HomeMy WebLinkAbout018-2011-76-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605035
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] 3108656
Permit Holder's Name: City Village Township Parcel Tax No:
Kernon Bast TOWN OF HAMMOND 018-2011-76-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
,7 6-2- GS T 30.29.17.1091
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
s rw ~pDd r
Bldg. Sewer
Holding St/Ht Inlet 1914
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic 75 z 4 Dt Bottom z 3
Dosing 75 1 Zy 7 33 1 Header/Man. 3• / .
Aeration Dist. Pipe
Holding Bot. System -7
PUMP/SIPHON INFORMATION Final Grade z • z
Manufacturer emand St Cover ( 17. Ada 3
GPM
Model Number 3j1
zqoivs-3
TDH Lift Friction-Loss System H TDH „Ft
j,v ,
Force main Length'X Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width I Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Z G,`J~ G (c ( 1. JqV1KT SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type ( $ysterry
21 / UNIT Model Number:
1 AM
DISTRIBUTION SYSTEM E'
Header/Manifold Distribution ~t x Hole Size x Hole Spacingl Ven An pe
Length_ Dia L Peipe(s)
ngth Tg Dia ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over (x Depth of xx Seeded/Sodded x Mulched
Bed/Trench Center 7 , S Bed/Trench Edges,----___ Topsoil ' No ~ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: -71-t / Insp tion #2:
t._1
Location: 1531 78TH AVE At~
1
1.) Alt BM Description = Il
2.) Bldg sewer length = Z,4 Piv" yr
- amount of cover = i
Plan revision Required? ] Yes to Zy '
Use other side for additional information." _
SBD-6710 (R.3/97) Date Ins tor's Si ure Cert. No.
fiber PUMPS® ~
Pump Specifications
290 Series 3/4 hp
Submersible Effluent Pump
LITERS PER MINUTE
0 50 100 150 200 250 300
50
4 I I
I 14
45
~ I
i
40
12
I
35
10
~ 30 ~
LL W
Z ~
W
O 8
Q Z
= 25 ( o
J I ~ W
O Q
20 6 O
I I ~
i
I j
15
4
i
10~ f
2
5
0 0
0 10 20 3 40 50 60 70 80 90
GALLONS PER MINUTE
290 P1 R010/1212015 ®Copynghl2015 Liberty Pumps Inc. All rights reserved. Specifications subject to changewithout notice-
. PA J-
County
zs1 l l i D Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
$ Ma W 37 71
'JUN052018 ~•~rjC►3~
State Transaction Number
rmit Applica ion ;
X4_ 2,
accordance ~3rs"A3 bode, submission of this form 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 ( 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 Priv Law, s. 15.04{1) m), Stats.
L Application Information - Please Print All Information ~-5
Property Owner's Name Parcel #
-Uv
-n r
Property Owner's Mailing Address Property Location
~L. rj Govt Lot
City, Slate Zip Code Phone Number Section
C- ? T/ L N; E W
11. Type of Building (check all that apply) Lot # ` 4
Subdivision Name
I or 2 Family Dwelling - Number of Bedrooms ( ?
bk ab Bloc -
❑ PabliclCommereial - Describe Use a ❑ City of
CSM Number V Mage of
Q State Owned -~Deseribe Use own of 1
Z k 96 - ('a.
III. Type Permit: (Check only one box on line A. Complete line B if applicable) a
A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only D Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued /
B. ❑ Permit Renewal Permit Revision Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner
IV. Type of POWTS System/Component/Device: SCheck ll that apply) Q~ C v
?von-Pressurized In-Ground ❑ Pressurized In-Ground' At-Grade ❑ Mound > 24 iii of suitable soil ❑ Motmd < 24 in. of suitable soil
-
❑ Holding Tank ❑ Other Dispersal Component (expl etreatment Device (explain)
ain V. Dis rsaUTreat nt Area Information:
igu Flow (gpd) Design Soil Application Ratc(~, f) Dis~al Area Required (sf) Direa PSystem Elevation
VL Tank Info Capacity in Total # of u
allons Units ? v
Gallons G
I
New Tanks Existing Tanks rl~" o a m
U vi v
Septic or Holding Tank
Dosing Chamber ti' "7 f
VII. Responsibility Statement the undersigned, assn ` ousibility for installation of the POWTS shown on the attached plans.
