HomeMy WebLinkAbout012-740-08-5112-SAN-2022-081 "^ Department of Safety �°'�n' V�
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� � �'�� ' -';� & Professional Services,
� 1K Sanitary Permit Number(to be filled in by C�
��� � � 4 Industry Services Division 3 �
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Stau�Transaction Number
Sanitary Permit Application � �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this focm to the appropriate govemmental unit Q
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addt
the Department of Safety and Professionai Services.Personal information you provide may be used for secondary �1�i c�� ��,�_� L� Q�
pwposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �
�, ._ .._ • �C�F1ifVt71�&t�Qt�lf ;���C�1i��`�` ..8� ,.; c =, ..; ..,.
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Properry Owner's Name Pazcel�
Lt:c�•th � �� tJ %�v� t ��Z7�-/C�C��:3//Z
Property Owner's Mailing Address Property Location
�l� � l�_ I� � Go�t.Loc—�
City,State Zip Code Phone Number �
, 4 f .�-� '/., i C.?
/�'CLJ `' 'c��i LV .� � 3 5 7 /<, Section
� a,.�.� `. ' "'(��wC���l�t&PPTY) Lot# T `��N R 7 E o
�or 2 Family Dwelling-Number ofBedrooms -3 Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑C'ity of
❑State Owned-Describe Use — CSM Number ❑Village of
i j110WllOf t�lv/J�L'�-Il
l
I
�III.�ype+�f Pp�''f5 Pe�emit.(C�teok either KNew"or KReplacemegfi"and ath�r applieable�n line A. �Ch�Qek nue Iio�on line B.=C��piete�wre�if
ticab]�
+ � —,- -------- - -T---
'� �New System ❑ Replacement System ❑ Other Modification to E�cisting System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tanlc In-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventiona!)
C• ❑ Renewal Before �Revision
❑ Change of Plumber ❑ Transfer to New Owner �st F'revious Permit Number and Date Issued
Expiration Z ( "' � �`� �0 1g1�1
�Y i�!'��aAd"�`�Hk-�tfPtlC(�1itr1t:
Sn, - �gP ) P� PP (gP � P 9 , .,: ..
Desi Flow d Desi Soil A licazion Rate d/s Dts ersal Area Re uued(s� Dispersal Area Proposed(s��System Elevation
yS"t> C �- �•�r� ��5-�— e7 7� 5
Capacity in Total #of Manufacturer
Taak Information Gallons Gallons Units � ` o '$ �
New Tanks Existing Taaks � C y � y � � �
0
� U v� � v� u; C7 0.
Septic or Holding Taak �Gyq � f f, r �� ��r
v v
Dosing Chamber
I
�:ReS�ionaib��Statelrtsut�•I;��6e•�itn�rs�aed;asse►me responai6flit���as4a1tatlott ofthrPE3'6V't'S.shown on the atfael�pla�ss. ' :;
Plumber's Name(Print i Plum �-s 5i�nature � � ��
Jerry Ruid � g - '�'IY�'�F:S Number Business Phone Number
xcavatin , LLC
---� ����7 L z.. 7�S- �t 2- z�c.,`1
Pl s i , , ip Code)
Stone Lake, WI 54876
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i° ��:r�a c��� .. . �,:;
� y . . .
S' � � � � Pernut Fee Date Issued Issuing Agent Signature �
�Ap ❑Disapproved I _
'Y"V ❑Owner Given Reason for Denial $ J "• � S�`�'�' 1�'r "��'�'���'����'�'''�`
Conditions of A�rovaUReasons for Disapproval D ��j'��•
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�S� o�02 (� J C1 MAY 2 4 2012
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��4�0;CS'� 2I _ �7� SAWYER Cf�liC`dTY
ZONING AD►�ilViSl�i�ATtOf�!
Attach to complete plsns for the system and submit to the County only on pa er not less than S 12 a 11 inches in size
NO REFUNDS�AFTER
SBD-6398(R.03/22) ISSUE OF PERMtT
PAGE 1 OF 4
In-Graund Gravi�y Plan
Index � Cover Sheet
Comparent Manuai Deslgn fteferences:
Version 2.0, SBD-10705-P(N.01/01, R. 10H 2)_ ,,
Pg 1 of 4 Index 8� Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section 8� Plan �ew
Pg 4 of 4 Management Pian
A#tachmert#s: :
POWTS lica#ion for Review
Soil Evaluation R rt 8� Site Ma
Project Name/.Descrfption
Owner Name(s): L c� ��;.��.�- P� v i r�=�`� Phone•
OwnsrAddross: li[� f'�er-!�s ��! �Cw C�i4r� � Z'ip: s3s7�r-
Project Addross: ����w l��I s��y� L;ti.
t3ovt. Lat � 1/4 of 1/4, Sec�ion � , T `-i� N-R 7 E Q or W�
Tawnship: Ku��'�L�— County: ���:<., Y-�-�--
ProJect Parcei 1D�: �t 2�ti oc�Ys�o z.
De�igner Ir�forma�on
DsstBner N�ams; �e�Ruid Excavating, LLC Phone: 7� L/�.Z._ 2 �o�!
Designer Addross: Stone 18ke'W154878 �p; S`( g 7�,
E-MS��:�C cs�� � C-eti�tJf`�/C�.r� N 2..1 'Tbia space resezved for appmval stamp.
Ucense Number: 2 � �-`� ��
Remarks:
Signa�ture: �--� Date: �-� s= z� -Zz.
on..d,wbr,dmea copy.
