HomeMy WebLinkAbout010-839-01-4408-SAN-2022-099 " "' Industry Services Division Counry , �
4822 Madison Yards Way ' • '� -� -�
; ,_�� - Madison,WI 53705 Sanitary Permit Nu e (to be filled in by Co.; �
'_ _ P.O.Box 7302
Madison,WI 53707 ��.,c� � ��� �
Sanitary Permit Application State 7'ransaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for stateowned POWTS are submitted to Project Addre (if different than ailing addre; .�
the Department of Safety and Professional Services.Nerso�al information you provide may be used for secondary .�l���ij ���,j" �(�, �
purposes in accordance with the Privacy Law,s. 15.04(])(m),Sta[s. ,�"' �
I.Application Information-Please Print All Information Lv t,tF,C�r `Cc-�l -�j � �
Property Owner's Name Parcel# ,
5�-c�►a- a-3y v�-� , -�
i ' � i �" oy-c�c�o ._���co,� o►o-g.�-o�-N�IoB
Property Owner's Mailing Address Property Location
�j , L`t'L - ��' i�./ Govt.Lot
City,State Zip Code Phone Number
l�' � L C L�� �.{� � .'�J /�� ✓,r- '/<,5`' '/<, Section ��
II.Type o uilding(check all t6at apply) Lot# T J�9 N R 0 E o W
�I or 2 Family Dwelling-Number of Bedrooms �� �j Subdivision Name G �3/ # `, _/{�
J ��
Block#
�ublic/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number illage of
�Town of�I,G��
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box oo line B.Complete line C i
a licable.)
A' ew S stem e lacement S stem ther Modification to Existin S stem ex lain Additional Pretreatment Unit ex lain
� Y � P Y S Y ( P ) ❑ � P )
B' �l-Iolding Tank In-Ground �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 lssued
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispe I Area Required(s� Dispersai Arca Proposed(s� System Eievation �
3r�o �� �i�� 5�� �� $ql
Capacity in Total #of Manufacturer
'Cank Information Gallons Gallons Units � v U �, L N o
u v, .in
New Tanks Existing Tanks y o o� � Y p � �y
a�'. U V� m v1 Cc. C� L�.
Septic or Holding Tank L �•;1 ! ��' ei�
J V 1
Dosing Chamber � �
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumb r's Signature MP/MPRS Number Business Phone Number
S � � 79�,.aC�/ ���s-s�--�s�.�r3
Plumb 's Address(Street,Ciry,State,Zip Code)
�1�5�I1� `7' ��n � ���.�' t�a.��l�. �r�� �� � ��3
VI.Cou /Department Use Only
Permit Fee Date Issued Issuing Agent Signature
� App oved ❑Disappnrved $
��� ❑Owner Given Reason for Denial �W�� � ( �5�� ✓�� ��f�.(,�.����)l/L/�•-->
Conditions of ApprovaUReasons for Disapproval D 5� 5� r'•.�'
�J �"�l,i �'"r--;
!� S� a a -- C� � JUN 0 6 2022 \�. ��
�� ��GI NQ � 3
- SAWYER COUNTY
ZpN1NG ADMINISTRATION
Attach to complete plans for tbe system and submit to the County only on paper not less than 8 V:2 x ll inches in size
NO REFUNDS AFTER
SBD-6398(R.02/22) 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. 10112)
. �
Pg 1 of 4 Index & Cover Sheet J � a '�
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): � r� � ��.�.�1� Phone: - -
Owner Address: �5�_3 C`i�1.�f� _� (�6'��C�.��s.�-i- Zip: �.�5�� %�
Project Address: �(C��O��G�t�/" �Q � ��ti4��'�, l�r J ��o�
Govt. Lot: � �:- 1/4 of�1/4, Section_�, T 3 9 N-R ��� E❑or W �
Township: �.t,�U�(p,l'LX County: ��,t,.l;�C��
Project Parcel ID #: ��7'����`�"3y�-��' -�� '`� 04- ��'C� -�C`�UUO ��
Designer Information
Designer Name: �1�L� �j�'(LI'�- Phone: �-�i�s'�- (D�
Designer Address: l�'�/1����I�.'Y1�'f�(�(�.;�j p� �l�li(, �, Zip: `j�C�;�
E-mail: ���' . �,�,..�?-'
License Number: ������
Remarks:
Signature: Date: �'����
ginat signature required on each submitted copy.
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IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer:
l�i, ����
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing cred it) Septic Tank(s)Volume(s):
,�5 D gal gal gal gal
Effluent Fflter Manufacturer:
SOIL COVER I ��`�NlG•: �: ��� ��6�
min.12"
(rypicai) Effluent Filter Model#: 1J'��� 2
12"
TYPICAL TRENCH m'depThch
CROSS SECTION VIEW �"P'�'� �� • �
� ��° Provide minimum 3 ft
.a �,:
(NO SCale) �-yPcal�•.-� .'� � . separation between trenches.
