HomeMy WebLinkAbout024-741-16-1108-SAN-2022-222 � � Industry Services Division County D
4R22 Madison Yards Way Sawyer �
� � Madison,Wl 53705
_' SanStary Permit Number(to be filled in by(
: P.O.Box 7302
_ Madison,WI 53707 (� 3 q � l� �
Sanitary Permit Application S`a�Tm°Sa°"°°"°"'beT ,
^ �
In accordancc with SPS 383.21(2),Wis.Adm.Codc,submission of this fonn to thc appropriate govcmmcntat unit �
is required prior ro obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than maifing a
the Department of Satety and Professional Services.Personal infortnation you provide may be used for secondary Twin Lake Rd
puiposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
1.Application Information-Please Print All Informarion
Property Ouner's Name Parcel k bal.f^ 7�/ ^ �6 ' ���
Greg Krauska and Cindy Skack - - - - -
Property Owner's Mailing Address Property Location
2209 Lukewood Dr �
City,State Zip Code Phone Number
Chanhassen MN 55317 NE �,,,NE �,,, s���;o„ 16
II.Type of Building(check all that apply) Lot# T41 N R � E or
�1 or2 Family Dwelling-NumberofBedrooms 4 � SubdivisionName
Block# `
�'ublic/Commercial-Describe Use �
❑City of
�State Owned-Describe Use CSM Number illagc of
2� I Y� .��l Y 3 ❑✓To�or Round Lake_ _
111.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on Iine B.Complete line C if
a licable.)
A� ❑✓ New S stem �e lacement S stem ❑Other Modification to Existin S stem ex lain ❑Additional Pretreatment Unit ex laui
Y� P Y� � Y� ( P ) ( P )
B' �1-lolding Tank �In-Ground �At-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
C• ❑Renewal Before �Revision hange of Plumher �Tr.�nsfer to New Owner Li,t Previous Permit Number and Date lssued
Expiration '�
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Arca Required(sf) Dispersal Area Proposed(sfl System Elevation
600 .7 857 892 88-97
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Uoits � � o � ;
New Tanks Existing Tanks � o � � � � � �
a U �n ti �n f.�. c7 p..
Scptic or Holdine Tank 1250 1250 1 Wieser
Dosing Chamber � � �
V.Responsibility Statement- 1,the undersigned,assume respo i ity for ins Ilation of the POWTS shown on the attached plans.
Plmnber's Name(Print) Plumber's Signat MP/MPRS Number Business Phone Vumber
Dan Burch 253808 715.416.1642
Plumber's Address(Street,City,State,Zip Code)
N5921 County Hwy K Spooner WI 54801
VI.County/Department Use Only
�A o CH ❑Disapproved Permit Fee Date Issued lssuing Agem Sfgnaturc
�,� $ �{��`�° ��3° � a a � - � —
❑Owner Given Reason for Denial � �-a
Conditions of Approval/Reasons for Disapproval ; ' ) ;'�
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: . r �JI r� 'U
��301�� � _
�� ,. ���� �-,� . T� au� o s 2022
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Chk!#S�-_- --
R�pt##.,��t.,_.
w�o��d �3 t�9 SAbWE� COUf�lTY
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Attach ro complete plans for the sys[em and submit to the Counry nnly on paper not less than 8 u2 x 11 inches in size
SBD-639A(R.02/22)
PAGE 1 OF 4
In-Ground Gravity Plan
index & Cover Sheet
Component Manual Design Refe�ences:
Version �G, SBD-10705-P (N.01/01 , R. 10/12) ., .
a .�
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: Enciosures:
POWTS A plication for Review
Soil Evaluation Report & Site Ma
Project Name / Description
5 ;�;, � K
Owner Name(s): �3�� U rl 2/�v 3 r. /� d- L� v� � Phone: -
a Lvl/6WOOIJ �2 G�H�'HASSM� Zip: 5S 31 ?
Owner Address: a cZ Y
Project Address: '�� ^� �a�G �2r�
Govt. Lot: �1/4 of /v �1/4, Section / G , T�N-R 7 E�or W �
Township: J� ��U`� �`�" County: �A "'�'�`�
Project Parcel ID #: 5 7 � a `-( � y ( 0 7 i !� � ot � D d o � ob ��
Designer Information
Designer Name: Dan Burch Phone: �15 _416 _ 1642
Deslgner Address: N5921 Cty Hwy K Spooner Wl Zip: 54801
E-mail: Burchplumbinginc@gmail.com This space reservzd for approval stamp.
License Number: 253808
Remarks:
Signature•
Date: � � — a �
Originel signature required On each submttted copy.
