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008-2009-01-000 (4)
TYPE MANUF C R V CAPACITY Septic Dosing tl Aerat ia Holdin , TANK SETBACK INFORMATION TANK TO P!L WELL BLDG vent to Air tntake ROAD Septic y � I � � I 2 lea Dosing it Lt U 11 rr Aer n Ho g PUMP/SIPHON INFORMATION Manufacturer CA F�3 Model Number r- Z TDH Lib Friction �oss� Syslem Head TD� 1 FY Forcemain Lengt Diiaa((1Jn 1 t Dist to well i o JJ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes (Privacy Law. s 15 04 (1)(m)) Permit Holder's Name City Village Township Mary Vadnais TOWN OF EAU GALLE CST BM Elev Insp BM Elev , BM Description .L'. TANK INFORMATION ELEVATI Z T St. Croix Permit No btate Plan ID No Parcel Tax No 008-2009-01-000 Secuon/To-n/RangelMap No 01.28.16.568 STATION BS HI FS ELEV. Benchmark All BM Bldg Sewer , St/Ht Inlet SUHt Outlet DI Inlet f Dt Bottom •$ 1.S-7- Header/Man. 3 `S Dist. Pipe Bat System j de ta: U rZ Or KC A 1 _6 77' 8 `r 3 Boa a IM 3. e o3. o loo. o PAL PACCIU [r 1 IUIv STJ I tM R Width Length DIMENSIONS I No PIT DIMENSIONS No Of Pits Inside Dia. Liquid Depth Z SETBACK INFORMATION YSTEM TO k1i0. LDG WELL LAKE/STREAM LEACHING nufacturer CHAMBER O UNIT Type Of System i 2n -) 1 i ] ! � Model er I'11CTCIQI tTtnst everese Header/Mandcl I � rstnbuuon , , If p pets) rr=h/ x Hole Size rr x Hole Spacing Vent to Air Intake Length oia J� V —JII' Length Dia Spacing �4 5, Q cnu rnvco _ Depth Over Depth Over xx Depth of xx Seeded!Sodded Mulched Bed/Trench Center Bed/Trench Edges TDpsod ._. xx Yes No __ - ' Yes No COMMENTS: (Include code discrepencies. persons present. etc.) Inspection #1-V4tAl (,(/o j*K6 ins /y t/Qn/#2 � Location: 598A 270TH ST y S14% 4V 1 L 1.) Alt 8M Description = Fell, .�lrt:r�l"tro�ia'ii��S�! 2.) Bldg sewer length = Z 3 l - amount of cover = S,tt -RA"4e- -3 as pv Plan revision Required? Yes No 9'7G /� Zz4 Use other side for additional informati Dd1E Inse ctor's bi nature r D•6710�R.J'`7) ` � P 9 Carl No Ir a. S`r��-* W;l( y21�t�r�� . 3.0 r�s e,. l{,er-� uT.r►o.. s�i Industry Services Division county 4822 Madison Yards WAY Madison, WI 53705 saaitay Permit Number be filled (to in by Co.) l%4lh 4!%' Y P.O. Boat 71k-!� Madison WI537 6 q,� 00nynt 5�'��,1 Permit Applibatio star TraassAiorr Number to accord a v� 11(2), will. Adnm Code, submission of this form to the emcaaamtund J" W TJ - $ O - C- is roguirod o6tammg a sanitary peanut Nose: Application forms for sate-*"POWTS arc submimod to Project Address (f dif thus -oiling address) the Department of Safety and Professional Services. Persaul information yor provide may be used for sc000dary in eccadaoce with the Pri lAw, s. 15.04(1 xm), Sets. Sq (day �� �a r b/ i. A tkm Information - please Print Alt laforaat OU 1 I ca 1 Property Owner's Name Parcel 0 R cy 1IAJAU, 40,6$- db69- d%- ado Property Owner's Mailing Address pry l cabou 598 A '? 70 r—5 r cloth. Lot City, State Zip Code Phone Number W 426d uiu 'r !J I rya e —V-1V' N-111' Y.. section 1 11. Type of Building (cfieck All that app1Y) Lot A T a8 N R /1 ©1 or 2 Family Dwelling - Number o cams a / Subdivision Name a DlubhoCommencud - Describe Use Block # W V1rr J�I+rE �- Dutyof iry of fate Owned - Describe Use CSM Number of Y]Toan of EAw 1, ALLt - ej& M- Type of POW7'8 Permit: (Che& either "N or "Replaeemeur and other applicable on Mae A. Cheek one boa an Hoe B. Camplae Mae C if applicable.) A' Syatasu I LL❑JJIairotmd psepecemew System ❑Other Modification to Existing System (explain) :]Additional Pretreatment Unit (explain) B' []HOW" ~W" Tat1r (eeowMivsul) Ou4rade Mound 4 Z. Iodividrul Site Dtarga TIPS (axplaa) C. Rmeml Before Elpe isioo of Plonber u' -21"Ies to New Owner Previous Permit Number sod Dale Issued Expiration rill. Dispersallrreatment Area and Teak Information: 'LD r Design Flow (gpd) Design Soil Application Rate(gpdrst) Dupetml Area Rogrmcd (st) Disperssl Area Proposed (st) Systtmr Elevation i 3 a0 /. g I Sad 1 346 1 99. as `•., 97. a to.)re. Capacity in Total N of Memriachsrer Gallons r R u Tank Information New Tads EdsftTmdu Gallons Um �st Gl�-IO 94mPC/`\/1 s g U iA v. ueWooarsmisy htatement- 1. tb taaarsfped, assum respossibilky Ear iastRutlan of the POWTS shown an the attacbed plans. Plumber's Name ('Print) Plumber's Si MP/MPRS Number Business Pftam Number w , >'+ -�' (, / /a93i99 71X s77-_r.?eo P.Q. 6av /03 E.4w L"CA/R.! WX J' 76; Vl. CousitylDepadment Use Only Approved ❑ D' Permit Fee Date issued issuing Agent Signature ❑ Given for Denial S r it Conditions erHisovaF 3) AP eN c { ASPS ' 44 Par z) Jkl So)Icb ✓t: �a K vu�d � M�txMno: t`o•, �6 o an f pu}tl,�- ' cse c%tuor.tcps f f �1 Attuh to r..O- 0- plams rat the syglen mad sahoh to the Coney tub an paper art hu thin a vt 111 lodes to An SBD-6398 (R- 03/21) F J /yi�A(Y /JAfQdAfS - ?8A 176 re Sr,., Iar /, V11irt Ajdr Ive.4odas WE, We /, 18Ad, /4 ndu aF EAu GAacE, ,�urrLa, f O io' Ya 07.65' A•cAr ear Att S/S 323.VS SfrQACrs,rr^r t N Art- /oo. o roA 01 O N 7 /at.7 70A a r Lor / r r 6 x So A mrx CELL .T2,.s `r 70 ` iYeuro /a..i rs �bS o,.i 97.8 Ga,ire�� LAr, AoAEc,- 9Rss` -W vAk ScN. ya , Fa dC[ AAA+ ��O J SKAAJ y3o/Sao A!cAyAO rwK y /ec 3d7v ,2-1a. Pew .sAvro ® `it*AWo (1Et AvulraAy A H h 8 P< f JVIJ Wisconsin Department of Safety and Professional Services Division of Industry Services 4822 Madison Yards Way PO Box 7302 Madison, WI 53707 August 23, 2022 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2024-8-23 Plan Review: PWTS-082201980-C Michael Hassett 1503 Fairway St Eau Claire, WI SITE: Vadnais 598A 270`h St Eau Galle Township St Croix County NE'/. NE I/. Sl- T28N — R16W FOR: Description: 2 bedroom-300 GPD — 21" to limiting factor- Effluent Filter - Maintenance required. Phone.608-266-2112 e Web: hup:!/dsos.e-i.eov Hmail dsos( vsisconsmsov Tony Evers, Governor y, p4 Dan Hereth, Secretary coneftwow APPROVED DEFT, of SAFM AND PROFESSIONAL SERVICE. DIVISION OF MIATM SERVICES SEE COMESPONDUCE Mound Component Manual — Ver. 2.0, SBD- 10691-P (N.01/01, R 10/12) Pressure Distribution Component Manual — Ver. 2.1(May 2022-2027) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the'enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • The site shall be properly prepared prior to plowing. Any grasses longer than 6" shall be cut short and removed. To avoid matting, any leaves or loose organic matter shall be raked up and removed. Cut trees and shrubs flush to the ground and leave stumps. Avoid operating equipment on the Mound site. If necessary, use only tracked equipment, during dry conditions, with minimal passes, to avoid compaction. • Components and soil removed from an existing drain field shall be properly disposed of so that there is no risk to public or environmental health. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. • 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. 