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Home My WebLink About111-838-12-2112-SAN-2022-119 "'"'•: Industry Services Division Counry � = 4822 Madison Yards Way �CC 4� (� � ; _�_' -- Madison,WI 53705 Sanitary Permit Number(to be filied in by C = P.O.Box 7162 _ Madison,WI 53707-7162 G'i � � � `�� Sanitary Permit Application State Transactson 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 fom�s for state-owned POWTS aze submitted to Project Address(if different than mailing adc the Department of Safery and Professional Services.Pcrsonal information you provide may be usecl for secondary � pu�poses in accordance with the Privacy Law,s.15.04(1)(m),Stats. C` _ � I.Application Information-Please Print A11 Informallon J�'�-� Pro rty Owner's Name Parcel# �^ur � ��.r� �f� �r�S 222 �3� 1;� �L 1� Property Owner's Mailing Address Property Location p�T ( �v— ��.f � Govt.Lot City,State Zip Code Phone Number �,+ C(� ��C!`:i vLJ� V-c.�� tS-�l 3 t-t��!3a 3 /,� ��4, ��%a, Section �� II.Type of Building(check all that apply) Lot# T �v N R � E o W ��I or 2 Family Dwelling-Number ofBedrooms Subdivision Name Block# �ublic/Commeroial-Describe Use �City of ❑State Owned-Describe Use CSM Number illage of ` ��'�`�'�T ❑Town of III.Type of POWTS Permit:(C6eck either"New"or"Replacement"and other applicable on line A. Check one boz on line B.Complete line C if a licable. A' ❑IVew 3ystem �Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) ILJ B' ❑Eiolding Tank �In-Ground �At-Grade �Mound [ndividual Site Desige� Other Type(explain) (conventional) C. �Renewal Before �Revision hange of Plumber �I'ransfer to New Owner �st Previous Permit Number and Date Issued Expiration s'jc�•-�� _ �j�h� IV.DispersaUTreatment Area and Tank Information: ( -� ?� t,4n;t,5 �a� fo�c$; Ce l Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation i oP . C-3'� �.�C r .o �� 5 � y3:�15� �r L��s Capac in Total #of Manufactarer � Tank Information Gallons Gallons Units � � �o ',d, � New Tanks Existing Tanks � o _ � y p � � a U in � v, i:. C7 a. Septic or Holding Tank ,�� ,� �j�� C� �<t:�L �L Dosing Chambcr � � V.Responsibility St�ttement-I,the undersigned,assume responsibility for instaUsaon of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber' ignature MP/MPRS Number Business Phone Number �f�.: �� a��o ��5-��.�--a��ya Plumber's Ad ss(Street,City,Statc,Zip Code) ��7-N i�� s��r-� 1?� ;n,-�,e� � S =G, VI.C un /Department Use Only �Ap rov ❑Disapproved Permit Fee Date Issued Issuing Agent Signat]u�re� � � `f�y✓ ❑Owner Given Reason for Denial $ ��.Oo � ��I��% ��/'�`�"""�'I TGV�/W�-- Conditions of ApprovaUReasons for Disapproval D h�� j ,� � � : C CST �- �� JUN 17 2022 } �� ' � ; � SAWYER C�U�'�i" ZONfNG ADNiiPllS�f+-(/a:'J"d Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x 11 inehes in size SBD-6398(R.03/21) NO REFUNDS AFTER ISSllE OF PEAMIT � PAGE 1 OF 4 in-Ground Gravity Pfan Index � Cover Sheet GS � Componerrt Manual Design Referenca� � ��h� Veraion 2z0,SBD-10705-P(N.01/01,R.10/12),,. `�.� �p�„/� fUtoh�a5' � Pg 1 of 4 index 8�Cover Sheet �J. �01� Pg 2 of 4 Plot Plan . Pg 3 of 4 Dispersal Area Cross-Section&P�an�ew Pg 4 of 4 Management Pian Attachments: E r : POWTS lication for Review Soil Evaluation Report&Site M Project Name/Description oYvner Name(s): �r�n�� c��rnPS Pnone:�15 _`f3'{ _�3�3 OwnerAddr�s: �l�l��N HO��e/ R�A Cvu��er«� Zip: S�[4S,2�f Projed Address: S c'c/�'�E'- Govt.Lot: N E 1/4 of �1/4,Section 12 .T 3� N-R�_E or W� Township: U�ll4�e e� �c.2.f�eru�Counly; �G rJ�;. Project Parcel ID�: /�I `6 3`� I o� a r 1� Deaigner IMormation o��g��: Cr��; ��r�5�� ano�:�I S _�K> _�ZfS�I� —� D�ignsr Address: S 0�`2-N �t;/n��sl +P{� �,)'i�l{ei Zip: S�L S`f Ca E�naiL• c�cill��i.