HomeMy WebLinkAbout002-940-12-3202-SAN-2022-167 �
Department of Safety c°"°`y �
, & Professional Services, ��'�' � �
$ - Sanitary Permit Nu ber(to be Yilled in by C
�; Industry Services Division
(„ "3�� l l.R -'� 4-�
Sanitary Permit Applieation State Transaction Number �
In accordance with SPS 383 21�2),Wis Adm Code,submission of this form to the appropriate eovemmental unit —
is required prior to obtaining a sanitary permrt.Note Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing ad• �
the Department of Safety and Professional Services Personal information}ou provide ma�be used for secondary • �
purposes in accordance with the Privacy Law,s l�04(1)(m),Stats. ��'J��'� W� ���(,(�,� �
I.Application Information-Please Print All Information
Property Owner�s Name Parcel#
-a-itlGlV'i s i�t, �- f4-���G�,1(.�V'�t F L ��-�-inS Q�2 -�`�0- i Z - 3'Z.DZ
Property Owner's Mailing Address Property Location
� 3� ZN� ���. S• JCiI�� l�� GovtLot
City,State Zip Code Phone Number
V'V\1�11� D(t s � (�1 f� S-S`-/U Z. 7/S -�'��f-G�(7>Q U� '/< S(.�1i '/<. Section �,_
II.Type of Building(check all that apply) Lot# T � C N K W
'�1 or2 Familv Dwelline-NumberofBedrooms � SubdivisionName
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑V illage of
�Townof�S � f ' f'
III.Type of PO��'TS Permih(Check either"�iew"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A
❑ New System �Replacement System �Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit lexplain)
�e.u�s 6N i ��d -F(�r P��-
B' ❑ Holding Tank ❑ IrnGround ❑ At-Grade g yp ( p )
❑ Mound ❑ Individual Srte Desi n ❑ Other T e ex lam
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permit Number and Date Issued
❑ Transfer to New O�vner
Expiration �S _f S,� t'/L/�S
IV.Dispersal/Treatment Area and Tank Information:
Design Floti'(gpd) Desien Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(st) System Elevation
o . 7 �Z� nao r- 93 ,a�
Capacity in Total #of Manufacturer
Tank[nformation Gallons Gallons Units � � �o �„ u
New Tanl:s Eristing Tanks '` c y ` y L b �
c _
c_ U -✓� �, cn i� U �
Septic er—I�Felding Tank �Q� '�t�, I R(,�,S(n U 5.�'.�,,�
Dusing Chamber
V.ResponsibilitV Statement- 1,[he undersigned,assume responsibility or installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/.AkF'f�S Number Business Phone Number
�QSC✓� ue��� (o7S7�1 ��s`-'74�-3353^
Plu ber's Address(Street,City,State,Zip Code)
�. 0 � �� � !o �C' �D�� c.c�L ��'�l
VI.Countv/Department Use Onlv
� ����� ❑Disapproved Pennit Fee Date Issued Issuing Aeent Signature
❑Owner Given Reason for Denial ������ 7��-') ��-..i ���t'�-��"`�"'�'���"'�""�
Conditions of Approval/Reasons for Disapproval
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Attach to complete plans for the system and submit to the County only on paper no[less than 8 1/2 x 11 inches' �
saD-b�9s�x.o�izz� �p REFJNDS AFTER
ISSUE OF PE'F+M�''f
3 f 0:�
PAGE 1 nF 4
in -Ground Gravity Plan
lndex & Cover Sheet
Component Manual Design References:
Version '�Q, SBD-10705-P (N.01 /01 , R. 10/12) _ ,
� ` \
Pg 1 of 4 tndex & 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� : }�(,� I�IS � , °� �"� �-S�l.ccl �t�Q �CL ( -�-cV1S Phone : �5 - (�3 - <v(DO
O�rmerAddress : F730 2N� 1gtJ�, 5 , 5�,�-e t �{sa �qP �S � Mt� Zip : SS�f02
ProjectAddress : �'b �51�! �,t) � I � I �i1'15 Rd }�CE,c,, c,�C,t✓�G� t,�J ` S�f�S�3
Govt. Lot: _�1 /4 of _s�� 1 /4, Section 1 'Z , T�N-R � E ❑ or W�
Township : �55 `Q.j�� County: ��,�,� �p,,�
Project Parcel ID #: C�0 Z - �f�0 �- / Z - � 2C, `Z
Designer Information
Designer Name : �C�Sev� �ue �- ��-� Phone : 7 l S - 7yk - 3353�
Designer Address : �, �j , � (ol� ' � � e� �L� � Zip : S�� 2_/
E-mail : �tr,� Cd�c ��� �urQS ; �ac�
—r
License Number: i� � � '7S1
Remarks :
Signature : Date : � �/� Lz-
Original sign tur„ r2quir2d on each submittad copy.
