HomeMy WebLinkAbout014-941-08-4405-SAN-2022-194 °`"%`�":\ Department of Safety c°'Y"n' �
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a � `Tti & Professional Services, "'`'`�' �� �
a� ��� r` )<i Sanitary Permit Number(to be filled in by Co.) �
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Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary peimit.Note:App(ication forms for state-owned POWTS aze submitted to Project Address(if different than mailing addres �
the Department of Safety and Professional Services.Personal information you provide may be used for secoadary ��3 s� ,� s��,vs-�,� l.�
p oses in accordance with the Pnvacy 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
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City,State Zip Code Phone Number
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` ...� _ , �.'�-�: � :'� z `: �',`:� Lot# R E or�C3
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I�'1 or 2 Family Dwelling—Number ofBedrooms .3 � Subdivision Name
Block#
O Pt�blidCommercial—Describe Use ���
❑City of
❑State Owned—Describe Use ��� CSM Number � ❑Village of
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;�:z}�;�af:��'�a��C:�ueck`e�esr��PTev�'ar'�Repls�cement"-a�d ot��r�`a�p#i�btc nn��te A»::�k aae be;�u lin�s B.C+aucpleta.#�se C if
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`� L� �iew System �,`2eplacement System �Other Modification to Existing System(explain) ❑ Additional pretreatrnent Unit(explain)
f�n.1� �C-. IG. 1` �
B' ❑Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑Individual Site Design ❑ Other Type(explain)
(conventionat)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner
ist Previous Permit Number and Date Issued
Expirafion ����j_ 1 e2s �?�
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[...e... � � . .✓. . .. ..h.:... .� u,....r�:'. i.
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Rz�sad(sfl Dispersal Area Prenexd(s� Sysum Elevation �
ys�� P s . ex�s%���� 6i5' � q'c�-o �s:s�
Capacity in Total #of anuficturer
Tazilc Information Gallons Gallons Units � � � 'g �
New Tanks Existing Tanks � 4 y � � � � �
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SepticorHoldingTank 1�� ., ._-_. %q��� i �i�5er x
no�g c�t�
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Plumber's Name(Print)� � Plum er's Signature , � MP/MPRS Number Business�Phone Number
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Jerry Ruid Excavating, LLC � � n�y Z��,Z�� �, z 7%�= �-r,z� Z-�U;
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Stone Lake, WI 54876
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�.A ❑Disapproved Permit Fee Dafe ssu d Issuing Agent Signatwe .
$ ,\d �° g�g�a a •�y�
❑Owner Given Reason for Denia] Yv '
Conditions of ApprovaUReasons for Disapproval �,�����j,,,�
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M 4� ZOPIING AU�1��iI�TR'+i ICN
Attach W complete plans for tLe system and submlt to the County only on paper not lesa th�n 8 lrz i 11 inches in size
NO REFUNDS AFTER
SBD-6398(R.03/22) iSSUE OF P�RMtT
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PAOE 9 OF 4
In-Ground Gravity Pian
Incf�x & Cover Sheet
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Pp 1 of 4 index & Cover Sheet
P� 2 of 4 Plot Plan
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Pg 4 of 4 Managemerrt Pian
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POWTS for Review
Soil Evaluatlon 8� Si�e Ma
Pr�oje�t Nart�e � Ds�iptlon
Ow1�tie�M(s): T'��.r k 13 E-r�� c�.s� PhOr»:
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TowrwlNp: L e,� �-�s�� County: S���..: „c.r
PeoJ�et ParoN ID/: G� ��9 t1 I a � �l�l aS
D�slgnor Ittfottnatfon
�� �, Jerry Rutd Excavating� LLC p�M: 7iS -`�Z- ��i�
o..ip�.r Redn.�• stone Lska� w� saa�s ap:
E�l1�8: , r v�d (� GEw�Tvr�lTG( . •,,cT 'lbia sp.a ro,med for.pprw.l snmp.
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� SOIL EVALUATION �� '°-40' ❑ SYSTEM PAGE 2 OF
SITE MAP � � � � PLOT PLAN
PROJECT NAME �p, DE810N FLDNF �+�0 a�
�El�rr v tS i Attach d�slpn 11ow nkuitdons for commsrdel plena.
�o.Fcr�oor� 1/3Sz,n� N �vs�a��nsn�smndem(Tedes 3ea.ao,a s�et.ans)
sier,neac $ eM�,; Ioo.0 Fr e"'ny's� /
(� �1 Faca MMn: /
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81W�adelt%1 r— w�ll M �"�•m'�iey IMPORTANT:
d TrYaw.r �"�( �Y O md��a a�f1O1Y Show prourd ebvatlon cmbw at eWtebie Intnvak.
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Jerry Ruid Excavating, LLC 5"N 5 eZ e��cer
W208 County HWY A
Stone Lake, WI 54876
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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 SPS 362-384,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 Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Disaersal Area Ooeratina Limits:
Design Flow = `is�= 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, e1c.)
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 ac[ivities, etc.)
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 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 Seotic and dose tank(s)shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third (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 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 faiiure or malfunction to:
Name of individual or com an �c-f'�'1 1Z- �Lc Phone: �'�' `'��l Z��-`t���
P Y
Local government unit: S C- Z- Phone: ��s- (� 3 �-1 - �2�i��
Local gwemment unit address: +o�"��' �`'��^�N S` N`�r �"'"`'� �1" ZIP: -�`��' `�3
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 the department in
accordance with SPS 384,Wisc. Admin. Code.
Continaencv 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 Page
�'�'�-��'"—�"'���� PRIVATE ONSITE WASTE TREATMENT county
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�� �SP$ �,; SYSTEMS Sawyer
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( POWTS)
��-� INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� .- �� �
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Descripti . Parcel Tax No:
lc�.�' ►� � '��� �� s�'�;� o�. �� . 0i y�a y,� o g� y���-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic U,;e�- ppp Benchmark �, ��o,o�
Dosing f3►�n� � �i N•�b'
Aeration Bldg. Sewer �,�,o��
Holding St I Ht Inlet q/R? `
TANK SETBACK INFORMATION St/Ht 0utlet ti�.�5 `
TANK TO P/L WELL BLDG vE"T To ROAD Dt Inlet
AIRINTAKE
Septic .�-lo fi�-S� l � �t-I � NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative
Surface
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 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P I L Bldg Well Waters °� GP ❑ Chamber Motlel Number:
❑ EZFIow
CELL TO ❑ Mound o Other
- — ---__— __ — _—_ —
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) �X Hole Size X Hole Observation Pipes
Length Dia Length Dia _ _Spac j _ _ �, Spacing ❑Yes ❑ No �
SOIL COVER
— -- _ ____ -
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center �Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑ Yes 0 No � 03 j Q� T � � � I �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCN
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