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HomeMy WebLinkAbout008-2009-01-000 RECEIVED W�ia C MAY 2 6 20151riclustry Services county ? ;:( ••:::, : 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) ST.ORC IX COUNTY P.O.Box 7162 �OMMUNI DEVELOP n WI 53707-7162 -: 5 7499 D Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit j D is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04 1 m Stats. I. Application Information zfRease Print All Information Property Owner's Name Parcel# "Fe�- U��h�I s 0 - �vo9-(�/ - o av Property Owner's MAiling Address e�t Property Location Govt.Lot l//I City,State y Zip Code Phone umber A�� ��y %, Section / LW6 t4 0"I (' W _ $ c�0 Y, 7�5 9�g-�)�Q ��— (circle on IL T pe of Building(check all that apply) Lot# T -2 g N; R 6 E ,',.r 2 Family Dwelling-Number of Bedrooms / F Subdivision Name tj - Block# (10/1 IT )ioF Pv1'e 114 P Q C ou'S ❑Public/Commercial-Describe Use � El city of ❑State Owned-Describe Yse A CSM�Number ❑Village of 0 V 7j` 7 D (-7 Town of "&I lIL Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS stem/Com onent/Device: Check all that apply) Q ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil .Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dispersal/Treatilrent Area Information: 4 Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(s System Elevation b 2o w � 7So _75`0 VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units u o 0 New Tanks Existing Tanks w q U b Y uP/ lalz 5-25 ° o d~U yr Septic or Holding Tank r_ X.&O,p Dosing Chamber -6 o Sr190 VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's,' nature MP/MPRS Number Business Phone Number Plumber's Address(Street Oty,State,Zip Code) VIII. un /De artment Use Only Approved Disapprove Permit Fee ;D�tej;;d/� I suingAg ignature n Reason for Denial $ (P� IX.Co Masons for Disapproval 1 Septic tank,eftnt toter and 3� v 9 r '�- �' G ✓� dispersal cfllfxnusf all be services/maintained hLr d vApe,;ppm ilment plan provided by plumber. I N' a'`� V / + ntents trust he maintained V r u pw tlppiieatile code/ordinances. T t ; 'iC. rb uz 1,G Attach to complete plans for the system and submit to the County only on paper not I n 812 x 11 inc.he�siz_e SBD-6398(R0313) To o )7c)tti.. o� y,. Crtuc� Ele+s �"✓ 9G.0 on Sly V-e v% Coax TI o i \ I II inv 16 �► BENNIE W HELGESON Page 2 5/21/2015 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 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, Fee Required$ 250.00 Fee Received$ 250.00 Balance Due $ 0.00 rar M Swim POWTS Plan Reviewer,Division of Industry Services (608)789-7892,Mon-Fri, 7:15 am-4:00 pm WiSMART code:7633 jerTy.swiin@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist,(715)634-3484,Monday-Friday 8:00 am To 4:30 pm o5yPNR DIVISION OF INDUSTRY SERVICES '1� roe 3824 N CREEKSIDE LA a� I cp HOLMEN WI 54636 3 (a� �. � Contact Through Relay http://dsps.wi.gov/programs/industry-services 92 P www.wisconsin.gov Q= �OssION�tSw Scott Walker,Governor Dave Ross,Secretary May 21,2015 CUST ID No. 220292 ATTN:POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/21/2017 SITE: Identification Numbers Jerry Vadnais Transaction ID No.2542130 598 A 270th Street Site ID No. 812409 Town of Eau Galle Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. NE 1/4,NE 1/4, S1,T2 8N,RI 6W FOR: 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.01 101,R. 10/12),Pressure Distribution Component Manual-Ver.2.0, SBD-10706-P(N.01 101,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. CONDITIO The owner,as defined in chapter 101.01(10), Wisconsin Statutes,is responsible for compliance with all code APPRO requirements. DEPT OF S No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06 PROFESSION stats. DIVISION OF INDU The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • A sanitary permit must be obtained from the county where this project is located in accordance with the 5E CORRE 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.