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HomeMy WebLinkAbout008-1005-30-050 Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM County: St. Croix INSPECTION REPORT sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 579039 0 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. State Plan ID No: Permit Holder's Name: Hillstead, Dennis & Kristine city Village X Township Parcel Tax No: ~j I VI CST BM Elev: Insp. BM Elev: BM Description: Eau Galle, Town Of 008-1005-30-050 GS Section/Town/Range/Map No: TANK INFORMATION 02.28.16.236 TYPE ELEVATION DATA MANUFACTURER ~ CAPACITY I STATION BS HI FS ELEV. Septic T~ 3 Dosing L 1 1 Z156 Benchmark OZ. 001- ~ S 75a . BM Aeration Alt 4 GeJ ~ gr Q Z Bldg. Sewer U q Holding St/Ht Inlet /6,1 f TANK SETBACK INFORMATION A 9Z 9 ! • 74' St/Ht Outlet TANK TO P(L WELL BLDG. ent t it Intake ROAD Dt Inlet Septic ~0 A)A- / . Dt Bottom Dosing j 45r- W3 $ 7. S Z 9 XW 3d Z / Header/Man. Aeration Dist. Pipe Holding 3. z 7 7. 3 _ _ =_m Bot. System s.$7 y.7 3 PUMP/SIPHON INFORMATION Final Grade Manufacturer Z. z2- 16 Z). 3 & errand St Cover Model Number c GPM u P TDH Li 1~ 41- 6 jtj. Q/ Friction Loss System Head s•~ 7- TDH lFt / th / Dia. Dist. to well Forcemfn5'6 .15 SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Tre hes DIMENSIONS ^C PIT DIMEN~NS No. 1117) Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO INFORMATION Type f P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ystem: CHAMBER OR Maw --a ' 7i % 4(o Nl'~ NA' . UNIT Model Number: 0 DISTRIBUTION SYSTEM *A J Header/ManifoId/ DisVibution 1•!J Pipe(s) ` LL j x Hole Size ,I x Hole Spacing Veto Air I ke Length Dia Length ✓ 7J Dia I g SOIL COVER Spacing YZ 2 ~ v x Pressure Systems Only Depth Over Depth Over xx Mound Or At-Grade Systems Only .c Bed/Trench Center ) . / Bed/Trench Edges T Depth of xx Seeded/S dded Topsoil f xx M hed F- s ~ No z s W No COMMENTS: (Include code discrepencies, persons present, etc. Inspection #1: Inspection #2: / Location: 575 250th Stre Woodville, WI 54028 (SW 1/4 NW 114 2 T28N R1 6W) NA Lot 1 164.1) / 1.) Alt BM Description = u Lr3Q Parcel No: 02.28.16.236 2.) Bldg sewer length = 33 r - amount of cover = o c,,SL.1L Plan revision Required? Yes ~No t 5 i.5 Use other side for additional information. SBD-6710 (R.3/97) Date Cert. NO. Sign re - - C- r% t dustry Services Division County Y 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) a F.O. Box 7162 ~N ~a Madison, VVI 53707-7162 C h~ (1, ~0L©PMENT ; J V Sanitary Permit Application State Transaction NumQber In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 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 address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes m accordance with the Privacy Law, s. 15.0 1 m Stats. 75 2 56 iki-, 5 I. Application Information - Please Print All o tion Property Owner's Name ~ta&~ Parcel # 4 p 1605-30 - 6S Property Owner's Mailing Address Property Location 557 -220 Govt. Lot City, State Zip Code Phone umber , , /a, Section LoE90tk'-i i-C r 6-~~Z 7 j5) 6/ D~ r! 3 circle E ronW IL Type of Building (check all that apply) Lot # T N; R L" 4 or 2 Family Dwelling - Number of Bedrooms Subdivision Name n w . Block # El PublidCommercial - Describe Use dk C!J - ❑ City of V J 4 El State Owned -Describe Use 106 CSM Number ❑ Village of ~--if Q✓/L /d' &/Iown of C~ ~c LT-cg IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) G x A' New System ❑ Replacement System El Treatment/Holding Tank Replacement Only El Other Modification to Existing System . (explain) El Change of Plumber ❑ Permit Transfer to Now List Previous Permit Number and Date Issued, B• El Permit Renewal El Permit Revision Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) ❑ 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. Dis ersaVrrea t Area Information: Design Flow (gpd) Design Soil Application Ra gpdsf) Dispersal Area Required j~nff Dispersal Area Propos (sf) System Elevation 600 %1,0D 7.:). '7.3 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units n`li o ti v New Tanks Existing Tanks w q Y P, w" c7 a Septic or Holding Tank 3"0 l l QS'QV- Dosing Chamber 7TO / t ~ 4,11 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/MFRS Number Business Phone Number f Plumber's Address (Stree C' ,State, rp Code) VII oun epartment Use Only Pe//r--roil Fee Date suQed Issuing It Signature pproved waP rven Reason r Denial tD~~' { LX. Condi 1.JiMfi asons for Disapproval 31 pt><flsnk; etittlent fifer stu!' l (iO~DL~ ~~1~. J~~ ~l-C/ dispersal cell must'all he aae.