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002-1034-40-000
Wisconsin Department of Commerce Safety and Building Division GENERAL INFORMATION Personal information you provide may be used for secondary purposes Permit Holders Name. Nathan Borowicz CST SM Elev Insp M Elev BM Descpmhop Bo (EJ(//q�/ TANK INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) [Pnvacy Law s 15 04 (1)(m)I City Village Township TYPE MANUFA TURERf, 5 � n51 CAP A CITY Septic 1. 1.J / W i t� t0, ON +1f �7 (-5 Dosing O'41 o o —' > Holding TANK SETBACK INFORMATION C.00. 4J �- TANK TO P L 1 WELL BLDG Vent to Air Intake ROAD Septic pp Dosing 750 > 50 hB • LD7 Q r� t O �__ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand ZOC r GPM Model Number 15z t y40 TDH LI�t O�Fncllgn L-� System }i;adS_6 T12 I Ft Forcemain Ler�iFyO , Dial ) k Dist to Well \ SUIL ABSORPTION SYSTEM OF BALDWIN ELEVATION DATe 7. I--v St. Croix I C:1C71MA 002-1034-40-000 16.29.16.233A o7. L3 I vd STATION BS Q O HI5. 65• 85 EOEV Q Benchmark 10.7 fDo AIt M ., tne Bldg Sewer Z..7�i SUM Inlet II•Z fr (C• tlHt Outlet Dt Inlet Dt Bottom Header/Man Dist Pipe ►.N /02.1 Bot System 2,dM / D) • l q Final Grade St Crer qq ,,7// (o YI "r- °I 10/.73 S%d n13.o3 BED/TRENCH DIMENSIONS Width I t /1O Length 60e nc es Z PIT DIMENSIONS No s Insioe Di Ligmtl Depth SETBACK INFORMATION SYSTEM TO P!L n BLDG WELL LAKE/S RE LEAC ING CHAMB R OR UNI nufacturer. Type itlyvem r �`O /O x a I Motlel Numbe VIOI KIMI I IVIN OTJItM HeaderrMandold Dislnbut J ' ,I Pipes) r r Z x Hole Size p x Hole Sqa ng I L �' Vent to Au Intake Length Dia Length Da Spaong� �'� ouiL VVVCK x Prwssurw Svcfnme nrdv .. ni, n, c—A- e..-,--- n-. L1ppth Ov Q�I Bed?safieliI epth Over BedrTrench Edges xx Depth o I xx SeedetltSoddetl Mulched L , I J L. iT111 v Topsoil Yes No �` No ItYes COMMENTS: (Include code discrepancies, persons present, etc) Inspection #1 O1d„J 6/Z1' Inspection #2 j iv:w//aw Bit �SZ Location: No Address Available 1 ?a"�D� — er r v.3 11 Alt BM Description = 1 9 bipt.1 for.p \ I 1l 2) Bldg sewer length = I I b 63% Se�'tl�> � � Z(7 ` /cars 5CVI - amount of cover = -;I L4 7 ` �T J1J� - c) e�1 a„} C' Plan revision Required? Yes 1rA No �� 1 Use other side for additional informal n I z SBD-6710 (R 3l97) Date Insepct/gre G-vt r F ;xeslnuearo tV`Li. -�� ( ��/ \ r - Industry ServicesSDlvislon Counl) - sccrol. {1 ton Ave Isl S� 1400 E Washington I 'ir-,1�- '" - g Samtan Permit Nam ber(to be nl led in Fix Col P O. Box 7162 /' Madison, WI 53707-7162 APR 3 0 2021 63 I Z� S SanitaryPermit Application State Iransa°noo Number t'Y " t5-04210W9-C In accordance nuh SI S 193 �_ I (2) k t .1Qit1...�tldesulwtlssum of this torn to the appr • wvemmenial w n required pnor 21 ohtaimn a sane in pemmt tote Apphcauon forms lur state.nt tied POAv7 [ed to the Department of Salvo. and Prole vonal Services Personal in formation wu provide may he used for sewn a Protect Address Uf crent than mailing address) purposes in aeatrdancc mth the Pncacs I am s 15 04i1) m). Stats '-365 Cis Rd 1, 1. Application Information - Please Print All Information Propem Oaner s Name Parel 9 Kane & Nathan Borotcicz rrEX Doz- !03 — qO -000 Propem Orsner's Madm, Address Property Location 2276 180"' Ave Gost Lot Cits .State /IpCode Phone Number NUNE'- Section 16 Emerald. ",1 54013 Ili-781-4864 (circle one) T29N R 101 or N' It. Type of Building (check all that apply) Lot" ® 1 or 21 tinily Dwelling -Numb of Redroonts _��� Subdiv swan lame a —�❑ PuhhelCommerclal - Uescnb ��_ Ovl Blook d S.P— ❑C,t,nf ❑ Statc OHned-Describe Ilse -- -- --- CS\f Nu cr V, 30 ❑Village of P.1�3 I o Dom-' elT2 ®-s+n of Raidsun I11. Tv a of Permit: Check only one box on line A. Complete line B if a licable) A ®Nee System ❑ Replacement Sstem ❑ I reatment/Holdimp Tank Replacement On % ❑ Other Modification to 1 listing Ssstem (explainB.) ❑ Permit Renewal Pennit Rcvivon ❑ Change o1 ❑ Permit I ran ier In New List Prev lows Permit Number and Date Issued Before Eapuation Plumber Omer fI B. IV. Type of POW'TS SN stem, Component/ Device: kCheck all that apply) r t$11 ❑ ]iris-Pressunzed In -Ground ❑ Prmssunzed In -Ground ❑ %[-Grade n - as Mound <24 in, of suitable sod ❑ Holding Tank ❑ Other Dispersal Componen -plam) ❑ Pretreatment D vice (explain) / /06 V. Dispersal/Treatment Area Information: 9" (0 Design Floe (gpd) I Design Sol] 'trplicatl0ts, Dispersal YQa Required is Dispersal Area P scd (s i System ifevation 600 liate(gpds0 600 181962 �e,� 10150 4m �� J VI. Tank Info Connell) as Gallons _ /; LL ki�1Ae--1't Rej - loud Rof L 8 u N1anu acmrcr t r Net, Tanks Esiam rank s F _V G3Ilolis Llllls i :J �'!, i f. L C - v G Septic or I loidmg I ank f 1250 125 Wieser ® El❑ El Dosut, Chamber 750 1 750 1 Y ❑ ❑ ❑ ❑ ❑ V II. Responsibility Statement- 1, the undersigned, assume sligsi ' ity for inflation of the POWI S shown on the attached plans. Plumbers Name (Print) Plumber's Sign NIPMIPRS Sumber Business Phone Number Iodd Sinz 139462 715-23s-264a Plumber s Address (Street Cm State. /m C ode) E5609 708" Ave NIcnomome W 154, 51 County/Department Use Only �V,ill. IEI. Approved ❑ Permit Fee�e�. DD tel ucd I s g AgenLSignat e - ❑ - oven Reason for Denial Is q(/ �/l I�� Z( IX. Conditions Approv Diaiti,prorm 3\-�t`,S �iSub^ It I MB0-MPr.uM q SYSTEM OW / rL - }�so, I �a di 1. Septic tank, effluent flier and dispersal cell must be 5arrvjc551Lalntelned , I.\ P f i L( (.a by as per management plan provided plumber. !s " 0 All rements must be maintained — 04 I.s-W$ Ipv�U e f le plans for the r_�stern and suArnu to tthhe�C ouni; wi, on paper not less Iha.%%'1 a tl inche, in sire t f f- S�iD-�3 8 ( 3) -lij 5) idl l,Cr�'tywIT1 �S l4M', LiSf S ,lll'U'a.Q Q.Sp_ th 0. I%4Lr got0L3iC.y [j7J5� 781 -Lf2w tdo?c- t Zy �D i 4YN�" 400 go+� spot w Ifti iosb \k It�Sm�Fx SYsf�+ n Will Heidt Soil Testing Mo dovi WI54755d (715) 579-9584 id na22713 p�a0mNA-ber T,v2o.2D Z April 25, 2021 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2023-04-25 Plan Review: PN% TS-042100659-C TODD L SINZ E5609 708th .Ave Menomonie WI 54751 SITE: Borowicz Cty Rd E Town of BALDW IN St. Croix County Total Amount: $250.00 FOR: Description: 600 GPD-.New Residential Mound Maintenance Required DIVISION OF INDUSTRY SERVICES 2331 SAN LUIS PL GREEN BAY WI 54304-5211 Contact Through Relay http/ldsps w gov/programs/industry-sernces www wtsconsm-gov Tony Evers - Governor Dawn Crim - Secretary CONDITIONALLY APPROVED DEPT OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE Mound Component Manual — Ver. 2.0, SBD-10691-P (N OUOI. R 10/12) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLN APPROVED. This system is to be constructed and located in accordance with the enclosed approN ed plans and with any component manual(s) referenced above. 7 he 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. stars. