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HomeMy WebLinkAbout008-1099-80-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579069 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. 2586182 Permit Holder's Name: City Village Township Parcel Tax No: Michael & Karen Humphrey TOWN OF EAU GALLE 008-1099-80-000 CST BM Elev: Insp. BM Ele : BM Description: Section/Town/Range/Map No: ~D•~r 43 Iryl llJe 35.28.16.5366 TANK INFORMATION h rj. ELEVATION DATA q. -3 1 py, TYPE MANUFACTUR CITY TATION BS Ie FS ELE6.N Septic ldb0 Benchmark A*-~ 1 9lP 17-1 Aga =ion 6 k- 525 Bldg. Sewer L Q Holding S Ht Inlet 22 TT IO.J V TANK SETBACK INFORMATION SUHt TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic \ 1 Db, -75' Dt Bottom lA I"I 3CI I y 9 a . 61 Dist. Pipe yob Ada* Holdin Bot. System ' 0 2, 3 PUMP/SIPHON INFORMATION Final Grade Manufacturer I n FU ids Demand ~"`_Covelfi GPM 1 '0;~) Model Number k / Ng In UC 1 11~"O 0 C~ ~v IV /a0 - 'S b TDH Li WLY&,A4,FrictionrLLos~.l System Heads. s , TDH Ft L- j M Nai in r~ 53 IOfo.9 1, Forcemain Length n,t Dist. to Well ~ , SOIL ABSORPTION SYSTEM J BED/TRENCH Width Length No. Of e t6 PIT DIMEN S No. Of Pits Inside Dia. / Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WE L LAKE/STREAM LEACHING Manufacturer: INFORMATION Typ f System: UNIT Model Numbe _ ^ J 166'1 ` 1W , p O~ CHAMBER OR N r) ~ DI N SYSTEM r t Distributi(on~ t t x Hole Size it x Hole Spacing i Vent to Air Intake rLength~ , Di a / 5t Length Dia Spacing , SOIL COVER t x Pressure Systems Only xx Mound Or At-Grade Systems Only Aeqpl' ~!/Hv Depth Over i epth Over xx Depth of xx Seeded/Sodded / xx Mulched Bed/Trench Center ` ` ed[Trench Edges Topsoil \ I ~t~ / ` ► f LLfff Yes fir] No Yes FE] No COMMENTS: (Include co discrepencies, persons present, etq) „ n , pecti #1: `J'~'PlInspection #2: Location: 2578 PIERCE/ST CROIX RD o OR 5/ , Lark 1.) Alt BM Description j6I 2.) Bldg sewer length = 66,4* ( l HOY*) 1~tt gb' ')"+~2" 11~'~UA~ • o/ l - amount of cover = p0 6~02(,SHo9) aM qec Vllf j h00SC( p►v l Plan revision Required? Fw~- Yes No Use other side for additional informat 1 0 4 SBD-6710 (R.3/97) Date s pctor's Signature Cert. No. vrr^~TKE'.mp Industry Services Division County xY RECEIVED 1400 E Washington Ave P.O. Box 7162 Sanitary Permit Number (to be fined in by Co.) AUG ~ 7 2015 Madison, WI 53707-7162 5 7~6 /a 9 Q (f( t Application State Transaction Number S P C a3~ ~s mission of this form to the appropriate governmental unit ccordance with S~ 383.21( 2 W iS Ada i.. } 1~ Z Address ject Address (ifdifferertt than marling address) uined prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Pro / Department of Safety and Professional services. Personal information you provide may be used for secondary 1~1 in accordance with the Privacy Law s. 15.04(l m Stats. t1 ~i1C kdec ~OI L Application Information - Please Print Information M{' Q Property Owner's Name j (''I # 1Ck~,~l , H ~ ooh'-/o9q-8~ -c~o® M Property Owner's Mailing Address hh Property Location CP 5'` 0 crcry CmvtLot 5310 a City, State t Zip Code PhonqNurnber E V, S Section Z~ 3 ~ ~ (circle pr\ T _N, R-L~i E W H. Type of uilding (check 11 that apply) Lot # SubdivisianName 'm2 Family Dwelling-Number of Bedrooms r_,~ O c 0-h Z~~ Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number 0 Village of LG "Ib m of 3r 00 11L Type of Permit: (Check only one boa on line A. Complete line B if applicable) A. ew System ❑ Replacernerut System ❑ Treatment/Holding Tank Replatxsruent 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 System/Component/Device: Check all that a I 'A &n2 of ILYJ . _-7) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound 2:24 in. of suitable soil EKMound < 24 in, of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) _ f f V. Dis rsaVIF__ nt Area Information: Z Design Flow (ad) Design Soil Application Rat Dispersal Area Required (st) Dispersal 0irea proposed System Elevation © 07 d 790 /a.