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State of Wisconsin Lift Station Design Checklist

Department of Natural Resources
Bureau of Water Quality Form 3400-168 (R 08/20) Page 1 of 7
PO Box 7921
Madison, WI 53707
dnr.wi.gov

Notice: In accordance with s. NR. 108.04(2)(a), Wis. Adm. Code, this form is authorized to accompany final plans and specifications
for any reviewable lift station project that is submitted to the Department of Natural Resources (Department) pursuant to s. 281.41, Wis.
Stats and s. NR 108.03, Wis. Adm. Code. Completion of this form is required by the Department for any lift station plan submittal to
evaluate conformance with requirements in chs. NR 108 and NR 110, Wis. Adm. Code. Manufacturer's drawings and/or specifications
reproduced from manufacturer's data and bearing the manufacturer's labels will not be accepted.
All necessary information must be provided on this form. Failure to complete this form correctly may result in rejection of
this form by the Department. Personal information collected will be used for administrative purposes and may be provided to
requesters to the extent required by Wisconsin's Public Records law (ss. 19.31 - 19.39, Wis. Stats.).
Please complete this form for each lift station that will be installed as part of the project. The applicant shall answer all
questions listed below unless otherwise indicated. Questions specific to each type of lift station are listed in items 13 to 16.
Please type or clearly print your answers to all questions.

1. Type of Lift Station (s. NR 110.14(3)(a), Wis. Adm. Code)

A. Lift Station Name or Identification:

B. Please specify the type of lift station proposed for this project (select one):
Wet well/ Dry well
Submersible
Septic Tank Effluent Pump
Simplex Grinder Pump: Submersible Non-Submersible
Duplex Grinder Pump: Submersible Non-Submersible
Pneumatic Ejector
Primed Suction lift Self Vacuum
Screw Pump
Other (specify)

2. Design Report (s. NR 110.14(1)(b), Wis. Adm. Code)

A. Will the project involve the installation of a new lift station or major rehabilitation of an existing lift Yes No
station (i.e. replacing pumps with larger units or changing the type of lift stations)?
If you answered “Yes” to A, please include a design report (including detailed design calculations) consistent with s.
NR 110.11, Wis. Adm. Code with the plans and specifications.

3. Location (s. NR 110.14(2)(a), Wis. Adm. Code)

A. Is the lift station located outside of the floodplain? If you answered “No” this question, please Yes No
answer the sub-questions under A.
i. Is the lift station flood-proofed (two feet above the 100-year flood elevation or provided with Yes No
solid watertight covers)?
ii. Does the project conform to the requirements in ch. NR 116, Wis. Adm. Code? Yes No

B. Will the lift station be located out of the traffic way of streets and alleys? If you answered “No” Yes No
this question, please answer the sub-question under B.
i. Please explain why the lift station must be located in the traffic way

C. Is the lift station located at least 200 feet from public water system wells Yes No
(s. NR 811.12(5)(d)3., Wis. Adm. Code)?
 Lift Station Design Checklist
Form 3400-168 (R 08/20) Page 2 of 7

D. Is the associated force main at least 50 feet from public water system wells and does it meet the
material, joint, and testing requirements of s. NR 811.12(5)(d)2., Wis. Adm. Code, OR is the
associated force main at least 200 feet from public water system wells
(s. NR 811.12(5)(d)3., Wis. Adm. Code)? Yes No

E. If you answered “no” to any of the above questions (C-D), please answer all sub-questions under E. The below are
required for sewers that do not meet the separation requirements from new or existing public water system infrastructure.
i. Has the public water system owner given written approval or no-objection to the lift station Yes No
plans?
ii. Has a plan submittal with a request for review been sent to the DNR Public Drinking Water Yes No
Engineering Section?
iii. Is a copy of the written no-objection/approval(s)from the public water system owner and DNR Yes No
Public Water Engineering Section attached to this plan submittal?

F. Is the lift station located at least 100 feet from all existing private and non-community wells Yes No
(s. NR 812.08(4) Table A, Wis. Adm. Code)?

G. Is the associated force main at least 25 feet from all existing private and non-community wells Yes No
(s. NR 812.08(4) Table A., Wis. Adm. Code)?

H. If you answered “No” to any of the above questions (F-G), please answer all sub-questions under H.
i. Has Form 3300-208 (Application for Sewer/Existing Private Well Separation) and/or Yes No
Form 3300-210 (Application for Variance) been submitted to the DNR Drinking Water
and Groundwater Program to request a variance to the 25-foot separation distance
and/or 100-foot separation distance, respectively?
ii. Is a copy of the approved variance to the 25-foot separation distance and/or 100-foot Yes No
separation distance attached to this plan submittal?

