HomeMy WebLinkAbout024-741-28-1411-SAN-2022-113 >;"'"' Industry Services Division County v 1
= 4822 Madison Yards Way Sct f✓� -2/-' �
; ,�_ = Madison,WI 53705 Sanitary Permit Number(to be filled in by G �
' pt - P.O.Box 7302
`_ Madison,WI 53707 C 0.\\ l5' �� ( � 3 �
Sanitary Permit Application ��,�pY� StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis fortn 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 then mailing add �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance wiffi the Privacy Law,s. 15.04(1)(m),Sta[s. 1 (O�ILf�/ !1„G�9�� S e�' L�
I.Application Information—Please Print All Information � � �
Property Owner's Name Parcel#
J�S� S��e�-'e� dZ`�7�// ZSI �//
Property Owner's Mailing Address Property Location
2,� i l� O Vi C(.� �� Govt.Lot
Ciry,State Zip Code Phone Number Z o
� M N ��q$3 '/<> '/4, Section �
W�narL,� a ,
IL Type of Building(check all that apply) � ��t# � T y� N R d 7 E or
r 2 Family Dwelling—Number ofBedrooms Subdivision Name
Block#
�ublic/Commeroial—Describe Use _
❑City of
�State Owned—Describe Use CSM Number illage of
�I�? � 103► �o�,of ��n� l, c��
DI.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 System �Replacement System �Other Modification to Existing System(explain) �Additional Pretreatment Unit(explain)
LJ
B' �I-Iolding Tank n-Ground �AAt-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 Issued
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation
Y�o . 7 � Y3 6's-Z 4'6, 0 - qZ .23
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � o � �
New Tanks Existing Tanks y c � " � p � ro
c� U v� � v� u. C7 0..
Septic or Holding Tank � Op� �GO� / �/'� CS Q�
�
Dosing Chamber � �
V.Responsibility Statement- I,the undersigned,assume responsibility for installxdon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumbers Signature MP/I�1PRS Number Business Phone Number
Dylan Schultz 1516129 715-558-5904
Plumber's Address(Street,City,State,Zip Code)
7076N Stone Lake RD, Stone Lake, I, 54876
VI.Coun /Department Use Only
� App ove ❑Disapproved $ermit Fee Date Issued Issuing Agent Signature
��� �O�.a° � I �le� I�� '�I �"_.,"`r
❑Owner Given Reason for Denial
Conditions of ApprovaU�2easons for Disapproval c? � r�
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��E�COUN�'„ ,
�t{�(',ADMINISTRA(��lv
Attach to complete plans for the system aod submit to the Couoty only on paper not Iess than 8 In x ll inches in size
SBD-6398(R.02/22) NO REFUNDS AFTER
ISSUE OF PERMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version �Q. SBD-10705-P (N.01/01, R. 10/12), . ,
a .�
Pg 1 of 4 Index & Cover Sheet
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): 56s� S��aP.-�ei Phone: - -
OwnerAddress: Z�Y�( M•`Rqo n�ew �l� Zip: S�S9�3
Project Address: I �a yYw /�{'9"'�S� L,�✓
Govt. Lot: 1/4 of 1/4, Section 2 g , T y1 N-R D 7 E 0 or W�
Township: �a�n � �N�� County: S�'"')' �
Project Parcel ID #: OZ y?y( 2Ql y ( /
Designer Information
Designer Name: Dylan Schultz Phone: 715 558 _ 5904
Designer Address: �076N Stone Lake RD Zip: 54876
E-mail: dylanschultzl8@gmaii.com ,,�t,,�, ,�,; r�, „ :,
License Number: 1516129
Remarks:
Signature: Date: � ` `I - Z �
Onginal i ture req - i each submitted copy.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o Scale: �40 40 so 80 �SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: ��o n 9rid ��� DESIGN FLOW: ��v GPD
Attach design flow calculations for commercial plans.
PROJECT ADDRESs: l � � w l��"'^S'� L�l A' Pipe Material !ASTM Standard (Tabies 384.30-3 R 384.30-5)
1 V Sanitary Sewer.�«�U /
BM Symbol: � BM Elevation: � �� FT Fwce Main: /
BM Description: l v �'" � ' r` n'��"�
Indicate north by IMPORTANT:
Slope Gradiem(°�) Well Symbol ('rf applicable): Q drawing an arrow Show ground elevation contours at suitable intervals.
of Tested Area: on the approprite line.
