HomeMy WebLinkAbout028-742-36-3207-SAN-2022-282 - �� ��'`= Department of Safety c°°°�' �
� ' �r _ & Professional Services, �
., � Sanitary ermit Num e (to be filled in b� �
- s . Industry Services Division �
� .
_ � (�3 q�.l� � R�
Sanitary Permit Applieation State Transaction Atumber �'
In accordance with 5PS 383?1(2),Wis_Adm.Code,submission of this form to the appropriate governmental unit �� �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to f'roject Address(if different than mailine �
the Department of Safety and Professional Services_Personal information you pro��ide may be used fw secondary
p�nposes in accordance«�th the Privary La�v,s. 15.04(Ixm),Stats.
I.Apptication Information-Please Print All Information S{���
Property Owner's Name Parcel# (" - - - - -
� � � C,� � �('Ni �, �O1�5 0�$-�N� -3!v� 3 a-o"l
Property Owner's Mailing r1ddress Property Location --"`-"'"
����� � ' `�' Govt.Lot
City,State Zip Code P6nne Number
WW�'�l �^'-r ��� � I C ��(.E.�a-3��(,� 'WV '/<,Sl��;/,, Section�p _
� --7
II.T��pe of Building(check all that appl}) Lot# T N R � / E o W
�1 or?Family Uvclling-NumberofBedra�ms Subdi�isian Name
Block#
❑PubliclCommercial—Describe Use
❑City of
Q S[ate Owned-Describe Use - CSM Number ❑Village of
�Town of J Di� �-�c __
III.Type otPOWTS Permit:(Ci�eck either"New"or"Repiacement"and other applicable on line A. Check one 6ox on line B.Camplete line C if
a licable.)
A.
❑ Ne�v System ,�Replacement 5ystem ❑Other Nlodification to Existing System(explain) ❑ Additional Preoreahnent Unit(explain)
B.
❑ Holding Tank -Grouud ❑ At-Grack: ❑ Mound ❑ Individual Site Design ❑Other"fype(explain)
(conventional)
C- ❑ Rrnewal Befoxe ❑ Re�ision ❑ Change nf Plumber ❑ Transfer to Ne« Owner ist Pre�ious Permit iVumb�:r�d Date Issued
Expiration C�O�I��/ �� `��
1 l
iV.Dispersal/Treatment Area and Tank InCormafion:
Desi_�Flo���(�d) Design Soil Application Rat���i'sn Dispecsat An:a Rcquired(stl Dispeisal Arza Proposed(sfl System Ele�-ation
�� . / G y c�� l�:
Capacity in 7'otal #of Manufacturer
Tank 1nPomiation Gallons Gatlons Linits � � �� �
New Tanks Fxisting TanF:s ,� � � � � � y ��
�? a � � � .a M �
n. U v� ; vs cw C:+ fS,
Septic orNolding Tank � � �
�S
I)osing Chamber
V.RespOnsibility StatemeIIt- I,the nndersigned,assume responsibitih�fur iastallation of the PO�YTS s6own on the attac6ed ptans.
Plumber's Name(Print) Plumber'- ' ture MP/MPRS Number t3usiness Phone Number
� 1 � `�
Plumbe s Address(Street,Ciry,State,Zip Code) I
��57{� �U1�`�'� 4' ��'0-Q �Q.�'�-� � � (t�, �-Q,�
VI.Courtty/Department Use Only
� �f � Permit Fee Date I�sued lssuine Age�u Signatun
�A taQ �llisappro�ed
y '" Q Owner Ciiven Rea,son for Deaial � (��•� ('���� f'�a
Conditions of ApprovaUReasons for Disapproval -� -
-
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v .�Zb{�}ir.a�7�.f�R�l�liS;-RnTIG(v
,lttacd io cnas�kte pia¢s tor[he sy slem aod submit to thc Conah oalt on paper sot tess thae 8 t2 x 1 t inches ia s¢e
�f 3 o c�3
SBD-6393(R.03!22) NO RcFUNDS AFTER
I�SUE OF PEFty1lT
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):�,��Yy�JC. 4,��ri L -;�o��eS Phone: �lS -�-�(� - 3 � 7�
Owner Address: t �a�t-l- hl L�LAp�� � - �u.1G�� l�� Zip: �� $ `-G3
Project Address: ���
Govt. Lot: � W 1/4 of �ul 1 /4, Section_�(�, T�N-R 0 7 E ❑ or W �
Township: �'j pi(�,�PX ��-� County: �Y,(.�,U��
Project Parce) ID #: �j��0�-$ " �'�a� 'C�� ��1� '3 �a-- 0 4D -- �C�B C� 3�
Designer Information
Designer Name:���C]�.f�1 � . Phone:�l5 -� ��D�
Designer Address:l�. N `TrnL� .�.u1c��'`�1� I-�a.�'�- �• Z�P� ."����_
E-ma i l: ���t�,c-?��. c;��. , , , .,� . �
License Number: �9�'� �
Remarks:
Si nature: `�� Date: —g'-"c�-c�
g Ori ' al signature required on each submitted copy.