~O ✓ /0 ,Q , 33 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o $ y New Tanks E)dsting Tanks c v.5 a.. V rn rn & (1~1 /6 k- B I Septic or Holding Tank ! o p 0`-' ( - e, Dosing Chamber e v 0 Vll. Responsibility Statement 1, the undersigned, assume respo» Miky for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number seP1 t,,;e e~ eso~ Plumber's Address (Street, City, tare, Zip Code) r 764 f t. (0 ` r U~ ~e C. r !~`f 764? VIII, oan fDe rtment Use Only Permit Fee Date ed issuing Ai6fit Signature ppr a = S (oZS no 8 1 /5 ven Rea, Denial L IX. Condi#vWd$W @WMv*sons for Disapproval 3~ 1. Sephe lank, effluent- filter i nd ~•o ► dispersal cell must au be servi o f'maititained Q,( oL eKe4J~ as per management plan provided by plumber. ii. ~°sttltbMdl~a . ; .,I~ia►~a tnust:4a'r~iMa~tYhc1 M of iods f ardnawa. Attach to complete plans far the system and submit to the County only on paper not less than S nn z 11 isrhes in size SBD-6398 (R. 08/14) ` ~ `v'l 1- ~ L ~ ~.I frtw m ~ lZ r~ ti C~ 4C12 L S f 7'0 L 1) V, -i ~oi.~ < E G~ 4 to z>C`,#o,,, t4- S Aol i.JCZ l~ E G C~,+~~ 4''~'r1L I i i i i t Y ISO i 4C) As u.c. ~r~R7.~1s DIVISION OF INDUSTRY SERVICES a ~,o yTO 3824 N CREEKSIDE LA r HOLMEN WI 54636 Contact Through Relay http://dsps.wi.gov/programs/industry-services www.wisconsin.gov ~0 'ss1014 ~1sw Scott Walker, Governor Dave Ross, Secretary August 21, 2-015 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: 08/21/2017 SITE: Identification Numbers Michael Humphrey Transaction ID No. 2586182 Pierce/St Croix Rd Site ID No. 816129 Town of Eau Galle Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. SE1/4, SETA, S35, T28N, R16W FOR: Description: Two Bedroom Mound System w/Accessory Bldg. Facilities Object Type: POWTS Component Manual Regulated Object ID No.: 1551296 Maintenance required; 300 GPD Flow rate; 14 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.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code COND requirements. AP No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, DEPT OF PROFESSI stats. The following conditions shall be met during construction or installation and prior to occupancy or use: DIVISION OF IN Reminders • A sanitary permit must be obtained from-the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. SEE CORK • 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 8/21/2015 i 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 GBalance Due $ 0.00 Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swiin@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm L BENNIE W HELGESON Pale 2 8/21/2015 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 Gerard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swiin@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 430 pm c ` INDEX SHEET PROPERTY OWNER: PROJECT NAME: PROJECT LOCATION: 5 C S ©F 5E'4 Sec . 3S- -r.