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Cross Section of a two cell EZ Flaw In-�Groun� Dispersal Componeni
Gell SeparaUon
I3 3 t� � 31 I
�.g_ � Final Grzde
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4 ... �r �'- . r},,�} b �+�,� .. .. � � � i�
�. Cell#1 �� ' - � �� � r � :,�rJ} i� ' 't,
� Cell.#2 � �� ,�tt���
� Geotextile Fabnc
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Design Flow '.�0 / Loading Rate � � � = Required dispersal area �Z� Cell #1
System Elevation: �T. u s
Required dispersal area `�5� / 50 (EISA) = y number of units �
— � � Final Grade: ��S �G
Geotextile fabric to meet Comm 84.30(6)(g) � (.�SCo"1G L-Lj Cell #2 �? os
Minimum of 12" of cover over top of cell �-� System Elevation.
Two Observation/vent pipes to be provided per cell 3 X 7� � G-'CL.S �� ,;��
Flnal Grade
Not to scale ��� ��,��\
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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 = 3� 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(s) shall be pumped by a certifed 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: �CIVl-��CLS�SS�� c1' C�'�S Phone: `-715 �-�l�"Ss'(_S^
Local government unit: ���� e✓ �t�• ��- c Phone: �i �-G�3 ���z'��
Local government unit address �Ua � �� Z�P: ����
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.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
,'���-='"T"`�;�� PRIVATE ONSITE WASTE TREATMENT county
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,�;
r`r, ; o$ ,�t SYSTEMS SaWyer
P ( POWTS)
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\ry���FJIIcI,.:A�,t'r�
' INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT) /
GENERAL INFORMATION ��— I 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#:
��Y i> 'f' k:�cp�nd`ru � ��S �S �� �
Insp BM Elev: BM Description: Parcel Tax No:
1C�0.O I O�'^ .�R C���2�Cee�� S, ) . �o�.� -I�O— �d^^3�0�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Q � '� �j on� Benchmark �op,o '
Dosing
Aeration Bldg. Sewer
Holding St I Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet �S;23'
TANK TO P/L WELL BLDG A R iNTAKE ROAD I�C�e�— �� �N `��:,2� '
Septic NA �Settarrr p.�r 4S t� `
Dosing NA Installation
Contour
Aeration NA Header/Man. �3•�3 �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative 3 � r
Surface
Manufacturer Demand Finai Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N ?,` L �p ?p` #of Cells o� 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 � � ' � ❑ Mound o Other
---- � fi-� '�'� �YSD_ _ _ _ _-- - --
DISTRIBUTION SYSTEM X Pressure Systems Only
Hea�der I Manifold Distgbution Pipe(s) - - P -- '�X Hole Size � Xp oleg Observation Pipes I
Len th Dia Len th Dia S ac � S acin ❑Yes ❑ No �
SOIL COVER
--- _ _____
Depth Over Depth Over � Depth of Seeded/Sodded Mulched
Cell Center I Cell Edges I_Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��'s,S��� �l-2 l�'.
� a� �,(�-t`�-/ C� �- �-e ��S � C?�;s�� .�,
-
----__ __--
Plan revision required?❑Yes❑ No '' O 3 ,,,, � /
�3 �� � — — ~ — _-- C�9 S� ,�o �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL CDMMENTS ANO SKETCH
SANITARY PERMIT N�MBEF ��- I�7
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