Loading...
HomeMy WebLinkAbout008-1027-90-350 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No GENERAL INFORMATION (ATTACH TO PERMIT) 597440 State Plan ID No Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] r's Name: Cit Villa e Townshi ax No: Ml & Debrones y g p Parcel T TOWN OF EAU GALLE 008-1027-90-350 Per::---: CST BM Elev: nsp. BM Elev: BM Description: _ ^ Section/Town/Range/Map No: (sU 1 -6 M 1 10.28.16.141 D-15 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ba~e(' .r ~ s' /ZS(o 7.53 /dz• 3 /db Dosing C I v - -f .756 Alt. Bt~ oo~ Jr- ~d I d Bldg. Sewer Holding SZS 16-55 '9~ St/Ht Inlet l/ 45 9a s~ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/9A- BLDG. Vent to it Intake ROAD Dt Inlet Septic r ~Dt Bottom Dosing Header/Man. 1G. b3t5 4:5 S 7? 7 Aeration Dist. Pipe Holding Bot. System PUMP/SIPHON INFORMATION Final Grade q Manufacturer ~ l 7' 7 Qi Defmand St Cover l L Model Number V ~ 7' 133 J N /~6 7 C 6 Ilk -7-4 9s• TDH Lift Friction Loss - System Head , TDH ,757 6 Force main Ler : / Dia. Z r~ I Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Qf rrenc PIT DIMENS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 7 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type ystern CHAMBER OR O ✓ T4 #4 ^jA- UNIT Model Number: DISTRIBUTION SYSTEM / Header/Manifold r' Distribution Pipe(s) C~% ►1 Ix Hole Size ' y' S x Hole Spacing : D V r Intake length 61 Dia Len9th J Dia Spacing ~ SOIL COVER x Pressure S=BBe tems Only xx Mound Or At-Grade Systems Only Depth Over xx Depth of xx Seeded/Sodded , ff ^ • / r Bed/Trench Center Topsoil / Mulched / ►T`, L_h No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 5 / / 2433 50TH AVEP y J 1.) Alt BM Description G LA./ 2.) Bldg sewer length = yZ - amount of cover CJ / S Plan revision Required? [j Yes )<ONo Use other side for additional information. SBD-6710 Date Insepc - ~ ~ (R.3/97) tot's Signature Cert. No. sg~-aol - asN d County , n ~ 19 01 ~ 7017 F02ZJ V49MCKHP Sanitary Permit Number (to be filled in by Co.) r.v, DUA t Ivy I y ' Madison, Wl I 53707-7162 L d ST. CROIX COUNTY State Sanitary Permit Application Tra9 coon Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit o' / 2 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 Department of Safety and Professional Servies. Personal information you provide may be used for seconda 1 y 3~ SU purposes in accordance with the Privacy Law, s. 15.04(1 (m), Stats. n 1. Application Information -Please Pr'nt II Information nc ll t (E Lt y Property Owner's Name Q► Parcel # - Property Owner's Mailing Address Property Locatwn 7 1-- Govt. Lot S City, State Zip Code Phone Number - 'ou Section Y3`yG (circleong), (~t T~ N; R_Eo W II. Type of Building (check all that apply) Lot fTl or 2 Family Dwelling - Number of Bedrooms l Subdivision Name V[. st)bt~~~lec~ ❑ Public/Commercial -Describe Use Block 71 ❑ City of ❑ State Owned - Describ~Use1 CSM Number ❑ Village of 140 C ELL mown of X J III. T heck only one box on line A. Complete line B if applicable) New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to xisting System (explain) B El List Previous Pe it Number and Date Issue Permit Renewal ❑ Permit Revision El ' Change of Plumber El Permit Transfer to New Before Expiration Owner IV. Type of POWTS S sfem/Com onent/Device: (Check all t ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-G&W, Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) a ment Device (explain) V. Dis ersal/Tt• tment Area Information; Design Flow (g ) Design Soil Application Rat gpdsf) Dispersal Area Required (s Dispersal Area Proposed (sf) System Elevation VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U O ; New Tanks Existing Tanks o u P U iin y ~ w L7 a g a ,l lok 5)5 9e a. L CI Z Septic or Holding Tank ;5- / Dosing Chamber `7 -7 S- 10- / t ✓ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum2S`<'7 re MP/MPRS Number Business Phone Number 1 / / Cam' ...5 ~.t v~ • p J(^: D Plumber's Address (Street, City, S te, Zip Code) VIII. Coun /De artment Use Only 41,prove is Permit Fee Date Issued Issuing nt Sign tur ❑ Owne n Reason for $ U 7 a~' / _jf IX. Conditions o pproval/Reasons for Disapproval 2 /~On 0, 11 I Des ~T A-k APP SYSTEM OWNER: l~l ar In / . ,l 1. Septic tank, effluent filter and f'~ T ~ dispersal cell must be serviced /maintains!: ' -r• r as per management plan provided by 4 & 2. All setbac requlreKi d 1 pans or t e system and submit to the County only on paper not less than S 2 x 11 inches in size as per applicable code/ordinances. I 1bo',Q4 IN(,lll-ID no SW nt 16kv SBD-6398 (R0313) Ilk W41poi d fi~S ~t~✓ ~ Plow p~ ~r 7 5- k"rI*,-, I~ ~tx V iF- A) ~L) 47 Bak ~ 7s° CrG[, ~ U b I Il c S°Ds s sQ ^G'- ~3S ' ~J d O v o Ni. f D ~ . e~ ~ poc Pye l~ co V.X+c klv- a 33 z a ~Q L ~/TOP ~r~ ,P ohba~ i~~RrarF._l DIVISION OF INDUSTRY SERVICES ,Nr - ~ pF 3824 CREEKSIDE LN HOLMEN WI 54636-9466 v Contact Through Relay D lip I s P http://dsps.wi.gov/programs/industry-services www.wisconsin.gov k ' _SSI Scott Walker, Governor SgfON P_ Laura Gutierrez, Secretary August 04, 2017 CUST ID No. 220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 110 1 CARMICHAEL RD SPRING VALLEY WI 54767-8709 HUDSON WI 54016-7708 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 08/04/2019 Transaction ID No. 2980023 SITE: Site ID No. 841071 Michael Jones Please refer to both identification numbers, 2433 50TH Ave above, in all correspondence with the a enc . ~ OJ Town of Eau Galle PQ P. St Croix County QF NE1/4, NW1/4, S10, T28N, R16W~~~ FOR: s ~FS~ ~N Object Type: POWTS Component Manual Regulated Object ID No.: 1719826 s Maintenance required; 600 GPD Flow rate; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); EfFluent._Fi1b'et~ The submittal described above has been reviewed for confonnance 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: • The design included the principles and best management practices of the Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD-10706-P (N.01 /O1). It is reconunended €o fence off dispcrs.d .)res prio::r~sif dlnrm'' C(mstI 11k `hog" ter .9r oi( disturbance, t10111paction and use of the site. .'ith new construction, it is recommended not to activate the pump in the dose tank until the tanks are i;unnped prior to homeowner occupancy. I ,.'astewater generated from contractors cleaning of equipment and tools and/or left over construction products shall not be discharged into the drains discharging to the private onsite wastewater treatment s}stem (PO\i I's). 