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Items- POWTS Design Approval • This system is to be constructed and located in accordance with the approved plans, the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD-10691-P(N.01;01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD-10706-P (N.01 i 01). • Fence off dispersal area prior and during construction to protect and avoid disturbance, compaction and use of the site. • With new construction, it is recommended not to activate the pump in the dose tank until the tanks are pumped prior to homeowner occupancy. • Wastewater generated from contractors cleaning of equipment and tools and/or leftover construction products shall not be discharged into the drains discharging to the private onsite wastewater treatment system (POWTS). Waste generated shall be properly disposed of on -site or off site. • Any tall grasses, leaves and shrubs shall be cut short and removed prior to tilling the surface for installation to prevent matting under the dispersal area. • Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches. Smearing and compacting of wet soil will result in reducing the infiltration capacity of the soil. Proper soil moisture content can be determined by rolfing a soil sample between the hands. If it rolls into a 1 /4- inch wire, the site is too wet to prepare. If it crumbles, site preparation can proceed. If the site is too wet to prepare, do not proceed until it dries. • Insulate building sewer beyond 30 feet per SPS 382.30 (11)(c). • Provide surface water diversion around the treatment tanks and mound dispersal component. • The owner is responsible for the operation and maintenance of the pris ate onsite wastewater treatment system (POWTS) in accordance with SPS 383 and the approved management plan • The owner of a POw'TS shall he responsible for ensuring that access opening covers remain locked or secured except for inspection. evaluation and maintenance or sen icing purposes. • Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • Provide a copy of the approved POWTS plans and this letter to the owner. 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 'instal lation/operation In granting this approval the Dig ision of Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely. Mark S Finger POWTS Wastewater Specialist, Division of Industry Services (608)574-1189 mar4.finrerciv;i _,ny APPLICATION FOR REVIEW -Complete all pages- _ - NOTE. Personal information you provide may be teed for secondary purposes '• - `` (Privacy Laws 15.04(l)(m), Slats.I Private Onsite Wastewater Treatment Systems Division of Industry Services tans to be E-filed. Provide SharePomt User name below. For plan status, check our webslte at Entail technical code questiorts to.-n.:c Several counties have been delegated certain authority to review plans in lieu of Division of Industry services. For a current list of those counties and their designation check our websde at 1. Project Infomtatloonn - Fill in all known Information. Confirmation of assignment to a reviewer. /t Project/Site Name: 4*m �Ji�D(tJ/C L Transaction ID: Location, Number & Street otprooiect (if unknown, indicated merest road) Previous Related Trans. ID: o : Iu.J IE Estimated Completion Date: Asslgned Reviewer: Legal Description: !J %!� NE t-Y $16 7-1-9r✓ /*6 ter/ County _.47'MOVe Assigned Office: Mall to your office of choice below: La Crosse, Green Bay .yD ❑ City ❑ village 10 Town of 2. After plans are reviewed, please: (chock all that apply) ❑ Call customer 1, 2 (circle number)' NOTE: We reserve the right to re -distribute plans to another office If ❑ Requesting party will pick up needed to reasonably balance turnaround times. check ❑ Mall plans to customer 1, 2 (circle number)' nttp Iiosps ai.go, for next available review date — "Refers to customer number from below. 3. Complete the following designerlownerlrequeeting information lJtilim the check bozos when designer. owner or requesting party is the same to avoid repeating information. Designer Information (Customer I DSPS Other Please Specify Below (Customer 2) DSPS Fist Nam La$t Name � First Name Last Name Customer Number ACustomer O JD S/FIZ Cons r�Name r� �% Y 5/A),_ rLl)wi Qlh+l 1'/JL. Cam n Name Company Address r SLO 9 t7P Avc Address City (nGD M/F Ss1��te Zi +4 (9 di 's) S/75�— City State Zp+4(9 digits) L✓l rfZ6 Plane Number Email address Cell phone Phone Number E-mail address Cell phone (area code) %f S Z5S (area code) Check if applicable Check if applicable or specify relationship [I Owner Owner LJ Other —s relationship Information and Plan Submittal Checklists. To request electronic plan review complete the appropriate application form and e-mail it, along with your registered SharePomt usemame to - - _ . If plans are being submitted via paper, they _-� will be assigned to a reviewer after receipt at a DSPS office Submittal checklists can be found in each applicable component manual a2peanng on the POWTS program page under Publications HolmrtlOnalaska Area DSPS Green Bay DS PS 2150 Midwest Dr Ste 104 2331 San Luis Place Onalaska, W154650 Green Bay, WI 54304 60&785-9334 920492-5601 Fax 605-785-9330 Fax 9204925604 Email n Email " , ..:.,eilc Make Chec s Payable to: Division Check box to invoics( Designer Signature SBD-10577 (R 3119) Its OR sign below TOTAL AMOUNT DUE S Review Code 7633 5. POWTS SUWAL (check all that apply - Incomplete forms prey result In processing delays) 84;❑ Aerobic Treatment Units) ❑ Chlorinator ❑ Tank Replacement Only ❑ REPLACEMENT ❑ Commercial System ❑ UV 131141"l lien Unit Add GfBuard Filter SYSTEM TYPES) NOTE: Submit separate sheep for each system It submitting multiple systems an the same sits Enter Fee ❑ Revision to previously approved plan f9S.pg ❑ Wl lianwm Review (i.e. replacement of a septic tardy, addition of an effluent filter a pratreatmant device to an existing system, etc.) $SOfir pormen[ Manual --- — Alt treatment components are previously approved ❑ At -Grade Component Manual - Ver, 2.0, SSO-10854 (N,03/07, R. 1/12) Design Wastewater Flow in under s. SPS 384.10 (2) or (3): ❑ I_ ngrywrd Component Manual -Ver. 2.0, 58D-10705-P (N 01I01. R 10112) Gal P day Design wastewater flow of the proposed system: and Component Manuel -Var. 2.0, SSD-10691-P (N.01101, R 10112) ZIP [I Pressure, Distribution Component Manuel - Ver. 2.0, SBD-10706-P (N.01/01. R 10/12) TWOWv 1,000 gird or less $ 250.00 ❑ Other- Please specify �GO' 1,001 - 2,000 gpd $ 325.00 _ 2,001 - 5,000 $ 400.00 ❑ Soil Eased Individual Site Design' _ One or more treatment components are not previously approved under s. SPS 384,10(2) or (3): ❑ At Grade (Individual site design/deviation From component ❑ Non -Pressurized In -ground Design manuals and use of components without product ❑ Pressurized In -ground Wastewater Row in approval): ❑ Mound Gallons Per day ❑ Orip4lne Design wastewater flow of the Proposed system' ❑ Constructed Wetlands GPD 1,000 gpd or less $450.00 ' Documentation must be provided to support treatment and dispersal claims. In a separate 1,001 -2,000 god $600.00 statement. provide rationale for the project and attach supposing documents (code sections, test 2,D01 - 5,000 gird $750.00 repots, technical papers, research articles, etc,) greater then 5,000 god $900.00 plus $0 08 for each gallon over 5000 god state -arced facilities n Holding tanks previously approved under s. SPS ❑ Holding Tartk Component Manuel, Ver. 2.0. SM10055-P (N.03I07, R1/12r WaseDesigsigwster Flowh 384.10(2)(3). Design wastewater flow of the proposed stem: Galion Per day ' Non -state owned Commercial and Residential Holding tares that completely utilize this manual 5,000 gird or less $ 90.00 and have an estimated daily flow of lee than 3000 galki per day must be submitted to the GPO 5,001 -10„ 000 god $180.00 epproprade governments! unit for review instead of the Department (see SPS 383.32(3xa)) greater than 10,000 qpd $225.00 ❑ Holding Tank Individual Site Design', (i.e. site constructed, 45 day holding capacity, Co- Deelgn Holding tanks including site constructed tanks NOT mingled wastewater. etc.) Wastewater Flow 0Desi previously approved under s. SPS 394.10 (2) or (3). Please specify, Gallons Per day VVasterwater flow of the Proposed systten. Documemaeon mode be provided to supped the rationale for Me pared. a separate statement. 