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HomeMy WebLinkAbout028-1041-50-000 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600210 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, S. 15.04 (1)(m)] 2980780 Permit Holder's Name: City Village Township Parcel Tax No: RAYMOND SIERACKI TOWN OF RUSH RIVER 028-1041-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: t. ~r~~~ a ~ ; 35.28.17.260B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER • s CAPACITY STATION BS ' HI $ FS EL Vim. 0•$ Septic y L , Benchmark z 5!40 5 79 Dosing I Alt. BM 01' a-~ ~/`'--,tiffs 5 ~Sa /0/.1 •73 /oo /d IiG ZS Bldg. Sewer 4-1 '97,43 Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO aP WELL BLDG. Vent t Air Intake ROAD Dt Inlet /Q, 9a 77 Septic q& I (P? 1311 - Dt Bottom 14.1 Uo 17 1 :11 Dosing /3 Z 2`17 Header/Man. 74 14 , v Aeration Dist. Pipe .78 `I(o.o Holding Bot. System .4' 47 W - 2 Final Grade PUMP/SIPHON INFORMATION 3 • 79 97,0 •7 Manufacturer Demand St Cove ? ~7 G eJ GPM J'J1~ J• / 99.0 Model Number / a L~/•g 9y v-711 TDH IL4 aL Friction Los System Head T H Z • z , Forcemain Len tg h Dial • f Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of~Tf ches PIT DIM NSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /b 1 '6 ;~f SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of S q 12-CHAMBER UNIT OR Model Number: 3 f DISTRIBUTION SYSTEM Header/Manifold / Distribution .!r x Hole Size / JxHoleSpacing Ve o Air In e & Z I. Pipe(s) 47 t / ✓ 4 _ / r Length Dia Length Dia 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 rr-- Bed/Trench Edges Topsoil No 1 ---F.~es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: /a Z / Inspection #2: Location: 1984 CTY RD iG GoJtt_ p ~ ;..~~4fL• pro ~ 1.) Alt BM Description - i C-f 2.) Bldg sewer length = J 3 J~ - amount of cover = **7 / -F ap el Plan revision Required? ❑ Yes V( No /6 2-7 Use other side for additional information. ,f Date Insepctor'S Sig ure Cert. No. SBD-6710 (R.3/97) -J County Industry Services Division S- k ;d) 9 ? 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P SEP ! v ` P.O. Box 7162 6_ r f Madis I 707 16 > ' sr. Ct=cOIX COUNTY .4p Ael OnUELOPMONT Sanitary Permit SRKCRYYHVMYAP StateTransactgionNQumbner In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this torm 10 me nyp ~N. e_.,_..- ut / v vv is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing dress)) 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(1 (m), Stats. I-0 I. Application Information -Please Print All Information Property Owner's Name Parcel # Property Owner's Mailing Addre s Property Location 5 -9,j„1-7 0 f ) . • / Govt. Lot ` C~ } C fl, C4 City, State Zip Code Phone Number sF y, may., Section 3 3 ~ flLy (circle one 7I5 T c~ is N, R t 7 E ol2} 11. Type of Building (check all that applyPoo Lot # CJ 1 or 2 Family Dwelling - Number of Bedrool Subdivision Name ck#-~~ ❑ Public/Commercial - Describe Use 4 L CA. V%01. ❑ City of ❑ State Owned - Describe Use / CSM Number ❑ Village of 7 ~ I'i 1 ~wn of K LA-S 1~ III. Type of Permit: (Check,, only one box on line A. Complete line B if applicable) A. ❑ New System LYReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date 1 / 7 ed Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat ent Area Information: .r4 Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal? Area Propose sf) Systemisation 600 -5 V1. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U New Tanks Existing Tanks Ir.o 2 td i° Septic or Holding Tank C3 LI-) t Y'C C ✓ Dosing Chamber 57C- V11. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPS Number Business Phone Number ~09.1 Bs(~I+ou~ M P gal baa 7~s-X78 _s Plumber's Address (Street, City, State, Zip Code) VIII oun /De artme t Use Only Approved 11 Disapproved Permit Fee Dat Issued Issuin ent Signature er i Reason for Denial r 9 Z9 J7 $ 01- IX. Condttt ~qr,&approval 0 into r ec 3) Gar ~ ; j-.O/~~j +;i er irn cell must all be s ,i^ic•rs _ as s per rrtar:ay w ernen' plan p:c,-iide7 bV plwnbe;, 1L•Q1, ~t.~ elk 2. AA s~,k regt,.lt-!:,er1m5 mU*t M, i:' a rtt~ Ir:E I n per aWliciblst rryl,-1 :,rdintu rgz, b~te~ 'S 6&4.A1jr^ _J Attach to complete plans for the system and submit to the County only on piper not less tha 81/2 x 11 inches in size aD Go ~ SBD-6398 (R0313) ,~cR s /0, 3,Z e, a •F RL-ks ~t r U e f Nf-: Sec 3 s 7-.:)8 A) R 17 u.1 qq,o Orb. o r ~3 .:M t coo . o a S~uP 7 5 re f J~ 5/op.~ l t V ~ f ~G ~ o f fOly$E S [ nc, tJ, j'eS E'~ g~ C { ~ ~ eel l,J~~$•ers' j~S~ Gcl. x~sr~5 TaIt QCs d 3 x +c, oe: .t Y ro?.-4 f 1 C~T; y /f'o~d ` /`0 4 7+rF~. DIVISION OF INDUSTRY SERVICES - ion 3824 CREEKSIDE LN 9 HOLMEN WI 54636-9466 <p 3 E S ~a Contact Through Relay P S, K http://dsps.wi.gov/programs/industry-services 11 Cw www.wisconsin.gov ~~os'sro~~tiSw~ Scott Walker, Governor Laura Gutierrez, Secretary August 17, 2017 CUST ID No. 921620 ATTN: POWTS Inspector BARRY BIGAOUETTE ZONING OFFICE PIERCE PLUMBING INC ST CROIX COUNTY SPIA N7053 CTY RD BB 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/17/2019 SITE: Identification Numbers Raymond Sieracki Transaction ID No. 2980780 1984 County Rd YY Site ID No. 841133 Town of Rush River Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. SE 1/4, NE 1/4, S35, T28N, RI 7W FOR: Description: Four Bedroom Mound System \ Sloping site Object Type: POWTS Component Manual Regulated Object ID No.: 1720156 Maintenance required; Replacement system; 600 GPD Flow rate; 20 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code DONDITIO requirements. APPRO No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, DEPT OF SAF stats. PROFESSIONAL The following conditions shall be met during construction or installation and prior to occupancy or use: C' F INDUS' Reminders • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. 4~ SEE C4RP • In spection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. • The existing POWTS shall be abandoned per SPS 383.33, Wis. Adm. Code. • All POWTS component piping material shall be SPS 384, Wis. Adm. Code compliant. • The area within 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • 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. BARRY BIGAOUETTE Page 2 8/17/2017 Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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 4erard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swim@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm BARRY BIGAOUETTE Page 2 8/17/2017 Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. 