*.Aft l ms)ntai"Ag ~`t.. 111` N.r'~'CC~ l.✓` P.rM.a es, per managernent plan prolA ed by plun*W. 2. V" ~4~~1►tf~l~Millt~Q WK~ tiodi / adlnsno~s, Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size SBD-6398 (R0313) IXIJ j - e S rl i ICOPY '~~yART3tF~r DIVISION OF INDUSTRY SERVICES 3824 N CREEKSIDE LA o` P HOLMEN WI 54636 Q Contact Through Relay S ` httP://dsPs.wi.9ov/Pro9rams/industry-services P S 4 www.wisconsin.gov ~~ossloN~1S~ Scott Walker, Governor Dave Ross, Secretary June 09, 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: 06/09/2017 SITE: Identification Numbers Dennis Hillstead Transaction ID No. 2546882 250TH St Site ID No. 812928 Town of Eau Galle Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. SW1/4, NW1/4, S2, T28N, R6W FOR: Description: Four Bedroom Mound System / 5% slope Object Type: POWTS Component Manual Regulated Object ID No.: 1537128 Maintenance required; 600 GPD Flow rate; 20 in Soil minimum depth to limiting factor from original grade System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01101, 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. CON The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code AP requirements. DEPT OF No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, PROFESSI stats. DIVISION OF IN 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 At~~a SEE 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 6/9/2015 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 ,5~rard M Swim Balance Due $ 0.00 POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jen-y.swirn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm i BENNIE W HELGESON Page 2 6/9/2015 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 drardtM Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART coder 7633 jen-y.swirn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 6314-3484, Monday - Friday 8:00 am To 4:30 pm t5:CEi ED MAY 14 2015 MDEX SHEET ,61NDUSTRY SERVICES PROPERTY OWNER: hh i S ~I Sfe~~~ ~".S7 ~5 o tti _ S~~ cr t W 00CLj; j (.e LL)- T. SV D a V PROJECT NAME: TDe vi V% 1, N ~I s ~P a c~ PROJECT LOCATION: s W o Sew : a R 1 L MUNICIPALITY: COUNTY: S f . Cr i u DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N. 01 /01) MOUND COMPONENT MANUAL VERSION 2.0" SBD- 10691-P (N.01101) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout ITjO Page 4: Septic Tank and Pump Chamber Cross Slra~Y Specification SgFET JNq YAND Page 5: LD 7 S-0 - T'1.R _ Tank SID Ices Page 6: Pump Specifications' RY SERVICES Page 7: Observation Pipe Detail IVpENCz 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 7 / . n~ ,'W f c?~S 14 77 -Xi b Z 4Q~ t -s i s S lv~ - -c - - - R o` J / { ~I d 1 , 4---t i Synthetic Covering ASTM E 33 Distribution Pipe Medium Sand sS- Topsoil t c au 9,f.'73 3 E I. b Con v- ~fev 97• y S °/d, Slope. C U Of 2y- 2 Force Main Plowed Aggregate From Pump Layer D j,33 Ft. Cross Section Of A Mound E I.-S3 Ft. F e 9a Ft. G S Ft. A /O Ft. H / Ft. Signed: . f3 Ft. License Number: K 10,E Ft. Date: L gO, Ft. J 7 Ft. Ft. n T [ W c~ ? Ft. Observation Pipe A Ire W - T--.-----___.------._-__ j Distribution 6 LL-;0 f 2 2 Pipe Aggregate Observation Pipe a 7 7 L ases ~ 14rif Plan View Of Mound / a ..r 3 O Perforated Pipe Detail Cleanout Access Threaded e'd vi. Cleanout ; N . , I u PVC Pip( 0 0~ o' End Manifold /j > 7 Holes Located on Bottom Are Equally Spaced Force Main From Pump X j S First Hole Next to Manifold Cleanouts Distribution Pipe Layout p 7 > i. rr R 4~ 7' S X ) Y ar Hole Diameter Inch Lateral " / Inch (es) Manifold " Inches Signed: Force Main " Inches License Number: Invert Elevation 9. 