HomeMy WebLinkAbout032-2176-16-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 600217
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:
DAN & KELLY OLEN TOWN OF SOMERSET 032-2176-16-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
a- 12.30.19.1501
TANK INFORMATION ELEVATION DATA -y
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Q
Septic - ~ ~ Benchmark
!Ao- ow
Alt. BM
Aeration- ~ Bldg. Sewer 793
Holding.__ _ _ St/Ht Inlet
6.93
TANK SETBACK INFORMATION St/Ht Outlet SID Sib
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / J o Dt Bottom
w
Dosing Header/Man.
o.a3 v~.
Aeration Dist. Pipe
Holding
Bot. System
2~7~-
Final Grade
PUMP/SIPHON INFORMATION Ct " ~(D 65r~
Manufkc"urer Demand St Cover
Model Number
TDH Lift Friction Loss - System Head TDH Ft
Forcemain Length 2,ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width t Length No. Of Trenches PIT DIMENSS No. Of Pits Inside Dia_ CiquidDept#.
DIMENSIONS r-> m r ~"(J qY,,/ \1
SETBACK SYSTEM TO P/L BLDG WELL LAKp, &TREAM LEACHf G Manufacturer:
INFORMATION ' Type Of System: CHAMBER OR -r;vF /4rt.-} r
r } UNIT Model Numbe : C
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Si" Ix Hole Spacing Vent to Air Intake
~1 jr It Pipe(s) --1 1 LDia L ~ Dj~"~ ~ Spacing/"'
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 P Bed/Trench Edges Topsoil
Yes Noes F', No
COMMENTS: elude code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1625 83RD ST
1.) Alt BM Description
2.) Bldg sewer length ~r~.(
- amount of cover
Plan revision Required? Yes ❑ No 1 / 1~ r' ! t "a" I I `i q8
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's ig ure Cert. No.
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.P.+yt~ County
t f Safety and Buildings Division
y r~ NOV 012011 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit NJ, ly
umber (to be filled in by Co.)
t%, S P S, Madis 162
ST. CROIX COUNTY COMMUNITY DEVELOP ENT 707p92 p ~ Z / 7
Sanitary Permit Af $C~TT490EK State Transacti Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of uns Corm 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 Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04 l m tats. q~
I. Application Information - Please Print All Inf m tion (J
Property Owner's
Nam;CFk Parcel # i. ) 141,
- ?
Property Owner's Mailing A e s Property Location
fa.3~, iq, iso~
Govt. Lot
City, State I Zip Code Phone Number y, Section.
c - circle on
T, N; R
II. Type of Building (check all that apply) Lot #
Tom- or 2 Family Dwelling - Number of Bedrooms Subdivision Name
(yA Block # J '
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use / +1 CSM Number r❑ Village of
Z ~ 1'f7 W li7i~2iZ Ks Town of
III. Type of Permit: (Check only one b on line A. Complete line B if applicable) 7,6
A. ew System El Replacement System
❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. El Permit Renewal Permit Revision El change of Plumber 11 Permit Transfer to New List Previous Permit Number and Date Issued
^
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that apply)
g Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 m. I suitable soil
o mg Tank Other ispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat nt Area Information: '
Design Flow (gpd) Design Soil Application Rate(grid sf) Dispersal Area Required (sf) Dispersal Area Proposed ( System Elevation
Ly i L-7 T
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units Q o
New Tanks Existing Tanks c y y
6 b~LZ ~o e V
Septic or Holding Tank a /
Dosing Chamber
VII. Respo sibility Statement- I, the undersigned, assume responsi ' • or insta tion of the POWTS shown on the attached plans.
Plumb r' am P7,) = Plumber's S j ' MP/MPRS Number Business one Number
17
/4
Plumber's Address (Street, City, tate, Zip Cod
A
VIII. untv/De a ent Use Only
Permit Fee Date ued Iss gent Signature
X proved ❑ $ I
v n Reason for Denial I 7 7
QW7 A A
IX. Condi o + isapproval
3 act
ulspar::,; cell must all §g sal ices ! r,+~+nt'. /
as per l-tor.3gement plan p'o +ided by plumber.
