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in accot;dance�ih SPS 38321(2)_Wis.Adm.Code,submission of this form io the appropria*w govemment2l unit � 1
is requi:ed pr:or u ob�ining a sarti2ry pe^�it. Nott:P.ppii:zzio^Forms tor sate-o�+�ned?L�v+'TS 2re scb^ittr..+m ?:o;ect Addr,.ss(if differeni:han naiIing address) �
:he Deparr.enc of Safery and?ra_cssioaai Servia. Person2l ir;ormz�ion you proYide ma;+be used far sronda.-y �.�
ourvoses in ac�cordanu with the?riv Lavr.s.3�. T m).St�u. r r �,�-,, I 1�
I. Aa ticatioa informa£ioa-Pieasc Prini Alt.s.ormaiion � �3�b ry '�OCf L✓� �
Proper!y Owner's Name I Parcel r
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� ?ropem Own��s?�!zil;•ng Address Properry i.,oczeon
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; Ciq•,S:�te i Zip C�de � ?hone Nu•r.be: + �_�����s �tion b
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� �r I.�yBe f$uildidtg(check a�l�hai apply) :,oc� ;
�i a 2 PamiIy J�veiling-Numb�r ofBedrooms
3 � ' i Subdivision Nzme
s�ock= TzoDt E L.tJ. E STi4T�5
❑Pubf idCommcrcial-Desaibe iJse �
�City of
❑S�ate Dwned-Describe Use CSM?v umber �viitaga of _
�ownof �SS �.o� �
T�1.Type of Permit: (Check oniy one boz an tine A. Complete liae B if appticab3e)
A. �ew SySi�r.t � 1�Replzc�c:�t Syst�r, � n?reatmeaUF?oidir.g Tu,k Repiarzme�t Oaly I! Q Orha Modifiation sc Existing Syscem(explain)
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8. I i,•st?revioas Permit Ni:mber and Daze Issuec
❑?ermit Reaewal i�?er-iu�evision L C:�ange oi?I•W bc ❑Ptrmit?:�ssfa to Ivew ,
Before Expir2sion Owner —
Fv.T• ofPOwTS S m/Co� eatlDevice: Check$if that a 1
�Non-?ressuized in-CKourid u?ress�C in-Gra�.*id !At-Crade ❑Mour:d>24 ia.o:`sn.�l�SCi3 ❑Mo�d<24 ia of suit3ble soil
G Holding Tank ❑OtherDispersat Comoonent(ex�i�in} �Pre�e�riert;Devtce(explain)
v,Dis i/T'reat�eent Area Infcrmation:
Desim Fow,(gpd} Design Soii App14�-ion Ra�e(gpt�st? i Dispe;szt Ar�R:yuired(� � Dspersai Ara?ropo (s� Sysum Elevation
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�7I.ReSpo�esibility Stzument-I,me undersigaed,assame respo�t�ifiry for iastallaiioa of the YflWTS 53ro�ra o+i LDe aCaChed pla�.
?!um�r's Name{?rint; PIuiicer's Si�aw�e � MDIMPRS I3umber Business Phone Tdunber
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P;umber's Address(Street.Ciry,Sr�ce,Zip Code)
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VIII. ouatv/De artmeat Use Oniv
Ap3 TW �Disapproved ?ermi:r'x �L4n:ed � :ss�:g Ag�Signa:ure
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D.o�,«c:��,��ro���: ; OE�. 1�
IX.Coaditioas of perava�ffteasans for Disapprovai ��7�
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SBD-63S8;�0313) NO REFUNDS AFTER
ISSUE OF PERMIT
PAGE 1 OF 4
In-Ground Gravity Plan �
Index & Cover Sheet
Component Manua!Design References:
Version 2.0, SBD-10705-P {N.01/01, R. 10/12) . ..
Pg '� of 4 index & Cover Sheet
Pg 2 of 4 �'lot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enciosures:
' POWTS Applicaiicn for Review
Soil Evaluation Report & Site Map
�
Project Name / Description
Owner Name(s): �, 3 L-�n� �.. l- C. Phone: (�oZ 4oZ_ 634 1
Owner Address: � 0 S 6 [ ►J O ' �r<<h l--� : �( 2.�, Zip; f-���, S`f��f3
Project Address: 9 3�Sb �.1 (3�o �,-c L✓�
Govt. Lot: � 1/4 of s w 1/4. Section�_, T�N-R�_E�or W �f
Township: (3 r�s s 1�.� 2- County: S�wc.�-e �-
Project Parcel ID #: C�D Z -�t�b -- o � _ 34 D �
Designer Information
Designer Name: �o � �.-4 �4�''�e Phone: ��S - �q�- a�3�
Designer Address: ��S�ct W S� t�w� �7 f-�ay�c.l�-t.�-Zip: ��g`t3
E-mail: _ ... ,.
License Number: Z�(o Z i Q�
Remarks:
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Signature: �o� Date: ,� z zL
Onginal signa ure required on each submitted copy.