-)g A) R i 6 W MUNICIPALITY:w CTa (fie COUNTY: Ll-o iy DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N.01/01) ITIONALLY MOUND COMPONENT MANUAL VERSION WW%BD- 10691-P (N.01/01) SAFETY AND CONTENTS: NAL SERVICES Page 1: Plot Plan 7USTRY SERVICES Page 2: Cross Section and Plan View of Moun Page 3: Distribution Pipe Layout DPage 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: W 1000 fsdP M P\ _ 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 PIO 5r. c u C y ~'oi ou~~" See, h t e ~ r ± /CO S- G Lt- I ~ n Uict + A5. -t~ CIA, C lit ~e Ser-c° 1~/ ,moo ~~,f. See f# 'e '7-~ k- S f q w1~l.l.~ B~ C)~►1 e) I s/ G~,u. v"~rlL ShoP C t6'a".-%4L Ffc;~. 9?.~' ~oSe~ W i%r~ 1 9 Iko Xcea~- As . Pag-e Q. Of Synthetic Covering ASTM C 33 Distribution Pipe Medium Sand /OS! 15` Topsold _ H_ z _ww, F 5 c~nz LC . s' 3 r E D Con 40 LLt- % Slope. G.4.Of 2= 2 %2 Force Main Plowed Aggregate From Pump Layer D /,83 Ft.CZ2 Cross Section Of A Mound E -D 31 Ft. F ~a Ft. G aS`~Ft. Signed: A Ft. H Ft. 6 50 Ft. License Number: K 11-7 Ft. Date: L .73, Y Ft. 06 c9+ w Rckfe p `Y J 7 ° Ft. 300 Ft. o Mih , 31 c15a / rep = 7 07" W a~ Ft. L M Observation Pipe A I. 4 t Distribution ~1-1.L---0 f 2°- 2 %2' • Pipe Aggregate Observation Pipe Plan View Of Mound C) e a~. 0~...1" ,(•G C5C Porforol4A Pip* 041011 C-r ~ C IECIv+C~-~ / 0 End Vl.w P.rr.crulca PVC plpr E; t/110- JoOab Holes Located on Bottom are Equally Spaced , 5 f "rp rC o M c. Lr9 e e C. "J l l ~ G/CL1:61-c iUex~4 ~E'0.~ ~6«75 pitlrlbullon..• Pip, Discribucion Pipe Layout P R S 3 x~ Y a Signed: Hole Diameters Inch License Number: Lateral "Inch (es) Dace: Manifold " Inches Force Main Inches T641 I~d~ ~ s`C Page( 9 SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" ftkVENT PIPE 12" MIN. ABOVE GRADE 6 WEATHERPROOF ? 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W/ PADLOCK E _ WARNING LABEL 2y r. a. 18" LIN. ' ~8 MIN• INLET i ' k~ : y3 WATER TIGHT SEALS GAS- TIGHT, APPROVED FILTER A SEAL JOINTS WITH APPROVED ALM ARPROV£0 P P PIPE 3' 5.. --B - v4 - ON 3' ONTO ONTO SOLID C SOLID 54Ii SOIL PUMP OFF ELEV . ~O'T. V"WOFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE _Yato.l (t0_ls_ I:.,, L~t•~ Is TANK MANUFACTURER : il SZ/ X TANK SIZES: SEPTIC i0oo GAL. DOSE VOLUME INCLUDING DOSE S-pf-) GAL. 6:o1 -FLOWBACK: 76) - 3 GAL. ALARM MANUFACTURER: _STE Who,6uts CAPACITIES: A = _20~ INCHES = e) ,7~ GAL. -MODEL NUMBER: SWITCH TYPE: ,ec. cl' Flm - , .B = '2 INCHES = t q b9 GAL. PUMP MANUFACTURER: c7w L C = 10 INCHES = GAL. MODEL NUMBER : q( El~b lI F SWITCH TYPE: D = ~~_INCHES = ~A AL. REQUIRED DISCHARGE RATE 33 GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 02,` FEET + MINIMUM NETWORK SUPPLY PRESSURE 3.a FEET + /(PQ FEET FORCEMAIN X A,' FT/100 FT. FRICTION FACTOR 3,6 FEET TOTAL DYNAMIC HEADFEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQU. D DEPTH SIGNED: LICENSE NUMBER: DATE: 1/88 /Da s -'o -f- 9 691" 93" 57" z ~ ra m Ivies ~ I I I I i' f \I ~ ~ Dr- p\ ➢ (n 3„ 611„ 5.. D ! ~Am No0 `I m m J frrl i m A~~ NHIr i. I 1./ I O -pt u ~ II ~ N II m \ >c z O c 54 rr- m D Z x In D M M D Z c n m c D ~ O D O r Z Z x Z Z D c m m M Z N T --I O I -i Z ~0 n D ~Z C) DAD ~D mpmlrTlmN (n O to D Z Z r0 DOpD- O ny ;o -00 Z qtr( n -u 200 CEO =gyp ~=mm--irr-Z X K Dz M D moo DC rg.. i~r~ONtn M ZA rn n m = N n ;uz 1n0 O.. .m..i m N "-yO N c r< Z 4 (n Z r < r W O) FI LD I cn O to C N 0 ` Z c0 c0 m m CO VI p rn (n D D m rn p 00 O (/)m D m is U O N- 0 X -i = N -1 < ° f N j r rC0 LO M Oz O Z Z D D m -a m. m to C )o 0 m D \r- r- P \ nr D O o 0 n < O = Z D N n Z m zz ;moo O Oz c: N A D -:3t!1 v 0 ?I A M r- ('7 D Z cc m T --A m O Z C) -H ;a c v O Q r VI M F M N M rn p O M < c n rn m O z Z n z ~ m z rn ~ y N rn \ = W1000/500-MR MIESER COOCAETE SCALE: REV NO. DATE: M o DRAWN BY:SWT z SEPTIC MANUAL W3716 US HWY10. MAIDEN ROCK, WI 54750 DATE: JANUARY 2001 REV. JAN. 2004 800-325-8456 FILE: W7000/500-MR al x t a}'~~l '4.C. p 4. Y - III I~~I ~I .:rF • n, • `C r. of METERS FEET 10 0 30 MODEL: 9871 s. 16 1 o EPO 3 10 i 2 1 S IrPOI ~ 0 10 20 0 2 0. pM ' i S S 10 CAPACITY t2 . M . Pump-Spedficatlons. Features and Benefits. '/m end '/1 HP •EP04 Impeller. semi-open design Up'to 60 GPM , witfrpump out vages.to•protect' Maximum head to 32' mechanical sesl. Discharge size 11!:` NPT •-EP05 impeller... pnciosed design Solids:maximum for improved performance. . Motor • Ru$ged .glass=filled therMopigstic All motors feature ball casing and base design provides bearing construction. super or strength and corrosion single phase:. I15V resistance, Materials of Construction 'Cast iron motor housing'for Cast iron efficient. heat transfer, strength, Thermoplastic and -durability. Stainless steel -Corrosion resistant threaded stainless steel shaft. -Available for-automatic and manual operation. •CSA listed-models available. OPeration and feauu$:stainless steel hardware, 704 9 Watertight cap 4" min, dia. Piping material can be ASTM D2665, D1785 or D3034 Slot j 611" 6" min. min. Infiltrative surface Water Closet Collar gar (3/8" min. dia.) Observafion 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 level Inflltrative 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 FILE INFf3RMATION LAN Page Owner SYSTEM •SPECIF.ICATIONS Permit 1# Tank Menufacturer: f eye ❑ NA DESIGN PARAMETERS Septic Dose ❑ Holding Volume: f 000 Tank Manufacturer: W (gal) re'r- Nr of Bedrooms:' ❑ NA C] NA Number of Public Facility Units: 19e'ptic eDose ❑ Holding yclume _S-Co *11A (gal) Estimated.(average) Flo Vertical Distance Tank Bottom(s) to Service Pad: /I w : (ft) aQG~ (gal/day)' Horizontal Distance l`enk(s) to Service Pad: Design (peak) Flow = (estimated x 1_5): .S e (ft) (gal/day) Specific servicing mechanics If horizontal must be provided if Vertical is >15 feet or In Situ, Soil Application Rate: Is >150 feet. Specifi c instructions to be provided 5 back. Standard (Domestic) Influent/Effluent (gal/day/n:2) . Effluent Filter Manufacturer; cnthly average ~01 y l o Fats, Oil & Grease (FOG) s30•m /L Effluent Filter Model: 675 1_7 NA al Biochemic Oxygen Demand (Bops) g Pump Manufacturer. talSus s220 mg/L . ❑ NA 1, To. F ndpd Solid. (TSS stB:O m L j r_1 High Strength Influent/Effluent Ft#mpAA° - ❑ Monthly average f NA (FOG) >30 mg/L` . Pretreatment Unite 3 (BODE) >220 mg/L Manufacturer: . Pretreated Effluent (TSS) >150 mg/L ,(NA ❑ Mechanical Aeration BONA Monthly average ❑ Disinfection ❑ Peat Fiite'r (BOD El Wetland ❑ E) s30 mg/L Sand/Gravel Filter ❑ Other: Fecal coliform (geometric (ean) s30 mg/L )VNA Soil Absorption System s10' ❑ In-Ground ravif Maximum Effluent Particle Size (g y) . ❑ In-Ground (pressure . . %•in dia. ❑ ❑ At-Grade (p ) ❑ NA Other: NA ❑ Drip-Line JR'Mound ❑ NA Other: C7 other: . MAINTENANCE SCHEDULE.. ❑ NA Service Event Service Frequency Pump out contents of tank(s) R When combined sludge and scum equals ono-third.(;) of tank volume ❑ Wheh the high water alarm is activated Inspect condition of tank(s) -At least once every: ❑ month(s) Inspect.dispersal-cell(s). 