Pl 's Name (Print) Plumb ey e MP/MPRS Number Business one MN1b,
1
Plumber's Address (Street, City, State, Zip )
VIEL ounty/De artment Use Only
rove Permit Fee Date Issued issuing ent Signature ~I
Appd -•-t.__,_ S / s I
rven Reason for Denial
DL Condi sons. for Disapproval I n~~ M- rLQ
1. , twk ietlAtlynt,llts 60 3) 8~: a~ e l
C 44W."N C'm 1 W aA Ill l4. W ; n.~o (tea
,K ptr gW%w1 • plan pto 4ded by plumber.
2 A# elft st ftqWWWW Inuat be M&t t .kf 4
as per owkwa c 1;c~atial>MSS'. 1{•~r'~',',~ n J
Attach to compiete plans for the system and submit the County only on paper not I o 8 112 11 inches
SBD-6398 (R. 11/11)
:1/
44f
f
System PLOT PLAN
PROJECT Kernon Bast ADDRESS 948 LaBarge Road Hudson Wi 54016 I
n
NE 1/4 NW 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
i
SYSTEM ELEVATION 107.0' DATE 5/10/18 BEDROOM 3
CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
E
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of chambers none
BENCHMARK V.R.P. Top of 1" pvc ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE (DWELL *H.R.P, same as benchmark
78th Ave
Scale = 1/4" = 10'
1.5 acre lot
Well is to meet all WDNR setbacks
G
Area 15' below system is to remain undisturbed
Pro 3
Bedroom
House
106,
i
107'
108' Property Line
M Huffcutt Combo Tank
Grading is to be done to
divert run-off away from B-3
system
0 B-2
O
4% Slope
i
B.M.*
G
System to be installed evenly k
along the 107' contour
B-1 ~'c0
Property Line
I
i
Property Line
0_4-g c
E
~~F.ennreu t DIVISION OF INDUSTRY SERVICES
T
2331 SAN LUIS PL STE 150
o 9 GREEN BAY WI 54304-5211
h ~ cm~•
3 S Contact Through Relay
P S http://dsps.wi.gov/programs/industry-services
S" www.wisconsin.gov
Y~G
e
° ss10 Scott Walker, Governor
Laura Guti6rrez, Secretary
June 05, 2018
CUST ID No. 226900 ATTN: POWTS Inspector
ZONING OFFICE
SHAUN R BIRD ST CROIX COUNTY SPIA
1432 120TH ST 1101 CARMICHAEL RD
cZ
NEW RICHMOND WI 54017-6409 HUDSON WI 54016-7708
DU
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 06/05/2020 Identification Numbers _
Transaction ID No. 3108656
SITE: Site ID No. 849704
Please refer to both identification numbers,
Kernon Bast above, in all correspondence with the agency.
1531 78"1'H Ave
Town of Hammond
St Croix County
NEl/4, NWI/4, S30, T29N, RI 7W
FOR:
Description: At-Grade (3 Bedrooms - New Construclion)
Object Type: POWTS Component Manual Regulated Object ID No.: 1764088
Maintenance required; 450 GPD Flow rate; 36 in Soil minimum depth to limiting factor from original grade;
System(s): At-grade Component Manual, Version 2.0, SBD-10854-P (N.03/07, R. 1/12), Pressure Distribution
Component Manual - Ver. 2.0, SBD-10706-P (N.01/O1, 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,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• Preserve dispersal area prior and during construction to avoid disturbance, compaction and use of the site.
• With new construction; it is recommended not to activate the pump in the dose tank until the tanks are pumped
prior to homeowner occupancy.
• Wastewater generated from contractors cleaning of equipment and tools and/or left over construction
products shall not be discharged into the drains discharging to the private onsite wastewater treatment system
(POWTS). Waste generated shall be properly disposed of on-site or off site.
• Any tall grasses, leaves and shrubs shall be cut short and removed prior to tilling the surface for installation to
prevent matting under the dispersal area. All loose organic material to be removed from the POWTS Dispersal
area.
• Prior to construction of the dispersal area check the moisture content of the soil to a depth of 8 inches
Smearing and compacting of wet soil will result in reducing the infiltration capacity of the soil Proper soil
moisture content can be determined by rolling a soil sample between the hands If it rolls into a 1/4- inch wire
the site is too wet to prepare If it crumbles site preparation can proceed If the site is too wet to prepare do not
proceed until it dries.
