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HomeMy WebLinkAbout038-1241-13-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600215 GENERAL INFORMATION 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: BAILLARGEON PROPERTIES LLLC TOWN OF STAR PRAIRIE 038-1241-13-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: IG.5•T 17.31.18.1315 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. r JV, Septic t S„~• S / Z Benchmark 12- /01 f /4t> Dosing Alt. BM 4" 0 6 cy • ~5 e vw Pre~eltiGff Bldg. Sewer r A. 81 S F; pa ~o /c~ S S ~ Holding St/Ht Inlet /2 . S~ s3 St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. ent to it Intake ROAD Dt Inlet Septic 7 x _ /J~ ~ Dt Bottom 40 Dosing .7 - //C~~ ~~7 / Header/Man.' i 72J -3,5 ~V / 6S•5g Aeration Dist. Pipe U~ 2 /D 3. T-IL Holding Bot. System . C1 •r z /d 2 Final Grade lb ~ PUMP/SIPHON INFORMATION • `1 J Manufacturer Demand St Cover fti G qg 9~ 35 Ol.~' S GPM 5~ J ~•O Model Number Zo' O 3 /4•g 971(34-1 TDH Lift Friction Loss System He TDH Bit Forcemain L/'~ Dial Dist. to Well /I SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 S l&w- w I~- SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: EZ INFORMATION CHAMBER Type Of Syste C _ / UNIT OR Model Number: 66-01 r fV DISTRIBUTION SYSTEM • Sx = 0I' Header/Manifoy / Distribution x Hole Size x Hole Spacing Ve Air I e 7 Pipe(s) Length IL Dia T Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only cl-t of Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 3 Bed/Trench Edges Topsoil es ❑ No es No COMMENTS: (Include co a discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 907 216TH AVE 5 V 1.) Alt BM Description = I Q6 a 2.) Bldg sewer length amount of cover = / n n 7 ~o d coat'.- a Plan revision Required? E] Yes )(K o + 7 1 7 L Use other side for additional information. J ( / Date 41nsepct&'sSi Cert. No. SBD-6710 (R.3/97) CSM L04 t Cl County c~xnt~ro• D Industry Se ✓ K~ _ _ ti 1 1400 E Wa Sanitary Permit Number (to be filled in by Co.) r SP f. K2A VIOP (p P.O.Box7162 S Madison, W1 53 7..7 i n~OF~sro:~P~~ ST CROIX COUNTY State Transactio Nttkiber ~ Sanitary Permit ApplicationMUN(rY /rJy In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropnate gov~ is required prior to obtaining a sanitary permit. Note_ Application forms for state-owned POWTS are submitted to I. Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(i)(m), Stats. f f/ i 1. Application Information-Please Print All Information Parcel # Property Owner's Name Property Owner's Mailing Address Property Location f~ Govt Lot Zip Code _ Phone Number - t' J '/4_A/1/L) Section /Y City, state I - (circle 9910 ! II Type of Building (check all that apply) Lot # Subdivisio Name I or 2 Family Dwelling - Number of Bedrooms # ❑ Public/Commercial - Describe Use Block eJ'SG~ G+~ ❑ City of ❑ State Owned -Describe Use ❑ Village of / M Number 6 CS Town of - l o b~- W III. T e of Permit: (Check only one on line A. Com lets ine a licable) System ❑ Treatment/Hoidin-e Tank Replacement Only ❑ Other Modification to Existing System (explain) A. New System Replacem~ox ❑ Permit Renewal El Permit Revision El Change of El Permit Transfer to New List Previous Permit Number and Date Issued B. Before Expiration Plumber Owner IV. T e of POWTS System/ComponentlDevice: (Check all that apply), 0 Non-Pressurized in-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank er ispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsaUTr7- Z~rl Area InformatiDesign Flow (gpdDesign Soil Application Dispersal Area Required (sf) Dispersal Area JP~mposed (sf) System 1Elevaki n Rate(gpdsf) l r~ 9~V ,J • SS VI. Tank Info Capacity inkk a 2 a ~ Toial # of m.1.. Gallons cturer ^ 2 U Gallons Units V v is 2 2 i7; iz New Tanks ( Existing Tanks Septic or Holding Tank Dosing Chamber 1 ❑ ❑ ❑ ❑ ❑ VII. Respons' ility Statement- I, the undersigned, assume responsi ih' for installation o the PORTS shown on the attached plans. Plum ame (Prin MP/NiF- Number t3 isiness Phone Number Plumber's i~ a It Plumber's Ad s (Street, Ciq-, Statte, Zip ode) j VII oun !De artment Use Only Approved Disappr Permit Feel Date ued Issuing Signature er Given Reason for Denial S d ' la 7 IX. Cond to Disapproval ;►sAi talN tatty lA K per ;VIr_*pnjen! pltn Vm4ded by pkutlbir• / 2. ' ;yatns'MA be Malydt i Ad to PK 10ril OM code 1 afdtillm". Attach to complete plans for the system and ubmit tot County only an notkm than 8 W 111 9es Z7 r r ~A- S S IKwny`' fa. tidr6 r✓°o~w~ . LO U NO015'13"E 2 S s_ s ~ j' F 90TH STREET w ® WEST LINE OF THE NWt /4 s - w S®®°154311W 435.85` SOO842'56" W 369. 