HomeMy WebLinkAbout002-940-04-1218-SAN-2022-299 ����� Department of Safety c°°"�'E�,� �
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_ � �a ��'j �� & Professional Services,
�a q��� ��� II1dUStI'y .�CI'VIC@S�1V1SI0[1 Sanitary Permit Nun (to be filled in by �
_ Q' (p 3q �-8�
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Sanita� peY.l,nit A ppt ICatl�n State Transaction Number ' �
Ly 1
In accordance with SPS 383?1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 7•�
is reyuired pnor to obtaining a sanitary permit.Note:Application forms for stateowned POWTS are submitted to Project Address(if differeni than mailing -a
the Department ot�Safery and Professional Services.Personal information you provide may be used for secondary , / �
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ����� w
I.Application Information-Please Print All Information
Property Owner',Name Parcel# ..QO�a" -(j!�'".Q y^�
!\1 � '-' �a�'a.DL ,—y
(� 4�-GOO --DoelOd
Property Ow 's Mailing Address Property Location �pT�� � LZ�
� � �� � , ►�1
Govt.Lot
City,State Zip Code Phone Number �
��[ ( ��'T' ( A�( � ���/�/� ^7� 1/„ '/4, '/4, Section �
..r.. �- ..-.;.- ..G U�.� ��,6 0�. ��G�
II.Type of Building(c6eck all that apply) I.ot# T � N R�E o W�
1 or 2 Family Dwelling-Number of'I3edrooms � Subdivision Name
� B�o�k# �3y/�o� �-�'lt.�
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Desc;ribe Use CSM Number ❑Vil(age of
�1,Town of pr,C�� l.F��
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.
�A�lew System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B� gn ❑Other Type(explain)
❑ Holding Tank ►n-Ground ❑At-Grade ❑ Mound ❑ Individual Site Desi
(conventional)
C• ❑ Renewai Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to New Owner
[;xpiration --
IV.DispersaUTreatment Area and Tank Informallon:
Design Flow(b�d) Design Soil Application Ratc(gpd�'s� Dispersal Area Required(s� Dispersal Area Proposed(s� Systero Elevation�
/ 1 � C " 2 O ��la��
Capacity in Total #of ManuFacture
Tank lnformation Gallons Gallons Units � � o ,'�, ^
�e u V �., �
New Tanks Existing Tanks � � � � � � � �
0
a U �n � va ir, CJ w
Septic or Holding Tank �� � �C.� / / �
�, .
Dosing Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians.
Plumber's Name(Print) Plumb 's Signature MP/MPRS Number Business Phone Number
� � � 715 J�ib7,3
Plumber's Address(Street,City,State,Zip Code)
��5�i N �TU�� �1� �� � wa�� v�.� s�e�3
VI.County/Department Use Only
� �0 1'�.� Permit Fee Date Issued lssuing Agent Signature
Ap ro�e ❑Disapproved �
❑Owner Given Reason for Uenial ��'� I O `l$I 2� ��t�'�"�^-"'��/�""'��`-
Conditions of Approval/Reasons for Disapproe�al
���:: � � l(�f�� �� �C�������
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�� ' �� Ch� 1 ��a
OCT 1 1 2022
�S� �� -- � I '—( Rc:; ,:� Ne,w_ (.N_cr��`�38co�I
�µ SAWYER COUNT�
�ONWG A�MINiSTRAT ON
Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 x I1 inches i�size , J��s�
-I
SSD-639s�R.o3i22� NO REFtJNDS AF7ER
IV�� � ISSUE OF PEFci,AlT
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 Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): I,��`7�1�, � ����d'�G�1 �: ��� Phone:�lJ -(r.��'- �lfo
Owner Address: �J`��',�11� �U-�'���� (Z�. �c/c,��1�u.�Zip: �����
Project Address: �Q/yt,,P
Govt. Lot: �Y��r��1/4 of 1/4, Section Q� , T�N-R (x' E❑or W�
Township: �jQl.�� �'� County: �
Project Parcel ID #: `rJ 7�f,�oZ'"�'���-�0 u—i B�-`dbC�-- 00� C��
Designer Information
Designer Name: �� Phone��S ��- `�
Designer Address:l(? 7 jL,�- Zi : `vJ��►��
E-mai I: (,C�_..."`."_` �S�' ,..
