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Home My WebLink About024-641-24-4203-SAN-2022-210 - '`�� `` Department of Safety c°°nty � ,� ;�a " & Professional Services, �(..�-� � , � Sanitary ermrt Na r to be filled in by C , , : - Industry Services Division � C�3� I �q �' � Sanitary Permit Application State Transaction Number y� In accordance�vith SPS 383.21(2),Wis.Adm.Code,submission oFihis form to the appropriate governmental unit � is required prior to obtaining a sanitazy permit.Note:Appiication forms for state-0�i�ned POWTS are submitted to Project Address(if dit7erent than mailine ac tfie Depariment of Safely and Pmfessional Services.Personal infomiation you pro��de may be used for secondary 1 Q�7 u ` , �� C, purpt�es in accordance�ti�th the Privacy Law,s. 1�.04(1 xm),Stats. f l � �� .��y- I.AppGcation Information-Please Print All Infoemation Properey Qwner's Name Pan;el# � , SC�r► � --f- p. �i.- (v�,l- y_�t Pmperty er's Mailing Address Property Location �V � � l.:� �� Gevi-�e�— City,State Zip Code Phane Number �t�— L-(,t�4�'� (��I� r11 N ,'�j��'7� IU J�.��3 �..I_-Z� 1�1�� %<,�'4, Section ��7 �r� II.Type ot Building(check all that appl}') Lot# I' � N R � E o t$�1 or2 Famity Dwelling-NumberofBeilraoms � ^ Subdiiision`�anx t� B1ock# ❑Public/Commercial—Describe tlse � ❑City of ❑State(hmed-Describe Use — CSM Numbcr ❑Viliage of Q�,ro�ar �r•nj nr� 1 ccK� III.Type of POWTS Permit:(Check either"Ne�s"or"Replacement'"and ather applicable on line A. Check one hox on line B.Compiete line C if a licable.) A. ❑ Ne�� System Replacemeat System ❑Other Modification to Eaisting System(e�cpiain) ❑ Addilional Pretreatment Unit{esplainj B. ❑ Holding Tank �In-Ground ❑At-Grade ❑ Mound ❑ lndividua}Site Design ❑Other"fype(explain) (con�entional) C- ❑ Renewa!Before ❑ Re�ision ❑Change of Piumber ❑Transfer to New-O�vner List Prc-�-ious Permit Numbe.r�d Bate Issaed Expiration �N � ? N.DispersaUTreatment Area and Tank Information: Design Flon�(epd) Iksign Soil Application Rate(�'sn Dispersal An:a Requimd(sfl Dispersal Area Proposed(sfl System Ele�ation s,J4."ZS' � ' � � � -J� 1"��-� .�=��Tr~-�tS.zs Capacity m Total #of Manufacturer Tank tnformation Gallons C:illons Linits ' � o � v_ Nea•Tanks Existing Tanfs ,d � � � y ��, �°� o � u a � �s ci U �n �, �n �z. C: A. Septic or HoMin¢Tank � ��C� , � Dosing Chamber � �'C �� V.Responsibilih'Statement-I,ttre andersigned,assume responsibitih for instali�tion of the YOWTS s�otva on the attached plaas. Plumber's\ame(PrinE) Plum ignature MPlMPItS Number 6usiness Phorre Number Cu;� . � � Q _.._ � 34l �7t5-�5 ��7:3 Plumber's Address(Street,City,State,Zip Code) '�5�l � �G�vt �Q � z �--� VI.County/Department Use Only ��1 ❑Disappro�ed Permit Fee Date Issued Issuing Agent Signatun '"(/�✓ ❑Owrer Given Reason for De�tial � l�� '��Io�02 ��A.'�'I�""""�! Conditions of hppriSvalfReasons for Disapproval 4 ,-,�y= � , � :.' ^ ��. .... � � � ,J�4:. . . . . � �� ' �� Date 8 �2 _ �� aUG � C s� �� 1�? cnk# ��r �_.� � - - _ ;, �;��.