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 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. BENNIE W HELGESON Page 2 5/21/2015 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 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, Fee Required$ 250.00 Fee Received$ 250.00 Balance Due $ 0.00 rard M Swim POWTS Plan Reviewer,Division of Industry Services (608)789-7892,Mon-Fri, 7:15 am-4:00 pm WiSMART code: 7633 jen-y.swim@wisconsin.gov cc: Edwin A Taylor,Wastewater Specialist,(715)634-31484 ,Monday-Friday 8:00 am To 4:30 pm RECEIVED INDEX SHEET MAY 1 v .2015 INDUSTRY SERVICES PROPERTY OWNER: _er uQA hats 379 9A .).70 t-k - 55+r-e,f- PROJECT NAME:. PROJECT LOCATION: IVF-' ®f A)E- Sec. i T.� AJ R ►(, w MUNICIPALITY: COUNTY: ST. CROI k DESIGN: PRESSURE DISTRIBUTION MANUAL VERSMY' SBD-106706-(N.01/01) MOUND COMPONENT MANUAL VERSIONV79 %� $ 10691-P (N.01/01) H CONTENTS: L SERVICES 3TRY SERVICES Page 1: Plot Plan Page 2: Cross Section and Plan View of Mou NDENCE Page 3: Distribution Pipe Layout Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: W t400 f soo_--M R Tank Specifications Page 6: Pump Specifications' Page 7: Observation Pipe Detail Page 8: POWTS Owner's Manual &Management Plan-Pg 1 Page 9: POWTS Owner's Manual &Management Plan-Pg 2 Name: Bennie Helgeson Signe Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 USA rum .c , Z),05166kr_-S 9D �y Slop-- Top 454 l -Pty L �l '(3 `� z ,'voca/ 5-06 Poly/©k '05°F,/Ach P"` on Sic:. l 16 Page 0f 9 Synthetic Covering ASTM C33 Distribution Pipe Medium Sand �`, Ede end•-87 G Topsoil F —J E _ v. s' D % Slope-' ' cow Elea, 97. 9 CEUOf 2 %2 Force Main Plowed Aggregate From Pump Layer Q -? 'Ft. Cross Section Of A Mound F I, y Ft. F W2 Ft. G . S– Ft. A Ft. H �_ Ft. Signed: BQ Ft. License Number: K 9,S" Ft. Date: L 62 Ft. 7 SC) ° sct, rec. � —� Ft. W Ft. Observation Pipe i --.------------------------------------ -- Al a c -- - ------------ ---r------------------ --.1.� W -----—---—— -------—--—— J Distribution �-LL_: Of 2'– 2 % Pipe Aggregate Observation Pipe 75U a - � 4C6,_ Plan View Of Mound �yG(CSC Perforojea Pip• Oeloll ' f E•Clvt o�-/ End Vls.w P�rlarolro r ' T� t\obu��� PVC Pipe".lo .(Gi►t� cr r �u�� ..• \ io Holes Located on Bottom �-. are Equally Spaced .,S (t '�'C�t•�G�ct.�5 —� pitl,IDullon..• Plpr Discribucion Pipe Layouc P � IR X � �I Y Signed: Hole Diameter Inch 1 License Number: Lateral " .5 Inch (es) Dace: Manifold Inches Force Main " Inches o�es Qeir �a+,e taj •• 1l.(.l.w.bel— o�C Page_5t_Of SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" PkVENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF ? 25 ' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE -- WITH CONDUIT MANHOLE COVER W1 PADLOCK E Ae WARNING LABEL -1,4" MIN. N 18" IN. x.b. INLET `i°� mos. , f � WATER TIGHT SEALS GAS. TIGHT APPROVED F 1 LT m ---+- A SEAL _ JOINTS WITH APPROVED ALM_ -L- APPROVED PIPE PIPE 3' �5 . B ' ON 3' ONTO ONTO SOLID C ; SOLID SOIL SOIL PUMP OFF ELEV . pO'OTT. VIA OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: 9`t x s f/ a (5ek TANK SIZES: SEPTIC ©oo GAL. DOSE VOLUME INCLUDING DOSE GAL. j_7' f3 /, FLOWBACK: GAL. ALARM MANUFACTURER: patkL,-S CAPACITIES: A = ZQ� INCHES = ab_ / GAL. -MODEL NUMBER: 104- _ SWITCH TYPE: Alec h stile B = 2 INCHES = GAL. PUMP MANUFACTURER: G = /0 INCHES = �� y GAL. MODEL NUMBER : __,,�87/ ,E o'y /I r . SWITCH TYPE:, j ,�_/ �a @/4- D = ./,Y,S-INCHES = GAL REQUIRED DISCHARGE RATE 3.3 GPM PUMP E ALARM WIRING AS PER I LHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE r-5-FEET + MINIMUM NETWORK SUPPLY PRESSURE . 3.�S FEET + //O FEET FORCEHAIN X �F 3 FT/100 FT. •FRICTION FACTOR. . 