License Number: �9�� �
Remarks:
Signature: Date: �d�����a
riginal signature required on each submitted copy.
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� � Septic Ta k(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA l�/,�e s {'!,
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) 7s�Dae, 9B� ge� ae�
Effluent Fllter Man facturer:
�'� _ ��,-oti��-� ��;� _ r��P
� r>"� 8�z
Effluent Fllter Model#:
min.17'
SOIL COVER (ryplcep
12"
min.Iranch
depih
�ryp'�''� _ � TYPICAL TRENCH
�—�3M1"'.
a CROSS SECTiON VIEW
(typlcaq (No Scale)
� a Provide minimum 3 ft
System Eievation=��)ft separation between trenches.
(typical)
QWck4 Standard-W
w/End Cap �Show location of inlet/outlet pipe connection on plan vlew.) Ohae(typ�lcal)�PB TYPICAL TRENCH
�(rypicalj
Installpermenulacturela PLAN VIEW
—————� InshucNone.
(No Scale)
�4V,k4dFw�vvd�aaVk�id�`7�'---- — �f-- ?�.Faoq��,��dk�ks v�'r�4��,�
�i"� o i i
�-�---- � �`�— ��-------y�--- , � �� �, �;,� a=a.ort
�i:rwaavwnru�xd'��i�._' 1 (bPlceq
--- _ .�.v..�,��kw�wws�x��� D
f B= .�.� ft —� m
(typlcal) Qulck4 Standard-W Chamber W
INSTALL PER TRENCH: (ryp�ca�) �
(mfd by Infiltrator Syslems,Inc.) �
Install pureuant lo menufecturer's Instructlone.
- Quick4 Std-W @ 20 fl'EISA/chamber= l b � ftZ �A
+ �„Palrs of end caps @ 6 ft�EISA/pair= ��ft°
=Proposed EISA per trench= �6 ft� Required Inflitration Area= 2�ft� Distribution Method:
x �trenches =Proposed Total EISA= �ft' �/�cc�;�.� ��,�;l�;/�
fn-grouna vravity Management Pian
lMPORTANT:
The owner of ihis in-ground gravity system shali be responsibie for its perpetual operation and maintenance pursuani to
requiremenfs of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code, this system shall
be considered a human heaifh hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Mainfainer in
accordance with SPS 383.52 (3),Wisc.Admin_ Code.
AAaximum Disnersal Area Operatina Limits:
€]esign Flow= /,S�J gpd; BODS<_220 mgL"'; TSS <_150 mgL-'; FOG 5 30 mgL"'
Insaection Checklist INSPECT EVERY 3 YEARS
o type of use
o ageotsysierr�
o nuisance factors (i.e. odors, user complaints, etc.)
c mechanical malfuncKiort(i_e., pumps,valves, switches,floats, etc.)
o material fatigue(i.e.,leaks, breaks, corrosion, etc.}
o solids volume in anaerobic treatrnent tank{s)and any distribu`uon appurtenance(s}(i,e., disfribution!drop 6oxes)
o negiect or improper use (i.e., exceeding design capaci5es, prohi6ited activities, etc.)
o exteni of pondir�g in distribution cell prior±o dosing
o dosing irregularities-if applioable (i.e., pump re-cycling, 8oat switch settings, etc.)
o etecfical components-if applicable (i.e.,wiring, conneciions, svtitches, controis, Gmers, alarms, efc.)
o distritrution lateral or�ateral orifice plugging {measure taterai distai pressure—compare to design specification)
o surFace discharge of effiuent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Sentic and dose tank(s)shall be pumped by a certified septage servicing operator iicensed under s. 281.48 Wis.
