HomeMy WebLinkAbout002-840-28-5224-SAN-2023-024 .
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•�"""°` Department of Safety c°""`y �
� � = & Professional Services, � �� e r `—
; � _ , Sanitary Permit Number(to e filled in by
�, �_ , Industry Services Division c;J
'',� ` ;��" (,%:s�i 3�-f� w
..;- i
, Sanitary Permit Application State Tranuction Number b
In accordance with SPS 38321(2),Wis.Adm_Code,submission of this focm to the appropriate governmental unit �
is reyuired prior to obtaining a sanitary pertnit Note:Application fonns for state-owned POWTS are submitted to Project Address(if different than mailing a� —�
the Department of Safety and Professional Services.Pertonal information you provide may be used Cor secondary �-�.�a N
purpa5es i�accordxnce wi[h the Privacy Law,s.15.04(1 xm),Stats. J�
I.App6cation lnformation—Please Print All Iniormstion � r�Ke `j�
Property Owner's Name arcel#
�n�,e. d- Ti�� � ;e�11e�Kor� o� -`��la -a�-saac�
Roperty Owner's Mailing Address Pr�p�ty Location
NKI
s�-�.J o !e� Go��.Lot a
City,State Zip Code Phone Number
���. � ��D� ll���� —S�Oy� ��.Section ��
II.Type of Building(check ail that apply) � Lot# T � N R E o W
�Q 1 or 2 Family Ihvelling—Numbcr ofBedrooms ^— Subdivision Name
BI«-k#
❑PublicJCommcrcial—Describc Osc ,_
❑City oC __
❑State Owned—Describe[Jse CSM Numbcr ❑Village of _
_ p��„�oe 13u55 G-�-'� _
IIL Type of POW'['S Permit:(Check either"New"or"Repiacement"and other applicable on iine A. Check one box on line B.Complete line C if
a licable.
`�' �New System ❑Replacement Systcm g y ( p ( p
❑Othcr Modification to E�cistin S stem ex lain) ❑Addieonal Pretreahne�t Unit cx lain)
B' ❑Holding Tank �(in-Gmund ❑At-Grade gn ❑ Other Type(explain)
❑Mound ❑Individual Site Uesi
(conventional)
C. ❑Renewal Before ❑Revision ❑Change of Pliunber ❑Transfer to New Owner
ist Previous Permit Number and Date Issued
Eupiration
IV.DispersaUTreatment Area and Tank Information: �Z p �'G� p� t,t,n: 5 'jb q. ,,
Design Flow(gpd) Design Soil Application Rate(�d/s� Dispersal Area Reyuired(s� Dispersal Area Pmposed(s� System Elev ion
(o C�O .? tSS? �7CT(7 �l�•S� .
Capaciry in Total N of Manufacturer
Tank Information Gallons Galbns Units � U U �, N �
New Tanks Existing Tanks � o y; � � p "
� �
a. U in y v� w C7 a,
Septic or Holding Tank � � �.n 2 lJYQ� �e ��
eCw f'r
Dosing Chambcr
V.Responsibility Statemeut-I,the uedeesigned,auume respoasi6ility for installation of the POWTS s6own on the attached plans.
Plumber-s Name(Print) Plumber's igtature MP/MPRS Number Business Phone Number
C�r�.� �� � ' aaa�ry ���=a6� -a�ya
P(umber's Address(Street,City,,tate,Zip Code)
Sc�8�-N �� �n 12� �.c� ��1 � S� � lo
VI.Coun /Department Use Only
Pc�it Fee Datc Issued Issuing Agent Signature
� � ❑Disapproved (�!�,' ��� �,. _
❑Owner Given Reason for Denial a /W��D � /'�� �'�3 . ''f""'�'����;��r���
Conditions of ApprovaUReasons for Disapproval
� � �. ._ ._ ..���...�-�-,��_..n_�.� ����c� ���������
� �IG1 ��-��. � � r_, �
_ �
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,
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��:�a�° �.�..�--.n.---...._ �_.__.....� l�AR 1 7 2Q23 �
CS� �� _��� . �,��, wo���__�- ��
�-'-' l _�___,
c`1� SAWYEFZ �f�;�;�v,��
AUuh to complete plaos tor the system aod submit to the County onty oo paper aot kas than 8 1R x 11 inches i '�� ��3+ti � �
�L33(p
N�R�Ft1NDS Af i'ER
I�UE OF F�ERMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index 8� Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POwfS 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
OwnerName(s): RancQe��d-To(�va N�eQerKaa�K Phone: �lS -�- S6�
OwnerAddress: $ISb-(.J KoeAPle� �cQ �5�b'+�. (.J Zip: �S`!£S(oo"2
Project Address: �j IoZ l'1� 13 ry lCen A rfbkJ �rX
Qa��
Govt.Lot:�o _ th�of �f4-Section o2g ,T YC7 N-R � E❑or W�
Township: h-X�.75 ��1� County: 54G�y�r
Project Parcel ID#: �Dc�- �y0 "oZ� ` Saa�
Designer Information
Designer Name: ( _(' .� �a/�1�5�/1 � Phone:�j� a/n� -o2K o�
DesignerAddress• Sa�S -j`/ / nc�1�r1 14� W�n�✓-Zip: �`����0
e-mai�: t�0(1f�r1�S�1lIe��i�e. Co�/1
License Number: o�o�Q p4(�
Remarks:
Signature: ` Date: 3—Io2—oZ 3
Original si ture required on each s mitted wpy.
