HomeMy WebLinkAbout026-1294-49-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: I
(ATTACH TO PERMIT) State GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: City Village X Township Parcel Tax No:
Oeverin Homes LLC, aka Oeverin Pro ertie Richmond, Town of 026-1294-49-000
CST BM Elev: Insp. BM EEllev: BM Description: C~ bm AV ISection/Town/Range/Map No:
TANK INFORMATION 6 ELLEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic M O Benchmark I9, loo. o
aovng' / Alt. BM 9 r
Aeration / Bldg. Sewer u,-+ ~y
Holding j St PTinlet
StRitOutlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD PH"W
/
Septic ~I ~ /'I ~ t I Dt'8vttorn / /
Dosing L L Head Man. l~
~Z,5
Aeration Dist. Pipe
Holding t._ System RDr
q . .c~
PUMP/SIPHON INFORMATION Final Grade
Manufa De M nd St Cover
n -CA
Mo I Number
TD Lift Friction Loss "T m Head Ft
Forc ain Length ia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width ' Length No. Of Trenches PIT DIME ONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/ST EAM LEACHING Manufacturer: '
I-Ir
NFORMATION Ty Of Sys em: + CHAMBER OR
f (7 1 I5 I 1~ 1 1 UNIT Model Number:
DISTRIBUTION SYSTEM U ,v Iv
Header/M nif Id I Distribution x Hole Size x Hole Spacing Vent to Air Intake
p U I Pipe(s)
Length Dia Length Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over i t Depth over xx Depth of xx Seeded/Sodded r ulched
Bed/Trench Center BedlTrench Edges Topsoil
L1 Yes 0 No Yes NJ No
COMMENTS: (Include iode discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1302 116th St New Richmond, WI 54017 (SW 1/4 SE 1/4 28 T30N R1 8W) Richmond Acres Lot 49 Parcel No:
1.) Alt BM Description= c om- 4 w 1 f v+ 1(1 cT -"r1u U~-
2.) Bldg sewer length = 2'~1 1 S~~L Oft
- amount of cover = L +
Plan revision Required? ? Yes No
R
Use other side for additional information.
SBD-6710 (R.3/97) Date n epe0es ignature Cert. No.
I
A-% V- I!k tr. rk
: _ Countv
r 1 Safety and Buildi Div'
prl 201 W. Washington Av `i Sanitary Permit Number (to be filled in by Co.)I
CJ~1F 4+ Madison, VVi 53707-7162 3
OUN 7 Y a
Sanitary Permit Application State Transaction N r
In accordance with SPS :8321(2), Wis. Adm. Code, submission of this form to the appropriate govcmmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing ress)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privac y Law, s. 15.04(1) m), Stats.
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
eue d),~~EA) p~ ~p A
Property Owner's Mailing Addre
Properly location 14- j Govt. Lot
i State n
ty , lip Code Phone Number_ - ection
/ cle on
T~ N: W E W
II. Type of Building (check all that ppiy) Lot #
r 2 Family Dwelling-Number of Bedro Subdivision Name
O I lock 1!
❑ Public/Commercial - Describe Use
t P I
❑ City of
❑ State Owned --Describe Use CSM Number Q ti-page of _ z-
2 Da S I lQjt~?IdIJ C.~.~-S W l of
1I e f ermit: ( eck only one box on line A. Com lete line BB if applicable) t O
System ❑ Replacement System Q Treatment/Holding Tank Replacement ly Other Modificazion 20 -xis ting System (explain)
i
~I
Pertnit Renew ermit Revision ❑ Change of Plumber ❑ Permit Transfer to New 'List Previous Permit Number and Date Issued
Before Expiration Owner
IN' Tv e of P01VTS System om onent/Device: Check all that apply)
- ressur-zed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of suitable so , a
❑ Holding Tank ❑ Other Dispersal Component (explain)___ _ ❑ Pretreatment Device (explain) f/i f
V. Dispersal/Treat t Area Information/ rjlO
Des- Fto~t (gpd) Design Soi pplicati Rate(gpdsf} Dispec Ar Required ( Dis sal roposed srf Svstem Elevano
VI. Tank Info Capacity in Toal # of Manufacturer
Gallons Gallons Units ! o e
r New Tanks Existing Tan}:s
! /V o
:z U
Septic or Holding Tan}:
I~
~osing Chamber
VII. Responsibility State t- 1, the undersigned, assu r ponsihil-Ty for installation of the POWTS shown on the attached plans.
