The URL can be used to link to this page

Home My WebLink About028-162-00-0700-SAN-2022-247 _ � County � Department of Safety C��L�, �. — � � & Professional Services, � � s p Sanitary Permit Num er(to be tilled in by( E` Industry Services Division (� 3 G� a 3�' � � Sanitary Permit Application State Transaction Number � In accordance with SPS 383.21(2),Wis Adm Code,submission of this form to the appropriate governmental unit N is required prior to obtaining a sanitary permit Note.Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing a --C the Department of Safety and Professional Services Personal informahon you provide may be used for secondary � purposes in accordance with the Privacy[.aw,s 1�.04(1)(m),Stats. � ��/_ �,I �� , 1.Application Information-Please Print All Information lJ W Property Owner s Name Parcel# �aU �� '` �1 civ'c 0.re-l� t3. t��'�� C�2� l�Z C� C� C� 7L�C Property Owner's Mailing Address Property Location �`I� C��"4��T"� J�" Govt.Lot City,State Zip Code Phone Number �J�- PQtI � � �� S�1l(v (1l L- (��`7!i' S y y-� - '/<, '/<, Section Z3 II.Type of Building(check all that apply) � Lot# � T �Z � R '7 , i r `� 1 or 2 Family Dwelling-Number otBedrooms Subdivis�on Name B�o�k� P��;� �;d e ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Villa�e of �fownof�� i'- � III.Type of PO��'TS Permih(Check either"rew"or"ReplacemenY'and other applicable on line,�. Check one box on line B.Complete line C if a licable.) ,a. ❑ Ne��S�stem �'Replacement S�stem ❑ Other Modification to Existins System(explain) ❑ Additional Pretreatment Unit(explain) T�4L K�i'1 � B' ❑ Holdina Tank �1 In-Ground ❑ At-Grade . p� ❑ Mound ❑ [ndividual Site Design �Other Type(explain) (conventional) DY�t,�,'e l� ❑ Change of Plumber List Previous Permit Number and Date[ssued C• ❑ Renewal Before ❑ Revision ❑ Transfer to New Owner E�piration 4�r-� (S�7c — �.., . ? IV.DispersaUTreatment�rea and Tank Information: �� Design Flow(gpd) Design Soil Application Rate(epd/st) Dispersal Area Required(s� Dispersal�rea Propos�("�f'� System Elevation � �sz� . � (�H3 %1Fa ��*] go.oz� ��ws��. Capacity in Total #of Manutacturer Tank Information Gallons Gallons Units � � c '� ; � tiew Talil:s Existing Tanks '` o y � y L � � a U v� �, v� u. C: G. Szptic o�H^��qd n ,Tank 'O �b 1 Gj��j � T�,� t �— l .1— Dosing Chamber V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the PO�VTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/M�Pf26 Number Business Phone Number ��:, l�ti��1 ��s�s� ��s �y�' -3�.ss�_ Plumber's Address Street,Ciry,State,Zip Code) �� 6( �.�.� s�d�� VI.Co ty/Department Use Onlv �A d e ❑Disapproved Permit Fee Date Issued Issuing Agent Signature i� ❑Owner Given Reason for Denial $-l��e�D � I�01 I�oZ ��Dl/1/l�- Conditions of Approval/Reasons for Disapproval ..-�l �aac .__� ��....�a�.. _ � � ,� �� +� :. �� ' i3c�� _.__ �I; �� hk# � ,;�; L � - EP 0 S ?.�22 ' ` C��p�" I�o�- �tt y.N'�,1./J �af� # 33�� __------ - I� ,�,- _ Attach to complete plans for the system and submit to the Counh�only on paper not less than 8 l/z x 11 inches in size � a�3 �� ssD-6�9g�x.o�izz� NO R�FJNDS AFTER ISSIlE OF P�FiMtT J1 I (j r �CZ.0 lU �, � ��4��GCr� �' . I�c't:SC�I'1 SCc,�� ( ' (� �(/�l� l`��c.�;nz�., S-� 'O ?��_ 'ic S�� a�,i..l � Gn�tl Ssr�tv ,(�I�j1I � ,�i Y JjY1 _"__ _l��1� '//`��\\ _ `� ` / (,�� - ��o- 7 `� � 3 � (?5�� W :S�t;�-E-fi� �'C�. =� �TC�-v�l�- i(z�>l0.ce.w��.�� 1,�( �- w ( S 6(� U e+r-� ��c:ct-�e'c� 5 2.3, �T 'fZ � , 2� � �r,rt � P;v�� d�e S��c�. s, ��Er �l�E � �— Tow�� e�F sPc �� t�(�� 5�,�,,�,� CO, � �'�- ��u , - � � ` + � �Z8 1(�Zc�U G�oC _� _ �_._.._ -- • � p ��(f� Ql_ �� wlQ�1hC\ . .�, ��1 = (DU E, v, �. l ��-� C�'p�x� I5i C�c ny � N ,E.C�r+n�� cf' �ov�� - uNt � � l�>p� � �� = q(�, 3� � ��is-�, s�T. �-��f = q$' + �u�s+- . s�sf�,,� _ �o3oZ, � ��-4�� f ��-y �: ��t �..ti-;�d Powzr�/ Vz��T �ti� eXt s�u�y ;� �'�rnc��z ��c�(�.;zu CD�Yj E�cs��n ' / S��2 f ��1� ' �g l �� / Pc�„,r ht�e k«- � �.zv��-h� � y� g L:Y(2� � 1 !� _ � �' �,� I-Ev�a--�c 2 �sc c s�d � � 3�; (�-c,�1� t a�d P�; A� -('C�a,.,t�w - �;,�--�ti�c ��o�Zz �. -�i t�'' t�� prr��v�c�Y -f� Q�P`�x� . 50��-�-Gi �o a� �� i�fi c�.,,� J ason 1�� ?s7sl � � (-Z�f�z \ E� � �. J �! T�t,� '�-��5 = l _ !r:i -.it:... � . �. ^1�-� llUilj �" S;I��`'r0 ?'i'� IC1SP. DT�: 5 rr M'if. :=..30`J.