HomeMy WebLinkAbout018-2011-74-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597381
GENERAL INFORMATION State Plan ID No
2953331
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]
Permit Holder's Name: City Village Township Parcel Tax No:
OEVERING HOMES TOWN OF HAMMOND 018-2011-74-000
CST BM Elev: Insp. BM Elev: BM escription: Section/Town/Range/Map No:
/6#, /6 / GAT 30.29.17.1089
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
Septic Benchmark
z ~v , -b /61-1 Dosing 7 50 Alt. BM 971/
Bldg. Sewer
16,4 c~ ,
Holding St/Ht Inlet 1 1
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO I WELL BLDG. ent t it Intake ROAD Dt Inlet `
Septic , t~ 2 ~ Dt Bottom
76 Dosing `70 1~ Z Header/Man.
Aeration Dist. Pipe
Holding Bot. System V7,,6
Final Grade
PU
.40 0
MP/SIPHON INFORMATION Manufacturer Demand St CoverGPM ~ Model Number / Z'7
TDH Lift Friction Loss 5 System Hea ITDLJ J
11, Zvi z om 1
Forcemain
1 /0 1 1Z Length`/ Di a. Dist. to Well
/JA-
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. O Tr nches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS J Z /256~ / ra e-
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Typ f Syst m: A UNIT Model Number:
" 6TO~ I'
DISTRIBUTION SYSTEM
e
Header/Manifold Distribution ~r Ix Hole Size rl Ix Hole Spacing Ve t o 411nt
\
~ Pipe
1 0 p g` ~ 3 X J
Length_ Dia Len th Dia S acin
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only «
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Z •3S Yes I] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1541 78TH AVE
1.) Alt BM Description = tJ7~•Cr
2.) Bldg sewer length = 'P V
- amount of cover = 07~4' n
S Q d
Plan revision Required? ❑ Yes
Q'
No
U-7~
se other side for additional information. o J (tf
SBD-6710 (R.3/97) Date Insepctor's Sig re Cert. No.
I
County
!,a ?V p~^y Safety and Buildings Division
<I ~ D 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit umber (to be filled in by Co.)
` p Madison, Wl 53707-7162
zap r 5 -73'9
T CROIX f f Permit ~ rr)"' State Transaction Number
it
~Nlilh'SS 383.21( Wis. Adm. Code, submissia
is required prior to obtaining a sanitary permit Note: Applicati , i 3 are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
putposes in accordance with the Privacy Law, s. 15. 1 m , Stars.
t" f1
41
L Application Information -Please Print n a on
Property Owner's Name Parcel #
0,1
Property Owner's Mailing s Property Location j c.' 1
L Gov[ Lot ,
City, State Zip Code Phone Number K -1/, ~_E_ y. Section 0
Z1 T2L~N; R / E
11. Type of Buil ding (check all that apply) Lot #
1 or 2 Family Dwelling-Number of Bedroo L. Subdivision Name
Ok ~ Bloc t„Q /t
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
4"'-% wn of -
Z
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
System ❑ Replacement System ❑ Treatment/Holding Tank Replacement 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: (CheYk all that apply) k J( IQ
❑ No-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 rsaVrrea ent Area Information:
Design Flow (gpd) Design S it Application Rate(gp f) Di persal Area Required Dispersal Area Propo d (s system Elevation
,~-77
0 -:5
VL Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units L U T
New Tanks Existing Tama ~:A v p E! R s m
1/~ ~fi K~f M~ U cn > co C~i
Scptic or Holding Tank `
Dosing Chamber
VII. Responsibility State ent- 1, the undersigned me responsibility for installation of the POWTS shown on the attached plans.
