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HomeMy WebLinkAbout008-1059-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600349 GENERAL INFORMATION State Plan ID No Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 2939356 Permit Holder's Name: City Village Township Parcel Tax No: Scott Larson TOWN OF EAU GALLE 008-1059-90-000 CST BM Elev. Insp. BM Elev: BM Des tion: .57(p Section/Town/Range/Map No: 0,4 20.28.16.303 TANK INFORMATION ELEVATION D TA TYPE MANUFACTURER , CAPACITY STATION BS HI FS ELEV. , Septic Benchmark Dosing Alt. Br V ~OV rP• ~ Bldg. Sewer 95 F I d l alc. ~Z.S /4/.5 Holding St/Ht Inlet N-0 mil/ B ` TANK SETBACK INFORMATION SUHt Outlet \ TANK TO LjP WELL BLDG. ent toit intake ROAD Dt Inlet \ Septic ( P,5 Dt Bottom , 5 -d 7. 7 Dosing Header/Man. Aeration 67- i ~ Z I Dist. Pipe A0 16.4.1'- - Holding X03. S. Holding Bot. System ~ . ~ /Q~• PUMP/SIPHON IN =ORMATION Final Grade AS Manufacturer CV~ Demand St Cover F11 tCJ GPM ~p. Model Number -7 TDH Friction Loss System Head TDH Force main Lengi Dia. st Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS L4, (2~ SETBACK SYSTEM TO J P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type O Wtem: JZ6 / UNIT Model Number: ti DISTRIBUTION SYSTEM Ix Hole Spacing Ven [ Air In ke Header/Manifold O PI / Ix Hole SizY-1 Length /Dia 4 + Pipe(sLength) .504 Dia Sp acing Z7 _ ,Z5 I~ SOIL COVER x Pressure Systems only xx Mound Or At-Grade Systems Only a Depth Over 1-63 Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center / Bed/Trench Edges Topsoil es E] No J es ❑ No COMMENTS: (Include co a discrepennccies, persons pre nt, etc.) Ind-pect~n!#1: 7 Zy ✓r Inspection #2: Location: 2254 20TH AVE V.~~ CGJC. - 1.) Alt BM Description 2.) Bldg sewer length = /5 - amount of cover .7 ov- S y5~e.ti. ~~GY.c✓t-Oe~ Plan revision Required? ❑ Yes No C ' Cl Use other side for additional information. 7 T p ~f SBD-6710 (R.3/97) Date Insep is Sign re Cert. No. County , Industry Services Division <c ? 1400 E Washington Ave Sanitary Perm°it Number (to be filled in by Co.) P ^ P.O. Box 7162 r, iA ZdI Madison, WI 53707-7162 ry. el.mit Ann]'^ M7VgW0 State Transaction Number Sanita M In accordance with SPS 38321(2), Wis Adm Code, submiss Wy'Cp~ TwerrtTS'ental unit° is required prior to obtaining a sanitary permit. Note: Applice „ate-owned POWTS are submitted to Project Address (if ifferent than mailing address) the Department of Safety and Professional Servies. Personal Information you provide may be used for secondary ,+4, _ upurposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. ZJ -7A 1. Application Information -Please Print information Property Owner's Name Parcel 4 q.F+=~ 6 G c fit)' /C 5 `J YO C'0 Property Owner's Mailing Address Property Location - C C) f 1 ( Govt. Lot City, State Zip Code Phone Number O II n Section ctr~~l t i~\ L~-i t1CEt-1. ~1>~ ;7~ C t'L"? (circleone~l N Il. Type of Building (check all that apply) f,or # 3 . R E o W - Subdivision Name [y or 2 Family Dwelling- Number of Bedroo s r,77-) 11 IQCA Block ❑ Public/Commercial - Describe Use ❑ City of ❑ El State Owned -Describe Use CSM Number Village of „ own of III. Type of Permit: (Check,, oRenly one box on line A. Complete line B if applicable) A. 11 New S stem I~' lacement System y p ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Pen-nit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner 772 IV. Type of POWTS System/Component/Device: (Check all that a I) p ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil Q'IClound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Devic e (explain) V. Dis ersal/Treat t Area Information: Design Flow (gpd) Design Soil