HomeMy WebLinkAbout014-1017-60-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 592185
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 2775723
Permit Holder's Name: City Village Township Parcel Tax No:
Keith Bergmann TOWN OF FOREST 014-1017-60-000
CST BM Elev: Insp. BM Elev: BM Description: ) /~/y Section/Town/Range/Map No:
ftr/ 08.31 .15. 11 7B
TANK INFORMATION ELE TION DATA
TYPE MANUFACTURER CAPACIT STATION BS HI FS ELEV.
Septic ;a Benchmark
3: 77 5-
Dosing F! { Alt. M i ^i 0 f L 2 % S
.
Aeration 3 Bldg. Sewer 9 r G
e^, ,w
Holding a~ St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO ) P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom r,
Dosing I I Header/Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade 162
Manufacturer . Demand St Cover y
GPM
Model Number n.
TDH Lift Friction Loss System Head TDH Ft
a~, r 3 n7*4 .0 q~ to
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS T. _
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type CHAMBER OR UNIT Of System:
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold) 'Distribution f; Ix Hole Size rn rpacing Ven0o Air Intake
Pipe(s) R
L 1 r _ '6 qfq~ -311
L1ength_ Dia Length. Dia j ' Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 1xx Depth of xx Seeded/Sodded 1xX Mulched
Bed/Trench Center J - 71 Bed/Trench Edges Topsoil t _ Yes ❑ No Yes ❑1~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Z61(40 Inspection 02:~YW
At VWWor,
Location: 2725 CTY RD Q.tj jc,, y.,:ti~;~ ~~UW:• KIL, V ~xLor~ w-e l I t
1.) Alt BM Description = { 1 d S~f ~C~~ 5 Z , T rOM a5 l
2.) Bldg sewer length *•e $ibv Ply.f k2d SJ t ~t 1.,0✓. baf t`~J
y
- amount of cover = d b 'd t'' ~0
Plan revision Required? ❑ Yes No
7-
Date Use other side for additional information. _ y
Insepctor's Signat Cert. No.
SBD-6710 (R.3/97)
tog
. _IV
C E Safety and Buildings Division
r p" 201 W. Washington Ave. P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.)
' ~It
D NOV Madison, WI 5 -7 2
_ y
A5
_,a #l il't Rff~Z rri i Applicati~1C73M8B3BNwG 1teTransaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate gu-.___
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to ?reject Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04 1 )(m), Slats.
1. Application Information - Please Print All Information ! r
Property Owner's N e Parcel #
C7/ O
¢ ` I 11
Property Owner's Mailing Address Property LocationoJJ
-f~-'L ~ t U Govt. Lot
15-833 A O /
City, State Zip Code Phone Number 10/,= 1A A f O-k'/4, Section . one)
A c J SQ C~ 1. - 7& d d 9/ 6 3, 3 ~ N, R IE of
II. Type of Building (check all that apply) Lot #
I or 2 Family Dwelling- Number of Bedrooms Subdivisilon I"*V-,~ A c
1 ~n ~n Block # ~,m~V1m, `
❑ Public/Commercial - Describe Use ❑ City of
CSM Number El Village of
El St at Owned -Describe Use
/ X O, M t) U~V X-Town of
V
IIL Type of Permit: (ChVcko Compl ete line B if applicable)
4' ❑ New System placement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
El Chan List Previous Permit Number and Date Issued ~
B. El Permit Renewal El Permit Revision ge of Plumber ❑ Permit Transfe~t. New
Before Expiration Owner
IV. T e of POWTS System/Component/Device: Check all that apply)
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Mo < 24 in. suitabl sit
h
❑ Holding Tank El Other Dispersal Component (explain) ❑ Pretreatment Device (explain) 1-7
V. Dispersal/Treatment Area Information:
TTMevation
Design Flow (gpd) esign Soil Applicati Rate(gpdsf) Disper I Area Required (sf) Dis e al Area Proposed jt
> 5 0 30G~ 7 - DD IVI. T
ank Info apacity in Total # of Manufacturer
Gallons Gallons Units New Tanks Existing Tanks I v 'D SZ5
n n w C7 P,
Septic or Holding Tank J OO ! pdd
Dosing Chamber 00 t0~0
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumb Signatur M PRS Number Business Phone Number
1 ,?RA 1~ ~G~ ,Vo~ 7 7rs - 766 Plum is Address (Street, City, State, Zi Code)
1,14, OC)X do
VIII. County epartment Use Only
ued Issuing t Signature
A Permit Fee Date I Y
pproved asap $ ~ 11/ ' OO ~ / lit
0 n en Rea or Denial (C
