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HomeMy WebLinkAbout040-1284-00-000 Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Wisconsin Safety and Building Division Sanitary Permit No: INSPECTION REPORT 597423 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 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: David & Bridget Solberg TOWN OF TROY 040-1284-00-000 CST BM Elev: Insp. BM Elev: / IBM Description: _ Section/Town/Range/Map No: /60.0 /01:110 C'STgua'1 = n&t:0 cw5 ct~-~n'~ 09.28.19.1604 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS foHI FS ELEV. Septic Benchmark 0b . O s I Zoo/~ Dosing l I Alt. BM / Aeration Bldg. Sewer ~v Q1 •90 W Holding St/Ht Inlet , (r0 its- ~ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' sO / 3 I I Dt Bottom / Dosing 4j Header/Man. 11 (0 Je Aeration 't- Holding Bot. System -W Final Grade ~t ►1 3. roa 9~, PUMP/SIPHON INFORMATION Q / Manufacturer Demand St Cover 1 ~ Model Number G4 O L I) P/M 4 P TDH Lift Friction Loss ISystem He T Ft Forcemain Length f IDia.,, 11, Dist. to Well SOIL ABSORPTION SYSTEM Z2 011. leit RENC Widt73~a/±A fo4 Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth • DIMENSIONS SET BACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man ur INFORMATION CHAMBER OR Type Of System: UNIT Model t~yfgbe, cOf1 V (Xt.t,tz F T DISTRIBUTION SYSTEM o~Q OQ,p, Header/Manifold stribution ole Size x Hole Spacing Vent to Air Intake Dia Length Dia Spacing / 11-engthI01>1 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 E] Yes E] No Yes :L: NCOMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:Z~ Inspection #2: Location: 517 ORCHARD DR 1.) Alt BM Description = 5r/Q7-cov i'. 2.) Bldg sewer length = -5-01 amount of cover Plan revision RSquired? ❑ Yes No cl/ Use other side for additional information. ` - C;t _ Dat Insepctor's Signature Cert. No. r SBD 6710 (R.3/97) __Q1 nVM_cAj r U O ? County X, v~ J Safety and Buildings Division r 201 W. Washington Ave., P ()Box 7162 , Sanitary Permit Number (to be filled in by Co.) a hYa B9NWG28FMpVDM 59 7Z7103 JUL C T )D( COUP State Transaction Number t CRC ,oMMUN i ary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Departmebt of Safety and Professional Servies. Personal information you provide ma be used for second purposes J~ Y in accordance with the Privacy Law, s. 15.04 1 m ,,Stats. Y 5 -7 1. Application Information.- Please Print All Information Parcel # Property Owner's Name - e, -1 CIE r ~ Property Location oZ~, 19. 1(Ob4 Property Owner's Mailing Address L Govt. Lot Zip ~ole Phone Number L ; - y., 7\ : W Section city, state J { _ (circle one) t v ( G 1C f5 - 0 51 T ? N; R - E ox:~i Lot # -d-Type of Building (check all that apply) 10" Subdivision Name 1 or 2 Family Dwelling -Number of Bedrooms Block # t( l: < C f f f~' ! ❑ Ptiblic/Cotnmercial - Describe Use V4- - i ❑ City of CSM Number ❑ Village of 4State Owned - Describe Use Town of U Y 1 +-22- &a e f'S e of Permit: (Check only one x on line A. Complete line B if applicable) A r one, El Other Modification to Existing System (explain) ❑ olding Tank Replacement Only New System Replacement System 11 Treatrnent/H 111.Q.~ List Previous Permit Number and Dale Issued B. ❑ Permit Renewal - Q Permit Revision ❑ Change of Plumber 11 Permit Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) ® Non-Pressurized In-Ground' ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Pretreatment Device (explain) Holding Tank ❑ Other Dispersal Component (explain) V. Dis ersaUTrea ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf Dispersal Area Propose (sf) System Elevation q'7 L- CC rF `1 7 VI. Tank Info Capacity in Total 4 of Manufacturer Gallons Gallons Units New Tanks Existing Tanks c ° 72 a. U 00 h w C7 ° r, ~ - Septic or Holding Tank / •Z - Z er Dosing Chamber / VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MPA410R3'Number Business Phone Number Zj, X~ z e?n ./J Eob: Plumber's Ad ss (Street, City, State, Zip Code) l.. G(~d f l f i,cJ (r VI oun IDepartment Use Only Permit Fee Date Issued Issuin gent Sign e Approved O.Disapproved S q% ✓ L7 7 wne Reason for Denial IX. Condi ' easons for Disapproval Rte! aMi: piC P Pro wed by plumber. 