HomeMy WebLinkAbout026-938-17-5719-SAN-2022-195 �`"""`4� Department of Safety c°"�"'�•' �
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����;� & Professional Services, �� �
; K Industry Services Division Sanitary Permit Number(to be filled in by �
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Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this focm to the appropriate governmental unit � �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS aze submitted to Project Address(if different ihan mailing: '—
the Department of Safety and Professional Services.Personal informarion you provide may be used for secondary '6 �c�c� �/ S'
purposes in accordance w�th the Privacy Law s. 15.04(1)(m),Stats
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�Property Owner's Name Pazcel#
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Property Owner's Mailing Address Property Location
�Cri ��X �� Govt.Lot /
City,State Zip Code Phone Number
S/�i'I�YE�'-, Lc��'G�� �� s 1� 7� '/s, '/., Section �7
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��1 or 2 Family Dwelling-Number ofBedrooms � 3 � Subdivision Name
�� Block#
�Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use �,�' . CSM Number I ❑Village of
, �To�,of ����1 L�.JIe.
�:���?'�;�'.���heckoe�e��'l�ev�"ai�-��te�►iacetuea�'a�►d otla�rsppl�teable nu�z�: G��croua bo�o�t liue B.Cot�uplete�se>�if
�_: : � . , ,_
'�' LI New S stem Re lacement S stem
y '� p y ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Lnit(explain)
B' ❑Holding Tank In-Ground ❑ At-Grade ❑ Mound �� Individual Site Design ❑Other Type(explain)
(conventional) �
C. ❑ Renewal Before ❑Revision ❑ Change of Plumber ❑ Transfer to New Owner, �j
ist Previous Permit Number and D Issued
Expirafion i C��' b� , ' QZ
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Design Flow(gpd) Design Soil Application Rate(gpols� Dispersal Area Required(s fl Dispersal Area Proposed(s� System Elevation
y S C� . (a - 7S�� 7 t,� $S.c��— $3:v �
Capacity in Total #of Manufacturer
Tank Infotmation Gallons Gallons Units � � � ,zj �
Ncw Taaks Existing Taa{cs � Q � �� y � � e�a
U v� �v, v� ti. C7 G.
Septic or Holding Tank ,� — � "
�U 1 W t�s e.c� 7G;
Dosing chamber
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Plumber'�ame(Print) � Plumbe ; . . � , _ ,` _ --- <..
Signature MP/IvIPRS Number Business Phone Number
Jer., Ruid Excavattn � LLC �� Z,�.z��� �,��4�_ z;�`�t
Pl i , , ip Code)
Stone Lake,Wt 54876
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�A a ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
l'�'1� ❑Owmer Given Reason for Denial $ ���'� ���I a� �����/'"- �'�
Conditions of ApprovaUReasons for Disapproval +�J ��� �J���
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Attsch W complete plana[or t6e system end submit to the County only on papet not lesa than 8 ll1:11 inches in size .
sBD-639s�x.o3i22) NO RCFUNDS AFTER
ISSUE OF PE`WiAIT a�j i '-i
PAOE 1 OF 4
In-Ground Grav�ty Pian
Index � Caver Sheet '
con�po�►r�r ANr��ns�pn R�no�c
ve�sbr►a�p,aeo-�o�os-P M.o�ro�.R �a�2� . . .
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P� 1 ot 4 Indeoc 8 Covsr Shee�t
Pp Z d 4 P�ot Plan
P� 3 0#4 Diape�sel Area Cross-Section � Plan Vle�w
P� 4 ot 4 Manageme�t Plan
A�: `
POVVTS for RsvteM►
3oM Evaluslbn �SNs
ProJ�t l�m�/ D�xip�lon
p1w1K t1■1N(�): S�,�•. '� 'c!�,ac� N�L er� Phaf�:
OIwMr Add1Ms: t'c L3�x S'S 5 i on+�. 1.•4Jt� Zip:. =� y E 7�-
p1�0}ul�YOdIM�: 11�1�`' � Mosi: Py- �•
OOnL Lot L 1�4 os 1/4,8s�On i 7 .T 3� ��E or W Q
Tow�ll� S �,.N� L�Ke CouM�►: 5«�-' y�_,-
hs�et rsoN D� �' Z ��t 3�, i 7��7 19
D�i1011K hM+OHlf�tlo�1
��� Jerty Ruld Exca�ratlng, LLC ph�: 7iS -`f'12- 1�i d�
p�NpMr Itdd�Ms: �on. L��Mn!�.a��s _ �:
6�i: � e-u�d � Ge��.s�vr�lT'G( . •,,aT _ xb�aq,.a�..e.�sor.�.�n.mg
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, CXECK80%ASMPLGI&E CNECKBOXASAPP�IGBIE
� SOIL EVALUATION o ��� �40' � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME �pa DEBI6N FLOW N�O ��
�jY�p r� Attach design tlav ulalations for commerdel plens.
aao.�cr�oor�ae: Ibt`i4 w h<aRk� t�-r Dr. N PlpeMatarial/ASTMstandartlRebles384.303&384.3P5)
s.nw,ygsw.� �� /S� 4'U
BM 9f��� � �B�'�iO^. �C�'� FT Faca MNn: NA /
ew o�a�qim: i o� c� co..�c�eTG.
� i�i,y.,,�yy IMPORTANT:
ae tw�a A�ist%) wr��"�(��I� C ������'� Show pround ebvatlom m�toure at auHabb intmvele.
