028-642-29-4207-SAN-2022-245 Department of Safety c°"nry
e & Professional Services,
5�Qw e,+�'
a� - Sanitary Permit Nu er(to be filled in by �
t Industry Services Division
� 3�1 �- 3 a '�
Sanita� PeY,mlt Ap„llCatl�n State Transaction Number �
�� -�,
In accordance with SPS 38321(2),Wis.Adm Code,submission of this form to the appropriate governmental unit �/'1
is required prior to obtaining a sanitary permit.Note Application forms for state-owned POWTS are submrtted to Project Address(if different than mailing a
Ihe Department oY Safery and Professional Services Personal information vou provide maq be used for secondary
purposes in accordance with the Privacy Law,s I�0<t(1)(m),Stats t Z�/_c�'� --�.��I�� �^ � / �. G
I.Application Information-Please Print AII Information UJ7 C'�� �'`'r�
Property Owmer�s Name Parcel#
z0.f1DYl I CGt�1 n L(-C O 2 b'-(p�-Z-ZCl -`�ZD`�
Property Owner's Mailing Address Property Location
i�6 I �--a-Ke �e.c� �ve . c;���+ot
Ciry,State Zip Code Phone Number p
�� \��JVf 1 . �-l.�Z- :� .� 7� �7�5 - TVG.� �7�0, �)l�l�%,�G`'/.. Section Z-1
II.Type of Building(check all that apply) �o�# � T Z N R
�I or 2 Family Dwelling-Numbcr ofBedrooms � Subdivision Name
Block#
❑Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number r ❑Village of
�Z2� �To��m of - �
� � 7z _
III.Type of PO«'TS Permit:(Check either"New"or"ReplacemenY'and other applicable on tine A. Check one box on line B.Complete line C if
a licable.)
.a
❑ New S}�stem �teplacement System ❑ Other Moditication to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank `�n-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permit Number and Date lssued
❑ Transfer to New Owner
Expiration �h�` ?
1
IV.Dispersal/I'reatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Rcquired(st) Dispersal Area Proposed(st) System Elevation
SZ� - �7 ��f 3 C.eSD s'8, (v �
Capacity in Total #oY Manufacturer
Tank[nformation Gallons Gallons Units � � �o � ;
New Tanks Ecisting Tanks '` c y ` v � � �
c. U n �, ;n .. C: �
SepticerFleldi�Tank iO� �OQQ ( �' �S
Dosing Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility f r'nstallation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signatur MP/N1LR�Number Business Phone Number
.��� K���,,� Co�S'75� 7�S -Iyd��- 33SS
Plumber's Address(Street,City,State,Zip Code)
� n ._ �C�,c �o (o C�i��f c�J 1 .S�f�2/
VI.Co nt-/Department Use Onlv
�Ap Disapproved ��rmit Fee Date Issued ]ssuing Aeent Signature
❑O�aner Given Reason for Uenial ���.�� �I'�I�a T "�"_-`
Conditions of Approval/Reasons for Disappro�al �; � � �� j!��i�� ! �,�, ;� r+`'�;
... . � �� , � .:
f ,.��:/�''� {_'�_� �'�1. i ��
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� ��L � S�P 0 2 2022 E--
i� '� �::;�k# �3��v�N __ . _._... _�
� I�Je,w-- w�r td� 3353 SAVVYER C�.��3t�1��'
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Attach[o complete plans for the system an ubmit to th Counh�onlv on �aper not less than 8 1/2 x 11 inches in size
N�RLFUND�AFT'ER 3 b y�{3
ISSUE OF PEFcNlIT
SBD-6398(R.03/22) �
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): �Q,r�nn'����n LLG Phone: Z�- {oz - 371�
Owner Address: �f�OI Lc.ILe l�i2u� �le, MC� �cen� �v r Zip: S-3�o�,1
Project Address: �Z�(os� ��cl i� S �nd �� ��e,�,,,� W�'
�t: �' �) W 1/4 of�1/4, Section �-�( , T �Z N-R�E ❑or W �
Township: sp►�2,r� [_1�1� County: �G uiu
Project Parcel ID #: o z$-io�#z - 2�-�4 2a'7 Lo-�- (� CSvn ��zz� �' I�z
Designer Information
Designer Name: �cs� (��� Phone: 71�� - 7y8 - 3js
Designer Address: (�b, g�C ��O CQ���. W r Zip: ��2./
E-m a i I: ��1�f1� C�t��r-�-Y'o < <.o tn^ . ,
C �
License Number: (o�S'�S�
Remarks:
�
Signature: Date: �' .� -22-
Original signature required on each submitted copy.