2 3 Date: Holes Per Lateral 39 Number of Laterals Total Holes l D Page__~_Ofj SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" PUC. V ENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE TWITH CONDUIT MANHOLE COVER W1 PADLOCK E ~-WARNING LABEL 0 - 4 MIN. 2y" 18" IN. r. b. INLET ~ , 18 rniN. ~lu WATER TIGHT SEALS GAS. PPROVED TIGHT rA FILTER A SEAL JOINTS W APPROVED P4- 16k ALM PPROVEDIPIPf PIPE 3'B ' ON ' ONT O ONTO SOLID OLID SOIL SOIL C PUMP OFF ELEV ~-FT. OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE tat C7a.I S_ Iv. L,p.hera- TANK MANUFACTURER: Ld l eSey- 5- ICJ ct TANK SIZES: SEPTIC i~Sy GAL. DOSE VOLUME INCLUDING DOSE GAL. 5-;a 6,-,1 - FLOWBACK: GAL. ALARM MANUFACTURER: S E IRh,CcytbuS CAPACITIES: A = a5_ INCHES = Y03 GAL. MODEL NUMBER: 1 SWITCH TYPE: Met' k/A v%IcC_ f~-10J- B = 2 INCHES = .3~-Dy GAL. PUMP MANUFACTURER : 6CL'tI ~'.S ~ C = 7 INCHES = GAL. MODEL NUMBER : ;3971 PoS 0 F SWITCH TYPE: A4p, kawxltoal Flo6Lt- D = 1,3 INCHES = GAL. REQUIRED DISCHARGE RATE g,) GPM PUMP E ALARM WIRING AS PER I LHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 5~3 FEET + MINIMUM NETWORK SUPPLY PRESSURE . • • FEET + C C' FEET FORCEMAIN X 3. 7 FT/100FT.FRICTION FACTOR.. ~ FEET TOTAL DYNAMIC HEAD L FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID D_EPTff_ P SIGNED: LICENSE NUMBER: DATE: 1/88 a Of [Ln-q o :D 0 Z a a n V I W EE (D F- N a Z Fw- O W J Fa6112 Lo LLI Z U N -q- 0 O H a ^ o ° J ck: 9- ~ F= 10 0- V) W 00 _ a O ' Q Z) 0 w~ H° ~0 of 0 04 V ~ m° ~Q va ~ o ~ Lj C) oQ JV zz o ovw O Y, V) O m ap~ W W W U' < Z 22 2 CO N W N 0 Lo F= U) W a o n~ J N Q U- Pxu] c 3 co o} co N Q N NQ~Cj- -J P' HQ CO0H Nc0 O On 0 N (D co J> W V W Z~ Z ^ ~ 3 Q Z N J(D OOZ J F-(r - 0U)af 1}- w m owM=~ i ooY mo C) Q Z II~->ZC~OF0 HUH Q w olooQww°wo- z°~t< z3o a ° mc~~=J3m~ ¢ Q c) o z ° z w _ o w J ° Q ° Z Z of „FS F- % w N / 1\ / I 'I 1 .I ~ I I I I I I I ~ 1 .I I I I ~ 11 I W = 1 I ~ -S.' S ~ ~ I W II LO I S I I O U W W U cn V) rlic Q z \ K 1 ~ I 1 I JW „98 0 „OS „99 3871 MODEL 0 EP05 d. Y Submersible Purnp I i, n I ail. l , 1 ' ,I . I s M GO U L METERS FEET '0 - - MOOEL6 3871 s 30 x i v S - O 3 ~o x . Epp,E'. s ° 1° 20 40 S° uar o z 1 6 S ,o CAPACITY Pump: Specifications. Features and Benefits '/i° and'/: HP • EP04 impeller- seml-open design Up'to 60 GPM . with pump out vanes.to protect Maximum head to 32' ,.mechanical.seal. m Discharge size 11Y NPT 9-EP05 impeller. -.enclosed desi9R Solids: 1/4* maximum for improved performance. . Motor 'Rugged glass4illed.thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase:.115V resistance. Materials of Construction 'Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless steel 'Corrosion resistant threaded stainless steel shaft. 'Available forautomatic and manual operation. •CSA listed.models available. Veration and feaWre.:stainless steel hardware, Z~ 92 9 Water tight cap 4" rein. dia. Piping material can be ASTM D2665, D1785 or D3034 blot 660 min. thin. Infiiltrative surface Mater Closet Collar llar(3l8" min. dia.) 0bserGatfori pipes must: - • be located such that there are a minlmum of two installed In each dispersal cell at opposite ends from one another be located near the dispersal cell ends • be at least 6 Inches from the end wall and sldewall • be installed at an elevation to view the horizontal or levellnfiltratlve surface within the dispersal cell Observation pipes may be located less than 6 inches from and walls or side walls if specified in state approved manufacturers'Installation Instructions. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: W es c.