IX. Conditions of Approval/Reasons for Disapproval C.A Ol 111P I
SYSTEM OWNER:
t 5 a
1. Septic tank, effluent filter and mee+ 50 e~t~JAtk-
dispersal cell must be-serviced /.maintained /on
X15TjIV,./' ! ke a /1(r
as per management plan provided by plumber. 1~1 c V
2. All setback requirements must be maintained lJ
as per app ica jjd p r the system and submit to the County only on Gaper able an 8 112 x 11 inches in size
SBD-6398 (R. 11/11)
A~N\s ~Pvi 5b; kA.) J-p 6e. Ve[; Pe4
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COP
/~r~ia,ttE~ DIVISION OF INDUSTRY SERVICES
10541 N RANCH RD
HAYWARD WI 54843 6462
Contact Through Relay
http://dsps.wi.gov/programs/industry-services
131.
www.wisconsin.gov
Scott Walker, Governor
Dave Ross, Secretary
October 05, 2016
CUST ID No. 220357 ATTN: POWTS Inspector
BRADY J UTGARD ZONING OFFICE
UTGARD PLUMBING & HEATING ST CROIX COUNTY SPIA
PO BOX 413 1101 CARMICHAEL RD
AMERY WI 54001 HUDSON WI 54016-7708
CONDITIONAL APPROVAL Identification Numbers _
PLAN APPROVAL EXPIRES: 10/05/2018 Transaction ID No. 2775723
Site ID No. 828838
SITE: Please refer to both identification numbers,
Keith Bergman above, in all correspondence with the agenc .
2725 Cth Q
Town of Forest
St Croix County
NE 1/4, NW t/4, S8, T31N, R15W
FOR:
Description: Mound, 2 br res
Object Type: POWTS Component Manual Regulated Object ID No.: 16238.10
Maintenance required; Replacement system; 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), SSWMP Pub. 9.6; 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 constr~e,;;~~
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
requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department pe 45.06;" _
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Key Item(s)
• 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. In addition, the
owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the
mound component manual are complied with. A copy of this information must be given to the owner upon
completion of the project.
Reminder
• The orientation of the mound system must be such that the longest dimension is oriented along the surface
contour per SPS 383.44(6)(a)2.
• Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual.
• Surface water drainage shall be diverted away from the system area per Mound Component Manual.
• Materials shall conform to the requirements of SPS 384.
• 'The existing POWTS must be properly abandoned per s. SPS 383.33 Wis. Adm. Code.
BRADY J UTGARD Page 2 10/5/2016
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. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction/installation/operation.
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
Patricia L Shandorf
POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633
(715) 634-7810, Fax: (715) 634-5150 , M - F 8:00 a.m. - 4:45 p.m.
pat. shandorf@wisconsin.Qov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
BRADY J UTGARD Page 2 10/5/2016
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. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction/installation/operation.
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
Patricia L Shandorf
POWTS Plan Reviewer, Division of Industry Services WiSMART code: 7633
(715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m.
pat. Shandorf@wis c ons in. go v
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm
RECEIVED
SEP 1 4 20?0
MOUND AND PRESSURE DISTRIBUTION COMPONENT DR MTRY SERTI ;
INDEX AND TITLE PAGE
Project Name: KEITH BERGMAN
Owner's Name: KEITH BERGMAN
Owner's Address: 5833 LAKE ELMO AVE. N LAKE ELMO MN. 55042
2725 CO. RD. Q
Legal Description: NE/NW/S8/T31/R15W
Township: FOREST
County: ST. CROIX
Subdivision Name:
Lot Number: Block Number:
Parcel l,D. Number-, 014°1017-60-000 -
Plan Transaction No.: ;
S « y1
Page 1 Index and title -
Page 2 Data entry
Page 3 Mound drawings
Page 4 Lateral and dose tank
Page 5 System maintenance specifications
Page 6 Management and contingency plan ; %
Page 7 Pump curve and specifications
Page 8 PLOT PLAN ~ `y .
