HomeMy WebLinkAbout024-641-13-2310-SAN-2022-178 _ Department of Safety c°°°ty�Q� �
_ `� { - & Professional Services, �
- .. _ = Sanitary Permit Numb o be filled in by Cc �
,,,` ', �_ _ Industry Services Division
'4- ..., . l.0 3 � 1 � � 9J
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit � �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(iFdifTerent than mailing add "'�
the Departmeni of Safety and Pmfessional Services.Personal information you provide may be used for secondary `?(D�C, �1 p��� �O�1� � �
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ��
l.Application Information-Please Print All Information � �
Property Owner's Name Parcel
� �m. � �-C Gz� 4��-��t I- i �
Property Owner's Mailing Address Property Location
P _ � � Govt.Lot
City,S te Zip Code Phone Number
t �n, � S� %,,�_'6, Section_��
\JLJ
II.Type of Building(check all that apply) Lot� T �� N K E or
11�1 or 2 Family Dwelling-[�Iumber ofBedrooms___�____ " Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
3���.� � �S�/ �,-�o,�af ct�- �-�e
I[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.)
A' �Ncw S titem
y. ❑ Replacement System ❑ Other Modificat�on to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank -Ground ❑ At-Grade ❑ Mound ❑ (ndividual Site Design ❑Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner
I.ist Previous Permit Number and Date Issued
Expiration �
IV.DispersaUTreatment Area and Tank Information:
Des�*n Flow(gpd) Design Soil Application Rate(gpd�'sn Dispersal Area Required(sf� Dispersal Area Proposed(s� System Gle��ation
��� � � v �4 l�i ��� /
Capacity in �"I'otal #of Manufacturer
'Cank Information Gallons Gallons Units � � U ,'d, � y v_
W � U y y U. �
New Tanks Existing Tanks � c� � � � � �
0
i U �n v� �. c7 a
Septic or Holding Tank / �i.+� �y� � 1��. e e�
! C/ !i
Dosing Chamber
"`D 7S"u ti/ � � ►�' lC-
V.Responsibility Statement-I,the undersigned,assume responsibility for installadon of the POWTS shown on the attached pians.
P ber's Name(PrinU , Plu r' Signature MP/tiiPRS Number Business Phone Number
v
� C � .�
Plumber s Address(Street,City,State,Zip Code)
� l� l�ti�� � a�fE- � � r,� �'���3
VI.County/Department Use Only
� $ Permit Fee Date Issued Issuing Agent Signature
App o�e ❑Di,appro�ed
❑Owner Given Reason for Denial � `w►� �i 3 ���� ���-�C�X '�/vy9-
Conditions of Approval/Reasons for Disappmval ','
� S ;, , ,S.
9� �ate�,L �� .�._�...w��. Q��� �%!-`,�r'=y���/�-��.�`�,'•1` !°
, ;
r`;„i
� � '�`; Chk# ��H „ ��° 2 �
� 9 1 202
��� 0 ,�
Rcpt#� lnlor l�l � �'lc"
�S� �-�- � �> ( SAVVY�r� C{�U�TY
PVI H ZO�ING ADN;INIS`fFiaTlOf�
Attach to complete plans(or�he s�stem and submit to the Couoty only on paper not less than 8 ln x 11 inches in size
sB�-6s9s�R.03�z2> NO REFUNDS AFTER
ISSUE OF PEFsMtT
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 5 Index&Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section &Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s):_�(151n-���t 1'12��Ua (�ixk-[(�fil Phone: - -
Owner Address: "�1�U I �-UV�����'�-�•��'v�v-�lc�, �uy�Zip: 5 3 S�7
ProjectAddress: "?�o�5U1 l��lve_I�CtV�(Z{Q, 1�6u.�u�(�r(� �.�.'I'L�j��3
Govt.Lot: SU� 1/4 of 1�11.� 1/4,Section �J ,T �I N-R�E❑or W�
Township: �itn�.Y� 1 0�-�2 County: SCd.t.li�.1?,t'
Project Parcel ID#: 0��— �-L l— I,�'J— r���Q
Designer Information
Designer Name:���(�� Phone:7ls �-/107�
Designer Address:��75�71 Y�lTGury�'in�@c(..4�vt �.�iL�IE�/�9 ���,�:��C�=3
E-mail• :,,,,.
