HomeMy WebLinkAbout002-940-04-3409-SAN-2022-091 ��` /
� a'�� � COUf1C � Y � � � I
/,>>°�-,:_};�� Industry Services Division �
'_�>�� ; 482?Madison Yards Way �G w e � �
�s � j P � Madison,WT 53705 Sanitary Pcrmit Number(to be filled in by C
� _ ;. P.O.Box 7302
%;z; `_- ��' Madison,Wi 53707 � 3� � � � �
;.��,—��•. �
Sanitary Permit Application Statc Transaction Number �
tn accordance with SPS;R3.21(2),Wis.Adm.Code,submi,sion of this foim to Ihe appropriate;o��ernmen[al imit �
is rcquircd prior to obtaining a sanitary pcmiit.Notc:Ap�lication fomis for s[ato-owncd POWTS are submittcd to Project Address(if different than mailina a ,,,�
the Department of'Satety and Professional Services.Pcrsonai infi�rmation you provide may be used for secondary _�
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. f
i.Application information-Please Print All information a��S� �C'O �� L�✓� �
Propc�ty Owncr's Namc Parccl#
/� L.a.�1 L LC 6oz - ��o - o�t - 3�l09
Property Ow�ner's Mailing Address Property Location
D S 6 l N �� Q r�e� ��-, �� � c�,�� L�,�
City,State "Lip Code Phonc Number C.j
('�G� (,t,.1�(.V� � w S�V� 60 z-�loZ- b3�/ '�<, '/a, Section � 4
TI.Type of Building(check all that apply) � L��� T �� N R E o
nl or 2 Family Dwelling-Vumber ofBedruoms 3 Subdivision Namc
�F�+
Alock h
�ublic/Commercial-Describe Use _
'❑Ciry of
❑State Ow�ned-Describe Use CS�1�Iumbcr ❑Village of'
3-7 f z�-t2 s� Sbb-� �T�,�,�r� Bc�ss La �e
/
iiI.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A' �lew S Stem nRe lacement S etem ❑Other Moditication to F.xistine S stem(ex lain �Additional Pretreatment Uni[ ex lain
�..�� Y� �--� p Y• Y P ) ( p )
B' ❑Fiolding Tank �fn-Ground �t-Grade �Mound Individual Site Design Other Type(explain)
(com�entional)
C. �Renewal Before �Revision �Change of Plumber �fransfer to New Owner T_ist Previous Perniit Number and Date Issued
Expiration
IV.Dispersal/Treatment Area and Tank Information:
Desi;n Flow•(gpd) Desien Soil Application Ratc(,pd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation
� o ��1 (�43 � o �E az.S
Capaciry in Total dt of Manufacturcr
v
Tank Tnformation Gallons Gallons Unit�s � � J � � u
Ncw Tanks Esi�tino Tanks � c u = y � � q
0
a U rn y v: u. C7 �.
cptic r Holding Tank ( 0 Q� �_ �� � I es'�r
osing Chamhcr � �
V.Responsibility Statement-I,thc undersigned,a res nsibility for i llation of the POWTS shown on the attached plans.
Plumber's Name(Prin[) Plumb r'. , i ti c MPlM1iPRS Number Business Phone Nttmber
(Zo b L4 g�rr� �z(o Z f $ ��S-6�S - �i 3
Plumber's Address(Street,City.State.Zip Code)
1�k5 ll U.) s� �}w -I-i f�c` c..�Jar � W 1 �`f �`t�j
VI.Co n /Department Use On y
�Approc d ❑Disapproved Pennit Fee Date issued issuin�,4gent Signature
❑Owncr Givcn Rcason for Dcnial � ( ��'� � � ��` ��''� {ti�(,���2/✓.J-
Conditions of Approval%Reasons for Disapproval 5� , - ` �,
D � � ,
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� ( ' � - 0 � � l JUN 0 2 2022 � �.
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SAWYcR r�•,,;• �.._.