Plimr, 's Name (Print) PI er' Signature MP(MPRS Number Business Phone Number
e
Plumber's Address (Street, City, State, Zip 7)
IvM County/Department Use Only
Approved r TPer~rt Fee Dte sued IsSignatu e
en Reason for Den~ t
IX Condtti , t o¢ r ~pp,oval
1. t„ iernt 3~ : ~eaari~
~br~botai call 1`.it13~ all ~ ~fcasi rsl~lntY,^.gS: 4.~.` : J~ t~lCe~ t~tJl ~-1~ P GrM••''~'
> plan prarideti bV plumber. ti
2. ~S must kw rlalrl ir:Ed
a PV vpaw / tMfl+ ncu. 4~ ~avr t,~.J lul
Attach to complete plans for the system and submit to the County only on, paper not less than w z 11 inches in I ~ ~Q✓`
SBD-6398 (R. 11/11)
System PLOT PLAN
PROJECT Oeverino Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NW 1/4 NE 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 103.7' 5/18/17 BEDROOM 4
DATE
CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 1000 # of chambers none
BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE (DWELL *H.R.P. same as benchmark
78th Ave
Property Line 2 acre parcel
Pro 4 not to scale
Property Line Bedroom
not to scale House Scale = 1 /4" = 10'
Grading is to be done to divert Huffcutt
run-off away from system Combo Tank
B.M.* B-1
B-2
4% Slope
Well is to meet all
WDNR setbacks
Area 15' below
system is to remain
1 03' undisturbed
B-3
103.7'
104'
Prop rty e Line
"z_,('
oR71~~~ DIVISION OF INDUSTRY SERVICES
2331 SAN LUIS PL STE 150
GREEN BAY WI 54304-5211
Contact Through Relay
http://dsps.wi.gov/programs/industry-services
www.wisconsin.gov
Scott Walker, Governor
Laura Guti6rrez, Secretary
June 16, 2017
CUST ID No. 226900 ATTN: PO WT5 Inspector SAFE
A L SI
ZONING OFFICE'
SHAUN R BIRD ST CROIX COUNTY SPIA
1432 120TH ST 1101 CARMICHAEL RD
NEW RICHMOND WI 54017-6409 HUDSON WI 54016-7708
CONDITIONAL APPROVAL ' u
PLAN APPROVAL EXPIRES: 06/16/2019 Identification Numbers
Transaction ID No. 2953331
SITE: Site ID No. 839287
Oevering Homes Please refer to both identification numbers,
1541 78TH Ave above, in all correspondence with the agency.
Town of Hammond
St Croix County
NWI/4, NE 1/4, S30, T29N, R17W
FOR:
Description: At-Grade (4 Bedrooms - New Construction)
Object Type: POWTS Component Manual Regulated Object ID No.: 1712607
Maintenance required; 600 GPD Flow rate; 38 in Soil minimum depth to limiting factor from original grade;
System(s): At-grade Component Manual, Version 2.0, SBD-10854-P (N.03/07, R. 1/12), 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
requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s. 145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• Preserve dispersal area prior and during construction to avoid disturbance, compaction and use of the site.
• Any tall grasses, leaves and shrubs shall be cut short and removed prior to tilling the surface for installation to
prevent matting under the dispersal area.
• Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches.
Smearing and compacting of wet soil will result in reducing the infiltration capacity of the soil. Proper soil
moisture content can be determined by rolling a soil sample between the hands. If it rolls into a 1/4- inch wire,
the site is too wet to prepare. If it crumbles, site preparation can proceed. If the site is too wet to prepare do not
proceed until it dries.
• Abandon Existing System per SPS 383.33
• Pump Floats to be set and verified per approved plan. Anv changes may result in pump resizing to meet
TDH and GPM Specifications.
• Divert surface water from POWTS Area.
• Well setbacks to meet chs. NR 811 & 812.
SHAUN R BIRD Page 2 6/16/2017
• All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5
• Insulate building sewer beyond 30 feet per SPS 382.30 (11)(c)
• Tank Installation to follow all manufacture's recommendations.
• SPS 383.54(1)(e) The management plan for a POWTS shall specifically address the servicing mechanics of an
aerobic or anaerobic treatment tank or a holding tank where either of the following conditions exist:
1. The bottom of the tank is located more than 15 feet below the elevation where the servicinE4 pad is located.
2. The bottom of the tank is located more than 150 feet horizontally from where the servicing pad is located.
• Verify property line(s) prior to installation.
• Areas that are occupied with rock fragments, tree roots, stumps and boulders reduce the amount of soil
available for proper treatment. If no other site is available, trees in the basal area of the at-grade must be cut off
at ground level. A larger fill area is necessary when any of the above conditions are encountered, to provide
sufficient infiltrative area.
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 SPS
383.54(].).
• 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.
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
con struction/in stallation/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 S 250.00
This Amount Will Be Invoiced.
a When You Receive That Invoice,
Please Include a Copy With Your
Tim Vander Leest Payment Submittal.
