HomeMy WebLinkAbout032-338-22-5221-SAN-2022-286 _-��``""""'•� Department of Safety �°""ty ��� � �
�`� � = & Professional Services, �
_ �\_ = Sanitary Permit Number(t be filled in by
�,, , �_ _ Industry Services Division
4--�,;:�,..,����°' (, 3 q �-(� 8� �
�
Sanitary Permit Application State Transacti=n Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Applicarion forms for state-owned POWTS are submitted to Project Address(if different than mailing; �
the Departmcnt of Safety 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. /;� �� ; I
I.Application Information-Please Print All Information L, ��
Property O er's Name Parcel#
�1�+� �2� � � L�.0 �3a 3 � sa
Property Owner's Mailing Address Propeety Location
/l 15 � �� ( /6(J �i(� Govt.Lot �
City,State Zip Code Phone Number
l' ,�./1 ��.` l , /� �LIlI�/�, '/<, '/<, Section�.�_
I/V �l lil/ l b c./
II.Type of Building(check all t6at apply) � Lot# � T N R E o w
�1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑Ciry of
❑State Owned-Describe Use CSM Number ❑Village of
37 y� ��(�y13 �Town of ���n liE-V�
✓--�
IIL Type of POWTS Permit:(Check either"New"or"ReplacemenN'and ot6er applicable on line A. Check one box on line B.Complete line C if
a licable.
A' �New System ❑ Replacement System ❑Other Modiftcation to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holding Tank �In-Gmund ❑At-Grade gn yp ( p )
❑ Mound ❑ lndividual Site Desi ❑Other T e ex lain
(conventional)
C. ❑ Renewal Aefore ❑ Revision ❑Changc of Plumber ❑ Transfer to New Owner ��t Previous Permit Number and Date Issucd
Expiration
IV.Dis ersaUTreatment Area and Tank Informallon: EZ �Uw c.v�;-�5 `n 3 ��I 5 �
Uesign Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�/s� .� �7s� "7so �s.a�
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units s, � v '$ y � �
New Tanks Exis[ing'Ianks � o Y � Y � �y �
ri U �n � rn u. C7 a
Septic or Holding Tank �/ i � � u �,�
/\ l
Dosing Chamber
V.Responsibility Statement-I,t6e undersigned,assume responsibility tor installation of t6e POW'I'S shown on the attached plans.
Plumber's Name(Print) Plumbe' Signature MP/MPRS Number Business Phone Number
_ ` ��r� n . Si'1 ar�'��lv 715-:�-�£SLI�
Plumber's A ress(Street, iry,State,Zip Codc)
Sc� ��1-1t1 �rrt � �Q �i��l�e� Gt.L�- S`fS1�
VI.County/Department Use Only
� �� 11 Permit Fee Date Issued lssuing Agent Signature
Ap o ❑Disapproved ,
❑Owner Given Reason for Denial $ `��� ' b ��( I � �
Conditions of Approval/Reasons for Disapproval �
~--, �-,
�
� � <.- .. � V 1��.1 �� .. i `t t���`�4fI �� 5 r 'r �
�
� � '.ai � �3�� ;�
�� ��GI 6��, � 3 � __ — — ��
L f
_a � .�
C 1 �' ��� �"� ���� �;
CJ1 �d -- � b S 1�1-�..c� wG r�`�� 31�5� _... _
r-- 't� �
. . . " �� �V�V�f'J(� � � '�_._ `✓
Attach to complete plans for the system and submit to the County only on paper not less thao 8 u2 z 11 inches i' 'slzie"`�:1 j i V J,(
NO R�FJNDS AFTER �� � S�
SBD-6398(R.03/22) �SSUE OF P�FcMt7
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:
X POWTS Application for Review
� Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): 1'l�c.�'►1 �"��5 �..�� Phone: - -
Owner Address: !�I�'4� �, �}kr1 I�c� W►�"�-'� �� Zip: �`!�`1�p
Project Address: CO. �kN I��
Govt. Lot: a 1/4 of 1/4, Section�, T��N-R �� E Q or W �
Township: �if1-�,!' County: �tJ�/e�
Project Parcel ID #: 0 3 a 3 3 S aa saa)
Designer Information
Designer Name: C�. r � Phone:715 -��- oZ,��a
Designer Address: t� � D � Zip: _�Y��o
E-1'1181�: �Q���1�����1/L°� �[7� -l�:i,s.5� t<'2 re.ert'�<i I�ir a��pr,,,.ai <t.in��k'�.
License Number: �a��l�
Remarks:
.