5,000 gird priest; $180.00 6,001-10,000 gpd $300.00 ' please include all code Sections, test repots, tedhnlcal papers, research amides, etc.) GPD greater than 10,000 gpd $450.00 ❑ Soil Saturation Determination Report (using observation pipes) ❑ InlerpretNe Determination $240.00 — [] Esperimentar System (Ono rime additional fee). Submit for for individual system as par appropriate above system type) Ex mment Number $40D.00 J Priority Review (enter same amount as normal review fee listed above) $ _t'T Enter Total (rounded to the nearest dollar) $ SPS-10577 (R 4/16) MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN INDEX AND TITLE PAGE Project Name: Nathan Borowicz septic system for new home. Owner's Name: Nathan Borowicz Owner's Address: 2276 130th Ave Emerald Wi 54013 715-781-4664 Legal Description: NW1/4 NE 114 S16 T29N R15W Township: Baldwin County: St Croix Subdivision Name: Lot Number. NA Block Number: Na Parcel I.D. Number: 038-1241-08-000 Plan Transaction No.: Page 1 Index and title Page 2 Data entry Page 3 Mound drawings Page 4 Lateral and dose tank Page 5 System maintenance specifications Page 6 Management and contingency plan Page 7 Pump curve and specifications Page 8 Septic Tank/Pump tank. Page 9 Effluent fitter Page 10 Plot Plan n n Designer: Todd L Sinz ( License Number. MP139462 Date: 04/06121 Phone Number. 715-235-2644 Signature: A signed Pursuant to the Mound Component Manual for POWTS Version 2.0 8130.10691-15 (N. 01101, R. 10/12), and both SSWMP PubFcation 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01101, R. 10112) Version 7.0 (R. 11112) Pagel of 10 Mound and Pressure Distribution Component Design R or G, Site Information Residential or Commercial Design Estimated Wastewater Flow (gpd) Peaking Factor (e.g. 1.5 = 150%) Design Flow (gpd) Site Slope (%) Contour Line Elevation (ft) Depth to Limiting Factor (in) In -situ Soil Application Rate (gpd/ftz) R 400.00 1.60 600.00 7.00 100.00 18.00 0.40 4 Distribution Cell Information 100.001 Dispersal Cell Length Along Contour (ft) 1.00 Dispersal Cell Design Loading Rate (gpolff) 1 Influent Wastewater Quality (1 or 2) Isrlbution Information Center or End Manifold Lateral Spacing (ft) Number of Laterals Orifice Diameter (in) Orifice Spacing (ft) _ Forcemain Diameter (in) Forcemain Length fftJ ump an evahon (ft) 4.55 System Head (ft) x 1.3 i L 13.Vertical Lift 1.43 43 Friction Losss (ft) _ 0.00 In -line Filter Loss (ft) 18.98 Total Dynamic Head (ft) Lateral Diameter Selection in. dia options choice 0.75 1.00 1.25 1.50 x x 2.00 x 3.00 x Note Sand fill (D) calculations assume a Table 383-44-3 in -situ soil treatment for fecal coliiorm of <= 36 inches. 6.00 Cell Width (ft) Are the laterals the highest point in the distribution Y network? Este; i' of N If N above. enter the elevation ft of the highest point. 12.00 fly/orifice Does the forcemain drain back? Enter 1' or N 14.68 Forcemain Drainback (gal) 90.29 5x Void Volume (gal) 104.97 Minimum Dose Volume (gal) 26.93 System Demand (gpm) Manifold Diameter Selection in. dia. options choice 1.25 x 1.50 x x 2.00 3.00 Gallonslinch Calculator o r-on.,, Treatment Tank Information Total Tank Capacity (gal) 1250.00 Septic Tank Capacity (gal) Total Working Liquid Depth (in) Wieser Concrete I Manufacturer gallin (enter result in cell B49) Dose Tank Information Effluent Fitter Information 750.00 Dose Tank Capacity (gal) Lifetime Filter Manufacturer 16.12 Dose Tank Volume (gallin) LT1/8 Filter Model Number Wieser Concrete Manufacturer Project: Nathan Borowicz septic system for new home. Page 2 of 10 Mound Plan and Cross Section Views L Mound Component Dimensions Al6.00 ft E 23.04 in B 100.00 ft F 9.50 in D 18.00 in G 0.50 ft 600.00 (f?) Dispersal Cell Area 6.00 (gpd/ft) Linear Loading Rate ill H 100ft K 10.51ft 1 1220ft L 121.01ft J 6 92 ft W 25.12 ft 1819.62 (ft2) Basal Area Available 10.00 (ft) 1110 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 103.29(ft) --+ H —� F Dispersal Can 102.00 (ft) Lateral 101.50 (ft) ►� — Invert Dispersal Cell Elevation D 100.00 (ft) Contour Elevation 7,0 % Site Slope Geotextile Fabric Cover Shading Key $ Dispersal Cell See lateral details on Topsoil Cap 02 Subsoil Cap a a o 1.5 ftr���rr.. . •: ,.�. t,�f Page 4 for number, size, and spacing of laterals. 0 Laterals are equally ASTM C33 Sand ®0 4 F spaced from the Tilled Layer ©] Aggregate .1 < o� 0. ft Typical Lateral distributon cell's centerline in the ♦---- A « distribution cell (AxB). Project: Nathan Borowicz septic system for new home. Page 3 of 10 End Connection Lateral Layout Diagram L.•.•«a w•Pe oo•men„"' •- Turn - up v/Gall ••a1•�sorolwan iul plug Foipp rnan /'CrnWilon vu tpp or nu mIno0d yi • q pomr LMPrAI. 3 fMlemmn SCh 41`1 r•t:+. per SPt. Ta1NP 184 330A Number of Laterals Lateral Diameter Lateral Length (P) Lateral Spacing (S) Lateral Flow Rate System Flow Rate Total Dynamic Head Orifice Diameter Orifice Spacing l Orifices per Lateral Orifice Density Manifold Length Manifold Diameter Forcemain Velocity Dose Tank Information Electncel as per NEC 300 and ---0 SPS 316.300 WAC Disconnect Tank component is property vented Wieser Concrete Ca ci 750.00 Volume 1 16.12 Manufacturer Gallons gal/inch Dimension Inches Gallons A 26.01 419.35 B 2.00 32.24 C 6.51 104.97 D 12.00 193.44 750.00 Total 46.53 Alarm Manuafacturer SJE Rhombus Alarm Model Number Tank Alert Pump Manufacturer jZoeller Pump Model Number ISN461 1 5'L T A i B C Pump Must Deliver 26.93 gpm at 88.98 ft TDH Locking cover with warning label and locking device and sealed watertight 4 in. min. F— Alternate outlet location Forcemain diameter --11 2 in. Weep hole or anti - siphon device d Pump off Elevation (ft) 89.00 Dose tank elevation (ft) 88.00 va[c swr-.,rs '••�s systcl� Project: Nathan Borowicz septic system for new home. Page 4 of 10 Mound System Maintenance and Operation Specifications Service Provider's Name T L Sinz Plumbin Inc. Phone 715-235-2644 POWTS Regulators Name St Croix County Zoning Phone 715-386-4680 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 1250 gal Maximum TSS 150 mg/L Soil Absorption Component Size 600 ft" Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Septic and Pump Tank Effluent Filter Pump and Controls Alarm Pressure System Mound Other Service Frequency Inspect and/or service once every 3 years Should inspect and clean at least once every 3 years Test once every 3 years Should test month) Laterals should be flushed and pressure tested every 3 years Inspect for ponding and seepage once every 3 years Call T L Sinz Plumbing for your service needs. Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to SPS 384.