HomeMy WebLinkAbout024-741-30-5313-SAN-2022-077 ��'" "'` Industry Services Division County , �
4822 Madison Yards Way S��y—z� �p
: ,�: - Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) �
` Pi P.o.Box 7302
Madison,WI 53707 ���Q d� '
�
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for staieowned POWTS are submitted to Project Address(if different than mailing addres< d
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ,�Q ZG 71V �u.,e�� 13�c,G� /�� �
I.Application Information—Please Print All Information
Properry Owner's Name Parcel#
��� � 3�j�c �'h�G��ow ��Z o2y- 7y1� 3o-s3 �3
Property Owner's Mailing Address Property Location
3oZ G.�o�x �.:d�c Di' 3
Govt.Lot
Ciry,State Zip Code Phone Number
�ue�.Sv+� � w� SyO�(� '/<, '/<, Section 3 6
II.Type of Building(check all that apply) Lot# T �'�� N R �� E o
or 2 Family Dwelling—Number ofBedrooms � Subdivision Name
Block#
�ublic/Commercial—Describe Use
aCity of
❑StaYe Owned—Describe Use CSM Number illage of
own of ��'+�� ��4L
III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C i
a licable.
A ew System nReplacement System �Other Modification to Existing System(explain) �Additional Pretreatment Unit(explain)
LJ
B' �Iolding Tank n-Ground �At-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
�'• ❑Renewal Before Revision hange of Plumber ❑I'ransfer to New Owner 'st Previous Permit Number and Date Issued
Expiration 2� _ ��7
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpols� Dispersal Area Required(s� Dispersal Area Proposed(st) System Elevation
7fo � 7 I o �Z -#�� �o �.� q 3= gs`
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units � � o � �
U � v� '
New Tanks Exisbng Tanks L a y; � � a � `�
n. U in �, c7� ii. C7 0.
Septic or Holding Tank I 6 y S `> �(C�s � ��g S�-o�
r
Dosing Chamber � a
V.Responsibility StBtement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumbers Signature MP/1�1PRS Number Business Phone Number
Dylan Schultz 1516129 715-558-5904
Plumber's Address(Street,City,State,Zip Code)
7076N Stone Lake RD, Stone Lake, I, 54876
VI.C un /Department Use Only
� J ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial
$ S O.°O � �� '1 ` �-�i -Y,,�,c..�.n,:����-�luv�.c!}-
Conditi4ns of Ap rovaUReasons for Disapproval
� �--, �? �.
.� ,.. � ;rt �a - (;5�-i � ��„'��,�.�� J�
_ - � O
�I � C S� a � �s � r� MAY 18 2'022
��
SAV�'Y�MfN'�SURl�TION
Attach to complete plans tor the system aod submit to the County only on paper not less than B vz x 11 inches in s�ze
SBD-6398(R.02/22) NO RE�UNDS AFTER
M�.{ ISSUE OF PERMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12), ,.
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): 1�. ehn � S�):e Sak,��ow;�z Phone: - -
Owner Address: 3oZ G�o� X ��`�9 e, o�� _ Z�p; —� Syoi6
Project Address: I�Z�7/� S�a y ��� r�
Govt. Lot: 3 1/4 of 1/4, Section 3 6 , T �l 1 N-R 4 7 E Q or W �
Township: ��nd � �� County: S��Yz�
Project Parcel ID #: d 2y - �Nt- 3 0 - 5313
Designer Information
Designer Name: Dylan Schultz Phone: 715 _ 558 _ 5904
Designer Address: �076N Stone Lake RD Z�p: 54876
dylanschultzl8@gmail.com
E-Illdl�: �;rii� �t�<�ee t�eser�ecl fi�r�i},��ru�'al St;;.tnp.
License Number: 1516129
Remarks:
Signature: Date: S� � �-2Z
Original ature r on each submitted copy.
