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HomeMy WebLinkAbout028-1041-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 589779 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 2741 269 Permit Holder's Name: City Village Township Parcel Tax No: Sheri Macbeth TOWN OF RUSH RIVER 028-1041-60-000 CST BM Elev: Insp. BM Elev: BM Description: 136 , i ~ U Section/Town/Range/Map No: raD 6,0! ~ CMG 35.28.17.261 A TANK INFORMATION S ` ELEVATION DATA .XA TYPE MANUFACTI .-CAPACITY STATION 36 log FS ELEV. lso • Z Septic V J ! I es e"e- Benchmark _Z S"t iC 3, Dosing ` 7So Alt. BM ,0. Aernttan Bldg. Sewer c~. 7q (0 IH5lffi_ng_ Ht Inlet q.yZ 9YZg St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air intake ROAD Dt Inlet ~b Septic + r 1 1 Dt Bottom 2 cj Dosin ~f Z2 ader/ an. 7 Z•~o IDt ~ I Aeration Dist. Pipe 2~ , ( 1 bl . ) Holding Bot. System LJ .^5 ' DD ` Final Grade PUMP/SIPHON INFORMATION I , )b 2 , Manufacturer GPlln~and St Cover / ^Q, Model Number N ' 7 TDH Liftt' . Frictio~ ~ System Head , TD7 Forcemain Le Dia. 2 ti Dist. to Well t SOIL ABSORPTION SYSTEM Q L DIMEN BEDrrRENCH ION Width LNo. OtI~aeHea- PIT DIME ONS No. Of Pits Inside Dia. Li Depth DIMENSION SETBACK SYSTEM TO P &V4 BLDG WELL t LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type f y$teg; UNIT Model Nu er: DISTRIBUTION SYSTEM he ea9 er (anifold~ i Dipe(s) ion / x Hole Size'/ ♦ , x Hole Spacing V t to Ay In/~ ke Len th Dia' . Len th ~ 1' 1 ~ Diia a i, Spacing ` J Z i I" $ -Z SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only fvrvl~ez Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil G Yes No Yes ::No] COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: $ D //t_0 j' In ection #2: f l Location: 85 CTY RD YQ 1.) Alt BM Description = I w t P ~O $ 2.) Bldg sewer length 0 l t s on - amount of cover = j4 1 Plan Use other revision q V side for additional in YesJNo r formation. ID to Insepctor's Signature Cert. No. SBD-6710 (R.3/97) Industry Services Division County/ 1400 E Washington Ave 1~ r ( X x,o I' 1 ~01t~ AUG Q P.U. Box 71 , Sanitary Permit Number (to be filled in by Co-) Madison WI 53' 16 } = ,%J S7. CROIX COON VR✓ JO 7 •s'•,` 2.3~ State Transaction Number Sanitary Permit Application 04z In accordance with SPS 383.21(2), Wis_ Adm. Cade, submission of this form to the appropriate governnn.. 7y / is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitteo ._E Project Address (if dill rent than mailing addrelss) the Department of Safety and Professional Services- Personal information you provide may be used for secondary V purposes in accordance with the Privacy Law, s. 15.04(l m Stats. Qt~ / 1. Application Information - Please Print All information Property Owner's Name Parcel # .Shit- i Ala L-Nil n ; - l0Yl b Property Owner's Mailing Address Property Location 1 ~ c / Govt. Lot 3 ~ City, State Zip Code ~CPhoneNuumbee'r/ 1li~i4, Section lttC~/<~ Ltd . d~~ \7fS) fG~J7 ~1 S! T .r1 N; R~IEo e e IL Type of Building (check all that apply) Lot # Ll I ar 2 Family Dwelling -Number of Bedroo Subdivision Name Block # ❑ Public/Commercial - Describe Use Adt. ❑ City of _ ❑ State Owned - Describe Use, CSM Number ❑ Village of t Town of u S 4 oez £1 ~ 7J 11L Type of Permit: (Check only one boa on line A Complete line B if applicable) A. ❑ New System &Keplac:eruent System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of PO'*VTS S stemfCom nent(Device: Check all that a ❑ 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 ersaVFreat t Area Information: Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed ) System Elevation 13-01 -C-1 /6 0 - VI. Tank Info Capacity in Total # of Manu£acturer Gallons Gallons Units U v ti a ~ New Tanta Existing Tanks ~ ~ 16 f ~ y 40 Z t