P er's Name (PriFt) Plumber' ature MP/MPRS Number Business Phone D4nber
Z -
Plumber's Address (Street .ity, State, Zip Cod
VIII. Cou tiQ
nartment Use Only
%sued ssu-ng Agens Si = atur
d Permit Fee a I W~~
pprove I even Reason for Deni ai a I --t
Ik. Conditius,~r'sons for Disapproval
g1. Septic tank, effluent filter and M- ut"A C~,Q// ✓CI~disperse{ csll must mN _0
per mal agemant plan provided by plumber. 0kV40/ W fih%j /h~%1 ~f./J lLQ
2. All setback requirements d nances maintained ~~,~rtita fi on
as pet a o complete plans for the system and submit to the Coun only on paper not less than 8 ra x 11 inches in size 5 6o.
S
SBD-6398 (R. 11/11)
RECEiVED
JUN 2
. ST CROIX COUNTY of Comm
dings MMUNITY REVEL OIO6ITEVA
, Page of
WW l- oion n Department Buildings
Division of Safety and Bu
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 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. Id"
print all information. Revie Date
Personal information you provide may be used for secondary Purposes (Privacy Law, s. 15.04 (1) (m)). I.V 2 9
Property Owner Property Location
JQ! Govt. LotS( 1 /4 1 /4 Sol T v N R E( ) W
Property Owner's Mail AA ress Lp # Block # Subd. Name CSM#
State Zip Code Phone Number ❑ City ❑ Vlla e o Neara t Road
New Construction Use Residential / Number of bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments
~i / lly~~G/ ~e
and recommendations:
System Type System Elevation ~f'
/
F/-1 Boring # ❑ Boring P-
a-Pit Ground surface elev. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
s C ; L2
~3
o ~Z z
57 AJZg
, 77
V
® Boring # Boring Ps:
'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/fft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
J z, am
• Effluent #1 = SOD. > 30 < 220 mglL and TSS >30 < 150 • Effluent #2 = BOD. < 30 mg/L and TSS < 30 rxA MAI CST Name (Please Print) tire CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1432 120th St, New Richmond, WI 5401 --l'~- 715-246-4516
- 47
Property Owner Boring Parcel ID # Page of
a ,
❑ 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/rf
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
b s
Z 1
El 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 GPDIff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
❑ Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil ication Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM
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/_ ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (8.6/00)
Property Owner (p Parcel ID # Page of
Boring # ❑ Boring F3~l~
&Pit Ground surface elev. ft. Depth to limiting factor d= 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
Z
❑ 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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 '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 GPDJff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
I
-4 T-
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD, < 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.
SOD-8310 (R.6N0)
PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1 3 Cernohous Ave Suite A New Richmond Wi 54017
SW 1/4 SE 1/4S 28 /T 30 N/R 18 W Richmond COUNTY ST. CROIX
SYSTEM ELEVATION 90.2 90.1 5.5' below grade 6/25/15 BEDROOM 3
DATE
CONVENTIONAL XXX IN-GROUND PRESSURE NVENTIONAL LIFT HOLDING TANK __61 MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of foundation ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
kale = 1/4" = 10'
252' Property Line
AL14 10
Vent All piping shall be ASTM SDR 30/34, within
>6" Quick4 Standard 10' of tank, piping shall be ASTM F891
of Cover Leaching Chamber
with 20.0 ft2 of Area
12 5.6ft^2/pair of end caps ,
"
4 Long
3 4" Grade at System Elevation 116th St.
I
I
211' Property Line
Pro 3
Bedroom
House
B.M.*
10'
Area may be cut prior ST
to installation
B-3 10'
35' 96.5'
0'
Vents
B-1 95.5'
B-2 10'
70' 6% Slope
2-3' X 66' cells with >3' spacing
70'
Drainage easement, (c arly staked by surveyor!)
130th Ave 34 100'
3 -7yv
c , E1V County
s"T r~1 Safety and Buildings Division t r~
9 ~ u D 201 W. Washington Ave., . U box 7160 Sanitary Permit Number (to be filled in by CO.)
s,~ q
$ t NOUN, Madison, V53707-7162
pEVELOPMENT
" State Transaction Number
Sanitary Permit Application
In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary peanut. Note: Application forms for state-owned POWTS are submitted to Project Address (if different thaw mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
see in LIMPdance with the Privacy Law, s. 15.04(1)Cm), Stats. Z~
L 6ca .on Information -Please Print Ail Information Parcel✓#
Property Owner's Name ~ ^ ~
Oey rln
Property Location
Property Owner's Mailing Address Q
/J 2 5 L Pf SU_i~ Govt Lot 7
'/4, Section N
City Stale Zip Code Phone Number
T30 N; R or
5101 7 1
IL Type of Building (check all that apply) Lot #
Subdivision Name
1 or 2 Family Dwelling - Number of Bedrooms
1 G
J" 1 AO-49 AM Block 14
❑ Public/Commercial - Describe Use a City of -
CSMNumber ❑ Village of
❑ State owned -Describe Use own of / C
III. Type f Permit: (Check only one box on line A. Complete line B if applicable)
A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. El Permit Renewal El Permit Revision Change of Plumber El Permit Transfer to New
Before Expiration Owner
IV. T of POWTS S stem/Com onent/Device: Check all that apply)
>`lon_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. Dis rsal/Treatment Area Information: w 4/k f _z,13 ~Ia?rr
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) E3 evatpon
8
'v 6-13 6~S . 0/7T.