Application e(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed ( System Elevation V1. Tank Info Capacity in Total # of Man a urer Gallons Gallons Units dS o U New Tanks Existing Tanks j r • ; _ 4, ~a co E U v7) w C7 a. Septic or Holding Tank Dosing Chamber - CC: t VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Address (Street, City4 State, Zip Code) - VIII, County/Department Use Only pproved sapproved Permit Feeee Date l sueQd Issuing ent Signature ven Reason for Deal I IX. Condit t taso for Disapproval t ark, a fcn:-v e-jri, 3~ L : S 4lb~Net ':,i cell t +ust all be sit :fad! r t . lil -A, - _ n, / es per ,iwr.3Gement plan p! 'o iiden by plUnbe:. car+ ` 2. At ~e ,ktect„q !anus.rdamnrt:?aintK.M,c•: oUC k as per spF~ct>bl!t cxd3 / ,:M't2U1~lG2. Attach to complete plans for the system and submit to the County only on ape not le), than 8 112 x I I inches in size SBD-6398 (R0313) dc; .a f',; f l F GL 6 q 7, 7 F~4,-"L 4 F , Ctit1~C1<► ld zi p 1~~ uz/ tog y 6 3 N,~ . c qc", . cam' c) 4- ~otiYT+rFy DIVISION OF INDUSTRY SERVICES Tom 3824 CREEKSIDE LN HOLMEN WI 54636-9466 3 / I S a Contact Through Relay P S, K http://dsps.wi.gov/programs/industry-services w www.wisconsin.gov ~ossror;TtiSw Scott Walker, Governor Laura Gutierrez, Secretary May 15, 2017 CUST ID No. 220292 ATTN. POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 1101 CARMICHAEL RD SPRING VALLEY WI 54767-8709 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/15/2019 SITE: Identification Numbers Scott Larson Transaction ID No. 2939356 2254 20TH Ave Site ID No. 837659 Town of Eau Galle Please refer to both identification numbers, St Croix County above, in all correspondence with the agency. SWl/4, SE1/4, S20, T28N, R16W FOR: Description: Three Bedroom Mound System \ Sloping site Object Type: POWTS Component Manual Regulated Object ID No.: 1704167 Maintenance required; Replacement system; 450 GPD Flow rate; 18 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 requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, CONE) stats. APP DEPT OF S The following conditions shall be met during construction or installation and prior to occupancy or use: POFESSION Reminders "`pa < 'ION OF IN0 • 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. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made i W,- the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. v • 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. • All POWTS component piping material shall be SPS 384, Wis. Adm. Code compliant. • The existing POWTS shall be properly abandoned per SPS 383.33, Wis. Adm. Code. • 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. BENNIE W HELGESON Page 2 5/15/2017 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. 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 r M Swim POWTS Plan Reviewer , Division of Industry Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swirn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm BENNM W HELGESON Page 2 5/15/2017 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. In granting this approval the Division of Industry Services reserves the right to require changes or additions should aIL i.:..,. +t o . necessary _ C^u is r o n 1-1 13 +t,;.... con A, ,ons arlse M- - L11L.~lll 1V1 VV compliance. AJ per JULV JLULJ 1 V 1.111VLlllll~ in LLLLJ reVleW 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 M Swim POWTS Plan Reviewer ,Division of IndustryServices (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 INDEX SHEET PROPERTY OWNER: J e C~' c r ~'i PROJECT NAME: r, _s C ,4 PROJECT LOCATION: J J J MUNICIPALITY: i cn of e -f L - e^ C 1 COUNTY: S T. Cfe C'l k DESIGN: PRESSUREDISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N.01/01) MOUND COMPONENT MANUAL VERSIORI'~lalC'"OD- 10691-P (N.01101) JVED CONTENTS: ~FETYgND Page 1: Plot Plan STR SERVICES SERVICES Page 2: Cross Section and Plan View of Mo Page 3: Distribution Pipe Layout 4.