V rn vi va u C7 w . It Septic or Holding Tank r S C j ~-0 i k) " ei- Dosin Chamber c Z701 VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Name (Print J. _7 ela, 77, Plumber's Address (Street, C, State, Zip Code) Vll oun epartment Use Only Xppr.v.d rsapproved Permit FFeeee ~t Issu Issuing Si Patur teen Reason for Denial S & r u ~ v ` p Y 1X, CondifiV@ Reasons for Disapproval -nlt f 3) 1. fa tank, t=ltltisnt filte* t±nd dispemsei cell must ail be seitiicos ! nt~i_ it h/~e ~~...1 ' as per maragement plan pro-tided by plumber. oil- IN j!e-S w, allll~b 2. An-iethaGk requinments rnust,Jae thairtttriniad as per applicable code I L rdinancu. 4 Attach to complete plans for the system and submit to the County o ^ on paper not less than 8 112x II inches in six SBD-6398 (R. 08/14) , 'v- mat 0'r kUS4 A"IL) T o n p t c in , e s d VL c, -A) sec 3 S ` /7 I-J a3 ° J 4 0, AL. Fie-, J y I-1, q9 toy 6a-!, 7SS lhQ n`4i 44 f -s-e_ rc ilk/ Po /o o k et- ro 1:3C_ 0 i I Roa ,~tiy RA ~sg,~ DIVISION OF INDUSTRY SERVICES 3824 CREEKSIDE LN o$ HOLMEN WI 54636-9466 0 S Contact Through Relay P http://dsps.wi.gov/programs/industry-services y w www.wisconsin.gov 6d `G ~O ssrorNLSw Scott Walker, Governor Dave Ross, Secretary July 28, 2016 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 54767-8709 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/28/2018 SITE: Identification Numbers Sheri Macbeth Transaction ID No. 2741269 85 County Rd Y Site ID No. 826691 Town of Rush River Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. NE1/4, NW1/4, S35, T28N, R17W FOR: Description: Four Bedroom Mound System / Sloping site Object Type: POWTS Component Manual Regulated Object ID No.: 1613694 Maintenance required; Replacement system; 600 GPD Flow rate; 15 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.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. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code CONDIT requirements. APPI 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 stats. PROFESSION' The following conditions shall be met during construction or installation and prior to occupancy or use: DIVISION OF IND 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. -0k E C • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made 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. • The existing POWTS shall be properly abandoned per SPS 383.33, Wis. Adm. Code. • 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. BENME W HELGESON Page 2 7/28/2016 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 erard M Swan POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jen-y.swiTn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. BENNIE W HELGESON Page 2 7/28/2016 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 erard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swi:rn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formery Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. r JUL 15 2016 INDEX SHEET irk :::5~wr , PROPERTY OWNER: 11 5ke-t-1 $S' GrY 6 o (t 9di'j i n Wr, 5;-q OOQ PROJECT NAME: 5 h e u i M cx C Eef~ PROJECT LOCATION: /0u-) ~ Sc c -3,S- j D g A) R 17 c.4j MUNICIPALITY: LkS ~;c~►-- COUNTY: -~S C R O I I' DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N. 01 /01) MOUND COMPONENT MANUAL VERSION 2.0" SBALLY 10691-P (N.01/01) CONTENTS: QED ETY AND Page 1: Plot Plan -SE RVICES .TRY SERVICE"' Page 2: Cross Section and Plan View of Mound r Page 3: Distribution Pipe Layout W --'1 Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: Uj t.3 r, Tank Specifications Page 6: Pump Specifications Page 7: Observation Pipe Detail Page 8: POWTS Owner's Manual & Management Plan- Pg 1 Page 9: POWTS Owner's Manual & Management Plan- Pg 2 