HomeMy WebLinkAbout028-742-32-3403-SAN-2022-255 " Department of Safety c°°"`y �
� = & Professional Services, �
� S� - Sanitary Permit Numb o be filled in by
= Industry Services Division
(� 3 � '�-� � 9J
�
Sanitary Permit Application State Transaction Number �
hi accordance with SYS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ( �
is required prior to obtaining a sanitary pertnit.Note:Application forms for sta[e-0wned POWTS are submitted to Project Address(if di8erent than mailing 'vn�
the Department of Safery and Yrotessional Services.Personal information you provide may be used for secondary S�� `�►
purposes in accordance with the Privacy Law,s. 15.041 I)(m),Stats.
I.AppGcation Information-Please Print All Iuformation
Property Owner s Name Parcel# ��g�(�a��3 �3
� k)� �c' 1Y�-i �� L���.l�ti�'u�' rt"
Prope Owne '. Mailing Address Property Location
l � i� .L(. ��.�--"�
City,State Zip Code Phone Number c,
,^,�-,� `' \ ��G( i `J�Ya S� '.%, Section ��
��(� c W� �"G 3 � -
II.Type of Building(check all that apply) Lot# T �� N R 47 E o W
�1 or 2 Family Dwelling-Number ofBedrooms � �� Subdivision Name _—
Biock�
❑Public/Commercial-Describe Use �
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
— i�„�,�r 5p��r C�
°�"-
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.
❑ New System �Replacement System ❑ Other Modification to Existing 3ystem(explain) ❑ Additional Pretreatment Unit(explain)
�' ❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain)
❑ Holding Tank In-Ground ❑ At-Grade gn yp ( p
(conventionap
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued
F.xpiration �' ���{� �Z f�/�'�
IV.Dispersal/Treatment Area and Tank Informafion: ✓o" S , e e✓, �r D. �o.� 04
Design Flow(gpd) Design Soil Applieation Rate(gpdis� Dispers�rea equired(st) Dispersal Area Proposcd(sf� System Elevation
C ` �
Capacity in Total #of Manufacturer
y
7 ank Information Gallons Gallons Units A � o '� �
.cs ^ `> � a� a� n vi
New'Canks Fxisting7anks � o a� L Y p _ �y
n. U v� � va �,. C7 Q.
Septic or Holding Tank � /O O � T' /r . N � .
f�
Dosing Chamber
V.Responsibility Statement— 1,the undersigned,assume responsibility for installation of the POWTS shown on the attac6ed plans.
Plumber's Name(Print) Plumbe' � nature MP/MPRS Number Business Phone Numbcr
� ---_ S 0/ 7l5-SS����
Plumber s Address(Street,City,S43te,Zip Code)
l(�'7/ �t�?/�.� � �-Q �a�-�. � � �-�3
VI.County/Department Use Only
�A��.�/ ❑Disapprovcd $ermit Fee Date Issucd Issuing Agent Signaturc
�w ❑Owner Given Reason for Denial ��O� � �I� ��� ""l"'��'��'��-1 �"---'�-
Conditions of Approval/Reasons for Disapproval
('t1� I� ` ,��~r'��
U � ��� �%/��;;'�,
�I �� ,���- _� 1«1�.� "�
�
Chk� ���s SEP 1 �t 20�2
CS� v�- � � I 8 a Rcr�� N�.w W°r�d #3u5�f savvYER caurvrY
� Z����1�i�,r'�y'':i['di jTt<.i i.'u+iU
Atlach to complete plans for thc system and submit to the Cbun�y only on paper not less than 8 In x 11 inches in size
3 �3ua
NO REFUNDS AFTER ,
sB�-639s�R.03!22� ��UE OF PE�lJItT
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):��t,lj. � �� C, ��(�lEti�" �� Phone: - -
Owner Address: ti�a.ta5 N �c.G�.�e.a�R�. �C.� � u.'� Zip: �� �'�3
Project Address: ��?,yv��
Govt. Lot: �� E 1/4 of�1/4, Section��, T �t a N-R Q7 E Q or W�
Township: �D1C�,� �A� County: ��Q.�U�—�
Project Parcel ID #: �oZ��0�-3���f�
Designer Information
Designer Name: � � �"1 Phone: '�Jl S- S�S�_l(��
Designer Address:� 7 I� I� /�� Zip: �4
I, c,z� cQl�
E-maiL• .
License Number: ���?� �
Remarks:
Signature: Date: 9`�3`��-
riginal signatu e required on each submitted copy.