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. 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, Joshua Rowley POWTS Plan Reviewer, Division of Industry Services (715)634-5124 Joshua. rowlev@wisconsin.gov Page j of Q Private Onsite Wastewater Treatment System Index and Title Page Project Name: /%Aty !/AONA/S- ,7-/Sc /`fnrra �oUrs ��eu� Owner's Name: " Owner's Address: S98 A ,776 r� Sr APPROVED cor nc ceccry eND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES Legal Description: NE. NE / dBN /L QI SEE CORRESP Municipality: Town Village, Ginty of EAU L7A[14[ County: 5 r Lot Number. �, Block Number. CSM Number. Subdivision Name: LJN/r[ i�/rE /'/OA 06 u S - S9$ A 76 Parcel I.D. Number. D08 - Joo9- oo0 Page I Index and Title Page Michael J. Hasset Paget Plot Plan Wisconsin Designer Page 3 Cross -Section & Plan View D-1 1 5 2 Eau Claire, WI Page 4 Pipe Lateral Layout Page 5 Septic Tank / Pump Chamber Cross -Section & Specifications Page 6 Pump Performance Information Page 7 POWTS Owner's Manual & Management Plan Page 8 POWTS Owner's Manual & Management Plan Page 9 Filter Information Name of Designer. %''icyAEs -77 1�6s.serr License#: J-//S7 Signature: Date: I esimed pursuant to Wr following POWTS Component Manual and DSPS 381 385: Mound Component Manual for POWTS" Version 2.1 (May 2022-2027) "Pressure Distribution Component Manual for POWTS" Version 2.1 (May 2022-2027) Attachment: Soil Evaluation Report P O PLAAj /yi�(Y U�lOdR�S- SpBA ,174t:W Sr./ Ldr / L%Nirt Air-fFAAdAs /V E Al El /, aF /jA ,Q f • Aa t t F, uJ j d, T a � O 4o' Yo .4c4r tar A[t -5/5 383.'/3 Sfrdtcxs r,,r I ` �®/ e .Qrl -AO. o Too eF I ti /O/. 7 ro,4 o f 9zs` CG y ,4 uE G = s0 ,(pcX [ELL It/Ad Sis. Ec.- pppp /l.OS a•J 9%8 faJ load- • Ar. ✓. Fi. - 99. SS p/,)rs P a 97.Y' ,? Ax ScM. ya SKA J %SO�SOO �� �Ao J IArc Y /uc 311y, .7- sd. Patr ,54. ® j�itd/osco � lrr�L D.ci�tvAr A- 598R ,?7o n" Sc D M / ;-,r ft Z M Z17 ft Ir a ft G = It a M ft A = 46 ft B M J-40 ft I = I ft * M 75 ft * M /6 ft * = 70 ft * M .11.5 ft 4' $Ch. 40 PVC observation pipe 1.5 ft 0.5 It S,/TOP SM GEOTE)MLE FABRIC COVERING ASTM C33 SAND FILL Top WL TOE E Page 3 of 9 UPTURNED LATERAL A ACCESS BOX OBSERVATKM PIPE A WATERTKNIT CAP IDISTRIBUTION LATERAL( /YJIn. 6ch.40PVC DMN Lateral Invert El.= f ?. SS It FORCE MAIN (2- sch. 40 PVC D2885) —2—% SLOPE DISTRIBUTION CELL ft x XQ Itz 360 ft'(0.V-2.ra9greg@ts) Min. Required a 300 + A 40 z 300 fe Fr Ox A Ox 19 PLAN VIEW OF MOUND System El.= 99. 03' ft Conbur El.= ?1.8 ft Observation *0 r Observation pipeSe Id k*4 r Force .• Main ;� 'I. Distribution Call 8.3 It (0.5-- 2.5- sairepse) OW""'on Pon 4t 3 It z /I, JO' (A In. sch.40) OX- Upturned Lai" With Access Box Prohibit disturbance and vehicle traft wt#*i 15 It of downslops too. 1 1* - I 7d Bass! Area x 54 Rx 7545 re Min. Requlreda 300 + . Y z 7-f0 fe HOLE DIAMTER = 1 in. LATERAL DU. _ in. MMIFOLD DIA. in. (sch. 40 PVC dire D2685) FORCE b0►IN DIA.= _�_ in. P y$ ft. a 3 ft. X 3 ft. Y 3 ft. AJANIFOLD ( I .t In. sch. 40 PVC D2665) PIPE LATERAL LAYOUT OF MOUND (End Manifold with Aggregate) ht0OB6 �JmOa�`A9evC,� s�ee FORCE MAIN (2' sch. 40 PVC D2685) Aocess r8ox Minimum Number of Holes = 340 ft2 + 12 = RX Holes Page Y of 9 HOLES LOCATED EVENLY ON BOTTOM OF PIPE. 1 Holes/Lateral x 2 Laterals = 3 Y (3/16') Holes x 0.66 gpm / (3/16') Hole = ,% Y? GPM = SYSTEM FLOW RATE i PIPE VOLUME = 9G ft. Laterals (total) x 0.092 gaVft. = 8.8 x 5 = VY GAL = MINIMUM DOSE VOLUME PIPE INVERT ELEVATION = 99. SS ft. Page S of 9 COMBINATION SEPTICIDOSE TALI{ CROSS-SECTION — towUnnNc WT TO SCALE) FINAL GRADE MANHOLE RISER & COVER (sbw Craand surtaee am Gom cW e I aas.� a (a)• bik E w •� a Eatsnd (Owftte(s) for Pop" ammo" �� as r �a T k*L gar. 40 PVC Tart vent s tifn Sa. �b pvc Tani vru ELECTRICAL toaere1r—+ateoru• BUILDING SEWER loaladlrabove grada"2P JUNCTION BOA '°O1t ttaplonal Noad Bawran laW WS 32230(11)) above Rapiarul Flood Savatlon (ter vdh Cps 71 a nd aNEC 300) ............ ............ FORCE MAIN OPTIONS r� i se'mwr r� ale• u >waroio cE ' � -- `1 borlou or aeaT pnwrt It P laam�ter ,8 cs r p.•. c ann�a onrre raaarp� �s�r'atl�SOM RW e r frvlaaa �OAQ� •• Uarloa ...................................•.......................... MINIMUM OF 3' OF SUITABLE BEDDING BENEATH TANK & MAxrMUM BURY DEPTH OF gir Atrho ft of tart may be rat)tired per SPS 383.43(8)(g) Tank Manufacturer. ,SKAU 1d rews r Daily Wastewater Flow (DWF): 300 GPD Septic/Pump Size: 7,f4e /soo gallons Number of daily doses: 51 ( /9.9 9. Alarm Manufacturer S or #a/c it Model Number: .,r r4'l Switch Type: /'1EcNw.rrc�c _� Farce main volume: S'O ft x . /L! galfll _ G. S gal Actual dose volume: L y gal - _yt.. gal = 57. S gal (total dose vo)ume - volume orforce main) Diluent Pump Manufacturer. Lrrra bu,+r DOSE TANK CAPACCi ES: Model Number: 9 EC Reserve above alarm m7/. S in = 344 gal (D) Minimum Discharge Rate: 1, Y1 GPM Alarm float above on float .i in a WAS gal (C) On/Off float measurement YX In - 40 gal (B) Vertical lift (pump off to lateral invert). ............ ft Off above tank bottom g in = /J 3.8 gal (A) System head (distal pressure J. S x 1.3 ft): 3.3 ft fo ft Force main x /. 2 /1 DO friction factor . S ft (DOSE TANK DIMENSIONS: Filter friction loss ...................................... — ft Length /30 in Width .77 in Total Dynamic Head (TDH): /.3. y ft Outlet height —U in Ga1ion9finch f J'J1 EFFLUENT PUMPS 9EC SERIES - 00 HP W-OA-4S v 9 -aw T n.101t Imo, "(0) *C-m xc�sos aran.w� �m.� sEca�-A� nrc:eo..�u as'tus.�u e�Ru..0 me wponL.les*u�a� it C0m EpOIpi�w" cut lhwwaka Notes cast ion mwdwrAiuw dnbnler Who cWton No want Steel Nadwdw'smsd NIMwiMatbonadaadc FnMnm Stailkss Shd �� llppss�IDeiod aid bOboft Po1Nt Cad SJTW OUTOW •ars.wd 'o�1PlK-0t#�18-0In�! (am -a" ®ftinMln atl.oeMo UNJOAN I WWLkGW w POWTS OWNER'S MANUAL AND MANAGEMENT PLAN Page 7 of FILE INFORMATION Otmer .ilS - Permit B DFmrN PA R A ai F1 cuo: Number of Bedrooms (100 room Number of Commercial Units Estinlutcd now (average) 00 gailday Design now (DWF) — estimated x 1.3 00 U Soil Application Rate Voia /ft Influent/Effluent Quality (Cl NA) Monthly Average Fats. Oil $ Grease (FOG) S 30 mg/L Biochemical Oxygen Demand (BODs) :S 220 mg/L Total Suspended Solids (TSS) 5 150 mg/L Pretreared Effluent Quality (Ii(l'NA)T253 y Averagc Biochemical Oxygen Demand (BOD,)g/LTotal Suspended Solids (TSS)eLFecal Culiform (geometric mean)fu/loomL Maximum Effluent Particle Size 1/8 inch diameter Calculations: vmpersan unit inrg./Ivrodel Number: Soil Dispersal End Cap DWF + Aoolicatton Rue — Area R Uimd - USA + 144_ + / 0 3100 - SYSTEM SPECIFICATIONS Septic Tank Capecit, al O N Septic Tank Manufacturer A90f 4W.Ar CINA Effluent Filter Manufacturer EST" O N Effluent