3 FEET TOTAL DYNAMIC HEAD 3=1.FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH DIAMETER LIQUID b�Pe, T SIGNED: LICENSE NUMBER : DATE: 1/88 aw—oos 000tw3ild tOOZ 'Nv'A38 \ 1002 k8vnNvr :31VO 0909 IM ')1002! N301VF9 'otAmH sn 91LEM �`d(1NdW OIld3S Z � 1MS:.18 NMVNa 3131BUIB U3531m 0°\ :31Va ON A38 l-„4 l :31VOS aW—OOS�OO�LM �' W N � r F- W Z J U W Z O W (w U D cy- O V) !L' y l w J F- N Ln_ O wJJ U N ��//�� V I a U a F- OU a I �! W = ,- U O v J W: ~ U Z ZO (� SOH V)d K U Sc W \ N i Q O Oda ZZ H W U ° a ' o O a-U -i J U) F- N Ow oO O UI m lWjy WW (aJ aU 1 H Ln O x 0O /�� _ � r, 0I Q Q O U) OR o W Q ? w Y J U s \j ci 0 U) m N Fw-- m� oo O a ° a U O \W N N-0)�F-JV I �"_' a = V) w U W 1- \Me O)O' J1� JQ JZ1j Y' Z � J � ~ NM w O I U-)W10 Z l+.F F-r F'to ~ C� a J W U W Y Z w o N OJ f: J F- Q V) O Z 0_ U N = m H N Z Q O Z J�jz2U�O5�' °U °Uic Q ° yJ Z z W ih F-N Y Naooaww°wv�i1 Z. a3° U z a < V) o °wZ o Z W 3 m U 2 J r$m J 3 F ° Z Y < �W Q ° J J O a Z Q O FF- p Z Z J F- N U D a U Z a W D: Q V) Y Z CL a F „45 O z as / \ w II / \ > II 3 II w II W c a I J4J \ ,, w � w W iW j o=w ��w L- j < l9 £ < F-zU mom cn S 1 U) F- -KV J N Z „LS „£6 469 MODEL P0EPOS Submersible Effluent Pump i 1 _'>`, . • . ;�• it .,5 r .. METERS FEET v I 10 o 3o MODEL:3871- o , o 3 10 ° ob 10 zo ° 50 anu' 0 2 1 6 S 10 CAPACITY Pump.Specifications. Features and Benefits /+o end%HP •EP04 impeller-semi-open design Up-to 60 GPM . witiTpump out vanes.to-protect' Maximum head to 32' ,.mechanical.sdal, Discharge size 1 V?NPT ••EP05 impeller. enclosed destgrr' Solids:'/4"maximum for improved performance. . Motor •Rugged.glass4illed thermQplastic All motors feature bait casing and base design provides bearing construction. superior strength and corrosion Single phase:.115V resistance. Materials of Construction ,Cast iron motor houslog•for Cast iron efficient.heat trahster,strength., Thermoplastic and-durability. Stainless steel *Corrosion resistant threaded stainless steel shaft. •Available for-automatic and manual operation. •CSA listed..models available. 47eration and feature:stainless steel hardware Y . Water tight cap 48' min. dia. Piping material can be ASTM D2665,D1785 or D3034 Slot 6" min. 61. min. Infiltrative.surface Water Closet Cellar Bar X318,. min. dia.) Vbsdivatfori pipes must. • be located such that there area minimum of two Installed in each dis ersal ce ends from one another p 11 at opposite • be located near the dispersal cell ends • be at least 6 Inches from the end wall and sidewall • di installed at an elevation to view the horizontal or level lnflltrative surface within the dispersal cell " Observation pipes may be located less than 6 Inches from end walls or side walls if state approved manufacturers,installation Instructions. Specified in 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 sitlation 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 properly and safely abandoned'in compliance with s. Comm 83.33,Wisconsin Administrative.Codei • 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..- .0 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 maybe 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 blomat 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 TALK UNDER ANY_CIRCUMSTANCE. DEATH MAY RESULT._15 CAPE O"WRESCUE.:FROMTJ`I .1NTERIORW—* rANK°AR"t4OT BE-POSSvBtE. - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER Name h I � e_v to Name vt.50� a/n t wi O H Phone '7/ 7 Phone / - SEPTAGE SERVICING OPERATOR PUMPER ~LOCAL,REGULATORYAUTHORITY Name b 't o h' Name I'o 1, �O •.� Phone 7y5- �8 / Phone 7rs .3 n� - Y6 �o 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)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 00 FILE INFORMATION SYSTEM SPECIFICATIONS Owner C Tank Manufacturer: Wws ev- ❑ NA Permit# WSeptic ❑ Dose ❑ Holding Volume: /004 (gal) DESIGN PARAMETERS Tank Manufacturer: ❑ NA Number of Bedrooms: ❑NA ❑ Septic tS Dose ❑ Holding Volume: Soo (gal) Number of Public Facility Units: ❑ NA Vertical Distance Tank Bottom(s)to Service`Pad: 7 (ft) Estimated(average)Flow: a?0 (gal/day) Horizontal Distance Tanks)to Service Pad: 106 (ft) Specific servicing mechanics must be provided If vertical is>15 feet or Design(peak)Flow=(estimated x 1.5): 3Exj (gal/day) if horizontal is>150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: . I/ (gal/day/fe) Effluent Filter Manufacturer: Rcz.IY ❑ NA Standard(Domestic)influent/Effluent onthly average Effluent Filter Model: 5" S Fats,Oil&Grease (FOG) s30 mg/L Pump Manufacturer: 6.15441.1-S. El NA Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA Tratai.S.uspendedSolid&(TS5 s*0 mg/L --Pur-np,Model: _. : ,_,3g7/ �1�4.