HomeMy WebLinkAbout010-941-20-2402-SAN-2022-140 � ]ndustry Services Division Counry �
� 4822 Madison Yards Way �kwY�`'� �
� - Madison,WI 53705 Sanitary Permit Number(to be filled in by Co
Pa � P.o. BoX�302 �,�
� Madison,WI 53707 � ��� � ��v �
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Sanitary Permit Application StateTransactionNumb�r �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit .�'
is required prior to obtaining a sanitary permit.Note:Application fbrms for stateowned POWTS are submitted to Project Address(if different than mailing add Q
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance H�ith the Privac��LaH�,s. 1�.04(1)(m),Stats. �a-�7 3 � �O��d rG(
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
Gof�� �;�h �-��s�" olo- 9Y(- Lv- 2y�z
Property Owner's Mailing Address Property Location
�6� �/.tS� sk�*L �C` (jevr-tpf-
City,State 7_ip Code Phone Number I�r�
M�c�;so�
W� s"3 -T�� ry S� '/4, N�'/<. Section Z-b
Il.Type of Building(check all that apply) l.ot# ^ 'I' y� N R�._E or
1 or 2 Family Dwelling-Number ofBedrooms 3 Subdivision Name �
Block#
�ublic/Commercial-Describe Use '
❑city oY'
❑State Owned-Describe Use CSM Number Village of
i Town of!CwY�^'""�
ItI.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
`�� �New System eplacement System �Other Modification to E:xisting System(explain) �Additional Pretreatment Unit(explain)
B' ❑Holding Tank n-Ground �AAt-Grade �Mound lndividual Site Design Other Type(explain)
(conventional)
��• �Renewal Before �Revision hange of Plumber �Transfer to New Owner '
List Previous Permit Number and Date lssued
Expiration �h�� ( �� '�� ' ?
IV.Dispersal/Treatment Area and Tank Information:
llesign Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�J�� � 7 ��3 7S� q 2�- 9s'
Capacity in Total #of Manufacturer
Tank Information
Gallons Gallons Units � ° T' �`-'
� J ti
R � � � � �
New Tanks ExisUng Tanks � o := � � �
a U cn v, rn u. Ci o.•
Septic or Holding Tank Ia� �� � �./(GS[�
Dosing Chamber � � �
V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumbet's Name(Print) Plumber's Signatur MP/MPRS Number Business Phone Number
Dylan Schultz 1516129
Plumber's Address(Street City,State,Zip Code)
7076N Stone Lake RD, Stone Lake, WI, 54876
VL C u ty/Department Use Only
Permit Fee Date lssued lssuing Agent Signature
�A e ❑Disapproved
�w $�{vc�,�° � �6��a `�iy...i,r���-lu��•�-
❑Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval [��i'�t.'i r'f;�' --1
. . D � �',I�:,�;;�'�:%l_-1 ;
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�.. J U L 0 6 2022 � - �
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Z01diNG Ai;Nl;NISTFi,�;i(,7
Attach to wmplete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
NO REFJNDS AFTER
SBD-6398(R.02/22) 1SSUE OF PERMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 7,,�, SBD-10705-P (N.01/01, R. 10/12) , , ,
��1
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): G�"r d �%��^S �" rfi Phone: - -
Owner Address: 1 (��7 3 �/ f�.wa � 1 2ip; �gy3
Project Address:
Govt. Lot: 1/4 of 1/4, Section 2 b , T YI N-R D 9 E❑or vv��
Township: K�yy-r d County: SF�Y«
Project Parcel ID #: ol o- 4yr- 2d - Z yo2
Designer Information
Designer Name: Dylan Schultz Phone: �15 _ 558 _ 5904
Designer Address: �076N Stone Lake RD Z�P: 54876
E-ma��: dy�811SChU�tZi8�gf1181�.COfT1 �'!;i�sr�crresen�ed{orapprovalstamp.
License Number: 1516129
Remarks:
Signature: ��� � Date: 7�5� Z Z
Original� ure require each submitted copy.