Private Sewage Plan Reviewer, Division of Industry Services WiSMART code: 7633
(920)492-2214, Monday - Friday 6 am To 3:30 pm
tim.vanderleest~,wisconsin.gov
SHAUN R BRD Page 2 6/16/2017
• All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5
• Insulate building sewer beyond 30 feet per SPS 382.30 (11)(c)
• Tank Installation to follow all manufacture's recommendations.
• SPS 383.54(1)(e) The management plan for a POWTS shall specifically address the servicing mechanics of an
aerobic or anaerobic treatment tank or a holding tank where either of the following conditions exist:
1. The bottom of the tank is located more than 15 feet below the elevation where the servicing pad is located.
2. The bottom of the tank is located more than 150 feet horizontally from where the servicing pad is located.
• Verify property line(s) prior to installation.
• Areas that are occupied with rock fragments, tree roots, stumps and boulders reduce the amount of soil
available for proper treatment. If no other site is available, trees in the basal area of the at-grade must be cut off
p;-^
at ground level. A l..'ry rter o f the abo . ...,nditio,,., -terew ride
sufficient infiltrative area.
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 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.
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
v~- This Amount Will Be Invoiced.
lz~l el_14 ~ 1&eaf When You Receive That Invoice,
Please Include a Copy With Your
Tim Vander Leest Payment Submittal.
Private Sewage Plan Reviewer, Division of Industry Services WiSMART code: 7633
(920)492-2214, Monday - Friday 6 am To 3:30 pm
tim.vanderleest@wisconsin.gov
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date:5/18/17
Owner:Oevering Homes
Location:NW 1/4 NE1/4 S30 T29 N,R17W 1541 78th Ave Hammond
Manuals Used: At-Grade Component Manual version 2.0 SBD 10854 (N. 03/07)
Pressure Distribution Manual version 2.0 SBD 10706-P(N. 01/01 R. 10/12)
Page#
1. Cover Page
2. At-Grade Plot Plan
3. At-Grade Cross Section
4. Pipe Cross Section/Pipe Layout
5. Pump Chamber Cross Section
6. Pump Curve
7-8. Maintance and Contigency plan
9. Filter Specifications
Attachments: Soil Test n'
Shaun Bird
Signature
License number 226900
Page 1 of 9
System PLOT PLAN
PROJECT Oeverina Homes ADDRESS 1433 Cernohous Ave Suite A New Richmond Wi 54017
NW 1/4 NE 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 103.7' DATE 5/18/17 BEDROOM 4
CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 1000 # of chambers none
BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
78th Ave
Property Line 2 acre parcel
Pro 4 not to scale
Property Line Bedroom
not to scale House Scale = 1 /4" = 10'
Grading is to be done to divert Huffcutt
run-off away from system Combo Tank
B.M.* B-1
B-2
4% Slope
Well is to meet all
WDNR setbacks
Area 15' below
system is to remain
1 03' undisturbed
B-3
103.7'
104`
Property
At-grade System Sloping Site Cross Section and Plan View
a Dimension Feet
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Slope Direction
GENERAL INSTALLATION: The at-grade area is staked out along the design contour. Existing
vegetation is mowed and raked off the site. The basal area (L x W) is staked out and plowed with a
moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to
form a 1/4 inch soil wire when a sample is rolled between the palms of the hands.. The A x B area is
covered by clean aggregate deposited overhead by a backhoe. Special care must be used when
placing the aggregate to minimize compaction of the plowed surface. After the topsoil cap is placed,
the entire at-grade is seeded and mulched to promote vegetative' growth, limit erosion and protect
from freezing. The observation pipes are perforated in the lower 6-inches. and secured in place.
03/05 lgj Page of /
Pressure Lateral Layout
One Lateral - End Manifold
.4 Threaded
Cleanout
Lateral Turn-up Plug
Force Main
i
X
L Long
Sweep
90
Bend
e21- Pressure System Construction
Distribution Network Specifications
Lateral Diameter In. Laterals are constructed of Schedule 40 PVC
Orifice Diameter S 3 In. pipe. Orifices are drilled perpendicular to
X (Orifice Spacing o2 ~f In. the pipe with a sharp drill bit and face down.
I S7
L Lateral LengLh) Ft, Lateral turn-ups terminate with a threaded
Force Main Diameter In, ceanout plug and are enclosed in a 6-8 inch
Ft, diameter lawn sprinkler valve box accessible
Force Main Len
from finished grade.