VI. Tank Info Capacity in Total # of Manufacturer V 1 1
q
Gallons Gallons Units V. 2
New Tanks Existing Tanta
aU rn st✓ n
Septic or Holding Tank
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assum ponsibility for installation of the POVM shown on the attached plans.
Plumber's Name (Print) Plumber's MP/MPRS Number Business Phone Ntan _
~92V 17)
Plumber's Address (Street, City, Statc, mp Code)
VIII. Countv/De, artment Use Only
Permit Fee Date Issued Issuing Agent Si attire
Approved ❑ Disapproved $ " ~~a~c~
❑ Owner Given Reason for Denial
IX Conditions of Approval/Reasons for Disapproval SYSTEM OWNER:
1. Septic tank, effluent filter and
lT l P dispersal cell must be serviced /maintained
vese~t ~u s
as per management plan provided by plumb r.
be maintained
2. All setback requirements must
Attach to cornpkte planes for the system and submit to the County only oa paper not less than 81/2 x 11 inches in size
SBD-6398 (R. 11/11)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 5/28/15
Owner: Oevering Homes
Location: SW /4 SE1/4 S28 T30 N,R18 1302 116th st. Richmond
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specificati s Sheet
I
Signature
License n er #226900
PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
SW 1/4 SE 1/4S 28 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX
SYSTEM ELEVATION 96.0/95.8 4' below grade DATE 5/28/15 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
BENCHMARK V.R.P. Top of nail in wood post ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
Cale = 1/4" = 10'
9' B-2 90' B-1 252' Property Line
Vents Ar >
71B. M. *
65'
2% Slope
116th St.
B-3
20' 30'
ST
99'
Pro 3
100' Bedroom
2-3' X 66' cells with >3' spacing House
211' Property Line
All piping shall be ASTM SDR 30/34, within
Vent 10' of tank, piping shall be ASTM F891
>6" Quick4 Standard
of Cover Leaching Chamber
with 20.0 ft2 of Area
12" 5.6ft^2/pair of end caps
4' Long
3491 Grade at System Elevation
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber
5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 100'
Vent Al Grade Vent
3' 4" 3'
f:-~30/34 Septic Tank
5' Long 1" 5' S' Long 1 Grade at System Elevation
36" Grade at System Elevation
Spacing 5'
2-3' X 66' Cells
Same on other end Observation tubeNent
At end of cell
A
B
16 chambers per cell
System elevations:
A-96.0'
B 95.8'
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Bu er
.
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)------------
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Locatiolj ft,tJ %ai Sec.
T ~(7 N RJ
-l- -Z .W, Town of L
Subdivision
, .Lot #
Certified Survey Map #
Volume - Page #
Warranty Deed #
volume Page#
Spec house yes no _
Lot lines identifiabl ''ye. no
SYSTEM MAINTENANCE ~JD OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of'pumpin out the septic
tank every three Years or the system can affect the function of the septic tank as a treatment stage in the wa tif needed, by a o disposal system. licensed
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary ordinance.
maintenance
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification fo
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
the
wastewater disposal system is in proper operating condition and/or (2) after inspection and (if necessary), the septic signed tank is
less than 18 full, of sludge. pumping
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 i.3y the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. I/we atrdare the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
OF .APPLICANT(S) DATF
***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. 08/05)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
k Manufacturer: ❑ NA
eJ2,r I
Permit # eptic ❑ Dose ❑ Holding Volum% (gal)
Owner FTan
ufacturer: ~NA
k Man
DESIGN PARAMETERS
. Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal)
Number of Public Fact NA Vertical Distance Tank Bottom(s) to Service Pad: /l71 (ft)
'I'lty Units:
Horizontal Distance Tank(s) to Service Pad: (ft)
Estimated (average) Flow : (gaUday)
n--~ Specific servicing mechanics must be provided 'rf vertical is >15 feet or
Design (peak) Flow = (estimated x 1.5): C/ (gel/day) If horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: (gaUdaytW) Effluent Filter Manufacturer: L ~'"'a'J ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model:
Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer.A
Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA Pump Model:
Total Suspended Solids (TSS 5150 mg/L
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer.
