HomeMy WebLinkAbout002-106-17-0300-SAN-2022-078 ��''' ' � lndustry Services Division Counry �
� 4822 Madison Yards Way ,�c.v�I{� �
�=P - Madison,WI 53705 Sanitary Permit Number(to be filled in by
��,�� �� � '���� M di�son,W[5�3707 lY ��� � Q 6 � �
Sanitary Permit Application state Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:ApplicaYion forms for stateowned POWTS are submitted to Project Address(if different than mailing a �
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. �� l�� � �G$� �V�
I.Application Information—Please Print All Information O�
Property Owner's Name Parcel#
T���►�� � s��� �� oo2 -i�c_ �-r- �300
Property Owner's Mailing Address � Property Location
�/ 7 3 6 y 1�enSon 3l✓ c;o�c.Loc��
City,State Zip Code Phone Number
�rec,p � �y � ,�y��8 _ ��' Section �
II.Type of Building(check all that apply) Lot# T �� N R (3� E or
� 3 � ( O yL( SubdivisionName
1 or 2 Family Dwelling—Number ofBedrooms � �
Block# �Qy I��-�j
�ublic/Commercial—Describe Use
I� ❑City of
❑State Owned—Describe Use CSM Number illage of
— �o�,of a�,�s ��,��
IIL 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.
�Replacement System ❑Other Modification to Existing System(explain) �Additional Pretreatment Unit(explain)
�
B' �[-Iolding Tank In�'iround �At-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
C� ❑Renewal Before �Revision hange of Plumber �I'ransfer to New Owner °st Previous Permit Number and Date Issued
Expiration �,(y��� ?
IV.Dis ersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Glevation
�Sv . 7 G y 3 �s"U q2- zr- 9 y.7.�
Capacity in Total #of Manufacturer
�'
Tank Information Gallons Gallons Units � V o $ �
New Tanks Existing Tanks � a � " � � � �
� U 'v� � v� u, C7 0.
Septic or Holding Tank Q(j 0 /d OU r �(e S C�
Dosing Chamber O �
V.Responsibility Statement- I,the undersigned,assume responsibility for installatioo of the POWTS shown on the attac6ed plans.
Plumber's Name(Print) Plumber's SignaYure MP/1�4PRS Number Business Phone Number
Dylan Schultz 1516129 715-558-5904
Plumber's Address(Street,City,State,Zip Code)
7076N Stone Lake RD, Stone Lake, , 54876
VI.Cou ty/Department Use Only
p to e ❑Disapproved Perrnit Fee Date Issued lssuing Ageni SignaYu
� ��o� oo s ��ao �aa -�'�,-�,-,�-j�c�''�--
❑Owner Given Reason for Denial
Conditions of App%val�easons for Disapproval
� � ����� ��
� S� a-a - � � � �
�I � �� MAY 18 20
22
,
. ,
SAWYER C:OU(�7Y
Attach to complete plans tor the system and submit to the County only oo paper not less than 8 tn x 11 inches m size
NQ flE�11NDS AFTER
SBD-6398(R.02/22) IS3UE 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 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersat 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): �`^�����`^�- �-�SP��h� sh� Phone: - -
Owner Address: ___1V73�c{ 1��s��, alv� � }-���70 , v� Zip: S'' y�gs'
Project Address: 7 G 9� �✓ �s� A-��
Govt. Lot: 1/4 of 1/4, Section 3 � , T �b N-R �� E 0 or W.�
Township: T3�ss �til�� County: S�Wy-��
Project Parcel ID#: Do Z- 10G- I"J- 0 3 oG
Designer Information
Designer Name: Dylan Schultz Phone: 715 _ 558 _ 5904
Designer Address: �076N Stone Lake RD _ Zip: 54876
, dylanschultzl8@gmail.com ��,;� tiz,�,��,.cs�,.,e�i ,�„ .,, , �,��,l ��,,,,, ,
E-mail. } �� ��
License Number: �516129
Remarks:
Signature: Date: �` ���z 2"
Origi signature red on each submitted copy.