4. Structural Features (s. NR 110.14(3)(b), Wis. Adm. Code)

A. Is the dry well, including the superstructure, completely separated from the wet well? Yes No N/A
B. Are provisions made to facilitate removal of pumps, motors, and other mechanical and electrical Yes No
equipment without entry into the wet well?

C. Are any permeant ladders or steps provided in the wet well? If you answered “Yes” this Yes No
question, please answer the sub-questions under C.
i. Are the stairways in a wet well of a built-in-place lift station? Yes No N/A
ii. Please explain the special maintenance needs or physical conditions that prevent the provision of necessary access by
any other reasonable means

D. If a permanent ladder is provided for access to the dry well, is the depth of the dry well less than or
equal to 20 feet? If you answered “No” this question, please answer the sub-questions under D. Yes No N/A
i. If the dry well more than 20 feet in depth, is an offset made in the entrance ladder
Yes No N/A
with an intermediate landing at approximately mid-depth?
ii. Is the diameter of the intermediate landing area at least 5 feet? Yes No N/A
iii. Is the landing area provided with suitable barrier to prevent an individual from falling Yes No N/A
past the intermediate landing to the lower level?
iv. If an equivalent landing area is provided, please explain the design below:

v. If a man lift or elevator is provided in lieu of the landing area requirements, has an
Yes No N/A
emergency access been included in the design?
 Lift Station Design Checklist
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E. Is a caution sign proposed at the top of the entrance to the wet well that warns of the potential
for hazardous gases in a confined space and indicates that there shall be no entry without
proper equipment and supervision? Yes No
F. Is a sump pump provided in the dry well to remove leakage or drainage? Yes No N/A
G. Will the sump pump or valve vault discharge line be equipped with a check valve and discharge Yes No N/A
above the maximum high-water level of the wet well?
H. Is siphon break provided when the sump pump discharge line enters at the high-water level in the Yes No N/A
wet well?
I. Will the pump seal water leakage be piped or channeled directly to the sump pit? Yes No N/A
J. Will all floors and walkways be sloped to a point of drainage? Yes No N/A
K. Is the pump cycle (from on to off and then back to on) with any combination of influent flows and
Yes No
pumping rate at least 5 minutes or more?
L. Is the total fill time between pump on and off elevations in the wet well at average design flow 30
minutes or less to prevent septicity? Yes No

M. Will the wet well floor have a minimum slope of 1:1 to the hopper bottom? Yes No
N. Will the horizontal area of the hopper bottom be sized for proper installation and function of suction
pipe intake and pump inlet? Yes No

O. Will the exteriors of steel factory-built lift stations be provided with cathodic protection against
corrosion? Yes No

P. Will the interior of steel wet wells shall be coated with a suitable waterproof epoxy coating or
waterproof painting system or other appropriate methods to protect against corrosion? Yes No

5. Ventilation (s. NR 110.14(3)(c), Wis. Adm. Code)

A. Will the wet well be vented to the atmosphere using an inverted "j" tube or other means? Yes No
B. Is a permanent mechanical ventilation system provided in the wet well where routine entrance is
required to inspect or maintain equipment? If you answered “Yes” this question, please answer Yes No N/A
the sub-questions under B.
i. Please specify the air changes per hour (select one):
At least 12 complete air changes per hour if ventilation is continuous
At least 30 complete air changes per hour if ventilation is intermittent
ii. Will the air be forced in the wet well by mechanical means not exhausted from the wet well? Yes No
C. If routine entrance is not required to inspect or maintain equipment in the wet well, will a portable
mechanical ventilation equipment be available for entry to a confined space? Yes No
D. If the dry well is installed below the ground surface, is a permanent mechanical ventilation system
proposed? If you answered “Yes” this question, please answer the sub-questions under D. Yes No N/A

i. Please specify the air changes per hour (select one):

At least 6 complete air changes per hour if ventilation is continuous
At least 30 complete air changes per hour if ventilation is intermittent
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
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
E. Are the wet well and dry well ventilation systems entirely separated? Yes No
F. Will the switches for operation of ventilation equipment be marked and conveniently located? Yes No
G. Will all intermittently operated ventilating equipment be interconnected with the respective wet well
or dry well lighting system? Yes No
H. Will the manual lighting and ventilation switches override the automatic controls? Yes No
I. Will the fan wheel for ventilating hazardous areas be fabricated from non-sparking material? Yes No
 Lift Station Design Checklist
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6. Auxiliary Equipment (s. NR 110.14(3)(d), Wis. Adm. Code)

A. Will the dry well be equipped with automatic heaters? If you answered “No” this question,
please answer the sub-question under A. Yes No N/A
i. Is justification provided that demonstrates that the heat output from the pump motors or controls
is sufficient to keep equipment in the dry well from freezing? Yes No

B. Will a dehumidifier be installed where the dry well is installed below the ground surface? Yes No N/A
C. Will a running time meter be installed for each pump in the lift station? Yes No
D. Will a flow meter be installed? Yes No