Grade ••••::0.._....:_:
6-8 Inch Lawn
Sprinkler Valve
Box
03/051gl Page of
Septic-Dose r'atak Cross Section And Pump Performance Specif cations
Pump Manufacturer
Tank Manufacturer
Model Number ~j -5- L
Tank Model Number -1 PUMP
Total Tank Capacity Alarm Manor
Max. Bury Depth Alarm Model Number 1.
Switch Type 1YP
Filter Manufacturer , Total Dynamic Head (TDR) - Feet
Filter Model Number Elevation Head
Distal Pressure v~ _
Network Loss a
Minimum Pump Performance Required Foree Main Lass 0
GPM' @ Ft TDH Total S
Outlet Manhole Min. 4" Above Grade With Manhole Min. 4" Above Grade
Locking Device. Inlet Manhole With Locking Device
< 6" Below Grade Sealed Watertight Securely Mounted
weather-p
roof Junction Box
Fd-G•• -
~isherade
i
Vent Min. 12" Disconnect
Above Grade Means
With Vent Cap
Outlet Filter - - - -
inlet Wet Baffle ' : - - - - - -
A '
Switch Settings and Reserve Capacity %a„
Tank Volume = j GPI Weep
-740
imension : Inches Volume Gal. B Hole
Dimension,*
(reserve) A;
(alarm) B 2 3q Off Elevation C ,
(dose) C '7 '1 a-7 • : ; Bottum
<
(dead)
D S" D Elev "on
Total
.'iii <ai .t:t•tat ,~at.t,~>t.,.;,t ;,,,a > a . . f•>•a<> > : >•/<)<:>`>`,:::i :t•: t•t•a : >
a>.>. . a. a.< i a l a a t t{< t a t 1 iiat,tai 1 1 f 1•~ a'iiis is it>~
GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the
manufactwer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not
be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock)
installed. Piping at the inlet and'outiet is of approved material, connected to the tank with watertight fittings, and
laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank
excavation aid the sleeve is sealed watertight. Electrical serviccomplies with NEC 300 and Comm 16.23.
i
02/05 U Page of _
TOTAL DYNAMIC HEAD/CAPACITY
PER MINUTE
HEAD CAPACITY CURVE EFFLUENT AND DEWATERING
MODEL 152/153 MODEL 1 152 153
M S0 Feet I Meters Go'. Liters { Gal. Liters
5 1.5 { 69 ` 261 77 291
153 10 3. i 61 231 70 265
12 40 152 15 4.6 53 1 201 61 231
0 20 1 6.1 1 44 167 52 197
_ 25 7.6 34 129 42 1 159 ;
30
9.1 I 23 87 I 33 , 125
1
a 8 30
r 35 I i 22 8~
20 ^ ^ 42
a 40 I 12.2 j I I 11
Ft. (.3.4 J
Lock Voiv 136.0 t. (11.6m)I440
4 clisca
10
I
1
0 gp 100
20 40 60
GALLONS s 1/a
LITERS p 80 160 240 320 - 3 27/32
j
FLOW PER MINUTE 1 3 27/32
I
CONSULT FACTORY FOR SPECIAL APPLICATIONS 3 2732
• Timed dosing panels available.
Electrical alternators, for duplex systems, are available and supplied with
an alarm.
• Variable level control switches are available for controlling single phase I
systems. T -
level Double piggyback variable level float switches are available for variable I
level long and short cycle controls. j
• Sealed Qwik-Box available for outdoor installations. See FM1420.
• Over 130°F. (54°C.) Special quotation required. i -
12 '1 /8 1521153 Series T
152x153 MODELS Control Selection 5 1/8
Model Volts Ph move s Sim rex Du fex
111111
115 Non 8.5 t 2 or 3 ~L SK20e4
BN1 1 _
N152 115 7 Aura 8.5 Included 2 or 3
E152 230 1 Non 4-3 1 2 or 3
BE152 230 Auto 4.3 Inclu`ed 2 or 3
N153 115 1 Non 10.5 1 2or3 SELECTION GUIDE
BN153 115 1 Auto 10.5 Inclujed 2 or 3 back variable level float
i Non 5.3 1 2 or 3 1. Single piggyback variable level float switch or double piggy
E153 230 Induded 2 or3
13E153 230 1 Auto 5.3 switch. Refer to FM0477.
