HomeMy WebLinkAbout002-940-03-1108-SAN-2023-021 . � O�ig �
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:`--=.,%,,;� industry Services Division Counry �
'"% B _ 4822 Madison Yards Way SC�,�(,v �� �-. >
:' �,\j P - Madison,WT 53705 San�tary Permit Nuthber(to be filled in b: `
•, � S :- P.O.Box 7302 q �
'?''����% Madison,Wi 53707 � �.3 1 �`�3
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Sanitary Permit Applieation State Transacti^o—n Number �
In accordance with SPS 3R3.21(2),Wis.Adm.Code,submission of this fo�m to the appropiiate govemmental uni[ �
is rcquircd prior to obtaining a sanitary permit.Notc:Application forms for statc-owncd POWTS are submitted to Pro��Address(if different than mailing '�
the Department of Safety and Profession�j Services.Personal information you provide may be used for secondary
putposes in accordance with[he Privacy Law,s. 15.04(1)(m),Stau. � `�, � •
i.Application Information-Please Print All InformaHon Ccu e �p-� (ri N
Property Owncr's Nam�eW ����,h���; ,`J,�-,^ e��� Parccl�
Ga.,r Sv z�u� �.^��3-4�- z o d 2-2`f� -�3-- l I b�
Property Owner's Mailing ddress Property Location
P � � I Z p� Govc.Lot
City,State Zip Code Phone Number
�f,4,� � (� ( LJ G� �j�j ��'/,,�(_'/a, Section ��
II.Type of Building(c eck all that apply) � Lo�� T �� N R E o
�I or 2 Family Dwelling-Number ofBedrooms Subdivision Name
Block# �
�ublic/Commercial-Describe Use
�City of
❑State Owned-Describe Use CSM Number illage of
CS Ni �a�3 3� [�ro,�of t3�s s (_.� �.
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' �IVew System nReplacement System ❑Other Modification[o Existin�System(explain) �Additional Pretreatment Unit(explain)
�Y.. �--�
B' �i-lolding Tank �n-Ground �At-Grade �Mound Individual Site Design Other Type(explain)
(conventional)
C• ❑Renewal Before �Revision ❑Change of Plumber �I'ransfer to New Owner List Previous Permit Number and Date Ltsued
Expiration „
IV.DispersaUTreatmeat Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Uispersat Area Propo d(s� System Elevation
(��o .`7 d�� �'d 9 z a 3�S"'
Capaciry in Total #of Manufacrurcr
Tank lnformarion Gallons Gallons Units � a o � u
Ncw Tanka Existing Tanks � �� y : � u y y
cs n
a U fn � rn 'r.r:. (7 a.
c •c or Holding Tank 'Z� N � ! � � " �
V l W • �
Dosing Chambcr O �
V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Si�aturc MP/MPRS Number Business Phone Number
fJ �a.t� � (�� 1-�-� 1�661 Z� ��5-ss8 _�
Plumb r's Address(Street,City.State,Zip Code)
-10 �' (� S�'o n �1LG S�'�K-e L.���� (� � 7(o
VI.Co n /Department Use Only
�Ap� ❑Disapproved Permit Fee Date lssued Issuing Agent Signacure
❑Owner Givcn Rcason for Dcniai � lw�� 3��'�� - "��� �'�
Conditions of Approval�Reasons for Disapproval �j�, ���/ �f�
� p ��CJ�� \\'! r:;;
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� iEl
,:hk# j IS�' _ __�._ MAR 0 � 2023 :.
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��� ZC)i��ffv+a ra���4ii�u:_., ..
Attach ta complete plans for the system and submit to the Caunn•only on paper not less than 8 V2 x 11 inches in stze !a
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SBD-6398(R.02/22) NO REF�hDS AFTER
ISSUE OF f�ERN;IT
PAGE 1 OF 4
In-Ground Gravity Plan
Index 8� Cover Sheet
Component Manua/Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index&Cover Sheet
Pg 2 of d 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
Owner Name(s): G0.r`� Su Z4��2. �4��z— Phone: - -
Owner Address: �6 I�X I z B8 ZiP: 54848
ProjectAddress: ��y9 ti' ��9�1�'ne R�
Govt.Lot: IJ C 1/4 of Nl= 1/4,Section 03 ,T 40 N-R �9 E�or W�
Township: 4-�a�,war�1 County: SGw�ev-
Project Parcel ID#: ODL� Q40— �3 -- l l b�
Designer Information
Designer Name: ���4�t Sc��(LZ Phone: ��S- ��g S R o�f
Designer Address: �O�b � S'�oKc Lu{�e �d�S�o�e La�Zip: 5`-f 4�?�
E-mail:
License Number: IS�� �Z-�i
Remarks:
Signature• J�/�/ "��`�`�— Date: 3��Z3
'" Original signature required on each submitted copy.
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� Septic Tank(s)Manufaclurer: .
IN-GROUND GRAVITY DISPERSAL AREA �,��5� �. -
Stepped Elevation Trenches with Quick4 Standard-W Chambers SepUcTank(s)Volume(s):
3-ft Trench (down-sizing credit) L5 ga, ga► ga� ga�
,I, �li ,I� Eftluent Fliter Manufacturer:
` — I W W W ��L_ �r�� � n, � �
- SOIL COVER —min,12" � Z�
(typlcaq Efftuent Fllter Moclei#:
-------------
12"
min.lrench
TYPICAL TRENCH deplh — •', a
t�vni��n e•. Provide minimum 3 ft
_ __ - -
CROSS SECTION VIE ------ • -� �� 4 <:
' 34„ ' - .�{ ' ' separation belween trenches.
