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HomeMy WebLinkAbout012-222-00-0600-SAN-2022-153 i � �� � Industry Ser�°ices Division Coun � , �_ d822 Madison Yards W'ay ��,�� � - , _' = Madison,WI 53705 Sanitary Perm� umber(to be filled in by( S P.O.Box 7302 ��� Madison,WI 53707 ���� �S�% � State Transaction Number � Sanitary Permit Application � Ln accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit �� � is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address(if different than mailing a� the Department of Safety and Professional Services.Personal information you provide may be used for secondary �r'�,t�.N -f"�N "�.�L (_y,� purposes in accordance with the Privacy Law,s. I�.04(I)(m),Stats. I.Application Information-Please Print All Information Pro erty Owner's Nar�e Parcel# ��� t� � � �.�Q �wtire � I Z-2zZ -00�-��d0 Property Owner's Mailing Address Property Location 7Z ""�(�(�Se � Govt Lot Ciry,State Zip Code Phone Number � �,Sl�1 (.li.L ���p �S 1-- qk3-- ��s 2 '/, '/<, Section ��7 II.Type of Building(check all that apply) Lot# T "1� N R W �I or 2 Family Dwelling-Number ofBedrooms S� � ��- � Subdivision Name Block# �;� ��� �y� �ry,�{" � ❑Public/Commercial-Describe Use �City of ❑State Ow�ned-Describe Use CSM Number �Village of �Town of � ❑I.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 �Replacement Sy stem �Other Moditication to Existing System(esplain) �Additional Prctreatment Unit(explain) te.nr��e o N�y B' �Holding Tank �In-Ground �At-Grade �Mound �[ndividual Site Design Other Type(explain) (conventional)p�C($'�; C• ❑Renewal Before �Revision �Change of Plumber �I'ransfer to New Owner��'�st Previous Permit Number and Date Issued Expiration �y,�k� IV.Dispersal/Treatment Area and Tank Information: Design Flo�v(gpd) Desien Soil Application Rate(gpd/s� Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation 300 � rT ���l �xts-F-�n ' �shn Capacity in Total #of Manufacturer � 'l�ank[nformation Gallons Gallons Units � • J '� o New Tanks Gxisting Tanks '� o � � � � � � a. U v� v, v� u. C7 C. Szptic.ec�{eJdiwE Tank . � �� / �I � � Dosing Chamber � � � V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the PO�VTS shown on the attached pl:�ns. Plumbers Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Jason Kuettel 675751 715-798-3355 Plumber's Address(Strect,Ciry,State,Zip Code) PO Box 66 Cable, WI 54821 VI.Count��/Department Use Only .�,Z Permit Fee Uate Issued Issuing Agent Signature �Ap o ed ❑ Disapproved ❑Owner Given Reason for Denial $ `��� ��� S � `'�"� ��t'"�''�'"`"-�''�� Conditions of Approval/Reasons for Disapproval � �,i—�r�s—��'^„-1 �I' � ' �` J � ' �� a t : ��� �— �- �, _. . ____'-_ V� �..J , .� Cs � �� i a� ��� R , ���� ,., �� � --- - ��► ___-_--- L - sp,;.i�i`r°�_-; . ZpN1NG Auivii!•�;���;:.,.�����d A[tach to complete plans for the sys[em and submi[to the Counry only on paper no[less[han S 1/2 x 11 inches in size SBD-6398(R.02/22) NO REFJNDS AFTER 13SUE OF PERiu11T ; PAGE 1 C�F 4 in-Ground Gravity Plan lndex & Cover Sheet Component Manual Design References: Version�, SBD-10705-P (N.01/01, R. 10/12) , , , 02•` Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersa� Area Cross-Section & Plan View Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name / D�$cription Owner Name(s): �;oa � , d ff1�G��a I�elV�re�� Phone: �s� -qk3 - toz�S'Z- v Owner Address: �7 Z --�'irASe�' 1-a.�e ��dson t�-� ZiA: ��f0/� 'r,,� f"aw�, 4��c h;��" � Project Address: �7'{y�/� �t.cv�� �i�'Ct!� *7�cyu��✓�v�, c.vc Govt. Lot: 1/4 of_ 1/4, Section �`f , T �(� N-R 7 E❑or W� Township: ttl,��ti��-r County: ��U.e„�'' Project Parcel ID #: (� 1 Z � '�-Z�- -�� -- c7(aCC Designer Information Designer Name: ���A.�-�{�� Phone: 7f� -74� �'�S�'- Designer Address: ����� �; � �.��Q(� iA�r Zip: 5�2../ E-maiL• �'��n vz�f(�.S��lyl License Number: �c 7s�7�� Remarks: Signature: Date: `� S zZ Original signature re r on each submitted copy. ❑ SOIL EVALUATION '�'F ' _ � � SYSTEM PAGE 2 OF 1�` , c. y,:; SITE MAP PLOT PLAN . FROJECT NAt;= � .. � F,. � ,. ;rti ^� - �_:. y .}.. �o: c�r, � �VD.WIi^E\/ i�Nf'�— �< Q<p/pt p,,�l A�ac'� j2;,gn flow Cal;�la!ions �or comm?rqal plans PRo�ECr qD�ness �J�,��}n( r/)U^+ l R A'� P.Oe M1fatenal i ASTAI Slandard (Tables 3&1 30-3 d 3&1 30-5) �,,,-.,.,,�5 N Bh�SY'^�o' `�' BM'E'r,alo� 100. �•U F� SamtarySewe. SL.H "(u P..c+, SC�T H Fo¢e A�a•. en+oa;:-c��� crv+� f-iSN W�;c Sv�.3 Soe C'31�.em �, . . .. ��r 1�1PORTq`iT. 'r/e.�� 5y�ro.