2. AQ sse ck rcc~ irg ar►:s tm t: t tr rwast irefi p 6e-N
as per aKknbh wdw I crdinatlw9si. Y
Attach to complete plans for the system and submit to the County only on paper not less than 8 12 ill inches in size
SBD-6398 (R 11/11)
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pVG Vent Pipe
Leaches Gs
Chamber Systwn
~~s! Abs-O Mi0t1 Avs 1427 MISM
rE
'L Leackfing T ;;h 5
Vent or Obsevafion Pipe Chambers
4F D ia
Trersdi 2 Header
Manufacturer And Model 'V,
EISA 14ating , sq it per chamber Sail, Application is 9pdAA ~
kaftan Rate EISA = Chambers
Design Ic~tt~ _ Soft APP
- gpd 9n
2 Mws of . d ambers each
Page, yr
RECEIVE (f ST-ao n
Wis. Dept of Safety and Professional Ser D SOIL EVALUATION REPORT Page of 7l
Division of Safety and Buildings
ST. iea~7(d Wis. Adm. Code
~nt~A~ ~~~Ty DEVFL. County
Attach complete site plan on papefttttleTsss (han 8112 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal ref ce p ' t ( di 'on and Parcel LD.
percent slope, scale or dimensions, north arrow, an nd to nearest road.
Revie by Date
Please print all 8CDTT490EKA9211)(m))•
Personal information you provide maybe used for s. _ .
Property Owner Property Location
Govt. Lot 114 114 S T N R E (oral,
Property Owners M 1 Address Lot # Block # Subd. Name or M#
City State Zip Code Phone Number ❑ City ❑ Vliage OTown Nearest Road
~l
YJ/
New Construction Use: ® Residential / Number of bedrooms Code derived design flow rate -r; GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material s '4 "~Z Flood Plain elevation if applicable ft
General comments
and recommendations:
Boring
E Boring # 10 Pit Ground surface elev. ft. Depth to limiting factor in. Soil Applicallon Rate
Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDfft 2
in. Munsetl Qu. Sz- Cont. Color Gr. Sz. Sh. ff#1 f'f#2
/Z- Z1Z'
Boring
Boring # ~ Pit Ground surface elev. _ ft. Depth to limiting factor y//.S` in• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure sistence Boundary Roots GPD/ft z
in. Munseli Qu. Si. Cont. Color Gr. Sz. Sh. ff#1 ff#2
/ << c 4
t
Effluent #1 = BOD > 30:S 220 mg& and TSS >30 < 150 mg/L uent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name ( Print] Signature J~ CST Number
Address Date Evaluation Conducted Telephone Number
- ' ' SBD-8330 (RI I/1 1)
11 /
Property Owner Parcel ID # /L - Z<' Page _ of
Boring
Boring # ❑ /
Pit Ground surface elev. ft Depth to limiting factory in.
Soft Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Conti Color Gr. Sz. Sh. ff#1 * ff#2
~j Boring # ❑ Boring
It Ep ❑ pit Ground surface elev. ft Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPD/ft 2
in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 102
❑ 8onng
Boring # Ground surface elev. R Depth to limiting factor in.
❑ 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 5 > 30 < 220 rng/L and TSS >30 < 150 mg/L * Effluent #2 = BOD s < 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.
M-8330(R11111)
Property Owner Parcel ID f - / '7f ~f/ - iCyi Page of-,
❑ Boring _
Boring # Ground surface elev. " ft Depth to limiting factor ~f/.Q in. Sol fication Rate
Pit
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots * ff#1 GPD
in. Munsef! Qu. Sz. Cont Color Gr. Sz. Sh. N W2
-
-Za C
Z, I
b S n
Q Boring
Boring # in. Rate
❑ Pit Ground surface elev. ft. Depth to ilmiting fiactor Soil Avl3fication
GPD/ft s
Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots ff#1 * tfi#2
in_ Munsel! Qu. Sz. Cont. Color Gr. Sz. Sh.
