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Home My WebLink About024-741-02-1407-SAN-2022-225 � - � � ' Department of Safety County � ' ;,o� _ & Professionat Services, � _ �I Sanitary Permrt Numb to e filted in , ~� i ,- Industry Services Division � � (9 3�l 2-► �{ v� , Sanitary Permit Application State Tcansaction�umber � - In accordance with SPS 383_Z1(�),Wis.Adm.Code,submission ofthis form to the appropriate govertemental unit ^ � is required prior to obtaining a sanitary permit.Note:Appiicarion forms for state-o�i�ed POWTS are submitted to Project Address(ifdifferent than mailir the Department of Safely and Professional Services_Persanal infotmation you pro�ide may be used for secondary ��Q�l � �"'"'^`T �L_�� Pucpo,es in accorchrtce�t�th the Privac}-Law,s_ 15.041 f}(m).StaLe. Zw I.Appiicatiou Information-Please Print All Information �, �,�� Propetty Owner's Name Parcel# �-? o au- .� �'"j-��Q��Q o�� - �no- daoo�a roperty O er's kiailing Address Property Location o,�y 7Y1�� ,.'e{p7 C3e at-�at-= City,State Zip Code Phone Number Vl/ �`-(_�3 ��%•.__.L�_!/,, Section Q� li.T��pe oT Buiiding{chec a1t that appiy) LQ�# T�N R � E o �V O 1 or�Family tJwelling-Numb:roi Betlrooms_� — Subdivision IVame Block 4 �' ❑Public/Commercial—Describe Use � ❑City af ❑State Owned-Dzscribe Use - CSM Number ❑Village of ��a� �67a �o,�,of�,�� QI.Type of POWTS Permit:(Checi:either"Nev�^or"Replacement"and other applicable on line A. Check one box on Iine B.Compiete line C if a licable.) A. ❑ New System �teplacement System ❑Other Vlodi6cation to Existing System(explain) ❑Additiemal Prefr�Yment Unit(ezplain) B. ❑ Holding'fank �In-Ground ❑At-Grade ❑ Mound ❑ Indi��idual Site Design ❑Other"Cype(explain) (conventional) �- ❑Renewal Before ❑ Re�ision ❑ Chan e of Plumber ist Pre�ious Pennit Numbar�d Date.Lssued g ❑ Transter to New-Owner Expiration u�k� � tV.DispersaU'Treatment Area and Tank Information: Desi�n�lo�i�(�d) Design Soi!Aoplitation Rate(gpd:sn Di�rersa(Aa.a Res�uired(stl Di-per.,al Arza Pmpased(s� System Ele�-ation ��V t � " Capacity in 7bta1 #of Manufacturer 7'ank InfQrmanon Gallons Gallons Units Q � o -o � � New Tanks Existine Tanls ca � � J y U y v, L C 'L .O � �'S a U �n �, �n v., (; Gi, Stptic or Holdine Tank / � � ,/�v Dosiag Chamber V.ReSponSibilitV Statemfnt-I,the nndersigned,assume responsibilih�for instaHation of[he YOWTS shown on the attached ptans. Plumber's Name(Print) Plum 's Signature MPiT�1PRS Number Busine��Phoim Nwnber `1`l 3C� `7G — , �la�73 Plumbe -Address(Street,Ciry,State,Zip Code) � � � VI.Co nt,y/Department Use Only �App � fl llisappro�•ed P��F�ee Date[ssuc�cl Issuine.t�ent�igaature �✓ ❑O�nner Giti�en Reamn for Denial S �w� °t I a�a a �� Conditions of Approval/Reasons for Di�a�proval F-,,; �;�F � (�--1�a- ,�,, �,��;�_-__ � � �l � � � � ��:: ��g . , �s:J � �� I �� L C T �-2 — I � � �� w o f �a � 3�s AUG 3 1 ?�a2 S S � SAWYER� - Attach to complete plans for the s}stem and submit to the County only on paper not tess than S t12 x 11 i '" �10 R�Fi1NDS AFTER SBD-6393(R.03�2_') ISSUE OF PEH�IT PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References: In-Ground Soii 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): � '��i U la'!l� (�Cr"�-�' �,d'�Zv'r,rt�Sf--Phone: - - —��'-' Owner Address:�(� �;�L �3 i.c1� ��av�� C,�,�� Zip: � �d.`��3 Project Address: 1,�,��I N, �O1,U1,� �y, I� �c.��s,l�Q.o c�;� S�-�-C3 Govt. Lot: �� 1/4 of_ ��E 1/4, Section (��, T � L N-R ��7 E❑or W � Township: ��,4�� County: ��( �,� Project Parcel ID #: ��-(��-(,--�.--�-[.�- 0�-a a-� ('�z(- �U --(�pO07a Designer Information Designer Name: �� '��'t�/Q Phone:��S��-_�(�,� Designer Address: Cc � Zip: ��L3 0 E-maiL• �� -�� ,��, � �� License Number: ��j� � Remarks: --.__ Signature: � Date: �� /--,�� e riginal i re required on each submitted copy. I I �4p`l .