HomeMy WebLinkAbout026-939-12-5430-SAN-2022-056 i� Industry Services Division Counry _ (��
1400 E Washington Ave ��w t,r �'
_ ',�= P.O.Box 7162 Sanitary Permit Number(to be filled in by C �
�'. P= _ Madison,WI 53707-7162 / � � ��
- 6 N
Sanitary Permit Application state Transaction Number N
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit —� Q
is required prior to obtaining a sanitary permit.Note:Applicatioa forms for state-owned POWTS are submitted to I'roject Address(if different than mailing ac r 11
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �� �
u oses in accordance with the Privac Law,s. 15.04 I m),Stats. �y 6���W �"°�rt `h [�
\l �
I. A lication Information-Please Print All Information s�nc. lN�� , w�
Property Owner's Name Parcel#
I i � l�iane j�e-�Son 426- �139 - �L- �H30
Property Owner's Mailing Address Property Location
�ZZqs 16Zn� s�- wts�— d'��ot �
City,State Zip Code Phone Number Section � �
I N K�V���G , /�� ����y c�rcte one)
II.Type of Building(check all that apply) t Lot# T �Z N; R 3� E orQ
or 2 Family Dwelling-Number of Bedrooms -T � Subdivision Name
Block# —
❑Public/Commercial-Describe Use —
❑City of
CSM Number ❑ Village of
❑State Owned-Describe Use �`��y� -$� �4+ 3 7 �Town of �4 ��G
III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
`�' m �Re lacement S stem
p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain)
B• ❑ Permit Renewal �Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner �� � (�f� Z y acy ��
/
IV.T e of POWTS S stem/Com onenUDevice: Check all that a 1 � - p
Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dis ersal/Treatment Area Information:
Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
600 • 7 gS7 �lao 9y'- 9s� `
VI.Tank Info Capacity in Total #of Manufacturer
�:
Gallons Gallons Units ` o 'd �
New Tanks Existing Tanks � c v " y � � �
0
a U =n ti v� i,. C7 Ci.
Septic or Holding Tank �i U \Z,SU ( l✓i LL� x
1
Dosing Chamber
VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
� ��,,, 5����f2 )Sl6/Zy
Plumber's Add ess(Street,City,State,Zip Code)
7676�✓ �� I��.L �'�- S�Y�' 7�
V[II. o /De artment Use Onl
�A ro e� ❑ Disapproved $ermit Fee� Date Issued Issuing Agent Signature
�'}� �
-•• ❑ Owner Given Reason for Denial ��' �'L� 2 Z ' l'�'��'�'�'�����
IX.Conditions of Approval/Reasons for Disapproval „ � �
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r C �� 21- 3� "�-) �� �
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� APR 2 1 2022
Attsch to complete plans for the system aod submit to t6e County only on paper oot less tban 8 vz x I1 inches SA�E�C�UN�
ZQNtNG AD�INIST'FUT�
NO REFUNDS AFTER
ISSUE OF PERMIT
SBD-6398(R.08/14)
PAGE 1 O.F 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01l01, R. 10/12),.„
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Piot Pian
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): T�"'�6��y � � �"`^e 1�c-�v'son Phone: - -
Owner Address: 1Z29S I62.,� �' w�s-)� �,d�yrj(e � l�l� Zip: �Soyy
ProjectAddress: /���66yW �"`-�'��Y� �-N � s�"� ���, w' �l�?-�
Govt. Lot: � 1/4 of �1 l4, Section �2 , T 1 Z N-R�_E 0 or W�
Township: sun� �a�,c County: S h'-�Y�
Project Parcel ID#: �3 � 3�
Designer Information
Designer Name: �f�hr� 5��� �kZ Phone: 7f� _ SS8 _ S9�c�
DesignerAddress: Zd 76N s�-�►�c �^�.0 /'�� S-�. ��,w� Zlp: S�yS�
E�mail: drl6r��G<v/7 Ll"Q9/Y1�1�•(. �O�'✓� l I. . .1,.c fc'•�ct"\'ii� li�f :i!'�'fi i..., .i_. . .
License Number: � �/ � �Z.%
Remarks:
Signature: Date:
f `u' 2�
�nal signa r ed on each submitted copy.
