HomeMy WebLinkAbout032-540-22-5801-SAN-2022-116 �i�'-- Industry Services Division �a��Y c �l,�
�_ \+ 4822 Madisoo Yazds Way J Q '� �
i�::�����' = Madison,WI53705 SanitmyPe�mitNumber(tobefilledinbyG �
, j ::' P.O.Box 7162
_ Madiso4�53707-7162 (9 3� 1\lv �
Sanitary Permit Application S�"T'a"�`°°""°�n" �'
In accordance with SPS J8321(2),Wis.Adm.Code,submiasion ofthis folm ro ihe appropriaze govemmental�mit —
is required prior ro obmining a sanitary pe`mit Note:Appli�tion forms for statcowned POW7S are submitted ro Project Addmss(if different itian mailing add
t6e Dcpe�ent of Sefety and Pmfesvoml Services.Peisonal infortmdon you provide may be used for sccondery '�i
uryoses iu accoxdence with the Privncy Lew,s.15.04(lxm).Stats. �a
I.Applicadoo loformstlon-Please Print All Informatlon
Propeety Owner's Name Pe�cel#
(a1; ° ��, o3a-sLro-��-sSol
Properry Owner's Mailing Address { ,�/j� Property Location�T
tp { y�l'�, 1"(X' Govt.Lot�
City,Sute Zip Cade Phone Numbu
(,����-�e� w.z s-��r� ��s���r-o�.� - ,� - ,��;o�aa
II.Type of Building(c6eck sll that appty) � Lot a r� N R s E
�tor2FemilyDwelling-NumberofBedrooms � SubdivisionName
Y-�.
Block#
�ublic/Commerciel-DescribeUu ^
�Ciry of
State Owned-Describe Uu CSM Num6er illage of /�I 1
— �I'own of W y�Ge.f
III.Type of POWTS Permih(C6eck either"New"or"Replacement^and other applicable on line A.Check one bo:on line B.Complete Iine C'
a licable. �7�,,
'�' ❑New System �y µeeplacemrnt Sys[em �DtM1er Modification ro Enisting System(explain) Additlonal Preueatrnrnt Unit(ezplain)
ILY
B' ❑Fiolding Tadc �In-Gomd ❑^.o-G�ade �Mound Individual Site Design Other Type(eaplain)
(conventioml)
C• ❑Renewal Before ❑Revision ange of Plumber �I'rensfer to New Owner ����0�P�t Number eod Date Lssued
Expimtion �T�t l� '-�_�l
N.DisperseVfrestmeot Area and Tmk Information: �. Z �•W ;.vv i�n ,� CC I
Dwign Flow(gpd) Design Soil Application Rete(gpd/s� Dispersel Arce Required(s� Dispersal A(ca Pmposed(s� System Elevatlon
'�Cv �l�q 6 , 17.so'�qSEso
Capaciry in Toml N of Mmulacfim
Tenk Infolmarion Galbns Gallons Units � u �'$ "�
NewTanW FxutingTenlo m � �_°d m
a.U in� ri�i ii.U a�
Septic or Holding Tenk
� I 5X4.✓ re C�(5�
�,�8�e.��, o
V.RespoosibWty Statement-1,the undenigned,sasume raponsibIDty(or inshli�tloo ot t6e POKTS s6own oo the omc6ed plans.
Plumber's Name(Print) Plumbe Signanue MP/MPRS Number Business Phone Nwnber
C,u:� � �l� �ac� �o ��,s-ar�-a��ia
Plumber's dress(Street,Ciry,SPate,Zip Codc)
.5�f5`1' �� !1 �� �!/i�-�C'l Gc%�- ����5`1�o
VI.C uu /Depsrtment Use Only
�A � O Di roved �it Fa Da[e Iswed Lssuing Agent Si�aare
PP �PP �n(��o(�,y1yI�^,,.,,
❑Owner Criven Reason for Deniel s��•� �'I��I�� '`I """"�I"""'"'"
Conditions of ApptovaUReasons for Disapproval �., S--`,—
' °1 ���`� T� ''`�
�! C s�t- ��- 0�� � �uN 9 s zozz �';�� .
O���IGINAL �
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sAwv"�c.;�.�:�i�
ZONING ADMINISTRHT!urJ
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SBD-6398(R.03/21)
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2,�Q, 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 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
x POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): / '! ��[" �<J�� Phone: �IS - o�(- �����
Owner Address: ���fo ,I- � ��; K��r�e-� �� �,c����' Zip: ������j(a
ProjectAddress: ��am�
Govt. Lot: � 1/4 of 1/4, Section �;� , T L10 N-R S� E❑or W �
Township: �,1� i ��21 County: �Jrcc����f
Project Parcel ID #: � 3c7 s�l� :�a S�C� �
Designer Information
Designer Name: �('��� 4 � � Phone:71S -�C� - :���I�
DesignerAddress: �r,t�� i'!`R �a!'1QS�/� ) UJi�'� Zip: v '-«`t�
E-fllal�: L�j���f-�L'����C � ll�/C�: �U/' � ':hLc space re>erv,�d lur a��p[uv:� sl.3inj�.
T.-
License Number: o2o�C���U
Remarks:
Signature: � "`�`" �'°`� Date: �o " , `��
Original ' a e required on ch submitted copy.
Reset Page
CHECK BOX AS MPU(:ABIE. CHECK 80X AS APPLI(v1BLE.