° 'C Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: " 1-0 I C("Cj~_(-C j A, Tank Specifications Page 6: Pump Specifications Page 7: Observation Pipe Detail Page 8: POWTS Owner's Manual & Management Plan- Pg 1 Page 9: POWTS Owner's Manual & Management Plan- Pg 2 Name: Bennie Helgeson Signed;.., Address: N7649 Hwy 128 Spring Valley, WI 54767 Credential Number: 220292 ' " . / Vic-, Vk A a - ~Ixi z~ Ac" C'vt cr l c f ~C c ye 7 c _ _~-L-.Gz _ffE.:.. G" K 1 t,\, ~ LPL r I 1~ I -tc ts~ ~ :rC~~ Fh'_~ \ ~ 1 I I PC] ki r~ y ~ \ ~ yr { mfr t~r • 5 E ck .i• ,c'c _ / tLC Xc~tti+~ ~ ~ _ \ t 9 (firJ I j ' • j 1 f I 1 yy y Cam/ ~ ~ ti. a~ Cs'Y, l Synthetic Covering ASTM C 33 Distribution Pipe Medium Sand t9lev odd c, G T~p ~on 3 L~S81~L4kV t-`iK_..: Oc-9(. j °/d, Slope. JJ CCLLOf ZM- 2 Force Main Plowed Aggregate From Pump Layer D Ft. Cross Section Of A Mound E Ft. F ,7t`? Ft. G 5 Ft. A Ft. H Ft. Signed: B ~.SFt. License Number: K /c6 7 Ft. Date: L 7 5 Ft. ~JFt. 7 S-C,, 4 T d ~ f Ft . W T Ft. Observation Pipe B K - '~-Distribution 0 f 2 2 Pipe Aggregate Observation Pipe ~cz-s-1- ~re, C` -3 ~ Plan View Of Mound Perforated Pipe Detail Cleanout Access Threaded / End VI- Cleanout Perlorul(o PVC Pip( End Manifold Holes Located on Bottom Are Equally Spaced R i Force Main From Pump x S First Hole Next to Manifold P Cleanouts Distribution Pipe Layout P R rr S X7 !r Y ~7~ Hole Diameter_ Inch Lateral " Inch (es) Manifold Inches Signed: Force Main " -1 Inches License Number: Invert Elevation j C.>..3. 7' Date: Holes Per Lateral Number of Laterals 5` Total Holes '7 Page Of SEPTIC TANK S PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" PKVENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE - WITH CONDUIT MANHOLE COVER W1 PADLOCK E G6O`u~G~ - WARNING LABEL MIN. Zy" 18" IN. 18 MIN. INLET - - 9911 WATER TIGHT SEALS GAS- i Or 7-- TIGHT, APPROVED F IL - TE R ---i- A SEAL APPROVED JOINTS WITH. PIPE 3'~5. ALM APPROVED PIRA ONTO SOLID ' ON S34 OLID TSOIL SOIL PUMP OFF ELEV. L, FT. -C OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS -dS SEPTIC / DOSE _~ata l eTo l s_ IA Lahe re TANK MANUFACTURER: CSc `O 3 7 x S' S'j , 8 (~C3' TANK SIZES: SEPTIC 000 GAL. DOSE VOLUME INCLUDING _ DOSE G(pc) GAL. ) j.7 GvI, --;~FLOWBACK: 7S S"5 GAL. ALARM MANUFACTURER: 5 T L. R ovv\ buS CAPA ITIES: A = /9 INCHES = 3C)/. 6 kGAL. MODEL NUMBER: ris %O( SWITCH TYPE: eL hcirvt~cc~~ r=~c~ca~ B = 2 INCHES = .33, ~ GAL. PUMP MANUFACTURER: C = INCHES = 8 GAL. MODEL NUMBER : (U S SWITCH TYPE: D = /0-V INCHES = ~ijL~ ~7 GAL. REQUIRED DISCHARGE RATE 3S C."T GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE X3.7 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . • FEET + /yam FEET FORCEMAIN X FT/100 FT. FRICTION FACTOR . / FEET TOTAL DYNAMIC HEAD = 33 FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID DEPTH -3 6 16,76 6= P SIGNED: LICENSE NUMBER: DATE: 1/88 sr J7- C~ I LO Z) c U * J\ c Z N m U c af _j M~~''AA wQ ( NP a W VI - J ~OV ~(n0 0 ~ O x 00 I U. Q O I= of L d !n z U C tic Q O' p op I a ¢ 2 lr) \ U c U m~ n~ o O \IZ O i OJ J= LR] O O~?w O O U m O1 -J ww 00 O l~~1CUJV) 5~0 O J F- Q L~ 0 (n 00 CD e J Q N(D 00 r- F0 z N. O F. J Q i- V) F- C-4 Q r O 10 ns L'ig'r w::r- U w -J z 17 p O Y n LO JLO~ W Z J D Of H :D N~ ~ O Z m OLwIO30~ OOw Opw ¢ w ZpJ~>ZOZ~~00_ Om(n pU)- Q O Q OOQW wOwo < <~o U O F, 3 m U:= J co J Z LLJ LL) w a ~ O p Z. Z C! Vl a z I Iv is I I I