2. See FM0712 for correct model of Electrical Aitemator E -Pak.
3
A du p
p CUTION
otection devices and wrong should be done by a qualified 3. Variable level control Switch 10-0225 used as a control activator, specfy p
All installation controls, codes should be followed including the most or (4) float system.
. AU electrical and suety and Health Act (OSHA).
licensed electrician
recent National Electric Code (NEC) andthe occupational Safety
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
.
Man4acturersof.
Louisvie, KY 40250347
Step TO: 3649 Cane Run Road PoMa9 BCE N
QLGiL/JT
Q Louisville, KY 40211-1961 ~c~iJ r7
Z ® (502) 778-2731.1(&00) 928-PUMP
)azwa FAX (502) T74-3624
hitpJ/www.zoeUer.com
0 Copyright 2000 Zoeller Co. All rights reserved.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
2.2 Q Septic Tank Capacity a1 ❑ NA
Permit #
Septic Tank Manufacturer ❑ NA
3ESIGN PARAMETERS Effluent Filter Manufacturer El NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units NA Pump Tank Capacity al ❑ NA
Estimated flow (average) 9 0 avda Pump Tank Manufacturer 4t❑ NA
i Design flow (peak), (Estimated x 1.5) v gal/day Pump Manufacturer ❑ NA
Soil Application Rate k~ al/da /ft2 Pump Model 0 NA
Standard Influent/Effluent Quality Monthly average" Pretreatment Unit
Fats; Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :!9150 mg/L ❑ Disinfection ❑ Other.
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODs) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 40 mg/L -RCNA \ t-Grade ❑ Mound
Fecal Coliforrn (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other
iMaximurn Effluent Particle Size Ya in dia. p NA Other. ❑ NA
iOther: NA Other: ❑ NA
'Values typical for domestic wastewater and septic tank effluent Other: ❑ NA
IAINTENANCE SCHEDULE
Service Event Service Frequency
lips ect condition of tanks ❑ month(s)
P At least once every: ears (Maximum 3 years) ❑ NA
(Pump out contents of tank(s) When combined sludge and scum equals one-third ('Ya) of tank volume ❑ NA
(Inspect dispersal cell(s) At least once eve ❑ month(s)
every: ear(s) (Maximum 3 years) El NA
Clean effluent filter At least once every: ~ l ❑ month(s) ❑ NA
ear(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
-Oyear(s)
!=lush laterals and pressure test At least once every: ~ ❑ month(s) 0 NA
ether
At least once every: ❑ month(s) ❑ year(s) ❑ NA
13ther:
❑ NA
MAINTENANCE INSTRUCTIONS
!Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
(Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. 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
immbined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 tank equals one-third or more of the tank volume, the entire contents of
1-he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Administrative Code.
III other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
land any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
lk service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
F
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 or other chemicals theft
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of thi
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will bie
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluenlt.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. 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 POWT$:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain
(sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and water softener brine.
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 propefiy
and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:.
• All piping to tanks and pits 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-
• 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 compliortt
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by requirjed
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the nOed
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rule. in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN a
holding tank may be installed as a last resort to replace the failed POWTS.
16-The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluatpon
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed) as
a last resort to replace the failed POWTS.
"Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O~ A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name t
E Name_
b-Z Phone ~ - C;_ K I
Phone
SEPTAGE SERVICING OPERATOR UMPER LOCAL REGULATORY AUTHORITY
Name err Name y-
Phone - J Phone / -
-c-This document was drafted in compliance with chapter SP S 383.22(2)(b)(1)(d)&(t) and 383.54(4), (2) & (3), Wisconsin Administrative Code.
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
f
Owner/Buyer ~e Je r) 11
Mailing Address
Property Address' a(~ g (Verification reqnning & Zoning epart lent for new eonstniction.)
City/State
Parcel Identification Number— LEGAL DESCRIPTION
Property Location ~s r "
~.Y4 A~ Va,SeC. T~NRJJ _
W, Town of ~
Subdivision
Lot #
Certified Survey Map
- ~ Volume Page #
Warranty Deed #
f '4' , Volume
Page #
Spec house/ Dye
yes no Lot lines identifablT
no
SYSM 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
the system can affect the function of the septic tank every three years or sooner, if needed, by a licensed pumper-
the s stemthes are specified in Co tank as a treatment stage in the waste disposal system. Owner ma mat you put into
§ mm. 83.52(1) and in Chapter 12 - st. Croix Co maintenance
unty Sanitary Ordinance.