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3 Dylan Schultr
' 7076N Stone Lake Rd
Stone Lake,WI 54876
MPRS 1516129
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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 Septi���S(s�anufacturer:
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) �a�
gal gal gal gal
Effluent Filter Manufacturer:
. �oly.(e�
f
I min.12• Effluent Filter Model#: ���
Geotextile � ��,Pi���
Cover
SOIL COVER TYPICAL TRENCH
'r CROSS SECTION VIEW
min.trench s •
depth L ��� � . (No Scale)
«'P"'��> T '• •� ''�•�•". OBSERVATION PIPE DETAIL
/ '. •• ►. :' (No scale)
• e... .
SySt@fTl EI@VBtlOf1= R. � ' • � : Screw-Type or •�,• • Finished Grade
/ryp � � Provide minimum 3 ft Stip Cap(loose) "••. (mulched&seeded)
� IC2� • ' .
separation between trenches. a•0 Pvc P�� ;•.� ';=;.�, Topsoil Cover
Top of pipe to tertninate (min.1 foot)
at or above finished grade . '
(4)1/4"-1/ X 6"Slots
TYP I CAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) ��apart
,.
PLANVIEW Anchoring Device .••+':'.'' Infiftration
4��� Observation pipe shall be insfalled Surface
(No Scale) atjundion betwsen two units. ft
Perforated Lateral Observation Pipe ��p��i�
— (typical) (ty�icaq
r - - - -- - - - -- —�i`— --- - - - -- - -- -- - --}- - - - �
I ==_==_ _______ _--__ __ ___ _______ _______= I A= 3.0 ft �
�-- - - -- - - - ---- - - �� --- - - --- - - - - - - - - - - � cryP���>
B = 6.� ft rn
-� c�►,
(tYP���)
INSTALL PER TRENCH: EZ1203H Bundle �
(tyPical) �
� 10-ft bundles @ 50 ft� EISA/unit= 3�0 ftz (mfd by Infiltrator Systems, Inc.)
Install pursuant to manufacturer's instructions.
+ �_ 5-ft bundles @ 25 f� EISA/unit= �-� ftZ
= Proposed EISA per trench= 3Z� ftZ Required Infiltration Area= 6�3 ftz Distribution Method:
G �.L �
x 2 trenches = Proposed Total EISA= ��6 ftZ �`"'r ' Y
��
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 performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Disc�ersal Area Operatinq Limits:
Design Flow= G/�_ gpd; BODS<_220 mgL''; TSS S 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 wher� 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: �j��� J� �''�� Phone: 7�r��'Sy�f`
Local govemment unit: S°`"Y� °""'"�"� Z��',7 Phone: �`�" �3''— �Zdd'
Local government unit address: ��1 Krl✓�' � '�'' ZIP: �B�
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.
,�j�=�"`` . PRIVATE ONSITE WASTE TREATMENT county
�' �`''K�.
�����o�Sp ��j sYs-rEMs Saw er
�`'ry\�% ( POWTS) Y
�s'"—�'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��-0?g
Personal Infonnation you provide may be used Y'or secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
1 �h.►�I a � S ot
Insp BM Elev: BM Descriptio : Parcel Tax No:
��.� Cov�C ., �1�i� ��.��P�,�Q.. ��. p� _ ��(� �' �7 —C73C��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,;��� �ypp Benchmark (o�,o�
Dosing
Aeration Bldg. Sewer �S�
Holding St/Ht Inlet (S I
TANK SETBACK INFORMATION St/Ht Outlet 4�9S'�
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic �� �� q �-�j � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. 9 S`, 6��
Holding Dist. Pipe
PUMP/51PHON INFORMATION Inflltrative ,
Surface �Y,s
Manufacturer Demantl Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W '3 � (oS f #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
P I L Bldg Well ❑ IGP o Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO t � �' � N o Mound o Other
�S- ��"�--
DISTRIBUTION SYSTEM X Pressure Systems Only
Header 1 Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
-- - -- --_—-
SOIL COVER
Depth Over l 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�/ � ( � �l�-�
Plan revision required?❑Yes❑ No p �.� 23 c�-� 6��(.b �
�
Use other sitle for additional information Date POWTS Inspector's Signa u Certification Number
SBD-6710(R.3101)
A�OITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT Nl1MBEA: ��L-O^7g
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