� SOIL EVALUATION a S�1e� �40' � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: �p, DESIGN FLOW: C� �v�
m �� ���f l�✓ Attach design flow calcuiations for commercial plans.
r (J
PROJECT ADDRESS' ��7— N NC'�1 k�C��ne�ti F�� Plpe Matefial/ASTM Standafd(TaMes 384(:�3 8 384.30.5)
N Sanitary Sewer L f�� / 1— V�
BM SYmbd: � aM E��,��� lo3.Y c Ff Fpr�¢Main: /
eMoe�nPua,: �4� �J�'� in L`F" CJI��'�2��nE'
mmmia�orcn ey IMPORTANT:
Slope craeieM(%) � yy�i yy�(�appiinda): Q arewmq a�a� Show rourM elevadon contours at suifable intervals-
Of Tested AtPa: � on t�e apProprila line. 9
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; Reset Page j
Septic Tank(s)Manufacturer.
IN-GROUND GRAVITY DISPERSAL AREA Sku� PTe �t•:�
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) �
y� gel gal gal gal
(( Effluent Filter Manufacturer:
_j'' �Y�� . � l�E'�i�
Geoteutile I min.1Y Effluent Filter Model#: �L�~�
cwer I (rypical)
SOILCOVER TYPICAL TRENCH
'r CROSS SECTION VIEW
min.trench s �
depth � �• � No Scale
�ryP'��� •� �'•� ' � � OBSERVATION PIPE DETAIL
. � •� � � �rvosm��
p', .
S stem Elevation= �7 SDft �, . s"a"'-Ty°a°` •� FinieheE Gretle
Y Slip Cap Qoose) �+ .
(rypical) ' Provide mioimum 3ft �mwc,eas��aea�
separation between trenches. a°m rvc r�,� ';`,, roP���co,��
Top af pipe to tertninale (min.1(oot)
at or above finiaheC gretle
TYPICAL TRENCH �4>>��-� �Xfi�s�
(Show location of inlet I outlet pipe connection on plan view.) (a? epart
f.
PLAN VIEW AnchanngDevice Infiliretron
Qn� Observafion pipa ehell be installetl SuRace
(No Scale) aljundionbetxeentwounita. �ft
Perforated Lateral Observation Pipe
�tYPical) (NPica�) (�v���)
— - - -- �f- - - - - - - - - - -- - - - - �—� �
� - - - - - - - - �--'_ _' ''_ '_'__'= I A- 3.0 ft �
--- -- -------
- '__'__'_ -
- - - - - - -�f- - -- - - - -- - - - - - -- - - - � c�va��� m
F a = � n =; �,,,
crya��n
INSTALL PER TRENCH: EZ1203H Bundle �
�tYPical) �
� 10-ft bundles @ 50 fl� EISAlunit= � ft' (mfd by Infilhator Systems,Inc.)
�_ Install pursuant to manufacturers instructions.
+ •-� 5-ft bundles @ 25 fl� EISAlunit= ft'
= Proposed EISA per trench = 3�-�% ft' Required Infltration Area= � a� ft' Distribution Method:
x _� trenches = Proposed Total EISA= � ft' l�/�,J�'IY
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, 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 shall be performed by a registered POWTS Malntainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Deslgn Flow= �GC� gpd; BODS<_ 220 mgL-'; TSS<_ 150 mgL"'; FOG <_30 mgL"'
Insaection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, eta)
o mechanical malfunction (i.e., pumps, valves, switches, floats, eta)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o solids volume 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 distribution 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, connections, switches, controls, timers, alarms, etc.)
o distribution lateral 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 Checkiist MAINTAIN EVERY 3 YEARS (or when necessary)
o Seotic and dose tank(sl shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats.when the volume of sotids in the tank(s)exceeds on�third (1/3)the Ilquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shail be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filter(s)shall be inspected every 3 yflers and shall be cleaned when necessary to remove any
accumulated soiids acwrding to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wlsc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: ���� �Om�`xv� ,f- �i2� �C Z LC Phone: 7/s�+:���' �5`)��
Localgovernmentunit: JaK��'r' �o�v�"�� 7�n�M Phone: 115-�%i`I' ���2�
Localgovernmentunitaddress: 1�C��C%�U /�1��� St, �u,-fP �j�I t7���ir,et2�l ZIP: �z��`�-3
Any defective part of this system shali be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of faiied or maffunctioning components shall comply with SPS 383. Wisc. Admin. Code.
No product for chemical or physicai restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Plan
In the event that any failed treatment component of this POWTS 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 dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in acxordance with SPS 383.33, Wisc. Admin. Code.
i Reset Page
�"�"T"`'`:� PRIVATE ONSITE WAS�E TREATMENT county
�/�� �;,
�
j j?�`oSp l�� SYSTEMS Sa,W er
�,;�1 s.�l`� ( POWTS) Y
`�_>,s,�i�
INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �-�_ � ��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
1' I rJ��r �
i Y�.e, � �
Insp BM Elev: BM escription: Parcel Tax No:
�D .o' �r �01�' ;h 1 ?" 1��;� f'��.- b3�- sYo- a�- S`��1
TANK IN MATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � �pJ Benchmark �Oo.n'
Dosing
Aeration Bldg. Sewer �(�(,,a 3 �
Holding St/Ht Inlet �9, $ '
TANK SETBACK INFORMATION St/Ht Outlet S 9.Yp�
TANK TO PIL WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic ,Koc�� 6S� b�� ,�s� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. 9$.�.�
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative �
Surface `�7��
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS `N 3 � 6a ' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � GP ❑ Chamber Model Number:
� EZFIow
CELL TO -�-(Op �(oj t(oc` (l/ ❑ Mound o Other
------- —. --- --- ----____._---__.._._
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 I Sodded Mulched
Cell Center l Cell Edges Topsoil ❑Yes ❑ No _ ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
7��5�+��� `7�r 3/02�
Plan revision required?❑Yes❑ No D,� �.� �-3 � - � U q���, �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL C�MMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �Z� < <(o
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