HomeMy WebLinkAbout022-1030-50-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605046
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name: City Village Township Parcel Tax No:
Thomas & Melanie Waldon TOWN OF KINNICKINNIC 022-1030-50-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
11.28.18.165A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmarkt Il✓ l~1(,?
I
DQvAg (.VIR Alt. BM
A:Tf< 3 TS r() r. Y r
Aeration Bldg. Sewer
Holding St/Ht Inlet
- jJ
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BVent to Air Intake ROAD Dt Inlet
Septic Dt Bottom '71 b 0 0; 040
Dosing Header/Man.
Aeration , ist. Pip bli•t~
?T 46
Holding / Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number - - -
TDH Lift Friction Loss System Head TDH r. Ft
Forcemain Length A, Dia. Dist. to Well
d1C~ f ~~U!
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIM„ ONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYST O LD L LAK TREAM LEACHING Manufacturer.
INFORMATION CHA uBER OR
Sys
Type Model Numbek [ 5tt
1 11112 C Y
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
Length Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth ofxx Seeded/Sodded xx Mulched
Bed[Trench Center Bed/Trench Edges Topsoil E] Yes ❑ Ni ❑ Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 495 OLD CEMETERY RD
1. Alt BM Description = lp~ tt1~X
2.) Bldg sewer length = -7 r),
- amount of cover = j t' li2nQ L~ o~' t k;s ~t ~rrtt o~
J" ~-o..u cr /1 ex,~ar~v" F Tom-.
Plan revision Required? Yes No
a~
Use other side for additional information.
Date -__Ipctor's Signature _ Cert. No.
SBD-6710 (R.3/97)
~1, 7S100
~ t ~
Safety and Buildings Division County
15
X d 201 Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.)
SPS yt NVdison, WI 53707-7162
'ou ty n~ &0~
Sta,ransaction Number
U'
'1Sa ermit Applicati
P
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govcmmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to roject Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
ur oses in accordance with the Privacy Law, s. 15.04(I)(m), Stats. e em -e--+(e ,
1. Application Information - Please Print All Information ti )
Property Owner's Name Parcel #
Property Owner's Mailing Address Property Location i I I
ekle 46AI) Govt. Lot
City, State p Code Phone Number Section_
i V eet A ~~ct~ / L Z T N; R ~~eirclE or&)
Il. Type of Building (check all that apply) Lot # ~JJ
❑ 1 or 2 Family Dwelling Number of Bedrooms 3 Subdivision Name
0✓Lf.'; -Ct_ x, +/l Cc~:~~ ieti ~4f~
L, Block#
❑ Public/Commercial - Describe Use
❑ City of
El State Owned - Describe Use CSM Number El Village of
"aj AT
1 5:2q,g6 own of /kl4 t t~KlotA I
11. Type of Permit: (Check onl one box online A. Complete line B if applicable)
A.
❑ New System ❑ Replacement System ❑ Trcatmcnt/Holding Tank Replacement Only er Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Numb r and Date [,sued
Before Expiration Owner y`,,~ Cf ,A
IV. Type of POWTS System/Component/Device: (Check all that apply) 2
'pSlrNon-Pressurized In-Ground ❑ Pressurized [n-Ground ❑ At-Grade ❑ Mound? 24 in. of suitable soil Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
7-77-77777
V. Dispersal/Treat nt Area Information: i Design. Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System
Elevation
aj~-o C)
VI. Tank Info Capacity in Total # ofa facturer
Gallons Gallons Units
New Tanks Existing Tanks o v Y V
c, U ~ s ~ ii C7 a,
e"
Septic or Holding Tank
Z 1 cL c St
Dosing Chamber 612
VII. Responsibility Statement- 1, the undersigned, assume responsibility for ' stallation of the POINTS shown on the attached plans.
Plumber's Name (Print) Plumbers atur MP/MPRS Number Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
V 7
L~
VIII. County/Department Use Only
pproved ,approved Permit FLe~eT Date Is ieddll a Issuing ent Signa re
• ! / V
wne en Reason for Denial
sop;s foG,Disapproval t
IX. Condiffi
e!>~ V 1.~+ 1
f IS ark;'E~(flt ►11tR enti 3/ ~ ~ .4-1
o: oP cell ruse all be ^ICaS rozW rec r it
as per iar:3gemenl plan r .,c, /ided by plu,.-nW. E/~ b.J1 t .
2. All Seftter,.k ret tr,itnl?en;ts mustte mairtcir.E
as per;app6crVt cod,* / crdinancri.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2X 11 inches in size
SBD-6398 (R. 11/11)
II~ _ -
75/
1= ~ n
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.
