HomeMy WebLinkAbout024-110-00-3200-SAN-2022-312 - e -
County �
"'� Department of Safety � ��
O$ �C Professional Services, Sanitary Permit Nu r(to be tilled in by C �
�t . Industry Services Division
�o �3� �� � �
State Transaction Number �
Sanitary Permit Application _ �,,�
[n accordance with SPS 38321(2),Wis.Adm Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtaining a sanitary permrt Note Application forms for state-owned POWTS are submitted to Project Address(if different than mailing add
the Department of Safery and Professional Services Personal informauon you provide may be used for secondary �
purposes in accordance with the Pnvacy Law,s li.04(1)(m),Stats. ���r./ �`''� T^SI�� �
I.Application Information—Please Print All Information w •J-
Property Owner's Name Parcel#
�u�.-I-l� � i� �-�L'oc �s�� `� J�S � ��u�4-kC� a2�_ l(0 �n 0 --3�a
Property Owner's Mailing dress Property Location
( 7�� �OGSeI;P�� ST,
Govt Lot
City,State Zip Code Phone Number
W V1.��.1.1� u.�� �7 ' /v J ��,�) U-1() r ld�� �/a. ��i. SfC[IOR ' 1
II.Type of Building(check all that apply) Lot# T �1 R W.
�I or 2 Family Dwelling-Number ofBedrooms � �� Subdivision Name
❑Public/Commercial-Describe Use Block# _ �j� �t} �5'�l.Cl�
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
� �i'own of t�(i�U �Le
III.Type of POWTS Permit:(Check either"tiew"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i
a licable.
A.
❑ New System �t Replacement System ❑ Other Moditication to Existino System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
❑ Renewal Before ❑ Revision ❑ Change of Plumber
Expiration �
u�k.
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(epd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
` �0 ��7 � �yS-� q� z� '
Capacity in Total #of ManuYacturer
Tank Information Gallons Gallons Units � ` o y _
New'I'anks Eristing Tanks �`+..° � y � y � �' n
a? p u .n � �
c. U �n � rn ii. U a.
Se tic oti�lsldw Tank -�� �� '
P s / �U I� -�;2
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installafion of the POWTS shown on the attached plans.
Plumber's Name Print) Plumber's Signature MP/�[PFZS Number Business Phone Number
�"IJUI'� �u��'E� ��� ,�� �y 7.S/S/ 7/,S` �d��.�.SJ
,,�.::�'�;..^`i
Plumber's Address(Street,City,State,Zip Code) � �
: � . ��� �� C��l� wT ,5��
VI.C un v/Department Use Only
�Ap r � 3 ' ❑Disapproved Permit Fee Date Issued Issuing A�ent Sienature
❑Owner Given Reason for Denial � `W'� y� I 3�'`�� '" 1/�C���-�l/W�--
Conditions of ApprovaVReasons for Disapprocal _._ - _, :;��7�'f r:;;,��-`
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....��#_�.,.�.�3�..�.__ ._:, ,_� � '�l OCT 20 2022 � _.
CT �39� � �
-S 1 v�-� r" � a� N`et^� �lOr l� � SAV+�`�,� -� ; � ,�
7_ONINi,Av`r',�V 1� 4i'l !�
Attach ro complele plans for the system and submit ro the County only on paper not less than A li?x 11 inches in size 2 3 y� .�
sB�-639a�R.o�izz> NO R�FJNDS AF1'ER
ISS11E OF PEAMR
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
Ci,«-E-h �am�ly P�uo� 7�usfd
Owner Name(s): ?oS�ti �'an�l-kA Phone: 7� S - y�{�- l�/3
OwnerAddress: ( 7i�F RGCSe��e�-l- 5f (;(/�uSku; �'-r Zip: 54�fo3
ProjectAddress: (o�S'7zl,t� f-Uc�� Sslt�,� Rt� . }�uu����� , �T ���{.3
6av� Lot: 3� 1/4 of _ 1/4, Section�, T �FI N-R � E � or W 0
Township: �Ol�a �P County: �a-�U e,l�
ProjectParcel ID #: O2�{-110 - 00 -3?��� ( l�lC� �17L �� SS��GQ St,��D,
Designer Information
Designer Name: J0.Soh rUc�� Phone: 7/� -74� -3�i3�
Designer Address: � a • Q� �� ���e � t,,1 � Zip: �{�'2-/
E-mail: ��vr� L �Yy�tS � [-ev/�
License Number. (��5751
Remarks:
Signature: Date: ��� Z�LZ
Original sign ur required on each submitted copy.
