HomeMy WebLinkAbout014-941-03-1303-SAN-2022-296 °'� Department of Safety c°"°ty �
O= ; & Professional Services, �'�v '��� �
' Sanitary Permit Num er(to be tilled in by i �
i Industry Services Division
. � 3 � a�-� �
�
State Transaction Number �
Sanitary Permit Application �
In accordance with SPS 38321(2),Wis Adm.Code,submission of this form[o the appropriate governmental unit �� ,�
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submrtted to Project Address(if different than mailing ac .�
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 1�.04(f)(m),Stats �i fj��� ���-�ESQ N �L��
I.Application Information-Please Print All Information `i
Pro e y Owner's Name Parcel#
�0.�►� c:�.t� �'�0.�- �e") 'S�Y��i'rl C1�4- — y�-f I --03 -�I303
Property Owner's Mailing Address Property Location
�3� �� �13�tl ��. � �t'� Govt.Lot
City,State Zip Code Phone Number P{-.
l�LcS.� �(,1,�� M N .S(D(�JJ .��y'Z�f -��7 ���%.,�lG Y., Section ,J
II.Type ofBuilding(check all that apply) Lot# T 'T� N R W�
�l or 2 Family Dwelling-Number ofBedrooms � j Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
� �j`f t��(�C �'Cown of �-111�L'c.'
3c:°�31`t —
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 i
a licable.
�' �jNew S stem �
y ❑ Replacement System ❑ Other Moditication to Existm�System(explain) ❑ Additional Pretreatment Unit(explain)
B g ❑ Other Type(explain)
❑ HoldingTank �1[n-Ground ❑ At-Grade ❑ Mound ❑ [ndividual Site Desi n
� (conventional)
C• ❑ Renewal Before ❑ Revision ❑ Chan e of Plumber ist Previous Permit Number and Date Issued
g ❑ Transfer to New Owner
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(�pd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�� �y3 �sz y�� �
Capaciry in Total #of Manufacturer
Tank[nformation Gallons Gallons Units � ` o -� _
New�I'anks Ecisting Tanks �`�..° � L u y v " vi
` a � � � � �
c. U rn � v� cs. U a
Szpticer�{.IeMeng.Tank i�J�..�1 I(�iC� ( �.(;.T•f SIC�1�-
� '�'Ti
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installaHon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature , MP/�l4P�Number Business Phone Number
Ja�► d�u�f+� 1 ----, .�' -r�-�-- ���.s7sl ��s-���-��.�
Plumber's Addre s(Street,City,State,Zip Code)
�. p . �c'1c �� C'q.��. w� S�f�Z-(
VI.Countv/Department Use Only
�,A�p o� Disapproved Permit Fee Date Issued Issuing Agent Sionature ,
❑Owner Given Reason for Denial ��� � � I �� I a� � u��'
Conditions of ApprovaUReasons for Disapproval , '1 +f'�.'1;! '
�� ��� � I
� o ��-�1�a ------------°_--- .�':
. ,3::
4sr.#i4._._. . ._. .... `�, ., f
� �� �; �- i 3� �� � OCT 0 6 2�22 � -
�
� ��GI ����,L __. _____ .
/�I� _W.or�cl � 3FsS3 �-- r,� :�_ ;
SAVNYER C,�..,;. .
�s� �-� " � I I M 1-E Z�I�dG ADMiNf�tR�i�U�3
Attach to complete plans for the system and su it to the County onl}'on paper not less than 8 I/2 x(I inches in size
`� 3q� 3
ss�-6�9s�R.o�iz?� NO R�FJNDS AF'1'ER
IS3UE OF PEFiMtT
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 Appiication for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s): �5�- I'Ylu r ���� �'� Phone: ��L -"Z'�{I - Z�17
OwnerAddress: j3�18 (n3'� z. NU1 �[xsSUC• MN Zip: 5�+�'j�
Project Address: I 1�17�}IJ t+��ti'�w�,W.L S�/d'�f�
6eat:t�t: �� �W 1/4 of lJ E 1/4,Section 3 ,T '-1� N-R�E❑or W�
Township: ���vYX?'F County: �u'�{2(�
—�
Project Parcel ID#: C I�-F—�1`f! - G3—1343 L�+t I �CSm'� 3u�3t�f ` �`f�9S�
Designer Information
DesignerName: T�lsb�� 1'�Uc�'�el Phone: �1S -�- �.5�3�
DesignerAddress: 'P0� !�c'�CC�� [r����t✓� Zip: S�f�'2-I
E-mail: -4-�rn �'tt,��vt-��aS. u�n
License Number. (�'l.�l S�
Remarks:
Signature: Date: /d S ZZ-
Original signat re required on each submitted copy.
�6�S�Y'LVY� i � I �� = �GI.
