The URL can be used to link to this page

Home My WebLink About002-940-05-1215-SAN-2023-005 . �'' ` Department of Safety c°°°ty � t/� r � • = & Professional Services, .. s' = Sanitary Permit Numb to be filled in by t > , _ , Industry Services Division � .;,,. - �(�3�� 3�11 � Sanitary Permit Application S`ate T�"�°t'°°N°`�'be` `,�' �'" i In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis Form to the appropriate govemmental unit O is required prior to obtaining a sanitary pemvt.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing a� o, the Deparhnent of Safety and Professional Services.Personal information you provide may be used for secondary ��'�� purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. (J� L Applicallon Information-Please Print All Information Property Owner's Name Parcel# � t-- L b�e.� oo�9�O�!'�l5 Property Owner's Mailing Address Property Location �� 1✓Ci�J �� Govt.Lot City,State Zip Code Phone Number ^ ' ,1�' `�� ( ' %,, '/4, Section Q�_ �lZfLL/ (iC- c `-L �/ II.Type of Building(check all t6at apply) Lot# T /� N R Q E o ,� I or 2 Family Dweiling-Number ofBedrooms � Subdivision Name I3lock# ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of �Town of �Q� �K^� 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 i a licable.) A. ❑ New System �Replacement System ❑ Other Modificat�on to Existing System(explain) ❑Additional Pretreatment Unit(explain) B. ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type I explain) (conventional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date tssued F,xpiration ?9 - d�S �p'��1I �� 1 IV.DispersaUTreatment Area and Tank informallon: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System F.levation C� . / �' ' �j � ` /� s / Capacity in 1'otal #of Maciufacturer v Tank Information Gallons Gallons Units � y o 'd„ ^ New Tanks F�cisting Tanks � o � � y � � � n`'. U rn �, v� w C7 p.. Septic or Holding Tank /� /Q /�,r r � ' J ! F �V / Dosing Chamber V.Responsibility Statement-I,the undersigned,assume responsibility for installation ot the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Si nature MP/MPRS Number Business Phone Number ��'L ��.�=�1� " �.�0/ 7�J`�`�>�(07� Plumber's Address(Sheet,City,State,Zip Code) . ��7� � � l.�-� l�� , �i CU �-� �� VI.C u ty/Department Use Only �A ro ❑Disapproved Permit Fee Date Issued Issuing Agent Signature ❑Owner Given Reason for Deniai $ �QQ•�� I ,J- 3 �Le�iL�2C.�s��"�V1/Lvr Conditions of Approvai/Reasons for Disapproval , � � �.; .,�� - � �__�,�.�.. � � ��,�� ; o �� -1 � � ��GI �� w�k# . � �f F�� 0 6 2023 :--�-� C . _f�,I�L v , k�,a.f�f� # �-1 _.__-- _ ! s`7� �-3 — ��1 ►�� SAW��E� �;�,a� ; ZONING ADMi��,;-sr::,�,;;�t Attach to complete plans for the system snd submit to the County only on paper not less than 8 1!2 x 11 inches in size K�� NO R�FJhDS AFTER SBD-6398(R.03/22) I�ll�QF P�'t;V;IT 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 8�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):�(7'�' �-: L,l.t,l�{,�6'Y� Phone: - - Owner Address: �L��(p N ��,u �': Z-}-lG (t1',O,eZ`Zf� Ltlr Zip: Jc�E�'S�3 Project Address: j/�,� Govt.Lot: 1/4 of__1/4,Section C� ,T �}�j N-R�E❑or W Q Township: �..�j (��P County: ��tLt;!tLC� —�� Project Parcel ID#: OO�-�/�� 0��'�l� Designer Information Designer Name: i'�.1,d2{'1 �c2/� Phone:��-��73 DesignerAddress:�0"7 Q6�i�—�. Zip: ��.3 E-mail� '��c�i� ,.,. _ , License Number: �/C�� Remarks: � Signature: _ Date: ��a-3 Original sign2 required on each submitted copy. - - -- � .,,a,, �e � .