HomeMy WebLinkAbout026-939-12-5725-SAN-2022-076 �u�^"T"'��r� Industry Services Division County �Jl
� `� 4822 Madison Yards Way ,s c`;.,� �,�` y
�� ` Madison,WI 53705 Sanitary Permit Number(to be filled in by C }
` P.O.Box 7302 `
��,����'� Madison,WI53707 �;�--;,��� (J�'� �
Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this foan to the appropriate govemmental unit �
is required prior to obtaining a sanitary pernut.Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing ad
the Department of Safety and Professional Services.Personal information you provide may be used for secondary ���;�{"�j �; '�, ��7/ � --�
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.
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Property Owner's Name Parcel#
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Property Owner's Mailing Address Property Location
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Ciry,State Zip Code Phone Number
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�1 or 2 Family IJwelling—Number ofBedrooms � � Subdivision Name
Block#
�ublic/Commercial—Describe Use �f�► ��
�City of
�State Owned—Describe Use � �i CSM Number '� /yQ illage of
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�ro�of S�t;�<< �.�k�
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'�' �1ew System �teplacement System ❑Other Modification to E�cisting System(explain) ❑Additional Pretreatment Unit(explain)
Y�I
B' ❑Eiolding Tank �In-Ground �AAt-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
C. ❑Renewal Before �Revision hange of Plumber �I'ransfer to New Owner ist Previous Peimit Number and Date Issued
Expiration (,�y��� ?
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Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation
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Capacity in Total #of Manufacturer
Tank Infotmation Gallons Gallons Uniu � � � $ �
New Tanks Existing Tanks � Q � � � � � �
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Septic or Hoiding Tank �/�V� � C U � �(F-JG?jr
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Pl er's N Plu r's Signature MP/IvIPRS Number Business Phone Number
"�'erry��i`c��xcavating, LLC � ��
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9 Pemiit Fee Date Issued Issuing Agent Signature
�.A� � ❑Disapproved $ �00 � ` � ^ �„.- ` i . ,
❑Owner Given Reason for Denial ��i`I ,r� ����'i-���•<:���_��=��'�^�-'',,`v�=—
Conditions of ApprovaUReasons for Disapproval
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SAWYER r���'�Tv
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Attach W complete plaus for the system and submit to tLe County only on psper not less ffian 8 3/1,:11 inches in size
N�0 RE�UNDS AFTER
SBD-6398(R.02/22) ISSUE OF PERMIT
. �
PAGE 1 OF 4
In-�G�nd Cravity Plan
lnc�ex � Cover S�fieet
Componer�A��al Design Ref+�noes:
ve�on 2.0,s�o-�o�M.01/01,�. �a�zj.. •
Pg 1 of 4 . lndex 8� Cover Sheet
Pg 2 o�f 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Sectian 8� Plan View
Pg 4 of 4 Management Plan
�act�nerrt�: :
POWTS ' for Review
Soil Evaluation R 8� Si�e Ma
Project Narne/Descrtptlon
Own�r�(a): �tis e�.'i W�-.�rv�r" Phone:
OwIfK Aidd�: 1� i3�x .2. s�e;-9�L���'e. w:.�- �p: S`/�7�
�N: I�l F��t 3 W C�, �-I�..s y •L
L.o� 7� �o�f �t�Sectfon I� . T 3`� N-R � E Q or W 0
Tv�; S�.� � L�.6�� Cowhy: S�� w Y c:�"
PI�Ct Pae�sl�#: o�,E:�[ 3`��c l a� 7��
��t� 1�01'1t18�Ot1
��; Jerry Ruid Excavating, LLC p�M: 7iS -`-I'�,Z- ��i cf�
D�si�/ldd�ws: �tone t�ice,wt saS7s ap:
E-R1i�: --��'u�d � GGti7Tvr�T"G!. ti�?— Thia:pue raernd far approwl ammp.
Ut�ta!Numb�er: � '-( 2.�'t 6�
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CHECK BOX AS APPUGBLE CNECK BOX AS APPIJCABLE.
� SOIL EVALUATION S�'�� '°'40' Q SYSTEM PAGE 2 OF �
o ao so so �
SITE MAP PLOT PLAN
PROJECT NAME: �Oz DESIGN FLOW: YSO GPD
�0.�N e,r^ Attech design flcw caicx�lations for commercial plans.