�w_� ��r- R�07�aUS�' _�`� �`? o • ��X i3192. ; d-�6YGvd�.d1 l�tl� Sy� �� e � �E,>>/�,.S7 7'�'l�, �i'6 7 v,1 �s c.sr�� > �'_�o' � � r��ov�l �� ou�vtJ �x� L-�'G��'�7" �IK�./�� o� t cJ d1�7�/I�� "."► +i11.,� S��`j�`� N�.�I- � rD1v. � f1.lt � V1rlP- jdD��""��7�1"/ S�,D�h�' � �+ �2adr`,. t"!� ''�`f-- 9'7�.,1� � " " �Z — 9 7. y.?' � �. �E ..�� `�7 �g' � � . � sYsr� �--Y. `IZ• 75' �� . � G�i-1`��`7' S.T,�.�tl�k 9�� 7,S � � � H � � � � : h Cl� .•- �:. • � ( . . � E . i ,` (h t ' V E �y _ � ' �"�`, � ,b � � , � 6 � �� +i � � �� . ; � �� t - i 1 •� �t � ~�.__,__-. �� \ � � �� ,'�Q �� g� b 1 � =s` - - - � i � � � 3} �; �� "J�� 1� 1�� : �� ,. ` � �� P� � � � �=�� ; � ; � �f ,57�'�`:: 5•'� 4 [�S � �, � � � \ � .`�`� !� p / � / � � i � . " � i � � a Septic Tank(s)Manufacturer: IN-GROUND GRAVITY DISPERSAL AREA �;�.�;/�?� Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s}: . 3-ft Trench (down-sizing credit) /,��ga� ,�., ge� 98, ga, Effluent Fflter Manufacturer. .�.1'.Zr.�..��.� C'.`c� T�G,�,:�. � I Eifiuent Filter Model#: �.=�!'��,�;Z min.12" SOIL COVER (ryp�c��) 12" min,trench depth . «'P'�'� �� ° � TYPICAL TRENCH � ' - �--' �� ' "''��a� �< CROSS SECTION VIEW � {�-�---.— aa�� , .". .. • (No Scale) (�PIC21) '° .r .� e.. � a' • � • � � Provide minfmum 3 ft System Elevation = ��. 7 separation between trenches. (typical) �ufck4 Standard-W wl End Cap (Show location of inlet/outlet pipe connection on plan view.) �bse�ya�t�i�iPe TYPICAL TRENCH (typical) Install per manufacturers PLAN VIEW Instructlons. r ��. � ��,�- - - - �'�- - � _ � , ._.. - -�'� _._. � _._ _ ._.. ^ � (NoScale) , � ; i � � ,�� .. � �� .'�� r� ,��t � � �,�, ,� :,� � , � 4�� y �. _ _ `��' " `�' ,�� '�,G,I A= 3.0� L_ _.�� .— _. — _. ..�� — — — — — — — ��— — — �— �1�',_�#rf��t«#i��J (�YPical) � D 'r- B = -`�,,� ft --I � (typical) m Quick4 Standard-W Chamber C�J INSTALL PER TRENCH: (typical) � (mfd by Intiltrator Systems,Inc.) .�.' Install pursuant to manufacturer'e instructions. � �_, Quick4 Std-W @ 20 ft� EISA/chamber= � ftz + —� — Pairs of end caps @ 6 '�EISA/pair= �_ ft2 = Proposed EISA per trench= '�� ftZ Required Infiltratlon Area= .�:�.�, ftz Distribution Method: x , .� trenches = Proposed Tota! EISA = L�Z ft2 ��^csh�� 1�,�`,i fc�/� �� . �n-grouna c�rav�ty Management Plan lMPORTANT: The owner of this in-ground gravity system shali be responsibie for its perpetual opera6on and maintenance pursuant#o requiremenfs of SPS 382384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Nfisc.Admin.Code,this system shall be considered a human health hazard if not maintained in accorciance with fhis approved management plan. Furthermore,ail inspectlon and maintenance activities shalt be performed by a registered POWTS Maintainer in accordance with SPS 383.52(3),Wisc_Admin.Code. Mauimum Disaersat Area Oaeratina Limits: Jesign Fiow= 3 Oi� gpd; BODS<_220 mgL"'; TSS 5150 mgL''; FOG 5 30 mgL-' Inspection Checklist INSPECT EVERY 3 YEARS c rype of use o age of system .. nuisance factors(i.e.odors,user complaints,etc.) o mechanical maifunction(i.e.,pumps,vaives,switches,floats,etc.) ., material fa6gue(i.e.,leaks,6reaks,corrosion,etc.) o solids volume in anaerabic treatment tank(s)and any disfi6u5on appurtenance(s}(i.e_,disfibution/drop 6oxes) o negiect or improper use(r.e.,exceeding design capacities,prohi6ited activities,etc.) o e�enf of portdirg in distribution cell prior±o dosing o dosing irregularities-if appiicable(i.e.,pump re-cycling,float switch settings,ete.) o electrical components-if applicabfe(i.e.,wiring,connections,s�rritches,controls,timers,alarms,etc.) o distri6ufion(aterai or laterai orifice plugging (measure lateral dis!al pressure—compare to design specificationj o surface discharge of eff[uent or sewage