application Rate rY GPD /ft' In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 Effluent #1 = BOD > 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 equal opportunity service provider 4nd 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. sno -e»o �R Fmni I • / -liG 15" 400E'z5ll�/ ulbricht & Assoclates f Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 64016 21 16 -v loo y �V-i:5A w,-r&;e, D - �: 5� 96 svyy�sr� M Sv �' /dtl.4- 7io•�s o n I a • FS a f3 I I l`{�,uE Si TE z i 8 Sf,er,� P► P-a I r10 -71 5 D� ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBu fi er �.{ ,� - , D Mailing Address 1 8 3 - Property Address 16 (Verification required from Planning Department for new construction) City/State /1� u✓ R r It A enz Parcel Identification Number oZ6 — Il`F3 — �o — 01M Zp_3o. t0. Ifl�'S LEGAL DESCRIPTION Property Location. %4, ' /., Sec. . TAN -R1�W, Town of � c�L /12 d Subdivision �b e � a d 4r s . Lot # . Certified Survey Map # /0 , Volume , Page # Warranty Deed # 4, 71 7 9 2— , Volume 9� Page # T Spec house &'yes 0 no Lot lines identifiable 9f"yes 0 no SYSTEM MAINTENANCE Improper use and maintenanceof 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 masWplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expi on date. SI ATURE OF APPLI ANT 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 1 0 -- � Q4.A C� I �� Co I M 1 0 - L - ATURE OF APPLI ANT 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 r r POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page f of FILE INFORMATION SYSTEM SPECIFICATIONS Owner K(L eA-Son) Septic Tank Capacity 66) gal ❑ NA Permit # S -� 3 Septic Tank Manufacturer_ ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ZO ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A- — (n ❑ NA Number of Public Facility Units XNA Pump Tank Capacity a l kNA Estimated flow (average) al /day Pump Tank Manufacturer 1XNA Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer ETNA Soil Application Rate Q.�- gal/day/ft' Pump Model (rNA Standard Influent /Effluent Quality Monthly average' Pretreatment Unit [�NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODd :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD :530 mg /L Ain- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :_10 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: A Other: ❑ NA Other: "A "Values typical for domestic wastewater and septic tank effluent. Other: A MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: 3 9t ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cells) At least once every: 1 Ryear(s) Clean effluent filter At least once every: 1- fia year(s)month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ mo nth ❑ year(s) ) (,$NA Flush laterals and pressure test At least once every: ❑ mo nth ❑ye ) l A Other: At least once ever ❑ month(s) OMA y: ❑ year(s) Other: IkNA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. ♦ Page aof ` START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or:must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 9 6MRA Name Phone � 9. 3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name �. Ctbl y - 2voA�Gf Phone Phone S' ( kO This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. i r i� 1� � - 3 41- l iJ 1 8 9 o P y 5 1 67'3792 STATE BAR OF WISCONSIN FORM 2. 1999 KATHLEEN H. VALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., VI This Deed, made between David J Wsldroff and Julie A. RECEIVED FOR RECORD Wald roff, husband and wif e, 05 -23 -2002 9:30 AN -- WARRANTY DEED _ EXDPT # Grantor, and John Mickelson REC FEEL 11.00 -- TRAMS FEE: 191.70 COPY FEE: _ CERT COPY FEE: Grantee. PARES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in S Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lot aldroff Meadows, St. Croix County, Wisconsin. Name ard lit"l "NA OGL.AND ATTORNEY AT LAW P.O. BOX 359 HUDSON, Wl 54016 Part of 010 -1062- 10-000 Parcel Identification Number (PIN) This is not — homestead property. 