HomeMy WebLinkAbout002-840-17-5113-SAN-2022-246 Department of Safety c°°"
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o & Professional Services, �n-�-"� � Z
a' Sanitary Perm Number(to be filled in by C o ,
s Industry Services Division � 3� a 3 3 �
�
Sanitary Permit Application State Transaction Number �
In accordance with SPS 38321(2),Wis Adm Code,submission ofth�s form to the appropriate governmental unit �
is required prior to obtaining a sanitary perm�t Note.Applicauon forms for state-owned POWTS are submitted to Project Address(if different than mailine ad �
the Department of Safery and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats ������ ��u���1 �/d� �1,�
I.Application Information-Please Print All InFormation T
Property Owner'srlame Parcel#
L r�r� ��Ff��r`�✓� O� 2 �r�f� � � s� � 3
Property O�mer�s Mailing Address Pro ert�Location
I l(� I G �F8� �ve, �1� �+ !
Govt.Lot
City,State Zip Code Phone Number
�L �n���l-,�� /�7 /� .�,SCflCZ '��'3.. zZ�l -C%��� '/<. '/<, Section ( 7
IL Type of Building(check all that apply) Lot# T �� N R � ' 1
�''l or2 Famih Duellina-NumberofBedrooms �Z � SubdivisionName
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use
CSM J�Iumber ❑Village of
�{�U 3 � !o tv �To,�,of�c�ss_L.��1�z
IIL Type of PO��'TS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A
❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
Tt��Mf.G N�-
B' ❑ Holdine Tank
�In-Ground ❑ At-Grade ❑ Mound ❑ Individual Srte Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to Ne� O��ner � �
Expiration �,�•-U�i S /� �')
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Desien Soil A plication Rate(apd/s� Dispersal Area Required(st) D�ispersal A�ea Proposed(st) System Elevation
360 . 0.�" 0 6at� `1 S(i - ��isf) �S; l t (E�s-f,
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � ` o � �
New Tanks Existing Tanks 'v � y � V � b �
0
n, U v� y rn i�. V C.
Septic ordaeldixg Tank t"��� -'j f'�� � �l�/^//'..,
�V G>L.fL
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibili install ion of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Si�n�� � _�„s.- MP/I�I�PRS Number Business Phone Number
,/ ""-�.a�",p;,.G—r�,�,:�/ �7 /^ C � ( -.
V�l�{.�1� { `��f fe/ ..� .,� - l�7S 7Sl /�J—� ��' ���J�.
Plumber's Address(Street,City,State,Zip Code)
�.0 . �C?,c� �c� �� �-E' Gw � .�f�-/
VI.Countv/Department Use Onlv
�A � � ❑Disapproved Pennit Fee Date Issued [ssuing Agent Sienature
�-i-✓ $ �((Jo,dO °� �I a�a�- 7'V� -
❑Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval ,'L � ���Sjrj"�,�_
, � \�// I n1n I l
�,� � .%�lE:. �..����--�'��- , ,� U r`"' , f
�r �� �� �����
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�hk# :.� SEP 0 8 2022 �---
C ST � � � ��Pt#�,�'`� W o r 1 d ��3lfS �;AWYER GO����y`�'� /r
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ZOhING A�>Pvll�3i��-r,,;,'��.�;r._`;��
Attach ro complete plans for the sy"s[em and submit ro the Counh�only on paper not less than S 1,2 x 11 inches in size
seD-639s�x.o�i22� NO REFUNDS AF1'ER
ISSUE 4F PEFMIT
— - 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): �-ytntn ���E'v T�'Y� Phone: �U 3 - zZ I - C f9 �
OwnerAddress: II�IU `-Fb'� ��N. �{���jinpc��1,��,� Zip: SS��fZ
Pro'ect Address: /�f02S-c� Sc.c,��5z� %c��ciQ LtU�G (-��cyr��Qc� cL�r
..{- v� �-�
Go t. Lot: 1 1/4 of 1/4, Section I"� , T �C N-R � E ❑or W �
Township: ��� County: SQC�/�/�{'
Project Parcel ID #: �o,� k`ff� / � �j/ �3 (_c�T- �'�CS n `{��3 ����
Designer Information
Designer Name: �q��;c� �u���-� Phone: '?� S- -�->>'SS" �
Designer Address: �_p ���,, � („ C�(�(���,� Zip: Sz/�Z/
E-mail: •+�m � 0.r�C�vyi'�15. �a4� _. .
License Number: ��"lS�7S�
Remarks:
Signature: Date: 8�a' zz
Original sign ure required on each submitted copy.
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PdQTES :
PAGE40F4
In-ground Gravity Management Pian
IMPORTANT:
The owner of this in-ground grevity 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.
FuRhermore,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 Operatinq Limits:
Design Flow= �('J� gpd; BODS<_220 mgL''; TSS 5 150 mgL"'; FOG<_30 mgL''
Inspection Checkiist 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.,distnbution/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 Seqtic 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(�/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: (-�',�LL1Y'Y��l SS�v� �, �Cl�S Phone: �lS -7�� ��JS�
Local government unit: �Wyz� � �Clv-iil Phone: 71S=(03�'��Z���
J f/
Local government unit address:_�LV�u�C� (.4'� ZIP: S��7`�
�
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 uniess approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Continqency Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shall be reqlaced oursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and rep�aced 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.
'"''-""''"``��� PRIVATE ONSITE WASTE TREATMENT county
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i�j� os \7�'; SYSTEMS SaW er
( POWTS) y
i� P s ",
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INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �-� ����
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#:
Lynr� R�P�r�o� QqSs (��. `�
insp BM Elev: BM Description: Parcel Tax No:
�C�,o
� � oT GovLc.. �0,21., S�a\o ooa _ gYo —17--5(13
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �.,f�-- 7� Benchmark,4 (GO.c��
Dosing .� e.�,,,,G�� �1��--7'
Aeration Bldg. Sewer —
Holding St/Ht Iniet �$,l7 �
TANK SETBACK INFORMATION St/Ht Outlet q�g,pb `
TANK TO PIL WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ��.5' ±YS' g ` .rg � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative
Surface
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 � #of Cells Type of System Distribution Media Manufacturer:
� Conv � Aggregate
SETBACK P I L Bltlg Well OHWM of Nav � IGP o Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO ❑ Mound o ather
_ --_--- --_ ---- -- ----- -- --- _ _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) 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 � Topsoil __� ❑Yes ❑ No � ❑Yes � No
COMMENTS: (Include code discrepancies, persons present, etc.)
� �S�a�� ��'s���
i� s�I �Y�1 acewre..,���
----
Plan revision required7�Yes 0 No 63 �� 3 __ ___��� � vy ���o
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NUMBEA�_ ���- ��{�
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