^ �- '� � �.�__._____.��__ _.��__..�� # a. .� � � � � � � � � w� ,� �' c� �- _ � :. „_� . - _ � -:, �- - � . � � ,.,�, 1 �:- � - , ;�1 �' ,�` � � �� . � , �� r`� � : ,C � � � � ,•� � ��'_.~ _ � _..,.� � � � . ..,.�, '� . ' � 3� �y �` -�..�, . . `� ..�: °t �. .,,,�.. , �� Q �. '�L ''� �' � - ' t �` n -�� -.�.. ;� -�_.__ � ,� � � ___�__ , �. , ,�`�- �__`- �� '�s - -- � �, �. �� t �� , . � � . __ .�_ _�.._�,_.�.._��.w�.___�.��...�.�,.��,.�.,�._� ° �� `� � � c � � �� m.,Q � ., � � � � � � � � � � � � `� � �� P � � � �� c: � � �3 ' � � a � � � s�-.. � �� , �' �: � � � N � � , � Cti ,1 ti� � � `� �� i � �' �� - � �� ` � ;�., � L�� '� � �' �� " �"� � �;�, v �� .., »s,, � � ` c.v ;__� ,�' )v a ,,, +/�' � � � � � ' � 1� Y ` � -�_. O^ � ^'r�- *� e� � � � � � � �,: ,� � � � Septic Tank(s)Manufacturer: IN-GROUND GRAVITY DISPERSAL AREA ,z�/,�°°%t�,��_,� Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s): 3-ft Trench (down-sizing credit) �,J,�gel 9a, ge, ae, EHIueM Fllter Manufacturer. � �_ 1 C�l,o�r.� �.��,_ 7`'��dP. .. I IIII- —- - Etfluent Fllter Model#: ��CJ�27 min.12" SOIL COVER «vP�`�� 12" min.lrench depth �ryp'�''� ° TYPICAL TRENCH - a CROSS SECTION VIEW i'=-34" . , ' (typlcali�:� ;^ .. (No Scale) � �" Provide minimum 3 ft System Elevation=�ft separatlon between trenches. (typical) Qulck4 Standard-W w/End Cap (Show location of inlet/outlet pipe connection on plan vlew.) Oese�YPiro i�iPe TYPICAL TRENCH (typical) ——— ———_—_ mew�acturers PLAN VIEW nstel per �ns�r��"°"'. (No Scale) --- — �/�— ��_— � Hkkti4 Y�kJ }�;�!' �' � � + 11 I .i��; i��h,rca�uoN.uMdw�n_w�w.';��i l �A=3.Ofl ———— —�'———— cna�� A -yf-------�j�-- F- B= ..� ft -I m (typicai) Qulck4 Standard-W Chamber W INSTALL PER TRENCH; (cypioai> � (mfd by Inflllrator Systems,Inc.) T Inetell pureuaN to menufacWrere instructlane. � _,[L_Quick4 Std-W @ 20 fP EISA/chamber= 2 z o ftZ + ,�„L„Pairs of end caps @ 6 ftZ EISA/palr= �_ ft' =Proposed EISA per trench=,�,Z,11�ftZ Required Infiltratlon Area= 6�.� ftZ Distribution Method: x 3 trenches =Proposed Total EISA= ,�,Z�ft' ��L, s��,��.�,`r.,/d � PAGE 4 OF 4 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 requirements of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be pertortned by a registered POYVTS IlAaintainer in accordance with SPS 383.52(3),Wisc.Admin. Code. , Maximum Disoersal Area Oaeretina Limits: Design Flow= y 4`��7 gpd; BO�S 5 220 mgL''; TSS 5150 mgL-'; FOG 5 30 mgL'' {nsoection Checiclist INSPECT EVERY 3 YEARS o type m use o age of system o nuisance factors(i.e. odors, user complaints, efc.) o mechanicai maifunction (i.e., pumps,valves, switches,floats, etc.) o materiai fatigue(i.e.,leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatrnerrt tank(s)and any disfibution appurtenance(s)(l.e.,distribution/drop boxes) o neglect or improper use (i.e., ezceeding design capacfies, prohibited activities, etc.) o extent of ponding in disfibution cell prior to dosing o dosing irregularities-if appiicable (r.e., pump r�cycling,float switch setiings, etc.) o electrical components-if applicable;i.e.,wiring, connections, switches, controls, timers, alarms, efc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specfication) o surFace discharge of effiuent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Seotic