SHAUN R BIRD Page 2 6/5/2018
• Divert surface water fi•om POWTS Area.
• All piping shall conform to SPS Table 384.30-3 and SPS Table 384.30-5
• Insulate building sewer beyond 30 feet per SPS 382.30 (11)(c)
• Tank Installation to follow all manufacture's recommendations.
• Pump Floats to beset and verified per approved plan Any changes "tay result in pump resiziug to meet
TDH and GPM Specifications.
• Verify property line(s) prior to installation.
• Well setbacks to meet chs. NR 811 & 812.
• Areas that are occupied with rock fragments. tree roots. stumps and boulders reduce the amount of soil
available for proper treatment. If no other site is available, trees in the basal area of the at-grade must be cut off
at ground level. A larger fill area is necessary when any of the above conditions are encountered, to provide
sufficient infiltrative area.
• SPS 383.54(l)(e) The management plan for a POWTS shall specifically address the servicing mechanics of an
aerobic or anaerobic treatment tank or a holding tank where either of the following conditions exist:
1. The bottom of the tank is located more than 15 feet below the elevation where the servicing pad is located
2. The bottom of the tank is located more than 150 feet horizontally from where the servicing pad is located
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 SPS 383.54(1).
• In the event this soil absorption system or any of its component parts malfunctions so as to create a healtl
hazard, the property owner must follow the contingency plan as described in the approved plans.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction/installation/operation.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 250.00
This Amount Will Be Invoiced.
When You Receive That Invoice,
Please Include a Copy With Your
Tim Vander Leest Payment Submittal.
Private Sewage Plan Reviewer, Division of Industry Services WiSMART code: 7633
(920)492-2214, Mon- Fri, 6:00 a.m. - 3:30 p.m.
tim.vanclerleest(i ~vi."Ov
cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Mon-fri, 8:00 A.M. - 4:30 P.M.
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 5/10/18
Owner:Kernon Bast
Location:NE 1/4 NW1/4 S30 T29 N,1917 W 1531 78th Ave Hammond
Manuals Used: At-Grade Component Manual version 2.0 SBD 10854 (N. 03/07)
Pressure Distribution Manual version 2.0 SBD 10706-P(N. 01/01 R. 10/12)
Page#
1. Cover Page
2. At-Grade Plot Plan
3. At-Grade Cross Section
4. Pipe Cross Section/Pipe Layout
5. Pump Chamber Cross Section
6. Pump Curve
7-8. Maintance and Contigency p an
9. Filter Specificati S
Attachments: Soil est
Shaun Bird \
j
Signature
License number 26900
11`fiSi i !1~i!'
Page 1 of 9
I
System PLOT PLAN
PROJECT Kernon Bast ADDRESS 948 LaBarge Road Hudson Wi 54016
NB 1/4 NW 1/4S 30 /T 29 N/R 17 W TOWN Hammond COUNTY ST. CROIX
SYSTEM ELEVATION 107.0' 5/10/18 3
DATE BEDROOM
CONVENTIONAL AT-GRADE XXX CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 900 # of chambers none
BENCHMARK V.R.P. Top of 1" pvc ASSUME ELEVATION 100' Filter Lifetime Filter
❑ BOREHOLE O WELL *H.R.P. same as benchmark
78th Ave
Scale = 1/4" = 10'
1.5 acre lot
Well is to meet all WDNR setbacks
I
Area 15' below system is to remain undisturbed
Pro 3_
Bedroom
House
106'
a
107'
108, Property Line
Huffcutt Combo Tank
I
Grading is to be done to
divert run-off away from B-3
system
❑ B-2
13
4% Slope
B.M.'
