HomeMy WebLinkAbout010-182-00-1900-SAN-2022-107 �n
Industry Services Division Counry �
4822 Madison Yards Way )L
� __��� - Madison,WI 53705 Sanirary Permit N er(to be filled in by Co.)
s P.O.Box 7302 �
Madison,WI 53707 � 3 Gi I � (p �
State Transaction Number �
Sanitary Permit Application o
ln acwrdance 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 state-owned POWTS are submitted to Project Address(if different than mailing ad
thc Department of Safety and Professional Services.Pcrsonal information you pmvide may be used for seconda �"'��/�� •f����N�e�q� �j(�y,91
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. � 7 �
I.Application Information—Please Print All Information L(}-�-- f�f� ' � �;,`��
Property Owner's Name Parcel# `
� 3� I�� 4 I C~l$�-�C� -lSJG C1
Property Owner's Maili ddress Property Location
�� / t7` � (;e�vt-tvt—�
City,State Zip Code Phone Number
�l,w'l- V j� � ^ - '�w D� Section_��
II.Type of Building(check all that apply) Lot# � � T N R � E W
�1 or 2 Family Dwelling—Number ofBedrooms Subdi��ision Name
�ublic/Commercial—Describe Use Block# �G1 �,W O 1�'1 �
❑City of
❑State Owned—Describe Use CSM Number illage of
�"I'own of �LL!?'d
IIL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i
a licable.)
A' �ew S stem lacement S stem ther Modification to Facistin S stem ex lain Additional Pretreatment Unit ex lain
Y �eP Y � 8 Y � P ) ❑ � P )
B� �1-lolding Tank �In-Ground �At-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
C- ❑Renewal Before �Revision hange of Plumber �I'ransfer ro Ncw Owner �st Previous Permit Number and Date Issued
Expiration --
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation I
�l5'c� �O�3 �o� " 9.�,o
Capacity in Total #of Manufacturer
'I'ank Information Gallons Ga(lons Units � a o 'b„ �
New Tanks Existing Tanks v G � � aj A � �
0 2
a U cn �, in i�. C7 P.
Septic or Holding Tank ��
OC�C� � �l,�t ,..E��
Dosing Chamber O Q
V.Responsibility Statement- 1,the undersigned,assume responsibility for instsllation of the POWTS shown on the attached plans.
Plu ber's Name(Prin[) Plumber's Signatur MP/MPRS Number Business Phone Number
� � � r�'l �C� .�lS-S��S��✓�3
Plumber's Address(Street,City,Sta e,Zip Code)
l�7<�� 1 C�`Y��t'u����'i� �Z—� c �C[a-cQ �.� `�l�' �' -
VI.Cou /Department Use Only
1 Pennit Fee llate Issued Issuing Agent Signature
� A tvved ❑Disapproved
L� � {�n L
�� ❑Owner Given Rcason for Denial $ /� �o t-��� � a"� � -Gt �(�,�C x�I-���
Conditions of Approval/Reasons for Disapproval D 5� �5i��j� r,�
�� �5 LV'l�
`'� C S� �� - �7� .f U N 13 2022 �
�� �� � �
�
SAW`�ER COUNTY
ZONING ADMfNISTRATION
Attnch to complete plrns for the system and submit to the Couoty only on paper not less than S t/2 x 11 ioches in sue
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''�, SBD-10705-P (N.01/01 , R. 10/12)
a . i
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Piot 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):�T'�iluk{�'1t� �� , Ut"L����'a'� Phone: - -
Owner Address: ��(� � I �3 `f �Cc..u-�G�7v�Gt. � �?� Zip: ,-�� '�-���"'���
Project Address: RS �1 -�'f i� '�'�io'cc)G� ��t �;,�>1c�7�� �l�i `��f,rC'�4�
Govt. Lot: 1/4 of 1/4, Section�[_, T�N-R��E Q or W Q
Township: ��I,LCCt� County: ___�,��.�
Project Parcel ID #: (�� � � l � � — �C� �-- � J'Q(�
Designer Information
Designer Name: �� ���,� Phone: ���� /�
�-s , l
Designer Address: � �')//�l' �T�'Y� ��t,,��G�.Q C�� � Zip: �.
���� <, �
E-maiL• _
License Number: ���,��
Remarks:
,
Signature: Date: � �� '"��
' inal signature required on each submitted copy.
ow�: L-�
T�w�o-{k� �_ Dro�e�— S4w��r Co� 4-E�ywarc� Zw�,
'�t�Bx iZ3y �i�1•. oca—�SZ—oo —iQoa
l.uq�-{o+h�.,W l s v4sz- �o l r �1 an� 2 o Sw
s�: as�a� o�,�►�,�o� eG��y �ot �g �a�s<<,,.�oa-i.SQy i .�s a�
�
� Q sca�e I"=S�`
��c� '� �h ✓10 YVL2 �-K C�.
°d p so:� -tFs�t Ar� o.,I� 1
��'} �
I y
I � \�x
I y�.