PIOt PIe r1 Page 3 af y-
;-a
PROPERTY OWNER: C R�����1! ��;. �r1LSCt-1�.ClP ,�ctI 1"_= 40 Ff.
�except where noted)
legal Description: f'�T. :�� C� IHt �'�/� Src�-�.T'+Zti R C7���: �� =backhoe pit
�' % i -i E u: � '� 5, i�'C r�CP�S
D LS�4z31�'l� 3 I�-IZS,� S�ffFL[tR ��'�(�
North
� i I
�,<.��'!�.�� j i
, �f,� �� I
�G�e2rH r,��\ p � �y5� i
f' J �ER �caw*!y '.�,rIS �" n0 --i i
wv' ��. 1 , Z �I E
95�
, ,�8'c - �oK�a,
_ �. . — _
- ` . 0 ___�_-_
y_ �'v FiA'r I'ac"ROM oF ��L .—__- �.
� i sit�uc i.asi � _
Z '��( �DOYG 6.4FOE
i V ; f'rSS:�M,_ .
h' bcoRa.n IN.op' L _ '.
gZ p ,.�. , i
94,35� "7� i (� i
� �� � l U6"� '-- � -
97.zs� i'�i i+'
� � jl �
',�4 a,�;JP�. � I
j� �{ v i
_ ' �/'� Si � I
� , I
� G`�' "' `
w
+ y
iite location:
� i
�
�
� i
;
�
- j �_ �- PAG� 3 t�F 4 �� _ .
. i ' � 1 = ,= — ' � .
� E r_ , � v f C, `'
: � � i- : v t , �
n �
� _ .. _ � i �� C
v. � ` , ';i ,� ' �'_:,=�
� ,� c � ; � � ��:,:� �=- ^ ;, p
.' l� � :_`'.''�l ! s �' " ' J.' �
' c � j � � � z .` �>�r �`. .r
; .� � ' , ; `��� .,,_, ;
_ £_ : ��: '
` g ` g ►, : i _ . +;Y .. ; . :_ , — _ �: j'
� - ' < v ' �'`'`_'i � c Q v
<' ' ` � V � I i` _=. . _ . � J � �
- \ = '; � � ? � >_' - _ _ __ = Q, � .'+ ;: `�
- �i - Q = _ > - _ Y _ _ .�-�! v - _ �
� ^ � S - - =`� _ r.� � ?. � ._ �
_ � , c`- < ` ` _'"tt--Y^rt� � � v ^ � Q�
. V '� s yjf ` � `� � �, F � C � ��(�� � ��(� �
; O � ! j � ;� 5 �� � i' { :_� : �` � Vly �7 �
� � ,. ! �' i i� � � • s
T ' ;, �
.•. � � '� �v ! �� ! �� � i� � v � Fi �E
3 !'lt ` � � ? �� �a ` _ � �
� � /„ � � 1� ( Ii ! 3� _ =1
� � � = - '� � fi � ' c ,r
{� (y � tU _ � _ _ � i �� � ie i = ..
ui �
� L � � •� � 3 r _ �i i li { 1' ' — LS
� < �" ° � � " _ _ - - _�,.,�: �
� � � � � ^ 3 _ : ii � i, : `: . J � �
�-- >/� � _ � = ' :i '; � � C �
� Fpi .> - - - �' ; :� � ��(
Y Li`r It : ll ., �
� C � i- � G O �
� i r � iji
W�►,/ ii � r— � � _ _ %� Ii S 1. �: � M L .' .
LL. � '�� � L � - _' - �. +�..'�...: t ` _N
"� � � � `-� _ � � . � �
,� � � �: ° - �^ . . �
� �� i � � ' �i ^ „'� F .. . : a _ _, : ; � �y � � ` G
� � + � � � � �_ .>_ .. + ; O� ` � i } �
U! � 'N ; — — - �� � — ' � `y
_;; ; ^e :: -_ � ; �
t1 "= 'ct� ; : '___;,--�I' = ' �� = c ' '�
•� . • ' _ �; � � � .
� � �'%�,�; — _ ? • = :
� `.
,�, � �.}.�;��t: , i � - j � :� tf !4 i I! x
� cv o � . � ;-Y^- ; , �{ _ � � -- ` � � � � i �
�r � ' � " _ 'c � � �
� � 3i ^ `��`1�j; _ C � .j, i ' + C/� G� � �
...� � � . [ � .... ' '_,_ :=1 " ^
� N♦ � 3� �\ il � .v i . '� . � �. � i �
V � � � � y � � " � . ': `f� ` � \
� � � • �YY� . /�� V i � ���[ � �' �. �/ L^� f
� � j �'�`�^� ' � � � i i ! . ! ! � „ t :-.