Filter Model _ 0 DNA Pump Tank Capacity Sdo gal O N Pump Tank Manufacturer R "sr O N Pun Manufacturer rr ,F hlmpj ' O N Pump Model 6e O N Pretreatment Unit NA) ❑ Sand/Gravel Filter O PcatFilter Cl Mechanical Aeration O Wetland O Disinfection O Other - Manufacturer: Model. Soil Absorption Component (O NA) O In -ground (gravity) O In-ground(pressurized) O At -grade R Mound O Drip -line O Other: Vertical Distance Tank Bottom to Service Pad: ft Horizontal Distance Tanks to Service Pad: ft NA (Dispersal Unit EISA) or (Trench Width) - g Units or Total Len eth of Tranohlsi 6r So' O "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publication 9.6 (SSWMP Manual) ❑ WC Flowwtech Mound Component Manual" Version 13 O "EZ Flow Mound Component Manual" Version 8/20f2007 O SBD - 10854-P (R.1/ 12) "At -Grade Component Manta) Using Pressure Distribution" Version 2.0 O SBD- 10705-P (N.01/01)"In Ground Soil Absorption Component Manual" Version 2.0 O SBD - 10691-P (N.0I/01) "Mound Component Manual" Version L I O SBD - 10657-P (R.6/99) "Drip -tine Effluent Disposal Component Manual" O SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0 O Other. Service Event Service F zee Purrs ins d' Dells r2tam filter At least once - j6f 13 months 3 O Other. Inspect pjjnp & pump controls, alarm Pretreatment unit At least once : O months W 3 years O NA Flush and pressure test lalcvais At lent once : O months 11113 ears (3 NA at AKt ur Arvu ut'a:tZAT10N: For ne.w• construction, prior to using the POWTS check treatment uank(s) for the presence or painting products or other chemicals that may impede the treatment process and/or damage the dispeml cell(s). If high c(8lcentfffilons are detected have the COntents Of the tank(S) mmoved by a Wptage Servicing operator prior to use. S)stemstartupshall notoccur when sop coodidoas are froze[ at die inn trative surface. The property owner is responsible for the operation aid maintenance of the POWTS and submission of required reports. The quantity and quidih• of the wastewater stream will effect the performance and longevity of your POWTS. The installation of watt -saving appliances and fixtures along with prompt repair of leaks reduces the tvasteweter volume. Also the brine or waste from water soflenem inui removal units, other clear water treatment devices and foundation drains should be discharged to the growl surface whenever possible. Note: this does not include laundry waste, showers. dishwater, etc. This system is designed to handle domestic atrength wastewater, however, the disposal of food based greases., oils, vagetable/fruit peals, seeds, bones, and food solids, such as those produced by a garbage disposal should be minimized. Toilettistue is the only paper that should be discharged into the system. Other non -biodegradable Items, such as baby wipes, tampons, sanitary napkins condoms, eigarene butts, dental floss, and colton swabs, should not enter the System. Chemicals, such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, tea, should not be flushed into the system bx= they can seriously damage your POWTS and contaminate your drinking water supply. Maintain are regular flow Page Of 9 8 Y by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction ofsnow over the dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify, any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination ofsludgc and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire oontents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Ch. NR 113, Wisconsin Admin. Code. Specific servicing mechanics must be provided if vertical is> 15 feet or if horizontal is>150 feet and instructions to be provided below. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer'sspecifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a I day reserve under regular operating conditions, however water should be conserved until arty problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out ofservicc the following steps shall be taken to ensure that the system is property and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Admin. Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents oral[ 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 other 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: O A suitable replacement area has been evaluated and may be utilized for the location of a replaccmenu 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 renders it unusable. Replacement systems must comply with the rules in effect at the time of replacement. O 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 aL-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructionsofsuch systems must comply with the rules in of fectat that time. WA 1N .tt^ SEPTIC, PUMP, AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAYRESULT. RESCUE OFA PERSON FROM THEINTF.RIOR OFA TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS: POWTS INSTALLER Name: EO_ 6cetN /1/�ts- a7a/B99 t Phone: j/J 577- x-?ea SEPTAGE SERVICING OPERATOR (Pumper)? Name: Phone: Naame: me: S MAINTAINER G E s i%t f Phone: /s 7•-T26 LOCAL REGULATORY AUTHORITY Name: Sr Csa,, Ce Ce Q! !te/xvlrT Phone: 386 — Ne86 Installation Instructions for the GF1O Filter etaasraar--:��91rT�i 6i�1fi.�=-._4Nne 0 ® ® �~ Step 1: Locate and remove Stop 2: Before installation, Step 3: For Installations that the septic tank cover, on place the Ater case on to require or desire additional the outlet side of tank. the outlet pipe Make sure support. of additional support is the case Is positioned so not needed, go to Step 4) Glue a the Alter can be removed section of I' Sch.40 pipe to the from the tank for malnte• two hubs located on the bottom narice and wirke of the case and the hub located on the side of the case. erw.ea Stop 4: Glue the filter case onto the outlet pipe. Insert the fitter cartridge into the case. (Make sure the filter is completely Inserted Into the case.)) �'� �■ Step S: For Installations where It will be difficult to reach the handle, place 1' Schedule 40 pipe Into the tee on the handle and extend it to height that will make It easy to remove the filter. p Installation of an Same as anew systamonly the septic tank p existing system. m"tbepumped pdortolnstaliatlan a 6r o.l,W" =resmiod. g,i, =M i,vsa., Maintenance of the GF10 Filter n tksie frame In whkh septic uris are wMced b set by state and lain mdea Although they may be dffereK most regulatory agendas suggest two to fine Years, %b racomrrrnd the GF10 Mte toe clearrad when the septic tank is normally desired and pumped, or as headed. WARNING: If the liquid level in the tank is above the top of the filter, pump the tank prior to removing the filter cartridge. OCAUTION: USE RUBBER GLOVES WHEN HANDLING FILTERS! Stap 1: Remove the septic tank cover and pump the tank If necessary to prevent any solids from escaping to the field when the filter Is removed. i Stop 2: pull the filter handle arid slide the filter out of the case. Step & While holding the filter cartridge over the access opening of the tank, rinse the cartridge off with fresh water. Take care to make sure all solid material fags back into the tank Alrowl ffig"BE" TECHNOLDGV 3 Fairfield Blvd, Wa0ingfdd. CT Oe492 1-877.765-MS Far, 203-284 8514 Stop 4: Insert the cartridge bade into the case making sure that it Is properly aligned and completely Inserted into the case pu Wisconsin Department o(Cartxrherce SOIL EVALUATION REPORT pap I 3 DivWMof Safety and 8uildirtys of in accordance with Comm 85. WIS. Adm. Code Attech complete site plan on paper not less wan 81/2 x 11 inches in size. Plan must Cour4 5 T et el k- inCkWO. but not limited to: vertical and horizonW tMerence pent (BM), direction and Paroel I.D. percent scope, scale IX dirnensip(hb,110rw ar(ow, and location and distance to nearest road. P/sass, pRnt all Information. Reviewed by Dab PrwrW tnPorMbon YW WgNea may be used for aawrie" purporras tpnway Law, a. 16.0411) (rs)). Properly Owner Property Location Y C,1 � Properly Owners M&Wrq Address+ C GovL tot G 1A E 1/4 S/ T ZP N R J Wwol W •� d. Lot a Stock isQsw Pine GadDetls City State Ph" Number �l'' O VM own Nacre t Road 00a t E ti. (71S)6 e-r EscA- Gale Ave.ity L6o,FI. 1!` aR'MW Construction lase: Residentlel / Nurrfber of bedrooms Code derived desipn pow rate 1660 (op ❑ Replacement 0 Pubk or corni,s,cial _ Describe: Parent material 51 f 1 r MOW Plain aiwmtion if VOkoble AJA p, General comments f @ O� and recommendations: (($5 �s SAn Lt Hc�Fr LWPt— Eepy ll Lovt4-pttr 99. S gleam. MCC- t✓1 0:l GreuM aufam Nwv �i 7 Y It 1 e 1.. I - Of MM. ���� MIMM ■ ©CAL:.: i M1�l1.�I�l.,llllMM!!�a! MMM02M " u 1_�EMMM® mm- 1 •"•�•• " ' - Dab Evaluation Coriducied Telsphorw Number [)a (%E y // 15-- c'y Pro�perttyOwner r[iu I•SON Parcel ID# Page .� of 37 Boring # r❑i�BorinG ll� wt Ground surtana elev 9.9 n x n...x. r.,:...:." •1 t mom," MMM Boring # U goring n wr Ground surface day a n.,.x. Boring Is U Bar" Flo.* Ground surface elev, h. Death to lim tiro eahrr M ' Ef& M #1 = BOD, a 30 < 220 mDOL and TSS �,301150 mprL ' Effluent 102 = BODI < 3o mgll end TSS < 30 mg& The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to aecen smiees or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. ;R"3-0 ft al'" • P(bf pid Awn r PCL, l Te I so 1, j5, e ►%alto P r�� aan Sci fq 5' .S o r -� GL --nth AL)c 13.rt. �vi,7 pop Y vy 01 B. ,of "Pvc /psi r LOT 1 �c r► -e � en.c�CwS I l� 5 �ge ST CRo NTY SANITARY SYSTEM File#: Office Use Only OWNERSHIP/ADDRESS FORM Created212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. OWNER/BUYER INFORMATION Owner/Buyer ,!//EZY ✓At 041 S Mailing Address M D7(yy City/State/Zip lAkC D6V14 t 4C .' T )"= S`�p zb Phone Number (required) 7/C 31 7- -SVI F, Email Address (requ Parcel Identification Number (found on the property tax bill) ez>t3 ZCZA - <5 ( -eic) NEW SYSTEM: LEGAL DESCRIPTION Property Location 1/, , Sec. I T R ff,&Town of 6;-J 9441g Subdivision Plat: 4-MIT4 Pftisc A6AAa" , Lot # Certified Survey Map # Warranty Deed # Number of bedrooms 7 Vol Page # (before 2006)Volume , Page # Spec house O yes Etino Lot lines identifiable WYe5 O no OFFI E USEEOON-L New Property Address GC'S Jenfication of new address required from Comirudnity Development Department for new construction.) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd@sccwi.aov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov Sousa (0 3 3a Wocoranbepartment of commerce SOIL EVALUATION REPORT Page of 3 ru..:......1 Qnf.f nM RaAv+ne in4accordanceComm 85, Wis. Adm. Code complete site plan on paper not lesinRE� Lo� CCCountyAttach must 'gnd include, but not limited to: vertical a•,►��f�-^^tt■■•'oint or dimensions•►rt�tgand (BM), it distance to nearest rdad.Q(JdPlease Parcel I,D. n�5 /�percent slope, scale viewed Date 17J print Personal information you provide may be used aBf (Privacy Law, s. f 5.04 (1) (m)). + Property Owner ' . Property Location I Govt. Lot— 1/41/4 S T N R)(� El W Property Owner's Mailing Address IRA Lot # Block # ubd. Na CSM# P %�eci�bW 5 . `State City Zip Code Phone Number ❑ City ❑ Village Erown Nearest Road (o f<. ke ELL- GLlle- . New Construction Use: Residential J Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial -/Describe: // Flood Plain elevation if applicableJ Parent material S r/7 ft General comments and recommendations:t`c�F � " 1 �er Ott Covt'�DUtr 971 $ MOccti� :5 s-kr,K CfeQ- 99,0� ❑ Boring Boring # q7, 7 ft. Depth to Iimiling factor i �_ n. / �.,:. Qrrninrl surface elev. r cai e...,r,�r.,n Rab Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots PDHP 'Eff#1 'Eff#2 C YP, ;�- — -F k �t �i- C 1 . (o , � - - C) — Sf I' w Iu a S Ltilt 11 3 n Boring # rR�- . in9 '; 7, q ft Depth to limitinq factor r_rnunr/ enA�ro alnv in.I C..n e...Ji.-ofim Rnla Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fF 'Etf#1 'Eff#2 8 2 tn, II I C �l �-' _ ___A -_A tnn Efll lent Sl = t3UU > SU < zzu mgrL arq 100 +emu _ I J+I %Y� ..- --- - -- - - - - - CS ame (Please P - 1) Signature CST Number 2 Pla )0� /�� Address Date Evaluation Conducted Telephone Number 14L)e S /,a, �la �Q //- /S-C�`f 77��-3a7r� LeT 3-7/ 6 7 Property Owner (p I }� I I �o r. Parcel ID # Boring # El Boring p 2"Pit Ground surface elev. 7 . C: ft. Depth to limiting factor . a in. - Page �D of 3 Cnil enrJirorin D.rn Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fF 'Eff#1 'Eff#2 -lo to ; — t . G 8 - i love y' —1 YK P1I l 41 q i I - �eyf2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Rnil Annlimtinn Ratr. Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fF 'Eff#1 'Eff#2 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDMF 'Eff#1 'Eff#2 i Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BOD6 < 30 mg/L and TSS < 30 ng/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777. till D-8510(R 01100) ProperlyOwner (n I C 1,50 Parcel ID # 11 Boring # ❑ Boring "pit Ground surface elev. 9R. % ft. Depth to limiting factor a: In. Page or 3 Sal Application Rate Redox Description Qu. Sz. Cont. Color MOM or IN, "'M MITI", mt NMI F m®m Boring # 0 Boring lJ U Pit uruunu sunace elev, n. veyul w nnnuny lacer fill Sol Application Rate ! Horizon Depth in. Dominant Color Munsell Redox Description Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fP 'Eff#1 'E02 Boring Boring # Ground surface elev ft Depth to limiting factor in ❑ Pit Sol Application Bale Horizon Depth in. Dominant Color Munsell Redox Description Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fP 'Etf#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODE 