HomeMy WebLinkAbout026-182-06-1000-SAN-2022-183 �,,�^��"�'�r-0 . �., ) Industry Services Division County �
,�� ,� {��" ,�/� 4822 Madison Yazds Way s c�c��,'G(' �
�� ` r Q�� Madison,WI 53705 Sanitary Pennit Number(to be filled in by Co.) �
� ,� � ,y,�2 P.O.Box 7302
�'a�;�^�,��' c� d"' Madison,WI 53707 �C �� � � � �
Sanitary Permit Application StateTransactionNumbe' r �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriafe 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 mailin�address) (�
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �►�`��;r,', K�i� 1�}5 ��„��� �
putposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats c�S
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Property Owner's Name ` �i%i,•c� . ,.� • � �y Parcel#
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Property Owner's Mailing Address Property Location
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City,State Zip Code Phone Number 3
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�1 or 2 Family Dwelling—Number ofBedrooms �i C"�'a,^Y f-(��•�1�.t'S
Block# 2.;.� � c� � / �U
�ublic/Commercial—Describe Use �U J�
Gi �City of
❑State Owned—Describe Use �:� CSM Number illage of
--- �'I'own of ��� �^-'"�
,_...�:2 ��..s.�'.��c�.'s: ��'v.��''",�"<..,t" r�"" �a :v>�,� �'�'�:.� vt-,t s �m.. '�'�.�i._. "`t .`+,. �.- � S� . y.�v.. ..�'x '.*39°.. . �. °?=��
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A' �1ew System �eplacement System� �Other Modificaiion to E�tisUng System(explain) �Additional Pretreafinent Unit(explain)
B' ❑EIolding Tank In-Ground �AAt-Crrade �Mound Individual Site Design Other Type(explain)
(conventional)
C• ❑Renewal Before �Revision hange of Plumber �I'ransfer to New Owner ist Previous Peanit Number and Date Issued
Expiraiion ^
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Design Flow(gpd) Design Soil Applicaiion Rsie(gpd/s� Dispeisal Area Required(s� Dispersal�Area Proposed(s� System filevation� �� ���� �� �����
3ac� � 7�" h��- '�' . �o `r�{6 �(or� - �2•ZSr
Capacity in Total #of Manufacturer ,
Tank Information Gallons Gallons Units � � � g �
New Tanks Existing Tanks � Q y " a� a`� � �
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s�ri��xo�a�g i�x J�pl�Cj — 1�L�c7 / Lc�r e,r��r— X�
nos�g cs�� '� �
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�.:� .. . . ��.. � ,...,. �1,assume cesponsifisility for instalisiion of the PQW'FS shown on the attached plaas. °
Pl r's N e Plum er's Signature 'vIP!?vIPRS tiumber Business Phone'.`umber
'�erry�u��xcavating� LLC � ; � ���-���:.Z r�� -�c`i�- L�v�-�
Plu s i , ip Code)
Stone Lake�WI 54876
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�Ap � ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
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�� ❑Owner Given Reagon for Denial ? �TLf�V►�-
Conditions of ApprovaUReasons for Disapproval
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�nk# 31� AUG 0 3 2022
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� Rcpt#__ � S,��r,�Y��{� C;t�uNTY
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Attach W complete plans for the system and submit to the Coanty only on paper not less t6an 8 iR=11 inches ia size
NO REFJNpS AFTER
SBD-6398(R.02/22) 15SUE OF P�� ���,���
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PAGE 1 OF 4
In-Ground Gravity Plan
Index � Cover Sheet
Component Manua/Design Reterences:
Version'�, SBD-1070rP (N.01/01, R. 10/12) . .•
a.�
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Sedion & Plan �ew
Pg 4 of 4 Management Plan
Attachments: E
POWTS Ap lication for Revisw
Soil Evaluation Report& Site Ma
ProJect Name / Description
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OwnerNams(s): �(� ��F:.� Phone• -
Owner AddnsE: r�0 13 G.c 3 OC, J!U:.�c� L.tiKe. W,L .Zip; S Y S 7�,
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pNpJaCt Add�s; �icT�"k t..�.z�Rkr g G.,�d�
Gpyt LoR: 1/4 of 1/4, Section 3 . T 3�t N-R `�_E Q or W Q
Te�w�hip: S . ,„l L.�.k�-- Cou+�ty: S�-�y�-
Pro�ct Paresl ��: c� z�c H 2 c:•6 I vo�
Deslgne� Infonria�on
Jerry Ruld Excavating, LLC Pho�: 7�s _ycrz- Z,..��
Dpfgn�r Neme:
Dssignsr A�s: Stone Lk�,WI �76 �P�
E-Rlifl' � P v�d � GG'�.-�Tve y`fG( �v L� This space reeerved for approwl stamp.
LlCenae Numbsr: � `-( �..�c 6�
Remarks:
8ignature• �; �� Date: �-z- zz-
m .�mea mvr.
CMH�t80XABAPRri�LE � , . CXECK90XASAPPLGBtE
� SOIL EVALUATION o �'�� �40' � � [�] SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME
10a DE810N FLONF. �C� CiPD
�)2_ pw o Atlad�deapn 1bw alcul�tlom Tor wmrrerwl pl�ns.
rr�cr�e� _ `��T'Q�v K�e.g�, S �' ncle. N Plpe Mabrlai/ASTM Sfandard(Tabla 384.303 3 384.306)
e�,ey�rod: $ eue«.mrc ,a0•� � �ra.v N" Pvc_ ��� �-rn
BMD�erlPlkrc c /6� ��(�..1� FO/nY41rr. tiA' � / '�—
.�ce'GW i.�
�� i�tue,ronnyy . IMPORTANT:
��(x) —� wri emdd(r�aW�R O on u�r�%� Show ground ebwtla�cvrtbun at a�dhbls In6svmis.