I . I II W W 7 II 5 u8t~ .I - I. > I > I , . I \ I i p W ' ~ U ~ U I I ~ I I I i U I I Z i .I I . I I I Q-- -------FJ- Lij " cc~~ O ccs~ ~~95 09/17/2015 THU 15:20 FAX 715 831 4621 Firet 8uppiy IQ003/004 FIRST SUPPLY LLC 595 Cameron St, Eau Claire, Wl 54703 ITT GOULDS PUMPS Wastewater PERPORMANCE RATINGS COMPONENTS Total Head Gallons Per Item DesCdption (ft. of water) Minute No. EP04 EPOS 1 Impeller 5 53 - 2 Base 6 10 10 46 62 3 Pump Casing a 15 36 55 4 Mechanical Seal i 20 21 46 5 Ball Bearings 25 0 33 6 6 0-Rings B 30 - 11 7 Power Cord g 8 Oil Filled Motor 4 N Motor Housing/ 3 9 StatorAssembly 1 10 Motor cover 2 METERS FEET 10- 9 30 " " - --S GPM $ 2.5 FT 25 7 s S 10 - - _ - _ - P05 3 J.-..... EP04 0 00 10 20 30 40 50 GPM L i L L 0 2 4 6 S 10 12 ml/h CAPACITY 3 L~11'ater tight cap 4" On... dia. Piping material can: be ASTM D2665, D1785 or D3034 Slot ruin. min. ' Infiltrative surface Mater Closet Collar Bar(318" min. dia,) Observation plpes must: • be located such that there are a minimum of two Installed in each dispersal cell at opposite ends from one another • be located near the dispersal cell ends • be at least 6 inches from the end wall and sidewall • be Installed at an elevation to view the horizontal or level Infiltrative surface within the dispersal call Observation pipes may be located less than S Inches from end walls or side walls if specified in state-approved manufacturers' installation Instructfons. , POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner r' Tank Manufacturer: ❑ NA Permit # brSeptic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: t< J _ ❑ NA Number of Bedrooms: 0 NA ❑ Septic Nrpose ❑ Holding Volume: (c3 ~ o (gal) Number of Public Facility Units: WNA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : • b 0 (gal/day) Horizontal Distance Tank(s) to Service Pad: /00 (ft) Design (peak) Flow = (estimated x 1.5): C> (gal/day) Specific servicing mechanics must be provided If vertical is >15 feet or If horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gal/day/fe) Effluent Filter Manufacturer: /U0/y ~m Standard (Domestic) Influent/Effluent j ' o.nthly average Effluent Filter Model: [:1 NA ~2S Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA tea` ❑ NA Total $uspended SoIids.(TSS) 615.0 mg/L Pump Model, 5/005-- High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L ' Manufacturer: (BOD5) >220 mg/L ITNA dt1 ILIA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ PeatFIIteF Pretreated Effluent Monthly average ❑ Disinfection El Wetland ❑ Sand/Gravel Filter ❑ Other: (BODE) s30 mg/L Soil Absorption System (TSS) <_30 mg/L 1a'WA Fecal Coliform (geometric mean) s10, ❑ In-Ground (gravity) . ❑ In-Ground (pressure) ❑ NA Maximum Effluent Particle Size '/8 in dia. El NA El At-Grade Mound Other: ❑ Drip-Line ❑ Other. ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) El When 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 I~"year(s) ( years) ❑ NA Inspect dispersal cell(s) At least once every: J ❑ month(s) (Maximum 3 years) ❑ NA year(s), Clean effluent filter At least once every: %3 ❑ month(g) 0 NA Inspect pump, pump controls & alarm At least once every: /3 p yea th(s) [_-1 NA Flush laterals and pressure test 'At least once every' ~~❑~r onth(s) ❑ NA -3 bd'year(s) Other: ❑ month(s) At least once every: El year(s) ❑'NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on. the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code: All other. services, including but not limited. to the servicing of effluent filters, mechanical or-pressurized-components, :pretreatment units, and any servicing at intervals of :512 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) { START