5 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or M 608-264-8777. �1111 83 J0 (R 07/00) r Wisconsin DePfnnlsMofCortvrlerce SOIL EVALUATION REPORT Page of 3 Divklon of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County v S 7- L'�D//� Attach complete site plan on paper not less than 8 112 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 or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). Property Owner Property Location a C. �' 1 Govt. Lot 0IE 114A;F 1/4 S T a8 N R E( w Prolperrty Owners Mailing Address Lot # Block # u . CSM# P/YIP d!ct�bWS City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road IU�ooc�utll� iLL°I i.7yC (�►S)6 B- Fc�Lx G��11� (vow. Ave, CLY'New Construction Use: Residential / Number of bedrooms �% Code derived design flow rate 600 GPD ❑ Replacement ❑ Public or commerrcciiaal - /Describe: / Parent material �� IE� - ( l / Flood Plain elevation if applicableR General comments /s ` (�D�Qr [ �)S e opt/ 6e/l and recommendations: l$� SAS Cc�1rTF�- olL C0&1+0 v- Mccc y s -tic r,� E 1,e to - 99. o s' ---, n Borino nonng « ry U pit Ground surface elev. ft. Depth to limiting factor in. iCatiDn Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots *FW 'F= ZC.I 3 --� n a.,.\,\ f3oring n Pit Ground surface elev. ft. Depth to limiting factor n. Sol ication Rate Horizon Depth in. Dominant Color::Redoxcription Munsell Qu. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ff 'EfWl 'EIM Ire Lq - 1 c .� , I ., i... nn _-• ....w nee M ..\.\A Effluent #1 = BOD > 3o < zzo mgrL ano i oa you = 1a llpl#6 CS ame (Please ' t) Signature CSTN+(Ttw Address / Date Evaluation Conducted Telephone Number LOT � l- - ry' Sle v 10 t / � 1 1 � 4 / Pipe 4'� r�. R�blxh n� :5rIle 1 I' = yo ) Jo 13.rt. rvr.7 PO(- Q,(�e .9 ' LOT 1 C/— ago+ S+re 4 If sr-CAO Ac coITv STA PLUMBER (A TOWN OF_r= SEC- I ,T-j AND/OR LOT N, R NO, 644800 CRY PERMIT PREVI LIC.# p9 319g SUBDIVISION o. 6503/2 145.135 (ITWISCONSIN 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 may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be band on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (Q The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please Wtact the county authority. ISSUING OFFICER - DATE w1fO Q,42 */ILJNLESS RENEWED BEFORE THAT DATE VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (RI1/20) Wiscormn Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT /_w1531gK GENERAL INFORMATION (ATTACH TO PERMIT) Personal infonnabon you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)[. Permit Fbldel's Name'. City Village X Township Vadnais Jerome & Mwy I Eau Galle Town of CST BM Elev. linsp. BM Elev: IBM Description. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMPISIPHON INFORMATION I;�G�(=11 Loss @All A�QAOOTIA\I CVQTG•• t BED/TRENCH Width Length o. Of T ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK INFORMATION SYSTEM TO P/L LDG IWELL LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturer Type Of System: Model Number I�IIV •ill-1 r��lal �LYYV ■JJJ Header/Mandotd Distribution x Hole Size x Hole Spadnlq Vent to Air Intake Pipe(s) I LengthDia Length Dia Spacing criu r-rivw _ c.._.___ n_r.. — u.......r n. arr.a.ra c..erama nnry Depth Over Depth Over xx Depth of xx Seed"Sodded xx Mulched BeGliranch Center Bed/Trench Edges Topsoil Yea ❑r No Q Yes 0 No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection Location: 598A 270th Street Woodville, WI 54028 (NE 114 NE 114 1 T28N R16W) White Pine Meadows Lot 1 1.) AR BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? 0 Yes [ ,, No Use other side for additional information. Date Insepctor's Signature SBD-6710 (R.3/97) Inspection #2:_/_/_ Parcel No: 01.28.16.568 Cent. No Industry Services Division County ` Q Roo( i �''"- 2 1 2��9 MAY • 1400 E Washington Ave 9 P.O. Box 7162 Sanitary Permit Number (to filled in b Co.) �1�: g t Madison, 1114 \'i,�--,r'.T St, Croix County. t 707-7162 Developme Sanitary Permit App]'cation sta TnnsCactio(n�Number In accordance with SPS 383.21(2). Wis. Adm. Code, submission of thiski-m to the a All unit S �/ e:s4 0 is required prior to obtaining a sanitary permit, Note' Application forms for state-owned POINTS are to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide be used for econdary purposes in accordance with the PrivacyLaw, s. 15.04 I m . Stars. IL •# ! " p �( •„` ��_ J / L1 /'f' / (� information Please I. Application - Print All information Property Owner's Name Parcel N fc}aYv1 608-.1009-0/-Ong + I Pro Owner's Mailing Address / �� % �'70 el Property Location Govt. Lot � )k -A f r= y� Section � � y ,"� � City, State I I-z ��' Zip Code Pho Number /s cps, - o e r�i:�A O,k Sy 0 a d circle one T _ N: R E of V� 11. Type of Building (check all that apply) LoI N Subdivision Name �or 2 Family Dwell i ng- N umber of Bedrooms Oi_ Block An J �a"�1ene /�'/PaC}ewS ❑ Public/Commercial - Describe Use ❑ city of ❑ State Owned- Describe Use Pu CSM Iar ,❑.., �Village or �T'own or )f:7;, Number 7 y �0 � O (� 5d I11. Type Check only one box on line A. Complete line B if applicable) A' New S y stem ❑Replacement System ❑ TreetmenUHoldingTenk Replacement Only ❑Other Modification to Existing System (explain) tal'Pertnit Renewal Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner 5 7 3 S 3A 7 e o OWTS S slem/Com onent/Device: Check all thaf apply) ❑ Non-Prewunmr! In Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound> 24 in. of suitable soil Wound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain V. DisperstaliTrestrinjent Area Information: 4 r Design Flow(gpd) Design Soil Application Rate(g f) Dispersal Area Required Q Dispersal Area Propo (sp System Elevation 0 S— o . y 7 So 7 ro p9• VI. Tank Info Capacity in Total N of Manufacturer o Gallons Gallons Units 7 $ H� u s New Tanks Existing Tanks f/ aU 0 16 U Sepric or Holding Tank /Dn C-% Dosing Chamber 57�d ♦Ov 1 k/ V11. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si re MPlMPRS Number Basin s Phone Number h E� ��� �� 7/Sj 7,4 �� 7� h 1 a P ti .2 Plumber's tAddress (Street. City, St , Zip Code) 76 7 Vlll oun /De artment Use Only Approved ❑ �` Permit Fee Dale ssued Issui Agent Sign re $ G. m 9 5 31 l9 en Reason for Denial IX. ConditdYNTAtOW06RTasons for Disapproval �t 1IL 1. `i�P�!^ �, atlkxfr. Ilkr ►»! 3� S w.+ ('i d'L r r 7 � t�Afa.l� thwwsr 044 recant all kr-_JP'1 ' os'rk,� 1L w per ,mr3priten• plan p, c, ddan lry pUnlx:. �\ j , (- + Qnp i , d t1 ke, J 2 Alegi n� iNs+'was ntwt wr r. a nlrli a : r t .an per tfpkrbk coif I :Kr sum / r /� G % M ✓ AHaeh to complete plans for the system and submit to the County only on paper not less than 8 1 11 inches in Ora s) PI) i5 g asle/N^ SBD-6398 (R0313) 4+1, JeQ, d_ an LriftiIte" IQY, PL.