�(_. . High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/11 • Manufacturer: (BOD5) >220 mg/L X NA ❑Mechanical Aeration ❑Peat Filter L>i�'NA (TSS) >150 mg/L ❑Disinfection ❑.Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other: (BODs) s30 mg/L Soil Absorption System (TSS) s30 mg/L 5'NA Fecal Coliform(geometric mean) s10' ❑ In-Ground(gravity) . ❑In-Ground(pressure) ❑ NA ❑At-Grade Maximum Effluent Particle Size %a in dia. ❑ NA �![Mound ❑Drip-Line ❑other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE 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) (Maximum 3 years) ❑ NA year(s) Inspect dispersal cell(s) At least once every: ❑month(s) (Maximum 3 years) ❑ NA a Fdyear(s). ff Clean effluent Titer At least once every: �3 ❑month(s) ❑ NA year(s) Inspect pump,pump controls&alarm At least once,every: 13" month(s) ❑ NA ❑'year(s) Flush laterals and pressure test 7 At least once every:. ❑month(s) ❑ NA N'year(s) Other: At least once every: ❑month(s) ❑ NA ❑year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carving 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(g)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 ponding of effluent on the ground surface. The ponding of effluent on.the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any 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<_12 months,shall be performed by a certified POWTS Maintainer. 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) START UP AND OPERATION Page of For new construction, prior to use of the POWTS check'reatment 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 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 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 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 RESMT;- CAPE:0l1--RESCUE:FRONT THE-1NT1=0R:DF" IdK'I t4eT wpoSstetl. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER Name 0` Name �Ilt�s 4(ht �i Oh Phone 7 >2 -- -)7 Phone y3— —/3 S-g ) SEPTAGE SERVICING OPERATOR JPUMPERJ LOCAL REGULATORY AUTHORITY Name „� C Name Phone 7�S ~- °�'� Phone 7�s 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)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. ST.CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer qtr g Mailing Address_Property Address Address ' 70 S ^� (Verification required from Planning&Zoning Department for new construction.) City/State f i,®o Iv L��-e vJ'� _ Parcel Identification Number —4©D 9 w49 O O f LEGAL DESCRIPTION Property Location '/4,�U1.�1/4, Sec._L_,T 2.LN R1L_W,Town of E,,,— 6: Subdivision , Lot# Plat: 1'i rZ-e ,e c� Certified Survey Map# 7 1 ?07 a ,Volume / Q ,Page#_7• WarrantyDeed# �/ 9E/ 93 (before 2007)Volume ,Page# Spec house Oyes Lot lines identifiable We'sDno 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 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein,as set by the Department of 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. I/we certify that all statements on this foym 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 warl deed recorded in Register of Deeds Office. Numbe of bedrooms_ J//S�ItRE OF APPLICANTS) 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 kZ zf \ I L U' __�. ... _ i Property Owner Fo—, �Ve Parcel ID# Page of 3 F-31 Boring# ❑ Boring O - Pit Ground surface elev. ! G ft. Depth to limiting fa&or _in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl? in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 J -rC In t b CL g ' -�s l o -- I l c-)Yy c 41 10-NI R `� L ( c 5bk rn�� . 