Signature: �� Date: �^���o?
Original sign e r uired on each bmitted copy.
CHECN BO%AS APPLICABLE. CNECK BOX AS APPLIGABLE.
sca�e: 1"=SC' PAGE 2 OF
� SOIL EVALUATION o 5u, �SYSTEM
SITE MAP LOT PLAN/�
PROJECT NAME: oesicn F�ow: /SV cao
� 7.5'
Cp(���'s ��, Attach design flow calculations for commercial plans.
PROJEGi qDDRESS: III�� VV H�✓`' W Pipe Material/ASTM Standard(Tables 384.30-I3'y&�384.30.5)
� N SanharySewer �� / Vl.�.
BM Symbol'. � BM Elevation: PT ��
' �� Fmce Main�. /
BM DeScnption: I I�'I��� �Q�..
trMicate nortn oy IMPORTANT:
Siope Gratlient(/) qc� yryp Symbd(itappliraWe): Q tlrawing an arrvw Show ground elevation contours a[suifable intervals.
o�TesteaArea'. _�` ontM1eapproprtteFre.
Q�:�e ���v _ — — —
i
�� s.T,
� / �d
♦ y' ��,0.� ��Qo+f'� �
�-- '�nr'�
�
��y tz —+w� �e4s /
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/
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,�
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r ,�C
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IN-GROUND GRAVITY DISPERSAL AREA Septi Tank(5)Manutaclurer: •
�/u��c..t-� -�
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit) ' ',� �l
1y�ddL gal gal gal gal
Effluent Filter Manufxturer:
i3�5f
Geateztile I min.12' Etfluent Filter Model#' �T �� _b
Cover I (tyPical)
SOIL COVER
TYPICAL TRENCH
min.hanch ; . CROSS SECTION VIEW
aa'"' � No Scale
�ryP'��� T ''�^' � '. � � OBSERVATION PIPE DETAIL
� . , �p'•� (Nosw�a)
System Elevation=�5�� ft. � � � s���P�i�sa� '::.�' F�msnaa cr�aa
(rypical) ' Provide minimum 3 ft cm�i�naa a saaaee�
S@P8f8tlOf1 bBtWB2l1 tf@�1ChBS. 4^OvvCPipe C'�;, TopsoilCover
Topofplpetoterminate (min.lfool)
at or above fnishetl g2tla
TYPI CAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) �'>'�g'�"a�e51o°
PLAN VIEW ^^��^^9��� �^°°�^°^
OEservation piPe shall be inataped SuAace
(No Scale) 4��� a�w���,���������.
Perforated Lateral Observation Pipe S ft
— (typicaq (typical) — — «YP����
r- - - - - - - - - - - ��- - - - - - - - - - - - - - �� �
� '_____ _______ :_--__ :__ _______ � A — 3.0 ft D
______°
-- — — — — — � c�vP���> G)
� - - - - - - - - - - - - - - - �� - - - - - - - - - - - - - - m
I- a = SC� ft —_; w
caa��n
INSTALL PER TRENCH: EZ1203H Bundle �
(typical) �
S 10-ft bundles @ 50 R� EISA/unit=� ft� (mid by Infiltraror Systems, Inc.)
_ Install pursuant to manutacturer's instructions.
+ '^ 5-ft bundles @ 25 fl� EISA/unit= ft�
= Proposed EISA per trench = � ft� Required Infiltration Area= �� ft' Distribution Method:
x 3 trenches = Proposed Total EISA= �� ft' ���-J���
�
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 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 POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc.Admin. Code.
Maximum Disaersal Area Oaeratinq Limits:
Design Flow= �� gpd; BODS 5 220 mgL"'; TSS <_ 150 mgL''; FOG <_30 mgL"'
Inspection Checktist INSPECT EVERY 3 YEARS
c type of use
o age of system
o nuisance fadors(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 priorto 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 fateral 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(s)shall be pumped by a ceRified septage servicing operator licensed under s. 281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third (1/3)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 filterlsl 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 tocal government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: �n I nt`�f�'�(��f�d- SDG\S �L Phone: lJ I S-���O—�o��«
Localgovemmentunit:�fJ (,Ju:l� ��(�+ /1n Phone: 71�- �3��— Cl�bl�
Local government unit address: ��v�� ���f� �J�, 5�-l�� �Lf��4J2�ZIP: 5 �( �`�� �
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 faiied treatment component of this POWTS cannot be repaired, it shaii be replaced pursuant to
a plan submitted to the appropriate 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 shail be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.