HomeMy WebLinkAbout026-939-26-5214-SAN-2022-169 �
_�•' ° Department of Safety County C/�
� � = & Professional Services, s��y� }'
, _ � Sanitary Pernvt Number(to be filled in by C �
`� r= , Industry Services Division .
. - l��"1 I (.� S 9�
Sanitary Permit Application State Tiansaction Nu=ber �
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 forms for state-owned POWTS aze submitted to Project Address(if different than mailing adc �
the Department of Safety and Professional Sen ic�s.Personal infoRnation you provide may be used for secondary + �
purposzs in accordance with the Pricac� La�k,s. 15.04(1 xm),Stats. 4,.I / � L� '�'�--
I.Application Informatioa-Please Print All Information � G � Tl
Property(haner�s\ame Parcel#
�o���, ������ � �.� _ q3y _ � 6- sz�y
Property Owner's Mailing Address Froperty Location
`� ��� ��� I`{s Go�t
City,State Zip Code Phone Number
,5��,,,L �M�, l✓1 �( �( 71 -�'1�_�Section Z �j'
II.Type of Building(check all that apply) I,ot# I T 3 y N R � E or
�r 2 Family Dwelling-Number ofBedrooms �_ Subdivision Name
Block# �-
❑Public/Commercial-Describe Use
—" ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
3s ��s �d��a x��o,�o,� ���� ,H�t
III.Type of POWTS Permih(Check either"New"or"Replacement" and other applicable on tine A. Check one boa on line B.Complete line C if
a licabte.
`�� � iew System � Replacement Svstem '� (Jther Modi6cation to Existing System(eaplain) �' r1ddiUonal Pretreatment Unit(eaplain)
B' ❑ Holding Tank �Cmound ❑ At-Grade gn yp ( p )
❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transferto New Owner '��Previous Pernut Number and Date Issued
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System F,levation
G.(S U , 6 7�� 7.�O q Z' _ Qv.Z r
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � a c $ o
New Tanks Existing Tanks � o � a � � 3 �
r� U �n � �n w t7 G,
Septic or Holding Tank 'Q�U !d e v r ���C S i� �i
Dosing Chamber
V.Responsibility Statement-I,the under�gned,assiune responsibility for inqtallation of the POW TS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
� �� S��. �f z i�iF i z � ��s- s-r�- s-p��
Plumber's Address(Street,City.State,Zip Code)
7a 7c� S4�..,y /��,,� r� � 5��.,� /� � , �-•', s'�e�?�'
VI.Coun �/Department Use Only
�A �ro7 � ❑Disapproved Pennit Fee llate Issued Issuing Agent Signature
$ � � (�,,,,,,, �
��'✓ ❑Owner Given Reason for Denial ��� � ��� � �� � ���'�I�"""'�:3-
Conditiorts of Approval/Reasons for Disapproval _ ._ r,,____� ._,���___,,__
��s��:ii �� .��.��r� : ? :�,,
r ��f`�`�i��=��S _V ��J� i
���� ��` Date � �8 ��� t—_�-- _ -1
chk# 1 ��-$ JUL 2 5 2��2 J
��� � � ' �c�� ��V•!�_r��-1 �":.�'la�s 7 SAWYER C�URl�Y
ONtIdG ADMINISTRATION
Atfach to complete plans for the system and submR to the County only on paper not less than S ll2 i 11 inches in size
SBD-6398(R.03/22) NO REFJNDS AFTER
f9$UE OF PE'�,MIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soii Absorption for POWTS Version 2.1 (May 2022-2027)
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): ��r Z.,� ����i Phone: - -
Owner Address: �° �'x (Y r S'�'°^z �� w� Zip: �84�jn
Project Address: KM �«� �'�
Govt. Lot: 1/4 of 1/4, Section 2 � , T 3 � N-R��E ❑or W�
Township: S4� � �� 4C County: Stwy ��
Project Parcel ID #: 0 2 C - 9 3 9 - Z ,� - �'2 � y
Designer Information
Designer Name: Dylan Schultz Phone: �� 5 558 5904
Designer Address: �076N Stone Lake RD Zip: 54876
E-mal�: C1Y�af1SChU�tZlB�gfT181�.CORI This epace reserve3 for approva] stamy.
