HomeMy WebLinkAbout026-939-29-4201-SAN-2022-301 ��'`'�"`,��; Department of Safety c°""�' (�
� � �'���� S�-�wyeY� �
� p & Professional Services, �
, .,, � � Sanitary Permit Number(to be filled in by
, ��; �'� .,�` Industry Services Division
;� C� 3� ��a R,
� ,��d�..E�.�.
• • State Transaction Number �
Sanitary Permit Application �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this foRn to Ihe appropriaze govemmental unit �
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing ,�
the Departlnent of Salet��and Professional Sen�iees.Personal infortnation 5°ou proeide ma��be used for secondan� -)e..���, ���„�� ��
purposes in accordance w�ith the Privacv La�v,s. 15.04(1)(m),StaCs.
I." """` ' tion Informatian-Please Pri�t Ali Information
PropeRy Owner's Name Pazcel#
s �- c.LC��f 3 i 2,`'L�/2cy/
�� �-/�7�e�'.�(9�.�
Property Owner's Mailing Address Property Location
�,z�� �3 6--t h S�i� Go�.Lot
City,State Zip Code Phone Number
-�-� �_� �•, '/<, '/a, Section Z�
�l ' i'4.�C>.. r�--�f S j,�,`.L�, ..� � l-� (
II.Type�f�ildiag(ehec�C a11 t6at aPF�Y) Lot d T 3� N R c'�l E o
I�1 or 2 Family Bwelling-Number ofBedrooms �"' Subdivision Name
C_
Block#I
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
. �To�m of �,iU C� �..��-k�
IIL Type of POWTS Permit:(Check eiYher"New"or"Replaeement"and ot6er applicable on line A. Check one box on line B.Complete line C if
a lieable.
,�,
❑ New System �Keplacemeot System ❑ Olher Modifioat�on to Lixistmg System(explain) ❑ Additional Pretreatment lJnit(explain)
B.
❑ Holding Tank �In-Ground ❑ At-C'.rade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
ist Previous Permit Number and Date Issued
C'• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to Ncw Owner ?
Expiration (.th�
�":::� 1�'r+ea�t Ares and Tan�C Intornyatioua
Design Flow(gpd) Design Soil Applicafion Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
3� G �' �l1�� �-1�-� `�iN. Z�( -- `t 3.�;
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units D � U � � o
New Tanks Existing Tanks � o � � � � � �
a U ci� �, in ii C7 fS.
Septic or Holding Tank 7�' - �$'�� ` ��a l F�'� �
Dosing Chamber
V.�espt�asibility Stat�me�t--I,the undersigned,assume responsibility for inatallation of the POW'I'S shawn on the attached pians.
Plumber's Name(Yrint) Plu er's Signature MP/MPRS Numbcr Business Phone Number
Jerry Ruid Excavating, LLC t�_.V �'�.���`: �,�Z��, -� �j�._�<<_j�_Z�C.C�
Plu i , e ip Code)
Stone Lake, WI 54876
VI.GauntylDepar�ent Use Only
�Ap ro �� ❑Disapproved Yermit I�ce l�ate Issued Issuing Agent Signature
❑Owner Given Reason for Denial $ L�D•� '� ����a� ��/ ��"[/�-
Conditions of ApprovaUReasons for Disapproval �- �-n �
� .
,.,Y� I O 1.���� a' 'F_)�'L���� �y f ���
Ua�t._...�. :...�.s..-._._
,•,
� � W......._.._. ,
�'���' ��► �y�' . 3 S o y..� �k�. --- �,�
L _',�,,.
�t��,:�:' Ne.w ..Wo��� �3��� ��T 1 1 2022 ;-
cs-� �- a - � _ __.f
a 1 l9 . � ���n;r> �-� cr s{ __:��
''`l�,ll�j.^,-r l,�nrl�i`��,�� -jATiLI?�
.lttach to complete plans for the system and submit to the County only on paper no[less than 8 1/2 z 11 inches in size �� � � �
NQ R�FUNDS AFTER
sa�-639s�x.o3i22> IS3llE OF P�'FM17
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 Ma
Project Name / Description
Owner Name(s): �.m er sc�= Phone: - -
OwnerAddress: �'>>`� l3ia-rl�, 5;. ��d;�,qn��._K�-�c�CIS Zip: � -�`{72�i
Project Address: S `� 3� ��.��� ��
Govt. Lot: 1/4 of 1/4, Section z`� , T3`�t N-R `t EQor W Q
Township: S�L.�cl 1-,�=-IC�: County: `�t�-.- y< d"'
Project Parcel ID #: � Z F�`� 3`��S 2t:� Y 2 �= �
Designer Information
Designer Name: Jerry Ruid Excavating, LLC Phone: �r� -�`t�- z���c�
oun
Designer Address: �t��e Lake, WI 5�1��6 Z�P�
E-mail: � r��d �'? G<n>i vl'y�t'- /+ i:� ��� This space reserved for approval stamp.