UP AND OPERATION Page 51 Of For new construction, prior to use of the POWTS check' reatment 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 be4scharged to the soil absorption system In one large dose causing an overload that may result in the backup or surface discharge of effluent. and damage ;to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to -restoring powerto•the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the 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 tIram (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 dodo; • 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 maybe installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area Is available a holding tank maybe installed as a last resort to replace the failed POWTS• i 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..FROMTHS-"1NTERi.OR F *TAW'Mxl+rr 140T, Eig@g gt - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS'MAINTAINER. , Name E"v.v. r t~ ~S n~ ENe Pho ne / 5 ~ e 7 SEPTAGE SERVICING OPERATOR PUMPER LOCALREGULATORY AUTHORITY Name ©~1 v~ c ...~L C -73 _ S- iL~c time' 'r'£,t rC~ Phone `7l S" hone , / s 3fr 4 - e16 ?0 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. I START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting chemicals or sediment that may impede the treatment process and/or damage- the soil absorption. system. pIf high concentrations tare 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 be4scharged to the soil absorption system in.one tare dose causing overload that may result in the backup or surface discharge of 9 he effletent. and dam contents of the pump tank removed by a Septage Servicing Operator (pumper) ri age to o the system: To ev pump is contact have the or POWTS Maintainer to assist in manually operating the pump contros until normal effluentleve sn are restored within the pump tank. ben a Plum 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: acidsl 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, pesti cides, 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 svstemnrnnc h r, and safely abandoned 'in compliance with s. Comm g3_3s Wisconsin, Ad~,i 115trauve.Godei `rv"' • 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. O 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 'O The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. l 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 TALK UNDER ANY- CIRCUMSTANCE. DEATH MAY RIESULT CARE:OR RESCUE.:FRO-M TfiE=#NTEM.O.R:Z7F:: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS'MAINTAINER . Name E tr. v. t_ / e ~'c~~ f°1 ; ` Phone a SCG. Nam~`0 TL 7 / S ~7, Phone 7 f SEPTAGE SERVICING OPERATOR PUMPER 'LOCAL :REGULATORY AUTHORITY Name ©~lv~ s~ ENa e Phone e r' 3fr' - a~ ss' Q 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 SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer; Mailing Address Property Address r ti Aue (Verification required from Planning & Zoning a artment for new construction.) City/State .c~ h t Parcel Identification Number LEGAL DESCRIPTION Property LocationS+-u' % , _54- 1/ , Sea ,;t C. , T r4 N R W, Town of a (t 11 Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # Volume Page # Spec house 0 yes 0 no Lot lines identifiable 0 yes 0 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, h:,-rein, as set by the 1Denartrnert ofCorrun,eme and Depai-a ienr o" aturai 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 's 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 w anty deed recorded in Register of Deeds Office. Num,Ur of bed toms J 9 cn . "yam .'3 SIGNAT RE 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) i