-*-,p i — •.t,t vait LAM TN xiv jo-wrohm NA S '•SU7ROM *4 48 Sfi N a s 17 - /.SV i Industry Services Division County ' "61 t Sanitary Permit Number (too be(filled in by Co.) 24 2011 1400 E Washington Ave �Bo9V RO�NT07 162 gCY r 1 / ENT 1r W State Transaction Number Sanitary Permit Applicatiol, In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the approprmw _ S o Project Address (if different than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc - the Department of Safety and Professional Servies. Personal information you provide may be used for secu.- purposes in accordance with the Privacy law, s. 15. 1 m . Stats. f��U I. Application Istrormation - Please Print All Information Property Owner's Name Paarr�ceelV# I 11 (NOS Property Owner's Mailing Address l Property Location S g A c.,)7 6 Go,v'l. �Lot — A A & Section City, State Zip Code Phone umber l,l�ont^XJ,��C WI j'yo � -7/5 9R����6 circleof!� T _ N; R E C� of Building (check all that apply) Lot a Subdivision Name �II.,. �TType P11"Or2Family Dwelling - Number orBedrooms yy Block toll GD LI.�IYnt�Q 1'l�� /k4eQCj0L0S. ❑ City of ❑ PublicJCommercial - Describe Use x1 Nor ❑State Owned - Descri Use ❑Village of 6a 1 CSM um x 5 a C1 `7 7 0 Mown of 2t4 c Ill. Type of Permit: (Check only one box on line A. Complete line B if apply A' ew System ❑ Replacement System ❑ Treatment/Holding k acement Only ❑ Other Modification to Existing System (explain) B ermit Renewal - ennit Revision Change of 8 ❑Permit Transfer to New Owner List Previous Pfrm� N n �� ate Issu esf/2� fi 5 Before Exp,reoon s m/Coro onent/Device a at a l A- dJ ❑ Non -Pressurized In -Ground ❑ Pressurized In-Groun ❑ de ❑ Mound > 24 in. of suitable soil ErMound < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) / f V. Dispersairrrestment Area Information: .. r Ra Design Flow(gpd) Design Soil Application pdsf) Dispersal Area Required (sq Dispersal Area Propose/d�so System Elevation O e %se7 '7s`U ✓ 9 os— Vl. Tank Info Capacity in Total k of Manufacturer Gallons Gallons Unit a 0 .4 , u New Tmks Existing Tanks ✓�i V H to ti: V a Septic or Holding Tank /00h /a,C) r v �rS Dosing atanstia o - �� { f /te VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Address (Street, City, Stale'Kip Code) VII ours /De artment Use Only A Approved ❑ Permit Fee Date I ued Issuing nt Signature S Od Owner n Reason for Denial - IX. Coadi sous for isapproval t � y .,. i 3) 00-M&JS Sul r 4e � r..r �a P fin ' .w+y...t01 colmust aA ¢4-wIt�irM ! pa in ,l.•tl. tta msragerrwrt. t i�e.-- per plant pro istW uv ylurtber. I' 4 6,J0 4- ma`s � 2 M III ft*,OW. W muNtu l! a&nt: ir.e-1 J to W MpIII11" cads! I ithium . k /kA . Anacn to complete plans for me system ano summit to me wunry omy on P.P., nun tua man o ... , .. ,....,� .,.....� SBD-6398 (R0313) e.� N 9 I Al~ MNT&VV My y11N l%&Aq *,wdhw $A S P.Www wq 46 • I r G6/ MAY 2 6 20151nduatry sery �on, � y�j 1400 E Washin n Ave �` !rf ST ORx cOUN P.O. Box 711662 Sanitary Permit Number (to be filled in by Co.)�r�' .OMMUNI DEVELOP n, WI 53707-7162 C Sanitary Permit Application State Transaction Number In accordance with SPS 393.242), Wis. Adm. Code, submission of this form to the appropriate governmental unit ,� S I ...) / 3 v is required prior to obtaining a sanitary permit. Note: Application fomta for slate -owned POWTS arc submitted to Pro' t Address (if ditlerent than mailing address) the Department of Safety and Professional Service. Personal information you provide may be used for secondary j}ec �/'± purposes in accordance with me PrivacyLaw, a. 15. 1 m Stab. iTy r+�yD s,y, 1. A 'cation Information 'it. I ease Print All htformation ✓ / Property Owner's Name f fift Parcel a r .•e �dl- k ham( S nog - vC) 9_0/ - O OcJ Property Owner's MAling Address Property Location s�,9 a sy;��� _(154046) City, state Govt. Lot (n ip Code Phone ummberp / -y~—y(circllSeceojnn1� �?trC1'V III �� - S`/�� � %/� /-fit)-�iC}7U ILLTT pe of Building (check all that apply) Lola T g N; R lb E i� U 1 m 2 Family Dwelling - Number of Bedrooms / Subdivisio�n Name • d� Blocks l p ❑ Public/Commercial 6k-)A i 1 ( r �vt �-1 PcidoLtS - Describe Use �- ❑ City of ❑ State Owned - Describe ylse CSM Number ❑ Village of / OJ 7U-Townof AXL& I IL Type of Permit: (Check only one boa on line A. Complete line B if applicable Za A. ew System❑ Replacement System ❑ Treatment/Holding Tank Reply Only ❑Other Modification to Existing System (explain) B. ❑ Permit Rencwal ❑ Permit Revision ❑ e o lumb List Previous Permit g it Transfer to New Before Expiration wntt IV. Type of POWTS stem/Cam nent/Device: Check at 1 ❑ Nan -Pressurized In -Ground ❑ Pressurized Infiruund ❑ At- de ❑ Mound > 24 im of suitabicsoil ry .ty Mound < 24 N. o ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)V. enaVrreatArcalnfonnation: 5Elavation Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (a Sys75 0V1. Tank Info Capacity in Total a of Manufacturer Gallon Gallons UnitsNew Tanks BxiatinTa+ka`✓ aLC3 Septic or Holding Tank Dosrrng Clumbv VII. ResPonsibin Statement I, the undersi ed, assume re risibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's lure MP/MPRS Number Business Phone Number /-3z7 SL Plumber i Address (Street, ty, State, Zip Code) ' ,t1764 S-><f�. 577� VIII. lm /D artment Use Onl roved Duapprw Permit Fee Date sued 1 uing Ag ignature S ' Da t Rwon for Denial (OZ • 4b ./ L* �• ConditiORNIMIMARATRessons for Disapproval 1. Septic tank, aMaant Polar and �� r 5 Cad i✓'C.►• r �- QI l dispersal CON Must all be Sioprovide / y rgaintill AID tss par tp4rls ***fft plan provided plumber. I iE t 4M>Mb/oK/�q�'�nM+►a ai must batmintainid U � Ps►�pPNublatads/eD6mnas '.}I • t C/O_.lQ(A/. �,� �+t� �• Attach to complete daro for the wares. ...d r.�1. • •� r . G- .a nesesass• , r�,�.. -�-�: SBD-6398 (R0313) 0 v - fjl�?Ils L o 7' �LJh r Jcrr.. UaAruLtc ,,6--,6ckE.9 Pam" / o f 9 e�o�� Ao. (t- t , Top ovC 70 �S/oP y a 4� TOP 04-- Ij-PILL oa PI& ��r�.�2 � bbo,, /060/ Soo Gam, 5t�F«/ Gbse- 72t tk wvk- ?ory./olh� EkO, ""t\oPu` 96.Oo P� pro" na S1G� c_-CJ -e I "- 40' S7� C'AeEYk (rOO 7'1 j`&CC)A) D �, r— - GG1II-2 NV: 104 pE SeC.. 7..2gv k /6 6:&M5 s." 9C'COAY t OI =�`2p�^"'• NTo� DIVISION OF INDUSTRY SERVICES 4R E LA HOLMEN WI 54636 3 $ K Contact Through Relay 7 Ps http://dsps.wi.gov/programsfindustry-services to k www.vAsconsin.gov Scott Walker, Governor Dave Ross, Secretary May 21, 2015 CUST ID No. 220292 BENNIE W HELGESON HELGESON ENTERPRISES N7649 STATE ROAD 128 SPRING VALLEY WI 54767 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/21/2017 SITE: Jerry Vadnais 598 A 270th Street Town of Eau Galle St Croix County NE1/4, NEIA, S1, T28N, R16W FOR: A7TN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 2542130 Site ID No. 812409 Please refer to both identification numbers, above, in all correspondence with the agency. Description: Two Bedroom Mound System / 2.5% slope Object Type: POWTS Component Manual Regulated Object ID No.: 1534853 Maintenance required; 300 GPD Flow rate; 21 in Soil minimum depth to limiting factor from original grade System(s): Mound Component Manual - Ver. 2.0, SBD-10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. CONDITION The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code APPRO requirements. pEPT OF SAS No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06PROFESSIONA stats. The following conditions shall be met during construction or installation and prior to occupancy or use: DIVISION OF INDU Reminders • A sanitary permit must be obtained from the county where this project is located in accordance with the 44 requirements of Sec. 145.19, Wis. Stets. SE CORRE. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2xd), Wis. Stets. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. • All POWTS component piping material shall be SPS 384, Wis. Adm. Code compliant. • The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • A_c2Ry 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 BENNIE W HELGESON Owner Responsibilities Page 2 5121r2015 • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs 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. 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, rar M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm jerry.swim@wisconsin.gov Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484 , Monday - Friday 8:00 am To 4:30 pm BENNIE W HELGESON Page 2 521R015 Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs 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 malfimctions 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 cotmty for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise malting 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 aboveleftaddressee 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, M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm jerry.swlm@wisconsin.gov Fee Required S 250.00 Fee Received S 250.00 Balance Due S 0.00 WiSMART code: 7633 cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484 , Monday - Friday 8:00 am To 4:30 pm INDEX SHEET RECEIVED MAY 1 2015 INDUSTRY SERVICES PROPERTY OWNER: Terv-y VoLA na;S 5-99 A 170 i-k • 5+r <c't' U 06A.)Lll-e Wl-, 5-y01g PROJECT NAME: jc r vo-d n 0. r PROJECT LOCATION: N k y of- ,11E See - I T�:r N R I6 W MUNICIPALITY: COUNTY: ST. CRO/> DESIGN: PRESSURE DISTRIBUTION MANUAL VERS3Q£1OY SBD-106706-(N.01 /01) MOUND COMPONENT MANUAL VERSION��o 10691-P (N.01 /01) T CONTENTS: L SERVICES -TRY SERVICES Page 1: Page 2: Page 3: Page 4: Page 5: Page 6: Page 7: Page 8: Page 9: Name: Bennie Helgeson Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 Plot Plan Cross Section and Plan View of Mou NDENCE Distribution Pipe Layout Septic Tank and Pump Chamber Cross Section and Specification w I ocso/S-00 _ M R Pump Specifications' Observation Pipe Detail _ Tank Specifications POWTS Owner's Manual & Management Plan- Pg 1 POWTS Owner's Manual & Management Plan- Pg 2 Sign I Ic7 1 Pf L o 7L / �n-p �iPac�pL�7s pal., / o f 9 / 83 i / \'a-�'o II 1 , TOP of -P,10`e too .00 D Top or� Ghoc� Z W.ov cC.-I_e_ I''= kfo' 57`. c.P2Y� COCo.�UTy oFSec,/ 7.� qw R J6 tu /000/ Soo Gm/, Poiy io k SAS F, /frr IC9, of a70 ;fA Page .� Of 9 Synthetic Covering ASTM C 33 Medium Sand Topsoil 3 1 1_ T� % Slope•" Istribution Pipe G F D n Eleu. 97• $ CELLOf f- 2 ? Force Main Aggregate From Pump Cross Section Of A Mound Signed: License Number: Date: U,Sr : LCaA lIx'5 Re.+-e 7 So u l Sct r4rec� �e � 4 L Plowed Layer D L -_-:?6-Ft . E /,Y Ft. F IQ Ft. G S` Ft. A 6 Ft. H �_ Ft. B .5-0 Ft. K c7,S" Ft. L (o5 Ft. J 7•') Ft. I Ft. W Ft. Observation Pipe �--- 6 — -1-- K - I o 0 - Distribution C�I-l- Of 2�- 2 Z� Pipe Aggregate I Observation Pipe 75cU n LICc� ;'j Plan View Of Mound Pty-t— 3 a* 9 )eo..a r AC, f �5 • 1eallo�-7 C IFI Pip, Signed: License Number: DaLe: Pot total as PIP• O.lall /0 End Vlw )PO110,61tv -�/ ' Distribution Pine Larouc Holes Located on Bottom are Equally Spaced Ai P —1—= R S x Y _f 3- Hole Diameter 4_ Inch Lateral I Inch (es) Manifold /I Inches Force Main " Inches PIT %off / r��s % j-O Page_Of 9 SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" PLK-VENT PIPE 12" MIN. ABOVE GRADE E 25' FROM DOOR, WINDOW OR FRESH AIR INTAKE flv. yG v 18" IN. INLET ,ge✓ 93.— APPROVED PIPE 3' ONTO SOLID SOIL WATER TIGHT SEALS FILTER --•- �A R�ll'yy 1 o k _!._ 5 �s B -T- 90. o c PUMP OFF ELEV . FT. -�-- D WEATHERPROOF JUNCTION BOX APPROVED WITH CONDUIT MANHOLE COVER W/ PADLOCK E WARNING LABEL —--4" MIN. S.D. ���� I84Mips. GAS- TIGHT vAPPROVED SEAL JOINTS WITH 4,"ALM APPROVED PIPE N tfl NTO SOLID SOIL 3" APPROVED BEDDING UNDER TANK SPECIFICATIONS CONCRETE PAD SEPTIC / DOSE _ ta1al rtals ir. LaTv tS TANK MANUFACTURER: I�[c et- $- 8It x S S TANK SIZES: SEPTIC Oo O GAL. DOSE VOLUME INCLUDING DOSE 5--oo GAL. /7.936./. FLOWBACK: GAL. ALARM MANUFACTURER: 5TJ,5 RIJp,�,�,L4,5 CAPACITIES: A = C�INCHES = aO GAL. 'MODEL NUMBER: /01. SWITCH TYPE: ,B = 2 INCHES = i4.68 GAL. PUMP MANUFACTURER: C = /0 INCHES = 9 f1 y GAL. MODEL NUMBER: _�87/ E y /l F SWITCH TYPE:/oa� D = ��INCHES GAL. REQUIRED DISCHARGE RATE -3-3_ GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 'J %SSFEET + MINIMUM NETWORK SUPPLY PRESSURE . FEET //O FEET FORCEMAIN X ,�,3 FT/100 FT. FRICTION FACTOR . � FEET TOTAL DYNAMIC HEAD = /S:3_�FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH DIAMETER LoIcQUID OTPPTR- L L O 7 �f4/ iPr 75-4/ CC''�- �Qt_ SIGNED: LICENSE NUMBER: DATE 1/88 � MANHOLE 7 ACCESS l / r � 1` 1���FILTER F— C J BAFFLE TOP VIEW SCALE: 1 /4" = 1' SIDE VIEW SCALE: 1 /4- = 1' �y-e-, S;E:,.F y W1000/500-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2-1/2- BOTTOM: 3" COVER: 5" MANHOLE: 24" I.D. HEIGHT: 69 1/2" O.D. LENGTH: 109-1/2" O.D. WIDTH: 93" O.D. BELOW INLET: 57" O.D. LIQUID LEVEL: 51" WEIGHT: 11.450 LEIS INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN. SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 19.61 GAL/IN (SEPTIC) 9.84 GAL/IN (PUMP) LOADING DESIGN: 8'-D" UNSATURATED SOIL MN TANKS: WILL HAVE ONE VENT OVER OUTLET AND WILL HAVE TWO VENTS IN COVER OVER INLET TANK CAN BE USED AS: SEPTIC/SEPTIC, SEPTIC/PUMP OR SEPTIC/SIPHON W 0 6 Z A Q o � 00 OI Z CV N Z 0 U O 3 V)w CUSTOMIZED TANKS: SHEET NO. TANKS CAN BE CUSTOMIZED CONTACT WIESER CONCRETE O Z TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 0 33 6. d. A( •� 5,3 3 Tory` i rurnp specifications Features and Benefits '/» and'h HP • EPN impeller- semi -open design Up to 60 GPM . with pump out varles.10 protect Maximum head to 32' ,mechanical.seal. Discharge size 11/:' NPT •EP05 impeller - enclosed design Solids: Ibe