�--����s � �}1��� � :��i�. �
(D3 r� �UZ, � �1� �Ewce(rF �.;4ie,;r_ �t�tr�{h �
j3if8 — �
CctsS ��-e, M� 5�G�33 �a � �_o �3� y-�
320 — zy � - z� i7
� ��1'7`ffv ��f���eScn /Zc��
�-�. SGU� NE� S _3 � � �f (NiFkLJ
(�or I , csvn 3C•�3z�{ `��Y���
Tow�� c� Lz-��rcof
�acv�i �v- C.fi• , ccJ r
pl�{ -9`I-I - U3 — 130 7
j �j�y� _ �b0� @ �cttb�l1 0�
S}e�l s�(��n� o� Pcle �gl�C�.
Lc7 Lin��
�2
��e��V15 � LZ) P�Pcse<< Cells �� � C�,k�� �E+Cht�lr���e:s
.�--- �3z Clta.m.j}er5)
(3i= �r�.�3 ' _S'��-�em �e °
i (�g 3
(3Z, a�. 2l. � �I
9�,�3' — Q3.�� '
63 = q��. �� ,
P '��CS� �� 51�5���v1 = � 'f,� � �' . ��- P.rcPcSe� la;cEs�R I�� (�J wl
Tr��e� UV�-L�t-C
� p�:,up
'�YCLS t Glc,l� 'eLl;��`� = ��e.O 1 4�� S�a�FO f�PE
P , c�
�
��y'cl.u,�� '�'� N .W. C:L'�`Lluv" C,� (�cu1�e= �� .IZ� .
L✓C�CS�(�
3 �3 R
tve�e � No wF�t, c�N P�-oP��ry " � No�tine
� �� ���>v,epF S�?(L evn.fua�ze✓�� L,�,cyz
(��ss�biz Ne�� w<u, �:�a„�a �es
,
� � ;
�� �;� �
��._/ �
,.. ��� �asov� Ku��tel
�r1 U��)Q� v. I �,� fk
� � � u�tP lc7s�s�
+v Ey�GteSc�l''� Ex�s+;:�� �o�;�z�
��(_ ���� Qoc.E
� 3ui�o�n;G
\
�
—__ ------�
FNFILTAATOR C9AYB=R CRO�S-«CTIC'a
2 CELL(S)
�" Sch. 40 VENT / INSPECTION PIPES �
' � 3 `
4" 3034
or
sch . 40 �
` �(�. 1�� -
Z 3 ' X ��. IF� CELLS WITH � �I'
QUICK 4� CHAHHcRS b L END CA?S
j�� CHAHBERS AT 20 SQ_ FT_ _ �,�{(� SQ_ FT_
_� SETS OF END CFPS @ ��' _ ( Z g4_ cT. Total c �OS.� f}2
(p.0 .
/4 " APPROYED VENT CAP OrZ INSP�CTION CAP/ pLUG
4 " SCH 40 �i
PVC PIPE =IN.�� GrZ;,D=' � ti �. A�Z .
i � 1 i/ i/i /ili / i . /// / �._�__
i _ � � I . , Schematic of
Sin g(e-Laver
12 " min. - : - i - i - ' ����ip-(}}
� _ ` - . f - I � ` - - . USING INF]L7RATOR
' � '
� � - _ � - . QUICK 4 STANDARD �IuS
_ . � � • .� ' CHAMBERS
IZ' �.
.� I _ i
t � � I , H'�
I Innqrncr C..u-_m
�"X��ytf�t�. �"J
���.�;���:��::�`�`��'���������� SYSTEMC�� = ��f.D '
��/.�y.�'/."</.��/��f\%�i:/..�:.
\%�:;�`/,\'\/.�Y�/�i i-,
\�j�\i.\:.�::�•%��/\�/��%\;'� .
. �
i��':•%%:`i :/.�/i•%i�%��.�\��\.
-:v.:v
' PnGE Ge
PAGE40F4
in-ground Gravity Management P1� n
lMP�RTANT:
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, ali 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 S 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, 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 prior to 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 surface 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. 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 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:
� �.�G.St'Y� ' `�` � � � �
Name of individual or company: . �����L S Phone: �ls`= �4�'--' 'S�
C � �
Local government unit: �CC�ll,1.�1.►�E'_i'� � ' ��.G`1� Phone: 7�J- �3�— �2
Local government unit address: �c�-t,il�,i�� , l;� L- ZIP: ��'�{,_j
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, V�/isc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance �vith SPS 384, Wisc. Admin. Code.
Continqency Plan
In the ev2nt ihai any failed treaiment component of this PON/TS cannot be repaired, it shall be replaced pursuant to
a plan suomitted to the appropriate agency for revie��v 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 PO!iVTS is discontinu2d, it snall be abandoned in accordance ��vitn SPS 383.33, ��lisc. Admin. Code.