HomeMy WebLinkAbout010-841-36-5106-SAN-2022-176 �
Department of Safety c°°°ty �
• - & Professional Services, ° �
_' - Sanitary ermrt u b r to e filied in by Co.) ,
= Industry Services Division
Co 3�1 1 � � �
State Transaction Number r
Sanitary Permit Application .� • �
In accordance with SPS 383?1(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit —
is required prior to obtaining a sanitary permit.Note:Application for[ns for state-owned POWTS are submitted to Project Address(if different than mailing address) ---�
the DepaRment of SaYety and Professional Services.Personal information you provide may be used for secondary �{ ��.�� �� m���� �
puiposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. �
I.Application Information-Please Print All Information t,��
Property Owner's Name Parcel#
�
SOY� � � �d - �f�l � - 3fo�- 5LC7�o
Property Owner's Mailins Address Property Location
l �� G'�3 , o�.��� �—
City,State Zip Code Phone Number /'_
� ; . .\ � � y ^� C�____.�Section �4�
` \�l.J �t� /�
II.Type of Building(check all that apply) Lot# T -1 � N R U E o
�((or Z Family Dwelling-Number of Bedrooms Subdivision Name
�` Block# r�
❑PubliclCommercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
tt� !Q7 ��4 03 �T����e�t�2���
3%t�o :# ��
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 if
a licable.)
A.
❑ New System Repiacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' g' ❑ Mound ❑ Individual Site Desi�m ❑ Other Type(explain)
❑ Holdin I'ank �:1n-Ground ❑ At-Grade
� (conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber I.ist Previous Permit Number and Date Issued
❑ Transfer to New Owner
Expiration 1/ �
u y` ,
iV.DispersaUTreatment Area and Tank Informallon:
Dcsign Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation
O C? oZ- . (o �.o',�.���3,�°- 3 �5� 3 i
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units Q a� o ,'d, �
New'I'anks Existing Tanks y ^ y � � p y �
�
a U cn in i,. C7 0-
tieptic or Holding Tank �[�(1 � j ��LpCy,r- x
J v l J�-'V
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plu r'�Signature MP/titPRS Number f3usiness Phone Number
��vl�'�. 7�S-SS���o 73
Plumber' Address(Street,City,State,Zip Code)
��� N �T�1,�.� pc��. � u.:�.� � �c��
VL County/Department Use Only
�A r e� ❑Disappro�ed Pcnnit Fee Date Issued Issuing Agent Signature
/_ � �L/ O� e �/�
��/�1/ ❑Owner Given Reason for Denial C��. 6 ��I�'� �" IK^������1�''V y�-
Conditions of Approval/Reasons for Disapproval ^�������—��
� � rr•;
, � I � � NO REF'JNDS AFTER Date �� ��a� �---- i
� �L 3SUE OF P�F►�� ,;
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�✓ � �� �" ��� �cpt# �e,w Wcr� a � �'��� "r�YJ'r`t� �0��
�M'H ZONING ADI�AIIWSTflATtOt�
Attach tn complete plans fur the system and submit to the County onlv on paper not less than 8 1;2 x I1 inches i�size
SBD-6398(R.03!22)
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil 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)�(�.�. � f �Y1 Phone: -_. _-
Owner Address: ���� �- nl�'-j'Y�f11,�} (� ��i'1'UV�i l�'.�- Z�P� �����
Project Address: ����� I'Y�OY'�E'� �• �-{.4�� � �� ��-�3
Govt. Lot: 1/4 of 1/4, Section�, T �� N-R C�� E 0 or W �
Township: ��y�QJ'�CQ County: ��
Project Parcel ID #: (i�d— �'S�l— ���J`yl(;?(o
Designer Information
Designer Name:���1 ��1/yx� Phone:'�_-��- l�
Designer Address: �(�5"7I l��Clu- �Q� pC�1�1C-t(2f�1, Zip: �j�-��
E-maiL• ��-C���. ;�.'�,,
License Number: ����j
Remarks:
Signature: � Date: �—�7��--�o-
ginal signa required on each submitted copy.
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in-grouna vravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali be responsibie fior its perpetual operation and maintenance pursuant to
requirements o4 SPS 382-384,1Msc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code, this system shalf
be considered a human heaith hazard rf not maintained in accordance with this approved management plan.
Furthermore, alI inspection and maintenance activities shaft be perEormed by a registered POWTS Mainfainer in
accordance with SPS 383.52{3), Wisc.Admin_ Code.
h9auimum Dispersai Area Oaeratina Limits:
f�esign Ftow= �CJ/� gpd; BO�S<_220 mgL"'; TSS _< 150 mgL-'; FOG _<30 mgL"'
Insaec#ion Checkiist INSPECT EVERY 3 YEARS
o type oi use
o age oi system
., nuisance factors (i.e. odors, user complaints; etc.)
o mechanical maifunc6on (i_e., pumps,valves, switches, floats, etc.)
o materia!fatigue{i.e., leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatrnent fank{s)and any dism6u5on appurtenance(s) (i.e., distribution!drop boxes)
c nagiect or improper use (i.e., exceeding design capaci5es, prohi4ited activities, etc.)
o e�enf of pondir�g in disfibution cell prior to dosing
o dosing irregularities-i�applicabie (i.e., pump re-cycling, float srritch settings, etc.)
o elecfical components- R applicabie (i.e.,wiring, connections, switches, controls, timers, alarms, etc.)
o distribuiian tateral oriateral orifice plugging (measur2 lateral disial pressure—compare to design specificationj
o surFace discharge of efffuent or sewage 6ack-up into structure serve�
Mainienance Checklist (NAiAiTS,IN EVERY 3 YEARS {or when necessary?
o Sentic and dose tank(s)shall be pumped by a certified septage servicing operator Iicensed under s. 281.48 VVis.
Stats.when the vofume of solids in the tank{s)exceeds one-third (i!3) Yhe liquid vo(ume of the fank(s) or
as required by locaf ordinance. Disposal of contents shai! be pursuant to NR 113, Wisc.Admin. Code.
o Effiueni flter(s)snall be inspecied every 3 years and shall be deaned wF�en necessary to remove any
accumulated soiids according to manufacturer's soecifications. A servicing period will always be greater fnan 12
months.
Spsieen maintenanee reports sha11 be su6mitted to the propar(ocal government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any componeni failure or maifunction to:
Name oi individual or company:�t_��t_� �-1�1,7,t{^�C Fhone: �Jl S—S�S�'/(C��7�i
Locai govemment unii: , j Phune: �/5�7�� -�i o��cs
�
Locai govemment unit address:�(,,�����'j� 5(y�, Q �����ZIP: ���/ ,�
Any defective part of this system shall be repaired, replaced, or removed pursuant fo SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacemeni of failed or malfunctioning components shail compiy with SPS 383,Wisc. Admin. Code.
No produci fior chemical or physical restoratien oi ihe POUVTS may 6e used uniess approved 6y the dspartment in
accordance with SPS 384,Wsc.Admin. Code.
�ontin4encv Plan
in the event fhat any iailed treaiment component of this POV�lTS cannot be repaired, it shall 6e replaced pursuant to
a plan submitFed to the appropriate agencyfor review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersai component in a pre-determined area of suitable soiis.
�stem Abandonment
li use of fhis POWTS is discontinued, it shall be abandoned in accordance with SP&383.33,Wise.Admin. Code_