Form : 12-009 - Private Onsite Waste Treatment System Evaluation printable pdf download

OCONTO COUNTY PRIVATE ONSITE WASTE TREATMENT SYSTEM EVALUATION

Revised 1/2010

Form 12-009

1. DOES SYSTEM PASS s. 145.245(4) CODE REQUIREMENTS? (SEE #9)

YES____ NO____

2. PROPERTY INFORMATION

Property Owner:___________________________________

Legal Description: _____1/4 _____1/4

Property Address:__________________________________

Sec.________ T____N, R_____E

Mailing Address:___________________________________

Town of ____________________________

Phone #:_________________________________________

Tax Parcel #_________________________

3. PURPOSE OF EVALUATION: (circle one)

Reconnect

Bedroom Addition

Property Transfer evaluation

System renovation or minor repair. Describe:____________________________________

Non-bedroom addition > 150 sq ft.

Other____________________________________

4. BUILDING/DWELLING USE

Residential,_______ # of Bedrooms

Public/Commercial Use___________________

Code derived estimated daily flow__________gpd

5. SYSTEM TYPE

Conv. System___

Mound___

Holding Tank___

At-Grade___

Leaching Chambers____

In-ground Pressure______

Privy (Pit or Vault)______

Other_________________

6. PERMIT HISTORY

Has an Oconto County Sanitary Permit been previously issued?

Yes No

If yes, Permit #___________________

Original applicants name:____________________________________

Date Issued_____________________

7. TREATMENT TANK/FILTER INFORMATION

Treatment tank size _________gallons

# of Tanks____

Tank Pumped? Y

Pumper___________ Date_________

Manufacturer:___________________________

N %of solids in tank________________

Concrete

Steel

Plastic

Other________ Tank / Baffle Condition_______________________________

Filter Apparatus Type:________________ Manufacturer_________________________________

Are all risers, locks, chains, and alarms installed and in good working order? Y

N __________________________

Distance from all weather service road to holding tank manholes.___________________________

Water meter w/ remote reader in place for holding tank? Y

N Type & Reading____________________________

8. DISPERSAL CELL INFORMATION

Cell dimensions______________

# of Cells________

Depth of cover by observ. pipe _____

Total Dispersal area________________

Depth to system elevation

_____

Dispersal area required under current code________________________

Is water evident in observation/vent pipe? Yes_______ No________

Setback distance to Well:_______Lot line______ Building_________ Surface water_________

A SOIL BORING IS REQUIRED IN PROXIMITY OF THE DISPERAL COMPONENT. SEE #9

9. DETERMINATION OF A FAILING PRIVATE ONSITE WASTE TREATMENT SYSTEM

PER s.145.245 (4) WISCONSIN STATUTES A FAILING SYSTEM IS ONE WHICH CAUSES OR RESULTS IN ANY OF

THE FOLLOWING CONDITIONS. PLEASE INDICATE WHICH APPLY:

a) Discharge of sewage into surface water or groundwater

Yes

b) Introduction of sewage into zones of saturation which adversely

affects the operation of a private onsite waste treatment system

Yes

c) Discharge of sewage to a drain tile or into zones of bedrock

Yes

d) Discharge of sewage to the surface of the ground

Yes

e) Failure to accept sewage discharges and backup of the sewage

into the structure served by the system

Yes

10. Does the system meet all setback requirements from the dispersal component and treatment tanks to

well(s), structure(s), property lines, etc.? Yes

No If no, explain_______________________________________

The information on this evaluation reports observations made on the date of the evaluation only. This evaluation

form does not grant any warranty, expressed or implied.

Plumber or POWTS Inspector

Name (print) ___________________________________

License #___________Date____________ Signature______________________________________

CST Name (print) ___________________________ Signature _________________________________

CST License #____________Date_______________

>>>>PROVIDE DRAWING ON BACK>>>>

Form : 12-009 - Private Onsite Waste Treatment System Evaluation

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