and dose tank(s)shall be pumped by a ceriified septage servicing operator licensed under s. 281.48 Wis. Stats.when the volume of sofids in t6e tank(s)exceeds one-third (7/3)the fiquid volame of the tank(s} cr as required by local ordinance. Disposal of crontenis shall be pursuant to NR 113,Wisc.Admin. Code. o Effluent fiifer(s)shail be inspected every 3 years and shall be deaned when necessary to remove any accumulated soiids according to manufacturer's spec�cations. A servicing period will always be greater than 12 months. System maintenance reports shall be su6mitted to the proper local government unit in accordance with SPS 383.55�sc.Admin. Code. Report any componen�failure or matfunction to: Name ofi individual or company: �� i2� Phone: ��s J�-� � �F�� Locat govemment unit: " G'i.C, `{'L YL(�Phone: ��.'`��O� [ —C�O��<� Local govemment unif address:! � �U l�{�,�IYI 5� /.(fl��i , l.C.�� ZtP: � �2�L,� 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 compiy with SPS 383,Wisc. Admin. Code. No product for chemicai or physical restoration of the POWTS may be used uniess approved by the department in accordance with SPS 384,Wisc. Admin. Code. Continaencv Plan In the event that any failed treaVnent component of this POWTS cannot be repaired, it shali be repiaced pursuant to a plan submitted to the appropriate agency for review and approvai. A failed in-ground dispersai component may be abandoned and repiaced by a code-complying dispersai component in a pr�determined area of suitable soiis. Svstem Abandonment If use of this POWTS is discontinued, if shall be abandoned in accordance with SPS 383.33,Wsc.Admin. Code. � "'�''f`�.,; PRIVATE ONSITE WASTE TREATMENT County 'yi'� o'S� ��! SYSTEMS �� s �` ( POWTS) SaWyer � �--�� ,'%rCjFFsti .��SP.� -"'-'� INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �3_ QO� Personal infonnation you provide may be used for sccondary purposes[Privacy Law,s. 15.04(l)(m)] Permit Holder's Name: ❑City ❑ Village [�Town of: State Pian Transaction ID#: .�� Lu� �i.rs C�I�- _ Insp BM Elev: BM Description: Parcel Tax No: �� •a' Tv a� ,5\Gb 00�-��'_'bs-��1� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �d�a Benchmark fa0,0' Dosing Aeration Bldg. Sewer 9� �( ' Holding St I Ht Inlet q$ •3 � TANK SETBACK INFORMATION St/Ht Outlet 4"j,q � TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR WTAKE Septic i�.� �� l� �-.�a ' NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. R6.� Holding Dist. Pipe PUMP 151PHON INFORMATION �nfiltrative �S�t 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 W � L �� #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav Conv ❑ Aggregate ��(, INFORMATION P/L Bldg Well Waters � IGP � Chamber Model Number: ❑ AG ❑ EZFIow CELL TO �',2j D .r�� ❑ 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 Depth of Seeded/Sodded Mulched � 1 Cell Center Cell Edges ', Topsoil __� ❑Yes ❑ No � ❑Yes � �Vo COMMENTS: (Include code discrepancies, persons present, etc.) ��(�� 2 �1�3 �- _- - � - - -�� Plan revision required?❑Yes❑ No ,p �� I� , � / , G��r/ vl� �o Use other side for additional information Date POWTS Inspector's Signatur Certification Number SBD-6710(R.3/01) AOOITI�NAL COMMENTS AND SKETCH SANITAAY PERMIT NUMBER: � 3" dDS- / I / /� � � . �� ti) � L� _ (�°� , �� s ° s • 6` 3� �� 0 � ��i�b �� Qa ,` � �7 � : $e,r�z d'y�. 3 ,��c. `��/�.�I��. �9� �N � � Y� � �f'�-