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in SPS 384, 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 Jr 6-8" Diameter Lawn Sprinkler Valve Box Distribution tded Cleanout or Ball Valve 90 or Two Bends Same is Lateral Project: Nathan Borowicz septic system for new home. Page 6 of 110 Mound System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-84 Wis. Adm Code, and shall maintained In accordance with its' component manuals ISBD-10691-P IN 01101, R, t0112), SSWMP Publication 9.6 (01181), and Pressure Distnbution Component Manual Ver 2.0 SBD- 10706-P N. 01/01, R. 10/12)1 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 SPS 383,33, Wis, Adm. Code when the tanks arc no longer used as POWTS components Septic or pump tank manhole nears, access risers and covers should be inspected for watertightness and soundness Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subleot 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 serAce septic tanks under s. 281,48, Slats The contents of the septIC tank shall be disposed of in accordance with NR 113, Wis Adm. Code The operating condition of the septic tankard outlet filter shall be assessed at least once every 3 years by inspection The outlet filter shall be Leaned 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 fitter when removed from its enclosure. If the filler is equipped with an alarm, the filter shall be serviced if the alarm es activated continuously. Intermittent filter alarms may indicate surge flows of 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 me contents of the tank are not removed at the tlme 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 An switches, alarms, and pumps shall be tested to verify proper operation. If an effluent flier 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 mulcted as necessary to prevent erosion end 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. COW weather installatlons (October -February) dictate that the mound be heavily mulched as protection from freezing Influent quality into the mound system may not exceed 220 mglL BODS, 150 mg/L TSS, and 30 rg/L FOG for septic tank effluent or 30 mg/L BOOS, 30 mg1L TSS, 10 mglL FOG. and 104 cfuf100 mL for highly treated effluent. Influent flow may not exceed maximum design flow speed 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 K orifice Gleaning is required to maintain equal distribution within the dispersal cell Observatlon pipes within the dispersal cell shall be checked for effluent pone ing, Fondling levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Dprltdnpe eyPlan 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, it the dosing tank, pump, pump controls, alarm or related wrong 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. Protmilitritent Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system Project: Page 6 of 10 Home > Sump and Effluent Pumps > 150 Series Effluent Pumps 12 = 10 162 30 e 25 t5t 1 10 2 5 0 t0 GALLONS Lf7ERS u 0 4f O PUMP PERFORMANCE CURVE MODEL 151/152/153 160 200 24 FLOW PER MINUTE 70 !nl Sump and Effluent Pumps // Effluent Pumps // High Hea Mate 150 Series Effluent Pumr Effluent or dewatering submersible pump for tank, low pressure pipe (LPP) and enhanced flc STEP systems. T-11` CAST -A -SEAL 4" CAST -A -SEAL N I• I U I'1 I' I ---__-----J"L 1 W1250/750— MR TANK SPECIFICATIONS o o a LL I 1 r DIMENSIONS it o WALL: 2 Ile n BOTTOM: 3' COVER: 6' MANHOLE 24' I.D. PRECAST CONCRETE RISER i HEIGHT: 66' LENGTH: 12'-11' > WIDTH: 7'-2• a BELOW INLET: 5Y LIQUID LEVEL: 46' E WEIGHT: 14,860 LOS. I a INLET AND OUTLET. 'v ' e CAST —A —SEAL BOOT OR EQUAL GASKET m STE »_ s INLET AND OUTLET BAFFLE AND FILTER: a k' iy WISCONSOL SEE DETAIL #10 o c (OTHER STATES SEE CHART) W o LIQUID CAPACITY: 27.66 GAL/IN (SEPTC) W 16.12 GAL/IN (PUMP) C £ LOADING DESIGN: B'-0' UNSATURATED SOIL m Lo ro TAM( CAN BE USED AS: = a I SEPTIC/SEPTIC, SEPTIC/SIPHON, N 4' VENT OR SEPTIC/SIPHON a M COVER: MIX DESIGN /6 (NO FIBER) W z TANK: MIX DESIGN #10 (STRUCTURAL FIBER) N u� co CUSTOMIZED TANKS: •simmimp D'TLET FOR CUSTOM TANKS CONTACT WIESER CONCRETE � V Ix I Z n � REVIEWED BY ti u MP PAD REVIEW GATE N a DRAWINGS SUBMITTED' FOR APPROVAL APPROVED BY: &4EET NO. APPROVAL DATE: z PRODUCTS NEEDED BY: /-F ƒ� \�\ram §■«..\\»� �\� 2/� \ y}M- 2 \ «J2Z' ^ �= � % » 7 � . 4° -4,Po.(�caa1( 'M ,l x,fia- Fecl f,/ K ZS n O'-" sYs ram.. I l Will Heidt Sal Testing W3503 Hemlock Road M (7 5) 579-9584 5 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Nathan & Katie Borowicz Mailing Address _2276 130th Ave Emerald, WI 54013 Property AddrM County Rd E (Verification required from tannin Zoning Department for new construction.) City/State _Baldwin, WI Parcel Identification Number _002-1034-40-000 LEGAL DESCRIPTION Property Location NW_ V4 , _NE'/4 , Sec. _16_, T _29_N R_16_W, Town of —Baldwin _ Subdivision Plat: Lot # Certified Survey Map # _I 108240 , Volume _30, Page # 6837_. Warranty Deed # _I 109864 (before 2007)Volume , Page # Spec house ❑yes Ono Lot lines identifiable ❑ yes❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §SPS. 383.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, 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. Itwe, 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 Safety And Professional Services 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe 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. Number of bedrooms_ SIGN*TAMk OF APPL C NT(S) g O( / 20-21;L, DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) 0 g! AE��.E.. �u.,w., ® b� tl��j?e 4"RE I I I I I I I � I •� I I I =r vo,„G.n rs NG,F Q 29' WERIIANG EAVES 12" OVERHANG W91E5 h NVICAL 5 S i �. Z .. �r V�• sa" a LEFT ELEVATION I FRONT ELEVATION 20-110 1-1 15 NOTE: HALFSOALE REDUCTION IF PRINTED ON lIX17SIZE PAPER j1A D A r ?M �D O z A C) 2 m r m D O z ow,u tj NaNan & Kabe srm Roof IANa p = ® ® 6 gp$O[ �aj((ya�r$a§ 6eE H�d��e�{F r - LFAeAe W o vo�.c R W _ 4 ti ti O — - G F O RIGHT ELEVATION � sd W 29' °VERINNG FAVE$ 13' GVERNl�NG W91F5 iYPIC4L sub[ �i9 to yy F " 3 E w �js J O CLr Fr E nu�aowo rasa Y [� � Pad a_ (y�Z REAR ELEVATION 20-110 �2/5 R IN O •Ww, 21 ul J Q= O 2� v CpFC R�I Fy f }}}}g {g Ai a e Ifill;� 6, p ix FaFPa�PF.ax�F x i -' ramie sun.�nxrsmew E snrar rxNm vux rxw'anoxiw w,e nun - •vrarneu aurwe mxnxurnox ZL '• ._. vCu 3- e • "" ''.\ ..... ... a CRFaT 0.00M �� b �• t i 4SEASON —n_avuu �-} p �� � $CAR CJAA(E ' ON Y•i m i e S$ p b 6011 r NTZ� OYtR r 7— �e . r 4 r CpVEREIt roRCH � MAIN FLOOR PLAN MA[N FLW0.-196fi 5F WPAGE,rSNOP = 2592 SF _ 20-110 �3/5 a a W R W � H k O a ®, W � m i� W ' � - a J � Y4 SECOND FLOOR PLAN izaa nRE reer ffi4/5 b s WIC 9 e $NMY 1 —we.sErawrm mse '��g{e�yk@ o [P�Pi �g��gng D BE6 P5 i �k tkk �5 zo we cwc.Ere PIED JQ N07E• COLUMN AND IROSSSPACING VARIES SEEFLOOR PLAN OPTIONAL POST FOOTING `sffPu rwococ rvurm E sna arorPnxsu�x � � zmroP Pa u 5yoF ^A Hill �n5 v�m msuunaxiwwsi FW s°, C fr � w a+svr wa.carz 5$ z' aiz.xPnrzo � sousxPwv n.n mrvreeresiew unv�ooxrwnms nox z.c xwm can mxcaE*e Eoo.i.c - WALL SECTION 20-I10 F5/5 St. Croix County Accessory Structure Affidavit Katie Borowicz Name — (Owner) Typed or printed He/she is the legal owner of the following parcel of land located in St. Croix County, Wisconsin, with their deed or document of ownership interest recorded as Document dumber 1109864 St. Croix County Register of Deeds Office. 1127849 SET PABST REGISTER OF DEEDS S.. CROIX cc., WI 04/ 1!r 2021 11:02 AM EXEMPT: REC FEE 30.00 PAGES: 1 Name and Return Address This property is described as follows (include lot no. and subdivision/CSM I tune Borowicz or detailed legal description): 2276 130th Ave Emerald, WI 54013 Lot 1 of Certified Survey Map, Document Number 1108240, (Volume 30/Page 6837) OR: [ 1 See attached deed copy for legal description Parcel Identification Number (PIN) mxi14ama1 As owner of the above described property, I acknowledge that the Private Onsite Wastewater Treatment System (POWTS) services both an existing principal dwelling and an accessory building on this lot and is sized for a (4) bedroom home, with a design flow of 600 gpd, therefore, a maximum of (8) occupants. This accessory building may not be used as a second residence on this parcel. I also acknowledge that I will disclose this information and stipulation to any future parties interested in purchasing this property. Dated t-iG day of PC w 1 \ av AUTHENTICATION t C.2 Stgnature(s)--- authenticated this day of , TITLE* MEMBER STATE BAR OF WISCONSLN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY: St Croix County Community Development ACICNOWLEDGNIENT' STATE OF WISCONSIN 1 )ss St. Croix County. ) Personally came beforeme dus O day of the above nJ�ay�ed, µ� -f —K�lC'!. y u e known to be the personts) who executed the foregoing i T ge the same • ��r �.....