Name: Bennie Helgeson Signed, Address- N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 C4. r 1 i c ab e d` , Vl E ~ ~G~ CAS G' 4~ c~ c~ f qj 76 62 E'~ ~f S~ /V l l1 ~'G o /v W' SAC PVC S A) P, 7 cAJ B3 ~ qj, 7/ v - s- 3 ~-t, qq. Toy 6 J i ocisc A ro 13 e Pc.,L -.gin e r- c S y Synthetic Covering A-STM C 33 Distribution Pipe Medium Sand /0/, 5- Topsoil 3 E I; D °/t Slope CL;LOf i"- 2 %2 Force Main Plowed Aggregate From Pump Layer D 1,75- Ft. Cross Section Of A Mound E F = Ft. G ~S Ft. Signed: A Ft. H Ft. B 7s Ft. License Number: K Ft. Date: L Ft. y ~ - 6 00 6-;P i) Ft. ,&Sal ~v-e~ ~ec~ y / ;S Cod w'' r . Ft. W e) 9 .7Ft. Observation Pipe •T' svlCL _ r C Distribution ALL--0f 2- 2 %Pipe Aggregate I Observation Pipe ectscd 1500 Plan View Of Mound Perforated Pipe Detail Cleanout i Access j Threaded End Vi,W j 1 Cleanout / ~PorforclrU \ y pvc Pip( End Manifold \o~ End Manifold o`~ goo Holes Located on Bottom Are Equally Spaced Force Main From Pump X S First Hole Next to Manifold < % e Cleanouts Distribution Pipe La out P -7 R s 3 X Y_ Hole Diameter _ Inch Lateral 5 Inch (es) Manifold " Inches Signed: ~~qq Force Main " e Inches License Number: Invert Elevation Date: Holes Per Lateral Number of Laterals Total Holes Page-lOf-l- SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4 " PX V ENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 25- FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W/ PADLOCK E WARNING LABEL 4" MIN. 18" IN. INLET WATER TIGHT SEALS A- TIGHT - \/APPROVED rr'4 FILTER SEAL , JOINTS WITH. APPROVED Pal° - ALM APPROVED PIPE PIPE 3'~S B ON 3' ONTO ONTO SOLID C ' SOLID SOIL i SOIL PUMP OFF ELEV. ,QFT. -i- OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE _Tat, t (~G (s I~. Lni r-t~~ TANK MANUFACTURER: ic--sc - ~ X 's / L 1 13c ~ , TANK SIZES: SEPTIC GAL. DOSE VOLUME INCLUDING DOSE _5-(3 GAL. ,30 c17 6-r-1, -,pFLOWBACK: GAL. ALARM MANUFACTURER: 5S~ he,L"s CAPACITIES: A = c 1S~INCHES = GAL. -MODEL NUMBER: SWITCH TYPE: B = 2 INCHES =J~D /GAL.. PUMP MANUFACTURER: ,O2//L-- C = INCHES = 122, f LGAL. MODEL NUMBER: l SWITCH TYPE: /G~ccf D = INCHES = GAL. REQUIRED DISCHARGE RATE1 GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 9,cl FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . 6 S^ FEET + FEET FORCEMAIN X 3:7 FT/100 FT. FRICTION FACTOR Z FEET TOTAL DYNAMIC HEAD = BEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID DEPTH-_ ti SIGNED: LICENSE NUMBER: DATE: 1/88 ° ~o D 0 z (f~I D n L0 0 Cf) LLD (D W ¢ u 3 _N r~ Z Lj ~ ~Y Ln wZ 3 O Ur. O ~00 00 ~(f)0 %J O 1 V) cc U :2 in w Lo I ' 00 OF- va- ¢N InWU CY- r, cn p: ~nno 1 o O ZZ "l- a nI - - I r o Y, U O dN (iiF¢- W Q Q N ~ O Na_ P V) N C) o oQ -1WOVWi C9 CD j xC0 wth Z~ U) w ID N L-J (n o x (~~r1 ~ o o o~`t'In _I QwW rnT o 0~ w ¢ N N 0 LO O F- _1 n F- Q 4] (n Q N c0 n O Z N \;~x ~DO'ioJ>r W§U wZF- ~ ~3 0 ¢ L*L*J (D OOZJ HWF= HIn (n z Y N oI0 ~ 3 ~ I oW m ow C) Z fnJF W22 02- O (n Q ---I > z o O O C.7 In U 2 ¢ W ~~i-i1.I u0¢00¢I,.I ZO-IZ Zt< 0U)0 CL 0 3m0:2m-j mJ C73 ¢ Z O U C7 Z 0 Z W F- F- 0 J J ¢ Z Z O F- W N I 1 I I I \ :I 1 i I I I I I ~ I I ~ I I ~ 11 1 3 S I w 1 O < Q J .i N rl V! U I I r , (n I . 1 F- W i „LS \ / 1 I \1 d, i i i r 1 F- JW O „98 „05 „99 Alm ~TOTAL DYNAMIC HEAD/CAPACITY HEAD CAPACITY CURVE PER MINUTE EFFLUENT AND DEWATERING K MODEL 152/153 w~ MODEL 152 153 50 Feet Meters Col. Liters Gal. Liters 153 5 1.5 69 261 77 291 000" ' - ) 12 4 10 3.1 61 231 70 265 a 15 4.6 53 201 61 231 r 20 6.1 44 167 52 197 30 a 8 25 7.6 34 129 42 ) 159 0 30 9.1 23 87 33 125 I ..9 02 • 20 35 10.7 22 85 40 12.2 11 42 4 10 Lock Valve: 38.0 Ft. (11.6m) 44.0 Ft. (13.4rn) 014509 20 4 60 80 100 GALLONS LITERS O 80 1 240 320 / . 