HomeMy WebLinkAbout002-840-28-5224-SAN-2023-036 U
" '`� Department of Safety c°°"�' �
• = & Professional Services, �Q���r " Z
- _' - Sanitary Permit Number(to be filled in by(
_ . Industry Services Division
- (.y �`'I 3�� s+-�
. W
Sanitary Permit Application State Transaction Number ,
In accordance with SPS 383.21(2).Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit Cj
is required prior to obtaining a sanitary pernut.Note:Applicarion forms for statc-0wned POWTS are submitted to Project Address(if differcnt than mailing ad (>j
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(l)(m),Stats.
I.Applic�tion Information-Please Print All Ioformation �7a a-r� �rc K ��(�� �
Property Owncr's Namc Parccl#
�Z� �ell � ��n � i���e� "�� �od- ��lo- �S- S�a.o
Property Owner's Mailing Address Property Location a�
S�- c� , ler �Y Govt.Lot oC
City,State Zip Code Phone Number
�+f'J kJL�. �4— � -[��a 715- 7�7-��y3 _1� ,� Section ��
II.Type of Building(check all that apply) Lot# T � N R � E o
�I or 2 Family Dwelling-Number of Bedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�_ ,lgTown of ��i55 ��c��' _
IIL Type of POWTS Permih(Check either"New"or"Repiacement"and ot6er appiicable on line A. Check one box on line B.Complete line C if
a 6cable.
'4' �New S stem ❑ Re lacement S stem ❑ Additional Pretreatment Unit ex lain
y p y ❑ Other Modification to Existing System(explain) ( p )
B.
❑ Holding Tank �In-Ground ❑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 v� 3 ' ��Lr 3 �';��' ,�3
IV.DispersaUTreatment Area and Tank Information: ; � ;,l c� � � ' CCI�
Design Flow(gpd) Design Soii Application Rate(gpd/s� Dispersal Area Required(st) Dispersal Area Proposed(sfl System Elevation T��cr1't?-3�
�t /. l� 37s �lut7 `ia.c1 y3,do
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � o '�„ ^
Ncw Tanks Existin Tanks w c � " � � � "'
g � 0 2 � p =' :?
a U rn rn v. Ci a,
Septic or Holding Tank � I S� 1 G L � f� C't>� �/
.J(�c /\
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumb�s Si�mature MPiMPRS Number Business Phone Number
Cr�; �� 5�.�n l.'�.' �- �� �,�.v��G 7�S-�.��� -,�.S�Id
Plumber's Ad ress(Street,Ciry,State,Zip Code)
J�U ��� ` 1`l �� A��n P��' �J ��2 er ._I S`1��1 �
VI.C un /Department Use Only
�.y Permit Fee Date Issued Issuing Agent Signature
[�.A ro3 ❑Disapproved _
❑Owner Given Reason for Denial $ �0.� � I'�� I�� 1���-',""""L�"
Conditions of Ap�roval/Reasons far Disapproval
� � �� o � �
� a � � � ? ... D
�� �i Date
�GI
��
� � � �
., � APR 2 1 2023
C J�_ � � " � l U `°k� l"9 � 3'� ...,�.
j��-� SqWYER COUNTY N
Attach to complete plans for t6e system and submit to the Cowpty only o r not less than S v2 x 11 inches in s'u.e � �
`�� �.� ��
sBD-639s(x.o3i2z) NO REFUNDS AFTER
j'\ � U 1 SC=� ��SUE OF PEFtV!IT
M�
PAGE 1 OF 4
In-Ground Gravity Pian
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 & 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): �s�������`T��y�c N�e��er�kv`�,/ Phone: 7/S - ��7 - S-�,Y3
Owner Address: �SlSb-i.J Koe��°l�r ��.� ��;b���, �-c1� Zip:
Project Address: �?;�� -N ��vK��.� �r'r�� j�c.:�'
t't�T.