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W~`n ~ (off PL
SEPTIC TANK INSTALLATION AND EXISTING IN-GROUND
ABSORPTION FIELD TIE IN FOR A CONVIENCE BATHROOM IN A SHED
COMPONENT DESIGN
Owner's Name Thomas & Melanie Waldon
495 Old Cemetery Road
River Falls WI 54022
Located in the NE 1/4 of the NW 1/4 of Section 11, T 28 N, R 18 W.
TOWN OF KINNICKINNIC
ST CROIX COUNTY
Parcel # 022-1030-50-000
INDEX
Page 1 Index & Title
Page 2 Plot Plan
Page 3 Elevation data and calculations
Page 4 Dose Tank Cross Section
Page 5 Pump Performance graph
Page 6-7 Poly-lok PL122 Filter Instructions
Page 8 Septic tank specifications
Page 9-10 Owner's Manual & Management Plan
Page 11 Septic Tank Maintenance agreement
Attachments Warranty deed
Permit File
Prepared By Michael Rodewald
285 County Road SS
River Falls WI, 54022
715-821-6229
MPRS 931384
Design Pursuant to:
IN-GROUND SOIL ABSORPTION COMPONENT MANUAL FOR POWTS
(VERSION 2.0) SBD-10705-P (N.01/01; R. 10/12)
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Septic-Dose Tank Cross Section And Pump Performance Specifications
Tank Manufacturer Wieser Pump Manufacturer Gould
Tank Model Number W840/500-MR Pump Model Number PE41
Total Tank Capacity 1,340.00 Alarm Manufacturer SJ Rhombus
Max. Bury Depth 8.00 Alarm Model Number A B
Switch Type Mechanical float
Filter Manufacturer Polylok Total Dynamic Head (TDH) - Feet
Filter Model Number PL-122 Elevation Head 11.00
Distal Pressure
Network Loss 2.50
Minimum Pump Performance Required
Force Main Loss
2.51
GPM 16.01 Ft TDH Total 16.01
Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole Manhole Min. Above Grade
< 6" Below Grade Sealed Watertight Securely Mounted With Locking Device
Weather-proof
` Junction Box
! Finished Grade ' - ~ ~ - .
Depth of
Cover Vent Min. 12" Disconnect
Ft Above Grade Means
With Vent Cap
S S S S S S S S t t t i< t S S i i t L i S i t S S< S i t <
J > > T >
ata SaS ,S
Outlet
Outlet Filter
Inlet Inlet Baffle _
ata <at at
t < < t
A >
Switch Settings and Reserve Capacity y4"
Tank Volume = GPI Weep
Hole
Dimension Inches Volume Gal. i B >s
(reserve) A 22 260.04
y;y (alarm) B 2 23.64 Off Elevation C
(dose) C 7 82.74 <>< 1 ` ' Ft
Bottom
(dead) D 12 141.84 D Elevation
Total 43 508.26 A
>{>i}i>i>tataiataiat>S>iaS>taSata S>ta<a<aia<aS>iatataiaSaia<a taS aia iaiafaiaiaiataial><><a <a taia taint><ai><aiatat alai
GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not
be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock)
installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and
laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank
excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC.
02/05 LJ Page of
fir
~r s
Vastewater b
METERS FEET
40
PE51 _ MODELS:
PE31, PE41, PE51
35 HP:.33-40-50
10 2 GPM
30 P 41
- 1 FT
w
PE31
= 25
U
z 20
F e
s o ,
F- 15
O
10
_ t e. E
0 0 0 10 20 30 40 50 60 70 GPM 80
0 5 10 15 m3/h
CAPACITY
PERFORMANCE RATINGS
PE31 PE41 PES1
Total Head GPM Total Head GPM Total Head GPM
(feet of water) (feet of water) (feet of water)
5 52 8 61 10 67
10 42 10 57 15 59
15 29 15 46 20 50
20 16 20 33 25 39
25 0 25 16 30 26
35 8
D P L, 0K, INSTALLATION INSTRUCTIONS
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:u lM,i+st?Wat P" G'udiHOducan ~ .
»n,wewzat~i PL-122/PL-525/PL-625 FILTER
INSTALLATION INSTRUCTIONS
Center filter
with opening
0 ~ C7 _ _a
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LL =
vx
I
Additional pipe or
Polylok Extend & Lok-' Glue
for centering.
Step 1: Step 2: Step 3:
(A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
0 Certified is positioned so the filter can be housing, making sure the filter
NSF/ANSI Standard 46
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS
1
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Step 1: Step 2: Step 3:
Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back
if necessary. into the the housing making sure
• NOT USE PLUMBING
• ~ (B) Pull the filter out of the housing. the filter is properly alighed
WHEN FILTER IS (C) Hose off the filter over the septic tank. and completely inserted.
USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover
WHEN CLEANING FILTER septic tank.
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
INSTALLATION INSTRUCTIONS
]ILYANFO
Innovations in Precast, D!ainage Zabel v PL-525/PL-625 FILTER
& Wastewate, P!odam A Division of Pol 1ok Inc.
PL-122/PL-525/PL-625 FEATURES & BENEFITS
r r
Certified to
Features & Benefits: NSF/ANSI Standard 46
• Rated for 10,000 GPD
• PL-122 = 122 Linear Feet of 1/16" Filtration
PL-525 = 525 Linear Feet of 1/18" Filtration
41 41 PL-625 = 625 Linear Feet of 1/32" Filtration
PLA22 PL-525 PL-625
.Accepts 4" and 6" SCHD. 40 pipe
The PL-122/PL-525/625 Effluent Filter should operate
efficiently for several years under normal conditions • Built in Gas Deflector
before requiring cleaning. It is recommended that the .Automatic Shut-Off Ball when Filter is Removed
filter be cleaned every time the tank is pumped or at
least every three years. If the installed filter contains an .Alarm Accessibility
optional alarm, the owner will be notified by an alarm
when the filter needs servicing. Servicing should be .Accepts PVC Extension Handle
done by a certified septic tank pumper or installer.
RECOMMENDED PRODUCTS
- Polylok PVC Filter
' Extension Handle
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t
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Risers & Riser Covers Extend & LokT" Riser Safety Screens Filter Alarm Panel and
Polylok risers bring your Polylok Extend & LokTM Polylok safety screens SmartFilterTM Control
septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch
This allows locating and solution that can extend from happening by children Polylok filter alarm panels
servicing your filter easier the inlet or outlet pipe and and pets falling into open and switchs provid a visual
and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of
nating digging to find tank installation a snap. impending filter and tank
entrance. Fits 3" and 4" pipe. servicing.
For a full list of Polylok products please visit our web site at: www.polylok.com
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
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1201 IINSTRUCTIONS
& w"votions mPrecav. s,3,~a4 apbeo~ofPo,oo in PL-525/PL-625 FILTER
& Wasrewatet Pmroducts
PL-122/PL-525/PL-625 FEATURES & BENEFITS
Certified d
Features & Benefits: ® NSF/ANSI Standard 46l
. e Rated for 10,000 GPD
. PL-122 = 122 Linear Feet of 1/16' Filtration
PL-525 = 525 Linear Feet of 1/18" Filtration
F PL-625 = 625 Linear Feet of 1/32" Filtration
PL-122 PL-525 PL-625
.Accepts 4" and 6" SCHD. 40 pipe
The PL-122/PL-525/625 Effluent Filter should operate
efficiently for several years under normal conditions • Built in Gas Deflector
before requiring cleaning. It is recommended that the *Automatic Shut-Off Ball when Filter is Removed
filter be cleaned every time the tank is pumped or at
least every three years. If the installed filter contains an .Alarm Accessibility
optional alarm, the owner will be notified by an alarm
when the filter needs servicing. Servicing should be *Accepts PVC Extension Handle
done by a certified septic tank pumper or installer.
RECOMMENDED PRODUCTS
Polylok PVC Filter
. Y* Extension Handle
Rk 7,
14¢ t m - tie' - ~~`.Y • t ` ,
}
Risers & Riser Covers Extend & LokTM Riser Safety Screens Filter Alarm Panel and
Polylok risers bring your Polylok Extend & LokT"' Polylok safety screens SmartFilterT" Control
septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch
This allows locating and solution that can extend from happening by children Polylok filter alarm panels
servicing your filter easier the inlet or outlet pipe and and pets falling into open and switchs provid a visual
and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of
nating digging to find tank installation a snap. impending filter and tank
entrance. Fits 3" and 4" pipe. servicing.
For a full list of Polylok products please visit our web site at: www.polylok.com
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of 2
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity 64 to gal ❑ NA
Permit # Septic Tank Manufacturer 1Aj ea j , ❑ NA
DESIGN PARAMETERS Ci^rvi' ~►c o ati Effluent Filter Manufacturer L k ❑ NA
Number of Bedrooms C9-NA Effluent Filter Model /~L ❑ NA
Number of Public Facility Units RrNA Pump Tank Capacity 500 gal ❑ NA
Estimated flow (average) gal/day Pump Tank Manufacturer J~ esc,L ❑ NA -
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer 61W"'tS- ❑ NA
Soil Application Rate gal/day/ftz Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD5) <_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) E,,Qe k,:ij ❑ NA
Biochemical Oxygen Demand (BOD5) 530 mg/L [)~In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coiiform (geometric mean) <_10^ cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size %e it dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every ❑ month(s) (Maximum 3 Years) ❑ NA
':year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (%3) of tank volume ❑ NA
month(
Inspect dispersal cell(s) At least once every: I~'ear(s) 13 ear W s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA
ear(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
W year(s)
Flush laterals and pressure test At least once every: ❑ month(s) I&-NA
❑ year(s)
Other: At least once every: ❑ month(s) p NA -
❑ year(s)
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections 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 combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) 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 tank equals one-third (%3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator 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 10 days of completion of any service event.