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Dylan Schuttz
`" 7076N Stone Lake Rd
'- Stone Lake, WI 54876
MPRS 1516129
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IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
I min.12"
Geotextile � �ryP;�,� TYPICAL TRENCH
Cover
SOILCOVER CROSS SECTION VIEW
�Z• , �,� (No Scale) OBSERVATION PIPE DETAIL
min.trench ; •
depth •��' • (No Scale)
�ryPi�l) � — — —� .• '•:. Screw-Typeor •
'W� . �—Finished Grade
, • . ' Slip Cap Qoose) + ''�' ' (mulched&seeded)
\ 1 ';,�� •. '.�.
4"0 PVC Pipe Topsoil Cover
S stem Elevation=�y�y� ft. � ' • : �•:�
y ��� ' Provide minimum 3 ft Top ot pipe to terminate (min.1 toot)
�ryP � at orabove finished grade .
separation between trenches.
(4)1/4"-1/�"X 6"Slots
@ 90 apart
i*
TYP I CAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) Anchoring Device In(iltration
Surface
PLAN VIEW
(No Scale) 4��� Observation pipe shall be installed
at jundion between two units. ft
Perforated Lateral Observation Pipe �typical)
(typical) (tyP��i)
- - - - - - - - - - - - - �,�- - - - - - - - - - - - - - - - - - - -
� �
I =_____ _______ _--=_ __ ___ ______= _______= I A= 3.0 ft D
� - - - - - - - - - - - - - - - �� - - - - - - - - - - - - - - - - - - � criP���� G�
B = ft -_; m
criP���� w
INSTALL PER TRENCH: EZ120yP Bj ndle Q
� 10-ft bundles @ 50 fi2 EISA/unit= ��a ftZ (mfd by Infiltrator Systems, Inc.) �
Install pursuant to manufacturers instructions.
+ 5-ft bundles @ 25 fi� EISA/unit= ft2
= Proposed EISA per trench = �0 ft2 Required Infiltration Area= �S7 ftz Distribution Method:
x � trenches = Proposed Total EISA= q�� �Z ����'�y ,
,
PAGE 4�F 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 Dispersal Area Operatinq Limits:
Design Flow= �G(� gpd; BODS <_ 220 mgL"'; TSS <_ 150 mgL"'; FOG <_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.)
o 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 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 (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: �y�-�•� S��"�� Phone: 7���� �S y�
Local government unit: �a"yt/ C��^"�'� Z"�5 Phone:
Local government unit address: 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 chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingencv Plan
In the event that any failed treatment component of 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.
�� —" '`>>. PRIVATE ONSITE WASTE TREATMENT �ounty
,,.,.µ ,��,�;r�
(��\�SPs, ���� SYSTEMS
��� � ( POWTS) Sawyer
k�\�—.`e=` .
�F s'—"�'"-='`' INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � �. a��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)�
Permit Holder's Name: ❑City ❑ Village �.Town of: State Plan Transaction ID#:
I�M �-�1 t�.. b �+� �-4� �
Insp BM Elev: BM Description: Parcel Tax No:
l b o.�' �►�l �- n�yo�y'� s. S,�-�. N� �.,.� oa.� -�`73 9—I�-s--4�3 a
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELE'✓
Septic � �� �� Benchmark oo,n�
Dosing
Aeration Bldg. Sewer �pa,�j��
Holding St I Ht Inlet cl ,'7'
TANK SETBACK INFORMATION St/Ht Outlet g,� �
TANK TO P/L WELL BLDG vENr ro ROAD Dt inlet
AIR INTAKE
Septic �-5-� �- o� � *-7 � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header l Man. q�(,3'
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative G3�S�
Surface
Manufacturer Demantl Final Grade
Motlel Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INF RM TION
DIMENSIONS W 3� � �o ;�p` bb` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P�L Bldg Well N/aters � IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO �-�� � o� '�b� �n� ❑ Mound o Other _ �
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) HX leo Size X Hole Observation Pipes�
Length_ Dia �Length Dia Spac �__ Spacing ❑Yes ❑ No
_— — ------- -
SOIL COVER
-- --- - ---
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���1 5��� ��a-�
r`/
Plan revision required?❑Yes� No ��a` � ^ �j� � �-b �
� �--_-�7
�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITI�NAL COMMENTS AN� SKETCH
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