System to be installed evenly
along the 107' contour
v ❑
B-1
Property Line
Property Line
o4-g
At-grade System Sloping Site Cross Section and Plan View _
E Dimension Feet
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t 7-1 = Plowed f~ = Clean aggregate O = 4 in. sch. 40 pvc
_ basal area 'rti ; • 1/a to 2 '/a in. dia. observation pipe
Lateral with 2" Topsoil Cap
aggregate over pipe
Observation Pipe
Geotextile y--- Cr ~f With Cap
Fabric
L L' J'J~ Ft Lateral Invert
s ~ 4 ti L{L{L{L{ .
f r r r•r•r•{• J•J%r%r r J JJ J ' < Topsoil Cap
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C
Slope Direction
GENERAL. INSTALLATION: The at-grade area is staked out along the desigri contour. Existing
vegetation is mowed and raked off the site. The basal area (L x W) is staked out and plowed with a
moldboard or chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to
form a `A inch soil wire when a sample is rolled between the ;palms of the hands.. The A x B area is
covered by clean aggregate deposited overhead by a backhoe.. Special care must be used when
placing the aggregate to minimize compaction of the plowed surface. After the topsoil cap is placed,
the entire at-grade is seeded and mulched to promote vegetative gro*h, limit erosion and protect
from freezing. The observation pipes are perforated in the lower 6 inches.and secured in place.
03/051gj Page - of 1
s
Pressure Lateral Layout
One Lateral - End Manifold
.4 Threaded
Cleanout
Lateral Turn-up Plug
Force Main
i 4
X
L Long
Sweep
90
Bend
F
Pressure System Construction
S o ~1
Distribution Network S ecifications
Lateral Diameter In. Laterals are constructed of Schedule 40 PVC
Orifice Diameter 3 n. pipe. Orifices are drilled perpendicular to
X Orifice Spacing) In. the pipe with a sharp drill bit and face down.
L Lateral Length) Ft. Lateral turn-ups terminate with a threaded
Force Main Diameter in. ceanout plug and are enclosed in a 6-8 inch
gth r Ft, diameter lawn sprinkler valve box accessible
Force Main Len
from finished grade.
Grade •••••••::p' •
6-8 Inch Lawn
Sprinkler Valve = 1
Box
}a 5
E
QQ
n
03/05lgj Page of
i
Septic-Dose Wank Cross Section And Pump Performance Specifications
Tank Manufacturer Pump Manufacturer L
Tank Model Number Pump Mode1 Number .80 Total Tank Capacity t Alarm Manufacturer
i Alarm Model Number I I— L11101
Max. Bury Depth ~ ~
Switch Type
Filter Manufacturer Tow Dynamic Head (TDH) - Feet E
turer ~ R
Filter Model Number r~ Elevation Head p
. Distal Pressure ~
Network Loss
erformance Required Force Main Loss v
Minimum pump '
j GPIv @ Ft TDH Total 3
Outlet Manhole Mim V Above Grade With 0
Manhole Min. 4" Above Grade
Looking Deuice. 11de# Manhole Seenlrel MOllnted W-16 Locking Device t`[
< 6" Below Grade sealed Watertight y J
Wealher--proof 1
runWon Box
- Finished Grade - -
Vent min. 12" Disconnect
Above Grade Means
With Vent Cap
•Y•!., . i . i • i f~f i i Y • t . • , , > . •Yt/ Y ! t ! Y Y Y . t • r Y ,tY
putlet Filter
,f..-------- . t -
inlet fnlet Baffle
- t ~ 1, i
Switch Settings and Reserve Capacity %a"
<
Weep 3
Tank. Volume = GPI
3
Dimension, Inches Volume Cal. B Hole 3
4116
(reserve) A; 5
< (alarm) B' 2 OffElevstioa C
- Ft
9 7,
of _7
:aY Bottom
D' 3 D Elevation
♦ Total ?
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• i•t,< t,s ti • •,•T a•••s t<,•,'}.,s,• .~tY,,1•<' <~t l•<!ti Yti ,tl Yti •tl Y•Iaf 1tit~ f<!tT<!•f l~laT T•T<f lttaY<~ i •Y•,<,<Y, s !a,<,•t•, ik . ,•i
•,+i<<•: •la<<t ttl <s •t <t at•<i<<<, <It•<It .<t<tltt<a,<at<tt t, 1, t<1 ••t/1 t~1•1•<t tit It<f ,tt
J
GENERAL INSTAU ATION: The septio/dow tank is bedded and back filled w accordance with the :
manufacturer's product approval gno fications. Mwdmum depth of bury as specified by the manufacturer may not
be exceeded without prior 4pprovaL Manhole covers wWosed to grade have an effective looking device (padlock)
installed. Piping at the inlet and -outlet is of approved material, conmeated to the tank with watertight fittings, and
laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank .
excavation and the sleeve is sealed watertight. Electrical service plies with NEC 300 and Comm 16.28.
