HomeMy WebLinkAbout014-842-13-3304-SAN-2022-295 � -
- �
°' Department of Safety c°u°�., �,�
� & Professional Services, J�L�'� �
S ' Sanitary Permit ber(to be filled in by �
�� Industry Services Division
c� 3� a �� �
Sanitary Permit Application State Transaction Number �
In accordance with SPS 38321(2),Wis.Adm Code,submission of this form to the appropnate governmental unit �— �
is required pnor to obtaining a sanitary permit. Note Applica[ion forms for state-owned POWTS are submitted to Project Address(if different than mailing a �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. I�A4(1)(m),Stats. �
I.Application Information-Please Print Atl Information
Property Owner's Name Parcel#
u��S �� �- ���.��-G� � . R���i� �-L.. ;��us fi a��- ��Z- � 3 -- 3�� Y
Property Owner's Mailing Address PropeRy Location
� ��� lv i�-� �O l V��-G\ �t.b\L� Go t.Lot
City,State Zip Code Phone Number P�•
�C�. CL'C�i C� (,L� �- �7 �I .� 7(0,� -- 7,j�- �-�y� ��i '/a, .sl l.� Y.. Section i 3
II.Typ of Building(check all that apply) Lot# Z T Z N R �
'�1 or 2 Family Dwelling-Number ofBedrooms •� Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number • ❑Village of
ZZ�.3 i�7� �G%'�7 1�Town of �'�L`Ci
III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one boz on line B.Complete line C if
a licable.
A.
❑ New System �jReplacement System ❑ Other Moditication to Existing System(explain) ❑ Additional Pretreatment Uait(explain)
�U.S b N �
B' ❑ Holdin Tank n-Ground ❑ At-Grade
g � ❑ Mound ❑ [ndividual Srte Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Chan�e of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date[ssued
Expiration �Z-�C�I �/���L
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(apd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�-{�� � � ��f 3 S�Go �Z. 5 3 `
Capacity in Total #of Manufacturer
Tank[nfortnation Gallons Gallons Units � ` o y �
New Tanks E:cisting i'anks -«° � y � y � " v,
` p � u � 's 7
a U rn �n rn t� C: a.
Szptic�Tank
�COU lOcO / CC.�(ESF--�''—
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Pfumber's Signature � MP/I�tP-�S Number Business Phone Number
J QS6��� t��-1 r-�1�' —,��`°,>.-r_....-- �D�7.5 7�� 7�.�' �'!t�'.�.�.5.S�
Plumber's A dress(Street,City,State,Zip Cs�e) � yk�
� 0 ���'� �,� �a(v�e7 Gti'� � .��{��-�
VI.County/Department Use Onlv
�Ap �o�i II ❑Disapproved Permit Fee Date Issued [ssuing Agent Signature
❑Owner Given Reason for Denial � C��� � C'I 4� I a� �
Conditions of Approval/Reasons for Disappro��al
7 " .._'_.�E.. . . .
Y� � � � r
� ` �....��_ �_ � - �U �����'�� �.�' _��,�:�
,
� � .��
��i '�'� :._��c#_.._=.13�.a�._. . __.. � ; r.
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� QCT 0 �i 2022
s ..
R�:��t#�...�o,r�.��`38S 1 ;
----
�S� �� -- �. I o —_—�
✓Y��-4- SAWYEr� �:�:�v+,'`�7Y
� .attach to complete plans for the system and bmit to the County only on paper not less than 8 I/�s 11 inches in size '
SBD-6398(R.03/22) NO R�FJNDS AF"9'ER 1 (� �7 3 I
IS3UE OF PERMi't
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manua/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
�1.CVYICL S �• `!'�'� � (� , lu f-y
1
Owner Name(s): ���`�• T''u S f Phone: ��3 - 7�� - �3�f/
Owner Address: 1���/�/ �� ,6;�-c� �cc��.0 1`�uq��j�+^��i��ip: 5���-3
Project Address: �.ti- -F�
G�e�-�ot: t'� SW 1/4 of S�t� 1/4, Section�, T �Z N-R g E❑or W
Township: L-�1Yb0{� County: ��'
Project Parcel ID #: b I�} -��f L-l 3 "- ��G�
Designer Information
Designer Name: y�'C�S�,� �i,«tT-� � Phone: ?/S^ - ���- �.�5'�
Designer Address: � b , �� (�(,, ��j(,�, 1�.�`.�' Zip: .��'Zf
E-m a i I: '��t�►����11,�.�,i +7�S�C:-�!�� , �,�
License Number: �a�7S7S��
Remarks:
Signature: Date: 1� zZ
Original �g ature required on each submitted copy.