�..,,.�,yy4 3�y JU��E pNs�*Ti= Notary Pub c, State of Wisconsin ." My Co ston is permanent If not, state exptration date: (Signatures may be authenticated or acknowledged Both are not necessary.) Date: Q 00 f GC wloconsln��l1eediner(t df 8iteiy and Profmi4nal Services Division Of (ndtt9 ryServlra§ CS1`-aGal - d9� Pape of k 3 O 2021 SOIL EVALUATIOtW aPR lri ccardanoe with BPS 385, W5. Attach completealle plan on pAper not low tho' 2 x 11 Inches In size Plan most Include, out not limited to'. vertical and ittiti nce point (BM), direct?on and percent slope. sca's or dlmans!dne�f r, and Iocafon and distance to nearest roao Please print all information. Property Mvner Property Owner's Melsno Address ,2a?6 30' City i , State ZIP Code Parcell.D, t _0021031—`io—OOO—`f° —000 -- R4Vrjadby Date � PraPerty LGas ticnS+"o-, ,A660"1" t 23&P5 C-U/ rer • e ❑ 21 t✓ ��-� Govt. Lot yV I,J Y. Y. S /` Td4 N R /6 E (or) W i Lot # I Block # I Subd. Name of CSM# Phone Number I ❑ City ❑ %Alla9e gkTown nar—.le.te 1 1 New Construotlon Use: Realcienbal/NumberofbedroomoY_ Cole derived des?gn flow rete�op OPD ❑ ReplacementI❑PubCo or cornmarclal - Descr,be: Patent matenel ?qig r-r"� }X ' __ _- Flood Plan elevation U appllaable 144 ft General commseis and recommendations: r e cow( �nR� 1 b t'<5�.�S:.0 •«.,..�� (J-`F IOo�. e�47t2J1ep11:'ac�P.�T�--.%'Ds�� I i Bodng# ❑ Borina q44� -Pit Orounc Surface elev.lL—. Depth to limiting fectatr�O - Sall Application i Honzon Depth Dominant Color Redox Deactipllon I Texture Structure Consistence Boundary Roots OPD/Ft' +Effiil •042 In. Munsoll Ou.Az. Cant Color Or. Sz Sh. -- p:g �i.SY�'i,z 'rJ£ s FSSI 0VI 3 13_aD rlt;,;Lyj 1c5 '7-33 I_'�1� 44 _Y 3-vo 5 Vic Y I -7 I Boring#. Bonne go Pit Ground surface elev. z o;ft. Depth to limitin (actor' o J t Sall Ai3olloaticti Rate Horizo— n '�— Depth In. Dominant Color Munaell Redox Deaenptlon � Cu. Az, Cent Color Texture Structure Or. Sz. Sh. Consistence Boundary Roots OPDIFe 1Eff#1 °EtBr2 F �_'' ah�— r ��. Ixn4. — -- -- D 1 v 's rz a e-q b 1 d I - — S �C". � � ru � ¢Xrs1 `r 67_, - V_ Vr- •EHIueM.# �BOD.>�rQ S_ CST Name (Please Printl I>10s20SSa S /L a4 TSS>30L 100m L CST Number �< AddraegNill Heidt SO11 les,- Road Date rrpv�olustlon Conducted Telephone Number NGe�o-.'S, �t 1 5 %7�%�`�"1 Mondovl, WI 54755 SBD-8330(R04115) (715) 579-9584 fEI S I Boring # El Boring I - J $ Pit Ground surface eievL&&- ft. Depth to limiting factor� Horizon Depth Dominant Color Redox Description i Texture Structure �Sz. Consistence Boundary Roots wvvn nvl • GPD/F In, Munsall-- Qu. Az. Cont, Color Sh. { •Eff#1 'EH#2 o- /� I r I I a '&7 L 3 ,lY f3 512 S4:5- 1 ❑ Boring # ❑ Boring ❑ pit Ground surface slew. —A Depth to limiting factor In. Hcnzon -Depth In. DominentColor AUMIV Redox 2surlptlon vatads. Color Texture Structure Or. Sz. Sh. Consistence Boundary Roots u ^GPDIFr' • e •Etf#'1 `EffN2 I — i -- I 7 Boring # Boring Pit Ground surface elev. _ ft. Depth to limning factor _ In, Horizon Depth in. Dominant Color Munsell Redox Description Du. Az. Cont. Color Texture Structure Or. Sz. Sh. Coneletenca Boundary Roots VVII 11VVIIVAiIVII f[tlltl GPD/F? Hik1 -- ETf#2 " i Effluent 01=BOD,>305220MOIL and TSB>305150mg4 ` Effluent #2=800,>305220mg1LondTSS>305150mgIL o29.76 (S�o- e rfr. eP w 5"y�13 (IT5 i ORIGINAL y�-� b (p ego ..;o -'ter er{4 f�od5 Will Heidt Sal Testing W3503 Hemlock Road M (7d5) 5 9-95gq 5 1 NbL)Q-P 10Q,-2v.ZD Gv"77" u n �� (Ajw--&eA(661&A6 . C( �C COUNTY NO. 631275 STATE ANITAI�Y P (.*.2s+� 3��. a.E) PLUMBER Ni LIC. # 6Z TOWN OF g#LAW/P SEC- 6 , T_ N, AND/OR LOT . R_f(_ BLOCK UBDIVISION ERMIT O. _Z CHAPTER 145.135TZ) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and maybe renewed for a specified period. (a) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 e. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the cou V authority. AUTHORIZED ISSUING OFFICER - DATE THIS PERMIT EXPIRES 7f I T/ LO L SUNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R. 10/11) A Ii - -Ca-P nd 5fi v -a to 0 — ;�/s'H VFrllaTAtE\ �J r County Industry Services Division St Croix 1400 E Washington Ave P.D. Box 71sz Sanitary Permit Number (to be filled N by Cc) AUG 26 2020 \""?kaanent/ I Malillison, WI 53707-716 (v 3 12 -7� co" i Appllcatl State Transaction Number �PWTS G In accordance with SPS 383 21(2), Wis Allot Code, submission of As form propriate gove unit - 072001622-C is required prior to obtaining a sanitary permit. Note Application forms for stateowne submitted to the Department of Safety and Professional Services Personal information you provide may be used or ndary Project Address (1f different than matting address) purposes in accordance with the Privacy Law, s 15 04 1 m Stars r Cry Rd E --)�:23 ces- G 1. Application Information- Please Print All Information Property Owner's Name Par 1lnu.r��e� Nathan Borowrcc ff Property Owner's Mailing Address %Property Location2276 130"' Ave Govt. Lot NW R, NE G, Section 16 City, State Zip Code Phone Number Emerald, WL 54013 715497-5365 (circle one) T 29N R16EorW II. Type of Building check all that apply) Lot I Subdivision Name ® 1 or 2 Family Dwelli - Number of(aS ins I fps Block q El Public/Commercial- Des a Use ❑ City of ❑ State Owned - Describe Use ❑ Village of CSM Number�V. Q (�,;� D•Ct Q O ® Town of B DWIN III. Type of Permit: Ileck onl one bo on line A. Coin lete line B if applicabol A ® New System ❑ Replacement Sy in ❑ TreatmentlHolihng Tank R lacement Only ❑ Other ModificattoW Existing System (explain) I B. ❑ Permit Renewal ❑ Permit Revision Change of Perini er Nef List P� Permit Number and Date Issued Before Expiration her r OUv I W. IV. Type of POWTS S stem/Com onentfDevice: eck all tha I ❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ A e ® Mom > su Mound <24 in of suitable sod ❑ Holding Tank ❑ Other Dispersal Component xplan) Pretreatment Devi (e I V. Dispersal/Treatment Area Information: 9-14 Design Flow (gpd) Design Soil Application Dispe a qutred (sf) But Area Proposed (sf) stem Elevation 600 Rate(gpdst) 600 16 62 ✓ L0267 40 VI. Tank Info Capacity in Gallons Total p of t Man Manufacturer A� 't; U V New Tanks Lxisong Tan Gallons Units a` B 9 2 Septic or Holding Tank 1250 1250 1 1 HUNCUTT Dosing Chamber 750 750 V II. Res onsibili Statement- 1, the undersigned, ssume responsi Ofity for install 'o f the PO 7 XS ahowo 0o the attached plans. Plumber's Name (Print) PI er'a Signatur /MPRS Number Business Phone Number Todd Sinz 139462 715-235-2644 Plumber's Address (Street, City, Stare, Zip Code) E5609 708`h Ave Menomonie W154751 Vlll. Court /De artment Use Dot Approved ❑ D ved Permit FFte Date Iss ed I su g Agrtnt Si u j ❑ 1v nforDenial $✓D� 3�1�- Zol (X. Condition Approv oval 3) �>Wt�atft w. s Gv4 1z, SYSTEM OW �4 1. Septic tank, effluent filter and L)t oFrs dispersal cell must be / maintained i) f� tA' Vrµt 5ervced. as per management plan provided by plumber. P dum&!- 2 All Setbark rAquirPmPntq must ha, maintained a^ as per applicable ccde}8f19fti5 tTg!ale plan, for the sale," sad sobmi to the 'ounty on]) on pAper n less rhan 811. 