� Krauska j Skack
Sa'rI Re�ort PIoC Pla.n
North
�`1
°� Gregory A. IE�auska & Cindy C. Skack
.� #�####W Twirt Lake Rd
� PR`f NE 1/A M1[E 1/4 Lt�t 1 C5M 21�4t}#5943
� 5�.6 T41N �'7�N
ti.� T�rwn af Round Lake
�° 1.U7 Aeres
�
� �'° 'fax !(�: 253�13
�. 4� PiN: 57-024�?-41-��-�6-1 q1-{14�-0E�Q8Q
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PfDpdsed
4 bedraQm home �
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p� ..97'
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�j d S c . �93'
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�V70
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Q.�1 G �� �1
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dHWM tXf�lger Cat Eiawage
(11{�TES:
� Bench Mark = Nai{ in 14" D8H Mapte tre w/ orange ribbor� - Nv wetl
E�EtV = 1Q0.(J' - k.3k�@IEV. : 87'
SCafe 1:4p
I
IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer:
Wieser
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit) SepticTank(s)Volume(s):
1250 9al gal gal gal
Effluent Filter Manufacturer:
SOIL COVER ' POIVIOk
min.12"
«'pi`��� Effluent Fitter Model#: 525
12„
min.trench
TYPICAL TRENCH depth �
CROSS SECTION VIEW (�PI�I) �
'�° Provide minimum 3 ft
Q °:
(No Scale) �-yP ai�`.-� .a� " ' separation betwesn trenches.
.6 a . .
, . a
a
Highest Trench Lowest Trench(as applicable)
System Elevations= 94 ft; 92 ft; ft; ft; ft
Quick4 Standard-W
w/End Cap Observation Pipe TYPICAL TRENCH
(typical) (Show focation of inlet/outlet pipe connection on plan view.) (�YP���?
Install per manufacturer's PLAN VIEW
— — — J — — — instructions. �NO �JCB�@�
�— �.� , � � - - —�� - - - - - �� — �- � — ,� - -�
; ��`��� � � �`���� Ap �,���� �� , �A= 3.0 ft
_' � .�� � `
.,�k � ; „
� ��M� — = = — �— — — — � _._�":+YtP��"i��� � {typical) �
�'�- - - - - - - - ��- - - - - D
B = 88 ft -� m
(typical) Quick4 Standard-W Chamber GJ
INSTALL PER TRENCH: �typ��'�� O
(mfd by Infiltrator Systems,Inc.) -n
Install pursuant to manufacturers instructions.
22 Quick4 Std-W @ 20 ft� EISA/chamber= 440 ft2 .p
+ � Pairs of end caps @ 6 ft2 EISA/pair= 6 ft2
= Proposed EISA per trench= 446 ftz Required Infiltration Area= 857 ft2 Distribution Method:
. x 2 trenches = Proposed Total EISA= 892 �z �
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 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 Dis ersal Area O eratin Limits:
Design Flow= �� 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 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(1l3)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(sl 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: D8f1 BUfCII Phone: 715.416.1642
Local government unit: S8wye1'COUllty Z0111119 Phone: 715.634.8288
�ocal government unit address: 1061 O Malfl St. #49 ZiP 54843
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.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
/%'"��'''"T`t` PRIVATE ONSITE WASTE TREATMENT �ounty
-- _ >;=f
`� o `"Y�`� SYSTEMS Sawyer
`��ry�$ps ��'� ( POWTS)
���'=�,—=="`'`''�'�� INSPECTION REPORT sa�itary Perrnit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� �.��. �
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#:
��.rl�, ,�-C; S�l�c ��--��., C,a� �
insp BM EI : ' BM Descri tion: Parcel Tax No:
��.b tia;� ���y�� ,� �. riti�a�, o��r� ��� —�6 — cd8
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �� � Benchmark �pp,o �
Dosing
Aeration Bldg. Sewer q���`
Holding St/Ht Inlet q ,g �
TANK SETBACK INFORMATION St I Ht Outlet �'7 ys r
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIRINTAKE
Septic ' /v � � �,s� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �i'3.� r
Holding Dist. Pipe
PUMP I�IPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM f ��� �
TDH Lift Friction Loss Sys Head TDH Ft � .� �
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � L $$ $$ #of Cells a Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��`
INFORMATION P/L Bldg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO �.6` (�� � �?a' o Mound o Other Qy�
_- --_.-- - - - -- - - --- --- ---
DISTRIBUTION SYSTEM X Pressure Systems Only
� Header/Manifold Distribution Pipe(s) -- X Hole Size X Hole Observation Pipes
Length Dia l Length Dia Spac � Spacing ❑Yes ❑ No �
- -- -
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sotlded Mulched
Cell Center � Cell Edges , Topsoil__ ( ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies,persons present,etc.)
� �-�^��� (o��1 I .2�
Plan revision required?0 Yes 0 No 0 3 i bg �3 ��� / _ Gc��l�
w
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBER: ��2��-o�-�
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