NA ❑ Mechanical Aeration ❑ Peat Filter 74A
(B ) >0 1 mg/L
(TSSSS) >11550 m g/L ❑ Disinfection ❑ Wedand
Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other:
(BODs) 530 mg/L Soil Absorption System
Fecal Coliform (geometric mean) 510`mg/L '"NA -Ground (gravity) ❑ In-Ground (pressure) ❑ NA
/`El-At-Grade ❑ Mound
Maximum Effluent Particle Size in dia. ❑ NA ❑ Drip Line ❑ Other:
Other: -13f . NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume
❑ When the high water alarm is activated
month(s) (Maximum 3 years) ❑ NA
Inspect condition of tank(s) At least once every: year(s)
At least once eve ❑ month(s) (Maximum 3 years) C3 NA
Inspect dispersal cell(s) ry year(s)
month(s) ❑ NA
Clean effluent filter At least once every: ' year(s)
❑ month(s) NA
Inspect pump, pump controls 8 alarm At least once every: ❑ year(s)
❑ month(s} NA
Flush laterals and pressure test At least once every:. ❑ year(s)
Oft er: 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 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 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 5512 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 (02105)
Page of
START UP AND OPERATION
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 bedischarged 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, sani4r 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:
it absorption system.
so A suitable replacement area has been evaluated and may be utilized for the location of a replacement The replacement area should be protected infringed
upon by required
from disturbance and compaction and should not be 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 bio7lat 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.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER,
Name
S Name 1 -2 7 ell ~E_
Phone Phone J
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name Name ~i£) fs~
Phone Phone
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.
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Property Owner Gera Iek Sm Ak Parcel ID # Page Oi_ of _
Boring # ❑ Boring Q
3 pit Ground surface elev. ft. Depth to limiting factor is 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
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
1 T
F-1 Boring # ❑ ❑ Boring -
pit Ground surface elev. _ ft. Depth to limiting factor in.
Soil R lication 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 >30:5 150 mg/L ' Effluent #2 = BOD5 < 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 altemate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
M-8330(RAW)
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N 9' /
O 9e of
Wisconsin Department of Commerce VALUATION REPORT Pa
Division of Safety and Buildings
in ac dan a with Comm 85, Wis. Adm. Code
County
-S-t , C I
Attach complete site plan on paper not less than 8 1/2 x 11
include, but not limited to: vertical and horizontal reference Fnand t (~E 4 D Parcel I.D.
percent slope, scale or dimensions, north arrow, and local] distance to nearest road. 2 9 Y
Please print all informatidn. Revi ed by Date
r I!F 005
Personal information you provide may be used for secondary purples (Privacy Law, s. 15.04 1) (m)). l Qb
Property Owner ST CR ffly~Tgfaation
ZONI 6ddtJ.EjfE 1/45E 1/4 S a~ T30 N Rif 2 (orr1h
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
h
9 e. NW 1111 121a-t o f ic IM CfC
/ Q
City State Zip Code Phone Number ❑ Cih' C3 Village ® Town Nearest Road
FIK MIN 1 55 30 ( Vigo jo K;C..h M
C9 New Construction Use: L* Residential / Number of bedrooms Code derived design flow rate -5-C-) GPD
❑ Replacement ❑ Public or commercial - Describe: - -
Parent material __.'V_ W C%- S t"% _ Flood Plain elevation if applicable ft
General comments SVSj tS-f „I -T re- v,e s , -k B-
and recommendations: V K 1~0 a J ' F +
S ;+f; ;T' I gs, ig S,4e~ y ; s H lq
T
'514'e- /is I A0
Fil ring
Boring # tg pit Ground surface elev. ft. Depth to limiting factor ~S -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 >'~~f "5~ L r~1.~r t , (o ,
3 17 - , 5 Yf q16 o+ wr LLf;
5 5;t -10.5 ' Le
N 40 -
O-
® Boring # Boring J2, I Cq~ p
pit Ground surface elev. 1- ft. Depth to limiting factor 4 S in. Soil lication 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
3 - =I ~ 5 '(AV(, 1, Lo
Effluent #1 = BOD > 30:5 220 mg/L and TSS >30:5 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
T Name (Plea P Signature CST Nu, ber
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a ~"V Date Evaluation Conducted Telephone Number
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SOIL PROFILE DESCRIPTION
Owner: 0e,.1 CST: Gt/V1 d SJ I~
System Elev. Proposed: ft Syst. Range ft to ft Ld Rate: /
Q
# Elevation: 2,0 # Elevation: Z l0 # Z Elevation: 17-f.
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o Boring o Boring o Boring
Pit Pit pit
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