License Number: � �f Z� c.- 2_
Remarks:
Signature: ��---` '�.�� Date: /� - �� " ' Z
'gina ' ature required on each submitted copy.
Reset Page
��a�E . CXECKBDXAl11PPLIGIBLE
� SOtL EVALUATION o ��' '�''�' � � Q SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECTNAME: �a, oeeic,H�ow: 3oc� oPo
�M�e.r 5 d.� Attadi da�ipn 11ow alaletlom tor oomnrrdN plans.
nno�cr�oor� s`{3 8 p �,�-p Pa� �M.auw i�smr,mti cr.ew aea.aas a 3ea.sa.s�
Nv�� ><-�.
�11Jnpyt� NI BM(� Om !oG-� � �Y 8wwr. ��E �' L L
Byp� JO �A 0�4 W�,dl �!`j FanN�tc /
af�A�A�c�� ��BlR��ld(t�k 0 a�wiv�im 8how praund�at�u1LbN Inkwv�4. �
m nr�pRapld ia
Sr ��a5e.vo, I w �
ty U 41'CI'� \1 � � ` C9 . `
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2 �'1 �.f�
'� 3 � T.�
�`c �\ sysieeh4`1.2�( — `��
� Cab�,.� a"l,0
'
, �
--%� �r�ea� �� Lr�vc S nr��6
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3 '' � �_,o�,.,-f-o�r � •.� `resYe��
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Jerry Ruid Excavating, LLC
W208 County HWY A
Stone Lake, W154876
csr _ z�12`t62
rt r'RS
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\ �
' Septle Tenkla)Metxifec0eer
IN-GROUND GRAVITY DISPERSAL AREA �--'��s�� ��
Unifortn Elevation Trenches with Quick4 Standard-W Chambers �,„�,a�k�,��a,.�„�,r
3-ftTrench (down-sizingcredit) ���?,a, _,a, _�� _�
Em�am Fi�.n+..,r�w�r
����r�r��..
� �T �
EMuent Filfer MOCtl#.
Mn.12
SOIL CAVER ����
tr
m�.ama
��i � TYPICAL TRENCH
� CROSS SECTION VIEW
�7i�� � -�,,. (NoScale)
��' - �� �' Provideminimum3ft
Systam Elevation=`�`���'ft sePsratlon 6eWeen lrenches.
(rypice�)
Quick4 Stendard-W
w/EntlCep °�°"'"°"'°� TYpICALTRENCH
�ryPi�� (Show loptlon M inlet I outlet pipe conrrection on plan vie,v.) '�I�ba�. 1
P�,N VIEW
��huCtlw"� (No Scale)
-- -----1�-------�f---- -- � �
. - - . A=3.Oft
_— (�i) �
--------yr-------�r--- — �
s= �-!C� ft �; m
(rypiceq puick4 SterWerd-W Chemhar W
(dP�O 0
INSTALL PER TRENCH: imra w i�mam,s�,�..u<� �
i�m�w��m,�mmenurxw�eronm�m,a A
�� �uick4 Std-W(oj 20 H EISPJchamber= z Z'�%ft'
+ Peirsofenticaps�6KEI5PJpair= ���� ft'
=Proposatl EISA per trendt= �Z� ft' Requiretl Infiltradon Mee= �ft DISVibUfion MethOd:
x �_trenches = Proposed Total EISA= °5 �— R' �"`�""`��)
�
� � PAGE 4 OF 4
In-ground Gravity Management Plan
i�r�rr•
rr,e owner a this m-s�o�b srs�m ehal�oe r�por�sro�e ror ita perpea,ai op�on end mdnoe�,anw A,rs�,arrt co
requirert�ents of SPS 3�.�84�VVlee.Admin. Code. Pursuarrt to SPS 383.52(�,WbC.Admin.Code,thia eyatem�eil
be considered a human heeith t�ezerd ff not mahrtairred in axordar�e with thfs approved menagement plan.