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Jerry Ruid Eucavating, LLC �� 3 g .�. t
W208 CouMy HWY A
Stone Lake,WI 54876 57 sz-e..Y. _gs.v - £'S 3.o
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sePuc Txdqn)�Aaaeer
IN-GROUND GRAVITY DISPERSAL AREA /�X,t� w ces�r
Uniform Elevation Trenches with Quick4 Standard-W Chambers s,o,�Ta„kc„�a,„,,,,sx
3-ftTrench (down-sizingcredit) �; • e„ _�„ _�, _�,
' EfAuent Fibr MaufacWrer
L�I�et�w.�
i
Efivant FiHer MOEM R �-T '
mn+r
SOIL CAVER ����
�s
mn.�
av�� • TVPICAL TRENCH
"< •. CROSS SECTION VIEW
�"—jy��. . . _ (No Scale)
�•' � �� �' Provideminimum3R
System Elevatlon--��_y3ft separetbn heMeen trenches.
(rypical)
Ouick4 SmneeN-w
w�E��p O°'°"'°m"P4° TYPICALTRENCH
(h,Pi�) (Show loeation M inlat/outlet pipe connection on plan view.) Mok+n
��+nn��+«'s PAN VIEW
��h1tld1' (No Scale)
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L -----�r-------yr----- � 1 y
s= � e —_; m
(�Yv��O puicka Stanaardw Chamher . W
INSTALL PER TRENCH: ��� �
��,m M i�roamr swo�.i�l T
i�.m�w�.��m�,w�m.�w�r.n.wdan. A
�� �uick4 Sm-w�2o R'E�Sn/cnamher= Zb0 ft'
+ � Pairs af end caps�6 fl EISP,/peir= _�_ft'
=Pmposed EISA per trench= �-y ft' Required Infilhatlon Area= ���% tt' Distnbution Method:
x 3 trenches =Proposed Total EISA= �� ft' ����+ Y
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PAGE40F4
In-ground Gravity Management Plan
IMPORTANf:
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 Mainfainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Disoersal Arsa Ooeratina Limits:
Dssign Flow= YS G gpd; 80D5 <_220 mgL"'; TSS 5150 mgl''; FOG <_30 mgL''
Insoectlon Checkiist 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, 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 capacides, prohibited activities, eta)
o exterrt of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.)
o electrical componerrts- if applicable (i.e.,wiring, connections, switches, controls, timers, alarms, etc.)
o distribubon lateral or lateral orifice plugging (measure lateral distal pressure-compare to design speC'rfication)
o surface discharge of effluerd or sewage back-up into structure served
Maintsnance Checkllst MAINTAIN EVERY 3 YEARS (or when necessary)
o Setrtic and dwe tenk(s1 shall be pumped by a cert'rfied septage servicing operator licensed under s. 281.48 Wis.
Stats.when the volume of solida in the tank(s)ezceeds one-third (1/3)the liquld volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,W(sc. Admin. Code.
o Effluent flltx(sl shall be inspected every 3 yeers and shall be cleaned when necsssary to remwe any
accumulated solids acxording to manufacturer's specifications. A servicing period will always be greater than 12
morrths. ,
System maintenance reports shell be submitted to the proper local government unit in accordance wRh
SPS 383.55 Wisc.Admin. Code. Report any component feilure or malfunction to:
Neme of individual or company: J �Pf�� � ��� Phone: 7�-`� ' �`� 2� 2-�(o`�I
Local govemment unit: S �- L Phone: ��S- �3�1 - � Z��
LACaI govemment unit address: � �.lG �+-�G-��v � �. �4Y ��-d Zlp; S'`{ �.`-( 3
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (t),Wisc.Admin.
Code. Repair or rep�acement of failed or maifunctioning 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.
Continaencv Pian
In the event that any failed treatrnent�mponent 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
ebandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svsbsm 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''"—T"f`% PRIVATE ONSITE WASTE TREATMENT county
,,�..,
�� \ SYSTEMS Sawyer
``�i�,��� J�r � POWTS)
\�'OF _ "/.
'�'='"��'=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� � �cj�'
Personal infonnation you provide may be used for secondary purposes[Privacy C.aw,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description. Parcel Tax No:
�FA.c7' o-�- co�,c�.�— o _ �3�-I7- S"�I�j
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,.,� �p Benchmark dp,v '
Dosing
Aeration Bldg. Sewer �j�,5��
Holding St I Ht Inlet �tQ.33�
TANK SETBACK INFORMATION St I Ht Outlet �$��S�
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic �,�o .r3� �-t p' �..(p� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. $S.C S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM yyS• ( g�•6��
TDH Lift Friction Loss Sys Head TDH Ft S S. 2 Y•55��
Forcemain L Dia Dist.To Well S• 3 Y.YS�
DISPERSAL CELL INFORMATION
DIMENSIONS W ' � ` � ' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav �. Conv ❑ Aggregate ��!� ,
INFORMATION P I L Bldg Well Waters °� GP � Chamber Model Number:
❑ EZFIow
CELL TO � �F 6 0� F�on' �J ❑ Mound o Other
--------- _ -- --- --
DISTRIBUTION SYSTEM X Pressure Systems Onry
—- ___ P � ) ---- —- _ -_ _ , . - p
Header I Manifold Distribution Pi e s � X Hole Size X Hole Observation Pi es I
Length Dia Length Dia Spac Spacing ❑Yes ❑ No J
SOIL COVER
— -- - -- - -
( Depth Over Depth Over i Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil _ __ ❑Yes ❑ No ❑Yes ❑ PJo
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑Yes❑ No I U3 '� v(� a3' I �` � G� �( �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS AN� SKETCH
SANITAAY PERMfT NUMBER: v�o7 - (QS'
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