Boring # E] Ekxing Ground surface elev. R Depth to limiting factor in.
❑ Pit Soil Ap 6cation Rate
Roots GPD/ft s
Horizon Depth Dorninant Color Redox Description Texture Structure onsistence Boundary ff#2
in Munsel! Qu. Sz. Cont. Color Gr. Sz. Sh.
Effluent #1 BOD > 30:5 220 m9/L and TSS >30 < 150 mg/L * Effluent #2 = BOD s 30 mg/L and TSS 30 mg/L
= 6 u need The Dept. of Safety and Professional Sal in alteequal rnate format, contact the department at dd8- 66 3151Ior oTTY thr ugh Relayto
access services or need material rinal in an a
MD4330 (RI 1/11)
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1170.19
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LOT 9 C.B.A _ 23ACFF5
3.1 AGR I w S~ G I
C-5.4. ES Ire
575.4T
2r. ~ 1
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e{ • L~IM 17
16 3.0 ACRES Q
~t , 0.6A. - 3.0 A-FES (i
i 842.87'
~ b
wq 388.98'
I LOT 18
ACRES
• C.HA- 2A ACRES
W
N
LOT 19
W
ay 3.0 ACRES ~Q
1 m
C,BA _ 23 ACRES
I B.0. = 946.4
I
383.71'
/ 291.23'
A
LOT 20
y~y- f 3.0 ACRES T T
C.B,A. -2.7 ACRES r-
. =928.4 a
Q!,~t{ . ~ N CD ® o
S 'BD
• by 4Y~ t CB.A. - 1.9 ACRES
• t
T1.48'
338.98° 589°34'47W 2.04
LOT 22
® 3.0 ACRES i
LOT 21 ® L~O'T
3.C ACRFS ( ~~W QM 9
O.EA, = 3.0 AMES Yl CIOO I~ 9 ~ ~S ° o
. X22 z
C.B.A. - 0.96 ACRES
POLE SHED HOLSE
FIELD
DAIW EXISTMIG
I DRIVE
iko TH AVENUE. _13~97d v
h
i
589°14'08'W 223.79 S89•I4xvw
DOSTWG C£NTERLWE . souTH LINE DF THE SWi/4, SECTION 12 _
C~C~+1t,Y~1~~(i:i 03"7 1 r
HERS: DEVELOPERS:
~~4t+kr„F : County
Industry Services Divisio_q
E~ashingt(n[VF
gton Sanitary Permit Number (to be filled in by Co.)
P l" P. Box 716
Vr0 YJO Madison, W1 7~ -7~U 17 606Z/7
Sanitary Permit ApplicaMlf,11ROI~Xy COUNTY State Transaction Niumber
fd>~ a rplia[e'g(7tt51rr~~nit
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. I5.04(1)(m), Slats.
I. Application Information - Please Print All ormation
Property Owner's Name / Parcel #
71, -
ZZZ
/ _
Property Owner's Mailing Address Property Location
Govt. Lot
City, State Zip Code Phone Number /4, /4, Section
~ (circle o
T26, N R Eor
H. Type of Building (check all that apply) L.ot #
10 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
F] Public/Commercial - Describe Use 4 Block # / S -
1 dtV-. El City of
F-1 State Owned -Describe Use r El Village of
CSM Num
' ®Town of
z
W `G e'~
III. Type of Permit: (Check only one ox on line A. Complete line B if li e)
A. rVI New System ❑ Replacement System e ,cnt/Hi eplacement Only ❑ Other Modification to Existing System (explain)
J~
❑ Permit Renewal ❑ Permit Revision ❑ ge ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plum Owner
IV. Type of POWTS System/Component/Device: (Cl all that apply) v
DI Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑I It-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
,Js
❑ Ho mg an < Ott r Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treatme Area Information:
Design Flow (gpd) Design Soil Application Dispersal Area Required (sf) Dispersal Area Proposed (s Systgem Elevation *-7' / ~ Rate(gpdsf) / Lsu~
)C
VI. Tank Info Capacity in
Gallons Total # of Manufacturer U °
Gallons Units
New Tanks Existing Tanks ^ U u. C7 0.