�: G?_'.�;� u �. (t,�he-r� �nle-� �r��t�io�e Fs n�crizd � � �—� fi�PPOV�,p M.',�1HOLE c?rI�SH�D GF�riD� W/ L��, , {��%fa,�'i,vr c..�48�C. �:� - 4�� Hrrr. �a�� iN. I TILET � \ OUTLET , � A P P R � _,D �:4-�-�-.i:,E— � O PILTER aPPRO'/r�J h1EG. C�4{a1Cu, PIPE 3 ' Ot(TO S�]LIO m°d�l R ��y2- SO TL . . 3 " ;�.PPF t�''Y'�TJ EE�D1 h�`� U 1i�F p, lf:='fs SPEc�IFIC/,i Ic��15 ��PT�C 7-�,�`I� ?i,p!-(j�?CTL�Y�:. J�``L�%C�"l�C�+�'rTY� T:�,riK s ��c..: S=?T�C l��C� r:,r , L� DI OTES : 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 shali be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore,ali 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 Fiow= �C7� gpd; BODS 5 220 mgL''; TSS 5 150 mgL''; FOG<_30 mgL"' Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors(i.e.odors,user complaints,efc.) 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,conLois,timers,alarms,etc.) c 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) � Septic and dose tankfs)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(113)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�riill always be greater than 12 months. System maintenance reports shall be submitted to the proper locai government unit in accordance with SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to: Name of individual or company: �•�V'(��ISSE-v� � �C1'�S Phone: 7/S �C�'3'�JS�� , . Local government unik �Wi/?,r �'� �-e�it�-�1 Phone: 7/S=�3�'.��'=�� Local government unit address �—�CL�X�-�� L�� ZIP: S��'�3 Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51 (1),N/isc.Admin. Code.Repair or replacement of failed or malfunctioning components snall comply with SPS 383,bVisc.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,N/isc.Admin.Code. Continqency Plan In the event tha(any failed treatment component of thi,PO�NTS cannot be repaired,It sha!!be raclaced pursuarf to a plan su'omitted to tne approoriate agency for review and approval. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersai component in a pre-determired area of suitable soils. System Abandonment If use of this PO�NTS is discontinued,it shall be abandoned in accordance Niifh SPS 383.33,�Visc.Admin.Code. /;=—'�0."`` PRIVATE ONSITE WASTE TREATMENT county �, ,,, ��ji \ �� (�j� o'SP 1 SYSTEMS ,� S ).~' S awyer �� :� ( POWTS) �FT`--,:>�, �'Sj'-`''''' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2Z _ �c,�� Peisonal infonnation you provide may be used for secondary purposes[Privacy Law,s. L 5.04(1)(m)] Permit Holder's Name: ❑City ❑ Village ly�Town of: State Plan Transaction ID#: �✓t`� �-(� � /� � �- l��te__ Insp BM Elev: BM D cription: Parcel Tax No: ��•�, `Dd ✓� a�S��iv� � c��r-o�� 6�-$- I.��-Cv-CS7o0 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic '� � .�— 1p(,p Benchmark )c�.cT� Dosing Aeration Bldg. Sewer �g �g•( Holding St/Ht Inlet °�'7,7 � TANK SETBACK INFORMATION St I Ht Outlet ��,S� TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet AIR INTAKE Septic .�-Lo` ��' �p �..p� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist. Pipe PUMP/SIPHON 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 L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate P/L Bldg Well o IGP ❑ Chamber Model Number: INFORMATION Waters � EZFIow ❑ AG CELL TO ❑ Mound � Otherp� — -- — -- _-- --— -- - ------ - --___ DISTRIBUTION SYSTEM X Pressure Systems Only - —— _ __ _---- - --- Header/Manifold Distribution Pipe(s) I X Hole Size X Hole Observation Pipes i Length Dia Length Dia Spac i Spacing ❑ Yes ❑ No -- - -- -- - -__--- - SOIL COVER -- — - �-- � �-- Depth Over Depth Over �Depth of Seeded/Sodded Mulched Cell Center �Cell Edges j Topsoil _ � ❑Yes ❑ No ❑ Yes ❑ N� COMMENTS: (Include code discrepancies, persons present,etc.) '�`��1�� 16�a 2 � .S� 1�-�Pl�e ew��ohlr �— -- — — — , �-- Plan revision required?❑ Yes ❑ No b3 6� �J -. �/ _ _� �j�S� �� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) � AD�ITIONAL COMMENTS ANO SKETCH SANITARY PEAMIT NUMBER: �� -�.�(7 �� 7�� b� . . ;_ _�- � - _.: : - --- .� , , , ; ._ � .. _: _ . , ; __,__ ; � + _.;_. - _,___ ->- ;__ t _ : � __ ; . ._ ; , S�,r'Qiv� �• p��, � t��D�„b�.- , /9 � �e'r��5 M y � �� a,r�iwe�� ,�iy r �� lr �/oa � �� '�' - � � J � �� y, -,o�-- � � �m �� c l b�� ^� ow�, �-�— � �