02/05 U Page of
i
i
i
i
280=SERIES
1/2 hp Submersible Effluent(Sump Pumps
The uberty280.Series provides a cost effective -rid- Performance Curve: 280-Series
raW PUMP for on-site waste water systems, liquid 40 12
waste transfer and oonnmercial heavy-duty sump pump
applications that require higher: head or more flow. 35
11
Designed around Ubetty's unique -uni.Body- casting, 30 9
the 280-Serks will provide yam of reliable perfon-nance.
8
All Models Feal urfe: 6 [ills
• V'Oltex d* to % impeller POnT"ng passage of solids _AQ
tip m 1 5
3
• 416 stainless steel rotor shaft = 10
• Permanently lubricated upper and lower ball hearing 5 17 2
• Epoxy powder coat finish p 0
• All fasteners - compslon-resistant winless steel 0 5 10 15 20 25 35 40 45 50 55 80 65 70
• 1 %N Discharge U.S. Gallons Per Minute
• Stainless steel bottom screen - easily removable
• Maximum fluid temperature: 0 3 38 8 78 1 14 156 182 228 270 i
140° F. Liters Per Minute
280-Series Cord Lengths
s
Model 10, 25~ _ 35, ,3 501- Dimensionei Data:
280 Standard q*Onal Optional O Weight: 29 lbs.
I
Heighb 13°
281
Shmdard OPftW Optional Optional Major Width: 10° (model 287)
283 Standard
287 standard Opyorad w OVA Minimum Sump Diameters:
10' cord length standard on rrtodels. For optional Model 281, 283...14°
WW -Z 2. •3 Or -W sUR( to model member. Model 287 VMF...10-
Example: for nodal 280 with 35, cord, order 280-3
Factory switch Mode! 281,28:3 Mtmde1287
Motors VMF
pecif'/Cations Tum on level 13" 9.5"
% hp 60 Hz 3450 RPM Turn off level 7° 4.0"
Oil filled, thermally protected
(PSC) Permanent Split Capacitor The Modet 2M features a fully adjustable wide-angle float. MerenOW
8.0 amps (115NO adlusbnw is can be made easily bytethertng the fioatto the dis-
4.0 amps (20$,/230V) duvW biepOe orother moue frig point. vertical ioat modem 287 is not
Ino odell 280 Model 281 Model 283 Modell 287
anual, Wide angle "e angle VMF41wks
switch float switch float switch Vertical mag-
with quick-
with series rwucfloatfor
disconnect (pi99y_~ smaller pig _ i
plug will operate In
a 10" diameter
SUMP I
0 us Certified
~ amha eo dr.~ vihat nonce.
LfberW Ptunps • 7000 Apple Tree Avenue • Bergen, New York 14416 • Phone 8004193-2550 Fart
(5W494-1839
www.IHWW4-pumps.cam OOVPk *OL3reetyPWws,kw.2017
Alr%O tsMoved. WT200 FMn7
E
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of €
i
ILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Septic;Tank Capacity g;Ij 0 NA
AAY->-~ 117M2
Permit is Septic,Tank Manufacturer ❑ NA i
DESIGN PARAMETERS Effluent Filter Manufacturer t' 0 NA i
Number of Bedrooms 0 NA Effluent Filter Model 0 NA
Number of Public Facility Uniis1 NA 'Pump Tank Capacity 3 i 0 NA
Estimated flow (average) aUda Pump Tank Manufacturer ❑ NA I
I Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer 0 NA
Soil Application Rate
aUda /ftz Pump Model o Np,
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats; Oil & Grease (FOG) 530 mg/L 0 Sand/Gravel Filter O Peat Filter
Biochemical Oxygen Demand (BODs) 5220 mg/L 0 NA 0 Mechanical Aeration 0 Weiland
Total Suspended Solids (TSS) 5150 mg/L 0 Disinfection D Other:
t Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA g
r
Biochemical Oxygen Demand (BODs) 530 mg/L 0 In-Ground (gravity) 0 In-Ground (pressurized) l
i
Total Suspended Solids (TSS) _<30 mg/L 4A -Grade 0 Mound x
Fecal Cotiform (geometric mean) 5104 cfu/1 D0m1 0 Drip-Line 0 Other.