11 inch" io aize SBD-6398 (R03/14)14,46 J{7\ 1t f{cr"na^1 `n'•raV71 `s,z fl`/'.u. /.i4.1•.TV` is tbn.ae �ma,r'f�. Dw 3Il��Zo r �'1-LSrn2, July 29, 2020 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2022-07-29 Plan Review: PWTS-072001622-C TODD L SINZ E5609 708th Ave Menomonie W154751 SITE: Nathan Borowicz County Road E Town of Baldwin St. Croix County NW, NE, S16, T29N, Total Amount: $250.00 DIVISION OF INDUSTRY SERVICES 2850 MIDWEST DR STE 104 ONALASKA WI 54650 Contact Through Relay http.//dsps.w gov/programs/Default.aspx wvnv.wisconsin.gov Conditionally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPO DENCE FOR: Description: Four Bedroom Mound em \ Vsfte\ite \ 2 BldgsMound Componem Manual—Ver. 2.Q, D-N.OI/Ol, 0/12), essManual — Ver. 2.0, SBD-10706-P(N.01/01, 00 GPD, 6" dept to ligrade, Maintenance required, Effluent filter,ructionThe submittal described above has been reviewnform ce with appl' bl and Wisconsin Statutes. The submittal has beeTIO ALLY APPRO D. and located in accordance with the enclosed aps d with any component owner, as defined in chapter 101.01(10), Wiscoor is responsible for comp No person may engage in or work at plumbing in the stats. The following conditions shall be met during constru Reminders • A sanitary permit must be obtained from the co) requirements of Sec. 145.19, Wis. Stats. Tony Evers - Governor Dawn Crim - Secretary rtion ent r fro ng al Iministrative Codes is to be constructed referenced above. The all code requirements. licensed to do so by the Department per s.145.06, ,n or installat\andrto occupancy or use: where this pated in accordance with the • Prior to construction of the dispersal area, fheck the moisture content of the it to a depth of 8 inches. Proper soil moisture content can be determined Jib ling a soil sample between the hand . If it rolls into a 1/4- inch wire, the site is too wet to prepare. If it crumblo preparation can proceed. If the site is too wet to prepare, do not proceed until it dries. • Inspection of the private sewage system ilation is required. Arrangements for inspection shall be made with the designated county official in accordancethe provisions of Sec. 145.20(2)(d), Wis. Stats. NOTE: Discharge of Non -domestic wastewater to this system is prohibited without approval from the WL DNR. Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also receive a copy of the appropriate operation and maintenance manual(s) and be responsible for ensuring that POWTS is operated and maintained in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • 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. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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 In granting this approval the Division of Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, /A =1 Gerard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892 — voice \ (608)785-9330 — fax Jc(L\ �Ni nn,r, i_�w MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Nathan Borowicz septic system. Owner's Name: Nathan Borowicz Owner's Address: 2276 130th Ave Emerald Wi 54013 715-781 4864 Legal Description: NW1/4 NE1/4 S16 T29N R16W Township: Baldwin ly ;ditio APP VED County: St Croix DEPT. OF SAFET AND PROFESSIONAL RVICES Subdivision Name: Na DIVISION INDUSTRY SERVICES Lot Number: Na Parcel I D. Number. Plan Transaction No.: SEE CORRESPONDENCE Page 1 Index a title Page 2 Data try Page 3 Mo d drawings Page 4 L eral and dose tank Page 5 ystem maintenance specifications Page 6 Management and contingency plan Page 7 Pump curve and specifications Page 8 Septic Tank Specs Page 9 Effluent filter Page Plot plan Designer: Todd L Si License Number: MP139462 Date: 07/16/20 / Phone Number: 715-235-2644 Signature: I Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SBD-10691-P IN. 01/01, R. 10/12), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01, R. 10/12) Version 7.0 (R. 11/12) Pagel of 10 Mound and Pressure Distribution Component Design Design Worksheet (R or C) R Residential or Commercial Design Estimated Wastewater Flow (gpd) Peaking Factor (e.g. 1.5 = 150%) Design Flow (gpd) Site Slope (%) Contour Line Elevation (it) Depth to Limiting Factor (in) In -situ Soil Application Rate (gpd/ft?) 400.00 1.50 600.00 3.00 101.00 16.00 0.40 Distribution Cell Information 100.00 1 Dispersal Cell Length Along Contour (ft) _ 1.00 Dispersal Cell Design Loading Rate (gpd/ft') 1 Influent Wastewater Quality (1 or 2) (C or E) E Center or E Manifold Lateral Spat (it) Number of Lat als Orifice Diameter "n) Estimated Orifice acil Forcemain Dlamete in Forcemain Length (it) Pump Tank Elevation (fl System Head (it) x 1.3 Vertical Lift (ft) Friction Loss (it) In -line Filter Loss (it) Total Dynamic Head (it) 3.00 2 0.166 3.75 2.00 350.00 78.00 4.55 23.33 6.40 0.00 34.29 Lateral Diameter Selection in. dia. I options choice 0.75 1.00 1.25 ! 1.50 x x 2.00 x 3.00 x Treatment Tank 1250Informat� .00 Septic Tank C acity (gal) Note Sand fill (D) calculations assume a Tattle 38344-3 in -situ soil treatment for fecal colifom of <= 36 inches 6.00 Cell Width (ft) Are the laterals the highest point in the distribution network? Enter Y or N If N above, enter the elevation it of the highest point. (it) = 11.11 ft2/orifice �HuffcuttconcreM ufacturer Dose Tank/Dosek 758.00 Capacity (gal) 16.85 Volume (galln) Huffcutt coanufacturer Project: Nathan Bosystem. Does the drain back? �Y Enter Y or N Forcemain Drainback (gal) 5x Void Volume (gal) Minimum Dose Volume (gal) System Demand (gpm) Man ld Diameter Selection in. dia N, options choice 1.25 x 1.50 x x 2.00 3.00 Gallons/Inch Calculator tional) Total Tank Capa ' (gal) Total Working Liqul epth (in) gal/in (enter result in CL B49) Effluent Filter Information Lifetime Filter Manufacturer LT1/8 Filter Model Number Page 2 of 10 Mound Plan and Cross Section Views —t 1 /�f J Observation Pipe © K 0 l�5] A W • g 0 • L Mound Component Dimensions Al6.00 ft 22.16 in H 1.00 ft B 100.00 ft F 9.50 in z 10.35 ft DI 20.00 in G 0.50 ft J 1 8.14 ft 600.00 (ft2) Dispersal Cell rea 1634.62 (1 6.00 (gpd/ft) Linear Loadi Rate 1 10.00 (1 Mound Cro Section Vie Aggregate ersal Area K 10.65 ft L 121.29 ft 24.49 ft lsal Area Available 0 B Obs. Pipe Placement Finished Grade 104.46 (ft) —� 2 G I H ❑ j I F Dispersal I 103.17 (ft) Lateral 102.67 (ft)—* — Invert Dispersal Cell Q; t Elevation D 101. (ft) Contour Elevation Site Slope Geot ile Fabric Cover Shading Key n Dispersal Cell See late al details on 0 Topsail Cap o 5 ft Page 4 for number, size, ❑Subsoil Cap a and spacing of laterals. 2 Ci ASTM C33 Sand ait © F Laterals are equally ®� Tilled Layer c 0.