Y
CF16dC HOOCAS APPLJUBLE CNECK BOX AB APP{JG�BLE
� SOIL EVALUATlON o �'����40' � � ❑ SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME �o= aesior��ow: �l5-cU �
�G�.-�l� �v eF Attach d�sipn flaw calatla�ons for oommsrcW plara.
PRorECr�Dcf� 118� w I�_[�n v l.n� Pipe Ma�iai I asTM standard(Tab�es 3e4.9a3 8 384.3ab)
i v�.� N �r arwer: scl, H o / �v c:
BM 8�mibd: � BM 6�r�{forc FT Fotos M�In: /
BM Da�cAplbfC 2 C>" �rS�G�C Lv��`� 11�c.c�I
��.�,�r 1�e48IA�LI
���1 w�u S�miboi(��IaD�X O �a�%� show grourd eleva�n oonbura at witabls ir�als.
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\ Jerry Ruid Excavating, LLC
W208 Count,y HWY A
Stone Lake, INi 54876
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R�eet Pnae
�SepUc Tank(s)MarufaaWrer.
IN-GROUND GRAVITY DISPERSAL AREA ���s�—
Uniform Elevation Trenches with Quick4 Standard-W Chambers ���Te�kca��d,,,�,�cs�:
3-ft Trench (down-sizing credit) i����, �, �, �,
effluent Filter Manufacxurer:
( �-����Tlr+1�'
I EtflueM Filter Model th �! � �
��.�r
SOIL CAVER �����
�r
min.trench
cna�i • •' TYPICAL TRENCH
� • '":a� .. CROSS SECTION VIEW
F`�„�,� . . .. (No Scale)
,' �� �' Provide minimum 3 ft
System Elevation=�7'��ft separation between Venches.
(bPical)
Quick4 Standard-W
W�E��P °D�"e"°"� TYPICAL TRENCH
�tyPi�� (Show location of inlet/outlet pipe connection on plan view.) (tiv�l
i�u��r�anrt�a.ars p�N VIEW
��i0i�`�"`' (No Scale}
r— — -------�f---------��------- --- -� T
L . . —_ {� 1A (�Yw�9 �
-- — ----��-------��---- --- D
B= �� ft �=; m
�ryp'��� Quick4 Standard-W Chamber w
INSTALL PERTRENCH: ���� O
(mfd by Inflltrator Syefertm,Inc.) �
IrrotaG pursuent to menufacW�efs nstrudbns.
�� Quick4 Std-W(aj 20 fl=EISA/chamber= �Z�' ft= 'A
+ � Pairs of end caps @ 6 fi EISA/pair= �U ft=
=Proposed EISA per trench= 3 Z� ft= Required Infiltration A2a= ��3 ft Distribution Method:
x �. trenches =Proposed Total EISA= ��—ft� �r�1���Y
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali 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 heatth hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a regfstered POWTS Malntainer in
accordance with SPS 383.52 (3),Wisc.Admin. Code.
Maximum Disuersal Area Operatin4 Limits:
Design Flow= ��' gpd; BODS<_220 mgL''; TSS <_150 mgL"'; FOG 5 30 mgL''
Insqection 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, eta)
o material fatigue(i.e., leaks, breaks, corrosion, eta)
o solids volume in anaerobic treatmerrt 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 exteM of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.)
o electrical componerrts-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 Se�tic and dose tank(sl shall be pumped by a cert'rfied 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 coMents shall be pursuant to NR 113,Wisc. Admin. Code.
o Effluent filter(s)shall be inspected every 3 years and shall be cleaned when nec�ssary 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 governmerrt unit in accordance with
SPS 383.55 Wisc.Admin. Code. Report any component failure or malfunction to:
Name of individual or company: �'�rr lF �C.��cs Phone: �'�- `�t�'2.-2-�t�`�
Loca! govemment unit: S C' � Phone: ��5 � �=3`r-- � 2��
Local govemment unit address ���v����-�.-.� s�: 1-la-�Y w�„�� w�-- ZIP: ��`����3
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repai�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.
Contin4encv 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 soifs.
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
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'�'''"'"`` ,. PRIVATE ONSITE WASTE TREATMENT county
/��e' \\\r�' SYSTEMS
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`�Fss,�'�'"% INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� �g (
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village l�,Town of: State Plan Transaction ID#:
1.e ti�,n�r `R��. `T�S�-- I�ti�,-�-e� �-
Insp BM Elev: BM Description: Parcei Tax No:
�o�.o' Re� �,k „� IUa� ' 0�2 -��dro,8-�'c� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,i;Cc,.�- � �pd Benchmark pp,p�
Dosing
Aeration Bldg. Sewer � ( �
Holding St I Ht Inlet � cy ,.� `
TANK SETBACK INFORMATION St I Ht Outlet q� .� '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �-�S N � � �-q ` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. c�-�, �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number �PM srs,� �(�,c� �
TDH Lift Friction Loss Sys Head TDH Ft �.,3 �
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS W � L �/ #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �� ,
INFORMATION P/L Bldg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO ,y- ''� �- � o Mound o Other
— __a-� �oi-� � _ --�� __ __ _��___
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I 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 I Sodded Mulched
- ----
Cell Center 1 Cell Edges Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies,persons present,etc.)
��5��� 2��g���
Plan revision required?�Yes 0 No �a �� �3 . — 69��� �
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
A�DITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �-a.� b��
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