HomeMy WebLinkAbout014-842-28-2206-SAN-2022-112 ��'""' Industry Services Division County C (�
= 4822 Madison Yards Way J�V -e� �
; ;,�=p = Madison,WI 53705 Sanitary Permit Number(to be filled in by C �
= P.O.Box 7302
_ Madison,WI 53707 C0.`� �0 �� � � � v�- �
Sanitary Permit Application �i�`p,Y� State Transaction 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 senitary permit.Note:Application forms for statevwned POWTS are submitted to Project Address(if different than mailing a< �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. 1�.04(1)(m),Stats. ����ry�,e �
I.Application Information-Please Print All Information
Property Owner's Name Pazcel#
�ess�c.�, b��-� 6 I�( Sy 2 2 g zz o�
Property Owner's Mailing Address Property Location
(3 �y �W t«r�1- Ln Go�c.Lot
City,State Zip Code Phone Number ^, �/r,,/
f Ih Wc�,�/ W� S-tf�y� !II W '/., �" "" '/4, Section Z�
II.Ty of Building(check all that apply) Lot# T �Z N R �g E or�
or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block#
�ublic/Commercial-Describe Use
�City of
❑State Owned-Describe Use CSM Number illage of
o�,,,,of Ler�roo-�'
tIl.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 w System ep(acement System �Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain)
B' �I lolding Tank -Ground QAt-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 19- 'Q7 �� �
IV.DispersaUTreatment Area and Tank Informallon:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
150 � � 2�'� 226 G�,q3 - 9c, �a
Capaciry in Total #of Manufacturer
Tank Information Gallons Gallons Units � U �o $ � � N �
New Tanks Existing Tanks � c � « � � �
� 0 2
a U v� v� i.t, C7 0.
Septic or Holding Tank S'p ?�"'6 � w1 �
Dosing Chamber �
V.Responsibility Statement- I,the undersigned,assume responsibility for installadon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/1�4PRS Number Business Phone Number
Dylan Schultz 1516129 715-558-5904
Plumber's Address(Street,Ciry,State,Zip Code)
7076N Stone Lake RD, Stone Lake, W , 4876
VI.Coun /Department Use Only
� Disapproved Pertnit Fee Date Issued Issuing Agent Signature ,
❑Owner Given Reason for Denial $ lb�''� � a�� ��� '' I/""`^""^^I '"-"""�
Conditions of Approval/Reasons for Disapproval ,�a.` �
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eti �
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SAW�l�R Cr�_!,..
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ZON�NG AUt'vtiv��,;�:•.�'�_:'��
Attach to complete plans for the system aud submit to the County only on paper oot less thao 8 t/2: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 2�; 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): 3�s S`�-`'' �''`��" Phone: - -
Owner Address: � 3 � 96 � �^ro•� L� Zjp; SYsVS
Project Address:
Govt. Lot: N� 1/4 of_ N l� 1/4, Section 2g , T �12 N-R o8 EDor W�
Township: �cnrao� County: S'�'^'Y�
Project Parcel ID #: U�`'�� y22 8 2Zo 6
Designer Information
Designer Name: Dylan Schultz Phone: 715 558 _ 5904
Designer Address: �076N Stone Lake RD, Stone Lake, WI Z�p; 54876
E-mail: dylanschultzl8@gmail.com , _
� •
License Number: 1516129
Remarks:
Signature: _,�/ Date:
� - IZ- Z2
Original gn t e requiL� ch submitted copy.
CHECK BOX AS APPLICABLE. CH�=CK BOX AS APPLICABLE.
❑ SOIL EVALUATION o ��� �40 40' � � ��YSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: ��a ft 9�d� ,O� DESIGN FLOVV: �.r D GPD
Attach design flow calculations for commercial plans.
PROJECTADDRESS: I � �1 ` � �'�^�� � Pipe Material ! ASTM Standard (Tables 384.30-3 & 384.30-5)
N Sanitary Sewer s`'� YU /
BM S�rmbol: � BM Elevation: ��� FT
Force Main: /
BMDescription: �O���C 7il'�C�
Slope Gradierit(%) Indicate north by IMPORTANT:
of Tested Area: W�I Symbol (ff appllcable): 0 drawing en arrow Show ground elevation contours at suitab�e intervals.
on the approprite line.
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�I Dylan Schultz I I
7076N Stone Lake Rd � n-�� '�� 1' � I
I Stone Lake, WI 54876 �
MPRS 1516129 �I �, I�
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IN-GROUND [�GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit)
�
""",Z� TYPICAL TRENCH
SOII COVER (ryvicaq
CROSS SECTION VIEW
,z•
min.trench (NO SC210�
dept�
(baiwq .
