HomeMy WebLinkAbout002-278-00-0300-SAN-2022-090 �
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/���`�t'"'.;. lndustry Serviccs Division County �
%,`�;�� 482?Madison Yards Way �4W ��
j; � =p Madison,WT 53705 Sanitary Pennit umber(to be filled in by Co.) n `
� s P.O.Rox 730? Y�
'��> — -,:w^` Madison,W153707 � �j q �`�� (� �
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Sanitary Permit Applieation State Tnnsaction Number �
In accordance with SPS;R3.21(2),Wis.Adm.Code,submi,sion of this fonn to the appropriate gorernmental unit
•----- �
is rcquircd�rior to obtaining a sanitary pcmiit.Notc:.4pplication fornis for stataowncd POWTS are submittcd to Project Address(if different than mailine addres �-J
the Depaitment ot Safery and Professional Services.Pcrsonal inlin•mation you provide may he used for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. n �i,� � �
i.Application Tnformation-Please Print All information � � a f-O�� ✓�Q.
Propcity Owncr's Namc Parccl#
J� g La•�,� L�-C. ooz -��g -ao _0300
Property 0�3�ner's Mailing Address Property I,ocation
Id�l�7l N �I pC-'t�`� �"� � LI 'lC� Gov[.Lot
Ciry,State "Lip Codc Phone Number b O Z
CTC� l�e��e h� W � S y�}' ��l �,F p Z - 6 3 q I , '/., Sec�ion b y
iI.Type of Building(check all that apply) 3 L��� 'i T y� N R �� E o�
�( I or2FamilyDwelling-NumberofBedrooms 3 SubdivisionNamc
e��i
Rlock ti
❑E'ublic/Commercial-Describe Use
❑City of
�State Owned-Describe Use CSM Number Village of
3 rod i L-G N� �Town of �0.S 5 L0. L Q.
�5�4��5 S U
ili.Type of POWTS Permit:(Check either"New"or"Replacement"and other appiicable on line A. Check one box on line B.Complete line C if
a licable.
`�' �New S Stem ❑Re lacement S �tem ❑Other Modifica[ion to F..xistin S Stem(ex lain �Additional Pretreatment Uni[lex lain
Y� P Y� S Y• P ) P )
B' ❑Holding Tank �( fn-Ground �t-Grade �Mound ❑Individual Site Design Other Type(explain)
�
�(com�entional)
C. �Renewal Before �Revision �Change of'Plumber �ransfer to New Owner List Previous Pem�it Number and Date Isstted
Expiration
IV.DispersaUTreatment Area and Tank Information:
Desiqn Flow(gpd) Desien Soil Application Rate(gpci/sf) Dispersal Area Requimd(sf) Dispersal Area Proposed(s� System Elevation
�sc� ,=� �y 3 ¢� D`f R�f. S
Cup;�city in Total It of Manufacturcr
Tank Tnformation Gallons Gallons Units � � U � ` V '
ticu�Tanks Existing Tanks '` � y � y � �y q
a U rn y v; i:. C7 Ci.
cptic r Holding Tank I�o O _. roo� -
� ( e5-e►—
Dosing Cham6cr , � O �
V.Responsibility Statement-l,the undersigned, e responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Prin[) Plu er's i at MP/MPRS Number Business Phone Number
R o 6 L� �arce 22�Z.1 i S-6�i -�t_ Oci3(o
Plumber's Address(Street,City.State,Zip Code)
l`{S I ( v� S-� w '11 {-�a. w�.r� (,e.J 1 S`-�8`-{
VI.C u /Department Use Only
�,Appro�ed ❑Disapproved Pennit Fee � Datc issued issuine Agent Si�nat _
�� ❑Owncr Givcn Rcason 1'or Dcnial � /�•� � �� ( J I `�"� ���,
Conditions of Approval;Reasons for Disapproval S�r„l��5�,.,_„��.--,;--
ry �u�v/�I �f- ,.. � \.`�,,, ; :�: . ,
V r�—'�!- - � ��._J^t:.__i;�
�� CcST �a - ��°� JUN 0 2 2�22
IN
�
�AWYER COUNTY
ADMWISi'r�A�l:SN
A[[ach[o complMc plans for thc sys[em and submit to the Counh�only on paper no[less than R I/:r 11 inches in size
SBD-6398(R.02/22) NO REFUNDS AFTER
ISSUE OF PEAMIT
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 Z 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): Q 6 ��� �—�--C Phone: 60 Z - �f OZ _ (03 q )
Owner Address: l D Sb I �.1 d` B c'�e.� l��. �� R� Ffa�c�.� Zip: S`t �f y3
Project Address: Lo� 3 B c'od ; �-�-e.
