quired by the Department for any new
lift-station and/or major modifications plan submittal filed pursuant to
s. 281.41, Wis. Stats. The Department will not consider your plan
application unless you complete and submit this lift-station request.
Manufacturer's drawings and/or specifications reproduced from
manufacturer's data and bearing the manufacturers' labels will not be
accepted. Personally identifiable information on this form is not intended
to be used for any other purpose.
1.Type of Lift Station:
A. What type of lift stations are provided? (check the box that applies)

Wet well/Dry well

Submersible
Suction lift
( Self Primed
Vacuum Primed)
Septic Tank Effluent Pump
Pneumatic Ejector Screw Pump

Grinder Pump
Other (specify)___________________
Note: If only simplex grinder/effluent pump stations are provided, skip items 1B through 15, and 17.
B. Are motors and pumps readily removable without entry into the wet well for submersible
lift station?
Yes No
N/A
C. Is the total suction lift 20 feet or less for suction lift pump station?
Yes No
N/A
2.
Design report and calculations:
A. Have a design report and design calculations been submitted?
Yes No
3.
Location:
A. Is the lift station located out of all floodway and/or flood fringe areas; or, is the lift
station flood-proofed (two feet above the 100 year elevation or provided with water tight
covers)?
Yes No
N/A
B. Is the lift station located at least 100 feet from private wells or 200 feet from public
wells; or if not, has a variance from the Department's Private Water Systems Section
and/or Public Water Systems Section been obtained and included with this submittal?
Yes No
C. Have the force main-well separation distance requirements of ss. NR 811.16 and
NR 812.08, Wis. Adm. Code, been met; or if not, has a variance from the Department's
Private Water Systems Section and/or Public Water Systems Section been obtained and
included with this submittal?
Yes No
4.
Pump Cycle and Detention Time:
A. Is the pump cycle (from on to off and then back to on) with any combination of influent
flows and pumping rate at least five minutes or more?
Yes No
B. Is the total fill time between pump on and off elevations in the wet well at average
design flow 30 minutes or less?
Yes No
5.
Wet Well/Dry Well Access:
A. Are there no steps or ladders in the wet well (except for stairways in built-in-place lift
stations)?
Yes N/A
B. Is the dry well (pump chamber) for factory built lift stations less than 20 feet deep, or if
more than 20 feet, have provisions for an intermediate landing been provided at
approximately mid-depth?
Yes No
N/A
C. Is the dry well (pump chamber) for built-in-place lift stations provided with both a
stairway and an intermediate landing at a vertical interval of less than 12 feet regardless
of the depth of the dry well?
Yes No
N/A Page 2
D. If a man lift or elevator is provided in lieu of landing requirements, has an emergency
access been included in the design?
Yes No
N/A
6.
Caution Sign:
A. Is a caution sign provided at top of entrance to wet well?
Yes No
B. Does the caution sign read: Caution: Dangerous/hazardous gases.
Level 2 Confined space. Do not enter without proper equipment and supervision.
Yes No
7.
Ventilation:
A. Is wet well vented to the atmosphere using an inverted "j" tube or other means?
Yes No
B. Is permanent mechanical ventilation provided for built-in-place lift station where
stairways are installed in the wet well for routine entrance to inspect or maintain
equipment?
Yes No
N/A
If yes, does the permanent mechanical ventilation provide one of the following
provisions? (Check the box that applies.)
1.
At least 12 complete air changes per hour if ventilation is continuous?
Yes No
N/A
2.
At least 30 complete air changes per hour if ventilation is intermittent?
C. Does the permanent mechanical ventilation in dry well provide one of the following
provisions? (Check the box that applies.)
1.
At least six complete air changes per hour if ventilation is continuous?
Yes No
N/A
2.
At least 30 complete air changes per hour if intermittent?
3.
At least 30 complete air changes per hour for the first ten minutes and then
automatically switch over to six complete air changes per hour if ventilation is
intermittent?
4.
At least six complete air changes per hour when dry well is occupied and at least
two complete air changes per hour when not occupied if ventilation is
continuous?
D. Is the fan wheel made of non-spark materials if wet well is mechanically ventilated?
Yes No
N/A
E. Are all permanent wet well and the dry well ventilation systems completely separate?
Yes No
N/A
F. Is all permanent intermittently operated ventilation equipment interconnected with the
respective wet well or dry well lighting system?
Yes No
N/A
G. Is there a manual lighting/ventilation switch provided to override the automatic controls?
Yes No
N/A
8.
Heater/Dehumidifier:
A. Are automatic heaters and/or dehumidifiers provided in the dry well?
Yes No
N/A
9.
Pumps and Piping:
A. Are there at least two pumps, each capable of pumping the peak hourly design flow with
the largest unit out of service, or if three pumps are used, can the remaining pumps
convey the peak hourly design flow with the largest unit out of service?
Yes No
N/A
B. If a single pump serving 25 or fewer residential units is used, have provisions been made
to add a second pump without requiring structural changes in the future?
Yes No
N/A
C. Are pump suction and discharge piping (except grinder/effluent and screw pumps) at
least 4-inch in diameter, or if not, has a comminutor or mechanical bar screen or other
suitable equipment been provided?
Yes No
N/A
D. Is there a running time meter provided for each pump?
Yes No Page 3
10. Valves and Valve Vault
A. Are all valves (except ball check valves which may be located in the wet well provided
they can be removed without entering the wet well) located in a dry well or in a separate
valve vault that is either an integral part of the lift station or near the lift station?
Yes No
B. Is the check valve (except ball check valves which may be placed in a vertical run)
placed in a horizontal section of the discharge line?
Yes No
C. Does the valve vault drain to a wet well through a drain line which is equipped with a
ball check valve and/or a gate valve and which extends below the low water level to
prevent entry of hazardous gases to valve vault?
Yes No
N/A
11. Force Main:
A. Is a velocity of at least two feet per second maintained in the force main at the design
pumping rate?
Yes No
B. Have the following provisions been made if the force main contains high points?
Yes No
N/A
Check the box that applies:
combination automatic air release and vacuum valve
an automatic air relief valve
a manual air relief valve