License Number. ���3Q�
Remarks:
Signature:`� Date: � —
, Onginal signature required on each submitted copy. .
o�necs : � �-- �p � 4o�, ��(�e Tw
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IN-�F�OUN J C�RAV�TY DISPE�SAL. �REA � �<,c�� �.,�,�c(s) M�nufacturer:
�� � ���
l.Jnifai�m Elevatian Trenches wi�h EZ12�3HP �undle� fi�pii�:Tank(s)Vc�li.�rne(s�:
3-ft Tr�nch (down-sizing credit) ��s� �,.;, , �,.}, ��, ��4�,��
L(�IUC:III f'I�l('•1' �IIU(�GIUf(1C
—� -�----�- �--�----�-----�-._��_�.---- � �_�_Y__�__. � �i���.�' � �l'ry ��.����..
( ���-��- _� ����� min.17." riflur;nl f"iftc:r Mnd<�I l�',�=---,,�-_„CJ �� 2
t:;r,ota�xtlle I _._ ' ...,_ _ (iyplc��l)
L'avcr --- --
- _.._�_...___..__.___ _._ .._._....... _.___..__._______�.__._..._.._._._�_`.___.__
3I �� scau_cc�vr,. . I._ ._. TYf'IC/�l_ TRENCM
�„���.oF,��,:i,._ . ;; . CROSS Sf-:���TlON VIEW
��„pn, -�_ . �
(ivi»�:.,i� _-- -�-- --, ; -� .. . :,� ��10 5����� t�(3Sf�RVA"ftQN F'IP(_U(""fAll.
�r�o s�:.n���
�/ � O .'�Mn ' :iCtqW-1Yf�UDI ._
S 5lr.ni t�li�vntinn-- Jc`�C (I. _ W'w,�, 1'ud�;liudUndo
y• C...Ci..._.�.., „ SIiU C��p(loucu) o
��YI>ical) f'rovide minimum 3 ft ^+ •�_(rnulr.hn�lY.r,r.ndnd)
� .
sep�r�alion bc��WF3(;n irr,nches. �^U INC;I�ip�,_.__.-�- :.' ;y..,--..__lnp�iailC:nver
I���i ul plpn���Irnnkudu (tnin,1 frml)
;it ui;ibnvn In�inlm�l��i;riN� • '
(�I)114"�-II�?"X('�'Slvt: _ .. {_.._
�"'�1������ `�f����(`�) �:i�l(1W�Ui;l7�Il)I1 O��Ullf:l�6U��CI O1O(:f:OI'lI1Cl:llOf1<lll O��1t1 VIf'bV.� (n?!I(1 ;il,;�d
��. v ", 1 i
:V�,�.l.
P�/�p� �/,I Anchnnrrq Oi,rvtr.0.. -_•_.-.�':'....�.•;�.", Irlkllrihca�
/'11V U�C VY ���'•-:'' Sinf(�r.e
�
�u� OIr;urv;thun pii�u�,hatl hu in�;Lillud
(�I(J �('.C�i�:) �it�unchunbulwuunlwc�unds. �` �1.C.-�. '
{�t'frOr�atE'C� L'dl�rcll Ob:;e�v;rtion!'ipc . .
---- (ty(�ic�al) (�vl,i<;aq (�vPical)�
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f_.,,_ .__ .._ . . ----.--- _ ..�_. ._. .._____._ s = �O ft ._.__.._ ..____�_ ._.____._ _�._... __.______�__.____�..� �
��vr�ic��q Q
iN���n�_�_��R T��Ncri: __ �z�zo3F�� r��a�,�a�r -r,
..__._____..._____...w..__..____.____.____ (tvraical) -I�
�,�,,, 10�tt b�andles @ a0 fi' f:ISl�l�.irfil= ��,�� it` (rnfd by InfAtratar:�ystc;nis,m�:.)
lrist�ill pnrs�c-�nl tci mrmufacturcrPs instructlons.