Govt. Lot: 1/4 of 1/4, Section f�4 , T `�D N-R ��( E�or W �J
Township: ��SS L4�,�� County: Sqw� e �
Project Parcel ID #: Fj� Z — Z'� �3 — 00 - 63 OC�
Designer Information
Designer Name: _ �o b �,a �ar�� Phone: -I►S - 6YS - b� 3 �
Designer Address:l���t w S�" �wy Z7 ��.�1.c�4r�I L.(,�� Zip: 5� g� 3
E-maiL• _ , . , .
License Number: �7�o Z I g
Remarks:
Signature: � Date: �2 " 22
Original signature required ch s m ed copy.
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IN-GROUND GRAVITY DISPERSAL AREA � SepllcTank(s)Manufaciurer:
w � e S-��.
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit) Septic Tank(s)Volume(s):
(00 U gal gal gal gal
�o I y�O�Effluent Filter Manufacturer:
� — l
SOIL COVER i�
—min.12"
(ryplcaq Effluent Filler Model#: S 2 �
12"
TYPICAL TRENCH mldep�hch
, CROSS SECTION VIEW �"P'��" �
—_..__.___. .._._...__.__— .e., �
n a, Provide minimum 3 ft
(No Scalej � (1yPl ai) . .�� ° . separation between trenches.
.e n a ' .,
e
0
Highest Trench Lowest Trench(as applicab�e)
System Elevations= C(�4,� ft; ��-� ft; ft; ft; ft
Quick4 Standard-W
w/End Cap ObservatlonPlpe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (ryplcal)
Install per manufacturer's PLAN VIEW
� Instructlons. �NO SCa�@�
� -- - - -- - - - - - - �j�- - - - - - - - �� - - - - - - - - - —: -�
�, . ,� ' � ?��� �A= 3.Oft
'''i
i Y. ��YPical) �
� - -- — — — — — — - - �
- - ---��- - - - - - - - ��-- - - - - - - - — — D
{-- s = —10 tt _ _ _ _ _ _� G�
m
(typical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (typicaq �
(mfd by Inflltrator Systems,Inc.) -n
3�� ft Install pursuant lo manufacturer's inslructions. �
� � Quick4 Std-W @ 20 fi�EISA/chamber= Z
+ 2 Pairs of end caps @ 6 ftZ EISA/pair= ��- ft2
= Proposed EISA per trench= 3S Z" ftZ Required �nfittration Area= �'�� ft` Dislribution Method:
x 2-• trenches = Proposed Total EISA = �� ft2 �1 r�-`���7
�AGE �OF `
�n-g�ound �ravity �a�agerr�nt Plan
iMPORTANT:
Tne owner of;his ir:-ground gravi;y system sha!! oe responsib(e rcr its perpetua! operation and maintenance pursuant to
requirements of SPS 382-38�,Wisc. Admin. Cod�. Pursuant to S°S 383.52(2)>VVisc. Admir,. Code, this system shall
be corsidered G numar, neait� �azard •,f^oi maint2ired in accordance with this appreved managemert pian.
Furhermore, aii insoec:ior a^d mainterance activities shali be pe�orrned by a registered POWTS Maintainer in
accorda�ce wi'th SPS 383.52 (3),Wisc. �=,dmin. Code.
Maximum DispersaP Area Oaeratir�A Limits:
Design Flow= �'S� gpd; 30p;<_220 mgL''; TSS <_ 150 mgL''; FOG <_30 mgL''
(nsoection Checklist �NSP�CT �VERY 3 YEAFZS
c type o;use
c age of sys�em
c r�uisGnce`2ctors (i.e. odors; user�orrpiaints, etc.;
c mechanical malfunc�;on (r.e., pumps;vaives; switcnes,loats, etc.)
o ma:erial r2�igue (i.e., :ea�s, SreaKs, corrosion, efc.)
o sol:ds volume i:^, anae��bic treaG�ent tank(s) �nd ary distnbution appu�enar.ce(s; (i.e., distribution /drop boxes)
o neglect c-;mproper use (i.e., exceed+ng design cap2cities, prohibited ac�Nites, etc.)
o exter:;oT oonding in distnbution ceil pror tc dosing
c dosing irregularities-if appiicable(i.e.; pump re-cycling;float switch ssttings, etc.)
o efectrica( components-if appiicable(i.e., wiring, connectior.s, switches, controls,timers, 2larms, efc.)
o distribuiion Isteral or later2l orfice pi;�ggir.g (measure laterai dista! pressure-compare to design specification)
o su�ace discharge o?e�?iue^t or sewage back-up into st*UCfU�@ S@N$G�
Maintenance Checkiist �liAiN�A@�i �VERY 3 YEARS (or when necessary)
c Seqtic and dase tank�s;sh2!i be pumped by a ce�tified sept2ge servicing operator licensed under s. 281.48 Wis.