1~.osti ~ ent~r.Etcci sh.ifi be la a~fPC~ f~ zIispused of on-site or off 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. • All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5 BENNIF W HELGF.SON Page 2 8/4/2017 • Insulate building sewers beyond 30 feet per SPS 382.30 (11)(c) 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 Travis J Wagner Wastewater Specialist , Division of Industry Services WiSMART code: 7633 (608)598-0715 , Monday - Friday 7:00 am To 3:30 pm travis.wagner@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Helgeson Enterprises Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. BENME W HELGESON Pace 2 8/4/2017 • Insulate building sewers beyond 30 feet per SPS 382.30 (11)(c) 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 S 250.00 Fee Received S 250.00 Balance Due S 0.00 Travis J Wagner Wastewater Specialist, Division of Industry Services WiSMART code: 7633 (608)598-0715 , Monday - Friday 7:00 am To 3:30 pm travis.wagner@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Helgeson Enterprises Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. RECEIVED INDEX SHEET 1 U L_ 2 7 PROPERTY OWNER: N7 I C J1,X, -17 Q, V PROJECT NAME: n,I . fC 17 aS PROJECT LOCATION..T of AJ LO 1- Sec i 0 MUNICIPALITY: 70c..A(~2s h I p COUNTY: x'77 DESIGN: PRESSUREDISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N.01 /01) MOUND COMPONENT MANUAL VERSION 2.0" SBD- 10691-P (N.01101) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: P,.. Tank Specifications Page 6: Pump Specifications LLY Page 7: Observation Pipe Detail ~-TY AN' L SEP` Page 8: POWTS Owners Ma T rniaX ~Management°i'lan- Pg 1 r Page 9: POWTS Owner's Manual & Management Plan- Pg 2 J i- RE S Name: Bennie Helgeson Signed: Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 1 75- _ .57- C%oik 6©axl y -57- - Grcu~ U~ i esars c~,;_ 98,3 bq 4 1✓ O ~DO,eb pip LO Yl ~C ~N Cl-co, q3,( All N o ~J 1 h s a 3~, t \ i3v. ~ JYS• I ~X ~S SYlt'~c~ M. q V r 7C) P ©k ..r P06 4- (:'~~L9rti ~ ~ +~DOV1 C xele C, e_ e-I Synthetic Covering AS-17M C.33 Distribution Pipe Medium Sand _lcv ~7. 9~ Topsoil H = G -5/, 3 E D ' li ~ l.au1 y ~ % Slope. cc~14, v C2v- Cc(I Of 2"- 2 %2 Force Main Plowed Aggregate From Pump Layer D Ft. Cross Section Of A Mound System Using E Ft. A Bed For The Absorption Area F Ft. G v S Ft. Signed: A Ft. H / Ft. B 7Sf Ft. License Number: K -7,:~ Ft. Date: L Ft. (~O0 &nD oc_cl(n I~ Ft. r ~T Ft. 6 0 WFt. L Observation Pipe 8 K A W T_------- _Distribution e 11 0 f 2 Pipe z 2 I Aggregate Observation Pipe Ell fs Plan View Of Mound Using A Cell For The Absorption Area Perforated Pipe Detail Cleanout Access Threaded End V 14 w Cleanout - Pe~ioro1( 0 PVC Pipe roe ° End Manifold 0 o i ; ?cJ///v-y1 ~ Holes Located on Bottom Are Equally Spaced R / Force Main From Pump First Hole Next to Manifold Cleanouts _ Distribution Pipe Layout P ei R Le,:) 7 - r Sf X Y Hole Diameter -`-5? Inch Lateral Inch (es) Manifold " Inches Signed: Force Main Inches License Number: Date: Invert Elevation elf r Holes Per Lateral Number of Laterals Total Holes A II Page-.L-Of SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" PL)(-VENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF ~ 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE - WITH CONDUIT MANHOLE COVER W/ PADLOCK E - WARNING LABEL r MIN. ZVI 18" N. ~ 18 MIN• INLET J WATER TIGHT SEALS GAS- TIGHT APPROVED FILTER - _A SEAL APPROVED JOINTS WITH _ ALM APPROVED PIPE PIPE 3B ' ON 3' ONTO ONTO SOLID ' SOLID SOIL C SOIL