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Home My WebLink About014-842-16-2204-SAN-2022-230 Department of Safety c°°°ty� D � = & Professional Services, �'�' � - _ t . Sanitary Permit Numb r(to be filled in by Co.) �= Industry Services Division � ,,._ (� 3 � � � � R, State Transaction Number Sanitary Permit Application � � ln accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental imit � is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing addres the Department of Safety and Professional Scrvices.Personal infortnation you provide may be used for secondary �,'?��jC�s"w �i�, p�y�,�s (�• purposes in accordance with the Privacy Law,s. I 5.04(1)(m),Stats. I.Application Information-Please Print All Information �'�.��-��3 Pro ert Owner's Name Parcel# P Y 57'(�14�'c�-40"'�'(7�'-f(p-�01 ` .� " (��-(�vo- a46 Property Owner's Mailing Address Property L,ocation p��_g1�2'�b'r2�.p y 3�3 �o�u.-� ir.n. City,Sta[e Zip Code Phone Number (�c�w� �I L- L� � /�� i��" ��' ��Y�, � '�a, Section� II.Type of Building(check ali that apply) L�t� T�N R d O E o f�1 or 2 Family Dwelling-Number of Bedrooms__�_ �C� Subdi�ision Name Block# ❑PubliclCommereial-Describe Use — ❑City of ❑State Owned-Describe Use CSM Number ❑Village of �6f lo � 6�6 b�'�r��,�,e l��i'�.rnOf IiI.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if a licable.) A. �.Alew System ❑ Replacemcnt System ❑ Other Modification to Gxisting System(explain) ❑ Additional Pretreatment Unil(explain) B. ❑ Holding Tank In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) (conventional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date[ssued ❑ Transfer to New Owner Expiration IV.DispersaU'I'reatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd�'s� Dispersal Area Required(s� Dispersal Area Proposed(s�) System f:l v� ion � y v� , � � � � � �S Capacity in Total #of Manufacturer u f'ank Information Gallons Gallons Units p ;; c � � New'Ianks ExistingTanks � o �; � v a � c�'a a. U �n �, v� w C7 ci. Septic or Holding Tank ��Oa �,o�M � ��,�'� x vLN Dosing Chamber V.ResponSibility Statement- I,the undersigned,assume responsibility for installaHon of the POWTS shown on the attached plans. Plumber's Name(Print) Pl e 's Signature MP/h1PRS Number Business Phonc Number G/'� ----_..__ / � ` ��5 � NCl7� Plumb 's Address(Street,Ciry,State,Zip Code) � l t�5�!N �,m. c=Q k— F � � u��. ��-�c VI.County/Department Use Only > Permit fee Date lssued Issuing A�ent Signalure �A 6•�� ❑Disappro�ed $�� aa � _ C�"1.� ❑Owner Given Reason for Denial Conditions of Approval/Reasons for Disapproval n � '� � �� '� � J � ;Vt� �.��`,�i�� JI� � ii . �; �ate. �l ('1 ��.a. ��, ��--___----- �� 'r �.E. �� ZO2� '� � _ t ��r _,�--' ^� (�p r 1 d � 3 o�-a�,t��,�(1/Y�Fi CC�UNTY G S� d'p� — I � � /v?•� � � ��I��.��MINISTRATIOf� Attach to complete plans for the s}slem and submit to thc County onh on paper not less thrn 8 1/2 x 11 inchcs in size SBD-6398(R.03/22) NO REFJNDS AFTER � (a 9 a-S ISSUE OF PE�iMtT 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 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): �(�LLrK, � bYCI �j��U.�C.hu.� Phone:�5/ -_�-� Owner Address: cj�v� , LpC� �-� �_(1.0 QrLt.�1�-f; �„S Zip: ``�,J ��4� Project Address: ��(D�Q� V� � �i �C�, l�ih�S Z.PI �CCc.� r 1CLv� � ls�. -�j ��L � Govt. Lot: �_1/4 of 1��1/4, Section��, T��N-RQ�E ❑ or W � Township: ��y'�� County: � . Project Parcel ID #: �7� C?! �' - - - � CJ a-- " Oc� -- 4df� Designer Information Designer Name: ��C�.c�l, �J��V � � Phone:�I�S S�� (o �7� Designer Address: � ��'J7 1'�. P Z�P� � �� E-mail: � �� n��•. License Number: �� Remarks: Signature: �� Date: ��C� �� a� ' al sig tur required on each submitted copy. � � � � C�Q � � � � `� h � � � � � � � — � � .� .. �;: � 3, � �� .� � 'a sa � � .� � �` .� � �a 'p�`� � ��'-- �• jJ F' ��• �f � � c� � ? � � � � � '� � > 1� �j J� � � ``� � d� ..� � � �� `�� \ � �� ' 1r /\. �1.\ ' �'� ��- �� \ \ � � �� . `, � .. � ,, �� .n a � � � a � , ', � j�` h , -a \ ,; ; ; ;�' �% ,. � ti� `� !/., _.__�-__�_____ � ,,� \ , l /� ` P j � ' / i � � � i �! � /� �g � / � / Q ; , , �° ,� ,- ,cXr� .c a�v'd�,. � �fs'%'�,�,�:a�dc��a r�'�lY � � . � ` v a � � � � � � �� a°0. o�. c��-. � P 'a, � � � -�' �� s .�.s -�---1�- // ` � � � � � � �} � � � � � � � � � � � � v � � `' h � = v � � � � � � �J � a 5eptic?'ank(s)Manufacturer: IN-GROUND GRAVITY DISPERSAL AREA _ �,'.