�. �,tac �.:aoa . n. , of Testtd A�ea 0 �' 'JhC'x ^y/JU�A El�+�a;b�n CO��AefS d: SW!dC�2 in;@rya's �r ra iP:•,i'—e�� ' cUN��� R..d A�. � �yelc� K�-c�n� re � A��n��5 t375��fN ra�N 72� „ i��waa_�. w. IL.tc �-YZ i-RL-1�v ���: �y ,.,Jcj v�. � �- (o - IS I `t i 4 �'^' Z o7r�/ ���� c � n �x.,K-*l Ilax �J OIZZ2z-0006oC SA��: cti C� I � Ta.�,u I � :�� z���� � � ' ��� � I I ' - � � I ' . � r�+ , l�__. I I ��' I f I �,, � � �.ti - �"r,I„ r•� .�� ' �-r ��I 5..1+� �_�(H .sv.i�� ' � ��a �1 S��1 ,� �KIS �S{Gy�y= �lE�S �_70 ��nn ' iuc� cc I � LNS'�ab . I � V�'''vi EY+ ST� QI /� 1 � JJ�• • Ue�ct P�PE � I I-- 1 i I � �¢,aevnti Q I 5�.�,, z� - � �y � �,�P�s�a , �sr � z� _ � z� i � o u���sEQ � � i z ae� g, � s� s n w( I � � i.a�{ �' s � o re�n� f; l�r � I � ;f,pct� i i j — — Z ea � I i �j Uni{- (o i I ;vcr}�� +- ;^.L. �°.ti.r7 L,�✓� ( � � ,n ISi� 5.. , , N c/ � � � A �• � j � l�u�{-�e 1 ' I �Q Sc:� I I �A..i,� I M �P � lu�s �s'1 � -,z.,,� �i I s/Z i i i � — — -- — _—J PAGE40F4 In-ground Gravity Management Plan IMPORTANT: The owner of this in-ground gravity 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 be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operatinq Limits: Design Flow= �� gpd; BODS <_ 220 mgL"'; TSS <_ 150 mgL''; FOG <_ 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 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 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 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 Septic and dose tank(sl 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 (1l3) 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 filter(s) 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 shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: t-rG1�V1f ICS�iSYvLI.tSS�rL� f �M S Phone: 7iS= �4S' '��7^ Local government unit: SQ.i.�1 Ue.v � ZOtl.u�[' Phone: 7�-�=(03�-�"��� Local government unit address: __NEl�-�J txNY� (.t'�- ZIP: �sf �3 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-complying dispersal component in a pre-determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. , . ,'�S a ' �,��,��� ; ,x` � y '°"� � � I ,� '�� ". ;,u � � ,�� �.� ,�� � ��j � ��r� ��'� � ���'�� �; a �t <. a, , , , , �"� s.. � y �� %. � S i� � t:+�r. ' ''��4 a .. � . 0 'r ,.: , /. �, a- . , � �' � �. f+ r . y', .� ` . b . � � �y� ��� �y . 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' �� ` r,y �' �, ', � + � ��, : , ' . , ,� , i , ..� . li +r ,,a:,�,. '1 ; �.W. ,'�;i, . �.. '�. ,� � � � � }. ���.. � �F: ' � � M�L�� iE.. '¥�A' " �;JT . ....w�. . f . ..1 ' , . `���M� ,,;�-=�`=�'"�=`�'y;� PRIVATE ONSITE WASTE TREATMENT cou�ry �=j'��osp ���'� SYSTEMS ,:,,'l s i; ( POWTS) Sa.Wyer ���N,F�__�:;;' ''"-"-v�';' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2� � (� Personal infonnation you provide may be used for secondary purposes[Privacy C.aw,s.15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#: �o!!� `1�+1�1 �4� V�-�'ti1C� ��-th� Insp BM Elev: BM Description: Parcel Tax No: (00,fl � 5��, Caw�r' �h'S� �o.�i.sL. S l��D b( -- � —���0 D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,i,,� � Benchmark �� p � Dosing Aeration Bldg. Sewer �.$ � Holding St/Ht Inlet do.6 r TANK SETBACK INFORMATION St l Ht 0utlet oo.3 ' TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet AIR INTAKE Septic }��` �{-�oo ` �S- � NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist.Pipe PUMP 151PHON INFORMATION Infiltrative �g�,�� Surface Manufacturer Demand Final Grade Model Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist.To Weli DISPERSAL CELL INFORMATION DIMENSIONS W � #of Cells rype of System Distribution Media Manufacturer: SETBACK OHWM of Nav Conv ❑ Aggregate INFORMATION P/L Bldg Well Waters o GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other DISTRIBUTION SYSTEM X Pressure Systems Only Hea�der I Manifold Distgbution Pipe(s) p i X-Hole Size XP oleg Observation Pipes I Len th Dia Len th Dia S ac � S acin ❑Yes ❑ No J SOIL COVER ___ _ fDepth Over Depth Over Depth of Seeded/Sodded Mulched Cell Center 1 Cell Edges �Topsoil � ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) � -�-�,s��(Q� �l�' ��� � .S�. ���9�ewe-ti� o�`� —_._ � Plan revision required?❑Yes❑ No �,v��� '� _ � �� 6� � � --C� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A��ITIONAL COMMENTS ANO SKETCH SANITARY PEAMIT NIJMBER� a�2-��__ P��� a6� . ;�o � Q��sfi�PYc �'``�� � �'=P � Q,�� f' '' W�as�' � �so I3� ..,��Bro i � I / � � ���' I I S� � J ��,/�, � � ��.V �- �I � �5� _ `^'�'���