7' 1 e - U7 Q, - o a m~ 6(6' o ~ 1 ~ a s 1 ~ I r", 33' 33' f ti 5.c G~ ` ( r (r A Izz -40 7 ~ -(p Cp y co z `f CD v; s` ~ ~ = D r r T9 ~4Z r r n F - OD I B~? j ! N01°42'33"E 296.01 m-0 v w C4 : ci CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: r- Owner's Address: Legal Description: Township: County: ~~~~,=;,1 ✓ Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat / Attachments: Soil Test & House Plans License Number: Designer/Plumber: JZ Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01l01). Page 1 - f I _-_--NOp'15'13"E 2 ~s WEST IiNE of THE Nwt /4 90TH STRE_ET_ i S®®°i 5'13" VIP 435.85` _ 7soo,o421,5 "W 369. 7' V U7 a, AM at kl 6 G' 1:u •P tat ~ ~ O ~ ~ L - r 33' 33' GC~ ! 1. ! W 1 14 loo, Cb' R c f 12\ ~ I T9 0~'y ' 1 co j co I ~ J ' O • i / - I N01'42'330E 296.01' - 00 j W I a v ~3 SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page-of_ Project Name: f No. of Cells s--' Per Cell --ff ft Cell Width _ Total No of ft Cell Length sq ft EISA Per Cell ft Cell Spacing sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Gravelless Leaching Unit Model: 7 Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent 1 C [ R ■ Soil Backfill 36 in [ Geotextile Fabric [ -ft Infiltrative Surface 12 in it C Limiting Factor i in Slotted and Anchored Vent/ Observation Pipe with Cap . [ ■ [ a a e a [ e . e a [ . s [ [ [ . Plumber/Designer Signature: License Date: fi'.' f t 1 Y d L-j PL 525 EFFLUENT FILTER ~£a ro Polylok, Inc is pleased to add its new commercial filter to its existing line of duality effluent filters. The PL 525 is rated for over 10,000 GPD alarm (gallons per day► making it one of accessibility "C-~- Accepts PVC f the largest commercial filters in its extension handle ~class. It has 525 linear feet of 1;151 ~ filtration slots. Like the Polylok v AIR PL-122, the new Polylok PL-525 has an automatic shut off ball installed ' k 525 linear feet ~ with every filter. When the filter is of 1116° removed for cleaning, the ball will filtration slotsRated for over 10,000 GPD float up and temporarily shut off the system so the effl went won't leave the tank. No other filter on the market can make that claim! Accepts 4° & 6" , SOO, 40 Pipe The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the fi [ter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional E alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be " ' Gas deflector i done by a certified septic tank j_ Automatic shut-off , pumper or installer, ball when filter is removed 1. Locate the outlet of the u.. Patent INo# 6,U15,4a3 septic tank. 5,371,640 2. Remove tank cover and pump tank if necessary. e € 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing, mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4 or fi outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted, its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page --5-,of FILE INFORMATION SYSTEM SPECIFICATIONS Owner A Tank Manufacturer: 1V ❑ NA Permit # Septic ❑ Dose ❑ Holding Volume: 9 (gal) DESIGN PARAMETERS Tank Manufacturer: ❑ NA Number of Bedrooms: ❑ NA ❑ Septic % Dose ❑ Holding Volume: S'G'G' (gal) Number of Public Facility Units: NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gal/day/ftZ) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 5_220 mg/L El NA / S ❑ NA Total Suspended Solids (TSS) x150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BOD5) >220 mg/L NA El ~NA (TSS) >1 50 mg/L Mechanical Aeration El Peat Filter El Pretreated Effluent Monthly average e Disinfection El Wetland Y 9 ❑ Sand/Gravel Filter ❑ Other: (BOD5) 530 mg/L Soil Absorption System (TSS) 5_30 mg/L NA Fecal Coliform (geometric mean) 5104 F,2'In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA 1 At-Grade ❑ Mound Maximum Effluent Particle Size %8 in dia. ❑ NA ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency i Pump out contents of tank(s) KWhen combined sludge and scum equals one-third (%3) of tank volume When the high water alarm is activated - Inspect condition of tank(s) At least once every: El month(s) (Maximum 3 years) ❑ NA fAyear(s) At least once every: El month(s) 19y (Maximum 3 years) ❑ NA Inspect dispersal cell(s) ear s Clean effluent filter At least once every: El month(s) ❑ NA Z year(s) Inspect pump, pump controls & alarm At least once every: El month(s) ❑ NA j ® year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) 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 (%3) 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 5_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) i Page Z' of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. 