3 27/32 4 5/8 4 C FLOW PER MINUTE e CONSULT FACTORY FOR SPECIAL APPLICATIONS 3 27/32 4 • Timed dosing panels available: ~ e 3 27/32 • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 130°F. (54°C.) special quotation required. I 1521153 Series 12 1/8 J_T 1521153 MODELS Control Selection Model Volts-Ph Mode Amps Simplex Duplex 5 1/8 BN1 115 1 Non 8.5 1 2 or 3 BN15 2 115 1 Auto 8.5 Included 2 or 3 s~os4 E152 230 1 Non 4.3 1 2 or 3 BE152 230 1 Auto 4.3 Included 2or3 N153 115 1 Non 10.5 1 2 or 3 BN153 115 1 Auto 10.5 Induced 2or3 SELECTION GUIDE E153 230 1 Non 5.3 1 200 3 BE153 230 1 Auto 5.3 Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. A CAt1TION 2. See FM0712 for correct model of Electrical Alternator E-Pak. All installation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10-0225 used as a control activator, specify duplex (3) licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX 16347 Louisville, KY 40256-0347 ~ 4ew Manufacturers or. . ~f r SHIP TO: 3649 Cane Run Road Z ® q fi Louisville, KY 40211.1961 r =17-Y PUMPS SINCE ~,9,~i~ (502)778-2731-1(800)928-PUMP http://www.zoeller.com y PUMP !O. FAX(502)774-3624 0 Copyright 2001 Zoeller Co. All rights reserved. Water tight cap 4" min. dia. Piping material can be ASTM D2665, D1785 or D3034 Slot 6`" rain. min. Infiltrative surface 1l~fater Closet Collar Bar (3/8" min. dia.) Observation pipes must. • be located such that there are a minimum of two Installed in each dispersal cell at opposite end--', from one another • be located near the dispersal cell ends • be at least 6 Inches from the end wall and sidewall • be installed at an elevation to view the horizontal or levellnflltrative surface within the dispersal cell Observation ,pipes may be located less than 6 Inches from end walls or side walls if specified in state approved manufacturers, instaliation instructions. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner SYSTEM SPECIFICATIONS Permit # Tank Manufacturer: w iCSc-r ❑ NA Septic El Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: LA- 4-s e.- ❑ NA Number of Bedrooms: v ❑ NA ❑ Septic [Dose ❑ Holding Volume: '75-0 (gal) Number of Public Facility Units: ANA Vertical Distance Tank Bottom(s) to Service Pad: 7 (ft) Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad: ~ © ft O Design (peak) Flow = (estimated x 1.5): Specific servicing mechanics must be provided if vertical is >15 feet or Cj (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: y (gal/day/ft) Effluent Filter Manufacturer: R, 1y f o Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: J ❑ NA Fats, Oil & Grease (FOG) s30-mg/l- -e Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA Pump Manufacturer: o e- rC Total Suspended Solids.(TSS) s15Q 1211- -Puump Model; ❑ NA High Strength Influent/Effluent - Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (RODS) >220 mg/L XNA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat F(Iter Pretreated Effluent Monthly average C1 Disinfection ❑ Wetland ❑ Sand/Gravel Filter ❑ Other: (BODE) 5530 mg/L Soil Absorption System (TSS) s30 mg/L N(NA Fecal Coliform (geometric mean) s10' ❑ in-Ground (gravity) Imo~-Ground (pressure) ❑ NA Maximum Effluent Particle Size in dia. ❑ NA ❑ At-Grade L~Mound Other: ❑ Drip-Line ❑ Other. ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third (f,) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) •At least once every: ❑ month(s) -2 bear(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: ❑ onth(s) h7 year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: 3 0 yea~ts(s) [I NA Inspect pump, pump controls & alarm At least once every: month(s) ❑ year(s) El NA Flush laterals and pressure test At least once eve ~❑y~ nth(s) El NA n' . td' e ari s) Other: At least once every: ❑ month(s) Other: ❑ year(s) ❑ NA ❑ 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 (k) 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) C~ 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. res. under of power oratio up or Start these Pump tanks may fill above as highwater excess wastewater will be•discharged to the soil absorpt on systemtIn onenlarge dose causing an have the situa this avoid conditions is not recommended, -to stem the overload that the may re tank removed cby a Sept age Servicing Operator (pumper) phorgto r sto ngYpo er to the pump or contact a Plumber contents of h pump or POWTS Maintainer to assist in manually operatng 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 theellifse os theetreatm tent tanks and soil absorption system: acids antibiotics, baby ig cigaree butts, condoms, cotton swabs, uit and vegetable peelings, gasoli e, greases, herbicides, meat diapers, disinfectants, fats, foundation then (sump pump) p) discharge, 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 :dm; inistrative.Gode: • 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: syst p A repl should bebp protected from disturba ce• and compaction and should not be infringedaupon gby qur d The e replacement area setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the nee for a new soil.and site evaluation to establish a sultable replacement area. 'Replacement systems must comply with the rules in effect at the time of their permit issuance. soil' limitations. If the soil p suitable r and placement area is nt available due to in POWTS technology, aaholding/tank may be i stalled as a last esortption system cannot be rehabilitated 9 advances no must replacement arr area isiavailable a ho d ng tank may bel nstalledaas a p The site has performed to locate a suitable e egplacemen tarea replacement be perfo last resort to replace the failed POWTS. t me.emoval of the biomat at the infiltrative Mound and at- tasorption mss must comply with the rules in ffe t at that surface. Reconstructions 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 1 He4NITER16R OF' A-TAW1W Y 't4GT BE~POSS48t:E: ADDITIONAL INSTRUCTIONS: PP WTS INSTALLER POWTS MAINTAINER. ameEam ~r3.kv,, SOhone L7 1 S_ - 7 7 `7 I S 73 - -9 01 ~ . ' EMEE- PERATOR PUMPER- LOCAL REGULATORY AUTHORITY 0- 6 i Name S-~I I Phone~°~ /S~ S,6 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 C( 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 be=discharged to the soil absorption system In .one large dose causing an overload that may result in the backup or surface discharge of effluent and damage'to the system. To avoid-this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper),pdor 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 soli 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: acidsI antibiotics; baby wipes, cigarette .butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation ¢r~in (sump pump) discharge, fruit and vegetable peelings, gasoline, greases., herbicides, meat scraps, medications, oils, painting products, pesti did es, 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 Oodei • 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). 