3 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 I *Eff#2 F-1 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 *Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BODS<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. S13D-8330(R.07/00) W sconsinbepartment of Commerce SOIL EVALUATION REPORT Page of .3 Division of Safety and Buildings in accordance Comm 85 Wis. Adm. Code County S T Attach complete site plan on paper not less than 8 1/2, 11 inbWk, 0(:n must include,but not limited to:vertical a oral re r point(BM),directtOn and Parcel I.D. J percent slope,scale or dimensions, r a I and distance to nearest road. �� Please ���,print viewed Date IL 2 6$ Personal information you provide may be used for seconds purpose8(Prwacy Law,s.15.04(t)(m)). � D Property Owner tA_. _._� •.' . )?roperty Location Govt.Lot 1/4N 1/4 S 1 T N R )(� E(o W Property Owner's Mailing Address Lot# Block# ubd. Na CSM# IRS• ,p,�Q �1�QdaWS City State Zip Code Phone Number ❑City ❑village Town Nearest Road Ea-'N'ew Construction Use: Residential/Number of bedrooms Code derived design flow rate b0 GPD ❑Replacement // ❑ Public or commercial-Describe: Parent material S��T� � 7—(11 Flood Plain elevation if applicable 4 ft General comments , 'nom C� e p-( and recommendations: 56, Ow Ca/n,-(oL'ty- L7 Ie a Boring# Boring r�y U Pit Ground surface elev.�� y ft. Depth to limiting factor (c, _in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 `Eff#2 l -3 CL 1 c 5 Boring# FP ring t Ground surface elev. 7 y ft. Depth to limiting factor _in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 tyv t, t 2 I VLt D L�' 5 � cL Lu 10 `Effluent#1 =BOD >30:5 220 mg/L and TSS>30<150 mg/L `Effluent#2=BOD <30 mg/L and TSS<30 mg/L CST Name (Please PPit) Signature CAST Number Address Date Evaluation Conducted Telephone Number /�a`( 77a�l� '+" - ,� rrvt ��(�� // /S--e>� ?7�� -<307 rS-tf 67 r Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of .3 Division of Safety and Buildings in accordance with Comm 85,Wis. Adm. Code County s'T' Attach complete site plan on paper not less than 81/2 x 11 inches in size.Plan must include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. percent slope,scale 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 PC,L,' )e L 0G` Govt.Lot NE 1/4AjF 1/4 S / T N R f(� E( W Property Owner's Mailing Address Lot# Block# =P1 CSM# IRA, ! he /�eQc(owS City State Zip Code Phone Number ❑City ❑Village own Nearest Road WocAu, - IWT 590� ('7I5-)t 8 Fay 6'dle- ("New Construction Use: Residential/Number of bedrooms Code derived design flow rate GPD ❑Replacement // ❑ Public or commercial-Describe: Parent material S t17� /_�� ,r(l Flood Plain elevation if applicable [ >� General comments [� e v.� and recommendations ��s�. �s 5��� Lt o1c�Fv- t �D2►- ca n. (f o k uV- Mcw" I S 2 s�t,vt e 0 Boring# Boring / U Pit Ground surface elev. , y ft. Depth to limiting factor o�_in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'EfiQ - C Y P, � S11 k YLt�i- C uj . o 51 . r>2 ' ' t u a 5 c b ft 3 fl4 jvQ G i I Boring WP ing g it Ground surface elev. 7 y ft. Depth to limiting factor _in. Soll Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'EffJQ 2 ( ✓11 I► �t ` b p'-Y '7. _ 3 bk 'Effluent#1 =BOD >30:<220 mg/L and TSS>30:<150 mg/L `Effluent#2=BOD <30 mg/L and TSS_<30 mg/L CS ame (Please Pri t) Signature CST Number e P ,-- Address Date Evaluation Conducted Telephone Number CL G Property Owner (C��. I C 160 r% Parcel ID# Page --'? of 137 Boring# ❑ Boring Rpit Ground surface elev. 9 ft. Depth to limiting factor a in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 'Eff#2 -re IL 6 g _L1' V1, P t I I f 45 I 0 2 c. 421. y & (� Boring# Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. `Eff#1 `Eff#2 I I Boring Boring# Ground surface elev. ft. Depth to limiting factor in. El pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz. Sh. 'Eff#1 'Eff#2 i i i I- i `Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L 'Effluent#2=BOD15<30 mg/L and TSS_<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. S R D-8310(R.07/00) • .- . ` . plof pi n ►� o 9 1 U � T3J-1 . 10 1 , 7 Top 0+ lope ti 1 � To �� `' FVC- 1 t-aT i 1 �-�.i� 1 '' = TO )