� RCpt#�-w W�r 1d �*3Q � r. + � " Attacd to cumplete plans for t6e scstem and submN lo the Caunty onl�•on paper not tess than 8 in x I t iaches in size NO REFUNDS AFTER SBD-b398(R.03!22) IS$VE�F P�r{ a�'S�'S 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): b-{-�� L� SC%hv�.ex-`T'�-u�-fi Phone:�-a.3 8 - �� Owner Address: ��L� �J��-�"E a� L�.K� �lrn�,�rn� Zip: ��?�'-� � Project Address: �0(�'?�� i� ��v-�S�-C.i E'� ntr'. �Cd.c,f�C�2�, Ct:� .-�� Govt. Lot: �_1/4 of S F 1/4, Section ��`-t , T� � N-R ''(� E�or W Q Township: �,��, ��,({� County: �C�W � Project Parcel ID #: C��-�-F.— �p�� r- �—�-(,�� Designer Information Designer Name�� _��r_y�Q Phone:��SS -� Designer Address: ll.`� l I�T 1 Zip: SJ�:�L 3 E-maiL• � `-�?��<_;�-�..! . ; . ,. , License Number: ��L Remarks: Signature: `�� Date: �5"-1�7—�a� ri ' signat e required on each submitted copy. aw e�: l..e 4 : S i e�ev� (,.Scc��her T�S-�- Sqw,,�c,- Co. � fQo�,1� La�e lw� 10960 3`6k'� CT t�: Qtr.�_ oz�{_ b�t(-z`f- 4zc�3 L�.��e l= Lwto� I�Iu SSl��EZ Nt..S�SE ,S1 z�--( T �I�.+ 2- 06W 5;-�-e; f 0 63'} !J �o Ces-{' C�rc_�c 1)r � � �,P D��e 5a`"3e i Sc�e,��=3� o� O �6 20 i0 L BN�oo�cen'�cr oF door s:�( ,� BI. az.ss' � z, tiz.zS ` � 3. �t�.7 � ,� SO;�5�S�S[e�.Tr,� f�q.ZS� �l Tr.Z 88.�� I r 3, 2�S,L5� � �£sf' ST �r� `TaS� 3 � gn ioo ' �a `2GC. �LO0.'1DG� �-oac.,wml l 3 E-Z"r'�" so Z 3 78� �. -_-�-- _�-- �—�1��oos� l��e -�— IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s) Manufacturec /,.�,'.o s v✓ Stepped Elevation Trenches with EZ1203HP Bundles Septic Tank(s)Volume(s): 3-ft Trench (down-sizing credit) /� gal gal gal gal Effluent Filte Manufacturer: r �.-�,��i� , r� — Tii�P . Geotextile I —min. 12' Effluent Pilter Model#: ��d�/�2— cover I (rypi��) SOIL COVER 12" � ' , e... : min.trench ' e � '. TYPICAL TRENCH Provide minimum 3ft depth L leP��1 — — — —.. ,�� .• � . CROSS SECTION VIEW separation between trenches. (No Scale) Highest Trench Lowest Trench (as applicable) OBSERVATION PIPE DETAIL � �:2 S , SLSL� _G'� ft (No s�� System Elevations= ft ft; ft; ft; s�,aw-rYvao, SIiO Cap Qoose) ";i' FinisheC G2tle �mmonaa a seaeaa� 4"0 PVC Pipe � _ Topsoil Covar Top ol pipe to�ertninate �'� (min.1 foot) TYPICAL TRENCH (Show�ocation of inlet/outlet pipe connection on plan view.) a'orebovef1n19hetlgratla PLANVIEW 4„ � o�arva��o�o�Pasha��oa��s��ad c4�,��,� ape��s�o� at junction between two units. (No Scale) Perforated Lateral Observation Pipe ft nncno��9 De�ica i�lutratron (tYPical) (�YPical) (hPicai� ,. ...'. s�ee� , . ... r - - - - �� - - - - - �� - - - - - - - - - - - - - - - �� I "____ =_:____ ==_ =_'____ ______'= I A — 3.0 ft � ----- � - - - - - - - - - - - - - - - ��- - - - - - - - - - - - - - - - - - - - J �aa��> (� 'r a = � ft �; , m c�va�� w INSTALL PER TRENCH: EZ1203H Bundle (typical) � � mfd b Infltrator S � 10-ft bundles @ 50 ft� EISA/unit=��v ft ( v ystems, �nc.) Install pursuant to manufacturer's instrucfions. � + 5-ft bundles @ 25 ft EISA/unit= ft� = Proposed EISA per trench = �� ft' Required Infiltration Area= (O^�� ft� Distribution Method: x 3 trenches = Proposed Total EISA = �S`Oft� /.5��,�G/� /�,�,r,, ;� �� PAGE40F4 In-ground