'year(s) (Maximum 3 years) ❑ NA At least once every: 2 month(s) Clean effluent filter year(s) (Maximum 3.years) El NA At least once every: month(s) Inspect pump, pump controls & alarm At i`~ ❑ ear(s) ❑ NA least_once'every: month(s) Flush laterals and pressure test [7 year(s) ❑ NA' At least once every: ❑ month(s) Other; 0 NA At least once every: ❑ month(s) .Other: ❑ NA MAINTENANCE INSTRUCTIONS ❑ NA Inspections of tanks and soil absorption systems shall be made by an Individual carrying one of the following -licenses Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS 'Maintainer or Septage Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, g Icenany cracks certifi or leaks, cations: measure the volume of combined. sludge and scum and a check for any back up or ponding of effluent on She identify Servicing any cracks ground Aerator absorption system shall be visually inspected to check the effluent levels in the observation (Pumper). on the ground surface. The pending, of effluent on, the: ground surface may indicate a failing condition and re surface. The soil notification of the local regulatory authority. Pipes and to check for any pending of effluent When the combined accumulation of sludge and scum in any treatment tank equals one-third quires the .immediate contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of r 'n Wisconsin Administrative Code: O or more the tank volume, the entire All other services, including but not limited. to the 'servicing of effluent filters, mechanical or- reS accordance with chapter NR -1.13, 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 s of completion of any service event. GMW-005 (02/05) Page4- Of START UP AND OPERATION For new construction, prior to, use of the' POWTS chebk".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 this to pump failures. Start up or restoration of power under these. conditions is not recommended, as the excess wastewater, will beidischarged to the soil absorption system in.ohe large dose causing an overload that may result In the backup or surface discharge of effluent. and damage.•to.the system. To avoid this situatlon 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 ddve.or park vehides.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, foundatioo t0in (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 inure thatthe 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. e 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 PLAW. 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. 1❑ 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. V1 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. TANK$ MAY' CONTAIN POtSONOUS GAStES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY T4,14K UNDER ANY. CIRCUMSTANCE. DEATH MAY iESf~GT."CAFIE:ORBSGUE:FROl1A"F1'1E#t4TER10RcfikNK M10T:.E°P ADDITIONAL INSTRUCTIONS: ` POWTS:INSTALLER POWTS MAINTAINER . . Name E Name o t Q h Phone Phone -71 -2-;)" ~a°7 g 7 3 SEPTAGE SERVICING OPERATOR P MPER -LOCAL; REGULATORY AUTHORITY Name ~v~SO~ to fi~v~ Name LY©/k ~0ri 0 Phone ! Phone j -K-71 ,3 o ga-7 7?