�l'�5:�1��1C��i�e, �� o paca:_ssced iura_;p:o;:;;�.a,-ac. ucertse Number. c�c�o FS l C7 Remarks: s�g�sa,re• �\ 1 �''� �ate: �--l 7-�a � �� U��. � �ot ��-�°1 ....,, North � ��.� �pW i �h3 7�� 1 1 w „ � � �� µe� i--O� �� I � � � � � i , cj0 a i,,w i.T� z�� C� ;:Itv "� h � H ��C ��_,h�• �y — — — — — — — — pe ELjtn ecll (pK57J _ — U�qc�. R,O.w. 1//= 0�.0� � �rKs�S-N ��«�e- HO}�cf � ��JY�1 , `.a� .�D�-� in N (tl. S `cQP �`� ay�� rh�y1�P I�J.�i �.75 N� lua �S '— �_SySt`e,�n R�.1.;� >�i �o -�v �t3 '-l5' �a5e � SEED AND LOAM TO PROTECT FROM EROSION �� GEOTEXfILEFABRIC �i MIN�2"OF CLEAN FlLL T � 1 g' �T SPECIFIEDSAND � � �,-__ � 6" 36" 6" 48" 843 WITH 6"OF SAND TO SIDES SEED AND LOAM TO PROTECT FROM EROSI ON �� GEOTEXT�E FABRIC � MIN 12"OF CLEAN FILL � � ' 19„ 1z� SPECIFIED SAND �� =, � 12" 36" 12" 60' 643 WITH 12"OF SAND TO SIDES SEED AND LOAM TO PROTECT FROM ER0.SION �� GEOTEXTI�FABRIC � MIN 12"OF CLEAN FILL � � �g• 12 SPECIFIFD SAND �� -. � 18" 36" 18" 72" B431MTH 18"OF SAND TO SIDES Figure 2. 643 Sing�e Lateral in-Ground Cross Sections Eljen Corporetion ��,�,3 Table 3 OTHER SPECIFICATIONS Slope of in situ soil <_25%in area of component Vertical separation between bottom >_Equal to depth required by s.SPS 383 ofGSF unit and seasonal saturation Table 353.44-3,Wis.Adm.Code defined by redoximorphic features, eottom of distribution cell Level Horizontal separation between >_3 ft. distribution cells Piping material in the distribution Meets requirements of s.SPS 38430(2),Wis.Adm. system Code for its intended use Piping material for Meets requirements of s. 384.30Table 38430-1, observation,vent,and Wis.Adm.Code Slope of grevity flow perforated <4 inches per 100 feet away from distribution distribution laterel piping boxes,drop boxes or header Location of gravityflow perforeted Centered over the GSF unit distribution pipe in distribution cell Location of GSF Units, per row. Located as follows: Single A42 Line 12 sf/unit—Units are centered in a 3 foot width trench, 6 inches of sand on either side Single A42 Line 16 sf/unit—Units are centered in a 4 foot width trench, 12 inches of sand on either side Single A42 Line 20 sf/unit—Units are centered in a 5 foot width trench, 18 inches of sand on either side Dual A42 System—Units have 6 inches of sand from sidewall and 1 foot of sand in between units Single 843 Line 16 sf/unit—Units are centered in a 4 foot width trench, 6 inches of sand on either side Single B43 Line 20 sf/unit—Units are centered in a 5 foot width trench, 12 inches of sand on either side � Single 643 Line 24 sf/unit—Units are centered in a 6 foot width trench, 18 inches of sand on either side <<so�� = i.� = a�i.as�'a OCO'.