CNECK 80%AS APPLICABIE. CMECK BOX AS APPLIC?9LE.
� SOIL EVALUATION o s��: �aa � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: oesicry viow�. �cCln cPo
�o'
N1 e�el'�OfN ��Q«y ( Attach design flow calculations for wmmercial plans.
PROJEGT ADORE55: 7I cZ'�N B�'JFC/\ R(�M4� K!X Pipe Material/ASTM Standard(Tables 384.30-3 8 384.30-5)
^' /�I/ �^
�OoZ.7� � 'v SarMxrse»er: �! / ✓`•
BM Symbd�. �Y BLM_Elevation: �7� n Force Main: /
BMDescnption: �4� W�'t l/� �g�� (KK P�n�,
i„d;c�e„wc�py IMPORTANT:
Siope Gradiern(/) 3 � yy�l Syr�d(rt appiioMe): Q a.��a��o.. Show ground eleva�on wntours at suiWble intervals.
ot Tes�eO Area'. on ttre apqoprile Fc
(_clC �.PV"tG ���t���'7 L0.
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^ CTH E
IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer
SKuW Qre CaSf
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit)
i,a� gal gal gai gal
Etfluent Filter ManufacNrer:
'�� be5-E
I min.12" Eftluent Filter Model#: ��� �D Z�
Geatextile I (rypical)
Cover
soi�coveR TYPICAL TRENCH
1z� CROSS SECTION VIEW
min.trench � � �
(TyPP�I) L — .��. �. (No Scale)
T OBSERVATION PIPE DETAIL
;�, �No s��e,
S stem Elevation = � • ft. '- � sc�w-ryPao� Fm;snaa oreae
Y ' Provideminimum3ft suPcePpoosa� �m�i�n�aa,e�aa�
(typical) �
separationbetweentrenches. a°ePvcP�� ' TopsoilCover
Too or ciPa l01e=ninata �''� (min.1 fooq
al or above(inished grede
(4)1l4"-il "X6"Sbls
TYPI CAL TRENCH (Show location of inlet!oudet pipe connection on plan view.) �� npatl
PLAN VIEW A��,o��9oa��� �����,�e,b�
4n nt Obaervation pipe ehall0e Ina�alled Su�ece
%J
(No Scale) a�;��c,o�o�„ea��wo����. !D n
Perforated Lateral Observatlon Pipe
_ (typical) (tYpicap (ryPical)
--, -ff- - - - - - - - - - - - - -
� -- - - - - - - - - �
I =_____ __�____=_--_= I a- s.o n D
__ :__ :______ ___:___:
� - - - - - - - - - - - - - - - �� - - - - - - - - - - - - - - - - - - � �tyP��n G)
� B = �oa ft �i �,,�
(�YPical)
INSTALL PER TRENCH: EZ1203H Bundle �
(rypicap �
� 10-ft 6undles @ 50 fl� EISA/unit= � ft' (mfd by Infllirator Systems,Inc.)
� Install pursuant to manufacturers instructbns.
+ —' 5-ft bundles @ 25 it� EISA/unit= ft�
= Proposed EISA per trench= 3 ..0 ft� Required Infiltration Area= O-� [ ft� Distribution Method:
x 3 trenches = Proposed Total EISA = �� ft� CT�v �'�+!
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual 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'rf 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 Disoersal Area Oneretina Limits:
Design Flow= (o(.C7 gpd; BODs�Z20 mgL''; TSS <_ 150 mgL''; FOG <_30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o rype of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanical malfuncdon(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
c 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, e[c.)
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)
., Seotic and dose tankls)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 filterls)shail be inspected every 3 years and shall be deaned 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 govemment unit in accordance with
SPS 383.55 Wisc.Admin. Code. Report any component failure or malfunction to:
Name of individual or company:_�on �or�PS�n �- S�ns �/-L Phone: 7IS G�Co I— �o�72S
Local govemment unit: �A41YP( CO�.�.2'�i/ z0l\��S Phone: 7IS' �03�'— E�c�O�S
Local govemment unit address: ��(c%J �a i(� SL�. SK� f� L��I l7�+Yww� ZIP: J���g�"�3
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.57 (1),Wisc.Admin.
Code. Repair or replacement of failed or malf�nctioning 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,Wisc. Admin. Code.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shali be replaced pursuant to
a plan submitted to the appropriate 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.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc.Admin. Code.