Page Z of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the 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.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. 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
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
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 chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits 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.
• 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 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.
T
aluati a o ing ank
be i e ai a D4 115 TI ~2, f-D2- /J6w/ Co S7JZ lI~l1~~
❑ 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> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name A L C t Name
Phone `7m ' .-S - 6. 266, Phone 7t $ _ /U-2-$s
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ST. ~~b t t~UIJ 2o~Jt~J "
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Page 7i of 2
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the 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.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank,
Do not drive or park vehicles over tanks and dispersal cells. 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
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shaii be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits 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.
• 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 POXA7S 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 that time.
❑ A suitable replacement area is not available due to setback andior soil limitations. Barring advances in POA7S
technology a holding tank may be installed as a last resort to replace the failed POWTS.
r ~tj T v v u v u
a olding~ank
v be i taneo
❑ 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> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
i
Name z--
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name f ~jt. GHQ ( p Ui.f l 2CJ/J~~J
Phone Phone
his aocumem was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(11, (2) & (31, Wisconsin Administrative Code.
t f
k
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer Thomas & Melanie Waldon
Mailing Address 495 Old Cemetery Rd.
Property Address 4-4,75- 61~ err. T -1- 0.
(Verification required from Planning & Zo g Department for new construction.)
City/State River Falls Parcel Identification Number 022-1030-50-000
LEGAL DESCRIPTION
Property Location NE 1/4 , N W %4 , Sec. 11 , T 28 N R 1$ W, Town of KI n rl I CICI n n I C
Subdivision Plat: Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house OyesElno Lot lines identifiable Oyes0no
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 §SPS. 383.52(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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department 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 is form are true to the best of my/our knowledge. 1/we am/are the owner(s) of the
property described above, by virtue of a ranty deed recorded in Register of Deeds Office.
Number of b o S 4
k ~__j ~ )a_j O~A
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. 04/12) ,
C0 c
PRIVATE SEWAGE SYSTEM County: .St. Croix
Wisconsin Department of Commerce
Safety and Building Division Sanitary Permit No:
j INSPECTION REPORT 582048
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
T City Village Township Parcel Tax No:
Permit Holder's Name:
Thomas & Melanie Waldon TOWN OF KINNICKINNIC 022-1030-50-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
11.28.18.165A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER '~7S CAPACITY STATION BS HI FS ELEV.
Septic 'T.. 3 Benchmark
/
CS r ~GZU~ 3.1% 163 l
i 44 !1
Dosing DO42~ Alt. BM , / 3 ~Z(p
Aefetrdn Bldg. Sewer Z q '4L 9y e $
rn Pa a L
Holding St/Ht Inlet ~b• 93,
SUHt Outlet
TANK SETBACK INFORMATION
TANK TO k'/~ WELL BLDG. ent to it Intake ROAD Dt Inlet \
7 Dt Bottom ,5q
Septic -7 JrSd 76
Dosing 166' ~ 5 Header/Man. f
7
Dist. Pipe , r
Aeration
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
.
v GPM A
Model Number 1 40 ~ I ~ ~ • Z
TDH Lift Z • Friction Los j' System H`en TDH I G Ft VM.
Forcemain Length Dia.Z It Dist, to well 7r5 1 o
SOIL ABSORPTION SYSTEM J
PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
BED/TRENCH Width Length No. Of Trenches
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHLEACHING AMBER OR Manufacturer:
INFORMATION Type Of System: UNIT Model Number:
":7 /Sa
DISTRIBUTION SYSTEM t
ix Hole Size x Hole Spacing V o Air I ke
Header/Manifold Distribution
Pipe(s)
Length Dia Length Dia Spacing
w
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 7- Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes No Q Y=XN,
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspecti n #2:
Location: 495 OLD CEMEf RY RD a~ ~d.+v~ 1 C PhD
1.) Alt BM Description = l /
2.) Bldg sewer length = l Z G~ q,i 1L5 0 GI's-5 a
- amount of cover = b v
14 `
I D V,% GG C( '7
Plan revision Required? 0 Yes *11, 0
t2 1a l7
Use other side for additional information. lnsep or's S' iu Cert. No.
Date
SBD-6710 (R.3/97)