License Number: 1516129
Remarks:
Signature: Date: 7- 2 � ' � Z
Original � nature re � d on each submitted copy.
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C ra�ge �ii —��t.25' ) rP�s l�-l4 �2�j
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IN-GROUND GRAVITY DISPERSAL AREA SBPhG�anbk{Manufacturer
W
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) i o�
gal gal gal gal
r,-�Effluent Filter Manufacturer:
11'� � 1'JI\/ IJL�
1
I min.12' Effiuent Filter Model#: S L�
Geoteztile I (typical)
Cwer
SOI�COVER TYPICAL TRENCH
'r CROSS SECTION VIEW
min.trench a �
depth "�
�tyP;�,> � r — ,�I ,:• (No Scale)
/ OBSERVATION PIPE DETAIL
. b • ;; (Nosra�a)
S stem Elevation= ft. �' ' s�rew-rypa o�
y � Slip Cap(loose) '�'N, Finished Gatle
(rypical) ' Provide minimum 3ft , , cm��=nadgseatlad�
separation between trenches. a°e Pvc P�Pa ,� � .';�, Toaso��c�a�
Top of pipe to terminate <'� ,i�A (min.11oot)
atorabovetinishetlgratle !�'�
(4)1M"-1 "X6"Sbts
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) @ aPan
i'.
PLAN VIEW ""`"°""9°a"'� 's�Ka�°
4u/�{ Observation pipe shall be inslalled
(No Scale) �' atjundionbetweanhrounits, n
Perforated Lateral Observalion Pipe
(typical) (ryp;caq (rypicap
— — — —��— —— — ———— — ———— — — —— — —
�-- -_ --- - -- �
I =_____ _______ _--_= I A- s.o n D
__ ___ _______ ________ -
�--- - ---- - ---- - -�� --- - - ---- - � cryP���� �
- - -- ---- rn
� a = �� n �I c�
criP���> O
INSTALL PER TRENCH: EZ1203H Bundle T
��YPical) ,P
� 10-R bundles @ 50 ft� EISAlunit= 3�� ft' (mfd by Infiltrator Systems, Inc.)
Inatall pursuant to manufacturers insWctions.
+ � 5-ft bundles @ 25 ft EISAlunit= Z� ft'
= Proposed EISA per trench= 3 �s� ft' Required Infiltration Area= �� ft� Distribution Method:
x �_ trenches = Proposed Total EISA = ��� ft' ��...--�
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 wiih this approved managemeni plan.
Furthermore, all inspection and maintenance activities shall be pertormed 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 maHunction (i.e., pumps, vaives, 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 extem of ponding in distribution ceii prior to dosing
o dosing irregularities- if applicable (i.e., pump re-cycling, tioat switch settings, etc.)
o electricai components- if applicable (i.e., wiring, connections, switches, coMrols, timers, alarms, etc.)
o distribution lateral or lateral orifice piugging (measure lateral distal pressure-compare to design spec'rfication)
o suAace discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Seatic and dose tank(sl shali be pumped by a cert'rfied septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s)exceeds one-thiM (1/3)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 spec'rfications. A servicing period will always be greater than 12
moMhs.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any compoInent failure or malfunction to:
Name of individual or company:_�Y�'°1 S`�"�` }Z Phone: ���- Ss'� -�tly
Localgovemmentunit: S`'w4 �/ L"'��Y z"•`�S Phone: 7Fr ' GjY _ �Z57g
Local government unit address:_� W�� � W' /hF:^ S'�' Z�p; Sy �`/3
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacemeM of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemicai or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Pla�
In the event that any failed treatment component of this POWTS cannot be repaired, ft 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 soiis.
Svstem Abandonment
If use of this POWTS is discontinued, it shail be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
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