HomeMy WebLinkAbout002-940-28-5206-SAN-2022-211 _ �. �
Department of Safety c°"°� �-, L�
o & Professional Ser��ices, `� �' �� �
� S p - Sanitary Permit Number(to be filled in by �
: Industry Services Division
�3� �t�G �
Sanita� Pel mit AppllCatl�n State Transaction Numb�er �
In accordance with SPS 38321(2),Wis.Adm Code,submission of this form to the appropriate�ovemmental unit �
is required prior to obtaining a sanitary permit.Note.Applicahon forms for state-owned POWTS are submitted to Project Address(if difYerent than mailing �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary —
purposes in accordance with the Privacy Law,s. I�.04(1)(m),Stats- �_
I.Application lnformation-Please Print All Information
Property Owner's Name Parcel#
W1 i ���q�j �l�l: J c�1e S S�r- �r u s t � � 2 — `��4- �z�; - 5�D�o
Property Owner's Mailing Address Pro erty Location
�C�fc� N ��vV�� Lcz.�,'1�. ct����o� �
Ciry,State Zip Code Phone Number
�(. �.1."�t�(� � t�l% 1-- 5'�Fy�3 ���=s s-�- c�a.s-y —��' �, Section Z�
II.Type of Building(check all that apply) Lot# T �� N R � r
;�or2 Family D�nelline-NumberofBedrooms � i � Subdivision Name
Bfock# '�
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number 3 L ZS ❑Village of
� � �:..� C�Qownof�4�_�S,.t�-f'�
IIL Type of P01�'TS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
:�
❑ New S�stem �Replacement S}stem ❑ Other Moditication to Existme System(explain) ❑ Additional Pretreatment Unit(explain)
�e l_L- �!J L �
B' ❑ HoldingTank �In-Ground p�S� ❑ At-Grade
� ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
��• ❑ Rene�al Before ❑ Revision ❑ Chan�e of Plumher ist Previous Permit Number and Date lssued
❑ TransYer to Ne��O�vner
Expiration � �j - � Z, 3 5 3l (�($
IV.Dispersal/I'reatment�1rea and Tank Information:
Design Flow�(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(st) System Elevation
`�ov r `7 �tz � `tsz} �18, .Z�
Capacity in Total #of Manufacturer
°:
Tank Information Gallons Gallons Units 9 � J y �
New Tanks Existing Tanks '� c y ` v L a �
a U v� y v� i�. U a
Septic oclle4diug Tank ��jc C /CC�
Dosing Chamber �C�v �•Cr � il.,�..!? .�,q
\..Ci WL7 L-
V.Responsibility StBtement- I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signah MP/I�Q�RRS Number Business Phone Number
�a��Y� K��-�-�+� I ��-��-�s-� � �s�. �sy- 3 js�—
Plumber's Address(Street,City,State,Zip Code) f '
`Q, � . ��� � � C�Lt 6�l E'_7 (.t�L �-(����
VL Countv/Department Use Only
�A ❑Disapproved �ermit Fee� Date Issued Issuing Agent Signature
��� ❑O�tiner Given Reason for Denial ��' �1 I( ��`�� ������1 '`^'^`�-r �--�,r-
Conditions of ApprovaUReasons for Disapproval i � T� j; �•;.�r f! �1
c� 1�J! J�!�_-'.'��_�ll L_._- e
� L ��: - -�,, �
� , ; �►i�l� � � `�
� �� '� ° flaze AUG 17 �022 ;
�
Chk# _ �3 t�5 9 ,,-.; �
� J SP.WYER CC�Ut��; .