2 tlAlMil~i^~'~ !_.t,a r►>rt+ ir:~+i I$ PK NSF cad*/ adwwa. Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 z 11 inches in size SBD-6398 (R. 11/11) LA I r~--~+: ! a ~~y~- , ~ 1 9 ~ ~ +J ,w.. ff ~ f, m ~i i ~ fly Z-o ly/ ~ ~ ~ e--~-r rte.= ~ ' ` . ~ aP - y~.lyv , c L d I Pg of C1 Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner's Name: Site address: f5 1 7 O /ZC k An _Q 01,C (yr It s V 'v Gv i Block Subdivision/CSM Location: Lot being part of the 1/a of the a, Section, Town__gN, Range-/--W, Town of 1~ Pierce County, WL Parcel Identification # t9 - 7 k Design: In accordance with Department of Safety & Professional Services (SPS) Wisconsin Administrative Code ch. SPS 381 through 387 and 391. Design manual (choose one): ❑ Holding Tank Component Manual [VER 2.0, SBD-10855-P (N. 03/07, R. 1/12)] IA In-ground Soil Absorption Component Manual [SBD-10705-P (N.01/01)] Contents: Page l: Page 2: Page 3:/4 Page 4:/G C Page 5: A", Page 6: Page 7: Page 8: ,.1/7 Page 9: C e /L~ l i✓ JC`• ~L g A_ Attachments: Plumber/Designer: Signed: Credential Number: 4, Z2 517 Date: 27 6 -1/ I-1 l 411 h ~J 20 .v=ia \ 1 e or 2 Family Dwelling In ground Soil Absorption System (2-cell Conventional) Daily Wastewater Flow (DWF) _ # of bedrooms x 150 gal/day/bedroom gal/day Design Loading Rate (DLR) or Soil Application Rate = gpd/ftZ (per SPS Table 383.44-1, 2, or 3) Required Distribution cell area =DWF & gal/day + DLR gpd/ftZ ftZ # Chambers = Required Distribution cell area ftZ + Z 0 ft2/ unit EISA Chambers Chamber Manufacturer and Model: ,lAIES/1-I-P 6,)`fl cis f~. . fJ /ft2 Actual Distribution cell area =Required cell area 5t C' ft2 + ftZ/ unit EISA End Cap Pair= Cross-Section in-ground Soil Absorption System (2-cell): 4" Schedule 40 PVC vent pipe with vent cap R 12 inches minimum 12 inches minimum L 7 inches Soil Cover Trench 1 Sys- tem Elevation inch Chamber Height 7, ft 7, ft Trench 2 System I- Elevation 5- ft 5 ft Trench Separation Leaching Chamber Width ft to limiting factor Plan View In-ground Soil Absorption System (2-cell): Trench 1 ~ Modify ft header/ - ' design as ft ~LeachingChambers14 needed. Trench 2 4 inch Header Sch. ft with end camps Draw O for a Vent and 0 for Observation Pipe above. They will be located ft from the end of the cell. Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade. Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC. Combination Seprac~Tank and PUMP CHAMBER CR055 SECTION AND SPECIFICAT1NS f WCATHEF, yEJT CAP: PRoOf JutJCT101J bpX H'C.I, VENT PIPC APPROVE[) LOCKING ' !I Q ~ FROM ODOR, /'IAIJHOLE COVER cvt"iN wARIJIiJ4 Lr~aEL. wwoow OR FRESH S corJ~u~T W,JSP~o,~ PIP Sr ALIUTAKE ~ w ! r11czT1 s q-T" c-n-P ~ I . I Y' MI1..1. 6KMW, ~ LOOT I ~ I~r I6.'/rilN. i.r PROVIDE I>JLET ~ 'AIRTIGHT SEAL. I III BA A. I I I APPKOYED JOIu APPROVED JOWT zPt$~L I II w/C.T. FIPEO~K p• w/C.T. PIPE DR Tank construction I III .I I ALAM shall comply with ILHR (;3.15 and 33.20 a I II I I QM C I I I PUMP ~ OFF 0 COIJCRETC 6LOCK RISER E:XIT PERMITTED OQLy IF TAIJK MAIJUFACTURER HAS SUCH APPROVAL g~pplNC scPrlc F SPECIFICATIONS DOSE ill E~ (22JCR TAUK MA~IUFACTURE:R.: IJUMBER OF DOSES: PER DAy TAMK SIZE: LZ)y~/GA,LL0QS OOSE VOLUME ALARM 1* tAQUFACTURCR:.~L=:~~ IWCLUOIMC, 5ArKFL0W: 9 Z GALLO),~$ MODEL WUMBER:- LOl HI-y CAPACITIES: A= Zi, IIJCNCS OR ~ GALLpus SWITCH T7PC: - f Z 8 = IIJCHEt~OR G~LLOtJS (JUMP AQUFACTURCR: L Lt_z_ } C ; INCHES OR Z' ?ti.ILLOUS MODEL IJUMDEK: y _ r (1 Ot INCHES OR 23' GALLOIJS SWITCH TYPE: UOTC: PUMP AMD ALARr1 ARE TO 6L MIJIMUM-DI5CKARGE 'RATE~CFM INSTALLED 0!J SEPAR~,7F CIRCUITS VEKTIC,~L DIFFERENCE DETWCEIJ PUMP OFF AU01 DI5TRIBUTIOQ PIPE., hEET t MIUIMUM NETWORK SUPPLY PRESSURE FEET + FEET OF FORCE MIN.