HomeMy WebLinkAbout014-842-18-4101-SAN-2022-218 _ "' Department of Safety c°"°ty �
- � &Professional Services, ��w r �
� , _ _ Sanitary Permit Number(to e filled in by G
�, �_ . Industry Services Division �
� (0 3°I a'o-1 �
Sanitary Permit Application SteteTransectionNumber �
In accrordance with SPS J83.L(2),Wis.Adm.Code,submission of Ihis fortn ro the appropriaze govemmrntal unit �
is required prior ro obtaining a senitary permif.Nute:Application forms for stateowned POWTS are submitted w Project Address(if differrnt than mailing a1
�c Deparonent oP Safety end Pmfessional Scrviccs.Pertonal infortnation you pmvide may bc used for secondary
pu}poses in accordence with We P[ivacy Law,s.15.04(ixm),Stacs. `
1.Application Io(ormation-Please Print All Ioformstion Jam e
Property Owner's Name Parcel N
s f�e✓e S-�r4, O IY-8��f - -'-1!01
Property(hmer's Mailing Address Property Location
13 s;►no Q� �
Ciry,State 'Lip Code Phone Number tc p
Jr �J ��� -�o����I N t y..�'/.,Section 'O _
II.Type of Building(c6ecic all that apply) ^ Lot# T ya N R O E o W
�I or2 FamilyDwelling-NumberofBedmoms d � SubdivisionName
Block N —
❑Public/Commelcial-DescribeUse ^
❑City of
❑StateOwned-DescribcUse CSMNumber ❑Villageaf
— �"Iownof �enrc�tlt,`
III.Type of POWTS Permit:(Check either"New^or"ReplseemenP'and other applinble oo Nne A.Check one bos oo line B.Complete lioe C i
a licabla)
A� ❑New System �Aeplacement System ❑Other Modification to Ezisting Sys1em(explain) ❑Additianal Pretreatment Unit(ezplain)
B' ❑HoldingTank �n-0mund ❑At-Grule ❑Mound ❑Individual Site Design ❑OtherType(ezplain)
(conventionai)
C. ❑Rmcwal8efom ❑Revision ❑Changc of Piumber ❑Transfer to New Owner ���°1°1L9 Permit Numbcr and Dare Iseued
Expiration ('1b1�, 7
N.Dispersal/Treatment Area and Taok Informallon: ��llS on- .S un�s �� C c L
Design Flow(gpd) Design Soii Application Rate(gpd/s� Dispersal Area Required(s� ➢ispersal Area Proposed(s� Sys[em Eleva[ion
3w .7 �1a9 �lso 9 .�0
Capacityin Toml #of Menufactwer
Tank Infortnation Ge�bns Galbns Units a G '� N -y
NewTenks ExistivgTanks `� U�' $'� m
�U V 2 V w
Septic or Holding Tsnk �O 2 5 KqW Pf G �`
Dosing Chamber
V.Responsibillty Shtemen[-I,the uodersigned,sssume respoasibility for iattalladoa of the POWTS shown on the e[tachM phns.
Plumber's Name(Prinq Plum r's Signature MP/MPRS Number Rusiness Phone Number
� ; � ' � .s.� aaasra �is-ac6-a �a
Plumbcr's A mss(Sheet,Ciry, tate,Zip C«le)
'�$"v -N � 1'Zc� �.c��n,'�P� LtJ.� S�
VI.Coun /Depar[ment Use O y
�A � ❑Disepproved Permit Fce Date Iasucd I�ssui"ng Agent Signawre
�h/ ❑OwnerGivenReasonforDenial 5[�•pe 8I�'a/aa 1
Conditions of ApprovaUReasons for Disapproval !--y
�����1`���S��j"� \
���IGIN�L � : �;_ �, __ ,
� t�a'K _'�f a�I�a ,; --
,hk;� �oSq� ���AUG 2 2 ?022
CCST a-�-13�'� �tcNi:>►Je�_�,.�d��a"3�o� -----
SA';�J'Y c[;=
Attach fo compkte plans br fbe tyt4m�ntl�obmi[[o tbe Couoly only ve paper oot b�W�o 81/t a 11 iocbea Io du �
SBD-6398(R.03/22) NO REFUNDS AFTER
ISSUE OF P�FsMI"f �-�0��
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 Pian
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): �� P�,1e►�1 ��'�,,� Phone: G�.SI - `1�3� - �L1a
Owner Address: 13��3- �1 S; rr1on,5 1��Q uc��c�.�:��:,Q Z-'�� Z�p: -s�� �5� �3
Project Address: J� � ►'�'l �
Govt. Lot: N � 1 /4 of S E 1 /4, Section j �S , T LLN-R � E Q or W �
Township: �.L,� rt0�. County: �� � w��� ,T
Project Parcel ID #: � ��� ��l 02 1 � `�� l �i (
Designer Information
Designer Name: �i�� � `� / 'wM�sc�►� Phone: � l� - ���W - ���
Designer Address: sD ��" 1`l I h���n � �(,� � ��� Zip: 5����`1 �v
E-mail: � r� ��i,,,,,1�,,r� llc (� 1 ju�. Cv�l � � ,, ., .
License Number: <��f; �l �
Remarks:
. � � � - _
Signature: — � Date: � � o� ��
Originaf ' na e required on ach submitted copy.
CHECK 80%AS APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o sca�e:4°o ao' � 80 �SYSTEM PAGE 2 OF
SITE MAP -- — PLOT PLAN
PROJECT NAME: �C.(> cPo
/�) �o, oEsicNF�ow�
S�e�� S _C. � p Attach design flow calculations for commercial plans.