Stats.when the voiume of sofids in the tank(s) exceeds one-third(113)the liquid volume of the tank{s) or
2s required by(ecal crdir,ance. Disposal of cor,tents sha(I be pursuant to NR 113,Wisc.Admin. Code.
c EfFluent filter(s)sha!! be irspected every 3 years and snali be cleaned when necessary to remove any
accumui2.ed solids according to manuract�rer's specifications. A servicing period wiil always be greater than 12
mcntrs.
System maintenance seports shal! be s�bmitted te the prop�r Ecca! government unit in accordance with
SPS 383.5b Wisc. Admin. Code. Repor�any component iaifure or malfunctior to:
Name of individua!or company: �D .� �c� ��,.v-« � � l�g Phone: ��S —�SS� �� � �
Lcczl government unit: .5.2Lv�t�� l�0 �O✓1 �.�c, Phone: ��S—6 34 -�S2-S�j
Locai govesnrren; ur.it address: l a �1 D �V�,�;r S"� � �-I.ce l-�.� w�r�. l.e��P: S�-fss`t3
Any defective part of this system shal! be repaired, repiaced, or removed pursuant to SPS 383.�1 (1),Wisc.Admin.
Code. Repair or replacemen:or`aiied or rn21*unction;ng componerts sh2El cemply with SPS 383,Wisc.Admir. Code.
No prcduct ior cremical or pnysicai restor2tion oi:he POWTS m2y be used unless approved by the department in
accordance with SPS 384, Wisc.Admin. Code.
Continaencv Ptan
1n ,��e event that any railed tre2tmen;cornponen:o*:!',1S PO�S C2^�ot be reFaired, it shail be replaced pursuant to
a p!an submitted to tne appropriate agercy;or review and 2pproval. A failed ir-grour,d dispersal component may be
abandoned ar.d replaced by a code-compiyirg disoersai cempcner�in a pre-Cetermined area of suitable soils.
Svsterr�Abando�ment
if use or this FO�S is discontinued, it sha(i be abane�oned in accerdznce wi:� SPS 383.33,Wisc. Admin. Code.
-�"�;"''=T"`���r,;, PRIVATE ONSITE WASTE TREATMENT co��ty
,,>;-
='� o$ `� SYSTEMS Sawyer
���� �s �' ( POWTS)
.� �
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'"`"-''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� � D�p
Personal infonnarion you provide may be used for sec;ondary purposes[Privacy Law,s. 15.04(1)(in)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
� L�, G�C Q4ss �,Ir.R- ^
Insp BM Elev: BM Description: Parcel Tax No:
��.a` �c►� d- c�;�� ��'' � S s�. o�,l�r"(��l �' o°a -��8—oo_o3ao
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ie�� � apfl Benchmark o�,o �
Dosing
Aeration Bldg. Sewer t O I.� �
Holding St/Ht Inlet (0 (, � �
TANK SETBACK INFORMATION St I Ht Outlet l a�•8 '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic ksb' + � �-�p � �{-(o� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q 6 ,2 r
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative Q$..a r
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS W 3 � �,$ 6 � #of CellS Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��,
INFORMATION P/L Bldg Well Waters a GP �' Chamber Model Number:
❑ EZFIow
CELL TO .}��D� �a5'� �'Sb� ,�J ❑ Mound o Other QYr
— - — ---- — — -- ---_---- ----._ _____.
DISTRIBUTION SYSTEM X Pressure Systems Only
--_ ____—___--- — — T
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac_ _ Spacing ❑Yes ❑ No �
---- -._..l_
----_ _ --
SOIL COVER
---- — — —
Depth Over Depth Over D� epth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoii _ _ � �Yes ❑ No � �Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
��,�<<� �(�-�� z�
, �- , �
Ptan revision required?❑Yes❑ No �Q� s23 '�� �� ���I � ����/
(� b
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL C�MMENTS ANO SKETCH
SANITAFY PERMIT Nl1MBEF�._ __�_1-0Q�_ _
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