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 erard M Swim POWTS Plan Reviewer, Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.,swim@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm JUL 3 x 2017 INDEX SHEET a PROPERTY OWNER: PROJECT NAME: C k 1 PROJECT LOCATION: I9' g'Y Y ra, ~w~ rte; UJT-, J MUNICIPALITY: I COUNTY: Sr x/20/ k DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N.01/01) MOUND COMPONENT MANUAL VERSION 2.0" SBD- 10691-P (N.01101) CONTENTS: DALLY `ED Page 1: Plot Plan ETY AND Page 2: Cross Section and Plan View of Mound SERVICE °Ry SERVICES Page 3: Distribution Pipe Layout , Page 4: _ Pump Chamber Cross Secti Specification Page 5: IV L p 7 'Q - Tank Specifications Page 6: Pump Specifications Page 7: Observation Pipe Detail Page 8: POWTS Owner's Manual & Management Plan- Pg 1 r Page 9: POWTS Owner's Manual & Management Plan- Pg 2 Name: -1/~ f cA o (t e ~~_ay Signed: Address: X1705"3 C 7"Y, Rp Sip r JA 11 ~t J]-e7 c,L~s, s`9,7 ~ 7 Credential Number: 'V.:~) / 6 Q) 0 p,44 0- , CR S /0.3Z % to cLs cri C'C R1 i s t t~ e~- t ' Pc 35- 7--.2 /U I' VJ 176.rJ / S3 a.M, too, 00 r ( ~ ~~tk{' "/UI a ~ nt~R~Gvt 7 VC Nil V 1 X111 We 1 rc~ .~-(c~ r r+' tB1 I 0 0. oz t.j I,--s ES 5e '1 Ca XCS1~~J Tc}~ k- CL ~J' 3 O ~O os~,,y~ l ` j I 17-1; tR Y J ` Y crY, aT Synthetic Covering AST'M C 33 Distribution Pipe Medium Sand c ±._-(ems- -3;STopsofl ~SH= G fi. E I~ D 3 ~ . Slope. YS! o CELLOf ZM- 2 Force Main Plowed Aggregate From Pump Layer D .33 Ft. Gross Section Of A Mound E /.83 Ft. F AP Ft. G -6 Ft. A %0 Ft. H_ Ft. Signed: B 6 O Ft. License Number: K /0.0 Ft. Date: L Ft. L J 6,6 Ft. (B C70 G P1~ Ky ~lc~T~ T %,.~2 Ft. W. 8 Ft. d Observation Pipe 6 K T-t.~ rr vt u S 1 W i Distribution `i:~° Of ;2 - 2 %2 Pipe Aggregate I , a Observation Pipe 13a r ~ A-eo,° = J ~7 ~ . Plan View Of Mound 3 4' J Perforated Pipe Detail Cleanout Access E n d v i e, Threaded PerlorQlco Cleanout PVC Pip( End Manifold Holes Located on Bottom Are Equally Spaced ~ i Force Main From Pump First Hole Next to Manifold 1 3.5 rACA k- Cleanouts Distribution Pipe Layout P R S x~ Y/e Hole Diameter Inch Lateral " Inch (es) Manifold " Inches Signed: Force Main Inches License Number: Invert Elevation Zr 9,3 Date: Holes Per Lateral Number of Laterals J Total Holes ~Q~ PUMP CHA.MI;ER cKoss 4fECT'ioll Ami) 3PECIFICAT04S VEUT CAP Le Poc VF-N.17. pipr-- Lock, 'I WEATHERPROOF z~' FROM DOOR JUMCTIOM BOX mcLV`~to~ e- . OR FRESH I2"MIU. AIR I/JTAKE I n r-kU q3,5 GRADE (~("Ot>.KJC I 4" MW. ~ 18" hCI1J. COQDUIT IKILET PROVIDE I T AIRTIGHT SEAL I III 1 I I APPROVED JOIIJT A I III APPROVED JOIQT! W/C.I. PIPE I III W/C.I. PIPE EXTEIJDIMG 3' I II ALARM EXTE.MDI►1C. 3' O►JTO SOLID SOIL D I II OMTO SOLID SOIL I I i I ow c I I L L E V. ~71 SF T. _ PUMP OFF 0 COUCR£TE BLOCK 'I ol, ex} RISER EXIT PERMITTED OQLH IF TAUK MAIJUFAGTURCR HAS SUCH APPROVAL l { ~ cL_ ~ tF~IL 1 tt.~.t'~., p~5~ Uo~uw~~= ~D'~aI ~jo-IS,~v~ F.~tlelr•~S 5~~ SPEGIFIGATIOAJS l .X 5- ~(D DOSE TAUKS MAIJUFACTURER: IJQcICTlbct) VOIC..u TAMK SIZE: GALLOWS DOSE VOLUME t~_-= Q 7 9 ALARM MAUUFAGTURI`R: ""b" `~41I )TO`IU Doses Vol GALLONS Q~ 5:5 MODEL IJUMBER: I- -&s CAP CITIES: AIIJCNES OR GALLOA.S SWITCH TYPE: / /e~'- ~ n h 1C Cr INCHES OR ' 1 ~S/6GALLOUS PUMP MAMUFACTURER: y ouLIL / l r C= s.