Gravity Management Plan IMPORTANT: The owner of this int�round 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 pertormed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc.Admin. Code. Maximum Dispersal Area Operatinq Limits: Design Flow= �/C�� gpd; BODS <_220 mgL"'; TSS <_ 150 mgL-'; FOG <_30 mgL"' Insaection 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 vdume in anaerobic treatrnent 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, conirols, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification) o surtace discharge of effluent or sewage back-up into structure served Maintenance Checkiist 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. Admi�. Code. o Effluent filter(s)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 govemment unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company:��(a In 5-{'VQ�'YX Phone: ��S�S��'�73 Localgovemmentunit:��l. ; /� '11v1v�. /,Al'�C�^E.l_ Phone: �j�—�"�,�—�,�� ` `� ` � Localgovemmentunitaddress: �(��/f� rY�-��'��1� �� p(�tit'L ZIP: ��13 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. ContingencY 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. /;�'='��"""-^'��y� PRIVATE ONSITE WASTE TREATMENT county �� , � SYSTEMS '( ' �Sp -i � S awyer �"` ( POWTS) �.�� s_ ,_�;, \\�F`i:u�v=/ kU�__ INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �2� _ �� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. t5.04(1)(m)] Permit Holder1's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#: �(h�N S'-C 1�0�^a_r'�,,.5� �`��l�+�Le_ .— Insp BM Elev: BM Description: Parcel Tax No: �oo.n � �O�-s;l` oiY-6Yr - ��{ - �r2o3 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,,,� ( pery Benchmark (pp.� � Dosing Aeration Bldg. Sewer Q,3, l Holding St/Ht Inlet �p � TANK SETBACK INFORMATION St/Ht Outlet o. � TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic .}�p' � ` �� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. �jo .� � Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative Su rface Manufacturer Demand Final Grade Modei Number GPM S S• � �q•3� TDH Lift Friction Loss Sys Head TDH Ft 2 $$.� ' Forcemain L Dia Dist.To Well � ,3 r DISPERSAL CELL INFO AT ON DIMENSIONS W ,3 L � �' � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav �' Conv ❑ Aggregate P/L Bidg Well ❑ IGP ❑ Chamber INFORMATION Waters � AG � EZFIow Model Number: CELL TO .}-S ��'' •�j� �S- ` ❑ Mound o Other — ----- ---— -- ---- -- ------ --- DISTRIBUTION SYSTEM x Pressure Systems Only - — - -- —- Header/Manifold Distnbution Pipe(s) i 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 ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) ��.,s�►((� os�3��-3 Plan revision required?❑Yes ❑ No �O o t a ' � � �� Y [ — _ - Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS ANO SKETCH SANITAAY PEAMIT NUMBER:___ aa ^�1 �_____ `✓ ✓�ots5-2 ls+� ti � r �� / .. ._ _ . . ._ .. __ __ : . ' \��, . ._ . _ __ .. _ �� " _ . ' :_ .. � , , \�?C�� ',ab� , Y r � o � ��b' � �� -S`-j 1��c e � �� , L)€�X Sa` . �.g� �� 3�' �`�� x � Q 9� � 3��' � �`�� , �_ ��- �D ` ��\�C� �— tJ