Page 9 SOIL EVALUATION
Designer: BRADY UTGARD License Number: 220357
Date: 09/14-146 -c Phone Number: 715-760-0946
Signature: ~~l
Designed P want to the
Mound Component M ual for POWTS Version 2.0 SDB-10691-P (N. 01101), and
SSWMP Publication 9.6 esign of Pressure Distribution Networks for ST-SAS (01/81)
Version 3.11 (R_ 06/01) Page 1 of 9
Mound and Pressure Distribution Component Design
Site Information
R Residential or Commercial Design Note: Sand fill (D) calculations assume a
200.00 Estimated Wastewater Flow (gpd) Table 83-44-3 in-situ soil treatment for fecal
1.50 Peaking Factor (e.g. 1.5 = 150°/x) coliform of - 36 inches.
300700 Design Flow (gpd)
1.00 Site Slope
99.65 Contour Line Elevation (ft)
14.00 Depth to Limiting Factor (in)
0.50 In-situ Soil Application Rate (gpd/ft`)
Distribution Cell Information
50.00 Dispersal Cell Length Along Contour (ft) = ~ 6.00 Cell Width (ft)
1.00 Dispersal Cell Design Loading Rate (gpd/ft )
1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point
in the distribution Y
Pressure Disribution Information network?
E Center or End Manifold
Lateral Spacing (ft) If N above, enter the elevation (ft)
72 Number of Laterals of the hiq.1v ' ,..,:;n+
0.188 Orifice Diameter (in) (e.g. 0.25)
3.00 Orifice Spacing (ft) = 8.82 ftz/orifice
2.00 Forcemain Diameter (in)
95.00 Forcemain Length (ft) Does the forcemain drain back? Y
r). 90.00 Pump Tank Elevation (ft)
3.25 System Head (ft) x 1.3 15.50 Forcemain Drainback (gal)
11.48 Vertical Lift (ft) 30.89 5x Void Volume (gal)
1.06 Friction Loss (ft) 46.39 Minimum Dose Volume (gal)
15.80 Total Dynamic Head (ft) 22.28 System Demand (gpm)
Lateral Diameter Selection Mr Selection
in. dia. o tions choice cho~
0.75 x
1.00 1.25 x x 2
.00
1.50 x 3.QQ
2.00 x
3.00 x
Gallons/Inch Calculator
Treatment Tank Information 600.00 Total Tank Capacity (gal)
1000.00 Septic Tank Capacity (gal) 36.00 Total Working Liquid Depth (in)
weiser Manufacturer 16.67 gal/in (enter result in cell 649)
Dose Tank Information Effluent Filter Information
600.00 Dose Tank Capacity (gal) POLYLOC Filter Manufacturer
16.67 Dose Tank Volume (gal/in) PL-525 Filter Model Number
weiser Manufacturer
Project: KEITH 6ERGMAN Page 2 of 9
Mound Plan View
. . T
1!1 0 B . . . . : . . . . . J
Observation Pipe 3
I 0 A
. . B
. ' ' ' .
3 '
L "
Mound Component Dimensions
ft
A 6.00 ft E 22.72 in H 1.00 ft K E2ft
B 50.00 ft F 9.25 in 9.79 ft L ft
D 22.00 in G 0.50 ft J 9.04 ft W 300.00 (ft2) Dispersal Cell Area 789.30 (ft2) Basal Area Available
6.00 (gpolft) Linear Loading Rate 5.00 (ft) 1/10 B Obs. Pipe Placement
Mound Cross Section View
Aggregate Dispersal Area
Finished Grade 103.25 (ft) ►
~rfffir~ 2rs~rr>, G •j
F 101.98 (ft) Lateral
Dispersal Cell
101.48 (ft)-1► Invert
:
Dispersal Cell 33
Elevation E D
1
_ 4
4
99.65 (ft) Contour Elevation
1.0 % Site Slope
Geotextile Fabric Cover
Shading Key- Dispersal Cell See lateral details on
Topsoil Cap c = 1,5 ft Page 4 for number, size,
Subsoil Cap to c F51 J /~Q and spacing of laterals.