Wisconsin #Wr2V ® SOIL EVALUATION REPORT Page ( of Division of i in accordance with Comm 85, Wis. Adm. Code Attach compe e County ckClk C4 4er not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vMrnd horizontal reference point (BM), direction and Parcel I.D. percent slogT, ~®b arrow, and location and distance to nearest road. 1 ~ ~t11MUN Please print all informs Reviewed gate Personal Information you provide may be used for secondary r PropertyOwner x f 7'! cr L~ ~-vl'e3 nvt C r e $rrn' Cif"'S~'c Govt. Lot SW 1/4,1 L 1/4 S~J Tci N R E W r'. s c_ - 7` e r cxii 5 [1 Property Owners Mailing Address Lot # Block # Subd. Name or CS . J ~ ~±r '07t, i Ci State Zip Code Phone Number ❑ City ❑ Village [Blo-wri Nearest Road % 1► f %f ~ 5-41& C", ( 71s) r y:~'~ C=~ I i aa5 `1 C, F r j f ❑ Ze Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate Sw GP.R ac ement ❑ Public or commercial - Describe: Parent material L U s LtUe ' 7~- Flood Plain elevation if applicable General comments' i <f int.{ c 2vtc. c ~`7 C _ cv and recommendations: Car- C,-- ( 17 ❑ Goring t Vv 5 .4e Boring # Ground surface elev. Dep h to limiting factor o ` in. Soil Application `Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 y . r (C; 5C L- V(L 'S b ❑ Boring Boring # • Pit Ground surface elev./Gr )<< < ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? 9 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 "E02 4-- 1 10 CL I v y c, `ltZ -3,hl 7191 Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS : 30 mg/L CST Name (Plea, Print) Signatu ra, --mil CST Nu BSc Address Date Evaluation Conducted Telephone Number y /},,r •-~~7 _J/ `~'1'C. / _c:, 5,~~9 c; l l `!?q Gam,. y_ ~7~s~ ~7- 3.; /,7 `V / / c Property Owner i bv, Parcel ID SUS y -YO - cx' Page c-~ of -S Boring # ~❑~~Boring l~ Pit Ground surface elev.ZLaLL ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description 7 0- Consistence Boundary Roots GPD/fP In. Munsell Qu. Sz. Cont. Color Gr..Sz. Sh. 'Eff#1 10#2 / c C" S 7 5 C J C S~ f rJ ~ ~Y ~ Boring # U Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. I Horizon Depth Dominant Soil Application Rate Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 I~ Boring D Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Soil Application Rate: Consistence Boundary Roots GP N in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efwl •Eff#2 I f III_ I- i Effluent #1 = BOD6 > 30 < 220 mg/L and TSS >30 < 150 mg/L E=ffluent #2 = BOp6. 130 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. S D n-8330 (R.07/00) ~r Property Owner Dnv~- "1 Boring # 11 Boring Parcel ID # page (7 ) of 9 Pit Ground surface elev. ft. Depth to limiting factor In. Horizon Depth Dominant Color Redox Description Texture Structure Consistence •Boundary~ Roots Soil NAn in. Munsell Qu. Sz. Cont. Color Gr.:Sz. Sh. "EfV b; \ r-k 1 C Boring # Boring ~J ❑ Pit Ground surface elev. ft. Depth to limiting factor in, Soil Application Rate I Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i I i Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Cpnsistertce Boundary Roots Soil piiiD~ n Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. 8h. ~ 'Eff#1 'Eff#2 f i i'Effluent#1 BODa > 30 < 220 mg/Land TSS >30 < 150 mg/L Effluent #2 = B4D5, < 30.mg/L and TSS < 30 mg/L The Department ofGommerce is an equal opportunity service provider and employer, need ma If3~ou need assistance fo:access'' material in an alternate format, services :or please contact the department at 608-266- 3151 or TTY 608-264_8777; .SI3D-9730(R.07/00) De, czfI 5 yc~ 4C~ r--S -S7- CA061 S ~s~►7~~ Sc~tid~sr raS, til'tj 3 LO { UO ©f c~~ 5~c4sv1~ a, r I I -rod 3 JR e ~\w r. I - ~r