Waxlmum Effluent Particle Size Ys in dia, 10 NA Other: 0 NA r
Other NA Other: 0 NA
"Values typical for domestic wastewater and septic tank effluent. Other
• ❑ NA
IAINTENANCE SCHEDULE
Service Event Service Frequency
F
Rnspect condition of tank(s) At least once every: r s s) (Maximum 3 years) 0 NA
jPump out contents of tank(s) When combined sludge and scum equals one-third (l~} of tank volume 0 NA
hnspect dispersal cell(s) At least once every: month(s) (Maximum 3 Years) 0 NA
ear(s)
r
Mean effluent filter At least once every: month(s) 0 NA I
~ ears
Inspect pump, pump controls & alarm At least once every: D onth(s) (s) 0 NA i
•
Hush laterals and pressure test At least once every: °nth(s) 0 NA )
r(s)
ether. At least once every: a month(s) s(s} 0 NA
tither. 0 NA
i
MAINTENANCE INSTRUCTIONS
Ilnspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS
Maintainer; Septage Servicing Operator. 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
rvombined sludge and scum and to check for any back up or ponding of efifuent;on the ground surface. The dispersal cell(s) shall be
wisualiy 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
Iegulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (t) or more of the tank volume, the entire contents of
j:he tank shall be removed by a Septage Servicing Operator and disposed '.of in accordance with chapter NR 113, Wisconsin
Administrative Code.
a
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units.
I3nd 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 10 days oficompletion of any service event.
Page of
START UP AND OPERATION products or other chemicals thOt
For new construction, prior to use of the POWTS check treatment tank{s} for the: 'Con presence of painting e the treatment process andlor damage the dispersal cell(s). If high;oncetttrations
are detected have the contents of 1110
may Imped
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface. 4
es backup or surface discharge of efflulerd ble
During power outages pump tanks may fill abovhe oell(s)iand may resu ten the restored the excess _
discharged to the dispersal cell(s) in one large dose, overloading
avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to
i
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
the area within
~
tank.
within the pump
cells. Do not drive or park over, or otherwise disturb or compact.
and dispersal
Do not drive or park Vehicles over tanks r
15 feet down slope of any mound or at-grade soil absorption area.
r
the following from the wastewater stream may improve the perfonnance and prolong disinfectants; the life of the
foundation POW;
Reduction or elimination of T$:
l dra antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; dege ahse b,~a~ ~g~ scraps; ers, medications; oil; painting Pr°dudls;
(sump pump) water, fruit and vegetable peelings; gasoline, 9~ ,
pesticides; sanitary napkins; tampons; and water softener brine.
~l
i y i
insure that the system is proPe
to
ABANDONMENT out of service the fallowing steps shall betaken
When the POWTS fails and/or Is permanently taken o ve Code:
- 1
f
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrate
a All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
Servicing Operator.
• The contents of all tanks and pits shall be removed and property disposed of by a Septage
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with stoll,
gravel or another inert solid material.
CONTINGENCY PLAN taken to provide a code compiint
If the POWTS fails and cannot be repaired the following measures have been, or must be
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systelm.
Therelacement area should be protected from disturbance and compaction and should not beInfringeedill upon bin the uil
structure
for a P new soil and site and proposed lot lines and wells. Failure to protect the replacement
setbacks from existing ded
site evaluation to establish a suitable replacement area. Replacement systems must comply with the rule:l in
i
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to
replace the failed POWTS.
and site evalual~on
le replacement area. Upon failure of the POWTS a soil
as
The site has not been evaluated to Identify a suitable
m be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed) a
a last resort to replace the failed POWTS. bromat at the infiitra#ive r
I
Mound and at-grade soil absorption systems may be reconstructed in place following removal of the I
rface. Reconstructions of such systems must comply with the rules in effect at that time.
SEPTIC, PUMP AND OTHER TREATMENT INSUFFICIENT OXYGEN. DO
F A
THER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OOT
ENTER A SEPTIC, PUMP OR O
TANK MAY BE DIFFICULT OR iMPOSSIBLE.
PERSON FROM THE INTERIOR OF A
ADDITIONAL COMMENTS
i
i
POWTS INSTALLER POWTS MAINTAINER
Name Name r
~
Phone o~
Phone
E 7
SEPTAGE SERVICING OPERATOR (JUMPER) LOCAL REGULATORY AUTHORITY
Name A
e
Nam
Phone Phone
This docLunent was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383:54(1), (2) & (3), Wisconsin Administrative Code.