PUMP OFF ELEV -1- I OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS _ 30tAA rcJS In ~-.C114rte1~ SEPTIC / DOSE TANK MANUFACTURER: C~.Se,tr_ / Q ( 6a l. TANK SIZES: SEPTIC 0,S'0 GAL. DOSE VOLUME INCLUDING _ DOSE S-0 GAL. 4/0,75-6,1_ FLOWBACK: /~/•75 GAL. ALARM MANUFACTURER: Rt-InVALc1S CAPACITIES: A = ~J_ INCHES = AL. MODEL NUMBER: L0( SWITCH TYPE: /t-(,ec-12 au, B = 2 INCHES= GAL. - PUMP MANUFACTURER: o-c1'j;P~ C = INCHES = I 09 AL. MODEL NUMBER : lYc) . SWITCH TYPE: ^/ZJ4 r,-jiait lira D = ~ INCHES= GAL. REQUIRED DISCHARGE RATE GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE //Y5 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . III „~-L FEET + s 0 FEET FORCEMAIN X 7 FT/100 FT. FRICTION FACTOR FEET TOTAL DYNAMIC HEAD FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID 6P7R- C-, t6Z) SIGNED: LICENSE NUMBER: DATE; i 1/88 w O WO C) J \ Iw w Q U) '1 ~ L~ co ~ (1~ ~W J ragU ~ ~Z Z _ O O ~ 0 O H 0 U- N Eli) tr 00 _ c~ Y O a o Lf) ~j F- (n fl ` Q OO wp ¢ N C) ' OO O H U d Ln W C~ 0m _Q zz pff~~ol oCw LL J_ O Q W QU J\J Q O Nd ♦1 Q 0- u) InH W QQ GO S o o m ~ouwi D 3NO > W ~rJ cnQ wW n (DN S J tnt to U) 00- N ~OOOH_ir HN mCO F n~ O Z N NcD LO (D J>~ W-Q W Z( N~ ^ 3 a COW c0 00 z w J W ' N O[L~J.iO I-~ ~OF- OO Y OO W U Q ZJF->ZOOFO~~ mm N= ~ W Cf) Q0 -Z CJ pz~r< Z. 0O a a 3 v 0 0 0 w w D Q z z O J 0 F- J z z_ N 1 I I I I I I I I _ I 13 .I I W i 3 u s S w J W I O U Q J j Cn I ; ^ Q I V/ U ~ I I N ' I . ~ "9 u~ i w „L 5 i O ~ . I I I w J F- O „98 „0S „99 KEY CODES FOR ZOELLER PUMPS EFFLUENT BN = w/ Float In Box M = Auto Float Attached (vertical) PUMPS N = Non-Auto (manual) E = 230V Non-Auto (manual) AU1v/~~,47 Z27_ QUQL/TYPULfP3 ~7lYCE J,9~j~9 "FLOW-MATE" 137 Order # Model HP~ svs# a. 4~a gtu ' s _ n ZBN137 BN137 1/2 HP 115/1 Automatic Cast Iron 5/8" Solids, 1-1/2" Disc. Tethered Float (15') 497.64 ZN137 N137 1/2 HP 115/1 Manual Cast Iron 5/8" Solids, 1-1/2" Disc. 459.36 FEATURES: w HEAD CAPACITY CURVE The "Flow-Mate" motor, MODEL 137 1/2 HP pump housing, base, BN137 Model 137 impeller and switch case 25 Ft. Meters Gal. Ll, . 5 1.52 93 352 are constructed of durable 10 3.05 79 299 cast iron. Non-clog vortex 20 15 4.57 84 242 20 6.10 36 136 impeller. 15' Cord 25 7.82 8 30 15 Lack Valve: 26 10 5 0 0 10 20 30 40 50 60 70 80 90 100 110 "FLOW-MATE" 140 r ♦C~ Fs " ~rx.~e,ns.r~riu~'ca~r#' ~ ~ ' ~ ~ ,a~ ~ a~ 'i ~ ~"w "sgz ova ~ it f . ~ ~q Fr x ~f~~~ `~"~1~1 t1ftF s rs tk~~. ~ cx f GIC~+ ZBN140 BN140 1 HP 115/1 Automatic Cast Iron 1/2" Solids, 1-1/2" Disc. Tethered Float 15' Cord 675.84 ZN140 N140 1 HP 115/1 Manual Cast Iron 1/2" Solids, 1-1/2" Disc. 636.24 FEATURES: HEAD CAPACITY CURVE ! The "Flow Mate" is » .,•r w MODEL "140" 1 HP constructed of durable 1 BN140 45 TOTAL DYNAMIC HEAD/ CAPACITY cast iron. Non-clog vortex.. PER MINUTE EFFLUENT AND DEWATERIN3 bronze impeller. 15' Cord 40 Ft. Meters Gal. Llrs. 5 1.52 91 344 10 3.05 84 318 35 15 4.57 76 288 20 6.10 68 257 25 7.62 59 223 30 30 9.14 49 185 35 10.87 38 144 40 12.19 21 79 1 79 ~ 1 1, 2 45 3 72 5 9 fI Lock Valve'. 