��i�__ �, Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s); 3-ft Trench (down-sizing credit) �ac�ga� � 9a, ____, 9a, ,�„�,,,gal Effluent Fllter Manufacturer: �ry��r,i� ,�+Z—i`L2..'— �1G[.:�C. I � � Effluent Filter Model#: �T� n ��_,,, • min.12" SOIL CQVER (typlcel) 12" min.trench depth . «'p'�'� �� ° � TYPICAL TRENCH � ' • �-� �� ' �''��a��<; CROSS SECTIQN VIEW �i�vp4�� "� �. � � . (IVo Scale) IC21 ';'a n ., 4,. , 4� . � ` Provide minimum 3 ft System Elevation =�ft separation between trenches. (typlcal) Qufck4 Standard-W wl End cap (Show location of inlet/outlet pipe connection on plan view.) Obse�yp�cal) Ipe TYPICAL TRENCH (typical) Install per manufacturer's PLAN VIEW Instrucdons. ((�0 SCr'��@� ��;�'�� ,��f,�� ' �;r�:.— — — — �//� ` �. _ _. — ., ._ �� .__. — — —n V"d��k�1+4''�le ' -1 iP � f �''� i � .�a �" �'. ��4F�Ir M�f�1�h111��' S �,"�i �'i,' f �'��+ �: r ��i r ,+ 1 � "�I A ��p �� — — — — — — �`� ._ _._. .� _ — — — — --- — — ._._. �,��...'W,d w��;��ft'E.IL��,�i��Y� Ical '0 �'/�- -- �/`- - - - - - � ._.. � � �- B - --�_ ft --I rn (ryplcal) Quick4 Standard-W Chamber W INSTALL PER TRENCH: (typlcal) � (mfd by Infiltrator Systems,Inc.) � Install pursuant to manufacturer's Instructlona. � �. Quick4 Std-W @ 20 ft� EISA/chamber= � ftZ + �,_ pairs of end caps @ 6 '±z EISA/pair= ,�` ft2 = Proposed EISA per trench= � � ftZ Required Infiltratfon Area= G�_ ftZ Distribution Method: x �„� trenches = Proposed Tota! EISA = 1��,ft2 ,�,�ro��,} �;, .�� 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 POVYTS Maintainer in accordance with SPS 383.52(3),Wisc.Admin.Code. Maximum Dispersal Area Oaeratinq Limits: Design Flow= Lf S`('� 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 Seotic and dose tank(s1 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 wdinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code. o Effluent filterts)shall be inspected every 3 years and shall be deaned when necessary to remove any accumulated solids according to manufacturer's spec'rfications. 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��(�L� -,./"�f GC-I�7' Pnone:�,]C S -`�SF'S�7 3 Local govemment unit: Phone: /l��p3�� Local government unit address� SVY �(!►1. C l'G �[U�ZIP: ��_3 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 treaUnent component of this POWTS cannot be repaired,it shall be replaced pursuant to a plan submitted to the appropnate 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. ";''-"`;"`"r� PRIVATE ONSITE WASTE TREATMENT county �� Fr. J�� \'\ SYSTEMS ,y' �S ,��; Sawyer t � PS ` ( POWTS) `\�\ ` /j, k'�_ yr, �F=�s�<,�,•�i INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� _ �3� Personal infonnation you provide may be used for secondary purposes[Pnvacy Law,s. 15.04(1)(m)) Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: Yv(� �-�p�d, 'P M s��., �ra�'� �— Insp BM Elev: BM Description: Parcel Tax No: Qil�C� ' Qo'Cl�r-► o'� Q,ec . -n�z o�Y��-<6--a�-o TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,�„ a Benchmark ��_p� Dosing Aeration Bldg.Sewer ��,� � Holtling St/Ht Inlet �6 ,2 ' TANK SETBACK INFORMATION St/Ht Outlet �f �j' � TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic �� f�' �7� .�,�1 � NA Dt Bottom Dosing NA installation Contour Aeration NA Header/Man. � � Holtling Dist. Pipe PUMP 1 SIPHON INFORMATION Infiltrative � Surface `�Y�� 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 � � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate ��1� P I L Bldg Well ❑ IGP � Chamber � INFORMATION Waters ❑ EZFIow Model Number: ❑ AG CELL TO ,� -� d � T(oo� 1tJ _ _❑ Mound o Other QY� _— DISTRIBUTION SYSTEM X Pressure Systems On�y I Header/Manifoltl _- Distribution Pipe(s) 1 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 1_Topsoil _ _ _� ❑Yes � No � ❑Yes ❑ N� COMMENTS: (Include code discrepancies, persons present, etc.) 34�• -� �f �• ��ll,� �� 3 � r��.w s,� c�y. Plan revision required?0 Yes ❑ No p� p� a, � � ' � 6�'�' � � Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAI COMMENTS AN� SKETCH SANITAAY PEAMIT Nl1MBEA: 0202_"�� 1\�' � �� . _ _:__ � _ , � ._ . _. . . _ .. �� : �� . a� (� - �`(f � �b� , I : _ _ _ _:. ._ _. . , ' , _ r_ � , ; • � _ . ,._ . ;.._ : ...__ __ : �' � � . ,, . .. . , � : � +K ' �*� a , 6' t� � � �� , � � �� w� �� . �f� �a� ��8, � �O �� 3b�� w<<�-��5 �� fi� SCALF�—