HomeMy WebLinkAbout010-841-19-3407-SAN-2022-291 . � r t'�
_ '`'�i `-�''%�� tndustry Services Division County �
\,�J, _ 48?2 Madison Yards Way S4� �
= �\Sp ' Madison,Wi 53705 Sanitary Permit 'umber(to be filled in by
_ %- P.O.Box 7302
';�''%''-`-';�� Madison,WT 53707 �
,�.«,..,� c� 3 � �.�a
_ _ �,
Sanitary Permit Applieation State Transac[ion Number ,
In accordance�uith SPS;R3.21(2),Wis.Adm.Codc,sttbmission of this fo�m to the appropriate govemmental uni[ �
is requircd prior to obtaining a sanitary pemiit.Notc:Application fonns for stato-owned POWTS are submiUcd to Project Address(if different than mailing �
the Department of Saf'ery and Professional Services.Pcrsonal inli�rmation you provide may be used for secondary
purposes in accordance with the Privacy Law,,. I 5.04(1)(m),Stats.
i.Application Tnformation-Please Print All information S�i..Y�'�-�
Property Owncr's Namc Parccl#
�o ber�" a . (�,a,r t'� L• L�_13�rr�. O l p- 8�(- l Q - 3�t D`I
Property Owner's Mailing Address � Property Location
(4sl$ W S-� �u> �Z
Govc.Loc
City,State Zip Code Phone Number
�T�- ��-'rC �� 54 $�f 3 � �S -b�� _b-�'r 3(o S� ��4 S� '/,, Section �9
II.Type of Building(check all that apply) Loi# T �� N R b� E o
�I or2 F/a'm�ily Dwelling-,NumberL�ofBeejrooms I � Subdivision Namc
� "COF- D'�l ce G7c�"�L1 f00►'K Block H
�ublic/Commercial-Describe Use
❑Ciry of
❑State Owned-Describe Use CSM Number illage of'
.�,3 l�l7 �-1��3 �T���,�r�}�HT r�
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.
�(1Vew System ❑Replacement System ❑Other Modification to Existii�g System(explain) �Additional Pretreatment Unit�explain)
�r....
B' �Holding Tank �fn-Ground �1t-Gradc �Moimd Individual Site Design Other Type(explain)
(conventional)
C• ❑Renewal Betore �Revision ❑Chanee o('Plumber �I'ransf'er to�Iew Owner List Previous Permit Number and Da[e Issued
Expiration ��' � I�6/`,p
l 0
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(�pd) Design Soil Applica[ion Ratc(,pcVsf) Dispersal Arca Required(s� Dispersal Arca Proposed(s� System Efevation
��v ,s � 3 0 0 3 ao RS '
Capacity in Total 1=of Manufac[urcr
Tank information Gallons Gallons Units � � o � �
Ncw Tanks Bxisting Tanks c� � � � v u � 'vi
v O N � .D �Q
a U �n r� ii. C7 a
cpti or Holding Tank --'6� �.�' �i eSer
Dosing Chambcr O �
V.Responsibility Statement- i,thc undersigned,assume responsibility for installaHon of the POWTS shown on the attached plans.
Vlumber's Name(Print) Plum r's. tttr MP/MPRS i�umber Business Phone Number
RO � L�-g4rJ� 2.z(oZL 8 --(lS--6�-cfi3(o
Plumber's Address(Street,City,State,Zip Code) ,
(�� l l v� 5-4- w -1�I . �-c� �c�� . (.c� l 5�-`�3�-t 3
VI.County/Department Use Only
�A�� ��, ❑Disapproved Permit Fee Date Tssued Issuing Agent Signature
J /� � - -
�11� ❑Owncr Givcn Rcason f'or Dcnial C/�,J. ��I �� I�-a �1
Conditions of Approval!Reasons for Disapproval D r ' �?' � '
a � t���j� ';� t' �i
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CS�� (v� ��ld 3 S,�WYER COUe��`"�,�
�� " �-��0 �l� ?{�IVfi�1Ci ADMINISTR,����c�N
Attach to complete plans fm•the system and submit to the Counh only on pnper not less than S il.x i l inches in size � 1 ��^
o�
SBD-6398(R.02/22) N4 REFUNDS AFT��
1�3UE OF PEkMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Compon nt Manual Design References:
Version 2�SBD-10705-P(N.01/01,R.10/12), , ,
2,1
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): �0 h L a�rr� Phone: �l�S -b�-�t�- D�'t 3 Ce
Owner Address: ��k5�5� � ��^�L�� tt��.�-��-Z�p� 5�t 8`�
Project Address: 5�-wLG.
Govt.Lot: SE 1/4 of_�W 1/4,Section �R ,T �-f I N-R 0� E 0 or W�
Township: cLH a,Y` County: S�c�Her
Project Parcel ID#: (�(� — �`t� -l9 - 3 4 0-7
Designer Information
Designer Name: Rob l� Ixvrc� Phone: -IIS-b�t�-f�`�Z3�
DesignerAddress: Sai^'�.t a-s cc-6o�� Zip: 5'-{�`{3
E-maiL• �
License Number: 2 z�2 L�
Remarks:
Signature: � `�� Date: ����9- � �
riginal signature requi on each submitted copy.
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Comatov� . ���'�
IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Stepped Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
��� �--�
� m;�,��� �
cAO1ex1i1e � I ovP��e�� TYPICAL TRENCH
°ov"` Provide minimum 3 ft
soi�r,oveR CROSS SECTION VIEW
iz• � -- � (NO SC818� separation between trenches.
in.tren�n
m aepm L — J,°� .
(A'Pical) .