., ^ , ' .,
. aa
Highest Trench Lowest Trench (as applicable)
System Elevations= �� ft; � ft; ft; ft; ft
Quick4 Standard-W
w/End Cap ObservatfonPipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (typical)
Install per manufacturer's PLAN VIEW
instrucnons. �nJO SCa�@�
�-- — - -_—y- - - - �/� - - - - - - - �� - - - - — ��+r'a�dr�rx�t �
I � , v �, A= 3.Oft
�— — '� — — —�� °� �,��.Yrrrlr'.i�1.�14'� (tYPical) �
— — _ _ _ — — — — — �� — — — — — — — �� — — — D
�— B = _� ft 'n
m
(typical) Quick4 Standard-W Chamber GJ
INSTALL PER TRENCH: �ryp���� 0
(mfd by Infiltrator Systems,Inc.) �
Install pursuant to manufacturer's instructions. �
� Quick4 Std-W @ 20 ft� EISA/chamber= 2�D ft2
+ _L Pairs of end caps @ 6 ft2 EISA/pair= � ft2
= Proposed EISA per trench = 2�, � ft2 Required Infiltration Area= ��, ft2 Distribution Method:
x �_ trenches = Proposed Total EISA = 1',� ft2 l���ti�;� ,�PQ�,,�.���
.���
PAGE40F4
In-ground Gravity Management Plan
tMPORTA[�iT;
The owner of#his in-ground gravity system sha8 be responsible for its petpetuai operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin. Code. Pursuant�o SPS 383.52(2},Wisc.Admin.Code, this system sha11
be cansidered a i�uman health hazard if not maintained in accordance with this approved management ptan.
Furthermore, a}i inspecfion and maintenance activities shall be performed by a registered P�WTS Maintainer in
accordance with SPS 383.52�3),�sc.Admin. Code. ,
Nlaximum Disaersai Area Operatinct Limits:
�esign Ftow= .jd0 gpcls BO�$<_220 mgL''; TSS <150 mgL''; FOG 5 30 mgL''
inspec#ion Checkiist INSPECT El/ERY 3 YEAR�
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanica!malfuncfion(i_e., pumps,valves,switches,floats, etc.)
o materiai fa6gue(i.e.,ieaks, breaks,corrosian, etc.j
o solids�olume in anaerabic treatment tank(s)and any dis�ribuaon appurtenance(s){f,e.,disfribution/dra�boxss}
o negfect Qr improper use (i.e., exceeding design capacities, prohibited activities, zt�.)
o extent of ponding in distribution ceH prior to dasing
o dosing irregularities-if appiicable (i.e., pump re-cycling,fiioat switch settings, etc.)
o eleetrica[components-if appficabte(i.e.,wiring, connectians, switches, controts,fimers, atarms, efc.}
o distribution faterat or taterai orifice ptugging (measure laterat distal pressure—campare to design specification)
o surface discharge of effluent or sewage haek-up inta stn�cture served
Main#enance Checklist Ml41NTAlN EVERY 3 YEARS (or wh�r� necessary}
� Seatic and dese#ankfs)shatl be pumped by a certifred septage servicing operator licensed under s. 281.48 Wis.
Stats.whera the volnme af solids in the tank{s}exceeds one-third{9/3)the fiquid votume of the tank{s)or
as reyuired by loca(orriinance. Disposal of contents shal! be pursuant to NR 113,Wisc.Admin.Code.
o E�ffiuenfi fiiter(s?shali be inspected every 3 years and shall be c[eaned vvhen necessary to remove any
accumulated solids acc.arding to maneifacturer's specifications. A servicing period will always be greater than 12
mon#hs.
S�rstem rnaintertance reports shail be submitted to the proper 4acaf government urtit in accordance wi�
SPS 383.55 Wisc.Admin. Gode. Repor#any campanent faiture or maKvr�ctian to:
Name ofi individual or company:.��,1(,l..1�1 ��G��FJc Phone: ��� �� J c�`l�'z'3
Locat govemment unii: � CG�I-�L Phone:�IS�3��i���
Loca!govemment unit address: � �- �`��-t, � U,CIlGc�ldt�-�IP: r'J ��-.3
Any defective part of this system sl�all be repaired,replaceci, ar removed pursuant to SPS 383.51 {1),wsc.Acfmin.
Cade. Repair or replacement ofi faited or malf+unc#ioning componenfs shalt compiy with SPS 383,Wisc.Admin. Code.
tVo product fior chemical or physicai restoration of the POWTS may be used untess approved by�he department in
accordance with SPS 384,Wisc.Admin. Code_
Continu�ncv Plan
!n the even#iEhat any faifed treatment component of this POWTS cannot be repaired, it shaft be reptaoed pursuant ta
a plan submitted to the appropriate agency for review and approvai. A failed in-ground dispersal component may be
abandoned and replaced by a code-carnplying dispersai component in a pre-determined area of suitable soils.
SYstem Abandonment
tf use of this POWTS is discantinued, it shalt be abandaned in accQrdance with SPS 383_33>Wisc.Admin_ Code_