Other (specify) ________________________________
12. Alarms:
A. Does the alarm system activate in cases of power failure, pump failure and at low (if
non-explosion proof motors are used for submersible lift station) and high water levels?
Yes No
B. Does the alarm system also include one of the following provisions or if not, has a
written variance from the Department's Bureau of Watershed Management been
obtained and included with this submittal to allow a visual and audible (light and horn)
alarm system?
(Check the box that applies.)
A radio conveyed system
Automatic telephone dialer system
Telemetered
Other (specify) ______________________________
Yes No
13. What type of liquid level controls are provided? (Check the box that applies.)
Air bubbler
Pressure transducer
Encapsulated Float
Capacitance probe
Displacement switch Ultrasonic
Other (specify)___________________________
Note: If an air bubbler system is used, skip item 14A through 14I.
14. Electrical Equipment:
A. Is a weather proof junction box (for floats) located outside the wet well provided for on
the plan sheets?
Yes No
B. Is another weather proof junction box for submersible pump motor cables located
outside the wet well and provided for on the plan sheets?
Yes No
N/A
C. Are electrical conduits specified as rigid or intermediate metallic conduit (PVC conduit
may be used between explosion proof seals and the control panel) and shown on the plan
sheets?
Yes No
D. Is an explosion proof seal provided between the control panel and junction box, and
shown on the plan sheets?
Yes No
E. Is another duct seal or silicon seal provided at the junction box to prevent moisture
escaping from the wet well to the junction box and is the seal shown on the plan sheets?
Yes No Page 4
F. Is a redundant low level alarm for submersible pump provided and set such that the
pump motor is totally submerged at all times to prevent ignition of explosive gases in the
wet well, or is the pump motor rated explosion proof?
Yes No
N/A
G. Are all motor power cables and all other wiring in the wet well NEC rated SO or STO or
better?
Yes No
H. Are electrical level control circuits using floats/electronic transducers intrinsically safe?
Yes No
I. Are the floats/transducers suspended in the wet well or mounted on a portable pole to
facilitate maintenance?
Yes No
J. Is a weather proof fused disconnect switch or equivalent circuit breaker provided?
Yes No
K. Is a 110-volt ground fa