0 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 sultable 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. OV 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 SCAPE.OR RESCUE;FR011If'F1 E4NTERIO.R QF:ATiAi~tKK'ItA lt't tQT BEP@3Si8iE: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name J?e_L,%,!2 Name 'TC) k V @s ~ ~ Cx h t Ci t-~ C ~ 1 I Phone Of S- - 71 Q - 3-~ '7 Phone ~ 7 IS 73 _g SEPTAGE SERVICING OPERATOR PUMPER LOCAL,REGULATORY AUTHORITY Name ~11 a h f c0•~ Name ~C3.tiiz Phone / S 7 3 - S- 'f I Phone( 3 S'6 ff 6 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/Buyer1 e r 1 ~1-, Mailing Address CL r:x Property Address 5k3 SS C_ 1 b rn_ (Verification required from Planning & Zoning Department new construction.) City/State , SC AA L.C (vi l_lU Parcel Identification Number 7,y LEGAL DESCRIPTION Property Location , k,➢ ,Sec.' , T N R~W, Town of~j Subdivision ,Lot # Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house ❑ yes ~?Io Lot lines identifiable R`yes 11 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 thi form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a wa my deed recorded in Register of Deeds Office. Number of bedrooms 7 S_j ;;,,c SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) K48ETNOQ9KZHM - U1 a~zauua~az wcurwnm: 04. - -._I County Attach plan on paper rKA ~s than 8112 x I7 inches in size. Plan must nr , t t ~t~d #o_ vertical and hwizonW n fem"M point IBM , dueG~n and parcel LD_ D i - ~ percent siop~~ dimensions. north arrow. and location and distance to nearest road- 02 DWT ~I S`1`. CF~017S V pMMUNiTY DE,VELOPM~ase print am k9ormation_ / 57 " p ermnai i lkawtion you p-wl- MW be used far sewadwy (Privacy Law 11&84 (1) (#n))- Property Owner 5P FCmL Locatmn ~ 1ta~/i,~/va S T 5 N R / E t property Ownees Mairing Address Stock # Subd. Name or City T C State 74p trade Phone Number ❑ City ❑ Village OkTo~ Nearest Road tvsN u1c oL ( } • Code derived design flow rate iD,, - GP[ New Construction Use- !-Residential ! Mrrrrtber of bedrooms _ (Replacement ❑ Public or commercial - Describe- y n RtC / . 7 00. 01 3 Flood Plain etevaWi if a Parent material General comments arid m=nMend2fili au Bating D B~~ ~ Ground surface elev. tt Depth W tirniling 'r' Soil M tion R Texkne Structure Consistence Boundary Roots GPDtft2 Florizon Depth Dominant Color Redox Desarptipn ~ qEfffl T02 ;n Mimseil Clu_ Sz Cont. t.ofor Gr_ Sz_ Sh. - G k SzL r - Z - - 2 m _ L r = S ~ l fLt/~ .Z/fA . 2. 3y T, s #Z- El B GnxnW surface elev • , ~ R Depth ID limiting ff --eve in Sod'4pp'ica°°" Ratr GF01ft~ Horizon Depth Domeiart Color Redox l Texhse Skuckae -Eff#1 'Eff#2 in- (l+z Sz. Com Color Gr SZ' Sh. _ i4krrr~ell - ~ g L e-2o 3 r S y G "s - and TSS < 30 n1iL-- - _ /SAN A--' S < 3D 11 WW TSS >30 < 150 mgtL ant #s = BODS_ ' Effluent #1 = 8000 > 30 < _ 220 mgtt CST Number CST me (Please Print) ~~,r t Cr / t _ . - - [>^!t: E~.~urta6on t'.ondueted Telephone Address Fogerty Plumbing & Perk T"ag McKenzie 28288 Page _ of Parcel ID # Property owner ~ in. soil ticatior► Rate El gig Depih to &MTOV far3or ' t goring # Pit Ground surface elev_-ft GPDIfi BoundalY 7exhse Structure Redox Horzon Depth Sz -ER#t 'F~f#2 Dom CCkw iaer. u. Sz- ConL r Gr. Sz Sh. p COW Munsell G L r ,n. SrL 2 z ~ c G !SX ~ . o = 3 7s Z Sao S Boring fL Depth to &MbM fad _ Soa q (cation Rate Boring # f It Pit Ground surface elev. Structure CMsistence Boundary Roots GPDfEff#2 Redox Texture Depth giant Gr. Sz Sfr tio[n Mrets°..A Qu. Sz ConL Color - in. Boring g Depth to f in. ~ peon Rate El 8o in9 Ground sixface elev_ ft' pit l~ Boundary 'EfW 'Effg2 Redox Oesaip~► Texttrie Structule me Horizon Depth Dcnimnt Co Qu• Sz Cow Color Gr_ Sz Sh_ in. Murkseft . and TSS 30 < 150 mglL Eff4uent #2 =-aOD, ` 30 rngA- and TSS < 30 mgfL > • Effluent #1 = BOD,> 30 < 220 rtrgfL scrvicrprovider and employer- It you need assistance to access services or need mate at 6089W3,si or'Cut 608-264-8777. The Department of Commerce is to equal opportunity , please contact the dcpartmertt in an ahemat format rial SBO-8330 (R.6/W) Fogerty Plumbing #221180 28288 McKenzie Rd. Spconer, WI 54801 (715) 535-9609 ya SD i py,n dew-f r- /ilci~E _~q7 t1 ,~,~rir~ D IaT /sue-,nom, 79, p = oG~~ FIE T~.vk w wEL~ zv r} is-3 98 y' j f ~.EGD T j_