PROJECT ADDRESS�. I�LI T1�`N �,!'nJi� l� Pipe Material/ASTM Standard(Tables 384.30.3 8 384.30-5)
N sa������ �!" � P U C
BM Symbol'.� aM E�e���o�: 10 3.(4S FT
Force Main: I
eMoes�nPno� SE Co:ive.- ��- C�w�� ����/�
i„a�aie an a� IMPORTANT:
Slope Gradlent(%) Q '2�q Well Symbd(if applicable): Q d.awmp Show ground elevafion con[ours a[sui[able intervals.
of iested Area: _11G� n the approprite lire.
5�mu15
�`�c
f34�53 N
���
O�
�e,g r
� �_�x�
/ ` T
3.���
� � ��—��;�
z
_an
G�.
IN-GROUND GRAVITY DISPERSAL AREA Se ticTank(s)Manutacturer
S �4w Pr � C��f
Uniform Elevation Trenches with EZ1203HP Bundles Sep[icTank(s)Vdume(s)
3-ft Trench (down-sizing credit) 1
l�(rz.?) gal gal gal gal
Eflluent Filter Manuf cturer:
l�tiSt �; l-�e,"
Geoteztile I min.12" EtfluentFil�erModel#: �TT ��'�
Cwer I (rypical)
soi�coveR TYPICAL TRENCH
1z CROSS SECTION VIEW
min.trench � -
depth L .��, .� (No Scale)
�ryP"a�� OBSERVATION PIPE DETAIL
/T�; . e �•� MoScala)
System Elevation=���•7r7 ft. Y ��� � s«�-ryPao� F;,,;snadcaaa
�ryP���� ' Provideminimum3ft SlipCap(loose) �m�i�aaa���1
separation between trenches. a°aPvcP�Pa .00���co�a�
Topofpioatoterminate (min.lfooQ
at or above finisheE graae
(4)1/4"-'I/ "X8"Slois
TYPICAL TRENCH (Show location of inlet/ouqet pipe connection on pian view.) � a�n
PLAN VIEW n��noe„9oa��� i�ra�auo�
4n nc O�senation pipe shall�a inbialletl
s�ea�
(No Scale) "' aljundionbetweenlwounNs.
Perforated Lateral ObservationPipe �n
— (typical) (tyPical) (lyPical)
� - - - - - - - - - - -�� - - - - - - - - - - - - - �-�'__� �
I ::____:__:__:_ :_--_- I A — 3.0 ft D
- _: ___ '______ ________
� - - - - - - - - - - - - - - - �� - - - - - - - - - - - - - - - � (HPicaq �
- - - - m
`r= e = ` S n -_; W
(ry���)
INSTALL PER TRENCH: EZ120YP e�ndle �
t ical �
� 10-ft bundles @ 50 fl EISA/unit= �� ft' (mfd by Infltraror Systems, Inc.)
Install pursuant to manutacturels instructions.
+ �� 5-ft bundles @ 25 fi� EISNunit= �5 ft'
= Proposed EISA per trench= _:�a5 ft' Required Infiltration Area = L'�� fl' Distribution Method:
x a trenches = Proposed Total EISA = ��SO n� �f�;-f�/
�
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 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 Maintainer in
accordance with SPS 383.52 {3),Wisc.Admin. Code.
Maximum Dispersal Area Oaeratinq Limits:
Design Flow= �Ui; gpd; BODS <_220 mgL"'; TSS 5150 mgL''; FOG <_30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance fadors(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 ceil prior to dosing
o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.)
o electricai components- if applicable(i.e.,wiring, connections, switches, controis, 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 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 shali 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: �Dh I r��%S�l�`i?(� �-�r ilS cC�l�- �ZL Phone: �(�-�6(0 � ��t��
LocalgovernmentuniY. .��i+✓�el CDw'lc�/ ��(� �/1°, Phone: �1S � 3��— �S��S�
, �1
Local govemmentunitaddress: IOG�IL JT�«:n SZ. Scc. ` � �1�( ����GLt:�c�ZIP: � L�c5L13
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.
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 dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shail be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
'�"'`� PRIVATE ONSITE WASTE TREATMENT county
%,>,_-�,r
,;,
i
/, i D �
;�;� ����, SYSTEMS Sawyer
`����SPs .�' ( POWTS)
�ry��F;�-%_
�",°",'="'`- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT) p
GENERAL INFORMATION 2� — �� 6
Peisonai infonnation you provide may be used for secondary purposes[Privacy Law,s. L 5.04(I)(m)J
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
��r`.+" ST�� ��c�' ) \
Insp BM Elev: BM Description: Parcel Tax No:
�oo,o' SE �d�r � o�K -�l�- B-Yro�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS FLEV
Septic �W �jc10 Benchmark �o�
Dosing
Aeration Bldg. Sewer �`j�. �
Holding St/Ht Inlet Q6 y r
TANK SETBACK INFORMATION St/Ht Outlet R r
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic ��j �' �--�` .}S` NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. -�j��3 �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative �
Surface �Y�S
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL ELL INFOR ATI N
DIMENSIONS W L j �� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO rl-� -1- {.7o N o Mound o Other
-------- — — �s —
DISTRIBUTION SYSTEM X Pressure Systems Oniy
-- _ _--- ——
Header/Manifold Distnbution Pipe(s) —TX 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.)
��1�� as���-�23
- - _ ___
---
Plan revision required?�Yes ❑ No p��� 24 � � / ��'� �/ �
_ __ C� l,o
Use other sitle for additional information Date OWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS AND SKETCH
SANITAAY PEAMIT Nl1MBEA: a.2 - ���
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