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IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer:
LV i e se�--
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit) Seplic Tank(s)Volume(s):
100�gal gai gal gai
� � _ _ E(fluent FHter Manu(aciurer:
SOI�COVER �a �y����
min.12" {�
(ryplcal) Etfluent Flller Mafel#: �Z J
12"
min.Irench
TYPICAL �TRENCH deplh — -
CROSS SECTION VIEW �"��`��' �. �
_ ___ ___ _--- - .,.. .
' -• ' 4 <; Provide minimum 3 ft
(No Scale) I�--- s4°-4----_� •a • • separation helween trenches.
��YPlcal) .e e ' , . .
-' . 4
O
f-lighest Trench ---- ----------- --- Lowest 7rench(as applicable)
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System Elevations= q� ft; a � ft; ft; ft; ft
Quick4 5tandard-W
w/End cap ObservatlonPlpo TYPICAL TRENCH
t ical (Show location of inlet/outlet pipe connection on plan view.) (ryplcal)
�yp � Install per manulac(uror's PLAN VIEW
� Instructlons.
(No Scale)
r- - - - --- -- -- - -- - - - -��- -- -- - __ - _. /f- --- - - �,�� - - - - — �
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� � �.'`,� �.� ��` r ' j � A= 3.0 fl
��� ����. 'D�,� �'�' r � ��� �typfcol) �
�--- - - -- � - -- -- --- - - - �� - - - -- - --- ---- �� - - - - - == — = --= - D
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f-.--- B = �o ft ---------- - � m
(typicat) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: ��y��ca�� �
(mfd by Intlllrator Systems,Inc.) —n
Install pursuant to manufacturers inslructions.
�� Quick4 Std-W @ 20 f�EISAlchamber= 3�n ft2 "P
+ 2- Pairs of end caps @ 6 ftZ EISNpair= � Z ft2
=Proposed EISA per trench= 3 S� ftZ Required Infiftration Area= ��3 ftZ Disiribution Method:
x Z- trenches = Proposed Total EISA = 7oy ttZ q rc�� � �t
PAGE-�OF �
In-ground Gravity Management Plan �
IMPORTANT:
The owner of this in-ground gravity system shall be respcnsib(e fcr its perpetual operation and maintenance pursuant to
requiremerts of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52 (2),Wisc. Admin. Code, this system shali
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, aii inspection and maintenance activities shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersa! Area Operatina Limits:
Design Flow= �'S� gpd; BODS<_220 mgL"'; TSS 5 150 mgL''; FOG � 30 mgL"'
Inspection Checklist lNSPECT EVERY 3 YEARS
o type of use
o age of system
o ruisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunctior (i.e., pumps, valves, switches, floats, etc.)
o material f2tigue (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 fateral or fateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAfN EVERY 3 YEARS (or when necessary)
o Seqtic and dose tank(s)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 ('l/3)the liquid volume of the tank(s) or
as required by iocal 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
mcnths.
�
System maintenance reports shal!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 individua! or company: R 0 b L,c� bc�.r« � � �q Phone: ,�S —b��— �� 3 �
Local government unit: .S�W�1�r Co �o✓i�vtc, Phone: ��s-634 -SSZ-SP�
Local governmen±unit address: l� b�� rVlcz�r .S"� � �-1�''t �`�f W��� �IP: �t��f-3
Any derective part of this system shali be repaired, replaced, or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacement of fGiled or malfunctioning components shall comply with SPS 383,Wisc. Admin. Code.
No product for chemical or physicai restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shafl 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:his POWTS is discontinued, it shafl be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
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` '�"�'" PRIVATE ONSITE WASTE TREATMENT county
,/;t��--r__�\r
� o$ � ���� SYSTEMS Sa.W eT
�\��.��s� �.�, ( POWTS) Y
\`Fstiio�•%�/
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 22 �.��q�
Personai infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)J
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
l�r�.�. L l..C-- �as I��-- ,--
i�sp BM Elev: BM Description: Parcei Tax No:
�.o� !��(a-(��b�� Ya`` -+ S_ s,�.t. t�-"�'�dc P1� ooa- a�B-oo _oi o0
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w�a..�- 1 �;pa Benchmark ��,� �
Dosing
Aeration Bldg. Sewer �(o '
�
Holding St/Ht Inlet �`�,,,, �
TANK SETBACK INFORMATION St/Ht Outlet s;��
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic ,�-� �-�` �o' {-(O� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 9'Y$ �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative ��gl �
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � L (7$ 6 #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��1,
INFORMATION P I L Bldg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO 3.�` � j-� ❑ Mound o Other -- QY�
DISTRIBUTION SYSTEM X Pressure Systems Only
— — -______T_
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
---
--- -----— ---
SOIL COVER
Depth Over �Depth Over Depth of — � Seeded/Sodded � Mulched
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No�
COMMENTS: (Include code discrepancies, persons present,etc.)
� �s��(�.� 8��� �2—�
Plan revision required?0 Yes� No � � �� � L��^�. � - ) /�.� I r
_ �`� !� �
Use other side for additional information Date POWTS Inspector's Signature Certiflcation Number
SBD-6710(R.3/01)
AO�ITI�NAL COMMENTS ANO SKETCH
SANITAAY PERMIT Nt1M8EA: �� - Do2 f
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