HomeMy WebLinkAbout024-741-33-2201-SAN-2022-341 _ '" � Department of Safety c°°"ry �
_ � = & Professional Services � �
- �_ Z� - � Sanitary it Num (to be filled in by �
` = Industry Services Division
(� '3�I 31 rl 5,.�
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Sanitary Permit Application State Transaction Number ,
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit � �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing
the Department of Safety and Professional Services.Persona(informadon you provide may be used for secondary (�' (/ /�� (�w,�/�� /��i ui�
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. `��O ►`" ' '""�'l-"
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�,- �{I-. 3 - �-s.�o 1
Property Owe�er's Mailing Address Property Location
� '"4 ' Gev*.oeE
City,State � Zip Code Phone Number
y� �N� _'/a,__�f�_%a, Section_��
II.Type of Building heck all that apply) Lot# T N R �� E o W
�d!1 or 2 Family Dwelling-Number ofBedrooms_� "'— Subdivision Name
�v
Block# "—
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of _
� �Town of � �Y-G
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' �New S stem
y ❑ Replacement System ❑ Other Modification to Gxisting System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holdin Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Desi
S gn ❑ Other Type(eaplain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration
IV.DispersaUTreatment Area and Tank Informallon:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �
��G � -7 7 l� 7�
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � o 'b �
New Tanks Existing Tanks � o � � � � � �
c`. U v� , v� i.t, U fi
Septic or Holding Tank „ '1 �� �� _ ✓
v l/ �_.
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assume responsibility for i�stallaGon ot the POWTS shown on the attached plans.
Plumber's Name(Print) P 's Signature� MP/MPRS Number Business Phone Number
Gt.�� � ��f� l�— (0�.3
Plumbe s Address(Street,City,State,Zip Code)
�0 J7 1�1. � '�,�Yl `i � 'I(,�Q Ccc�l�- �; c c:.t.�C��� CL) �j� 3
VI.County/Departmeat Use nly
�Ap�i Disapproved $ermit Fee� Date Issued , Issuing Agent Signature
❑Owner Given Reason for Denial ��� , �~� 1 3 I�'� �t�'�������`�-
Conditions of ApprovaltKeasons for Disapproval ` r�� n
..,,- -� —
1�� `' _�"� I ,
� � � � �-J��.���- � �,
1
�, aaLr:.. .__
�► �` ��W� �,hk# � �_..�----�-�--�-o- _,R.�.r2 DEC 0 7 2022�—
`_t...(��^✓....�"y`t�r 1�,��� �� � r.i �
��� � � ^ � ( � � ZONING ADM NIOSTRATivV�
Attach to complete pleos for the system and submit to the County only on paper not less than S t/2 x 11 inches in size `� � � S )
NO R�FJ(vDS AFTER
SBD-6398(R.03/22) ISSUE OF f'EFc11�1�
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 Pian
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): �CL"��u�.� C(;2-`� Phone: - -
Owner Address: ?L�iC1� LC�-aY�, G Lc�'Gfl��.��t"�-Gi�.�� �.�.'� Zip: ���;�
Project Address: g'� N (, m� ,�:�-C��.y�T�ac����� �.y S�.�5�-��
Govt. Lot: �� 1/4 of_ 1�I,c� 1/4, Section�_, T �L L N-R (`�2 E❑or W �
Township: ���.(�L ��. County: ,� � .� �
Project Parcel ID #: �-�C�—"l �L—33��-�3�l
Designer Information
Designer Name: �Q.�- 5��� Phone: ��-�1 �� 7.3
Designer Address:l(`��711'��T�iu'►'�..i-l�u-`�� ��''k�� E ��P= ��-�3
E-mail: ,. , �_ .
License Number: �� Ct�'�(��
Remarks:
Signature:
� Date: � �-����"�-
riginal signature required on each submitted copy.
o,� ��- : �eg�d �.
Vv1.��1-}hew Q.. C�s�e�.- S w�.e,,- Co, 6Zov�t.�. (�.<<-e T"`�'�
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a,���o x� 'n�.�e
� �LC �to tM,e.G�' Co�� �6�s
�o��
Septic Tank(s)Manufacturer;
' IN-GROUND GRAVITY DISPERSAL AREA ��� ;,� ���
--
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) /�
gal gal gal gal
Effluent F�(It r Manufacturer:
.s.�-c,.cr�r_c� /�.-�6�L-=-��r i�l`
I 11.1 _ ,� �
Effluent Fllter Model#: �,�����L 7—�.