ZON{NG ADM i f�i i;�T"F,�;i;��;iri
Attach to complete plans for the system and submi[to the Counh�onh•on paper nu[less than 8 I/E x I 1 inches in size
SBD-6398(R.02/22) Np R�FUNDS AFTER
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 Dispersa( Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
i POWTS Application for Review
� Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): 1� 6 �.��.�,c� �.-L�- Phone: bbz - y�Z _ 63 4 1
Owner Address: �oS6 I ti t O� $v'��� (�;�� 2� �'��`-�w4'r�_ Zip: 5 `t g`�3
Project Address: ov, $�o�; ��1 �-.
Govt. Lot: E 1/4 of St.J 1/4, Section=_�; T �!� N-R O�_E❑or W ,�_f
Township: �sS Lak2 County: S�w e.r
Project Parcel ID #: p p Z --. �ty�� — D�-f_ 3�o I
Designer Information
Designer Name: ��b (,� g�t,r�'� Phone: 1 �S - 6�- b t 3 �
Designer Address: �4'S�l �J 5-�- E}w�`f1 �4y�4r� Zip: ;�{ �j ��
E-maiL• _
License Number: �-Z-�Z ��j
Remarks:
Signature: Date: �Q� 2 �2'�
Ori inal signat re required on each submitted copy.
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IN-GROUND GRAVITY DISPERSAL AREA � SepticTank(s)Manufacturer:
w � es-��
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit) Septic Tt�nk(s)Volume(s):
(�D U gal g�l gal gal
_ ' � � Ef(luent Fllter Manufacturer.
SOIL COVER ��(y�o I`
—min.12"
(ryplcaq Effluent Fllter Moclel#: �2 �
12"
min.Irench
TYPICAL l-RENCH ��n�n - �
CROSS SECTION VIEW «P�cal) •: d �
-- - • - — � '°�� Provide minimum 3 ft
a �.
(No Scale) i ��ypcal)�-:'a' �� � �° " ' .. separation belween trenches.
.. . °•' • e
0
Highest Trench Lowest Trench (as applicable)
System Elevations= �Z�� ft; �Z•� ft; ft; ft; ft
Qulck4 5landard-W
w/End Cap ObservatlonPlpe TYPICAL TRENCH
(typlcal) (Show location of inlet/outlet pipe connection on plan view.) Install pc�rymarndacturors
PLAN VIEW
' InstrucUons.
(No Scale)
�-- - -- - ,-- ---- --- -- - - - �i�- -- - --- -- - -- - �� - - - - _ -- - - ---: - -- �
I ;, i t �I�lI TA= 3A ft
� � 1 ��y�i�aq Z7
�- - - — — — — — — — — —
-�j�- - - - - - - -- ��-- - - -- - - - -- - - -� �
i— � _ �o ft --I �
m
(typlcal) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (typica�) �
(mfd hy Inflltralor Syslems,Inc.) —n
Install pursuant lo manufacturers instructlons.
�� Quick4 Std-W @ 20 f�EISA/chamber= 34� ftZ 'A
+ � Pairs of end caps @ 6 ftZ EISA/pair= (Z ftZ
= Proposed EISA per trench= 3s�"" ftZ Required Infiltration Area= ��3 ft` Dislribution Method:
x 2-• trenches = Proposed Total EISA = �� ft2 �ru-v���
PAGE �OF �
(n-ground Gravity Management Plan
IMPORTANT:
The owner of this ir-ground gravity system shal! be responsibfe for its perpetuai operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admir,. 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, ali insoection and maintenance activities shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersa! Area Operatinq Limits:
Design Flow= �'S� gpd; BODS<_220 mgL"'; TSS < 150 mgL"'; FOG <_30 mgL''
Inspection Checklist 9NSPECT EVERY 3 YEARS
o type of use
o age of system
o r,uisance factors(i.e. odors, user complaints, etc.)
c mechanical malfunciior: (r.e., pumps;vaives, switches,floats, etc.;
o material r2tigue {i.e., �eaks, breaks, corrosion, etc.)
