HomeMy WebLinkAbout002-106-11-2300-SAN-2022-212 r� __
County �
Department of Safety C � �
� & Professional Services, `-�a'w �
a� Sanitary Permit Num (to be filled in by
t Industry Services Division
�0 � �'1 � c� � �
4�
Sanitary Permit Application State Transaction Number i
� �
[n accordance with SPS 38321(2),Wis Adm Code,submission of this form to the appropriate governmental unit -�
is required prior to obtaining a sanitary permit Note Application forms for state-owned POWTS are submitted to Project Addres.s Sif difterent than mailing a �
the DepaRment of Safety and Professional Services.Personal information you provide may be used for secondary 7(y?VC� q�
purposes in accordance with the Privacy Law,s I�.Od(I)(m),Stats. � [] �� �,�
I.Application Information-Please Print All Information � C
Property Owner�s Name Parcel#
�� � J^ c'�z�o � 02- lo� -1 I - Z3ov
Property O�mer�s Mailing Address Property Location
� �� � � �� Govt.Lot
City,State Z�p Code Phone Number
�'�1�U'l V��l�'�� � �� SS.3 1 7 QJ�Z — `�S-7' ��'�{�v '/�, '/a, Section 3 1
II.Type of Building(check all that apply) Lot# T N R W �
� or 2 Family Dwelling-Number otBedrooms Z- Z 3 •-2� Subdivision Name
Block# S ��((� �5 f'���
❑Public/Commercial-Describe Use
� ( ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�Io�vn of�Ciss �1��� -----
IIL Type of PO��'TS Permit: (Check either"vew"or"Replacement"and other applicable on line:a. Check one box on line B.Complete line C if
a licable.)
`� �ew System
❑ Replacement System ❑ Other Moditicat�on to Existmg System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �'n-Ground ❑ At-Grade ❑ Mound ❑ [ndividual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Chanse of Plumher ❑ Transfer to New Owner
,ist Previous Permit Number and Date Issued
Expiration
IV.Dispersalll'reatment Area and Tank Information:
Design Flow�(gpd) Design Soil Application Rate(epd/s� Dispersal Area Reyuired(sf) Dispersal Area Proposed�st) Scstem Elevation
�oU � 7 �{z 9 �t`S� �tl.s'
Capacity in Total d of Manufacturer
Tank[nformation Gallons Gallons Units � � o � u
New Tanl:s Eris[ing Tanks �+° � y � v a� �' �
` o � � � � R
a U v� � v� w C7 a
Septic o�,}jnldipg Tank
i '� Z S� ( t�t.:i E 5�/L-
Dosin�Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility f ' stallatio of the PO�VTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signat MP/D?PR�Number Business Phone Number
��1 s�;�� l�u-���-�i i���s�s i ?►S=�9�'._3 3�S'�
Plumber's Address(Street,Ciry,State,Zip Code)
_?S - �(� C�l� �`c���.� �.c�� �Zlc��, 2(
VI.Co ntv/Department Use Only
�A � � ❑Disapproved Permit Fee Date Issued [ssuing Agent Signature
�� ❑Owner Given Reason for Denial $ `���� 3 ��'� ��� v i�y''--Q�-����""�"
Conditions of Approval/Reasons for Disapproval `� I G� � {� ,� 1 !,J ,;�' �
�'� � -l��.A?_� ,��f ��:;.i{
/'
� ,�'=`.___��(��a a - .___.� . _ ���� A�G 17 2022 ��
�Y �� � ��
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s � �-�- � `-� �' �=�r- �`N_�._lN.�.��_d____ 3us�-( 70Plli�:i�l�D�;l,:;�s�E,���,��a
Attach to complete pl•rns for the system and submit to the County only on paper no ess than 8 1/2 x I I inches in size
sBD-639a�x.o3i22> N�RcFJNDS AFTER
ISSUE OF PE'FtMI"f
�`i5
PAGE 1 OF 4
In-Ground Gravity Pian
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): (�(�Q„-�L ��, �1(1 C f Z �� Phone: q52 - -`�s'7-_"3 9y�G,
Owner Address: '�(�o fv ��;� �-ve. CLvinl'IC�SS�-r1. Ml� Zip: s"53� `7
Project Address: Posf' �U e. ���U�4^d� �� SzfY`�-3
�t. Lots L 3 •-Z��1/4 of 1/4, Section 3 i , T� N-R_�E ❑or W,�
Township: (�qSS ��e �z'��Pstr �`�� Count S�'�u'
��,�� y:
Project Parcel ID #: �C2 �(�4,-- �1 - Z3 oc
Designer Information
Designer Name: ICISC►� ��1�}�e1 Phone:�'_- 7�� - 3.�SS�
Designer Address: _fl,Q . � (�(, C�(��,�_� Lti�` Zip: S�{�2/
E-mai I: ��C0.n�U,l�a S, c.a��n , - �
License Number: (.o ls�?S 1
Remarks:
Signature: Date: � �7 ��
Original sign r required on each submitted copy.