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(:ell Separati�n
� 3' �j
� t I 3
{� �`� Final Grade
�r ' .- _ �i. C �,i�+ . .t . . � �,;��
` fi-� �F�'Y�'� . G .'U,� a�,� E µ�'j
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`kk ` "� : �`r � ceii�z - �� � c
— v , _ � � ,��, f �� : �,�i�}t' Geotextile Fabric
� �: , u� ���- �" �� _
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-- ��'``� ����:�;
Design Ffow 4� /Loading Rate -� = Required dispersal area �`{3 ceu tt�
System Elevation: ��'S�
Required dispersal area �nS?% /50(EISA)_ �3 (number of units)
Final Grade: �7•�i' �I�'��q �
Geotextile fabric to meet Comm 84.30(6)(g) "� u std1� C� Cell#2
Minimum of 12"of cover over top of cell � System Elevation r���`�
Two Observation/vent pipes to be provided per cell 3� X�Q r �-�LI.S
Final Grade C►7 �o- �)�tJ�J �
Not to scale
�/� (.Ch�fs
t� u.n i�s� S(7 = �l b d �f�
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 Dispersal Area Operatinq Limits:
Design Flow = �-(� gpd; BODS <_ 220 mgL"'; TSS <_ 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, etc.)
o mechanical malfunction (i.e., pumps, vabes, 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 lateral orifice plugging (measure lateral distal pressure-compare to design specification)
o surtace discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 251.48 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 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 will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: N\ > Phone: ��iS)��'g'33��
Local government unit: Saw�' �,o�,.'{zi Phone: (�1J� (��4-<3�d y
Local government unit address: (D610 wlo;.� �_ 5..,��-z�{`� ZIP: ���� _
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 failed treatment component of this POWTS cannot be repaired, it shall 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.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
'�`�`''"``'f"� PRIVATE ONSITE WASTE TREATMENT co��cy
T�',
J�� �'�
�����oSp �)�; sYsrEnns Sawyer
�,��� s ( POWTS)
\ry°� �y�/ INSPECTION REPORT Sanitary Permit No:
`F�s,,,�,,�
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 22 ..�°(�
Personal infonnation you provide may be used for secondary purposes[Piivacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village [�,Town of: State Plan Transaction ID#:
�om GlS �}'��i� I�W I2 M�2v. 1 Y�+3 J �(UO"1 ^--
Insp BM Elev: BM Descr ption: Parcel Tax No:
�o���� �� w-e.�� b� — SY�� �3 —33�
TANK INFORMATIO ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ���� �p Benchmark l0O.�`
Dosing
Aeration Bldg.Sewer
Holtling St/Ht Inlet
TANK SETBACK INFORMATION St I Ht Outlet �Y•o$'
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. 43,3S�
Holding Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative
�
Surface qa•s3
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS W 3 � qp` �jp� #of Cells a Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav �— Conv ❑ Aggregate
P/L Bldg Well ❑ IGP o Chamber
INFORMATION Waters � AG y� EZFIow Model Number:
CELL TO �4-�'b � �' .1-�� �t/ ❑ Mound o Other
- - -- --
DISTRIBUTION SYSTEM x Pressure Systems Onry
-- __ - --- -
Header I Manifold Distribution Pi e s � X Hole Size X Hole Observation Pipes
--- ----
P � )
Length Dia Length Dia Spac _� __ Spacing ❑Yes ❑ No
SOIL COVER
-- -- — —--
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center � Cell Edges Topsoil_ _ �0 Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
��s��� 1���-��a�
� �.��a�e� �(� ��r
Plan revision required?0 Yes� No �3 (� �3 � - _ � 6�'j � '� �
�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: ���.�-9�
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