�5 ft Typical La am spaced from the distribution cell's © Aggregate a o<. centerime in the A distribution cell (AxB). Project: Nathan Borowicz septic system. Page 3 of 10 End Connection Lateral Layout Diagram Later als centered over the A 3 B dimension p 0sTurn-up xballvalve or oleo noutplug I All laaerads are identical IE X� I Holes drilled on the botiorn of the lateral I equally spaced 5 "lee main ecinnircnon Via tee W Of0££ to manifold at anit point Laterals &fwcemain Sch 40 PVC per SPS Table 384 30h Number of Laterals Lateral Diameter Lateral Length (P) Lateral Spacing (S) Lateral Flow Rate System Flow Rate, Total Dynamic Heal Orifice Diameter in Orifice Spacing (X) ft Orifices per Lateral It Orifice Density gpm Manifold Length gpm Manifold Diameter It Forcemain Velocity Dose Tank Information Electrical as per NEC 3D0 and SPS 316 300 WAC Tank component Is property vented Huffcutt concrete Capacityl 758.00 Volume 1 16.85 Manufacturer Gallons gaVinch Dimension Inches Gallons A 24.23 408.30 B 2.00 33.70 C 8.75 147.5 D 10.00 168. Total 44.99 75 0 Alarm Manuafacturer Alarm Model Number C L Pump Manufacturer JZoeller Pump Model Number BN140 Pump Must Deliver 29.08 gpm at 34.29 ft TDH 1 'Locking Cover with warning label and locking device and sealed watertight 4 in. min. Aftemate outlet location Forcemain diameter 2 in. Weep hole or anti - siphon device ovation (ft) 79.83 Note: Switches containing mercury may not be used in this system. Project: Nathan Borowicz septic system. Page 4 of 10 Mound System Maintenance and Operation Specifications Service Provider's Name T L Sinz Plumbing Inc. Phone 715-235-2644 POWTS Regulator's Name St Cro x County Zoning Phone 715 2-4680 System Flow and Load Parameters Design Flow - Peak 600 gpd Maximum Influent Particle Size 1/8 Estimated Flow - Average 400 gpd Maximum BOD5 220 Septic Tank Capacity 1250 gal Maximum TSS 150 Soil Absorption Component Size 600 t Maximum FOG 30 Type of Wastewater Domestic Maximum Fecal Colitorm >10E4 Septic and Pump nk Effluent Fil Pump and Controls Alarm Pressure System Mound Other Service Frequency Inspect and/or service once ever r ears Should inspect and clean at least on5f every 3 years Test once every 3 ye Should test mont aterals should be flushed and pres5gre tested every 3 years I _nspect for ponding and see once every 3 years Call T L Sinz Plumbing for ybur service needs. 1. Observation pipes are slotted and materials onform to and are secured in as shown in the mound c ponent 2. Dispersal cell aggregate conforms to SPS 384. (6t' ie 3. All gravity and pressure piping materials conform the 4. Tillage of the basal area is accomplished with a mo bj 5. The mound structure and other disturbed area will b and help reduce frost penetration. Finished Grade 6-8" Diameter Lawn Sprinkler Valve Box Distribution L I I 384.30-1, have a watertight cap, . Adm. Code. iirements in SPS 384, Wis. Adm. Code, or chisel plow. ed and mulched to prevent soil erosion .......... .d Cleanout Ball Valve Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Nathan Borowicz septic system. Page 5 of 10 ■its Mound System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-84 We, Adm. Code, and shall maintained in accordance with W component manuals [SBD-10691-P (N.01101, R. 10112), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD- 10706-P IN 01/01, R. 10/12)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 genes may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383.33, 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 a. 281.48, State. The contents of the septic tank shall be disposed of in accordancewith NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet fitter shall be assessed at least once every 3 years by inspection. The outlet fitter shall be cleaned as necessary to ensure proper operation. The fitter 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 fitter shall be serviced it 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 then 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 en efliuent firer 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) an 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 BODs, 150 mg/L TSS, and 30 mg& FOG for septic tank effluent or 30 mg/L BODs, 30 mg/L TSS, 10 mg/L FOG, and 104cfu/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 lt should be compared to the initial test when the system was installed to determine 0 orifice dogging has occurred and orifice moaning is required W maintain equal distribution within the dispersal cell. Observation pipes within the dispersal tail shall be checked for effluent pondmng. 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. Continency Plan If the septic tank or any of ns components become detective the tank of 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 components) 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 wit be repaired or replaced in its' present location by increasing basal area if We 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. Pretreatment Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project Page 6 of 10 1q0 Flow -Mate In high head dewatering or effluent applications where pumping performance is critical, this robust family of pumps is known for reliability, durability and performance. These pumps are especially suited for harsh environments. Zoeller's cool run design and corrosion -resistant, i; powder coated epoxy finish add up r. to a long-lasting, trouble -free product. it r �s ti ° APPLICATIONS: • STEP or onsi[e epplim ns .,•,� ; • water transfer �� �O • Light commercial dew grin ,.i SPECIFICATIONS: i 1/2" NPT discharge 'h HP through 1 HP • Available in automatic or nonautomatic • Model 137, 139, 140:1/2" (13 mm) spherical lids capacity with vortex impeller • Model 145: 3/4" (19 mm) spherical solids ceps vortex impeller -: • Bronze construction available (139 series) • High head version available (145 series) 1 • Double shaft seal versions available for added prc on models 140/145. J For more information, see Technical Data Sheets FM2. with aaww6r.5n6 152e56 9 Dose -Mate This is our fastest growing line of effluent pumps.The 150 series is truly d a workhorse designed for reliability a under extreme conditions in an effluent environment.150seriespumpcurves 6 cover a wide range of applications. IC They are well suited to applications 1 with low pressure pipe (LPP) and rI enhanced flow STEP systems. Zoeller' coal run design and corros resistant, powder nish, 1 in addition to the hermeticall ealed,oil-filled motor and non -clogging vortex imp r add up to a long-lasting, e trouble -free product. i 4 APPLICATIONS: j • STEP or on applications Light co ercial dewatering • 1' NPT discharge 10 HP through 1l2 HP Available in nonautomatic or with a variable level piggyback mechanical switch i • 'h" (13 mm) spherical solids capacity with vortex i thermoplastic impeller '! For more information, see Technical Data Sheet FM2784 JM"!�"ERFORMANCE ,I s !„■■■•FENEN ®,,,..■,AVENNE ■■E NEED MONNE NVENVEORMN LITt" 6 W so lk td0 26o 210 2io 3i0 FLOW Plit MtM 4 �w 8 0All rights reserved. ZOELLER PUMP CO. 1 502.778.2731 1 NO.928-7867 (www.malleccom ' 4&rdbTT' 1,250__750 i I I I TANK LABELP 2' HIGH CONCRETE i FORMED LETTERS I I I I I I I I � I I OUTLET SIDE ELEVATION (TANK BASE, TOP, L COVER) ------------------------------ 3' 60' 3' 74' _ATION. DNS 0 The Best Just Got Better The most efficient, the lowest maintenance, the most economical effluent filter! Nearly Twice the Filtering Capacity • Estimated to go 3 Times • Longer Between Cleanings • , 0 Cleaning Made Easy • • Does Not Retain Solids Between Plates • Lowest Price • OINV- mom o - Eliminates the collection of solids inside the cartridge. - Nearly twice the filtering capacity of any other filter. - By eliminating solids between plates drastically reduces the need to clean. - Cleaning made simple and efficient. OOMM - LT-1 /8: 3500 GPD/Residential Strength 4 Filtration 1/8" - LT - 1 /16: 3350 GPD/ Residential Strengt Filtration 1 /16" - LT - 1 /32: 3000 GPp/Recommended for Commercial Use with Residential Strength - Filtration 1/32" - LT - 1 /64: 2500 GPD/Recommended for Commercial usage with Residential Strength - Filtration 1/64" - 2700 Inches of Linear Filtration (Nearly Tw;rp tha rmmna+;*;„„l I r- 00 Pe2Sao �2 sir (ZS'a /-7S-o eu%M U-a f1A vt- PtA- 145 (k5rlM n2t��S q„ C. d lyp ��1•U9u t2t, Z9 0�� \� l 1tlYLaEas'�`"fi it Z r/ W.wtmb o.ortim tof aww rw pmbodow aNvot" nvrramm�>a�a«vi4. SOIL EVALUATION REPORT Ie4oardr,O.wMW63WVW. AdM COU Coa�tr h� Im bodmx t PM MN� dnWoe�rw4rmts4@4 PuaMID. 