back-up info sfructure served Mainienance Checklis� MAIlVTAIAi EVERY 3 YEARS{or when necessaryE o Sentic and dose tankfs)shall be pumped by a cer[ir'�ed septage servicing operator Iicensed under s.281.48 Wis. Stats.when fhe volume of solids in the tank(s}exceeds one-third{9I3)ihe liquid votume of fhe tank(s)or as required by local ordinance. Disposal of cro�tenfs shall be pursuant to iVR 113,Wisc.Admin.Code. o Effiueni fllter(s)sh2fi 6e inspecced every 3 years and shal!be deaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. Sysiem maintenance reports shall be su6mitted to the propar tocal government unit in accordance wlEh SPS 383.55 Wisc.Admin.Code. Report any camponent failure or maifunction to: Name of individuai or company: �l IQ�Y�_�-�((�� Phone: �]t S—��,�--/(n7� Loca!govemment unit:y 1 l]_(J� Phone:�L��J��—�� Localgovemmentunitaddress:l(��/,n Ci�Y\.5 ,�L.U,� �/' � �lYiL,fJ,c�x—ZIP_ ��'�C� Fny detec6ve part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51{9),Wisc.Admin. Code.Repair or replacemeni of failed or maifunctroning camponents shali comply wiih SPS 383,Wise.Admin.Code. No product for chemicai or physical restoration oi the POWTS may be used unless approved by the department in accordance with SPS 384,Wisc.Admin.Code. ;ontinaencv Ptan In the event fhat any failed treatment component of this POWTS cannot be repaired,it shall be repiaced pursuani to a plan submitfed to the appropriate agencyfor review and approval. A failed in-ground dispersai component may be abandoned and replaced by a code-complying dispersai component in a pre-determined area of suita6le soils. Svstem Abandonment IP use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33.Wisc.Admin.Code. ��t'''�r'"`^�: PRIVATE ONSITE WASTE TREATMENT County � ` -, ��o$ �`�;\'; SYSTEMS SaW er `��PS��' ( POWTS) Y ''"'"`'"'"'' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION � �Z,2.� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �a �"I� -��—�e,.. �fi M�uhdC CR� _ Insp BM EI v: BM Description: Parcel Tax No: ,ob a ` be-�1�,,, s�d� o�d�.,. o��{-�!� - va �r Yo� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic ^ 1 , (o�D Benchmark ��,�� Dosing Aeration Bldg. Sewer �`4 S � Holding St/Ht Inlet q f.o TANK SETBACK INFORMATION St I Ht Outlet �'`1.8 TANK TO P/L WELL BLDG vENTro ROAD Dt Inlet AIR INTAKE Septic � �� .25 ' NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. q3,( ' Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative Surface ��6 � 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 y�{ Y #of Cells d Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate �.�1 � INFORMATION P/L Bldg Well Waters � IGP �Chamber Model Number: ❑ AG ❑ EZFIow CELL TO � � __-�-Sa�__- '�lao� -- ❑ - Mound ❑ Other __-- Q�-� DISTRIBUTION SYSTEM x Pressure Systems Only _ -- -- Header/Manifold Distribution 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 �opsoil _ _ ��Yes ❑ No � ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��s}�l(� ��!-2 �a.2 Plan revision required?�Yes ❑ No d a$ 2 3 3 __ -�.�_.'_. .�- - --� � 69 S�l� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS ANO SKETCH SANITAAY PERMIT NIJMBEA: ��2 �-.2S , . _ _, _ -�_. . _ _ _._._ _ - - ._ _ .., . .: _ _ _ _ ; _ __-- -- - -.. . . - - - - - --_ ... .'.. _. .. .. _:. _�: __ :. ... ..4 . i -�. .. .. .. __�. .. .. . _._ ... ._ . ' . . . . . . . . . . .. .. _.`.._ .._`._. . -; .. ._.:. :._. � . : . '.t __'_"."__' __._ . i ; . . ... :.. .......... . . . . . . , . .. . . . .._,...... _...... ._.i. ..:.. ..... ......_..; ... .: � , . _ ., . 1��-.I�. �... . �.. , " . . .1. _._..'_. :... . ..._..: .,��\� ��0 �--- �s ----1 �(e� . . _ . _ _ �F�o' 3� $` � a�`� x'� _ +�o . , �� , a , \ � e �K�� ¢:�- �� '' 3' ��i,c x�, g� ��r �` �� .,��►I N —�D C,�.��Y� A