46' 20 v t. 15 10 5 10 20 30 40 50 60 70 80 90 100 110 t a,. r~ Revised 2-15-07 3-3 Water tight cap 4" min. dia. Piping material can be ASTM D2665, D1785 or D3034 Slot 6`' min. min. Infiltrative surface Water Closet Collar Bar X3/8" min. dia.) absetvafion pipes must. • be located such that there area minimum of two Installed in each dispersal cell at opposite ends from one another • be located near the dispersal cell ends • be at least 6 Inches from the end wall and sldewall • be installed at an elevatlon to view the horizontal or level inflitrative surface within the dispersal cell Observation pipes may be located less than 6 Inches from end walls or side walls if specified in state approved manufacturers'fnstallation instructions. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner SYSTEM SPECIFICATIONS To vA -e -s Tank Manufacturer: Lk)I<Sc- r ❑ NA Permit # R-Septic ❑ Dose ❑ Holding volume: % S CU (gal) DESIGN PARAMETERS Tank Manufacturer: CA->/f-Se--- ❑ NA Number of Bedrooms: ❑ NA ❑ Septic M-Oose ❑ Holding Volume: 7 5-0 (gal) Number of Public Facility Units: 211A Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : 41n 0 (gal/day) Horizontal Distance Tank(s) to Service Pad: Q (ft) Design (peak) Flow = (estimated x 1.5): (gal/day) Specific servicing mechanics must be provided if vertical is >15 feet or If horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gal/day/ft') Effluent Filter Manufacturer: Standard (Domestic) Influent/Effluent ' 'Monthly average e ~O ~7 rd ❑ NA Y g Effluent Filter Model: ~4 Fats, Oil & Grease (FOG) s30 mg/t Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA Pump manufacturer: .1 ('r Total Suspended Solids (TSS) .6150 mg-/L Pump Models El NA _ 13 ~J- i y n- High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BOD5) >220 mg/L Y NA ~JA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter Pretreated Effluent Monthly average El Disinfection ❑ Wetland ❑ Sand/Gravel Filter ❑ Other: ((OD5) s30 mg/L Soil Absorption System TSS s30 mg/L 934JA Fecal Coliform (geometric mean) s10, " ❑ In-Ground (gravity) . ❑ In-Ground (pressure). ❑ NA Maximum Effluent Particle Size in dia. El NA El At-Grade O'tvlound Other: ❑ Drip-Line El Other: ❑ NA Other, ❑ NA MAINTENANCE SCHEDULE. Service Event Service Frequency Pump out contents of tank(s) hen combined sludge and scum equals one-third of tank volume ❑ Wheh the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) Maximum 3 C~ year(s) ( years) ❑ NA Inspect dispersal cell(s) At least once every: P mp~nth(s) meylear(s) (Maximum 3 years) El NA Clean effluent filter At least once every: J 3 El ye rth(s) ❑ NA ) Inspect pump, pump controls & alarm At least once every: 1 3 [ y efts(s) ❑ NA Flush laterals and pressure test At least once every ;3 El m arth(s) ❑ NA Other: At least once every: ❑ month(5) - ❑ NA ( Other: ) ❑ NA ~ MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code: All other services, including but not limited. to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02/05) e START UP AND OPERATION Page f of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage-the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be-discharged to the soil absorption system In one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to -the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundatign drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps; medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons,'and water softener brine discharge. ABANDONMENT. When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant ..replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot,lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a~suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil` limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soli and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES' OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY, CIRCUMSTANCE. DEATH MAY RESULT. -ESCAPE OR:RESCUE:FROM TH) :I'NTEPJOR OF A-TA94K'MAY NOT Sff-POSStBt-E: - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name Name TO k v s QC, LA C1 t fSvv Phone Phone t ' -71 S) ` SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name c>Y1vaS0cX i z~ r'e> es Name S Phon '71 Phone '7i J . ,3 9 C, ~16 9Z, This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. • START UP AND OPERATION Page of For new construction, prior to use of the POWTS check`. treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process 'and/or damage- the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. . Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be-discharged to the soil absorption system In one large dose causing an overload that may result in the backup or surface discharge of effluent and damage'to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) -prior to restoring powerto•the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soii'absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soli absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation brain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases., herbicides, meat scraps; medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT. When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administratide .code: 0 All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant ..replacement system: ❑ 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, iot,lines and wells. Failure to protect the replacement, area will result in the need for a new soil and site evaluation to establish a•suitable replacement area. 'Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank maybe installed as a last resort ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES' OR _LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY_ CIRCUMSTANCE. DEATH MAY 1189'l7GT: -ESCAPE :OR RESCUEFRONI T-HEZIF A-IW4t(-Mt:Y -NOT BEPOSS1Bt:E: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS'MAINTAINER. Name Name b~.v.Sow (nL V" cj( Q)('^ Phone 7i S~~ 3 6 / / Phone p S -3 7 9 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 0 ~ ,5 C-L ~ i cr r'o e Name -5-f CA74- (_06a1 Phon '71 S- Ali 1 Phone '~i' 3 y6c~ This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. j j 3 i C i { f , f i r S f I 9 ~ T I Iqo may'' ~ 1 .a _ -n~v--~e.+-.a..+an+w'xmauao.aa+~r.• E. ~ Eg I i iS i'ce`,. ~ a ~ ~ r , ~ m r 3 ~ c CD ` 0 26'-8" w D C CL P%3 C~ ~ co 3 N o D N ~ -pt C. co M C6 fn =r \ O I \ N _a x I \ z w c cn CD ~ f cn p to C _ °m~ M o rn - cn 3 ui m ca cl) 0m rp d (D j d z g m~ O O x ® x 5 m c CD =r o : N o 0 3 v n 0 tam) o Z 1 - o W = Z linen o i o - -p CZ? 1 02 L MFgl m C w CA) D w'ow Q Q 22ND ~r•~ W w Z l6 j O U ~ g ~ 2 Q 3 2 wa ~m 222$ O = y Q ~ ~ ? O W 0 0 0 0 0 11 ZZ O a ~ ~ L• zoz ~a~ Z O F w ~ ~ o ~ O N ~ S O D e4 II I~ I~ s tQt ~ I ' ~ ~ i I 00 Z I I b~ } I I z w Z ~OF I tv n I I I I OQM, Ud ~ai°-"~o I - I Q~--~-o~-?xw I I w ~n v I mooz:~°an, i l ' I I ass U- S2 :;79 ~owowZW I ~ 5 ~ ~ r; ~ I ~zooioz I I ° zv I I j ,;w?Q000 I I I Q - 4 w~~¢ I I w i I an.