�F �„ ,,,,,, 5-FL bundles @?_5 ft' F.ISAlunii=�,,,,,, (t'
_. _.._-------.--.____,_____.._.._._._.�___....___.._..-----_._._.______._____
= I'roposr.d f-•.ISn pr�r kr�nr,h- ,�S O ft' 12c.quicc�d Intillr.itian Arr.a= `U,�,,,,�„7 R' piskributi�n Mrthod:
x �,�,. kren�hes - ('roposecl �i�r7t�l !=IS/1 = �� rt' �i�' �+���i��,`,f`��1/
R��1 ,
1
PAGE40F4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-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 shatl be considered a human health hazard if not maintained in accordance with this approved management
plan. Furthertnore,all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersai Area Operatinq Limks:
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 tankls)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(113)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 filterls)shall be inspected every 3 years and shall be Geaned 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:�l,t(',(,!/�5'�� Phone: �L j—SSp—��073
Local govemment unit: Phone: �]ir—(�3�—�oZ�
Localgovemmentunitaddress:�U(�I) rnQ..E11.`Sr,�u- �/ l�i.cX+�cec� ZIP: S��L��_
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 ihe 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 PON/rS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
PAGE40F5
GRAVITY-DOSED
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4•e v����
>ionr�
Budding Elecldcal musl mmply wilh
1YMin.w2.0Rabove SPS316andNEC30o
Eslablished Flood Eierdiion W�1hef�F Ex�end maMde riser as ne�cssary.
(�YPical) Jundfon Box
Appmvetl APP�ved�o�}cing ManhWe
Vent Cap wilh Wamin
IMPORTANT: g Labe�Avadied
Mchor tank(s)as necessary ` � ��YP���
--co�d�a
pu�suant to SPS 383.43(8)(g) 4'Min.or 2.0 R ahove
Eslablished Flood Elevation
(NPiraq
�AirtigMSeal �.
Finishetl Grade �
�uick Discannect
18'Min.
CAPACITIES @��gaUn � . . ctyP��'�
Depth (in) Volume (gal) , a �
A � � y 9 � � ( � W�P `APP�d Joinlswi�h
p Hole ApprpveE Pipe 3 fl onfo
p 2,0 22 A SolitlGmund
/ � ��
rC� ii (bP��4
� � �
_Alartn
� �� � � � —On
� (cI � PUMP-0FF
'rPump Tank Liquid Level = l� �, in � PumP �—� ELEVATION = � ' � ft
° INSIDE BOTTOM
Force Main Diameter = '' in Concrele
�� B�� ELEVATION = �� ft
Force Main Length = >=) �ft 3'Appmved Bedding Matenal Benealh Tank
Force Main Void Volume = ����gal
[C] Total Dose Volume TDV = j � ,,', „'` gal/dose
(<02X design flow+force main void volume)
Vertical Lift = % ,� , ft
PUMP TANK: SEPTIC TANK(S):
Volume = ���gai Total Volume = /� ;`:J gal
Manufacturer. Eti;o c P/ Manufacturer(s): G.-,' .i - r/
Pump Manufacturer: c'_- - �- , .- �
� Install approved effluent filter at the septic tank outiet
Pump Model: /� :� (�atlachedpumpcurve.) immediately u�stream of the oumo tank inlet
Controis/Alarm Manufacturer. �; ; ,= 6.;'�, .,,, Filter Manufacturer. " "
��: -
Controis/Alarm Modei:
Filter Model:_f " •
Float switches containinq mercury are orohibited
�
TOTAL DYNAMIC HEAD/FLOW
� w PUMP PERFORMANCE CURVE PER MINUTE
� MODEL 151/1521153 EFFLUENT AND DEWATERING
14 45 153
,z
40 MODEL 151 152 153
Peet Meters Gal. Liters Gal. Liters GaL Liters
a �Q 35 152 5 1.5 50 189 69 261 77 291
� � 10 3.0 45 170 61 231 70 265
Q 15 4.6 38 144 53 201 61 231
a 8 25 151 20 6.1 29 110 44 167 52 197
� 25 7.6 16 61 34 129 42 159
� 6 20 30 9.1 - - 23 87 33 125
35 10.7 - - - - 22 85
75
q 40 122 - - '- - 11 42
10 Shut-off Flead: 30 ft(9Jm) 38 ft.(11.6m) 44 ft(13.4m)
Z 0145088
5
o Model 151 Models 152 / 153
10 20 30 40 50 60 70 80 90 100
GALLONS
IfTERS 6 7/32 �- 6 7Y32 --�'
0 40 80 120 760 200 240 280 320 360
FLOWPERMINUTE 37� 45/8 31B -- �--- 498 -�+
014508A
�
CONSULT FACTORY FOR e 37�8 'ife
SPECIAL APPUCATIONS e a —�- � I 3�
0 3�,8 " —1
• Timed dosing panels available e e� — �
• Electncal altemators, for duplex systems, are available and � """�`
supplied with an alarm � � � �
•Variable level control switches are availabie for controlling �
single phase systems �
• Double piggyback vanable level float switches are available i
for variable level long and short cycie controls —
• Sealed Qwik-Box available for outdoor installations - See ,Z,�g �
FM1420 """b I I �
• Over 130°F (54°C) special quotation required � I
s are
415/16 -I
151h52/153 Series _�44 --- s
S��
1 5117 5 211 5 3 MODELS Corrtrol Selection
Model Volts•Ph Mode Amps Simplex Duplex
N151 115 1 Non 6.0 1 2 or 3
BNi51 115 1 Auto 6.0 Induded 2or3
E151 230 1 Non 3.2 1 2 or 3
NE521 �� 1 Non s.s ���� zors "Easy assembly"
BN152 115 1 Auto 8.5 Induded 2 or 3 (pump&discharge pipe
not induded.)