Stats.whers the votume of solids in the tank(s)exceeds one-third (9!3) the liquid voiume of the tank(s) or
as requirea by Iocal ordinance. Disposal of contents shall 6e pursuant to P!R 113, Wisc.Admin. Code.
e Effiiuent fllter(s1 sh21i be inspecied every 3 years and shali be cleaned vrhen necessary to remove any
accumulated so�ids according to manufaciurer's spec�cations. ."v servicing period wil!aiways be greater than 12
months.
Sysfem maintenanee reports shall be submitted to ffie proper focal govemment unit in accordance wiEh
SPS 383.55 Wisa Admin. Code, Report any component failure or matfunction to:
Name of individuai or company:_�yQ4'l ��'���c.r c,� Phone��S�J �'t�7�7.�
Local govemment uni't: Pnone: �l rJ ��j��c�-g'g"
Locai govemment unii address: � �0 `` � Z�p_ �j�E c��
Any defective part of ihis system shali be repaired, repiaced, or removed pursuant to SPS 383.51 (1),Wisc.Rdmin.
Code. Repair or replacemeni of fiaited or maifunctioning components shalf comply wiih SPS 383,Wisc. Admin. Code.
No produci for chemicai or physical restoration oi fhe POWTS may he used uniess approved by the department in
accordance with SPS 384,Wsc.Admin. Code.
;ontinaencv Ptae�
in the event ihat any failed treatment cromponent of this PQln1TS cannot be rspaired, it shait be reptaced pursuant to
a pian submitfed fo the appropriate agency for review and approval. A iailed in-ground dispersai component may be
abandoned and replaced by a code-crompiying dispersal componenf in a p�e-defermined area of suitable soils.
Svstem Abandonment
li use of this POWTS is discontinued, it shali 6e a6andoned in accordance with SPS 383.33,Wisc.Admin. Code.
�: '"�T'"'` PRIVATE ONSITE WASTE TREATMENT �ounty
-- ,>,,,,
!�'��oS \l�'� SYSTEMS SaW er
'�i� ps %"-` ( POWTS) Y
\�'� �j;
�,="'v'- INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � '� _ �C��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(rn)]
Permit Holder's Name: ❑City ❑ Village ($.Town of: State Plan Transaction�D#:
"r �- ��,, c,.� b BRss c�k� ^
Insp BM Elev: BM Descripti n: Parcel Tax No:
l���O� -� w�� � �
�oas2 0 � �n� �b�2 -4Y(5 -�Y- 1��g
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �„��r- '7� Benchmark ��,p�
Dosing
Aeration Bldg.Sewer T
Hoitling St/Ht Inlet `l3•S �
TANK SETBACK INFORMATION St I Ht Outlet c��, 3�
TANK TO P/L WELL BLDG VENTTO ROAD �y Inlet �'+
AIR INTAKE `+'� rT'f � C13. � �
SeptiC �- � �/ �-S` -�--s- ' NA J�t�nm �� p�,'�- �l3 � �
Dosing NA tnstallation
Contour
Aeration NA Header/Man. r-/3A �
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative �a, o �
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 �N 3 L #of Cells Type of System Distribution Media Manufacturer.
SETBACK OHWM of Nav � Conv ❑ Aggregate �.y��,' �
INFORMATION P/L Bltlg Well Waters � �GP � Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO �$� N 1,/ ❑ Mound o Other QY,�
— --- - -- -- -- __._.._
---__.
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 j Depth of Seeded/Sodded Mulched
Cell Center Cell Edges j Topsoil_ _ _ ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
�-,5�ll�i 9 I��-(�3
Plan revision required?❑Yes ❑ No I O� �S- �� � � � /c����
v _
Use other side for additional information Oate POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITAAY PERMIT Nl1MBER: �2��-�°t___
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