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Cross Section of a two cell EZ Flow In-�rounc� Dispersal Componer�l:
Cell Separa6on
3 � � ft 3'
,�,; E`i Final Grade
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�b�+ c i . Cetl#1 � . .; ��� � rs C� '�} ��y7�� .. , � .� ;"�7
5,.
�`` ,�� ,�``�_�,,� � "�r
,
., ceu�z �
_ ���r , � a � t��� Geotextile Fabric
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o ya �����
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Design Flow 3t;_C / Loading Rate � �� = Required dispersal area `fz9 ceu tt�
System Elevation q�� S �
Required dispersal area �-� / 50 (EISA) = q (number of units)
Final Grade �S p¢v2
Geotextile fabric to meet Comm 84.30(6)(g) � �,(S:nG �2� j ' �C ��'' Cell #2 �
Minimum of 12" of cover over top of cell J System Elevation ��• 5
Two Observation/vent pipes to be provided per cell �l�.S �{5 ' F�/e
Final Grade:
Not to scale
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 352-384, 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 Disqersal Area Oqeratinq Limits:
Design Flow = ��j GG gpd; BODS 5 220 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, 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 Septic 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 failure or malfunction to:
Name of individual or company: �.1(�iSvY1i,(SS.e��t �i SEnS Phone: 7U�- �y� "3335
Localgovernmentunit SQ-�v {,e.� �.(;. 70�'1i.�%�{= Phone: �IS�-w3µ- �'ZL��'
Local govemment unit address: kc�;a �^�� (i.� .� ZIP: �1((���j
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 shatl 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.
��s`""T"'`�;; PRIVATE ONSITE WASTE TREATMENT county
l';�n'� ,��� SYSTEMS
; � P S awyer
�,,`� s ;,� ( POWTS)
\k�F�i.�T�/��r`/.
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � � �p�� �
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#:
�af�( Y'lo�'`-��47 ��rSS �t�-�, �
Insp BM Elev: BM Description: Parcel Tax No:
(
(oo.a l��„ ` ;,,. 30`` oGv.'�� ooa .. �ob- �� -�30�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,.,;�g.�- -��j Benchmark (po,o�
Dosing
Aeration Bldg. Sewer 9 S"��a'
Holding St/Ht Inlet "r 5'.1 `
TANK SETBACK INFORMATION St/Ht Outlet 9Y,q �
TANK TO P/L WELL BLDG vEN-r ro ROAD Dt Inlet
AIR INTAKE
Septic .}.a` �v �- (v NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q�,S `
Holding Dist.Pipe
PUMP/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 t,(p �' #of Cells a Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P/� Bldg Well Waters � GP � Chamber Model Number:
� EZFIow
CELL TO }—S f/ ❑ Mound o Other
-- - — -- ___- ____-- -- --_ __..
DISTRIBUTION SYSTEM x Pressure Systems Only
Header/Manifold Distribution Pipe(s) � X Hole Size X Hole Observation Pipes J
Length Dia �ength Dia Spac �I Spacing ❑Yes ❑ No _ '
— --- _ �__-
SOIL COVER
_ _ --
De th Over De th Over De th of Seeded/Sodded Mulched
P P P
Cell Center Cell Edges _Topsoil _ _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
��s�►ll� 9��-��a�
� -- -- - _� �
3 _ - -- -
Plan revision required?❑ Yes❑ No ,� 'I�� i}3 � , /����
--1 � � U
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITI�NAL COMMENTS ANO SKETCH
SANITAAY PERMIT NIIMBEA: o��-..Z��_
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