Septic or Holding Tank ❑ ❑ ❑ ❑
Dosing Chamber ❑ ❑ ❑ ❑ ❑
VII. Reapo sibility Statement- I, the undersigned, assume resp ibi 'ty for installation of the POWTS shown on the attached plans.
Plumb ame rint) i Plumber' ature MP/MPRS Number Business Phone Number
Plumber's ddress (Street, City, State, Zip Code .
VIII. County/ epartment Use Only
Approved risappr., e P ermit Fee Date I sued Issuin ent Signat e
rven Reason for Denial $
IX. Condi~kete'"Disapproval
3~ ~o G.L Qf
1.
be spl_Fcs ! r ec
oKparaui Cell must all ef
ss per i)W.Vement plan pro naed by plumber.
2. `A1 ttelbW* rwAim mn2s must ue na;ntr ir':ed
as per vXareFls cx)6 / ,::rtlin1, nr n,.
Attach to complete plans for the systems and submit to the County only on paper not less than 8 1/2 x I I inches in size
SBD-6398 (R03/14)
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16
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name:«
Owner's Address: -
Legal Description:
Township:
County:
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
j Attachments: Soil Test & House Plans
Designer/Plumber.License Number.
Date: 7 - / 7 Phone Number z_- ~
Signature 'Designed pursuant to the in-Ground soil Absorption Component Manual for POWTS Version 2.0 SBD-10P70 P (N.01/01).
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4°S~40
PVC Vent Pipe
v ft Vert DIP
ieachIng
Chamber System Elevation
~..e ~i~s~Pt3 5014 Svs [ant IM
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1 L L ac wn-g l"rsnch I
r't Vend Or ObSSTvafion Pipe Chambers
47 YM
# Trend 2 Header
Manufacturer pod And Model
EISA Rating~~, s4 per chamber soO Application Rate : 7 gib it
Soil App~ion Rate EISA = ` l C!haaniaers
gpd Design Flow
2 mvis of r ►amtse each-
page „4-- 01
,"`.ate r ~;v..~..-,,•rrj~.--`''.
I
P 52j` EFFLUENT FILTER
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters. The
PL-525 is rated for over 10,000 GPD Alarm Accepts PVC
±galEons per day; making it one of accessibility extension handle
the largest commercial filters in its ;
class. It has 525 linear feet of 1/16-
f Itration slots. Like the Polylok.
PL 122, the new Polylok PL-525 has
an automatic shut off ball installed 525 [in ear feet '
with every filter. When the filter is of 1116" Rated for over
removed for cleaning, the ball will filtration slots t o,ooo GPD
float up and temporarily shut off`
the system so the effluent won't
leave the tank. NO other filter art Accepts 4®& 6"
the market can make that claim! SCM 40 Pipe
PL-525 00"l'H tv11c'1"Mav;
The PL-526 Effluent Filter should
operate efficiently for several years
under normal conditions before
requiring cleaning. It is recom-
mended that the filter be cleaned
every time the tank is pumped or
at least every three years. If the
installed filter contains an optional
alarm, the owner will be notified ~r
by an alarm when the filter needs " Gas deflector
servicing. Servicing should be IT
done by a certified septic tank I Automatic shut-off
pumper or installer. ball when filter
is removed
1. Locate the outlet of the U a Patent Nog 6,015,433
septic tank. 5,371,644
2. Remove tank cover and pump
tank if necessary.i i +z • 'i. Locate the outlet of the
```-~'septic tank.
3. Do not use plumbing when
filter is removed. Ideal for residential and com- 2. Remove the tank cover and
mercial waste flows up to pump tank if necessary.
4. Pull PL-525 out of the housing.
10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
5. Hose off filter over the septic 4" or 6" outlet pipe. If the
tank. Make sure all solids fall 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.