& INCHES OR ~ GALLOUS MODEL MUMBER: 32,71 F POS"i2 F` D= INCHES OR/ GALLOQS SWITCH TYPE: A/(e,'-h4o1.1 cQ(J ~~a~- MOTE: PUMP AUD ALARM ARE TO DE MIAIIMUM DISCHARGE RATE e OC2, GPM INSTALLED OM 5EPARATE CIRCUITS VERTICAL DIFFEKEIJCE BETWEEU PUMP OFF AUD DISTR10UTIOM PIPE.. X133 FEET + MlkJIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . FEET + 0 FEET OF FORCE MAIM X _2A:LZYgrt•FRICTIOAI FACTOR.. `a FEET TOT Dy1~JjAM.IC NEAR FEET ~OcJ0 L _ IUTERUAL DIMEW61 i OF TAIJ~: E'.,CiTH -;WIDTH ;LIQUID DEPTH 3l I,• SIGIJED: _ LICE.QJ F ,JUMBER,. DATE: i o I°n W) O N Lf) UJ ~ Ft Q H ' ~ O O 00 Z Z o ~o C/) ~A 10 L d ao oX a ~ 111 ° pl o O rr co Q Z C~ a. F N o r- d 0OQ -IU J QO Q ~J~ 00 ~a Of N L~ N W w co C~ V) tl W<W < Z JN Q U WO N 01 LLaW U Oro w Nrlm (n QaN N co JF- p n M 0 Z mW,I O U ~C5 L' O ~N NI- N WQ ' N= Q~ Jn W Q W a .JJa - FS a. z LLJ N~..OHO H OOw OZw U ZF--' N 6 ~Z=-3o= mY ovw a awQ w Z _:i N O N 0 F" 0 O-J J L'i p 90 a ~ Z Z J 2 0 ~ «Z4 W J N I/ / It / / W =II { i W II w Li / Q J J D I i U I cn U F WZ e ti8 O= «0~ «l9 09/17/2015 THU 15:20 FAX 715 831 4621 First Supply FIRST SUPPLY LLC 59$ Cameron St, Eau Claire, WI 54103 ITT GOULDS PUMPS Wastewater PERPORMANCE RATINGS COMPONENTS Total Head Gallons Per 'T itain at water) Minute No. Description EP04 005 1 impeller i 5 53 - 2 Base 10 9 10 46 62 3 Pump Casing e 15 36 55 4 Mechanical Sea[ 20 21 46 7 5 Ball Bearings a 25 0 33 6 0•Rin 91 30 - 11 7 ' Power Cord g 8 Oil Filled Motor 4 Motor Housing/ 3+r 9 StstarAssembl 1 10 Motor Cover = METERS FEET 10 4 30 - ~-SGPM - - - t2.9 PT 7 25 s Li 6 20 5 - 15 4' EPOS 3 10 2 EP04 • - - . 5 1 0 00 10 20 30 40 50 GPM 0 2 4 6 6 10 12 mVh CAPACITY 3 - Water tight cap 4" min. dia. Piping -M` aterial can''be ASTM D2665, D1785 or D3034 Slot Wi rain. 6" min. Infiltrative, surface Dater Closet Collar far (3/8" min. dia.) Observatlori pipes must: e be located such that there area minimum of two Installed in each dispersal cell at opposite ends from one another e 'tie located near the dispersal cell ends • be at least 6 Inches from the end wall and sidewall • be Installed of an elevation to view the horizontal or level inflltratlve surface within the dispersal cell Observation pipes may be located less than S Inches from end walls or side walls If specified In state approved manufacturers' installation instructions. v ~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer. `C S w ~ ❑ NA Permit # Septic ❑ Dose ❑ Holding Volume: A2570 (gal) DESIGN PARAMETERS Tank Manufacturer: (mot) prr,~~~_ ❑ NA Number of Bedrooms: NA Seti El ❑ c Dose [I Holding Volume: 7,570 al Number of Public Facility Units: 5^A Vertical Distance Tank Bottoms to Service Pad: ft Estimated (average) Flow : 4/00 (gal/day) Horizontal Distance Tank(s) to Service Pad: 6 D (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (Peak) Flow= (estimated x 1.5): Qd (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (0 (galldaylftZ) Effluent Filter Manufacturer: 67,1 61,- ❑ NA Standard (Domestic) Influent/Effluent +Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) s30 mg/L Pump Manufacturer: GQ4~ acS Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA ❑ NA Total Suspended Solids (TSS) 6150 mg/L Pump Model: --3 g High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (B.ODO >220 mg/L gNA R*9A (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODO s30 mg/L Soil Absorption System (TSS) <30 mg/L VNA Fecal Coliform (geometric mean) s10, ❑ In-Ground (gravity) l Ground (pressure) ❑ NA El At-Grade 'Mound Maximum Effluent Particle Size YB In dia• El NA ❑ Drip-Line ❑ Other: 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 ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ©-y`ear(s) Inspect dispersal cell(s) At least once every: ❑ rpnth(s) p ear(s) (Maximum 3 years) El NA Clean effluent filter At least once every: month(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: month(s) ❑ NA 1 .5 ❑ year(s) Flush laterals and pressure test 'At least once every:. ❑ m tit(s) ❑ NA 3 ear(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 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) 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 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 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 maybe installed as a __~st resort to replace the failed POWTS, j 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-POSSIBtE. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTA.NER. Name rKr Name w. c G. tl v. __in k Phone - `S° Phone 17 7 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ' Name To (n O v L 2` Phone Phone This document was drafted b the staffs of the Green Lake Marquette and Waus by hara Count 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 treatmentprocess '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 priorto 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 tone large dose causing an overload that may result in the backup or surface discharge of effluent. and damage to the system. To avoid thissituation 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 63.33, 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 dines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitablereplacement 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 maybe installed as a ~st 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 cz RESULT: -ESCAPE OWRESCUE FROM THE INTERIOR DF A-T-AMK MA-Y'NOT IC-PerSSI+StE: ADDITIONAL INSTRUCTIONS: I I POWTS INSTALLER POWTS MAINTAINER. Name ar t- Q -e-- Name v~ C3 c-. Phone L 0,5--~ . c w Phone ( y I SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name C C ( Phone S -73 - -Si _30 Phone /S 3~Ka 91 J This document was drafted by the staffs of the Green Lake, Marquette and Waushara County PATS 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 SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owned uyer Mailing Address 4 ( r 1 y~ Property Address (Verification required from Planning & Zoning Department for new construction.) City/State ,'E U)T Parcel Identification Number L LEGAL DESCRIPTION Property Location 15 % 1/ Sec. 35_, T ~ NR 7 W, Town of (C k~ ~ ~ Subdivision Lot # Certified Survey Map # Volume , Page # Warranty Deed # Volume Page # Spec house ❑ yes en Lot lines identifiable &-ye's ❑ 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 thi~form 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 wnty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed 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)