The property owner agrees to submit to St. Croix Coon P
owner and The
a master plumber, jounle tY ~g & Zoning Department a certification fo
wastewater disposal system plumber,
an plumber, restricted plumber or a licensed pumper verirm, signed by the
less than 1/3 full of sludge. proper operating condition and/or (2) after inspection and ~ (1) is in s that ar the on-site
pumping (if necessary), the septic tank is
Ilwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set b the Department of Commerce stating that your septic system has been maintained mussttbe the co eplleted ~ re ated Resources, State of Wisconsin.
'Zoning Department within 30 days of the three ear expiration date, ~ turned #o the St. Croix County Planning &
Uwe certify that alt statementnts ou
property described above, by virtue a n form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
deed recorded in Register of Deeds Off ce.
lumber of bedrooms
IGNA OF APPLICANT(S) / DATE
~T
E
*'"*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)
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581 7.21 J .1 _ 00
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N89'45'02'E 1332.44'
TOWN ROAD
N89°4502'E 1332.59
211..70 21170 212 59-- _212`85--
Fi.W.L. = A
065.50
DT 76
0 ACRES N LOT 75 CIS
20 SO. FT, LOT 74 LOT 73 LOT 72
106750 2.00 ACRES j 2,00 ACRES 4 2.00 ACRES 2.00 ACRES
A 87,220 SQ. FT. J
87,139 SQ. FT, 87,225 SQ. FT. 87,122 SQ, FT,
~ 8 S
z
827.75"
21170 D,RAl,iAG, E EASEMFNIT 211.70 877' 172-94' 21251' 2126`
S i LINE. OF THE N'W114 OF THE NE1[4 ~
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68
W;,:consitt Departme~, Htwertro--°°~'~..."rr~`~ " SOIL EVALUNHON REPORT Page c~1
Division of Safety an( Buikfi F CE,'VE~~'l:*s
in accordar with Comm 05, Wis. Adm. Code
County j r CYGl.
om Clete Si Clan o t ij ex ~ loll x 11 ntdros in sire. Plea nlusl - -
ldtadt Complete,
~6 l~
Include, h it not Ihn d to: ~ (0%, l ltc~irt ~rti l rvfvr rice point (M), direction and Parur l I.D.
percent r tope, seal or dimensions, rtotth at tow, and I cation and distance to nearest road.
R towed b Dale
f all lnfum adun.
l Personal a,tformelhrr prI'm secondary purpvsas (f?rivnr:jrlnvr, a. 15.04 (I) (m)).
M~mpd o);
'ropertyOwner PtopoilYLocation
} Govt- Lot 114 ,V 114 S 'T It / E (oK
Properly Owner's Malling Address Lol >1 Uluc k # Sulnl. Name ul CSM/t
CRY State zip Code- Phone Nunibor U City U village L, n Nearest Road
.New Consbudiort Usa:'(-residential / Number of bedtoonts Code derived design flow rate GPD
U Replacement o; U Public or cennnetuial - Describe:
1--
Parvnt material _-4--t--Fl--- Flood Plain elovation if applicable _ - - - R•
General cottnnenls
and raconmtendatiorts: y/ DTI Boring N Boring
r~ r C
K~ Pit Ground surface elev. IL Ueplh to limiling factor in. -
Soil A Pplicalion Rate
I lotizon Deptli Dorninanl Color Iredox Description l extuto Sbuclure Cunsistence Boundary P(MAS GPUIIC -
in. Munsell _ Qu. Sz. Cont. Color Gr. Sz. Sh. 'Effit1 Eff#2
u
3 CJ (0' ~'.2P "l.5 ~r ` l~Zn SCI 2
f Boring # U Boring -
u ~p;t Ground surface elev. -t6 (C- ft. Depth to IimiGng factor _ _ in. Sol Application Rate
Horizon Depth Dominant Color Redox Description Texture Stiuduie Consistence Boundary Pools GPDIft`
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sit. 'Efrffl 'Efr#2
( f~ i2 1~ yr312-
2 IZ X53 ~C' 4 r y 1_ 2ry
tL~-4Eal~`. QZP-7,5.yr yi Set Zrmbk nc4r`
Effluent #1 = BOD > 30:< 220 rrtg(L arm] TSS >30.< 150 rmg/L ' Effluent ff2 = B0135:-: 30 mglL and I SS < 30 mglL
CST Name (Please Print) Signal CST Numb,ir
_(101t'Yl D4\v ,yaC~tc Pr
Address Dale Evaluation Conducted 1 efepltonn Number
ii 1
CZ7 L {'arccl It.) it __!y__ - Page - - of
f
Boring----
E -Pit Ground surface efov.! 69-10 it. Depth to litnitirry tactu - in.