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�Dylan Schul�
,�, SN1too, 3a'f�yw� Jitir� Corn�r boa. d Sw Cbrne<- �7076N Stone Lake Rd
Stone Lake, WI 54876
g ( y'1,2.s' � MPRS 1516129
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3. Gb.s
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Es.�- S.T. �►•� f R(o'
IN-GROUND GRAVITY DtSPERSAL AREA Septi�tcs(si anufacturec
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) i000
gal gal gal gal
Effluent Filter Manufacturer:
. �o� f.�c�
� SZS
min. 12' Eftluent Filter Model#:
Geote�Rile I (h,P����
Cover
SOILCOVER TYPICAL TRENCH
'Z� CROSS SECTION VIEW
min.trench � �
depth "�
�ry���� L r — � :� (No Scale) OBSERVATION PIPE DETAIL
/ r :•, (Noswle)
�. Screw-iype or
System Elevation = ft. Slip Cap(loose) ':.' , F���snea c�aa
Provide minimum 3ft , , cm�i=neaasaeaea�
(tYpical) roasoa coVa�
separation between trenches. a•e Pvc a�� �; � :';,
Top of pipe to terzninate �'• �,�p� (min.1(oo�)
atoraGovehnisheCgrdde !�'
(4)1/4"-1 "%6"Sbts
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) @ '� aaae
:•
PLAN VIEW AnchonngDeviw Infilt2lron
4n� Observation pipe shall be insfalled SuAace
(No Scale) atjunclionbahvaentwouni[s. ft
Perforated Lateral Observation Pipe
(typical) (rypi�yl) (typical)
-- - - --�f--- - -- -- - - --- - - -- --
�-- - ----- - �
I =_____ _____°_ _--__ °__=___= I a= s.o n �
-- --- -------
----- -�� ---- - -- -- - --- ---- - � cty���� m
e = SO n —_� w
cri��n O
INSTALL PER TRENCH: EZ1203H Bundle -n
� (tYPical) �
10-ft bundles @ 50 f� EISAlunit= 2�� ft' (mfd by Inflltrator Systems, Inc.)
Install pursuant to manufacturer's inshucHons.
+ � 5-ft bundles @ 25 fP EISAlunit= � ft'
= Proposed EISA per trench = 2S� ft' Required Infiltration Area= 6 y3 ft' Distribution Method:
x 3 trenches = Proposed Total EISA = �Sd ft' �r"""�
�
PAGE40F4
In-ground Gravity Management Plan
IMPOR7ANT:
The owner of this in-ground gravity system sha�l 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 registe�ed POWTS Malntainer in
accordance with SPS 383.52 (3). Wisc. Admin. Code.
Maximum Oisnersal Area Oneratinp Limits:
Design Flow= y.SU gpd; BODS 5 220 mgL"'; TSS 5150 mgL''; FOG <_30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age ot 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 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 dosinq
o dosing irregularities-if applicabie(i.e., pump re-cycling, iloat 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 Iateral distal pressure—compare to design specification)
o surtace discharge of etfluent or sewage back-up into struciure served
Maintenance Checklist 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 in the tank(s)exceeds one-third (1/3)the 1{quid volume of the tank(s)or
as required by local ordinance. Disposal oi contents shall be pursuant to NR 113.Wisc. Admin. Code.
o Effluent filter(sl shall be inspected every 3 years and shatl be Geaned when necessary to remove any
accumulated solids according to manufaclurer's spec'rfications. A serviang period will always be greater than 12
months.
System mafntenance reports shali be submitted to the proper local government unit(n accordance with
SPS 383.55 Wisc. Admin. Code. Report any compone�t fallure or maltunction to:
Name of individual or company:__��_�"'�_S`�"'�}Z Phone: 7�J� "Ss�"S9�
Local government unit: y u✓y e/Gwr�i Z��,r Phone: ��s �j v �z��
Local government unit address: (�l0 W�4� S'!• �� �� _____ZIP'_����
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 Ireatment component ot Ihis 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 ot suitable soils.
SYstem Abandonment
If use of this POWTS is disconUnued. it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
/,,,.` '``T PRIVATE ONSITE WASTE TREATMENT county
,,_.,,,\,Y�
�';i�sPs. ��J SYSTEMS Sawyer
��� ��j ( POWTS)
��'-''-'"��� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,� _ ��b
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#:
G���c �-i�ti �n�.� Ha wa�-� ^
Insp BM Elev: BM scription: Parcel Tax No:
L��°� Ba'�� ��h ( c���C �w ��^�- D lo —9Yl— �-o - 2Y��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic wi�c,,�� �Oot7 Benchmark v��'
Dosing
Aeration Bldg. Sewer q6,(�'
Holding St l Ht Inlet S"�
�
TANK SETBACK INFORMATION St I Ht outlet � , 3 �
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIR INTAKE
Septic .E.�oo' .�. ' ` fiS� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �($3
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
�
Surface ���
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N 'lj L 7p� � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav
Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO i-(pD� t �..� ❑ Mound o Other
- - - - __--- — -
DISTRIBUTION SYSTEM X Pressure Systems Only
-- - - - -- — -
HE�ader/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No �
—
--- —
Si�IL COVER
— -- _ -----
Depth Over Depth Over I Depth of � Seeded/Sodded � Mulched
Cell Center 1 Cell Edges I Topsoil__ _ _ ❑Yes ❑ No ❑Yes ❑ No�
CQMMENTS: (Include code discrepancies, persons present,etc.)
�, i -� (�r���
� �
Plan revision required?❑ Yes❑ No �3 Qt � 2 ` _-_/ � /Q� /� �
� vv �� �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NIJMBEA: 2.�-- I�o _
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