- This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory adencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page -Y'- of For new construction, prior to use of the POWTS check Areatment, tank(s) for the presence of painting-,pr , oducts,solverfts 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 Gperator(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 ln.one.targe -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) •priorto -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, foundatioq brain (sump pump). discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesti cides, sanitary napkins, solvents, tamponsi *and :water softener brine discharge. ABANDONMENT. When the POWTS fails and/or is permanently taken out of service the following steps shall betaken to insure that the system is properly and safely abandoned'in compliance with s. Comm--83.33, Wisconsin Adninistrative.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). a 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 PLAW 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 system's 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 i~ESt7G`~' ~SOAPE ~°~fL! SGL'iE:FROM~'~1~flTERtOR ~ ~K°tdt7~`I~'f~OfT:.)3E~~: _ ADDITIONAL INSTRUCTIONS: POWTS.INSTALLER POWTS hWNTAINER Name e ~~ow Name .1 Zoahl-e'_ O V\._< A v~ t c~ Phone '71 n -7 '70~a 7 g Phone (5 7 l SEPTAGE SERVICING OPERATOR PVMP.ER) -LOCAL :REGULATORY AUTHORITY. a. Namekv.SO►-% (n CQ ter: Name S L ro/ u `ou L't 0 V1 I? Phone C S 7 - S"$ j / Phone .3 0fo 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 t c Mailing Address S lje,? --2) Property Address (Verification required from Planning & Zoning Department for new. construction.) City/State ~Q Parcel Identification Number LEGAL DESCRIPTION j f Property Location CF !/4, /4 , Sec.T a $ N R f W, Town of _ & Subdivision N,q ~ Lot # Certified Survey Map # Volume Page # Warranty Deed # Volume Page # Spec house 0 yes 0 no Lot lines identifiable 9/yes O no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §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. Uwe, 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 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 Plannin & Zoning Department.within 30 days of the three year expiration date. g Uwe 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 warranty deed recorded in Register of Deeds Office. NAPP ICANT(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) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S e-C Mailing Address sj .ll Property Address AK 2 S_ 70 (Verification required from Planning & Zoning Department for new construction.) City/State,„ Parcel Identification Number LEGAL DESCRIPTION J J Property Location _S_C f , 1 , Sec. __LS T $ N R f ~ W, Town of Subdivision k Lot # Certified Survey Map # Volume , Page Warranty Deed # _ 41 i ~ Volume ~ ~"N Page # Spec house 0 yes 0 no Lot lines identifiable try no 'es: 0 SYSTEM MAINTEN--NCE 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. Uwe, the undersigned have read the above requirements and agree to standards set faxdi, herein, as set by the Department. of Commerce maintain th.e private sewage dispos 1 system -with the Certification stating that your septic system has been maintained mustt be cDepartment ple d and returned to the Stec Croix County Planning n. Zoning Department.within 30 days of the three year expiration date. unty & Uwe certify that all statements on this ;form are true to the best of my/our knowledge. Uwe am/are the owners property described above, by virtue of a warr y deed recorded in Register of Deeds Office. of the Numbe of beeal .SIGNATURE OF APP ICANT(S) l DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a co reference