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Home My WebLink About004-839-08-5219-SAN-2022-141 �� - lndustry Services Division County � ; , _ 4822 Madison Yards Way ��'"� � � ; ., = Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) � '= P.O.Box 7302 � Madison,WI 53707 6 3�O�g � Sanitary Permit Application State Transaction Number � � (n accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit � is required prior to obiaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different then mailing addre _ the Department of Safety and Professional Scrvices.Personai information you provide may be used for secondary � purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � -7 �'C�� f pn�„� S (� I.Application Information-Please Print All Information � Property OwnePs Name Parcel# Gi,or �va �Y►�+ D0 �1� 39•O�SZ� °� Property Owner's Mailing Address Prope Location � �ItN�� `'r�l � � q p �� ! � / O C er � Govt.Lot Ciry,State Z,ip Code Phone Number .p �M� (___ /y�I• �--�..�.L ��,Section �D `.o�� II.Type of Building(check all that apply) � Lot# �� T � N R � 8 E or or 2 Family Dwelling-Number ofBedrooms Subdivision Name Block# �ubliclCommercial-Describe Use � ❑City of ❑State Owned-Describe Use CSM Number � illage of 3?/31 �� own of �� III.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. `� ew System �Replacement System �her Modification to Existing System(explain) �Additional Pretreatment Unit(explain) u B" �iolding Tank In�'iround �At-Grade �Mound Individual Site Design Other Type(explain) (conventional) C• ❑Renewal Before Revision�-�`d�s� hange of Plumber �I'ransfer to New Owner ist Previous Permit Number and Date Issued Expiration � Z2, ^� d�Q �1 �cl 2� IV.DispersaUTreatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �/So . 7 �Y3 � 7$ �17. s- /oo.s' Capacity in Total #of Manufacturer Tank Information Gallons Gallons Uniu � � v ,'�, � New Tanks Existing Tanks ` ❑ � " � � � � 0 n. U 'v� y r7a ij. C7 n. SepticorHoldingTank /O00 /Op(J l (�[ tl�� r Dosing Chamber � � V.Responsibility Statement- I,t6e uadersigned,assume responsibility for installs6on ot the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Dylan Schultz 1516129 715-558-5904 Plumber's Address(Street,Ciry,State,Zip Code) 7076N Stone Lake RD, Stone Lake, , 54876 VI.Cou ty/Department Use Only 7 Pecmit Fee Date Issued Issuing Agent Signature �App e ❑Disapproved �^ 7�" ❑Owner Given Reason for Denial $`�� (�`� � "-""--"�'� Conditions of Approval/Reasons for Disapproval . . 5....1� � �7 I �� =J ��_ J��j� �� c s� �a- o�3 �� y-�, I IN . R o 6 xQz �u� z� SflWYcR CC�:JP�i Y '�S4R_a��0 CcS T a _Q�Q � c ' Attach to complete plans for the system and submit to the County only on paper oot less thao S�2 x I1 inches in size NO REFUNDS AFTER SBD-6398(R.02/22) ISSUE OF PEAMIT PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Componeni Manual Design References: Version 2fQ, SBD-10705-P (N.01/01, R. 10/12), , , 2.� Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersal Area Cross-Section & Plan View Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name/ Description Owner Name(s): � �'y NO"5�s� ! Phone: - - Owner ,4ddress: I 9 S�°9 Deo�$�o04� P�.+l. Zip: �S v zy , Project Address: � ��y N �enhns r� Govt. Lot: 1/4 of 1/4, Section � g , T 3�I N-R � � E❑or W.� Township: G��'y County: S`�"Y� Project Parcei ID #: ooyg 39 0 �S Z/�i Designer Information Designer Name: Dylan Schultz Phone: ��5 _ 558 _ 5904 Designer Address: �076N Stone Lake RD Zip: 54876 dylanschultzl8@gmail.com E'ITi81�: i�l;is sruce resen�ed lor ap,�rncal sromp. License Number: 1516129 Remarks: Signature: Date: 7` 2 ' 2Z O � � I signature ired on each submittetl copy. ��— c� �� 2 � Y ow ✓�e� : L�� : G o�� -� �Q�o � �. �104.��4N O S4w�ttr CO.� �OVder4..� l w� ' l 1R809 �eerb�oaKe (�a'�� PtiJ : oo'-k- 839- b8- sZ � q �c�r�,-r9'�o✓\ � F'( wt SS�Z�} S� °8 T 3 q rJ (C. O 8 w S:fe: 6-75`1ti1 To�tavts f�d. LT zZ �,sH 3`t� 3� � (� S�g �7 3 4 2 � 276� / � -/ P 6z / 2 . � so - � 'y �1 ' x�c ti Q � +c� �% M J �3 �a�� Bh�oo $ 6�5y rJ � �� . � � J � � � i Zg-r a � ,�g� � ♦ ar� ioo, na:l,r�66e..� o.� w¢s� s.��le o-f- 36,� wti. P,Kc �-Fe" v�. � j3�, toz .b8� 7�. 103 ;7Z' SGa�G 0��= �fD ' 3 . I OZ .S'-F � v� D �� m ep yV ,Z So. �S� 5�. e �. 4Q.S' � raKge R'I.S�— loos"� i� �,J�cc �o M�-t- Co d e s�6 c<S � Un�<howh �aca.'Eio� C�.�l c� S�2e D'C'— �1.6.t1� 1 l Dylan Schultz 7076N Stone Lake Rd Stone Lake,WI 54876 MPRS 1516129 IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manu(acturer. v��"� Stepped Elevation Trenches with Quick4 Standard-W Chambers 3-ftTrench (down-siZing credit) G� SepticTank(s)Volume(s): � gal gal gal gal � Efflue t Filter Manufacturer: SOIL COVER I ��r�� min.12" (rypical) Effluent Filter Motlel#: �Z'� 12' min,Uench TYPICAL TRENCH aec� � CROSS SECTION VIEW �yP��O �' � � ' ' '"�� Provide minimum 3 ft •• • .a '•. (No Scale) �— s'a•��.