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Cross Section of a two cell EZ Flow In-�Grounc� Dispersal Component
Cell Separat�iori
3 f 3 ft 3'
�I„g____ ,��' R'� Final Grade
>c � ;'�F� ,b.�� � ��,ai � . +2�t �C,'�
`�` _ `.�ceu ui - ... ��t�� �4:`�x,`�..�'� ���ceu�z � „'��f'�:
_ , --�r.'�`_ � ���s ` µ,�a' � �y�};J Geotextile Fabric
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12"� \~ �"'r' � ��
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Design Flow�5U/Loading Rate o 7 =Required dispersal area (o�f3 Cell#1
System Elevation ���
Required dispersal area GSD /50(EISA)___i 3 (number of units) F;nai�rade: qb�9 �y4+��
Geotextile fabric to meet Comm 84.30(6)(g) � �\ Cell#2 �
Minimum of 12"of cover over top of cell u 5�5 �J System Elevation: ��_�o
Two ObservatioNvent pipes to be provided per cell � Rd,9 �
�7 X (05 ' �' CC.S Final Grade e
Not to scaie
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Disqersal Area Oqeratinq Limits:
Design Flow = �{S�D gpd; BODS <_ 220 mgL''; TSS <_ 150 mgL''; FOG 5 30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
c material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution /drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.)
o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tankls) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any ,
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: �. �i'�1 USS e{� Q" �S Phone: _�(S-- ��/�- �jSS�
Local government unit: �Q,I,lIU�2-Y� W � ��1-�Xl�( Phone: �7��-(o3�F- SLbB
Local government unit adtlress: ��,�)�W,�� W r ZIP: ��* �
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemicat or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqency Plan
In the event that any failed treatment componentbf this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
'°'�''—��T"��`� PRIVATE ONSITE WASTE TREATMENT �ounty
.<� r<,�,
��� �'� SYSTEMS
`����5�$ ���� POWTS SaWyeT
��L_-��i ( )
���="'�'=="'' INSPECTION REPORT sanitary Perrnit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� �a y�
Pe�onal infonnation you providc may be used for secondary purposes[Privacy Law,s. I5.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
��, �� C���, Lc.�. S ;�- C�l�- --
Insp BM Elev: BM Description: Parcel Tax No:
(oo.o ` o �..11 o�.,s� D�B- 6�t� - ��_���
TANK INFORM TION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W; ( ppp Benchmark �po,�,�
Dosing
Aeration Bldg. Sewer �3,�(�
Holding St/Ht Inlet ct , �
TANK SETBACK INFORMATION St/Ht Outlet �, , �
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic � }�` �Y� �� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. t�'�, S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative ,
Surface �.�f�
Manufacturer Demand Final Grade
Model Number GPM � �
��, 1
TDH Lift Friction Loss Sys Head TDH Ft o,3 �
Forcemain L Dia Dist.To Well � �3 '
DISPERSAL CELL INFOR ATION
DIMENSIONS W 3� L � �� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP o Chamber Model Number:
❑ AG 1� EZFIow
CELL TO ��p� -f—�p' .�. ' n Mound o Other
-- ---- —�__ __3"S'b
--- -- __ ---
_.---- —__—
DISTRIBUTION SYSTEM X Pressure Systems Only
------ — _ — � _.
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac , Spacing ❑Yes ❑ No
_
SOIL COVER —
— - — I
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center 1 Cell Edges � Topsoil � ❑ Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
�s� ��� ����1�.�
Plan revision required?�Yes 0 No 03 v$ �-3] � � _l �c� �
(n�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITI�NAL COMMENTS ANO SKETCH
SANITAAY PEAMIT Nl1MBEA�__�.��-�_
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