7. Electrical Equipment (s. NR 110.14(3)(e), Wis. Adm. Code)

A. Will all electrical systems and components (i.e. motors, lights, cables, conduits, switchboxes, and
control circuits) located in wet wells, or in enclosed or partially enclosed spaces where hazardous
concentrations of flammable gases or vapors may be present conform to NEC requirements for
explosion proof seals? Yes No

B. Will equipment located in the wet well be suitable for use under corrosive conditions? Yes No
C. Will each flexible cable shall be provided with a watertight seal and separate strain relief? Yes No
D. Will a fused disconnect switch or equivalent circuit breaker located above ground be provided for
the main power feed for the lift station? Yes No
E. Where equipment is exposed to weather, will the equipment be weatherproofed? Yes No N/A
F. Will the electrical supply, control, and alarm circuits be designed to provide strain relief
appurtenances? Yes No
G. Will all junction boxes containing terminals and connectors be protected from corrosion by being
located outside the wet well or through the use of a watertight seal? Yes No
H. Will the explosion proof seals for electrical cables that enter the wet well be located so that the
equipment within the wet well such as pump motor and the level control float switches or
transducers can be removed and electrically disconnected at the respective junction box without
destroying the seal? Yes No

8. Duplicate Units (s. NR 110.14(3)(f), Wis. Adm. Code)

A. Will the combined pump capacity meet or exceed the design peak hour pumping rate with the
largest unit out of service? Yes No
B. Where the lift station will serve less than or equal to 25 residential units with a single pump or
ejector, will the lift station be designed to allow for the installation of a future duplicate pump or
ejector with no structural changes? Yes No N/A

9. Pumps (s. NR 110.14(3)(g), Wis. Adm. Code)

A. Will all pumps, except grinder and effluent pumps, be capable of passing spheres of at least 3
inches in diameter, and have pump suction and discharge piping with a diameter of at least 4
inches? If you answered “No” this question, please answer the sub-question under A. Yes No
i. Please specify how the pump will be protected (select one):
Comminutor
Mechanical Screen
Other specify:

B. Will each pump, except self- priming or vacuum primed pumps with adequate suction lift capability,
be located so that under normal operating conditions it will operate under a positive suction head? Yes No N/A
 Lift Station Design Checklist
Form 3400-168 (R 08/20) Page 5 of 7

10. Piping (s. NR 110.14(3)(h), Wis. Adm. Code)

A. Will each pump, except submersible, screw, grinder and effluent pumps, be equipped with
individual suction piping that is straight as possible? Yes No N/A
B. When suction elbows are used, will the bell be placed above the floor of the wet well at a distance
which is not greater than 1/2 nor less than 1/3 the diameter of the bell? Yes No N/A
C. Will a suitable shutoff valve be placed on each discharge line, except for screw pumps? Yes No N/A
D. Will a shutoff valve be placed on each suction line of the dry well pump? Yes No N/A
E. Will a check valve be placed on each discharge line between the shutoff valve and the pump,
except for screw pumps? Yes No N/A
F. Will check valves be placed in horizontal sections of the discharge pipe or will ball check valves be
placed in the vertical run? Yes No
G. Will all valves be located outside of the wet well? Yes No

11. Controls (s. NR 110.14(3)(i), Wis. Adm. Code)

A. Please specify the type of liquid control system that will be provided (select one):
Air bubbler Encapsulated Float Displacement switch
Ultrasonic Pressure transducer Capacitance probe

B. Will the control system be located away from the turbulence of incoming flow and pump suction? Yes No

C. Will provisions be made to automatically alternate the pumps in use where multiple equivalent
capacity pumps are installed? Yes No N/A

D. Will the lift station be equipped with an alarm system? Yes No

E. Will the alarm system include audible and visual signals? Yes No
F. Will the alarm system be activated in cases of power failure, pump failure, and at a predesignated
high-water level? Yes No
G. Will the alarm system be activated in the event of unauthorized entry or other lift station
malfunction? Yes No N/A
H. Please specify how the alarm system will alert the responsible authority (select one):
A radio conveyed system Automatic telephone dialer system

Telemetered Other specify:

12. Emergency Operation (s. NR 110.14(12), Wis. Adm. Code)

A. Please specify one of the following emergency options that will be provided to ensure continued operation of the lift station
during an emergency (select all that apply):
On-site generator

On-site gasoline or diesel engine driven pump

Portable generator

Portable pump

Two independent electrical transmission routes

Capacity to hold the average design flow for a minimum period of 24 hours
N/A - Duplex grinder pump or effluent pump lift station which serve less than 3 residential units

B. For an on-site generator or pump, will automatic switching and starting equipment be installed? Yes No
 Lift Station Design Checklist
Form 3400-168 (R 08/20) Page 6 of 7