Highest Trench Lowest Trench(as applicable) OBSERVATION PIPE oeTAIL
�Nos�ia�
1
Srre.w-lypeor FinisheelG�atle
System Elevations= C15 ft; �� ft; ft; ft; ft SOoceP��°°�°> �m�ia,aas�aaea�
A"ID PVC Plpa Topsoil Cavar
To{�of�yIf�tole Ina�e (min.1/oot)
alarabbva'Yn�s'{�ie�qrade �
TYP�CAL TRENCH (Show location of inlet/outlet pipe connection on plan view.)
�nl v�•-vz°x e-siois
PLAN VIEW
(No Scale) 4��� oo�a�ro�vbasnauea�siaiiaa n�rn���yna��� �s�naiceo�
ai i��ooro�oaiwaa�iwo�����s. n
Perforated Lateral observaiion aipe
(typical) (ryP��aq (typical)
---- ----��---------------�� 'U
r--- r-� - y
I =_____�-j=-___ -- — ---- ----- I �A=3.0 ft �
�.---------------��.----------__--------J ��YPical) m
e= 3D n I �-`'
cry���a�� O
INSTALL PER TRENCH: EZ1203H Bundle �1
(typical) ...�
-3 10-ft bundles @ 50 fl�EISA/unit= �5� f[� (mtd by Infil�rator Systems,Inc.)
Install pursuant to manufacWrefs instmctions,
+ 5-ft bundles @ 25 fl'EISA/unit= iP
=Proposed EISA per trench=J S� ft' Required Infiltration Area= -3 D� ft` Dislribution Method:
x 2 trenches=Proposed Total EISA= 3Dd ft' c�rcw��/
PAGE�OF �
In-ground Gravity Management Plan
IMPORTANT:
The owner oi this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requiremer,ts of SPS 382-384,Wisc. Admin. Code. Pursuan,to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be cor.sidered a human health hazard if not mamtained in accordance with thls approved managemer,t 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 Dispersal Area Operatinq Limits:
Design Flow= ��� gpd; BODS_<220 mgL''; TSS <_ 150 mgL-'; FOG <_ 30 mgL"'
InspecGon Checklist INSPECT EVERY 3 YEARS
o type of use
c age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanlcal malfunction (i.e., pumps, valves, switches, floats, etc.)
o material faiigue (i.e., leaks, breaks, corrosion, eta;
o solids volume ir, 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.)
c extent of ponding io distnbution cell prior to dosing
c dosing ir�egularities- if applicable (i.e_ pump re-cycling, float switch settings, etc.)
o electrical components- if applicable (i.e., wirng, connections, switches, controls, timers, alarms, etc.)
o distribution iateral or lateral onfice plugging (measure lateral distal pressure—compare to design specification)
o surface discharge o?eff!uent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Seqtic and dose tank(sl shali be pumped by a certified septage servicing operator licensed under s. 281.45 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.
c Effluent filterfsl snall be inspected every 3 years and shatl be deaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
mo^ths.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any compo�ent faiiure or malfunction to:
Name of indivldua! or company: �o p l� (Jqrf� ��� phone: -1�S-b�i�t —O�t 3 �v
Localgovernmentuni?: S�wtiCr cC1 �0�1.��.G Phone: `IIS-634- 8Z8S
Localgovernmentur.itaddress: ID6�D �'�a�v�s�. �yQ k'�'tiyw2r-� ,� � ZIP: 54g�'3
Ary defective paR 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 restoratior of the POWTS m2y be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Plan
In the event that any�ailed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plar submitted to tne appropriate agency for review and approval. A failed in-ground dispersal component may be
abandcned and repl2ced by a code-complying dispersal component in a pre-determired area of suitable soils.
Svstem Abandonment
If use of;Ms POWTS is discontinued. it shall be abandoned in acccrdance with SPS 383.33, Wisc. Admin. Code.
�i�t-'� ''''RT""�`� PRIVATE ONSITE WASTE TREATMENT county
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i �;'�
�;�SPS ��� SYSTEMS Sawyer
'��� `, /� ( POWTS)
��F>,--�.�y�'`':�,
-""== INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _�� �
Persona]infonnation you provide may be used for secondary purposes[Pnvacy Law,s. 15.04(1)(m)J
Permit Nolder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
�bn2.f� '�ka rr� W �acr�_ a wa� r—
tnsp BM Elev: BM Description: Parcel Tax No:
����0� ���'1 � Co,tia✓� w,e�' S 1�,�n �S►1 a o I O � ���' ��—,3 Yv�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�,q�f-- '7So L P Benchmark Jpo,o �
Dosing
Aeration Bldg. Sewer ��,� '
Holding St/Ht Inlet q�,� '
TANK SETBACK INFORMATION St/Ht Outlet ��,�'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ,��o ,�� � g� k�$� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �rS 3S�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �
Surface 9`/-�S
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS W � L ` � #of Cells Type of System Distribution Media Manufacturer.
SETBACK OHWM of Nav � Conv ❑ Aggregate
P I L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO oe� �' ¢'�� �V ❑ Mound a Other
- --- - -- — _ _ _ _—
DISTRIBUTION SYSTEM X Pressure Systems only
- --_ __ _- - ---_ _ _-
Header I Manifold Distribution Pipe(s) � X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac 1 Spacing ❑Yes ❑ No
.
-- - -
SOIL COVER
___- -- -- - -_ _
fDepth Over Depth Over �epth of Seeded!Sodded Mulched
Cell Center l Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code tliscrepancies, persons present,etc.)
�-►�,s}�I(� �� l� J��
Plan revision required?�Yes ❑ No U 3 {,� a3 �____ • �
�� � (�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA: ��--��'�
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