�
��
Z�
3
L o ^
� Aa
1
� �'g'p �
p1
�
� o L v
�
�
i
A a��oo nQ,l�r;�l�� 3'„�
SE S:de nh �l" Da��
:3SD/ Igc. asa�'
i z. �16.35�
a. 9s Ry
."Z So',�s� Sc.ISI .G'�.Q3�
' [ cange qo.s' —�3.s')
� £Sf sT ,u Rt+,z�
-lE We�l �a rv�e��' code s�6�Cs
' IN-GROUND GRAVITY DISPERSAL AREA �jl ���t� Tank(s) Manufacturer:
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s) Volume(s):
3-ft Trench (down-sizing credit} /oc�f�ge� �_ gal 9a, ,_,__ gal
�, Effluenty�Filter Manufacturer:
_�/`{���r m,_ /`, .°,+, ._ / /.°[��!
� J
Effluent Filter Model #: _��� � .�.
min. 12"
SOIL COVER (typ�cal)
12"
min. Vench
depth ,
«'P'°a'> �� • � TYPICAL TRENCH
' � �� � �� ��°��a� � •: CROSS SECTION VIEW
F-�----- 34" � • '' '
(tYplCal) ;"a' ' � . . �NO SCa�@�
a . a ,. . 4.
• ` Provide minimum 3 ft
System Elevation =� ft separation between trenches.
(typical)
Qulck4 Standard-W
w/ End Cap (Show location of inlet / outlet pipe connection on plan view.) Obse(ryaPtica'j Ipe -�-yp�CAL TRENCH
(typical)
Install per manufacturers pLAN VIEW
Instructlons.
� ,'��������� �r ��— - - - - - �f-- - - - - - - - �� - - - _, �
(No Scale)
s
� � , c � � r� r ,..
, Y� ip.�� ,,:� , ����'� �m
� � A = 3.0 ft
, , 'r I
�9��t1�.it�Y�`���`��'A�"— _.� — — � � .�,����i ��" � ' � �� �h'Pical) �
� � _ _ _ — �� - - - - - - - ��- - - - - �� ,��������- - , �
F"' B = �� ft G�
� m
(typlcal) Quick4 Standard-W Chamber C�
INSTALL PER TRENCH: (typ�ca�) O
(mfd by Infiltrator Systems, Inc.) -�.'
Install pursuant to manufacturer's instructions. �
� Quick4 Std-W @ 20 ft� EISA/chamber = :;�;�Q ft2
+ �_ Pairs of end caps @ 6 ft2 EISA/pair = �_ ft2
= Proposed EISA per trench = �i ftZ Required Infiltratlon Area = ���; � ftz Distribution Method:
�=,�_L
x � trenches = Proposed Total EISA = ,���Z fl�� �;����>�-� ti��.,� , ���
L�-� ��
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner af this in-ground gravity system shall be responsible for its perpetuai operation and maintenance pursuant to
requiremenfs of SPS 382384,Wisc.Admin.Code. Pursuant to SPS 383.52(2j,�sc.Admin.Code,this system shall
be considered a human health hazard if not maintained in accordance with this approved management p�an.
Furthermore,all inspection and maintenance activities shalt be performed by a registered POWTS Mainfainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersai Area Ooeratinq Limits: ,
Design Flow= �„f'l'J gpd; BODS 5 220 mgL''; TSS_<75Q mgL°; FOG 5 30 mgL''
Insaection Checktist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e,odors,user complaints,efc.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids vdume in anaerobic treafinent tank(s)and any dstribu5on appurtenance(s)(i.e.,disfribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o e�rtent of ponding in disfibution cell prior to dosing
o dosing irreguhari6es-fi appiioable(i.e.,pump re-cyciing,float switch settings,etcJ
o electrical components-if applicabfe(i.e.,wiring,connections,switches,controls,timers,atarms,etc.)
o distribution lateral or laterai orifice plugging (measure lateral distai pressure—compare to design specificatiort}
o surFace discharge of effluent or sewage hack-up into structure served
Maintenance Checklist NU4iNTQiN EVERY 3 YEAi2S(or when necessary)
o Seotic and dose tankfs)shali be pumped 6y a certified septage servicing operator Iicensed under s.281.48 Wis.
Stats.when the wlume of soiids in the tank(s)exceeds one-third('i!3)tfie liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shal!be pursuani to NR 113,Wisc.Admin.Code.
o Effluent fitter(s)shali be inspected every 3 years and shall be cleaned when necessary to remove any
accumu�ated 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 Iocal govemment unit in accordance with
SPS 383.55�sc,Admin.Code. Report any component failure or malfurtction to:
Name of individuai or company:��'��2','�'� Phone:�[5� �'�'��
Locat govemment unit:� Phone:�7�5 �J,-j� Y'�
Local govemmenY unit address:���(.x(� I'N!L/yL5'�i �lu '�9 E i(,t^!��Zip_ Ej�� '�_
Any defective parE of this system shali be repaired,replaced,or removed pursuanf to SPS�.51{1},Wisc.Admi�.
Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physiqi restoration of the POWTS may be used uniess approved by the department in
accordance with SPS 384,Wisc.Admin_Code.
Continaenca Ptan
In the event that any fai(ed treatment component of this POWTS cannot be repaired,it shall be replaced pursuant to
a plan submitFed to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersai component in a pre�determined area of suitable soiis.
Svstem Abandonment
If use�of this POWTS is discontinued,if shall be abando�ed in accordance with SPS 383.33,Wisc.Admin.Code.