~4
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ST. CROIX COUNTY
SEPTIC TANK. MAINTENANCE j`iGREEMENT
AND
OWNERSHIP CERTIFICATICN FORM
Owner/Buyer
Mailing Address -G __(C - -
Property Address S / l ,Y
(Verification required from Planning & Zoning Depar tnt for new construction.)
City/State _ Parcel Identification Nurzber
31-
LEGAL DESCRIPTION
Pro ertLocatio ` d' -3 F
P Y of /a /4 , S c. , ~,Cf' N ly / W, Town of
Subdivision Lot #f7
1. . - ~L-'
Certified Survey Map # Volume , Page
Warranty Deed # Vo[tan ~ Page #
Spec house no Lot line,; identifiabl yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, 6 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 tine
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of 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.
l/we certify that all statements on this forhn are true to the best of my/oru k aowledge. 1/we an/are the owner(s) of the
property described above, by virtue of a'warrant i re „<<ir it T. l w',' olh)c~ 5 Orfi'o
~7 I
Number c edroo~ °i
GNAfN~ 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)
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Wircortsht Department of Commerce SOIL EVALUATION REPORT Page 0 3
Division of Safety and Bufldiligs
in accordance wiUr Comm 05, Wis. A{hu. Code
County
Mach cotolilete site plan on Impel 'Kit icss than 0 112 x 11 hwhes in size. Plan elust
Include, Mtt not fftnited to: vertical and horizontal reference pee (BM), ditoction and I'muel I.U. /
percentrlupe, scale or dimensions, uoiHi at low, and I tt ~r}d distance to neatest roa4.
Please prftlf aft blrurmAUon. R rowed Date
,s
Peraonel Ytromtaltrni ymr {novide mey be used for ADcnndarY P'Poa_ °fl~rY LfM,. 1„C1M-t) {m)). y t
Property Owner Pi ZZ catiu r
IC~C~1G~ ~ SIUU~ C.~•RU 111 M; 114 S j l 2~1 fJ Ii E(urCW
Properly Owners Mai_linyAddress Z Biuck # Sulxl Name ur CSM/t-
(
kee
City State Zip Codo Phony Number ❑ City [j village L"}-luwn Neatest Road
~Ac,g cY~ ICU( 6jL~L~, _---~-(Ify, ice- T -New Conshuctim Use: Residential I Number of bedrooms Cudo derived design flow rate GPD
❑ Replacement Public or commercial - Describe:
Parent rnaleriel Flood Plain elovation it alipficabfa ft.
_ lv
Gemat cornrnenls t]
and recorneendations:
Bonny
Boring # tzr Pit Ground surface elev. _DQ ,ka ft. Depth to limlling factor __3_Lo_- ill. _q2! _A rpiic jun Rate
horizon DepUr Dominant Color Redox Description 'I exluro Structure Consistence Roundary Roots GPD/le
in. MenSell Qu. Sz. Cont. Cok)r (Ir. SZ. Sh- 'Eff#1 'Eff#2
C•"1l l ~~.~2 _ ~r Lrrt°'t~k--fl }1Y C
(t_ _ 3L, ) G 5 c. ! 2-m 5bk c 5- - `
? , -`15 t L~ r 5 t~ ~l . y r /cc y k _5 Orr-) vY4-1 - ` I ~
Boring # U Boring ~0
L
Pit Ground surface elev. It. Depih to limiting factor in._ Sol Application Rate
Ilotiztxl DepUr Dominant Color Redox Description lexture Structuie Cansistonre Boundary Pouts _ GPD1ftr
in. Murrsell Qu. Sz. Cont. Color _ Gr. Sz. Sh. 'Efrftt 'Eff#2
I G - i< Cdr ~2 _ L'.mSUK-- -)--4r_
-
_Z-- ` - 3O `f C1 25b~ rr C
ter, I Qs - m l -
Mtenl #1 = BODS> 30:< 220 nxd/L amt TSS >3U < 150 nxglL ' Effluent #2 = BOD5 < 30 trig/L and 1SS < 3l1 mg/L
CST Nan (Please Print) I ,Signature CST Number
O
icti 5~ ht f ~k~~ z s 3 G
Address -
Uate Evaluation Conducted (elephon Number