-X, ` F lo~orcFRICTIOU FACTOR_2 FEET TOTAL OyQAMIC. HEAD FEET ......gal/in, As per. manufacturerU+ APR-12-2005 16:28 FERGUSON ENT HUDSON 715 386 6144 P.01 HGOULDS PUMPS Submersible Effluent Pump PE SPECIFICATIONS MOTOR FEATURES Pump -General; General: ■ Corrosion resistant • Discharge: 114" NPT • Single phase construction. • Temperature: 104°F (400C) • 60 Hertz ■ Cast iron body, maximum, continuous when • 115 and 230 volts ■ Thermoplastic impeller and fully submerged. • Built-in thermal overload pro- cover, • Solids handling: 'h" tection with automatic reset. ■ Upper sleeve and lower maximum sphere. • Class B insulation, heavy duty ball bearing • Automatic models include a • Oil-filled design, construction. APPLICATIONS float switch. • High strength carbon steel s Motor is permanently Specially designed for the a Manual models available, shaft, lubricated for extended following uses: • Pumping range: see PE31 Moton service life. • Mound Systems performance chart or curve. • .33 HP, 3000 RPM ■ Powered for continuous • Effluent/Dosing Systems PE31 Pump: • 115 volts operation. • low Pressure Pipe Systems • Maximum capacity: 53 GPM • Shaded pole design ■ All ratings are within the • Basement Draining • Maximum head: 25' TDH PE41 Motor. working limits of the motor. • Heavy Duty Sump/ PE41 Pump: • .40 HP, 3400 RPM ■ Quick disconnect power Dewatering • Maximum capacity: 61 GPM • 115 and 230 volts cord, 20' standard length, heavy duty 16/3 S1TW with • Maximum head: 291 TDH • PSC design 115 or 230 volt grounding PE51 Pump: PE51 Motor: plug. . • Maximum capacity- 70 GPM • .50 HP, 3400 RPM ■ Complete unit is heavy duty, • Maximum head: 37' TDH • 115 and 230 volts portable and compact. • METERS FEET PSC design ■ Mechanical seal is carbon, 40 ceramic, BUNA and stainless PE51 I I TI I i MODELS: PE31, PE41, Pe51 steel, 35 r HP:.33_40_50 ■ Stainless steel fasteners. 1. I. I 1 I 10 I: , I i 2 GPM I- i I i I A CY LISTINGS 30 FE41~ _ .i • I f I i 1 Fr o T 25 I _ I I I I I I I I I i I I I ~~0 C u5 20 I I •I i _ I 1 I Tested to UL 778 and + I 1 ' I+ I I I I I CSA 221108 Standards By Canadian Standards Associadon I ! I I File #LR3a549 10 ^--t I I L I I I i I I I I Gourds Pumps IS ISO 9001 RegiMrod. i~ I• I~ r I i I I I i I~ I ,;~.I f j 1 1 0 o 0 10 20 30 40 50 so 70 GPM so 0 5 10 75 m3/h Goulds Pumps 2044 ITT Water Technology Inc. CAPACrrY E L ffect"°'""°• 2004 ITT Industries B3'E37/41 (D 0 3F- CD N p ~ Y,as nHx o N N O O m o m ~ T h,- CfJmcma 4y tom. MS i i g m t e i Y p3p l[ 3 ~'F 2 c a •oo °co CD 3t~~ o E m ~s'~ s b CDt m m O~ .--0 =O r:':7~ by c7 CD L O« Cm to FE CL 2 r- pD fit ~C mj; X363 ~m 'D cm E m m b o L "(D M 3- o'x m Na m ~ m y j 42 m tyj E m c A a o3rnc ocmi`~~rn `~3cm6U c c j fill O N c m `p k C m F = m vi9 ? C a c N O d •W c O m C m.D c, .4 4 ( c -v=i t/ L }n'' m O 7 O A ta0 fd. (c • t~ c C o~~ mtS•~'= ANN: W~ 13 m m m o J ai 0 ~y 2rom moth ~o~ mEm ~y@ a 3 m w ~ 0 0 OR l4 C7com m c arm mm 0-6 ID LL C4 Co ~.Yz E g m cE mcr o m m vm m m' mo W Fs~~> IL-~m'N~3v m m Ve. go 'A .Rk S PE ~ g 6 ca € a c N tm ip S p ~ S %in G ILI 4k, g 7 Pon n I+ 9m E ° A Y e 1~ Q w~'< 0 ~ "fir ~ a g All * tlV1 S ~ ~R~A u r.~., u= € b u ~ E ~ C ffi 999 'ygt~' a £ x ro ~ i r~ d~ `YA;, ~ ~ _ ~r` Tai r>ti.i 1.~'1 ,5.~. ~~n : aF ®~~y+d'~~•vc°y,La4 ~~-~.~Qt~<~1 1 r 3a. di u n 1 WK 4 1 b ~;N,.uick4 Pies Standard Chamber Side and End iii tr F 48" (EFFECTIVE LENGTH) N n H 12" 34 p: v 4;Ukk4 Plus Ail-in-One 12 Encap Front, Side and End Views k 91.2" f a , t . 13" 8" IN, ERT 8" INVERT 5.3" INVERT 33 uick4 Plus All-in-One Periscope OUICK4 PLUS ALL-ONE PERISCOPE ) k; (360* SWIVEL CUICK4 PLUS - AJ 12.7" INVERT ALL-IN-ONE 12 ENDC ENDCAP ; 5.. 