~r o0 n'LLZ owZSLL= zoo~wQLLo I s " =aaQnz° I I ' a I I o ww 4 I I Q z J m Q 0 =O Oz~~'~¢''` I I ^I ~ I ? 0 Lj co <JZ I I Y I Z U I mU¢zZ- o a~ LU o w 0 a i b I o 4 x¢ z p p Z a l i i I e ~ x I a LLoxwm ww J ( e ( a € zi~9 Q LL zo-, °a I I I o I b j7- U O O D U I I o°y° 4 w~ZZp0w I I I w zu~~ OZpa I I m 1 1 ~3 Umc wow-`n+ i i t s 5 o = m ° ° 3 I I 3~ ~°`c9~g°LL ag 3 HIM a .atr,e~ ~ .aert~ g Aingi g oa Zl FIX ~w W=~ t7 FO W jL'+~3LL W~' ih-j ~$QgUB N o ,Z) luoo ~g s to ~3~OOa~~~ g~ A G ~m Y Y Y m A N aa~ W~zogc #g~ N2 y< a e m° n N -?S -9 o&WWm 33 LLz 3 via X% x X %W x w »ooLL mF~«~~5s m m m N N~ y o35y o.QSs°~o~~3 3~ W X% X X X X .4 a p 41~"34gw5~i8 V O o H m O ° ~ O O SN N N°~ e a a~~i<W <W So~;'a3=°~0~~° :FE All ~L p~ z I i ~ aQ ~ I i❑ D z I b I I0 0 0 I ❑ I 0 0 o o F1 ~ m (Di I I c I F-4 O I ~ I I Q I ° I D Gl I I O sb'-t~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 'l7 1 e_4_,,C ~U ~C S Mailing Address Ale Property Address 3 ~(J ° /act~/v~ LJZ DSO:}' (Verification required from Planning & Zoning Department for new construction.) City /State /State )60G~C~ e~27 Parcel Identification Number it?i/ ~ t~ r 0019-1q,?7-1n - 3 sr t LEGAL DESCRIPTION Property Location J , Sec. r O , T - S NR h ~ W, Town of L c, C, Subdivision , Lot Certified Survey Map # A 5-o Sy 7 , Volume Page # Warranty Deed # , Volume , Page # Spec house ❑ yes no Lot lines identifiable P /yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe 'tile nd rsi'-red have read ^ a h r q'i:cn-..nts an g . mntaii. ' i t1he uiiv&ii, 5.,::'agc u1Sp{;Su; :.ySiein `:':th the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this fo ' 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 warr y deed recorded in Register of Deeds Office. Number of bedrooms SIG`1VRE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) g'~ _ S r ae I j- o S j W1 Yn 'Commerce SOIL EVALUATION / Division of Safe anti REPORT Page of -3 ty yitflings ' in accordance with Comm 85, Wis. Adm. Code Attach com I County c Z ~x ~Oti"njg,r not less than 8 1/2 x 11 inches in size. Plan must J 'n c l~+f~II and horizontal reference point (BM), direction and B@rdi~ a or dimensions, north arrow, and location and distance to nearest road, Parcel LD.~o -7 tJ~►►~s~ •-~c ~ - yc -3~ ?lease print all information. i- Reviewed by Date Personal information you provide maybe used for seconds Property Owner vNrsi ry t.ocalion 13 t'v j tr Govt. Lot 1 /4 /V+ L 1 /4 S T N R I E (o W1 Property wner's Mailing Address Lot # Block # Subd. Name or CSM# EY)c State Zip Code Phone Number ❑ City ❑ Village own Nearest Road New Construction Use: 93 Residential / Number of bedrooms Code derived design flow rate Q- C-) 0 GPD ❑ Replacement ❑ Public or commercial - Describe: / Parent material L e'.> ASS U - Flood Plain elevation if applicable ft. General comments i ~d° S C~ /rl '1 t'l L-Z v( C,B.. and recommendations 4-o c v, / Boring # Boring L~ [a-pit Ground surface elev. 953 ft. Depth to limiting factor in. Soil A Ilcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Bff#2 ' ._S t IC1Y OR 0 s... rY. Sturm ❑ Boring Boring # i L-J wit JrCLnd SUrfB elev. 7 3 ft. Depth to limiting factor in. Ste, A. ,,rw,to^ pests Horizon Depth Dominant Color Redox Description Texture Structure Consi nce Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 -5 3 i 3?