000 Or dbmMft am" MM. at bcogm mw dbWm b mermM rad. rww "W eN oalor�ryr� aMrwd bl PW I of s- Iplowly owm ftwtY tawam _ ❑ C. OM Ld J� k,j A N E X A 16/ `T X R 0/ E (cfj VV ft4m'OWWSMmftAft M Lots BbOk! 8ubd.Nrmeroew -2 (}� e.�ti Bfue , aP 0.0* Phon Nwtbr ❑ a* _ ❑~ a Taws NOrwERwo {MNWCWA melon U@wWRwidrpij*jrbwdtrdtm�r cod.dOrlwdewgntlow AppO ❑ RePhwment P�wammwnolM—D�re _ tmoapw.rrdonrcwRo.etenT�.rt. Gw rw wm ww gg V —eA55-% . o.Palro>ilrm�t��M. �1 1 MM �om ..- c��ra�r�■r�rr� sm tom, DO* Ca* p. t OL In . CAL Ai '� T06n ah� a Ca�r6YnaO Pa Ri amain eumm nmoarur- LIn. ■ P ° amain svbom wvkl-3. Depth fo know bdor 4hL �[t�+t•ii/Y-iT.iIG�'7���i ■4Zt�����pF��i a �.�� �I � L1 ara�d aroma dW. _.._ R Dpth b l�dlfl� ho0a', M. 11010 1 Dopd� DCMIIM"C RodmcDaoa131bn Tom CoraAbnao ftwvwy Raab h� am Ou Cad Colo rk.6r.. -Pm wrdit*RM,v3O% 1%LondMl=d160mp11 '@IM*02-B=, Sdt220TpILmdTdfa3Dgl5Dn OL . f-�r rc-zq-A"0 9•-ryv",- /Z)O.o rm Will Heidt Boil lest".1ci, IN3503 Hemlock Road pADrIdovi, WI 54755 717,-S79-9584 APPLICATION FOR REVIEW >� ®S • \i y -Complete an pages - Ps NOTE: Personal information you provide may be used for secondary purposes [Privacy Law s. 15.04(1 xm). Slats.] Private Onsite Wastewater Treatment Systems Division of Industry Services ffi-Prans to be E-filed. Provide SharePoint User name below For plan status, check out website at Email technical code questions to "_ _ _.._'_ L :" , ___: _ Several counties have been delegated certain authority to review plans in lieu of Division of Industry services. For a current list of those counties and their designation check our website at h it+•-c: -_ 1. Project Information - Fill in as known Information. Confirmation of assignment to a reviewer. ProjerdlSfte, Name: 1Q6rotj(c-z &�I (L Transaction ID: Location, Number 8 Street project (if unknown, indicted nearest road) Previous Related Trans. ID: Estimated Completion Date: Assigned Reviewer: NIi� Legal Description: lJ0'14 6 N S ( 6 TZ014 County S f i rp OL Assigned Office: Mail to your oRfu of choice below: La Crosse, Green Bay ❑ City ❑ V'dlage 09rown of j3*A W1AJ 2. After Plans are reviewed, please: (check all that apply) ❑ Call customer 1, 2 (circle number)' NOTE: We reserve the right to redistribute plans to another office If ❑ Requesting party will pick up needed to reasonably balance turnaround times. Check ❑ Mail plans to customer 1, 2 (circle number)' for next avaaable review dab 'Refers to customer number from below. 3. Complete the following designerlownedrequaw ing Information. Utilize the check boxes when designer, owner or requesting party Is tiro same to avow repeating informatlom Designer Information (Customer 1) DSPS Other Please Specify Below (Customer 2) DSPS First N Las�jJameZ Customer Number First Name Last Name Customer Number �O �jfAJ 6Z �4� Comparry Na L /NZ ?W 4 �L/ xy �/U L Company Name raj Address 5107 lbf � AV4 Address city Hew li'tAl tt C State c +4 (9dIgits) City state Zip+4 (9 digits) Phone Number E-mail address Cell phone Phone Number E-mail address Cell phone area code t- ) I ItJ - I+�� uotf � (area cede " ) Check if applicable ❑ owner Check If applicable or specify relationship Owner ❑ Other - specify relelionshi Information and Plan Submittal Checkllsta To request electronic plan review complete the appropriate application forth and e-mail it, along with your registered SharePoint usemame to_'"'i_ �___ "- - - c ,.- ,. If plans are being submitted via paper, they Will be assigned to a reviewer after receipt at a DSPS office. Submittal checklists can be found in each applicable component manual appearnLIg on the POWTS Program page under PublicationsIF�;:i: �•,�:na :,.,r�: La Crosse Area DSPS Green Bay DSPS 3824 Creekside Ln 2331 Son Luis Place Holmen, WI 54636 Green Bay, WI 54304 606-785-9334 920-4925601 Fax, 608-785.9330 Fax 920-492-5604 EmaIL _y;5_.:I�I,;u :ct.ec,_e a,cnT. ov EMait:_i s_ 1J 1, ";': ,,.. , Make Checks Payable to: Division ndusfry Se a OR heck box to invoic esign sign below TOTAL AMOUNT DUE $ 20 Designer signature Review Code 7633 SPS-10577 (R 4/18) 5. POWTS SUBMITTAL (check all that apply- Incomplete forme may result In processing delays) ❑ Aerobic Treatment Untie) ❑ Chlorinator ❑ Tank Replacement Only ❑ REPLACEMENT ❑ Commercial System ❑ UV Disinfection Unit ❑ Add Effluent Fitter SYSTEM TYPE(S) NOTE: Submit separate sheets for each system 11 submitting multiple systems on the same site Enter Fee ❑ Revision to previously approved plan $95.00 ❑ Miscellaneous Review 0.9. replacement of a septic tank, addition of an effluent filter or pretreatment drAce to an existing system, etc.) $80Ihr n'Compment Manual All treatment components are previously approved ❑ At -Grade Component Manuel - Ver. 2.0, SBD-10854 (N.03/07, R. 1112) Design Wastewater Flow In under s. SPS 384.10 (2) or (3) ❑ In -ground Component Manuel - Ver. 2.0. SB0.10705-P (N.01101, R 10/12) Gallons Per day Design wastewater flow of the proposed system: [Wound Component Manuel - Ver. 2.0, SBD-10691-P (N.01101, R 10112) /^ p ❑ Pressure Distribution Component Manual-Var. 2.0, SBO-107D6-P (N.01/01, R 10/12) D 1.000 gpd or lase $ 250.00 ❑ Other - Please specify 1,001 - 2.000 gpd $ 325.00 2 001 - 5 000 400.00 ❑ Soil Based Individual Site Design' One or more treatment components are not previously approved under s. SPS 384.10 (2) or (3)• ❑ At Grade (Individual she deogn/deviatton from component ❑ Non-Pressudzed In -ground Design manuals and use of components without product ❑ Pressurized In -ground Wastewater Flow in approval): ❑ Mound Gallons Per day Design wastewater flow of the proposed system: ❑ Drip -line ❑ Constructed Wetlands GPD 1,000 gpd or less $450,00 ' Documentation must be provided to support treatment and dispersal chime. In a separate 1,001 — 2,000 gpd $600.00 statement, provide rationale for the protect and attach supporting documents (code swims, test 2,001 — 5,000 gpd $750.00 reports, tectmlcal papers, research articles, etc.) greater than 5,000 gpd $900.00 plus $0.08 for each gallon over 5000 gpd State-owned facilities: Design Holding tanks previously approved under s- SPS Wastewater Flow In 384.10 (2)(3). Design wastewater flow of the ❑ Holding Tank Component Manuel, Ver.2.0, SBD-10855-P (N.03/07, RIM 2)' Gallons Per day proposed system: ' Non -state owned Commercial and Residential Holding tanks that completely ublue this manual 5,000 gpd or less $ 90.00 and have an estimated daily flow of less than 3000 gallons per day must be submitted to the GPD 5,001—10„000 gpd $150.00 appropriate governmental unit for review instead of the Department. [see SPS 383.32(3xa)] greater than 10,000 gpd $225.00 ElHolding Tank Individual Site Design", (i.e. site constructed. <5 day holding capacity, Co- Design Holding tanks including she constructed tanks NOT mingled wastewater, etc.) Wastewater Flow m ly approved under s. SPS (3). Please specify. _ Gallons Per day Design wastewater flow of the proposed system: Design posed s st m 5,00gpd or less $0.00 ' Documentation mull be provided to support the rationale for the project In a separate statement 5,001 — 10,1100 gpd $30300.00 please include all code sections, test reports, technical papers, research articles, etc.) GPD greater than 10,000 gpd $450.00 ❑ Soil Saturation Detenotnatlon Report (using obseivatlon pipes) ❑ Interpretive Determination $240.00 ❑ Experimental System (One time additional fee). Submit fee for individual system as per appropriate above system type) Experiment Number _ $400.00 Priority Review (enter some amount as normal review fee listed above) $_(%� Enter Total (rounded to the nearest dollar) $ n SPS-10577 (R 4/18)