9„ ii Quick4 Plus Standard Chamber Specifications S I Size (W x L x H) 3411 x 53II x 1211 (86 cm x 135 cm x 31 cm) Invert Height 0.6I], 5.3II, 8.0II, 12.711 (1.5 cm, 8.4 cm, 18.5 cm, 22.6 cm) a Effective Length 48° (122 cm) Ik f ll INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY a) The structural integrity o9 each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Units"), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, k Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT rl TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE 1 INFILTRATOR® R (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential. special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. C t : ' I C Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units, the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure a to maintain the minimum ground covers set forth in the installation instructions, the placement of improper materials into the system containing 6 Business Park Road • P.O.-Box 768 the Units: failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook, CT 06475 terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, ttre Units must be in§talled in accordance with all site conditions required by state and.local codes; all other applicable laws; and Infiltrator's installation instructions. 800.221 .4436 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www. irlfi Itratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, ) to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. ..,~,..m»` ' s ~ t4:. £ .7~ ~ ;fin u:i*.: 'sw,l zl ~„<Es~'+ry^ i:: ~:w:•a.uc.aa. v<x....~rnnr ~nreaar,.:~iz~`"a~~ a~~,•.-~nks~.w:v~M n.~,m~.ua.~.~wa.~.ua~ , - yU S. Patents. 4,759,661, 5,017,041; 5,156,468; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329.959: 2.004,564 Other patents pending. Infiltrator, Equalizer, Quick4 and Quick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. PLUS0510101SI-2 is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc 0 2009 Infiltrator Systems Inc. Printed in U.S.A. POWTS OWNER'S MANUAL MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner "r Septic Tank Capacity / Z.0 a al ❑ NE Permit Septic Tank Manufacturer Ili I ES _2 ❑ NI Effluent Filter Manufacturer ❑ NF DESIGN- PARAMETERS ~ NF Number of Bedrooms ❑ NA Effluent Filter Model Number- of Public Facility Units NA Pump Tank Capacity E30 0 al ❑ NA Pump Tank Manufacturer Lo jtcS~R ❑ NA Estimated flow (average) V40 gal/day al/da Pump Manufacturer D (A L D ❑ NA Design flow (peak), (Estimated x 1.5) 6,0 gal/day z Pump Model P 6:_ q1 13 NA Soil Application Rata /ft ❑ NA Standard Influent/Effluent Quality Monthly average• Pretreatment Unit Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter GI Peat Filter Biochemical Oxygen Demand (BODa) 5220 mg/L ❑ NA [I Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection [I Other: R Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODb) 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100m1 ❑ Drip-Line ❑ Other: Other: ❑ NA Maximum Effluent Particle Slzq, Ys in dia, ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic, wastewater and septic tank effluent. Other: i ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: [1 month(s) (Maximum 3 years) 0 NA p ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) ,t least once every: ® year(s) Clean effluent filter At least once every: 13 month(s) ❑ NA ® ear(s) _-L LI ~ Inspect pump, pump controls & alarm At least once every:" month(s) NA 3 ® ear(s) • Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA 123. ear(s) Other: At least once every: 11 month(s) ❑ NA ❑ ear(s) Other: s ❑ 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; POINTS 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 combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal 011(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 W3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator 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 10 days of completion of any service event. GMW (4/01) LC7) START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or oth 1!Cal,, that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not ocaut 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 be discharged to the dispersal cell(s) In one large dose, overloading the cell(s) and may result In the backup or surface discharge of effluent; 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 POWTS: 