C�� �p� "- I "1� �('n�'�`lNl��'•! _lJ�^'Y�c� �k' 3J" C� ZC�Id1�+a E\��",/!ii�liSTF'v";j!i:)f1":
Attach to complete plans for the system and submit to the County only on paper not less tTian$V2 x ll inches in size
SBD-6398(R.03/22) NO RiFVNDS AFTER
15S11E OF PERMtT 33L% �
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manua/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): (�'1 t c�ae� U/� JCw�S S;. j V�u S f Phone: '7i i - s�- (oUs y
Owner Address: �C�Cv Iv -T(w��0�-+,^ L�c �-�yG�,�ctr��,;t�3' Zip: SzfS��F3
Project Address: —s�'t� �
�r
Govt. Lot: .2 1/4 of 1/4, Section '�7-� , T `-fG N-R G' E ❑or W�
Township: ��j. QSS Lc:�f�� County: �_�
Project Parcel ID #: C�C�`L - q�p�-2 y - �2-C���
Designer Information
Designer Name: �'q��1 t�.t,l���ef Phone: 7 �S - "7�� �:�5��
DesignerAddress: ��� � �C►� �(,� Cc��o(.e.. �,�.t :L Zip: s�f82j
E-mail: �`�m � G�.:��.�n��s: c:.errt
License Number: (��,S�7S 1
Remarks:
Signature: - Date: f� /� ZZ
Original sign r required on each submitted copy.
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Cross Section of a two cell EZ Flow In-�Ground Dispersal Componeni
Cell Separa[lon
� 3 �ft I+ 3'
n
�� Final Grade
� ,� J
`�-� "' � u x� '.. Gl� ;���,�„�� ��f���� � ���-`�
-� •.
'�'�` t-0� .
-�c.�..trt c,eV�z �7��,�"i�}:� Geotextile Fabric
♦ � v. ��' � 'r�.y� . �' A'�hi,��a�
12"�— � r, _ �.�'`� � ;��
- � '4�i , ���,d
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Design Flow 3c�0 /Loading Rate� 7 =Required dispersai area �Z� cen u�
--- system E�evation: 98,2'
Required dispersal area �f�v /50(EISA)= 9_ (number of units) � �
Final Grade: �d� �
Geotextile fabric to meet Comm 84.30(6)(g) �e���z
Minimum of 12"of cover over top of ceil System Elevation c/�'�Z�
Two Observation/vent pipes to be provided per cell
Final Grade j vl ' q-v<.
Not to scale
PAGE 4 OF 4
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 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 pian.
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 Disqersal Area Oqeratinq Limits:
Design Flow = 3�� gpd; BODS <_ 220 mgL-'; TSS <_ 150 mgL''; FOG <_ 30 mgL''
Inspection Checkiist 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 Seqtic and dose tankls) 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 failure or malfunction to:
Name of individual or company: �-, �CtS{'VL(A.SS�'-� `f' ��/!-f Phone: 71S 7�1�"'33S�r
�
Local government unit: ! Z01i.�-v-� ' Phone: ^7iS -(p3�- �z�'�
Local government unit address: (iv� ZIP: �,�{��f�
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisa 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.
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 dispersai component in a pre-determined area of suitable soi�s.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383 33, Wisc. Admin. Code.
%��=""'-`='���:r,, PRIVATE ONSITE WASTE TREATMENT county
�;>
=,'�`b�S � �; SYSTEMS SaWyer
i p
� S
```�� �— � ( POWTS)
��°r ��''� r� 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 Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
v��a.G�� �o„�s s.�`l�sfi �ss (.�I,�. ^
Insp BM Elev: BM Description: Parcel Tax No:
�vD.�� Lo.��. S l4� v� �S IZ. (�o� '��D �- �g—��U:(�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ��y � Benchmark S, ' (05:Y ` �00.� �
Dosing ��
Aeration Bltlg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG ARNINTA�KE ROAD Dt� o� �` � �;�,5 ,S� `�6.� `
Septic NA Dt Bottom
Instatlation , r
Dosing NA Contour � �•3 l vl.(
Aeration NA Header/Man. o(�.�'
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nfi�trative
Surface �•a� ��•��
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 � � p� � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P I L Bidg Well Waters ❑ IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO fiZs� � � �` ❑ Mound � Other
_ _-- -__ _ -- --
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distnbution 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 I Sodded Mulched
Cell Center , Cell Edges Tpsoil � ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
�-�s��l� �( � 3 l a-�
� �e��s ���
Plan revision re uired?❑Yes� No , —�I � �
__.
q �i�°7 a3 ��_ _��� I ���I�
Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITARY PEAMIT NUMBEA: ��
D(L
1
1
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