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7076N Stone Lake Rd
3. �S.SS� Stone Lake, WI 54876
.� Sa'.�s� s�sfe�. q�f•5` f
MPRS 1516129
��� 5ewet- �'��.35� s� R� 951��
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i N-G R O U N D G RAV I TY D I S P E RSAL A R EA Septic Tank(s)Manufacturer:
i�«s�
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume{s):
3-ft Trench (down-sizing credit) b��
� gal gal gal gal
Effluent Filter Manufa�turer.
p o(y (v c(,�
I min.12' Effluent Filter Model#: �d�V �o�K 'S Z'�
Geotextile I (typical)
Cover
SOIL COVER TYPICAL TRENCH
12� CROSS SECTION VIEW
min.trench s •
depth L •��.: � � (No Scale)
«'P"��� T ': . .: � . OBSERVATION PIPE DETAIL
/ . �;.'� ' �No s���
yPa o�
System Elevation= ft. �' '• . : si P caP�i��� �, '�'�,u• Finished Grade
�ryP���� � Provide minimum 3 ft (mulched R seeded)
separation between trenches. a�0 Pvc P�� �•:� ';�� Topsoil Cover
Top of pipe to tertninate ,:y'. (min.1 toot)
atorabovefinishedgrade . '
(4)1/4"-1/"X 6"Sbis
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) �� a�� .
>�
PLAN VIEW AnchoringDevice Infittration
4��� Observa6on pipe shall be installed � Surface
(No Scale) atjundion between two units. �� ft "
Perforated Lateral Observation Pipe ��P����
(typical) (ry�icaq
- - - -�� --- - -- - - - -- -- - - - - - -
r-- - ---- - - - �
I =__=__ =______ _--_= __ ___ __=____ ==_____= I A= 3.0 ft �
� - -- - -- -- - - -- - - - �.L - - -- - --- - - - - - - - - -- - � c�p���� m
B = ft �i W
(�vt���)
INSTALL PER TRENCH: EZ1203H Bundle �
� (typical) �
10-ft bundles @ 50 fl� EISA/unit= ZdU ft2 (mfd by Infiltrator Systems, Inc.)
3 Install pursuant to manufacturer's insVuctions.
`+ � 5-ft bundles @ 25 f� EISA/unit= 2� ftz
= Proposed EISA per trench= 2= ftZ Required Infiltration Area= I� 7 Z ft2 Distribution Method:
x 3 trenches = Proposed Total EISA = �d�� �2 G`a"``
`� �- �o u/S o� t�
PAGE40F4
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 pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= 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 Septfc 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: _�(``Z s`�`'lf Z Phone: ���-S�" �"'`Z
Local government unit: S`'`'"y� ��"n�r 7�h•`�. Phone: �`r 6 3 Y � g��
Local government unit address: N`�yW`'"� '^'' 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.
Continqencv 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 county
��������� ��s� SYSTEMS
�� , D S ��^,
`�� �s�����' Powrs� Sawyer
'`'��-�i%� (
"ss'—°�"=� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2�_ b-��
Personal infonnation you provide may be used for secondary putposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village �own of: State Plan Transaction ID#:
1�
�v� j--�ti\�¢. ��`/�., ...,�c.-�' �n� La�
Insp BM Elev: f BM Description: Parcel Tax No:
�00,c7 6` sl��;�. �oor ..si I �a`�` ��l(— 30—��I
TANK INFORMATI N ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w��- (6y L,P Benchmark p0,o�
Dosing
Aeration Bldg. Sewer �(, q r
Holding St I Ht Inlet �b,��
TANK SETBACK INFORMATION St!Ht Outlet �f6•a `
TANK TO P/L WELL BLDG vENr ro ROAD Dt inlet
AIR INTAKE
Septic �I�-'.d � �;i,� �` NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. �j S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Inf�trative RY� r
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 �N ' L ,z�y � n � #of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters °� GP ❑ Chamber Model Number:
� EZFIow
CELL TO ± � ��p �� -�$a� ❑ Mound o Other
----- —--
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac _ = TSpacing ❑Yes ❑ No ]
SOIL COVER
- -- —
Depth Over Deptn Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil ❑Yes ❑ No �Yes ❑ No�
COMMENTS: (Inclutle code discrepancies, persons present, etc.)
;�s�l� 6(8� ��
Plan revision required?❑Yes❑ No �� a �3 ) /�, � �� �
-— ^ _w -- v
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: 20� �O 77
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