/ F Laterals are equally
ASTM C33 Sand
~5 2-1
R Tilled Layer d 0.5 ft Typical Lateral I spaced from the
R Aggregate v o Q distribution cell's
centerline in the
A distribution cell (AxB).
Project: KEITH BERGMAN Page 3 of 9
End Connection Lateral Layout Diagram
Laterals centered over the A & B dimension ! = Turn-up vrtball valve or cleanoutplug I
Mlatefafs P
cal I<- }CHo les drilled on the bottom of the lateral S
equally spaced
tion via tee or cross to manifold at any point. Laterals & force main of PVC sch 40
(per COMM Table 8430-5)
Number of Laterals 2 Orifice Diameter 0.188 in
Lateral Diameter 1.25 in Orifice Spacing (X) 3.03 ft
Lateral Length (P) 48.48 ft Orifices per Lateral 17
Lateral Spacing (S) 3.00 ft Orifice Density 8.82 ftz/orifice
Lateral Flow Rate 11.14 gpm Manifold Length 100 ft
System Flow Rate 22.28 gpm Manifold Diameter 1.25 in
Total Dynamic Head 15.80 ft Forcemain Velocity 2.28 ft/sec
Dose Tank Information Locking cover with warning
label and locking device and
sealed watertight
Electrical as per NEC 300 and ►
Comm 16.28 WAC 4 in. min.
Disconnect
Tank component is properly vented Alternate outlet
location
Forcemain diameter
weiser Manufacturer 2 in.
Ca aci 600.00 Gallons
Volume 16.67 gal/inch A
Weep hole or anti-
Dimension Inches Gallons 4 6 B siphon device
A 25.21 420.25 C
B 2.00 33.34 Pump off elevation (ft)
C 2.78 46.39 90.50
D 6,00 100.02 D
Total 35.99 600.00
Dose tank elevation (ft)
3" Bedding un er tank. 90.00
Alarm Manuafacturer LEVEL
Alarm Model Number DLV
Pump Manufacturer GOULDS
Pump Model Number EP05
Pump Must Deliver 22.28 g p m at 15.80 ft T D H
Project: KEITH BERGMAN Page 4 of 9
Mound System Maintenance and Operation Specifications
Service Provider's Name UTGARD Phone 715-268-6995
POWTS Regulator's Name ST. CROIX Phone 715-386-4680
System Flow and Load Parameters
Design Flow - Peak 300 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow - Average 200 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L
Soli Absorption Component Size 300 ftz Maximum FOG 30 mg/L
Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL
Service Frequency
Septic and Pump Tank Inspect and/or service once eve 3 ears
Effluent Filter Should inspect and clean at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test month)
Pressure System Laterals should be flushed and pressure tested eve 1.5 ears
Mound) inspect for ponding and seepage once every 3 years
INSPECT FILTER ONCE A YEAR
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to Table Comm 84.30-1, have a watertight cap,
and are secured in as shown in the mound component manual.
2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code.
3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code.
4. Tillage of the basal area is accomplished with a mold board or chisel plow.
5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion
and help reduce frost penetration.
Lateral Turn-up Detail
Finished
Grade
6-8" Diameter Lawn -Threaded Cleanout
Sprinkler Valve Box Plug or Bail Valve
Distribution
Lateral
- - Long Sweep 90 or Two
45 Degree Bends Same
Diameter as Lateral
Project: KEITH BERGMAN Paoe 5 of 9
Mound System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
General
This system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall maintained in accordance with its'
component manuals [SBD-10691-P (N.01/01) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system
maintenance and maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death.
Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access
openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound,
defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an
effective locking device to prevent accidental or unauthorized entry into a tank or component.
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic
tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be
assessed at least once every 3 years by inspection.
The outlet fitter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions
are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm,
the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending
continuous alarm.
The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the
tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of
when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such
products are used they shall be approved for septic tank use by the Department of Commerce.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper
operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary.