o solids volume in anaerobic treairr�ent tank(s) and any distribution appur�enance(s) {i.e., distribution/drop boxes}
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o exten;of ponding in distribution cell prior to dosing
c dosing irregularities-if appiicable ;r.e.; pump re-cycling,float switch settings, etc.)
o electrical components-if applicable(i.e.,wiring, connections, switches, controfs, timers, alarms, etc.)
o disiribution Iaterai or fater2l orfice piugging (measure later2l distai pressure-compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAfNTA[N EVERY 3 YEARS (or when necessary)
o Septic and dose tank;s)sha!1 be pumped by a certified septage servicing operator licensed under s. 281.48 V1.'is.
Stats.when the volume of solids in the tank(s) exceeds one-third('f/3)the liquid volume of the tank{s) or
as required by fecal ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin. Code.
o Effluent filter(s1 shall be irspected 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
mcnths.
�
System maintenance reports sha(!be submitted ie the proper loca!government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component faifure or malfunction to:
Name ofindividua! orcompany: R0 .6 L.c� ��..rc'e. � � �q Phone: ��S —���� �� 3 �
Local govemment unit: .Sc'c�.vt,1t� Co z�-ovt,,.te, Phone: ��5-634 _gz-SP�
Local govemmen± urit address: l � ro l D �(,ct.�r S'f � !-{t �� W�e.t`�. L,e,�IP: �-E��3
Any defective part of this system shalf be repaired, replaced, or removed pursuant to SPS 383.�1 (1),Wisc.Admin.
Code. Repair or replacemen�of;ailed or malfunctioning components shall cemply with SPS 383,Wisc. Admin. Code.
No product for chemical or physicaf restoration of the POWTS may be used unless approved by the departrnent in
accordance with SPS 384, Wisc. Adr-sin. Code.
Continqencv Plan
1n the event:hat any railed treatmen;component of this POWTS cannot be repaired, it sha(I be replaced pursuant to
a plan submitted�o the approp�iate agency;or review and 2pproval. A failed in-graund dispersal component may be
abandened and replaced by a code-complyirg dispersal componeni in a pre-determired are2 or suitable soils.
Svstem Abandonment
If use of this FOWTS is discontinued, it shall be abandoned ir accerdance wi±h S?S 383.33,Wisc. Admin. Code.
'""�``'-="'�"`'��;;� PRIVATE ONSITE WASTE TREATMENT county
;,y,:,.
=�'�SP$ ,:, SYSTEMS Sawyer
��� ( POWTS)
\N F,` ,;:��
�'=�"��" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 � —O� �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04{1)(m)]
Permit Hoider's Name: ❑City ❑ Vil�age �Town of: State Plan Transaction ID#:
A$ ��� CCC. �ss 1R1�-
Insp BM Elev: BM Description: Parcel Tax No:
yw�V' 1Vq� d- rb�� 1V 51 �l �tt �n ' /���-• b�a.i9Yo .��..-3C�6�
� t,, - < <
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W;,e,�- D a0 Benchmark �pp,o�
Dosing
Aeration Bldg. Sewer �?7,4 '
Holding St/Ht Inlet �(,g �
TANK SETBACK INFORMATION St/Ht Outlet Q(, 6 r
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic -�ap� �-�.5� .} � .y-�a� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ��7 '
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative 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 W 3� � (� $ #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate 'T'f< ,
P/L Bldg Well ❑ IGP �+L Chamber '�''i�'
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO .}- �a` fi� �a �J a Mound o Other � y�
—— ----- ---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) - - � X Hote Size- , X� Observation Pipe�
Length Dia Length Dia Spac � ; Spacing ❑Yes ❑ No
SOIL COVER
--- -------- -- ___
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center Cell Edges Topsoil __ �Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
�.�,s�II�P 91�-81 �.z
Plan revision required?❑Yes❑ No o���� � � � —� 6�t��� �
� �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA: ��____a_�I___
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