HomeMy WebLinkAbout002-940-13-5504-SAN-2022-133 ' Industry Services Division County �: �
'\ , 4822 Madison Yards Way � �' �
� „ � ; Madison,WI 53705 Sanitary Permit Nu e�(to be fil►ed in by Co
'= P.O.Box 7302 �
Madison,WI 53707 �p�j q � �� �
Sanitary Permit Application State Transaction Numb�T �
ln 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 forms for state�wned POWTS are submitted to Project Address(if different than mailing addn �
the Dcpartment of Safery and Professional Services.Personal information you provide may be used for secondary Ge'�� �/ ���'�� �
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. a J ��'
I.Application Information-Please Print All Information Lt�'J�,. �J°,�
Property Owner's Name Parcel#
� �a.�� - ��;�, ��ev.-�r�c�f ooa-� �o-c -�sa��
Property Owner's Mailing Address Property Location
�3� � J'� Govt.Lot �
City,5tate Zip Code Phone Number C
� J 1 L�(J�f �t �/1 �6��/ �� y° �J�. y<, Section�
II.Type of Building(check all that apply) � Lot# T �� N R � E o W
�1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block#
�ublic/Commercial-Describe Use
�City of
❑State Owned-Desc;ribe Use CSM Number :7 �� ' illage of
l�J��. L'� p�. �('I'ownof �Q.�`JS Ls-c-f�'.-.�
CSrn i5/3 �fd
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on►ine B.Complete line C i
a licable.)
`�' ew S stem lacement S stem iher Modification to Existin S stem ex lain Additionai Pretreatment Unit ex lain
� Y �eP Y g Y ( P ) ❑ � P )
B' ❑Holding Tank 1�-Ground �4t-Grade �Mound Individual Site Design Other Type(explain)
�(conventional)
List Previous Permit Number and Date Issued
C'• ❑Renewal Before �Revision hange of Plumber �['ransfer to New Owner �
Expiration �7 q („�y�, �
IV.DispersaUTreatment Area and Tank Information:
Design Fiow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Reo���*ed(s� Dispersal Area Proposed(s� System Ele�•ation Tr-��acr(�,a
�75D � �� 1 �I =;� ��� �s S 7'r�/q
Capacity in Totai #of Manufacturer
Gallons Galbns Units � o 'd o
'Cank(nformarion � � U � � y
New Tanks Existing Tanks y ❑ e� " y p � �
a U cn � cn v. C7 Ci.
Septic or Holding Tank � �1� i�i�� , ` �
..` 'V y�
Dosing Chamber � � �
V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber' ignature MP/h1PRS Number Business Phone Number
� '��1 / 7!5-��-1b�7�
lu er's Address(Street,Ciry,State,Zip Code) '
�(�. �7 G� ����/� � G(.7— j��'
VI.Cou /Department Use Only
7 Permit Fee Date Issued Issuin A ent Si ature
�.Approved ❑Disapproved � g Sn
��✓ ❑Owner Given Keason for Denial $�U�'� � I 1 I� 1�.����V1M/1--
Conditions of ApprovaUReasons for Disapproval ;;;,,,��
. �/i G�;�_J',�"�.; �� i1J; �= , ; 1
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Attach to complete plans for the system and submit to the County only ou paper not less thsn 8 V2 z 11 inches in size
SBD-6398(R.02/22) NO REFUNDS AFTER
iSSUE OF PERMI7
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 . `
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Pian
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): ��� ��1;��'i�-��-��ti �. I Vt:�,�S-f Phone: - -
Owner Address: ��� �`� u��(;��-�1_,�.��P ; � Zip: -,�'� j�l O
Project Address: �;q� l� (�� (�. �ce.r t,�dz�� � � ��.3
Govt. Lot: � �7 � 1/4 of S� 1/4, Section�, T `�� N-R a 1 E 0 or W �
Township: �S�J (��_ County: �j(�x�c��
Project Parcel ID #: 0� � " CI�(?�` � � `��0 y
Designer Information
Designer Name: ��C�i� `�.��VZLd1� Phone: ` �d5 - S� 1� 7�
Designer Address: ` �'7 /�,l � � � � �Q, Zip: J`��-��
E-mail: �a�� � , _ ;
i 1i_':> >i'dti' 4"� �. '. ... . .;.' .
License Number: ���� �
Remarks:
—
Signature: Date: �p ✓ �7��-3 �
O ' inal signat required on each sutrmitted copy.
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PAGE 4 OF 4
fn-ground Gravity Management Pian
IMPORTANT:
The owner of this in-ground gravity system shall be responsibie for its perpetuai operation 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 heaith hazard'rf not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shali be perPormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disoersal Area Ooeratinq Limits:
Design Flow= {1�Jr�L_ 9Pd; BODS_<220 mgL''; TSS S 150 mgL-'; FOG_<30 mgL''
Insaection Checklist INSPEC7 EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e_odors,user complaints,etc.)
o mechanical malfunctiort(i.e.,pumps,valves,switches,ftoats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids voiume in anaerobic treafinent tank(s)and any disfibu5on appurtenance(s)(i.e.,disfribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,efc.)
o exterrt of ponding in disfibution cell prior to dosing
o dosing irregularities-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 laterai orifice plugging (measure laterai distal pressure—compare to design specification}
o surtace discharge of effiuent or sewage back-up into sfructure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
0 5eotic and dose tanktsl shail be pumped by a certified septage servicing operator licensed under s.281.48 W is.
Stats_when the volume of solids in tFie tank(sj exceeds one-third(1/3)the Iiquid votume of the tank(s}or
as required by local ortlinance. Disposal of contents shali be pursuant to NR 113,Wisc.Admin.Code.
o Etfluent fiftertsl shali be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacturer s specfications. A servicing period will always be greater than 12
months.
Sysfem mainfenance reports shall be submitted to the proper tocal govemment unit en accordance with
SPS 383.55�sc.Admin.Code. Report any component failure or matfurtction to:
Name of individual or company:�UQ1� J�-�l� Phone: ��GS���O�
�oca�govemment unit: � C Phone: lJG��i=�C/—$,�j-'�
Localgovemmentunitaddress:� l� ZIP_ 5�0'G3
Any defective part of this system shall be repaired,replaced,or removed parsuant to SPS 383.51(1),Wisc.Admin.
Code.Repair or replacement of faifed or maifunctioning components sfiall comply wiih SPS 383,Wisc.Admin.Code.
IVo product fior chemica�or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wsc.Admin.Code.
Continqencv Pian
In the event that any failed Veatment component of this P01NTS 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 pr2detennined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discon6nued,it sha11 6e abandoned in accordance with SPS 383.33,�sc.Admin.Code.
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