Mound and Pressure Distribution System
No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be
seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for
vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the
mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the
mound be heavily mulched as protection from freezing.
Influent quality into the mound system may not exceed 220 mg/L BOD5, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30
mg/L BOD5, 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design
flow specified in the permit for this installation.
The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be
flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test
when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution
within the dispersal cell.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any
levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring.
Contingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in
proper operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately
repaired or replaced with a component of the same or equal performance.
If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or
replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal
media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition.
See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: KEITH BERGMAN Page 6 of 9
GOULDS PUMPS
Submersible
Effluent Pump
:Y
E w"04 EP05
Series
APPl €CATtt3NS
Fully submerged in high ® EPOS Impeller: Thomo al,v,
'rrµ{ iti~ .lily ieslyrlt~d for the 9re turbisue oil for Bearings s iwpt„ anti h,wr;
fub tic enclosed design ,of heal ~~l~wrn~ uses; rkation and efficient W V hall he~tnu~
imf mvprj performan rc
beat ti'c3!}Sfer_ ~ nn5trtar~tlnr.
"uenl ~ term ■ Casing and Base: Rugged
k A4E%5
Available for autorn&,il thermoplastic clesicgsi hrovtdpe, AGENCY LISTING
mannual operadon. Ate.. superior strength and ,>rrc,ll n
. 1Y~ (yr •;t,riil} mate models rndWe re5lsdani.e. F.,m,x'rsart SY.drNl.3rr1 Ati..tK..thnrt
e:141 idt '4_'t C" ff€E~ # rRiR544
L rtt~srlt,l Mecharl" Pon switch ■ Motor Housing: (j_, rrr!"
asSembled and preset at the tot efficient heat trarv fel- (xx" Pump, n 1%0 14701 Rrj1'tVf ed
;P," C€1 €tATI(}1+IS factory. strettrtth, and durahllii~l
. . ■ Motor Cover. Therrnoj~ast,_
h,ntlhnrl capability: FEATURES cover with integral handle and
m.iMlnwrn EF'04 imps fltwt Switch attathMe * tl -
y
~Ji EC~Pti :.,p to 60 GPM. Impeller Themu)plas_
tic semi-opers design with ■ Power Cabie ~eve,t~ putt
~t,ft hoods : up to 31 feet. rated oil and water 'W
Pump OUt vanes for mechanical ra7r e
,c -44e size, V/z" NPT.
h seat protection.
st-al- carbon-
r+ -vIt ! r,:ttnst. stationary.
IjA t41 pi,txtnmers
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continuous
1110 C) intermittent 3~es rr~
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address -5-8
Property Address 7
for new construction.
(Verif
icatioon required from Planning Zonis epartment )
City/State te Parcel Identification Number & O - C70 Cl
LEGAL DESCRIPTION 5 q0 V~
Property Location 1/4, W W 1/4, Sec. g , T c3/ N R,.,/,5-W, Town of
Subdivision Plat: , Lot #
Certified Survey Map Volume , Page #
Warranty Deed # 9 lo?, 3 (before 2007)Volume , Page #
Spec house D yes Xno Lot lines identifiable)( yes ❑ no
SYSTEM MAINTENANCE Al\rD OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this fork 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 warran deed recorded in Register of Deeds Office.
Number of bedrooms OC
SIGNATURE OF A7PLICANT(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. 04/12)
RECEIVED
Wis. CAW W; ''rofessional Services Sr-) L E fM_vk, ` EUN RE 80N65QC7CUS90 page -~of~
Division of Safety and 3uildings
ST, CROIX COUNTY in accordance with SPS .',EIS, Wis. Adm. Code -
County
ere ty
,OM ~ELOPMENT
ere si,, plan on a er not less than 8 1!2 x 11 inches in size. Plan must C- IR
nclr!de but not limited ion vertical and horizontal reference poin (BM), direction and Parcel I.D.
neicent sloloe. scale or dimensions; north arrow, and location and distance in nearest road
Please print all information, Revi d by : Date
I in`ormatia: you provOe, may be used for =dary nn, c~s~ .~ida ,p 1 arv- 15.64 (1) (m)).