- s ❑ NA Permit # 5'Septic ❑ Dose ❑ Holding Volume: j~SV (gal) DESIGN PARAMETERS Tank Manufacturer: W, ~S c✓s ❑ NA Number of Bedrooms: 5i ❑ NA ❑ Septic 'Dose ❑ Holding Volume: 75 © (gal) Number of Public Facility Units: fR NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : 5va p (gal/day) Horizontal Distance Tank(s) to Service Pad: ICIC (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): DO (gal/day) If horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: .6 (gal/day/fe) Effluent Filter Manufacturer: v/7 1C ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: S~ S Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: 6 o, d 15 Biochemical Oxygen Demand (BODS) s220 mg/L ❑ NA ❑ NA Total Suspended Solids (TSS) !51 BO mg/L -Pump Model::- 3 1~1(- 15P L) High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BODO >220 mg/L NA ❑ Mechanical Aeration ❑ Peat Filter NrNA (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODE) :530 mg/L Soil Absorption System (TSS) s30 mg/L ER NA Fecal Coliform (geometric mean) s101 ❑ In-Ground (gravity) _ ❑ In-Ground (pressure) El NA Maximum Effluent Particle Size % in dia. ❑ NA ❑ At-Grade XMound ❑ Drip-Line ❑ Other: Other: ❑ NA Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) ER"When combined sludge and scum equals one-third (i) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ® Year(s) Inspect dispersal cell(s) At least once eve ❑ month(s) ry' year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: [9month(s) ❑ NA (3 ❑ year(s) Inspect pump, pump controls & alarm At least once every: month(s) ❑ NA is ❑ 'year(s) Flush laterals and pressure test 'At least once every:. ❑ month(s) ❑ NA Wyear(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 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 (3) 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 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) 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 be4scharged 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. p 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 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;4NTERIOR Of:*fi~ MAY MOT BE-POSSWLE: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. 'BC e e5 Name Name b h S to o Phone / 5 _ Phone 7 ? / SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Y ~h , Name v~ S o Name (7rai co 017 Phone 7 Sg I/ Phone 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)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page ~Of-7- 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 !none large dose causing an overload that may result in the backup or surface discharge of effluent. and damage'to the system. To avoid thissituation 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 , p g products, pesticides, sanitary napkins, solvents to mpons; 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 Admiriiatrative .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 maybe installed as a last resort to replace the failed POWTS. V 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 TALK UNDER ANY- CIRCUMSTANCE. DEATH MAY RESt?CT: -ES~APE.OR RESCUE :FROM 1= tflT:ER1'6R ~ ~4~-fiA#f'C~MA~' 1iFC?T l3E'P6S'SE~ ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name is i _9 Name ` ` VOh`l Sc:~d~ CZ Vii Phone Phone 7 S Z SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~j L" , / a+ Phone f 7 % 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)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer n ~llc se e c,- .Mailing Address S`s 7 s, S~ t ,OC-10 Property Address .S7S (Verificatio required from Planning & Zonin g Department for new. construction.) City/State ~atxQu c ~ ~-Q ~ - Parcel Identification Number Q~.. l~5 3b - a5 LEGAL DESCRIPTION f j \ L3'~' J Property Location .~It) % 1/ , Sec, , T N R_) St_W, Town of _Ea Subdivision Lot # Certified Survey Map # Volume page.# ~ /3S Warranty Deed # Volume Page # Spec house ❑ yes J.no Lot lines identifiableZyes ❑ no SYSTEM MAINTENANC 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 §Comm. 83.52(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 standards set forth, heroin, as set by the Department of Commerce and the D et the. private sewage disposal system with the Resourc Certification stating that your septic system has been maintained must be completed and returned to the Ste Croix County Plannin & Wisconsin. Zoning Department.within 30 days of the three year expiration date, g I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a Warr y deed recorded in Register of Deeds Office. Number of bedrooms b Gl SIGNATURE OF APPLICANT(S) 05 /o S /a d! 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. 08/05)