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 properly and safely abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code: 4 • 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 compliant replacement system: 0 A suitable replacement. area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at that time. 0 A suitable replacement area Is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. O 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 may be installed as a last resort to replace the failed POWTS, r _ 0. Mound and at-grade soil absorption systems may be recbWtructed 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 OF A PERSON tROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTAi;LER POWTS MAINTAINER Name Q 2 ~L 5oAV E Name Phone -715-- Z 7 3 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name :r0(4NSo/,J 5-4ev(.f, +eo-/ Name - S-~C4td/X Zo J Phone 7/5 Z -7 -3 Phone - lU This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address u'bSCnj w O S Property Addre (r P'w (Verification required from Planning & Zoning e ment for new construction.) City/State { ub Sc>J Parcel Identification Number OC~ LEGAL DESCRIPTION Property Location Jy LO '/4 , W 1/4 , Sec. T Q B N RJ9 _W, Town of _ __Rp~j Subdivision Plat:n C3' e~C1~ A,? i SI Lot # /p Certified Survey Map Volume , Page # Warranty Deed # (before 2007)Volume Page # Spec house D yes140 Lot lines identifiable Ayes D 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 §SPS. 383.52(1) and hi 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 r,mst be compieted and retarned to the St. Crvi;": County Planning & Zoning Department within 30 days of the three year expiration dat . Uwe certify that all statements on t ' form are true to the best of my/our knotivledge. Live am/are the owner(s) of the property described above, by virtue of a w anty deed recorded in Register of Deeds Office. Number of bedrooms 7 IQ 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 fi-om the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 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Plan must County J~ C ` X include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner > Property Location L) f!7 / a [let ~~i o ~ P P _ Tlr u 8oet-to! 1 /4 A/ ~/1 /4 S T g N R / L~{er) W - Property Owner's Mailing Address Lot # Block # Name CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ~k 5-17 3 86-- 9~>a ra of^~ ~4f~% be >"t~~ New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate 7 GPD ❑ Replacement ❑ Public or commercial - Describe: 666 - Parent material G% a r « / ~7 u- cx S Flood Plain elevation if applicable /y71_ ft. General comments to A cd c/ ' e ~t z s Sl 7 O k~ c Act y d ab sB ~ ~ and recommendations: jj tv r Q v a/ 6c q it s f 4 f/ Q C on v L n Ti G rr -rx-1`c rri c/t~ 7r /0- 1.('r hi ~/6) Y1 T ` 't e < vt S . Q (/e Y ck fe c7 7 / / S'S~ ~s © Boring G Boring # c7 3 n) Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appfication Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Ef1#1 *Eff#2 a S 2n~ C. 6 J-0 41 L S 1!7 -s- o.7 6~ /C Y)v 6 s q -1 7 'l F~] Boring # Boring 29 Pit Ground surface elev. C ~a~oc ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EfT#1 *Eff#2 34 S L, K A_ c s Z 0.6 'Oft -1 it ` Effluent #1 = BOOS > 30 < 220 mcA and TS >30 _ 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg1L CST Name SPlease Print) Signature CST Nurritw Address Date Evaluation Conducted Telephone Number Property Ownera ra; E~ 4 . /rr f F~~ Parcel ID # ` ~,Z ` ` (''G' C?C page aof F3_1 Boring # Boring pit Ground surface elev. Depth to limiting factor > It 6- in. Sal lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Efr#1 "Eff#2 rrl i Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD9F in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 ❑ Boring Boring # ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 -Eff#2 Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg!L ` Effluent #2 = BOOS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R 07/00)