Ut�Ta-y 1�e-icJF.-t-s C�r�(e�
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Jerry Ruld Excavattng, LLC
W208 County HWY A
Stone Lake.WI 54876
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MI R�er ananl
�' Sepbc Tenk(s)Me�vRsch�rer
IN-GROUND GRAVITY DISPERSAL AREA c.��csc�
Unifortn Elevation Trenches with Quick4 Standard-W Chambers �,„�Ta�kc,��w,�,,
3-ft Trench (down-sizing credit) �a� _,a, _�, _�
/ ri �� EMueM FIIMr MamRecWrer
FiSL'�l!"�'i "L�.
I EfAuantFilbrMOGtl# �� � �
min.12
SOIL CAVER MDim)
ir
Mn.6mfA
im�� • TYPICALTRENCH
� � �`.<�•. CROSSSECTIONVIEW
F'�,�q (No Scale)
' . Pravida minimum 3 R
Sys[em Elevation=_ft separetbn 6ehveen trendies.
(ryv��p
Duick4 SterMaitl-W
w/Erw Cav O698rvam"'�°° TYPICAL TRENCH
�ryPi�) . (Show locatlon of inlet/outlet pipe mnnection on plan view,) in�en oern.�w�.nws p�N VIEW
��"`"""� (NO Scale)
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B- `t v ft —_; m
(�'P'��1 �uick4 StantlarE-W ChamDer W
OrW�9 �
WSTALL PER TRENCH: �mn cr mnmam�sy.m�.i�.� T
In�IvunuenimmenufacWrafansbuGbns. A
"LZ Quick4 Sttl-W Q 20 fl EISPJc�amber= �NG e'
+ � Pairs of enC caps�6 R'EISA/pair= 6 ft'
=Proposed EISA per trench= �14F-; R' Required IMiliretion Area= -rl� ft� DlStribUt10f1 MBtl10d:
x � trenches = Proposed Total EISA= Ny e' ��'aviYy
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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 3PS 382-384,�sc. Admin. Code. Pursuant to SPS 383.52(2), Wisc. Admin. Code, this system shall
be Considered a human heaRh 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 wfth SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dlsoersal Area Ooeretina Limits:
Deaign Flow= 3ov gpd; BODS<_220 mgL''; TSS 5150 mgL''; FOG 5 30 mgL''
Insoection Checklist INSPECT EVERY 3 YEARS
o type Of use
o age of system
o nuisance factors(i.e. odors, user complaints, eta)
o mechanical malfunction (i.e., pumps, valves, switches,fioats, eta)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o wlids volume in anaerobic treatmerrt 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 exterd of ponding in distdbution cell prior to dosing
o dosing irregularitles- if applicable(i.e., pump re-cycling, float switch settings, etC.)
o eleCtriCai components-N applicable(i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice piugging (measure lateral distal pressure—compare to design spec'rfication)
o surface discharge of effluent or sewage back-up into structure served
Malntenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Seotic and dose tanklsl shalf 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)ezceeds one-third (1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shail be pursuant to NR 113,Wisc. Admin. Code.
o EfHuent Nitx(sl shall be inspected every 3 years and shali be cleaned when necesaery to remove any
accumulated solids according to manufacturer's specifications. A servidng period wiil always be greater than 12
momhs.
System maintenance reporte shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component feilure or malfunction to:
Name of individual or compeny: � �+'r Y �� .c� Phone: ��S- `�l`l 2�2-�{u`�t
Local gwemment unit: s c ` Phone: ��S� � 3 �(—£7 Z�8
LoCai govemmerrt unit address: �UC�/d jr�`�N S i� !'{m y L.xts c� ZIP: =-`��`�3
Arry defective part of this system shall be repaired, repiaced, or removed pursuant to SPS 383.51 (t),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
axordanCe wRh SPS 384, Wisc. Admin. Code.
Cor�tinaencv 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.
Reset Pa e
'�'�_"-':"T"��� pRIVATE ONSITE WASTE TREATMENT county
i�;i' ''>-r:,
�=�� asp ���,, sYsrEnns Sawyer
����1� ,� ' ( POWTS)
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'^��'-�^�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� - � ��
Personal infonnation you provide may be used for secondary purposes [ Privacy Iaw, s. 15.04 (1)(m) )
Permit Holder's Name: ❑ City ❑ Viliage � Town of: State Plan Transaction ID#:
fla��, �;�,o s� C.�kklt�
Insp BM Elev: BM Description: Parcel Tax No:
�oo.o � �.� ►�, �6� f��. o� k Da� -- 1 � - 06 - �c�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�e � oap Benchmark �po,o �
Dosing
Aeration Bldg. Sewer ��';q �
Holding St / Ht Inlet q�`,� '
TANK SETBACK INFORMATION St I Ht Outlet qs- 3S r
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic .�3p` r S� ��� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. 9 y-7S r
Holding Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative �
Surface ��S �
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W ,3� L ( b� # of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � I �
INFORMATION P / L Bldg Well Waters °� GP t� Chamber Model Number:
❑ EZFIow
CELL TO fi,Z�� ��,$' t',� N A'_ ❑ Mound o Other QY�
- - - — - --- .--- - ----.. ----_-- — ---
DISTRIBUTION SYSTEM X Pressure Systems Only
_____ -- _- - -
Header I 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 ; Dep oth f Seeded I Sodded Mulched
Cell Center Cell Ed es � To_soil ❑ Yes ❑ No ❑ Yes ❑ No
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COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?� Yes ❑ No � 3j . � /��� � �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710 (R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA: �_rI� _
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