0Q) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this I i� , day of May _ 2002 y --- - + 'd J. W sldroff + - — • J A. W sldroff AUTHENTICATION ACKNOWLEDGMENT Signature(s) David Waldroff and Julie A. Wa ldro ff, husband STATE OF WISCONSIN ) and wife. - --. -.._ )ss. n _ _ County ) authenticated this ay of May 2002 Personally came before me this _. day of the above named < Kristina Oglan - - ° -- TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (It' nut, . -- instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Ogland Notary Public, State of Wisconsin Hudso W 5401 — My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) „- , ___•) + Names of persons signing in any capacity must be typed or printed below their signature. Inf-don prdassrooa s company. F«d du Lac, vm STATE BAR OF WISCONSIN eoos2ali WARRANTY DEED FORM No. 2 -1999 ��'� �•'�, i STOF • PON[ — � � � • • j % �l �' • 20' DRAINGAGE H.W.I EASEMENTt cy Fps y9.d C5 L1 g88°23'30"W 3 TOWN tea • �' • ca- N88 3• FT.) MIN FM _ 939.5' rs _ — — 3 UNI �' LOT 3 • . 0.95 3: �. I .M. 1.673 ACRES LOT 4 •' �, • ' I (72,877 80. FT.) 1,631 ACRES TO MEANDER LINE (7i 036 60. FT,) 1.8 ACRES t TO MEANDER LINE • ` • • .. . -- .. J TO O.H.W.K ., 1.8 ACRES t /py/ /�� �'� �/•C I I • X63 j iyy .. LOT 5 I I cc + .s — - �`. ` ,. w .. -'- - - - - 1.842 ACRES 1 Q (80,251 SO. FT.) cq 70 MEANDER LINE 2.0 ACRES i \% TO O.H.W.M. y LOT 6 Lo N .� \ � `% 1.881 ACRES (81,081 SO. FT.) ca• 4p I � O.H.W.M. WETLANDS \ (+ CK ...«••.».... MIN FFE = 939.5 1 a I I 32%vr ��►en.ee_ _ - .`• +► s MIN FFE = 989.5 OUTLOT 1 `k• I 1 ACRES 2.2 ACRES .\ '• ��'` `. �� 1 ER LINE TO O.H.W.M. �' I �i` � 3Tt 78.0 166.00 v/ 5E1µ OP 371 j M 18.7' L1E SW 1 /,( OF SECTION 20 ��°6d� E \ .•-......w..•„ .NNNM.Nw.J - Ml�nl ° 44GD [JG'JD� OWaaD [ply BRIDGE ~ Wisco�GSin Depfiment of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings • in accordance with Comm 85, Ms. Adm. Code County - Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale ordimensions, north arrow, and location and distance to nearest road. Please print all inIformadon. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 16.04 (1) (m)). Property Owner Property Location Govt Lot tIE 1/4 C 0/4 S2() T N R E(orLW, Property Owners Mailing ` Lot # Block # Si nd. Name or CSW :QR City State Zip Code ho Number ❑ City ❑ Village Town Nearest Road n - iLk)t -64016 in5g5!6�661 I r- Qte-hnn6r- - jd i C4v- 12J. A-: New Construction Use: Residential / Number of bedrooms Code derived design flaw rate, _ GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material tic) Aw C S In Flood Plain elevation if appiic ft General comments s y S-f <vr\- e V • �/ 5� ��`"' r and recommendations: A 1-4. e I-e DEL 2000 ST CROIX. }` COUNTY ❑ Boring Boring # (�«-� �,.� ` I Ground surface elev. � ft. Depth to limiting factor Iii ® Pit San acation Rate l Horizon Depth Dominant Color Redox Description Texture Stnxture Consistence Boundary Roots GPDW in. Munsell Qu. Sz .Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 I 1 S. 2 M4'- c5 .5 .8 3 rn s l - 059 no ❑ Boring per, Boring # ® Pit Ground surface elev. ft Depth to limiting facto in. .Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Etl#1 *Eif#2 n%, -pr CS !V42 . .9 2 r (y 8 3 p m 5 /. 2. * Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L " Effluent #2 = BOD < 30 mg/L and TSS 5 30 mg/L CST Name (Please Print) Signature CST Nufftw Z 53 30 Address Data Evaluation Conducted Telephone Number J f r i property Owner /,Ja /d 1 4�& Parcel ID # Page L. of B9 # ❑ Bonng / p► [@- Pit Ground surface elev. C 18• 3 ft. Depth to uniting factor l 1 O in. Rafie Horizon Depth Dominant Color Redox Description Texhme Structure Consistence Boundary Roots GPOW in. Muneell Qu. Sz. Cont. color Gr- Sz Sh. .12111#1 `Ef#2 6-1fa S; C-5- v .5 . g 2 nna k , 3 ZI 1 11-2 R) pit Ground surface elev. 98. l ft Depth to limbV factor in- Rate Sa Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDJF in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff# •Eff#2 S;1 2nrnkk V 1 v� • 8 3 MS Boring Borin # ® Pit Ground surface elev. 97.QV ft Depth to limiting factor in. r-EMM oft Rate Horizon Depth Dominant Redox Description Texture Structrxe Consistence Boundary Roots GPD/fE in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. TM _ ---, 2 C 2 2 Mp C Effluent 01 = BOD > 30 220 mg& and TSS >30 150 mg& ' Effluent #2 - BOD 1 30 mg& and TSS _< 30 mg& The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an ahemate format, please contest the department at 608- 266 -3151 or TTY 60 &264 -8777. SBD4330 (807/00) I -s. PAGE OF NAME W6kjd rp 4 k LOT# 4 LEGAL DESCRIPTION UF'/.5WI,,SWT 3p,N,R $ E (or) dD SCALE: F'= !Y 1 BM 1 ELEVATION 160 - O BM I DESCRIPTION 4o p o�' ee1 fe- c A PAL BM 2 ELEVATION BM 2 DESCRIPTION 1 SYSTEM ELEVATION ��• �� _ X ALTERNATE ELEVATION f. .O� ' CONTOUR ELEVATION 3 Q �. O Ca L-0 A;p Vol s�Ngti ,c .tom vh c c GNATURE �� DA E �� ��