Furthertnore.ali�Dn arb mdrrtenance ac6vi�es sha�l be peAomied by a►aglate►ad PONRS NrhrWnw in
exordence wRh SPS 3�i.52(3),VVisc.Admin. Code.
M�dtAufn Dhosraal/tree Ooar�a Lllnit6•
DNign Flow. 3or� 9pd; BOD6 5 220 mgL''; TSS S 150 mgL''; FOG 5�mgL',
Inaactlon Ched�st fNSPECT EVERY 3 YEARS
o type ot use
o �e of sy�em
o rwisance faQors(l.e.odas. user complairrts.eAc)
o medtWCel malfurx:Uon(7.s.p�mtps,veb�.�,fl0afs, etc)
o ma�erled fatlpue(i.e.� leal�, breal�s,cortoslon� etc)
c sai�vdume In er�eroeic treetrn�n tank(s)ana any c6�ibu�on appurterrnce(s) p.e.,�etricu,�on�dr�boxes)
o neglect a Imp�oper use(i.e..eocceedn9�9��.P�ibited activitles. eta)
o �of ponding in distributi�ceil pria to dosing
u dastr�9�rregtderitles-if applic�bb(/.e.,PumP re'cYclin9,float switch settings, eta)
o elecMcal oomp�et�s-if aPdicabb(i.e..wMng.connecdons, sa�efros,controls�timers,alarms, etc.)
o dlstribudon 1�1 w i�aral orffice P�uggi�9 (measure laterai d�stal preeeure-canpare to ded9n epedflatlon)
o suAa�e dixhmge d dfluertt or eewage b�Ic-up irrto�rudure aerved
MAINTAIN EVERY 9 YEARS(w when n�er»
o ahell be pianped by a certlfled�senidrg operatw Iicensed uadx a 281.48 Wfe.
sc�s.when�ne vaua+a or wnas m me�enqs�e�axsa.o�adrd���e,e iquw voa,m.or u,e aroo(s>w
es required by loCal Ordnenca. OFsposal of oo�shall be�rsuant to NR 113.Wisc.A�Mn.Code.
o shall be ir�peC[ed evsry 8 yMrs and�ail be de�ed wh�n neo�y to romove arry
�aim�dated aofl�ac�r�ng to manufaeturer's spadficeidons. A aervfdng perfod wIH always be pnseFsr than 12
montl�s.
Sys6�rtt msinlenence rsporb efWl bs wWnitDea Eo the propsr local gover»nwnt urdt fn�or�np wMh
SPS 3BS.S6 NRse.AdnHn.Coda Report aery�romporront tsiluro or maNurnxion to:
Name of ind'rvidual or canparry��rr-7 �.,.d �Y�...�i�n.� Phone:7i5� 44 2� 2`(v`�
Locai gonertenern urit: SG Z anone: 7/5-E 3 Y-o 2�f5
LOCHI gOverrnnerrt wdt�dres5: �l�l� Mo�.cn� S! . E{o.�r��er�t✓i ZIP:S Y vY 3
My defec6ve part of thfs syslem�fail be repaired. rePlaced�m removed pursuarrt to SPS 383.51 (1)�Wisc.Admin.
Code. Repalr or replac�r�ent oR fetled or maffunctkr�g componerrts�II comply with SPS 363,Wisc.A�nin.Code.
No product Tor chemicai or phyaicai r�tmetla�of the POVYTS may be used uniess approved by tt�e depertrrieM in
awordanCe with SPS 384.YVIx.Admin.Code.
C.a�dn�v Phn
In the event that any h�ed treatrnent oomponertt of th�POWTS cenrat be repsired,it shail be replaoed Purauant to
a pian submitted to the appropriaEs ayency for review end appraval_ A feiled M-ground diepersei compor+er+t maY be
abandorred and repfaced by a codecomplying di�ersal oomponerrt in a pre-detertnirred area of suitabie eoiis.
Svateltl/�bandOntrlent
if use ot this POVYTS�.dboDntlnued.it shali be a�r�oned in aaordance with 3P3 383.33.Wisc.Adrtdnn.Code.
I^�.�°�_°_1