E152 230 1 Non 4.3 1 2 or 3
BE152 230 1 Auto 4.3 Induded 2 or 3
N153 115 1 Non 10.5 1 2 or 3
BN153 115 1 Auto 10.5 Induded 2 or3
E153 230 1 Non 5.3 1 2 or 3
BE153 230 1 Auto 5.3 Included 2 or 3
SELECTION GUIDE
1. Single piggyback variabie level float switch or double piggyback variabie levei OPTIONAL PUMP STAND PIN 10-2421
float switch. Refer to FMo477. • Reduces potential clogging by debris
� Replaces rocks or bricks under the pump
2. See FM0712 for correct model of Electrical Altemator E-Pak. • Made of durable, noncOrrosive ABS
3. Vanable level control switch 10-0743 used as a control activator,specify duplex • Raises pump 2"off bottom of basin
(3)or(4)float system. • Provides the ability to raise intake by adding sections of 1'/z"
or 2" PVC piping
0 CAUTION • Attaches securely to pump
All installation of controls,protection devices and wiring should be done by a qualified • Accommodates sump, dewatering and effluent applications
Iicensedelectrician.AllelecVicalandsafetycodesshouldbefollowedincludingthemost NOTE: Make sure float is free from obstruction.
recent National Eleetriwl Code(NEC�and the Occupational Safetyand HealthAct(OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeiler pump.
O Copyright 2014 Zoeller Co. All rights reserved.
�"``` PRIVATE ONSITE WASTE TREATMENT county
f,�;.
���/�,SpI \\`j\'; SYSTEMS
'.��� s ' ( POWTS) Sa,W er
�� ��-; Y
`
���r,s----�:-.
� -'-"=''-" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ � 7�
Personal infoimation 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#:
�G�0�1 �—V,,,Qr� CAC�Lc/� �p..�� �I/�R� �—
Insp BM Elev: BM Description: Parcel Tax No:
laa•�` Na,��ci���► Y�� u /� s��.. �"�/til, � 0.1 -6Y( - �3 - �3ia
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w i 2�- _ �p Benchmark �� d�
Dosing - cc�.,�pu 7'S�
Aeration Bldg. Sewer ^
Holtling St/Ht Inlet 83 7 r
TANK SETBACK INFORMATION St/Ht Outlet 3,cF '
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIRINTAKE
Septic .4�5' �vl� � NA Dt Bottom 7�,,'2 '
Dosing �� •� � •� NA Installation
Contour
Aeration NA Header/Man. o D
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infi�trative ��a o�
Surface
Manufacturer (S Demand Final Grade
Model Number GPM ' 1� �. la, �.'
TDH�.y Lift Friction Loss Sys Head TDH Ft
Forcemain L �{�` Dia �� Dist. To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N ,3 L � 70� 7p #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bltlg Well Waters � IGP ❑ Chamber
❑ AG r� EZFIow Model Number:
CELL TO �{--(�� �op` N �-�ao ❑ Mound o Other
---- - — ---__ __- -----
- -
DISTRIBUTION SYSTEM X Pressure Systems Oniy
- - -___ - -----
Header/Manifold Distribution_Pipe(s) ; X Hole Size - X Hole Observation Pipes�
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No
SOIL COVER
-_ _ --
Depth Over Depth Over Depth of Seeded/Sodded Mulched
--
Cell Center Cell Edges Topsoil �Yes ❑ No ❑Yes ❑ Nc�
COMMENTS: (Include code discrepancies, persons present,etc.)
��,�/�,� � (�3/23
--- - - -
Plan revision required?�Yes ❑ No p �l 6 Gj � ( �
_
al-- a�' —
- - --� 6
Use other sitle for additionai information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA' �.2. - �7 g
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