� � � �� — _�� Sa�'_! ? :i �r �; i �t i �i �J u� ! �
�F a =- i '" '^ .� � ;` :o i r
� a; � -�- � ' � ; s,�� :: � : �
!/�� _ _ _ V �i ; � v Y j .
1 y � �f�� I � j � = � V ( � 1� : ��{ � L � y.
1 1 L'y�r ?J' `7' � � f .1 . �l � i• � � � 1 �.
E � C�� T t • :. � fy. �.:� .,..^
'�`�'` � Cti'? `' ^ - = c- :,_ ' i 1: � ;. ��.: _. ._.. 1 -
� v � .. _ " , r. � �; � .� ��
, . :� :� � ,
� � i � -� � ; i1� � � 1; o :.7 ;
� . _ . � �/� �F�' ' � �� � ��� F #j �
� Y � �V " 1 `i ' �' !� F �
r�`i : �= 3— > J !' ? E' : � � �' !
� o ? � z ;j} ' :. � : J;f = 3 :
. �
S � � ;{: ; �' % �' � 4 �
� � �.t � � e'` , l• � � '
� " n � � �� ` I'•� # q -
� � _:��: �
�,,:. •,
�-r, -
in-grouna c�rav�ty Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali be responsibie for its perpetuai operation and maintenance pursuant to
requiremenfs of SPS 382-384,UVisc.Admin.Code. Pursuant to SPS 383.52(2),�sc.Admin_Code,fihis system shall
be considered a human health ha�rd if not maintained in accordance with fhis approved management plan.
Furthermore,ali inspection and maintenance activities shali be performed by a registered PO4VTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin_Code.
Maximum Disaersal Area Operatina Limits:
�Jesign Flovr= ��-/S j) ggd; BODS<_220 mgL-'; TSS<_75d mgL''; FOG_<30 mgL''
-T—
Mspection Checkiist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanica!malfunc6on(i.e.,pumps,valves,switches,floats,ete.)
o materia!fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatment fank(s)and any dismbu`uon appurtenance(s)(i.e.,distribution/drop boxes)
.. negiect or improper use(i.e.,exceeding design capacities,prohibited activities,efc.)
o e�enf of pondir�g in distribution celi prior to dosing
o dosing irregulanties-i�appiioabie(r.e.,pumo re-cycling,float switch settings,etc.)
o elecfical componenfs-if appiicable(i.e.,winng,connections,s+rritches,controls,timers,alarms,etc_)
o distribution Iaterai or tateral orifice plugging (measure lateral distal pressure—compare to design specification}
o surtace discharge of effiuent or sewage back-up intc structure served
Niaintenance Checkiisf iVIAiNTAIN EVERY 3 YEARS{or when necessary?
o Seotic and dose tank(s)shall 6e pumped by a cer[iried septage servicing operator iicensed under s.281.48 Wis.
Stats.when the volume of solids in tfie tank{s)exceeds one-third(9I3)the liquid volume of tfie tank(s)or
as required by Iocal ordinance. Disposal of contenfs shall 6e oursuant to NR 113,Wisc.Admin.Code.
o Effiuent filterfs)sha(I be inspecied every 3 years and shail be cieaned when necessary to remove any
accumulated solids according to manuiaciurer's specifications. A servicing period will always be greater than 12
months.
S�rsEem maintenance reports shall be submitted to the prop�r tocal government unif in accardance vrith
�PS 383.55 Wisc.Admin.Code. Report any componeni failure or malfurtction to:
tVame of individuai or company:���(�����'1�Q Phone d�5'S^j�'"��J��
Local govemment unit: Phone- `�������
Local govemment unii address:� (p�{p: 5��3
Any defiec6ve part of this system shaii be repaired,repiaced,ar removed pursuant to SPS 383.5i(9),Wisc.Admin.
Code.Repair or replacement of failed or maifunctroning components sfiall compfy with SPS 383,Wisc.Admin.Code.
No product for chemicai or physicai restoration oi the POWTS may 6e used unless approved by�he department in
accordance with SPS 384,Wisc.Admin.Code.
�ontinuencv Ptan
in the event that any iailed treatment component of this POWTS cannot be repaired,it shail be replaced pursuani to
a plan submiited to tha appropriate agencyfor review and approval. A failed in-ground dispersai component may be
abandoned and replaced by a code-compiying dispersal component in a pre-determined area ofi suitabie soils.
�Ystem Abandonment
ff use of this POWTS is disconti�ued,if shalf be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.