Sol n ENrfAica6rnt Rate
Horizon DepUt UominanlColvr RedoxDesctfpGon iextule Strutlure Consistence Boundary [toots -_Gf DIfF
in. mtrusell all. Sz. Cont. Color ("r. Sz. Sh_ - - 'Elflil TIM
0-1 (0
S l 2 rY13 bl~ rY~ f - - --=L-{ - r -
U Boring
LJ Boring #
U Ground surfa:o elev. --------ft. Ueptlr to lirnitiny laclur Pit Sull Application Rate
U
Horizon Ueptlr Dvrninant Color i.edox Description lexture Sttudure Consistence Boundary Roots GPU/fF
in. Munsell r iu. Sz. Cont- Color Gr. Sz. Sh. --'Eff#1 'Eff#2
~ Borlr.y
Boring # Ground surface elev. It. Depth to limiting tr,ctur
u 0 Pi, _ Soil Application Rate
Horizon Ueptlr D:r,nutant Color Redox Description texture Structure Consistence Boundary Routs GPD/IF
in. Munsell Qu. Sz. Cont. Color Gr. Sr Sh. 'Eff#1 'Elf#2
Effluent #1 = BODs> 30 < 220 tngil- and TSS >30 < 150 myiL Ellluent 112 - BOD, < 30 myiL and 1 SS < 30 mgfL
.l lie llepattment of Commerce is all equal oppottunity service pcovidcr and employer. If you need assistance to access services or
need ntatetial in an alternate format, pimse contact the dopattnicnt at 608-2663151 or TFY 608-264-8777.
s n o-u to r n.otronr
PropertyCwner ParcelID#~0 / - Page of=+
[3-1 Boling # El Boling
Ground surface elev. rd 9.10 it. UepUr to linrilurg factor- bt.
W-PR Sol A p tirm Rate
Iloiizon Deptlr Dominant Color RedoxDescriplbn Texture Swam Conn sistonce BuurrcJary Roots GPD"
In. Mmisell Ou. Sz. Cant Color Gr. Sz. Sir. 'Elflfl '0112
3 40-7o CZ -t. r L+ ko sit 7~ng r f j f
i
Boring # ❑ Boling
(_J ❑ Pit Ground surface elev. It. Depth to limiting factor in. Soq A icatlort Rate
i
Horizon Deptlr Dominmit Color Redox Description Texture Structure Consistence Bcxnxiary Roots GPD1IF
In. Mansell Ou. Sz. CatL Color Gr. Sz. Sir. 'Elf#1 'EQ#2
- I
I
I
i
I
F Boring # ❑ Bodry -
❑ Pit Ground surface elev. It. Depth to linutiny factor in.
Sol Application Rate
Horizon Deptlr Dominant Color Redox Description Texture Structure Consistence Boumlaey Routs GPDIIF
In. Munsell Gu. Sz. Cont. Color Gr. Sz. Sir. 'Eft#1 'Eft#2
' Effluerd #1 = BODS> 30 < 220 ntglL and TSS >30 < 150 nrg1L ' Elliuent 112, = BOU, < 30 nng1L and TSS < 30 uvA
The Vepattment of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in art alternate forrttat, please contact the depmuncnt at 608-266-3151 or "ITY 608-264-8777.
sao.uw rR.rn+aor
r ,
3(3
SCALE: .I.I~I~.s~•ItIP~rIt,II-,(,wi;i,~ri<<r,'~3a~Izq.rl,P.l~-:r~~~~
NAME: _SA,a I I
4-
I.,_ yC ~ -
L; mk ELEVATIOR_ lap BM I D SCRIP"I 101.1: 4-ve 6-
BM 2 ELEV,\"llc)rJ:
L~
F3M2DESCRIPI~IC~PJ: ~~_-d.~_~']~u~- ~Pe__
SYSTEM ELIV;\ I l~ ~r l /G y, 2 d
SYS ENI YI'I or tea).^c~
~ o
~l Coy
I~
ey
NOTE 60 ft. wide area disked and seeded
for drainage easement. Does not appear to
have damaged POWTS sites