HomeMy WebLinkAbout014-842-17-3202-SAN-2022-344 Department of Safety c°°°ty� �
;~�,�_ ; & Professional Services, ` �
Sanitary Permit Nw •(to be filled in by G
,,, �i Industry Services Division �
,.,, - �v � � � 31J �
,
Sanitary Permit Application State Transaction Number �
[n accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtainiog a sanitary pernvt.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ad
the Department of Safety 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. ��
I.Application Information-Please Print All Intormatioa
Property Owner's Name Parcel#
� �. �-��.� e • l 0/ • y �I 7• o�
Property Owner's Mailing Address Property Location
� �� �• . `«'�
City,State Zip Code Phone Number
W �� _. �L �! � ! � (�A ./ V�� '/,, i't+ '/,, Section_l-�_,
,a�- U
II.Type of Building(check all that apply) Lot# T -{ N R E o W
�I or 2 Family Dwelling-Number ofBedrooms ,j � Subdivision Name
Block tt
❑Public/Commercial-Describe Use
'� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
'""_ �Town of �-^P�{�-r(�()'{-
IIL 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 System �Replacement System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain)
B.
❑ Holding Tank [�In-Gmund ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
/
(conventional)
C� ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration 93 �2 / �b' G�
_�
iV.DispersallTreatment Area and Tank Information: - ,3 l q
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Pmposed(s� System Elevation
'� ,. l � '
Capacity in Total #of anu acturer
Tank Information Gallons Gallons Units � o 'b �
New Tanks Existing Tanks � � � " � p � �
0
a. U �n �, �n ii J p.
Septic or Holding Tank „
. � `� /
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assume responsibility for instsllation of t6e POWTS shown on the attached plans.
Plumber's Name(Print) Plumbei's Signature MP/MPRS Number Business Phone Number
�
L ��`f� �� � ��J`�J5 ���473
Plumb 's Address(Street,City,State,Zip Code)
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VI.County/Department Use Only
Permit Pee Date Issued Issuing Agent Signature
�Adp Disapproved t� -
❑Owner Given Reason for Denial $ Yd v'°� i�� � I ���- 7���l��'�'�'-`"�".
Conditions of ApprovaUReasons for Disapproval � • _
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Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 11 inches in size ' "1 dG�
NO R�FJhDS AFTER
SBD-6398(R.03/22) ISSU�OF PF�M���
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manua!Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s):�1,U7���, `C���.li l�� �C'l�C��C�Phone: l5-�- C�J
�
Owner Address: � � �,_��[ Sjl'1�i1�� . �'u!�C� Zip: � �'�i�3
--,t�?�
Project Address: �Q�ti=�
Govt. Lot: �19� _1/4 of s i,� 1/4, Section � � , T �l`�-N-R�E ❑or W Q
L���.j�C�.?-�` Coun 1 ,U
Township: ty=
Project Parcel ID #: (.�( �-� �� "Z� � �Z ��
Designer Information
Designer Name: �� 0�1.-(1 �-C�� Phone: ��-5��ltc�.�
Designer Address:�(��Z7% l� ��.'Y\`Z���t�-�fl7l�� P�Z�--��.�. ZiP: � �.���
E-mail: E-��-�cLY��;c..��.
License Number: �����
Remarks:
Signature: � Date: l ���������
Original signature required on each submitted copy.
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. Septic ank(s).Menufacturer
' IN-GROUND GRAVITY DISPERSAL AREA .�1-�i/�iu-Fo�
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit) ��ee, S"y�9a, 9a, ��
ENluent Fllter Manufacturer:
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Effluent Flllar Modal#: 1 �U ��.Z
min.17'
SOIL COVER ��yP����
12"
inln.trench
deplh TYPICAL TRENCH
(NPicoq .'
a CROSS SECTION VIEW
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nva��o , � ..' (No Scale)
� Provide minimum 3 ft
System Elevation=�ft separatlon 6etween Irenches.
(typlcal)
Quick4 Standard-W •
w/end caP ObaervatbnPipe TYPICAL TRENCH
(typical) (Show location of Inlet/outlet pipe connectlon on plan view.) pypmap
Instellpermenulacturefs PLAN VIEW
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INSTALL PER TRENCH: (tvp�ca�> �
(mfd by InTlltralorSystems,Inc.) T
Install pursuant lo menufncWrers Instructlone.
- �Quick4 Std-W @ 20 fl�EISA/chamber= 3/�ftZ �
* �L,Pairs of end caps @ 6 f!�EISA/pair= _�ft'
=Proposed EISA per trench=,�ftZ Requlred Infiltration Area= �,�ft' Distribution Method:
x _�1 trenches=Proposed Total EISA= L'Gz�ft' i v�, �,-..ti�G�/��
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsibie for its perpetuai operation and maintenance pursuant to
requiremenfs of SPS 382-384,�sc.Admin. Code. Pursuant to SPS 383.52(2j,Wisc.Admin. Code, this system shall
be considered a human health hazard 'rf not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be perfortned by a registered POYVTS Maintainer in
accordance with SPS 383.52 (3),Wisc.Admin. Code.
Maximum Disoersai Area Oaeratinq Limits:
Design Flow= � gpd; BODS_<220 mgL"'; TSS 5150 mgL-'; FOG 5 30 mgL''
Insoection Checklist INSPECT EYERY 3 YEARS
o type oi use
o age of system
o nuisance factors (i.e. odors, user complaints, eta)
o mechanical malfunction (i.e., pumps,vatves, switches, floats, etc.)
o material fatigue (i.e., leaks, 6reaks, corrosion, etc.j
o solids volume in anaerobic treatrnent tank(s)and any disfibution appurtenance(s)(i.e.,distribu6on!drop boxes)
o neglect or improper use(i_e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in disfibution ceii prior to dosing
o dosing irregularities-if appiicabie(i.e., pump re-cycling,float switch settings, efc.)
o electriq! 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 specificafion)
o surtace discharge of effluent or sewage 6ack-up into structure served
Maintenance Checklist MAINTAlN EVERY 3 YEARS {or when necessary)
o Seotic and dose tank(s) shall be pumped by a ceRified septage servicing operator licensed under s. 281.48 W is.
Stats.wheri the volume of solids in the tank(s)exceeds one-third(1/3)the�iquid volume of the tank(s) or
as required by locaf ordinance. Disposal of contents shall be pursuant to NR 113, Wisc.Admin. Code.
o Efffuent fiiter(sl shail be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids accorcling to manufacturers spec�cations. A servicing period will aiways be greater than 92
months.
System maintenanee reports shali be submitted to the proper locat governmenf unit in accordance with
SP5 383.55�sc.Admin. Code. Report any component failure or maffunction to:
Name of individuai or company: 1�`i. 1(1� _ Yt'f Q.b'�L7�- Phone:`7�5�����J��
, ¢�'
Local govemment unit .� Phone: ���J '�'��`—��+, 6
Locai govemment unit address: ZIP: 7����
Any defec6ve part of this system shall be repaired, repiaced,or removed pursuanf to SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacemeni of failed or malfunctioning components shall compiy 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,Wisc. Admin. Code.
Continaencv Pian
tn the evenf that any failed treatrnent component of this POWTS rannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency ior review and approvai. A failed in-ground dispersal compo�ent may 4e
abandoned and replaced by a code-compiying dispersa! component in a pr�determined area of suitable soiis.
SYstem Abandonment
If use of this POWTS is discontinued, it shall 6e abandoned in accordance with SPS 383.33,Wisc.Admin. Code.
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