PRWR�,lEcr ADDREss: l�/C��t 3 G�J �o �w�y' � Pipe Matarial 1 ASTM Standerd(Tablea 384.3a3&384.3Q5)
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/!�O•C� santtarYsewer. � ��
sM gymbor:�, s�e�on: Fr Foroe�e�n: /JlA /
B�►o�p�,: i3 ar�o r� �� L�ooS`
i„��,,,�,py IMPORTANT:
Slops c�afent(96) wsl�symbd(aappnc.ds): Q araw�r�.n anow Show ground elevatlan contours at auitable intervals.
of Tes�ed Ara� on ths approprks�e.
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Jerry Ruid Excavating, LLC
W208 County HWY A
Stone Lake�WI 54876
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Septle Taric(s)AAsrAerb+ar.
IN-GROUND GRAVITY DISPERSALAREA w����r
Uniform Elevation Trenches with Quick4 Standard-W Chambers s�T�,,u.��c.x
3-ft Trench (down-sizing cxedit) 1aYJ�, �„ �„ �,,
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pllu�«a Fuar Moae�� �—T �
min.72'
SOIL COVER ���)
mh�.�trr1�
c�� • • TYPICAL TRENCH
• . • '"':�••. CROSS SECTION VIEW
�-�� .. .. . . (No Scale)
, ' ..•�•
• � �' Provids minimum 3 ft
System Elavatlon=`��S�ft �°�0����•
(h�P��eq
�uick4 standeb-w
w/EnC Cap (Show locatlon of inlet/outlet pipe conr�eetiai on plan view.) �RD' TYPICAL TRENCH
(�'�) ��� PLAN VIEVV
YWoid1s (No Scale)
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ttra��� a,�a sm�a�►+a-w cnam� w
INSTALL PER TRENCH: �� �
�mr°br��traroor�r�a x�� TI
qWd D�+ruM b rtrnufa�Ms In�udlda
I ka c�,�a�a sm-w�20�e eisaa,�_ � Z� t� �'
+ � Pairs of end caps�6 4l�EISAlpeir= � ft
�Proposed EISA per trench= �ft° ReQuired Infiltratlon Area= ��� ft� D'Islt7buti0�M6thOd:
x a trend�es=Proposed Total EISA= �2 ft2 ���-u��Y
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. . . . PAGE40F4
In-ground Gravity Management Plan . �
IMPORTANT:
The owner of this in-ground gravity system shall be responsibie 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 pian.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maint�iner in
accordance with SPS 383.52 (3),Wisc.Admin. Code.
Maximum Disaersai Area Operatina Limits:
Design Flow= ys C� 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, efa)
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, efc.)
o exterrt 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 spec'rfication)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Se�tic and dose tank(s)sha11 be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats.when the volume of solids in the tank(s)exc�eds 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 filteKs)shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's spec'rfications. 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:���'�'`� � � ��-� Phone: ��-S - ��i�� Z`���
Local govemment unit: � C �- Phone: 7i5—C� 3 �f"����
Local government unit address: J C��,I O /ul��� 5 i; s�--����`f� ��Y U��z.--� ZIP: ��`a��-1�
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
acxordance with SPS 384,Wisc. Admin. Code.
Contincencv 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.
Reset Pa�e
��> �' F`� PRIVATE ONSITE WASTE TREATMENT county
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o$`' \ `�' SYSTEMS Sa,W er
I�,��`� e.s������)
�� ���/ ( POWTS) Y
�>-s'—°�"'=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.a.6"7�
Personal infonnation you provide may be used for secondaiy purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Pian Transaction ID#:
Cqs2 InJ�M�� Sa� l.0�-- '_
Insp BM Elev: BM Description: Parcei Tax No:
l�° •a � �.�n, a� �aC oa-(fl—a31— f2S"7��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �„� 1 � Benchmark po,p�
Dosing
Aeration Bldg. Sewer
r
�'�o.(�7
Holding St/Ht Inlet � �
�
TANK SETBACK INFORMATION St I Ht Outlet �s� �
TANK TO P/L WELL BLDG vErvr ro ROAD Dt Inlet
AIR INTAKE
Septic -�g� ,�-�' �� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. c��3 r
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
i
Surface � y�3
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO M TION
DIMENSIONS �N � L � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ,J,�,t�`'.
INFORMATION P/L Bldg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELLTO �� -I- ��'� -}� � ❑ Mound � Other �,Y f
----- _- — -- -------- —
DISTRIBUTION SYS EM X Pressure Systems Only
Header/Manifold �Distribution Pipe(s) X Hole Size X Hole Observation Pipes �
Length Dia �ength Dia Spac Spacing ❑Yes ❑ No
_ __--- _
SOIL COVER
--__ -- - - - ----._ —
� Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center l Cell Edges Topsoil _ _ _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No I,� � Za �3 ���-- - � C�� ���
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT Nl1MBEA: �.� --07,�
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