�S i ��7 ' �I. /c� CR I�Kl�� CS �� #� �ra�usr.l� SYSz.e� ]�-( w.;?5 �i3+� = 33� Eljen Corporetion ��c 3- f� PAGE 4 OF 4 In-ground Gravity Management Plan IMPORTANT: The owner of this inyround graviry system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384.Wisc.Admin. Code. Pursua�t to SPS 383.52(2),Wisc.Admin. Code,this system shall be considered a human health hazard 'rf not maintained in accordance with this approved management plan. Furthertnore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52(3),Wisc. Admin. Code. Maxfmum Dispersal Area Operetinq Limits: Design Flow= -! � gpd; BODs�220 mgL''; TSS 5150 mgL"'; FOG 5 30 mgL"' Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors(i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps,valves, switches,floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s)and any distribution appuRenance(s)(i.e., distribution/drop boxes) o neglect or improper use(i.e., exceeding design capacides, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.) o electrical components-'rf applicabie (i.e.,wiring, connections, switches, conVols, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Seotic and dose tank(s1 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 liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc. Admin. Code. o Effluent fllter(s)shall be inspected every 3 years and shall be deaned when necessary to remove any accumulated solids according to manufacturer's spec"rfications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local govemment unit in accordance with SPS 383.55 Wisc.Admin. Code. Report any component failure or maifunction to: Name of individual or company: Q D!1 �MG�1 �' S�nS �'� Phone: �jS'o�lc�v -;��y� Localgovernmentunit: SG41�P� ��OW�� i)/l��"� Phone: �/S'� St��c�� Local govemment unit address: I t�G��Z� /12a�� S�. ��'f e G�( �1�.(4iu'�( ZIP: S�(�E�1?7 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. 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�omplying dispersal 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. ° `>r>, PRIVATE ONSITE WASTE TREATMENT County `�/�Y*µ"'\I\�r� SYSTEMS ��S�/Ji~l ( POWTS) Sawyer k�___/�,� ,. ��'""�''` INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2�_�1� Petsonal infonnation you provide may be used for secondary pu�poses[Privacy Law,s. 15.04(I)(m)J Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �hk �sah �v �o„�.�, — Insp BM Elev: BM Description: Parcel Tax No: (oo.a' �� /�` s.2�u. 2 Y" � 1�1 — 83� 12- �112 TANK IN ORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEU Septic �j�../�VJ oop Benchmark o i Dosing Aeration Bldg. Sewer Q'�,�q� Holding St/Ht Inlet y'),,�g' TANK SETBACK INFORMATION St I Ht Outlet �6 gY r TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR INTAKE Septic .�-�o` ��S� I Y� -1�1 Y � NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist.Pipe q6,o' PUMP/SIPHON INFORMATION Infiltrative � Surface `�3�`i�?' Manufacturer Demand Final Grade � Model Number GPM T� C3 `l S�oY� TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W /' L �� #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav Conv ❑ Aggregate �� P I L Bldg Well ❑ IGP ❑ Chamber INFORMATION Waters � AG ❑ EZFIow Model Number: CELL TO l$� �� N ❑ Mound �X Other �Y3 -- - -- - — DISTRIBUTION SYSTEM X Pressure Systems Only Header/Manifoltl 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 Mulched Cell Center � Cell Edges Topsoil __ � ❑Yes ❑ No 1 ❑Yes ❑ No � COMMENTS: (Include code discrepancies, persons present,etc.) ��,S�rl� c�� Plan revision required?O Yes❑ No �„� �,� _�3 �—�c� � G� �b /(o � � L Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) .. ..... ....:. . .. ....:. . !_. . .......... ........... .i..............i_... .� . .,_..._... _.: .... .. . . . . . . .. . . . . . � . 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