C. For a portable or on-site generator, will the generator have sufficient capacity to meet the total
electrical demands of the pumps, controls and auxiliary equipment? Yes No N/A

D. For an on-site or portable pump, will the pump have a capacity equal to or greater than the lift
station peak design pumping rate? Yes No N/A

E. For a portable generator, will electrical connections be accessible without maintenance personnel
having to enter the lift station? Yes No N/A
F. For a portable pump, will quick disconnect fittings be used to connect the portable pump to the
suction and the discharge line and be accessible without maintenance personnel having to enter
the lift station? Yes No N/A
G. For a portable generator or pump, how many lift stations does the unit provide emergency
operation for: N/A

H. For connection to two independent electrical transmission routes, will the routes receive power
from the same electrical grid network which supplies power to the lift station service area? Yes No N/A

13. Suction Lift Pumps or Wet Well Mounted Lift Stations (s. NR 110.14(4), Wis. Adm. Code): Yes No

A. Will the total dynamic suction lift be 20 feet or less? If you answered “No” this question, please Yes No N/A
answer the sub-question under A.
i. Is justification provided for the higher heads based the certified pump performance curves and
Yes No
detailed calculations?

B. Will the pump equipment compartment isolated from the wet well in a manner which will prevent the
humid and corrosive sewer atmosphere from entering the equipment compartment? Yes No

C. Will wet well access not be provided through the equipment compartment? Yes No

D. Will wet well access be at least 24 inches in diameter or equivalent area? Yes No

14. Submersible Lift Stations (including submersible grinder pumps) (s. NR 110.14(5), Wis. Adm. Code):
Yes No

A. Will submersible pumps be readily removable and replaceable without dewatering the wet well or
disconnecting any piping in the wet well? Yes No
B. Will the removal of one submersible pumps from the lift station interrupt the operation of other
pumps in the station? Yes No
C. Will junction boxes for motor power cable connections and for intrinsically safe control circuits be
weatherproofed? Yes No
D. Will the motor control center be located outside the wet well and be protected by conduit seals or
other appropriate measures meeting the requirements of the NEC to prevent the atmosphere of the
wet well from gaining access to the control center? Yes No

E. Will pump motor power cables be designed for flexibility and serviceability? Yes No

F. Will ground fault interruption protection be provided in accordance with the NEC requirements? Yes No
G. Will power cord terminal fittings be corrosion-resistant and constructed in a manner to prevent the
entry of moisture into the cable, provided with strain relief appurtenances, and designed to facilitate
field connecting? Yes No
H. Do the specifications require that the pump motor comply with the NEC explosion proof requirements? Yes No

15. Duplex Grinder Pump Lift Stations and Septic Tank Effluent Pumps:
(s. NR 110.14(9), Wis. Adm. Code) Yes No

A. Will each pump have a minimum 1¼-inch pump opening and discharge piping? Yes No

B. Will the total motor horsepower for each pump be 5 horsepower or less? Yes No
 Lift Station Design Checklist
Form 3400-168 (R 08/20) Page 7 of 7

16. Simplex Grinder Pump Lift Stations and Septic Tank Effluent Pumps:
(s. NR 110.14(10), Wis. Adm. Code) Yes No

A. Will the pump serve 3 residential units or less? Yes No

B. Will the submersible pump be designed for total submergence during operation? Yes No N/A

C. Is the location of the pump station and pressure service laterals shown on the plans? Yes No
D. Will the pump be readily removable without entry into the wet well or dewatering the wet well? Yes No
E. Will all valving shall be accessible without entry into the wet well or dewatering the wet well? Yes No
F. If a pump station discharges to a common pressurized sewer, will a redundant check valve be
provided? Yes No N/A
G. Will all valves including redundant check valves be installed at the pump station (expect if a pump
station discharges to a gravity sewer)? Yes No N/A

H. Will all pumps have a minimum 1¼-inch pump inlet opening and discharge piping? Yes No
I. Will level controls using float type displacement switches be suspended in the wet well to facilitate
maintenance? Yes No
J. For submersible pump lift stations, please specify one of the following below to minimize the
potential for ignition of explosive gases (select one):
The pump motor be rated explosion proof in accordance with NEC requirements
The motor shall be listed as safe and appropriate for residential use by the Underwriters Laboratories, Inc.
N/A - Non-Submersible pump lift stations
K. For non-submersible pump lift stations, in order to reduce the potential for ignition of explosive
gases with non- explosion proof pump motors, will the pump motor be completely isolated from the
wet well atmosphere in a separate gas tight housing? Yes No N/A

Certification

I certify that this document, to the best of my knowledge and belief, is true, accurate, and complete.

Date Signed
Signature of Consulting or Municipal Engineer Responsible for Preparing This Form

Wisconsin P.E. Number