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ce,u_s �,�� ;
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Qr���se d 5�..�s�e-� = �'-��Z� � a; � ,
Sy,S�e.rr► ���� = 4�. 3 S ` — �"`�. t7 ` yP
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o v�ev►ca �
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-- ___�_- _ --�--�-��--= �___
�Q.S�vI �u.��� ODSC L�-�{��C. = �Q � f
w��P � �o�s�si rn�-__-
�� (� Z ( ZZ
Cross Section of a two cell EZ Flow In-Grounc� Dispersal Componenl
Cell Separation
I 3 � 3 f� I, 3' I
�f � Final Grade
--1�
'.4, � . _. 'tr - ` r b ���� � ��- -�..�;;;E,�d
z �
. Cell#1 � •. � v; °� Ll�`'6 �"4 F4�-�
� • � f�f�}" ceuu2 ' 1.�' �}rl Geotextile Fabric
♦ ' � �' ��Y
12" I � �� �s �
'I `� � !�'+'� � +� ��;{
— � t'{
.����. i� � :��` 2 ,�r'.7
{�3,i
� s`�,�' �'�I - �'�,� k.`?�T�S,
K`?? � �z�i��.1�
" + � �� Y , y�,���,��
..Lti, � �3 1 ``-��
Design Flow 3G`D /Loading Rate ,7 =Required dispersai area_�19 ceu#�
System Elevation:Q��2`��
Required dispersal area_��D _/50(EISA)_ �f _ (number of units)
Fina�Grade: 99�`�te.
Geotextile fabric to meet Comm 84.30(6)(g) � �(SCr�J(. �� 3`x�S� Cell#2
Minimum of 12"of cover over top of ceil System Elevation Q`f��
Two Observation/vent pipes to be provided per cell �L�
Final Grade �}%:S��U�.
Not to scale
PAGE 4 OF �
i �-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shaii be responsible for its perpetuai operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system sha(I
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 S 150 mgL"'; FOG 5 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:
Name of individual or company: �- �i'1'��� � �`�1 S Phone: 715'- �7�1�335��
Local government unit: ��� `� � «�� Phone: �� � " �v3�'�Z�`y _
Local government unit address: � ���� C.I�Z ZIP: ,�i��3
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, VVisc. Admin. Code.
Continqency Plan
In the event that ar�y failed treatmeni component of tnis POV�/TS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the aporopriate 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 PO��1TS is disconiinued, it shall be abandoned in accordance �,vith SPS 383.33, U�/isc. Admin. Code.
/��`''�'-"""'�� PRIVATE ONSITE WASTE TREATMENT county
�,:.
,;� . �
�>j� o$ ��'; SYSTEMS SaW er
����PS;�-� ( POWTS) Y
\�FF S 1.��\\�''%
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� .- �j��
Perso�al infonnation you provide may be used for secondary urposes[Privacy Law,s. 15.04(1)(rn)]
Permit Holder's Name: ����y �City ❑ Village Town of: State Plan Transaction ID#:
G�� �►�;1 ."I�-s �- ��J. �I�� �
Insp BM Elev: BM Description: Parcel Tax No:
I��•� r �� � e s�G� o��{- I►0 -bo - .32c�
TANK INFORM TION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W � � Benchmark �pp,p�
Dosing
Aeration Bltlg. Sewer� 97.S�
Holding St/Ht Inlet 47•6! �
TANK SETBACK INFORMATION St/Ht Outlet 9�.33 '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic a-t5� �S1 �1� �r�,2� NA Dt Bottom
Dosing NA Instal�ation
Contour
Aeration NA Header/Man, �TS;tf��
Holding Dist. Pipe
PUMP/SIPHON INFORMATION �nfiltrative �y���
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 t fS' YT #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv o Aggregate
INFORMATION P/L Bidg Well Waters � IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO �- fi-� ` ' ❑ Mound a Other
-- -- =�___ ___�_ � _ __� —_ ----- -
DISTRIBUTION SYSTEM X Pressure Systems Only
_ __-- --- ,— ----- _.
Header/Manifold Distribution Pipe(s) i X Hole Size X Hole Observation Pipes
Len th Dia Len th Dia S ac ;
9 9 p Spacing ❑Yes ❑ No �
- - -- —
SOIL COVER
- —_-- --—-- — —
Depth Over Depth Over Depth of ��Seeded I Sodded Mulched
__
Cell Center Cell Edges � Topsoil _ _ ___ _ ! ❑ Yes ❑ No I ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
���1� i� (�-31�--.�
, _ __ _ _�
Plan revision required?0 Yes ❑ No �p3 (3 �� � — —�� � — J 6� � r� �
L
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AND SKETCH
SANITAAY PERMIT NUMBEA: �'�_,�1�_.
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