� � / % � G� �����n I ��
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S�� � � Gylan Schultz
S � , p � 7076N Stone Lake Rd I
Stone Lake, WI 54876 I
�� L,f C, � I �G� � MPRS 1516129 I
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Septic T�ank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA w«3�-
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) I�O6ga� 9a� gal 9a�
Effluent Filter Manufacturer:
PO�y l.cr..
i SZ�
Effluent Filter Model#�.
�a iz
SOIL COVER (typ�caq
�z^
m�in.trencn
depth
�roo�=an • TYPICAL TRENCH
�_— a CROSS SECTION VIEW
�.,
�tyP���> �3 (No Scale)
� , . ' q�.0'�Z' Provide minimum 3 ft
System Elevation= ft separation between trenches.
(typical)
Quick4 Standard-W
w/End Cap Observalbn Pipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (ryv��0
InstallpermanufacNreYs pLAN VIEW
instructions.
(No Scale)
��e 4►,A��. :eo*1G1!!f#-----��--------��— �ta►R�.r�sse�t !t —� T
I . d � . :I I A=3.Oft
� , 1 �riP���, �
L���t.a+�nat�aiill�'tY�` iYY�Y�'�aixs�'�ii .
— -----��-------�f----- — —J D
I-� B= 6 � n �—=1 m
(rypical) Quick4 Standard-W Chamber W
�tYPical) O
INSTALL PER TRENCH: �mtd by��s�trarorsysterns,��o.� �
/� �'1 O Install pursuant to manufacturefs instructions. �
Quick4 Std-W @ 20 fl�EISA/chamber= � ft'
+ � Pairs of end caps @ 6 fl�EISAlpair= � ft'
=Proposed EISA per trench= 3 Z� ft' Required Infiltration Area= ��J ft' Distribution Method:
x Z trenches =Proposed Total EISA= 6SZ tt' _���
PAGE40F4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-gravity system shall be responsible for its perpetual operavon and maintenance
pursua�t to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2),Wisc. Admin. Code, this
system shali be co�sidered a human health hazard if not maintained in accordance with this approved management
plan. FuRhermore, all inspection and maintenance activities shall be pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3), Wisc.Admin. Code.
Maximum Dlspersal Area Ooeratinst Limits:
Design Fiow= ��U gpd; BODS 5 220 mgL-'; TSS 5150 mgL''; FOG <_30 mg�''
InspecUon Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanicai maifunctlon (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids vdume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution/drop boxes)
o neg�ect or improper use(i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregulazities- if applicable (i.e., pump re-cycling,float switch settings, etc.)
o electrical components- if applicable(i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distai pressure-compare to design specification)
o surtace discharge of effluent or sewage back-up into structure served
Malntenance Checkllst MAINTAIN EVERY 3 YEARS (or when necessary)
o Se�tic and dose tank(s)shall be pumped by a certified 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 Iiquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Eftluent filter(s)shall be inspected 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
months.
System maintenance reports shali be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunctlon to:
Name of individual or company: p�/�"n Sc�` '�f 2 Phone: �7�S- Ssg-S qu y
Local government unit: Sh�ei c w.�-�i ��^;ni Phone:
J
Local government unit address: �����✓P�� w' ZIP: �`r��
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair 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.
Continaencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be repiaced 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 dispersai component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
;=�"``��^, PRIVATE ONSITE WASTE TREATMENT County
�k�2���' P,`�`\1� SYSTEMS
' S S awyer
������j' ( POWTS)
���%�'"�"•'�`� INSPECTION REPORT sanitary Permit tvo:
----�
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2�.-1 I�
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(i)(m)]
Permit Holder's Name: ❑City ❑ Village C�Town of: State Plan Transaction ID#:
�03� ��'`4 e� u4
Insp BM Elev: BM Description: Parcel Tax No:
(o�.�` ` oz .. -�Y�.. �-g- (K l
g� 1 c ., �f�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,;,e�- ap Benchmark ��,b►
Dosing
Aeration Bldg. Sewer
9���s'
Holding St/Ht Inlet GS 7 1
TANK SETBACK INFORMATION St/Ht Outlet �;S-3�
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic k�5� -� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q y,q �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative 1
Surface `�3•�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weil
DISPERSAL CELL INFOR ATION
DIMENSIONS W 3` � (�y ,6 #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �� I �
INFORMATION P I L Bldg Well Waters Q GP � Chamber Model Number:
❑ EZFIow
CELLTO .�- ` �-�S �, �a` ❑ Mound a Other Q
---_ —__�-�
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/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/Sodded Mulchetl
Cell Center �ell Edges �psoil___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
� ��l �(�I�.�
Plan revision required?❑Yes❑ No dZ 3 � — _ 6`�� ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOO�TI�NAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �-�- I(,� _
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