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� �n-grouna vrav�ty Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali be responsihie for its perpetuai operation and maintenance pursuant to
requirements of SPS 382-384.Wisc.Admin.Code. P�rsuant to SPS 383.52(2),�sc.Admin.Code,�is system shalf
be considered a human health hazard if not maintained in accordance with this approved management pian.
Eurthermore,all inspection and maintenance activities shalt be perFormed by a registered POYVTS Maintainer in
accordance with SPS 383.52{3),Wisc.Admin_Code.
AAaximum Disaersai Area Operatina Limiis:
Desig�Flow= �1 S O gpd; BODS 5 220 mgL''; TSS<_150 mgL-'; FOG_<30 mgL''
insoection Gheckiist INSPECT EVERY 3 YEARS
o type oi use
o age of system
o nuisance factors(i.e.odors,user compiaints;efc.)
o mechanical maifuncUon(i.e.,pumps,vaives,switches,Floats,etc.j
o materiat fatigue(i.e.,leaks,breaks,corrosion,etc.)
o sotids voiume in anaerobiC treatrnent tank{s)and any distribu5on appurtenance(s)(i.e.,disfribution(drop boxes)
o negiect or improper use(i.e_,exceeding design capaciiies,prohibited activiiie�,2tc.)
o extenf of ponding in disiribution cell prior to dosing
o dosing irregularities-if applicabte(ie.,pump re-cycling,float switch settings,etc.)
o electrical components-if applicabfe(i.e.,wiring,connections,svritches,co�trols,6mers,alarms,etc.)
o distribution laterai orlaterai orifice piugging (measure Iateral distal pressure-compare to design specificafionj
o surtace discharge of effiuent or sewage back-up into structure served
Mainfenance Checklist MAIPiTA1N EVERY 3 YEARS(or when necessary;
o Seatic and dose tank(s)shaii be pumped by a ceriifed septage servicing operator ficensed under s.281.48 Wis.
Stats.when Yhe volume of solids in tha tank(sj exceeds one-third(1I3)the liquid vofume of the fsnk(s)or
as required by local ordinance. Disposal of contents shal!be pursuant to NR 113,Wisc.Admin.Code.
e Efffuenfi fiiterfs)shail be inspecied every 3 years and shalf be cieaned�vhen necessary to remove any
accumulated solids according io manufaciurer's specifications. A servicing period will always be greater than 12
months.
�g�sEem maintenance repotts shall be su6mitted to the prop�c loca!government unit in accordance with
SFS 383.55 Wisc.Admin.Code. Report any componeni faifure or ma(function fo:
Name ofi individual or company:��(�_ �y��,�,Y'� Phone:��S S-S-S'�(�J73
Local govemment unii: Phone: �L j����(Q'r�-r�
Local govemment unii address:� Yc. Zip: S����
Any defective part of this system shafl be repaired,repiaced,or removed pursuanf to SPS 83 3.51(i},Wisc.Admin.
Code.Repair or replacemeni of failed or malfunctioning components shall comply wRh SPS 383,Wise.Admin.Code.
No produci fior chemical or physical restoration of ihe POWTS may be used unless aoproved by the department in
accordance with SPS 384,Wisc.Admin.Code.
�antinqencv Ptan
4n the event ihat any iailed treatmenc component of this PONIfS cannot be repaired,it sha(I 6e replaced pursu2nt to
a plan submitfed to the appropriate agency for review and approvai. A failed in-ground dispersai component may 6e
abandoned and replaced by a code-complying dispersai component in a pre-determined area of suifable soils.
8vstem Abandonment
If use of this POWTS is discontinued,it shall be ab�ndoned in accordance wifh SPS 383.33,Wisc.Admin.Code.
''`''"T"'�'�� PRIVATE ONSITE WASTE TREATMENT county
�:,-- ,.,,
;�i���SP �\!, SYSTEMS Sa,W er
'�,�,� s_ ��� ( POWTS) Y
\aF`---:`:'
�'s"""-'"'' INSPECTION REPORT Sa�itary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �-�, ����
Personal infonnation you provide may be used for secondary pwposes[Privacy Law,s. L 5.04(I)(m)]
Permit Holder's Name: 0 City ❑ Village �Town of: State Plan Transaction ID#:
�. P�l� ��� L _��� S ►� C��--- .-,
Insp BM Elev: BM Description: Parcel Tax No:
l�i V 1 1 v �7�r' (�v♦ O� J�- w� ��Y� ��6 � �l� �.Jo � �L07
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,., C � � g�p �.�,6n Benchmark fvp.o�
Dosing
Aeration Bidg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet q , �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �y,a�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
4 '
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 �S- s' � #of Cells ,3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav 1� Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � �GP ❑ Chamber Model Number:
❑ AG /� EZFIow
CELL TO +S .y-�p� � (� ❑ Mound o Other
--- _- - -- - --- __- -_ _ --- ---
- ---- ----_
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 �ell Edges ! Topsoil _ � ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��s�j� U �-1 I�.�
� NZ.� Ce,��S ov���. �rt,P`�e�'�'J
Plan revision required?0 Yes ❑ No r
p 3 (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: ��-�O•C
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