Property O+ron:~ar - ^roGerty Location
R e er" Q Gorrt. Lot 14(:~ 1,'4 Q14 S T ~ N R I S E (or W
Proper) Owner's Mailin i4ddress- Lot # 3lock # Subd. Name or ,SM#
City State Zip Code Phone Number ; ❑ Cite ❑ Village [Town Nearest Road
I'S So V
Nevv Construction Use, FNResidential / Number of bedrooms _ Code derived design flow rate 3 GPD
( F'eplacement ❑ Public or cemlrercial - Descrih' _ Flnnd X13 n elsvatlon if apollcable ft
.
General comments t - 1
and recommendations S 5 v ~g~ S { Q (o yt Moo r,Q S eA a~ O 11. X65
0 114
o 71 Bormg i
~Boring tt
9_J-j L-i Pit Ground surface elev. 97.65 ft. Depth to limiting factor in-
_ - _ Soil A lication Rate
Horizon Depth Dominant Color Redox Description xture l Structure onsistence oundary Roots GPD/ft ' _
n. Munsell Qu. Sz. Cont. Color l Gr. Sz. Sh. ff#1 ff#2 I
0-9 1~ o i.2 ~ i _ s L a F
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I 1 Boring # Borina t
i Fi; ct: urfacs elev 99. Los Depth to limiting factor - in.
- 3.11, ApplIcal;c'- Rate
Horizon Depth Dominant Colof Redcx Desaipiion i I~exture Structure ,onsistence Boundary Roots GPD/ft
n Munsell Qu. S,, r.,ni. r.o!or - C,r. S-_. Sh - ff#I fN#2-
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" Effluent 4'1 = BOD 30 22G mall and TS 0 _ 1 w „gli_ i-ffh.ient # = BOD < 30 mg/I_ and TSS < 30 mg/L
- - - -
,7.'T Name (Please r rint) CST Number
--e 17
all C ~j0 1x ~4 .rate Evaluation Conducted Telephone Number
61
SB) -F330 (R1 1 11)
r
Property Ownpi e:4 1 ver~+Vhcs~ } parcel 1D # Page of 3 _
Boring Boring 4
#
~_j Pit Ground su ace elev. ! ~~ft- Depth to limiting factor in. Soil Application Rate
Horizon` Depth Dominant Color Redox Description $ Texture Structure onsistence Boundary Root-_ GPDlft
ir. Munsell Ou. Sz- Cont. Color_ I Gr. Sz Sh. ff#1 ff#2
- 15 o-10i L a F5b, ►._Y- v.,, i
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Boring 3?
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I lonzon Depth I Dominant Color Redox Description Texture Structure onsistence Boundary Foots GPD/ft
in. 4LIM-L,nsell Chu. Sz. Cont. Color GriSz. Sh * .ff#1 ff#2
ric G
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Pit iim a
Soil Application Rate
Horizon Depth I Dominant Color Redox Description Texture, Sinicture onsistence Boundary Roots GPD/ft
in. i Nu1 nsell nu. 5z. Cont. Color Gr Sz. Sh_ * =ff# i " ff#2_
Effluent ##1 = BOD : > 30 < 220 mg/!- and TSS >30 <'150 nig/L. Effluent #2 = 80p < 30 Ong/L and TSS < 30 mg/L
T11c Beht_ of Safer}' and ProfessimIL)I Ser"ices i an eytra1 OpporUmi1y ServiCC' provider and employer. 11' you need assistance to
aeccss SM ices OF nerd inatc.rial in an titer n to fo~rrrr.n, crmtact the d~~~;~rlment at 608-266-31-51 or TTY through Relay.
tyOrn,r~~,. PamclID=f_.--_~`~"---- Pace of
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(c, o11~i cr-, icE.S ❑l~ I,;); u:111\ .'i(n 1('.c -tIY1~.IClcr a.Pld Cnlh~oyOr. I IF VoI1 11(-"Cd BSSIstanCC. I'(7
(..he dep;~rln1(mi 8i (,08-266-,151 nr-1 lrou, i1 Relay.
acs n "1c'°cl r,rlic,ia! i' an . L, ,.c~ I~~i ~~1 if. cnuiact v' tl