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, foundation 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 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. ❑ 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 THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA ER POWTS MAINTAINER Name - Phone ?yam _ Ca Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY LN a me j Name L~ , r , Z r. Phone hone J _ _ sl This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) 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, foundation 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 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. ❑ 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 THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA ER POWTS MAINTAINER Name Name Phone Phone q/ -2 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 8322(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COLS' SEPTIC TANK MAIRTTENANCE AGREEA/D---T AID OWNERSHIP CERTIFICATION FORM OwnerBuyer I MaiIina Address Property Address (Verincation required from Planning & Zoning Dep Et for new construction.) City/StateT~`~,' Parcel Identification Number y/ l '-~'%C~C~ LEGAL DESCRIPTION Property Location ELI I/4 , 1/4 Sec. T._N R_W, Town of Subdivision Plat: Lot # Certified Survey Map Volume , Page 4 Warranty Deed T (before 2007~Volume , Page 9 Spec house Byes D no Lot lines identifiable X yes C no SYSTEM NL4IIN'TEN 41'NCF1 AND OVr NTR 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 part into the system can affect the function of the septic tank as a treatnent stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.2(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, 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 ofNatural Resources, State of Wisconsin. Cer tincation 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 expiation date. Uwe certify that all statements on orm are true to the best of my/our lmowledge. Uwe am/are the owner(s) of the property descnbed above, by virtue of a w anty deed recorded in Register of Deeds Office. L Number of S-IGNATUTRE 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 wa anty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer Minim Pump Performance Required Tank Model Number j , GPM @ .(0 Ft TDH Total Tank Capacity Max. Bury Depth Total Dynamic Head (TDH) - Feet Pump Manufacturer - Elevation Head Pump Model Number - Distal Pressure Alarm Manufacturer zli Network Pressure Loss Alarm Model Number kForce Main Pressure Loss Switch Type -1; tal Manhole Min. 4" Above Grade With Locking Device Vent Min. 12" Weather-proof (j F-M Above Grade With Cap Junction Box - - - - Finished Grade - - - Depth of Cover Ft Disconnect ' Means > s > : > > s > > s > > > > s r > s > > s s r s s s s Y > s > > > > > s s s s s > > > : > s t < t t < t < < t { t e e < { < < c t < t < t < e < < < t t t < < < < : t < c < < < i t { t { < < > > s < Outlet { Switch Settings and Reserve Capacity Inlet Tank Volume = 1/ GPI < Dimension Inches Volume Gal. <'< Y} A } t; (reserve) A X4 '~4» (alarm) B 2 B ? < Weep < Hole < (dose) C Off Elev. C \ f' (dead) D < t Total ; a t Y` D Y[ yi> Bottom of Tank Elev. % Ft { t t t < t < { < >t Y > > ) > > Y > } > > > Y } Y Y > > > > Y J > > > } } Y > } > } > > } > } } J Y Y > > > > > > Y > > } > > > > > Y < t [ t i [ [ i S { { S { < [ t t t t K { [ { < [ t < [ < < { K t { { [ < { {'e< < { < < { t < t < < < { { { < { S t GENERAL INSTALLATION: The dose tank is bedded and back filled in accordance with the manufacturer'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 outlet 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 excavation and is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 Wis. Adm. Code. 03/05lgj Page 6 of ~ 0 D PUMPS Submers I "VW Effluent Pumr Wel! 1 e L SPECIEICAI! IONS MOTOR FEATURES General: in Corrosion resistant Pump- General: o Single phase