maximum for improved performance. Motor • Rugged glass-fnled. thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase: 115V resislange. Materials of Construcllon Cast iron 'Cast iron motor housing for efficient heat trahsfer, strength, Thermoplastic anddurabllity. Stainless steel *Corrosion resistant threaded stainless steel shaft. •Available for automatic and manual operation. •CSA listed Models available. aeration and feature st$In/ess steel haniwa,. a To*- Water tight cap ---- 4" min. dia. Piping material can be ASTM D2665, D1785 or D3034 _�— Slot 6" min. Infiltrative surface Water Closet Collar Observa8o"n plpss must. 6" min. Bar(3/8" min. dia.) • be located such that there are a minlmum of two Installed In each dispersal cep at o ends from one another Aooslte ' be located near the dispersal cell ends • be at least 6lnches from the end wall and &A*wall • be Installed at an elevation to dispersal cell view the horizontal or levellnllltrative surface within the Observation pipes may be located less than 6 Inches from end walls or side walls If spedAed In state approved manufacturers'Installatlon Instructions. POWTS OWNER'S MANUAL St MANAGEMENT PLAN Page _LatI_ FILE INFORMATION Owner Serr Vad Permit # DESIGN PARAMETERS Number of Bedrooms: ❑ NA Number of Public Facility Units: ❑ NA Estimated (average) Flow: .)00 (gaUday) Design (peak) Flow = (estimated x 1.5): 3pp (gal/day) In Situ Soil Application Rate: . q (gsUdaym') Standard (Domestic) Influent/Effluent onthly average Fats, Oil & Grease (FOG) s30 mg/L Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA Total Suspended Solids SS 050 mg/L High Strength Influent/Effluent Monthly average (FOG) >30 mg/C (BODs) >220 mg& O NA SS) >150 m Pretreated Effluent Monthly average (BODs) s30 mg/L JSS) s30 mg/L 5'NA Fecal Coliform(geometric mean) s10' Maximum Effluent Particle Size )6 in dia. ❑ NA Other: ❑ NA nrv71111=1 1ar.I=ILtNeld.uud gvgTru :gPFrrFlrAT1nNS Tank Manufacturer: Wtesev— ❑ NA 5'Septic ❑ Dose ❑ Holding Volume: / 0 o 0 (gal) Tank Manufacturer: l_ 1) t c$c ✓ ❑ NA ❑ Septic 6S Dose ❑ Holding Volume: Soo (gal) Vertical Distance Tank Bottom(s) to Service Pad: % (fl) Horizontal Distance Tank(s) to Service Pad: / O O IN Specific servking mechanics must be provided If vertical is >15 feet or lt horizontal Is >150 feet. Specific Instructions to be provided on back. Effluent Filter Manufacturer: 'Po ❑ NA Effluent Filter Model: S"--2 S Pump Manufacturer: 60" S ❑ NA Pump Model: ,387/ EPoY Pretreatment Unit Manufacturer. [I Mechanical Aeration [I Peat Filler RNA ❑ Disinfection ❑ Wetland ❑ Sand/Gravel Filter ❑ Other. Soil Absorption System ❑ In -Ground (gravity) ❑ In -Ground (pressure) ❑ NA ❑ At -Grade Mound ❑ Drip -Line ❑ Other. Other: ❑ NA Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third (%) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: months) �'year(s) (Maximum 3 years) ❑ NA Inspect dispersal call(s) At least once every: a month(s) (Maximum 3 years) rdyear(s) ❑ NA Clean effluent filter At least once every: / 3 months) ❑ year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: 13 Ermonth(s) ❑ year(s) ❑ NA Flush laterals and pressure test Al least once every: 3 �year(s)❑ m r) ❑ NA Othef: Al least once every: ❑ month(s•) ❑ year(s) ❑ NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an Individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels In the observation pipes and to check for any pending of effluent on the ground surface. The ponding of effluent or 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 treatment tank equals one-third (%) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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:512 months, shall be performed by a certified POWTS Maintalner. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02/05) C)U C tQ- START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the Infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 property and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be 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 (pumper). • 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 the time of their permit issuance.. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. v ADDITIONAL INSTRUCTIONS: POWTS INSTALLER Name T Phone -711- 7 .2 Q7 SEPTAGE SERVICING OPERATOR (PUMPER Name \� 1 t O h Phone (`7ys) _3 7 7? if This document was drafted by the staffs of the Green Lake, Marquette and W C a3222 b 1 A POWTS MAINTAINER Name ��SOt` Sa(nl�t OVN Phone �s- `j — S8 ) LOCAL REGULATORY AUTHORITY Name ST C ro jig CO • 7 Phone (7fSA 3$(0' L/( 00" aushara County POWTS regulatory agencies in compliance with sections omm . ( )( )( it ) (f) and 83.54(1), (2) a (3), Wisconsin Administrative Code. START UP AND OPERATION Page —y— of y For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be -discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids l antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation dram (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator (pumper). • 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 the time of their permit issuance.. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort ❑ The site has not bean 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. ,r 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. -ESCAPE OR RESCUE FROM TfiE NTEMOR'OF A-TAt@C1 W NOT BE -foggy _ ADDITIONAL POWTS INSTALLER POWTS MAINTAINER Name t� -eeS O.._ Name iksp1 1 O h Phone �7/ S 7 2)_ 7 Phone y5- 7 _ Sg 1 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name w C) Name ST C t-c i Co. TiV Phone Sys — STD / Phone 7 / S 3 $ This document Was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)8(f) and 83.54(1), (2) 8 (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r'tr Mailing Address_ s9�� - _�ZCEA S�"� (.,l%enIs), �W� S�D� g Property Address S9' g * --) 7 0 14-k<�— (Verification required from Planning & Zoning Department for new construction.) City/State Idyed.t i I I-e- y..3 7F- _ Parcel Identification Number LEGAL DESCRIPTION Opg —400D 9-0/ "000 Property Location'/a , l�F '/. ,Sec. _L, T_N R1f,.__W, Town of E, G r i Pubft Lot # �. Subdivision Plat: I/ rl� �,e n r� C Certified Survey Map # 7 % U 7 6 , Volume / 0 , Page # -S-7— Warr antyDeed # 2 99/ 73 (before 2007)Volume , Page Spec house Dyes Lot lines identifiable R�W/❑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(1) 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 113 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 fop are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warra deed recorded in Register of Deeds Office. Numbe of bedrooms_ SIGNA OF APPLICANT(S) 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) U r I CDJ S `I �?) a'5 ?? Q r