{ �; � • separation between trenches. typlcal I ) .� � . . . . i • Highest Trench Lowest Trench (as applicable) System Elevations= ft; ft; ft; ft; ft Quick4 Standard-W w/End Cap Obsena[ionPipe TyPICAL TRENCH � �� (Show location of inlet I outlet pipe connection on plan view.) (Ha��O �yP � InstallpermanufacWrers pLANVIEW �°s"�"°°s (No Scale) � �Retx• rx — �� - - - - - - - �� - - - -�`A'!�tK.rs�r»Artss.v, — — — — � �. o� ��, � d �� A= 3.Oft l- - -��xi�iYi�" - - - - �� — �� - - - li a fyxatcax.cxatJ (�Yvicaq D B = n -_; m (typlcal) Quick4 Standard-W Chamber W INSTALL PER TRENCH: �TyP�� (mfd by InfltretorSystems,Inc.) -n �I Inetell pursuant to menufecturefe Instructiona. � Quick4 Std-W @ 20 fP EISAlchamber= 2�d ft' + � Pairs of end caps @ 6 ft'EISAlpair= �_ ft' �y� = Proposed EISA per trench = 2-2� ft' Required Infiltration Area= �ft' Distribution Method: x � trenches = Proposed Total EISA = �� fl' (�'��`Y � �� PAGE40F4 In-ground Gravity Management Plan IMPOR�ANT: The owner of this in-ground greviry system shall 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 he performed by a reglstered POWTS Malntainar in accordance with SPS 383.52(3).Wisc. Admin. Code. Maximum Discersal Area Ooeratina Limits: Design Flow= �SU gpd; BODS 5 220 mgL-'; TSS 5150 mgL''; FOG <_30 mgL'' Inspectlon 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 heatment tank(s) and any distribution appurtenance(s) (i.e.,distribution!drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activi0es, etc.) o extent of ponding in distribution cell prior to dosina o dosing irregularities-if applicable(i.e., pump re-cyciing, 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 specifica6on) o surtace discharge of effluent or sewage back-up into structure 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 (t/3)the liquid volume of the tank(s)or as r�uired by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc. Admin. Code. o Effluent filterls)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 than 12 months. System maintenance reports shali be submitted to ihe proper�ocal government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component fallure or malfunction to: Name of individual or company:_��"`� _ S`��} L� _ Phone 7�J -Sf��9�/ / 7is- G3v - �z�'6 Local government unit: S G Q/ Gc�. , 2�n,r Phone: �� --! �-- Local government unitaddress: �bb10 h'14�h `S� • a.�� `T ZIP: �gY� 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 fai�ed 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-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 accordance with SPS 383.33. Wisc. Admin. Code. '"'"'"E� PRIVATE ONSITE WASTE TREATMENT co�nty / `� - � �� `�' SYSTEMS Sawyer - , n �T.. I=; $P 1=� �`�� ( POWTS) A�Frss'�'-="'=i INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� I (..{ ( Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)] � Permit Holder's Name: ❑City ❑ Village �1 Town of: State Plan Transaction ID#: �a �� av,d� �.,� � Insp BM Elev: BM Description: Parcel Tax No: �aQ / "'I(II � \ i�� ah �S�^� ��„ ��,\ 1�`'�..�t WY�' JC�9 � V��Sr�� tJ � TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,�— � oup Benchmark ��A ' Dosing Aeration Bldg.Sewer ._ Holding St/Ht Inlet � x � TANK SETBACK INFORMATION St I Ht Outlet b , � ' TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIRINTAKE Septic ,}-�� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. �c'�U,g � Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative Surface (a�'� 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 W 3� L �i o' ' #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav $� Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters ° �GP ❑ Chamber ❑ AG � EZFIow Model Number: CELL TO fi ` (U ,d..'� � ❑ Mound o Other DISTRIBUTION SYSTEM X Pressure Systems Only �Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipe� Length Dia Length Dia Spac Spacing ❑Yes ❑No SOIL COVER Depth Over Depth Over Depth of Seeded i Sotlded Mulched Cell Center Cell Edges Topsoil ❑Yes ❑ No �Yes ❑ N� COMMENTS: (Include code discrepancies, persons present,etc.) � ��fQ� � � 2D(�a Plan revision required?�Yes 0 No �3 �� a C �vr„ ��'�<_--, C�� ( Use other side for adtlitional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3l01) A�DITIONAL C�MMENTS ANO SKETCH SANITAAY PEAMIT NUMBEA: �� -- G,�f�1.� Cco �- � �r`� ; _ ,__- .- ._ ,�� - . � - - .- ._ --- �---. - - - - - --- . � � �� o . . . . . _ �( ,,.� : : _ _ � � � , : _ : _ �o : ._ : - � -- :_ - . _!__+ _:_ _�_ � -� - ._ -- , _ : ,�,� ,�� ; :__ -- . : � � . __. __! ._ o i. __ t..... � � � ;� � 1 � '- _--. :. _ � . : ; _ _ - __ . : -- .. i � 7 � , ! '�� _. . , _ _ . . . _ . 7� 7' � _ 3' � . 3� w i�I' ' '�� , ,,,'�r�Y � � � � � � � . Q �a� � �.�1 � �q�--� � J � -� a �N� I 3 � ,.�y� � , � � �� . -�,d---- � ,,��,,�'�, �� ]LIIIC �