is made in the warranty deed. copy of the certified survey map if (REV. 08/05) 17, rNr~ } ~ I .nq f_ f i .l. 3 ~ J f' ~ f r ji f t bh I ~`iVLYDD 3 Wisconsin Department of Commerce /~ATION REPORT Page of Division of S f 111"s in accordah~e with Comm 85, Wis. Adm. Code County AttachffMIROWi 1 t less than 8 1/2 x 11 inches in size. Plan must inc tZ~~„ q ptyfie" d horizontal reference point (BM), direction and Parcel I.D. ~o 8 _ per Ntk°risTrope, scale or dimensions, north arrow, and location and distance to nearest road. 9 w~ - do d Please print all information. Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). g Property Owner AProperty Location 1 Govt. Lot 5)5 1/4 s 1/ S 3 T--) V N R I(6 E (or W Property Owner's Mailin Address 1 Lot # Block # Subd. Name or CSM# city State Zip Code Phone Number ❑ City ❑ Village Q Town Nearest Road 990tk A-JE Ie- r-1,11, Uo-)IeYl SA 5-y767 (715-)679 _3/ 1 ~ Q<.i.- dal Perc ,sT .u ~ New construction use: Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material b es C n L v Flood Plain elevation if applicable A].4 ft. i General comments and recommendations: c~a o 1813 „ cC c c cjt Pr c~ Pa 2c~~ ~ C~1( aK Con~uv- ~~d.5 Boring # Boring / ~ ~ Z Ground surface elev. ~ ' ft. Depth to limiting factor in. Soil Application Rate rl ' ~J l~ q 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 C)~ te /F-tu J a g v c~ `1 R r 73 b dab 7 sy~z Lj o 7, L C 51L. hA I i Boring # ❑ Bo ing pit Ground surface elev..~C}T ft. Depth to limiting factor 17- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP j in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ,fv CAIN - Co 6> go l -7 o ~ P- ~sb 1A J ~7 L b M--r If- N~ cf C 7. ~d Dy2 C O d I I ' 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 (Pleas Print) Signa CST Number Eeve PS0~ - Address 14 V UCJ Da valuation Conducted Telephone Number I ' a Property Owner gic. v-w rey Parcel ID # Page Q, of Boring # ❑ Boring / Q t Ground surface elev. 9 ft. Depth to limiting factor: 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 .6 r LA) ! - /C -i © VW Z tit fr L'L) r_- Tj 6- a 10Yk 7sY f 9Y i- o 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 ❑ Boring F-] Boring # ❑ Ground surface elev. ft. Depth to limiting factor in. pit j-J Soii 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 I Effluent #1 = BODS > 30 5 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BODE < 30 mg/L and TSS < 30 mg/L "I'he 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. SIIO-8330 (R.07/00) Iroperty Owner Mf ~e_ ~ red,- Parcel ID # Page o~ of -3 37 Boring # ❑ Boring f 9__P_ it Ground surface elev. Q~ ft. Depth to limiting factor in. Soil Application Rate Horizon . Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munrrssell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 (L 7 Z_ J 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 ❑ 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 = BOD5 < 30 mg/L and TSS < 30 mg/L 1-he 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. MID-8330 (R.07100) P-/Cl+ W h e V- ~ I yI ~ c h a e 1 ~ r~1 r~~j i~ y ~ G~.CS ~ti 5.`i` ~ ° ~~lorso►-Z ~ oa f~ 5T ~Ro~~ CDGcN7"`/ f SE 777 s AJ R LL.) ~ ~ so /e~ 6'i . slop ~83 P b'rc1. 62~ bb ~ g ~0 5 I oro C=~J m ~Ob,00 GroLacQ Qcf. O ~o O►titi cs~ S<<Q th c~ - 6vovck Ek('sf l w Shop c AA- G- ~'o o 6eek a 5 hop W it h i i i C~ F E ' S - ! o k / .2 90 ti .q k r 5 r ~ ~ ~ ~ .{q ,r. "y Y . f k: -.x -:z% :i' - ~ _ - V ..4