.a '
i �. '
�ryP�`��� Provide minimum 3 ft
� ' qi,y3—4a,�d separation between trenches.
System Elevation= ft
(typical)
Quick4 Standard-W
W/Efld CeP Observation Pipe
(typical) (Show location of inlet/outlet pipe connection on plan view.) �hP���� TYpICAL TRENCH
Install Der manNacturefs
�oso-��ro�s. PLAN VIEW
r m+��e�.-----��-------�f--- �� — � � (NoScale)
, „� , ,���� A=3.Oft
,. ,
� _, �ur
t-—— 1���'!�"�t��'———— �� —�—— (hPica�)
�'�-------��----�— �
F-f a y� ft ��� �
«P���� Quick4 Standard-W Chamber m
INSTALL PER TRENCH: �tyP���� �''�
(mfd by Infiltra[or Systems,Inc.) O
Ins[all pursuant to manufacNrefs instructions.
_�Quick4 Std-W @ 20 ft'EISAlchamber= 2 Z� ft' 1l
+ � Pairs of end caps @ 6 ft'EISA/pair= � ft� �
=Proposed EISA per trench= 22�0 ft' Required Infiltration Area= �'� ft' Distribution Method�
x � trenches =Proposed Total EISA= 2z� ft' ��`�"'`�y
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PAGE40F4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-gravity system shall be responsible for its perpetual opera8on and maintenance
pursuant to requirements of SPS 382384, Wisc. Admin. 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
plan. Furthermore, all inspection and maintenance activities shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc.Admin. Code.
Nlaximum Dispersal Area Ooeratins� Limits:
Design Flow= �s� gpd; BODS<_ 220 mgL-'; TSS 5150 mgL''; FOG <_30 mgL-'
InspecUon Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance fac[ors(i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue(i.e., leaks, breaks, corrosion, eta)
o solids vdume in anaerobic treatrnent tank(s) and any distribution appurtenance(s) (i.e., distribution/drop boxes)
o neglect or improper use(i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribu6on cell prior to dosing
o dosing irregularities- if appiicable(i.e., pump re-cycling, float switch settings, etc.)
o electrical components- if applicable(i.e., wiring, co�nections, switches, controls, timers, alarms, etc.)
o distribution laterai or lateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surtace discharge of effluent or sewage back-up into structure served
Maintenance Checkllst MAINTAIN EVERY 3 YEARS (or when necessary)
o Seotic 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 tn the tank(s)exceeds one-third (1/3)the Iiquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shail be pursuant to NR 113, Wisc. Admin. Code.
o Efflu�t fllter(sl 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 tha� 12
months.
System maintenance reports ahall be submitted to the proper local government unit In accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or maifunction to:
Name of individual or company: p��"^ sc�`"��f Z Phone: 7 �S' Ssg—S�u y
Local government unit: Sa�.d cw.��i �dn;,,i Phone:
Local government unit address: �'l�r�✓�� w' Z�p� �Y� �
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 POVJTS may be used unless approved by the department in
accordance with SPS 384,Wisc. Admin. Code.
Continaencv Plan
In the event that any failed treatrnent component of this POWiS cannot be repaired, it shall be replaced 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.
,% '�E�. PRIVATE ONSITE WASTE TREATMENT county
/� "�^+ �'\ SYSTEMS
�_��; o i
� S S aw er
'�� ' Ps' .:� ( POWTS) Y
�s,�,�
"` INSPECTION REPORT Sanitary Permit No:
Safetysand Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� ^ I ��
Petsonal infonnation you provide may be used(or secondary pucposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village C�Town of: State Plan Transaction ID#:
��S�Cq 'lS re�� �raD� '�
Insp BM Elev: BM DescriFition: Parcel Tax No:
�.� d��.. P�� o, - g �^ ��- ��.�
TANK INF(�RMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � p Benchmark �pp,e��
Dosing
Aeration Bldg. Sewer �(S 3�
Holding St I Ht Inlet �$; o�
TANK SETBACK INFORMATION St/Ht Outlet q►Y $ r
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic -}��' ,�op� d` fi� ' NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. q y S-
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative 93.7 r
_ Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELIL INFORMATION
QIMENSIONS W 3' L �(S' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber Model Number
❑ AG � EZFIow
CELL TO t-S'p` fi�' �� ❑ Mound o Other
- -_ --- — --- -
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifoid Di:�tribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
SOIL COVER
Depth Over �Cel�l thd esr _Topso_i�f —� �Yes/S� No - —I- O eslch� No�
Cell Center _
COMMENTS: (Include code discrepancies, persons present,etc.)
���ll� 6 �2Y��-2
Plan revision required?❑Yes❑ No o� �� a3 � � �t��,� �
Use other side for atlditional informatic�n Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NUMBEA: �a-��
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