(No Scale) I---��Y���a�> a , e a
n . ° o
______.-_ Lowest Trench(as applicable)
t-lighest Ti'ench ------�----
r, z � ft; ft; ft
System Elevations= "1� �� ft; ^��C�— ft;
Caulck4 Standard-W Observatlon Plp� TYPICAL TRENCi-1
I�YPical)
w!t=nd Cap (Show location of inlet I outiet pipe connection on plan view.) �nstall p�r manutacluror�s PLAN VIEW
— (lyplCal) , Instrur,Uons. �(�O SCa�B�
rf -_ __ _ - - — - — -- -
- - -- -- - i � -1
:
— -- -�j�_ _ ___ - ^• _
___ _. 3A ft
� -- -- — — - �� � �;- �`�'� � (�Ypicol) �
��, ; ,;,� . _ -- -- � - - - -J
{ . , D
�_ _ .__,
� - - �f-- - �Q�- -- - �- ��- -- - �
_ - - -- - - __ _ -
ft ---- ---- ---
--- -- --I m
B = W
f-`-- -Quick4 Standard-W Chamber
(typical) (typical) �
(mfd by IniHlralor Syslems,lnc.) �
�(�STf�LL PER TRENCH: Install pursuant to manutaclurers i�structions. ,�
7i 20 f�EISAlchamber= ���ft2
� Quick4 Std-W @
.}. _L_ Pairs of end caps @
6 ftZ EISA/pair= _� ftZ
�5� tt� Dislributi n Method:
= Proposed EISA per trench= � ftZ Required Infiltration Area= �
x Z,_ trenches = Proposed Total EIS� _
��L ftZ �r�.��s � � _
�
PAGE`�OFy
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be resporsible for its perpetual operetion and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 38352(Z),Wisc.Admin.Code,this system shal",
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.Ccde.
Maximum Dispersal Area Operatinq Limits:
Design Flow= ��� gpd; BODS<_220 mgL"'; TSS<_150 mgL-'; FOG<_30 mgL-'
inspection Checklist INSPECT EVERY 3 YEARS
o type of use
c age of system
o ruisance factors(i.e.odors,user complaints,etc.)
o mechznlcal malfunction(i.e.,pumps,va!ves,switcres,floats,etc)
o material fafigue(i.e..leaks,breaks,corrosion,efc.)
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,prohi6ited activities,eta)
o extent of ponding in distnbution cell prior tc dosing
c dosing irregularities-if applfcable(i.e.,pump re-cycling,float switch settings,etc.)
o e�ectrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution iateral or lateral onfice plugging (measure lateral distal pressure—compare to design specifcation)
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 tankls)shali be pumped by a certified septage servicing operetor 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 conterts shall be oursuant to NR 113,Wisc.Admin.Code.
o Effluent filterls)shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicirg 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 individua!or company: � � P�U�P�K q Phone: 11S—SSg —Sci p�
Local government unir:� Ct� Z p✓Liv�C Phone: �ls— b34—dZ$�
Localgovemmentunitaddress: ����'� ��Q"'i S� ��-{C( µ4"(W�.r�� Z�p: S�U�{.�
Any defective part of this sysiem shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning componerts shall comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physical restoretion 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 componer,t of this POWTS cannot be repaired,it shail be replaced pursuant to
a plar submitted to the appropriate agency for review and approval. A failed irnground dispersal component may be
abandoned and replaced by a code-complying dispersal component ir a pre-determir,ed area of suitable soils.
SYstem Abandonment
If use of:nis POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
'�,
"'-'�`>>; PRIVATE ONSITE WASTE TREATMENT co�nty
`-�� oS ,�; SYSTEMS SaWyer
��%;� Ps � ( POWTS)
ry �- ``v.
—� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 „ � � (
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�? �—���.��'��Qe �� �abs (��
Insp BM EI : BM Description: Parcel Tax No:
�� ��r ��+� 3�., y n�. S� s-,�e b� �-�" c,Jl�;(�e I�; oa�.-�Y� - �3- /(a�
TANK INFORMAT ON ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,����' � �� Benchmark oD-o`
Dosing
Aeration Bldg. Sewer y;'�S'`
Holding St/Ht Inlet c?S cr �
TANKSETBACK INFORMATION St/HtOutlet 4S� '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ttao �(�c�� � � �--'� � NA Dt Bottam
Dosing NA Installation
Contour
Aeration NA Header/Man. �i`r,c� '
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative �3 �,
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weli
DISPERSAL CELL INFO MATION
DIMENSIONS W ?� � L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��c`�
INFORMATION P/L Bldg Welt �raters °� GP � Chamber Model Number:
❑ EZFIow
CELL TO '1'4� f-,Z '�'�� N ❑ Mound � Other � �
-------- � -----_ - ------- Y-------
-- _ _ --
DISTRIBUTION SYSTEM X Pressure Systems Only
P � ) _ _ _ 1
Header/Marnfold Distribution Pi e s X Hole Size X Hole Observation PiF�es
Length Dia Length Dia _ Spac I; _ Spacing ❑Yes ❑ No�
SOIL COVER
- — -
Depth Over Depth Over epth of Seeded/Sodded Mulched
CeII Center �Cell Edges ', Topsoil T ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��,��I�( ���-�2 3
Plan revision required?O Yes❑ No pZ �g-1� , � i �� � ��
�_ � ��__�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKOE�H
SANITARY PERMIT NUMBEA; �3_=__�___
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