construction. ® Discharge: 11h" NPT © Si 60 Hertz s Cast iron body. a Temperature: 104 F (4000 17 115 volts ' C Thermoplastic impeller and maximum, continuous when a Built-in themial overload pro- cover. .r fully submerged. r s ~ teclion with automatic teset upper sleeve and tower rSolids handling: W o Class B insulation. heavy duty ball bearing maximum sphere. • Automatic models include a • Olt-Wiled design. construction. APPLICATIONS float Automatic • High strength carbon steel m Motor is permanently • Manual models atrailable. shaft. lubricated for extended Specially designed for the . Pumping range: see PE31 Motor. service fife" following uses: "performance chart or curve- .33 HP, 3000 RPM Powered for continuous • Mound Systems • 12.0 Maximum amps operation" e Effluent/Dosing Systems PE31 Pump' o Shaded pole design r, All ratings are within the • Low Pressure Pipe Systems ` Maximum capacity: 50 GPM working limits of the motor. • Basement Draining ` Maximum head: 25' TDH PE41 Motor: Quick disconnect power • Heavy Duty Sump/ p: • .40 HP, 3400 RPM dard length PE41 Pum cord, 20' stan Dewatenng ° Maximum capacity: 60 GPM ` 7S Maximum amps heavy duty 1613 SJTW with • Maximum head: 29T DH ° PSC design NEMA 5-15P, three prong, PE51 Pump: PE51 Motor: 115 volt grounding plug. • Maximum,capacity: 70 GPM ` .50 HP, 3400 RPM m Complete unit is heavy duty, • Maximum head: 37' TDH ` 9.5 Maximum amps portable and compact- - PSC design m Mechanical seal is carbon, METERS FEET ceramic, BUNA and stainless 40 MODELS: PE31, PE41, PE51 i steel. 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Property Owner Property Location - ✓ Govt. Lot 1/4 1/4 S JT N R E (or M# Property Ownef s Mailing Address Lot # Block # Subd. ame or 13 JIS l 1. City State Zip Code Phone Number 0 City ❑ village Town Nearest Road i M New Construction Use. 0 Residential / Number of bedrooms Code derived design flow rate /GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft• General comments 7 r~- and recommendations: c~c+SFV ~s7L± n, G~ - 9~ /GXo Boring # ❑ Boring ® pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDfft 2 in. Munselt Qu. Sz. Cant Color Gr. Sz. Sh.. ff#1 f'f#2 1-2 /Z Z S 5 l _1 -.3 76 3 1 1-7 5 it Boring # C1 Boring - ® Pit Ground surface elev. ft. Depth to limiting factor /e,7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure sistence undary Roots GPD/f3 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 1 G ~ h a 2 * pfflue9i #1 = BOD > 30 < 220 mg& and T 30 < 1 mg/L * E ent #2 = BoD < 30 mg/L and TSS < 30 mWL CST Nam (P a Pri j Signature CST Number Address Date Evalua do Conducted Telephone Number SBD-8330 (R)1/11 ) Property Owner .Ea24, 4~Gr~~! / jf U~h[~5 cS Parcel ID -/f Page of Boring Boring # 10 Pit Ground surface elev. /t f;f,S R Depth to limiting ftor ,2[ in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 ff#2 6 G El 0 Boring Boring # pit Ground surface elev. ft Depth to limiting factor in. Soil Apefication Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDM z in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. ft#1 E * ff#Z 1 Bonng W Boring Ground surface elev. R Depth to limiting factor in. l ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistenoe Boundary Roots GPD/ft z in. Munsell Qu. Sz Cant Color Gr. Sz. Sh. ` ff#1 * ff#2 I i I,''..'', Effluent #1 = BOD a > 30:5 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD a < 30 mg/L and TSS 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBa8330 (RI Ul l ) Page of ~~;'~/9°G Parcel ID # (f) Properly Owner F-31 Boring # ❑ Boring Pit Ground surface elev. /KAft Depth to limmiting factorZZ75--_ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ff#1 ff#2 6 41 - s 31 7 0 F-I Boring #Q Boring ~1l !-t Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture structure t~onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. f(#1 * ff#2 ❑ t3oreng Boling # Ground surface elev. fL Depth to limiting factor in. F-I ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cant Color Gr. Sz. Sh. * ff#1 ` ff#2 * Effluent #1 = BOD b > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD a < 30 mg/L and TSS < 30 mg/L The Dept, of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (Rf 1/i 1) L I -,OOI I ~ ! S32 CY) `O . ~Ed r ~go, N JO-96Z 3.££,Z*.ION / d' N / r o r v co OD z ~ VI i~ ! 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