-fig lovk c - Z~ ' Effluent #1 = BQD > 30:5 220 mg/L and TSS X30 < 150 mg/L *Effluent #2 = BOD 30 mglL and TSS 30 mg/L CST Name (Please Print) Signature ~ CST Number ' f riV) i`4v- Ic FSoe- Address J r jU 7~ y S~«t~. l~ck Date Evaluation Conducted Telephone Number y 3 3 - j7 -7 5) 77~ - ~.>7S1 Property Owner / C ~1 Ct 4 ~ 's Parcel ID # ~ C Page y of _ ❑ Boring # Boring F-31 _ c :Z,:~In. Pit Ground surface elev.ft. Depth to limiting factor .Boll Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consis pee- Boundary. ;Roots Ia?D/fF - in. Munsell Qu. Sz. Cont. Color Gr.,Sz. Sh. 'Eff#4 •Eff#2,' /c -3 ta f 3c1 0 F~ ~n s 6 l ~t i < c iJ t v ->/S c ` rQ CGS r/ SCL C 'S 6 vv~ ( J Boring # ❑ Boring C ❑ Pit Ground surface elev. `qtr; ft, Depth to limiting fa or in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ' ConsiMMM oundary Roots GPDAF I in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E01 "Eff#2 J /c"(2 r'%S YRs c s b W~ i L E 8 Boring Boring # 13 Ground surface elev. ft. Depth to limiting factor In. Pit Soil Application Rate ; Horizon Depth Dominant Color Redox Description Texture Structure Cgnsistence Boundary Roots GP /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ( f I I ' Effluent #1 = BODE > 30 < 220 mg/Land TSS >30:5 150 mg/L Effluent,#2 = BQD6_< 30 mg/L and TSS < $0 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistan4c to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777: SI)D-8330 (R.07/00) Property Owner M/ / C 11~ ~i f J Gl~-s' Parcel ID Page cJ of ® Boring # ❑ Boring ❑ Pit Ground surface elev. / Z 5 ft. Depth to limiting factor in. 1. j Soil Application Rate Horizon Depth Dominant Color Redoz Description Texture Structure :Con&ist . ce :Boundary,: Roots GPD/ff? in. Munsell Qu. Sz. Cont. Color Gr..Sz. Sh. ` 'Eff#1 •Eff#2.; _ J -30 /O f 3cZ O F~ 3~n s b I )2 i c.r_J t L) I ~l Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting fa or Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ConsiMerMW oundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 O /c L I~e-~ C v F I ~2 S S'~ t' c L i to l c -S b ham. 'v.4 t Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor in. ....Soil -A IfcatioR:ftate Horizon Depth Dominant Color Redox Description Texture Structure Cpnsistence Boundary Roots GPD/f>? in. Munsell Qu, Sz. Cont. Color Gr. Sz. 5h. •Eff#1 '0#2 I f I i Effluent #1 BQD6 > 30 5 220 mg/L= and TSS >30 < 150 mg/L ' Effluent,#2 = BODE. < 30.mg/L .and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. Ityou need assistance to access 'services-;or_ need materiai in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. .SIID-8330(R.07/00) l~s A~ LL ~7- a3 hV~GL j yE ~ ~1 li ~y' II ~ S tQ ~ i pie c UtY1 i p ~ ~ r j i r ~ <y 1 13 C' 3 '4 0 4 9'm• q q, 9s, i f "T To 7 4> :ate a, v`t 4... 02, ti r ~ A CD -5 ,w 0 N ~ GS Y f-N ' a .r r ° r F Aski Zi~ I,Vi r•S 'l {s '3"k4`Y,yf„~+.♦ .`♦"n,f. - ~;.'tiR ~R•y "4k'" ^ 5`~;. ~ 'k Orr ~x~',+r•w"',~~-~~ w"`s~' ~°T, '~s w.• ~ .y ~ ~~~AAA "A 4 I- 4~9 .1 4 2k*x~ i '~"_.dx.. ..-a.y •.♦1.. _ .~4~~.n 4i ♦ °t{ v~' °~+Rw ~t'~,' '41 1 °'.a \ @•h nn~*'^'. 14 ° Y~wxm. 1 ti " R..°. k'*'?qs~, Y `S~,•'''°44'°4tR' .va~•r>w.u`"'' 4 " ti..! } ~ ~'r~ '4v,~4`+' ~'~Ay~ s`~" r~q„♦ ~ i~ ~~o~~x'°q~, ? ` ' ''~ti•"s ~ yam' r ~ NO Y °y° . t'L 6MM, . rte k x q,{ ~a\:;. k; :,it 3►"y5ev a. f It" x