—min.12"
SOIL COVER (typlcat)
12"
min,trench
depth .
«'P'�'� �'� ° � TYPICAL TRENCH
_ • '� ' ' � d ° CROSS SECTION VIEW
i
�'icvp�a�> .:�a� '°. .. • . . (No Scale)
� a� � a�
, � ° Provide minimum 3 ft
System Elevation = � �� separation between trenches.
(rypical)
Gtulck4 Standard-W
w/End Cap Observatlon P(pe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (typlcal)
Install per manufacturer"s PLAN VIEW
Instructlons. (NO SCc'�I@�
r—., � ;� ,— - - - - �� - - - - - - - �� - - - - ,� .— �
� �����:� ���, ;�Y'i'_' °��y� ����v�+,������v� �
��y�ti��� i !� ,�,1 '� � � � I ��� , � ' `:�d �:`:� A= 3,Oft
�.���Rb"ic`��ca�,��� �L�, _._. _ _. _ _ � � ^ _ �� � `?#� ���:���tl�'.��tl���4��1�����,� ��YPical) �
._ �� .�_ � .�I� �.� �� �� �— �� _ _� ^ _� �
�
B = _G� ft � G�
m
(typlcal) Quick4 Standard-W Chamber W
(typical) O
INSTALL PER TRENCH; (mfd by InflllratorSystems,�no.) -n
�' Install pursuant to menufacturer's instructione. �
� � Quick4 Std-W @ 20 ft� EISA/chamber= � ftZ
+ �� Pairs of end caps @ 6 f!�EISA/pair= � ftz
= Proposed EISA per trench= -�„��:G .�. ftZ Required Infiltrat(on Area= .�`.�._ ftZ Distributian Method:
x trenches = Pro osed Total EISA =,��.,2.. �2 /�% � � a�� J�/
� p ._vY.�... "e.ii1'�t�� �f _
,�°
PAGE40F4
In-ground Gravity Management Pian
IMPORTANT:
The owner of Uiis in-ground gravity system shall be responsible for its perpetuai operation and maintenance pursuant to
requirements of SPS 382384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),�sc.Admin.Code,this system shall
be considered a human heaith hazard'rf not maintained in accordance with this approved management plan.
Furthermore,ali inspection and maintenance activities shali be performeti by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disoersal Area Oueretinq Limits:
Design Flow= gpd; BODS_<220 mgL-'; TSS 5150 mgl-'; FOG_<3Q mgL"'
insnection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanig(malfunction(i.e.,pumps,valves,switches,ftoats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treafinent tank(s)and any disfibution appurtenance(s)(i.e.,disVibution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,efc.)
o e�ent of ponding in distribu6on cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float swftch settings,etc.)
o elecVica!components-if applicabie;i.e.,wiring,connections,switches,controls,timers,alarms,etc,}
o distribuiion fateral or lateral orifice plugging (measure lateral distai pressure—compare to design specification)
o surface discharge of e8iuent 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 licensed under s.281.48 W is.
Stats.when the volume of sotids in the tank(s)exceeds one-third(7/3)�e liquid volume of the tank(s)or
as required by locaf ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent fiiterfst shall be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacturers specfiications. A servicing period will always be greater than 12
months.
System maintena�ee reports shall be su6mitted to the proper local govemment unii in accordance with
SPS 383.55�sc.Admin.Code. Report any component failure or ma(function to:
Name of individuai or company:�\�C�.1/ti �f I,�(t►�'�(� Phone: ����SS��,�-,7�
� Local govemment unit: � Phone: /�5���}{�p��
Local govemment unif address: /�^6La�--aSt �( k�Q� 6c�JT Zlp_�3
Any defective part of this system shall be repaired,repiaced,or removed pursuant to SPS 383.51(i),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemicai or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Continaencv Plan
In the event that any failed treatment component of this POWTS rannot be repaired,it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approvai. A failed in-ground dispersai component may be
abandoned and replaced by a codc complying dispersai component in a pre-determined area of suitable soiis.
Svstem Abandonment
If use of this POWTS is discontinued,it shall he a6andoned in accordance with SPS 383.33,Wisc.Admin.Code.