5. Replace the septic tank cover.
7. Replace septic tank cover. -
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ' of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner '
Tank Manufacturer: n,, /lo~5h:_~ ❑ NA
Permit #
Septic ❑ Dose ❑ Holding Volume: (gal)
DESIGN PARAMETERS Tank Manufacturer: NA
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (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): n (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: 7 (gal/day/ft2) Effluent Filter Manufacturer: ) o ❑ NA
Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model
Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BOD5) x220 mg/L ❑ NA ~NA
Total Suspended Solids (TSS) 5150 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 ❑ Peat Filter
El Pretreated Effluent Monthly average e Disinfection ❑ wetland
Y 9 ❑ Sand/Gravel Filter ❑ Other:
(BOD5) 530 mg/L Soil Absorption System
(TSS) <30 mg/L m NA
Fecal Coliform (geometric mean) _5104 V In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Effluent Particle Size %8 in dia. El NA El At-Grade El Mound
❑ Drip-Line ❑ Other:
Other: ❑ NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) ~Z'When 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: ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
year(s)
Clean effluent filter At least once every: ? Ye fts(s) ❑ NA
O
Inspect pump, pump controls & alarm At least once every: ❑ month(s) f~ NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ~j 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 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 4 1, POWTS MAINTAINER
Name f P Name
Phone l 7 - Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone s
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)&(0 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 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
r 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 5 _ 7 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ,
Phone Phone S
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.
ST. CROIX COUNTY
MPI' C T & NLSADN704"CE AGE S:`
AND
aG~ ~FIF OERMICATION FORM
Owner./Buyer 2
(Zseriiication requi~i .from P & Zug fo3 ne:vt+ cocnsluuctaon.)
City, She Parcel Identification Dumber Ff . -,-Z A,1 - -
L~~~ I~~ST~C)
Property Lo adOn x/4 , V4 ; Sec. _ 1-2 T J~) N RZ~ W Town of _ > s` t
Subdivision Plat: Q S Lot
Certified Survey Map 9 , Volume . Page
Warranty Deed (before 200'/)Volume Page 4
c pauses ye4no lot Ihm Aadf~ a no
SYSTEM M LN I`F~IANCE AND OWNER CERTff IC A: I~QN~
improper use and ai aw nce of your septie system could result in its prmnataae failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if neede4 by a licensed pumper. What yrnz put into
the system can affect the t Motion of the septic tank as a treatnimst stage in the waste disposal rystem der maarttenanee
respoasY~nWes are specMW in ISPS. 38352(1) and in Chapter IZ - St Croix County Sanitary Ordhnnoe.
The property owner agrees W submit-m St. Qon County Plawimg & .Zomg Deparment a ce iiog fo m. siped by the
owner and by a master pImnber. jommeyaman ph=bea, restricted pltmnber or a bo msed pumper vm*iap that (1) the on-sfts
-9 wwwaw disposal system ism proper uperw mg condition and/or (2) after inspection and pumping (ifaecessary), flee septic tank is
less than I13 fall of sludge.
Ilwe, the undersigned have react the above requir menus and agree to maintam the private sewage disposal system with the
stench; ds sa im-& beremi as set by the of Safty And Smdca am floe DopmImm oflWsMW Reams,
State of Wrl w vmmg Chit yaw seoie swum has must be c gleted and remmed to the St Croix
Ct ttp Plauzilm 8r. Zoning wig 3 of the &e Yew eWilim d~
Uwe certify that all st enta on ' 1brm are true to the best of my/our kaowledg& Uwe am/am file owm (s) of the
property described above, by virtue of a u s deed recorded in Register of Deeds Office,
.Number of bedrooms
SICx'~A3'E~ 07F APPLICAINTT(9)~ I7 4TE
* Any information t o& is naisregreseated may result in f be sanitary permit being revoked by the Plw=g 8c Zoning Depm them
Include with this application a recorded wartznry deed ;ice the Register of Deeds Office and a copy of the certified survey map if
reference is made in the wad, deed.
(REV. 041U)
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