Govt. Lot: � ��af � Section ;,2�3 , T�N-R � E❑or W
Township: I�<;55 ��t�' County: S��Y�-r�
Project Parcel ID #: UC�,;Z �yC7 � c� �,��CJ
Designer Information
Designer Name: �r� ; �; / h�i'�'St�� Phone:7/S -��6 - ����'�
�
Designer Address: SU����N �dr_y���n 1�' �i�'+�e� ZiP: � tl�`t�
E-mail: G��l1��wr,'t���Jt/tc(� le�c'. C��r1 , � _ ., .. �,,
License Number: ,��0�1C7
Remarks:
Signature: �� Date: ��`�7'{� �
Origin signature req ired on each submitted copy.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o s��e:�ao• � ao � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: oesicry F�ow: Cc cZl ca�
x� 10'
I'IiP�efK-ot/1 P��L�'- I AttachdesignFlowcalculationsforcommercialplans.
PROJECT ADDRESS: 77a�—� �"C I�e,'1 �rfC�cl �� � Pipe Material/ASTM Sta,n/daN(Tables 384.30.3 8 384.30-5)
BM Symbol'.{� BM Elevallon: �v�•7 C F7 � �ntlary Sewer '!--� i P i�G
n ForceMain: /
BMDescrip�ion: ��t•i boittn ���� ('C.Jc �/11[�
indicane nonn oy I MPORTANT:
Slope Graelerrt(%) 'J�°')-v yyeu Symbd('rf applirable): Q arawi q an armn SFrow ground eleva�on contours a�suitable intervals.
of Tested Area. � n me ap0�oprite Ilne.
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SEED AND LOAM TO PRO7ECT FROM EROSION
� � J�i
�- GEOTEXT'ILE FABRIC
MIN 12 OF
CLEAN FILL
T' �
19"
�Z" SPECIFIEDSAND.- �. ;�� �
6" 24" 6"
���
A42 WITH 6"OF SAND TO SIDES
� SEED AND LOAM TO PRO7ECT FROM EROSION
�v � JY�fi
� �� GC-0TDCTILE FABRIC
MIN 12"OF
CLEAN FlLL
T �
19'
12 _ SPECIPIEA SAND :�� ��,. �
12" 24" 72"
�,�
A42 WITH 12"OF SAND TO SIDES
SEED AND LOAM TO PROTECT FROM EROSION ��,y
�v � �/
� GEOIDCIILE FABRIC
MIN 17'OF
CLEAN FILL
T' �
- :�.. -: 19"
12' SPECIFIEDSAND�. � �;. �
18" 24" 18"
60"
A42 WITH 18'OF SAND TO SIDES
Figure 1.A42 Single Lateral In-Ground Cross Sections
a� R-Ha �.�;t5 Rf a��� _ <«�+�
Eljen Corporation
�age - 3a� �(
Table 2
SIZE AND ORIENTATION i
<_ 10 feet= Number of product rows x product
width. Product width is shown in Table 2b;two
rows of A42s can achieve a 6 foot width. Units
may also use up 18 inches of sand on each side of
, the productto achieve a 6foot width. For
Distribution cell width (A) instance, B43 units used with 18 inches of
specified sand can achieve a 6 foot width; refer
to Table 2c for configurations. A 843 unit with 12
inches of specified sand on each side can be
placed in two rows to achieve a 10 ft wide celi.
>Design wastewaTer flow rate=design loading
rate of the fill material=square footage of
Required tt of Products product (shown in Table 2b), round up to nearest
whole number; Min 5 643 units per bedroom or
6 A42 units per bedroom in residential
applications
Distribution cell length (B)a Multiple#of GSF units x 4 ft+ 1 ft
Orientation Longest dimension parallel to surface grade
contours on sioping sites.
Deflection of disiribution cel�on concave < 10%
slopes -
Design wastewater flow=soil application rate for
the in situ soil at the infiltrative surface or a
Basal area lower horizon if the lower horizon adversely _
affects the dispersal of wastewater in accordance
with s.SPS 383.44(4) (a)and (c),Wis.Adm. Code
The designer may use Effluent#2 in accordance
Soil Application Rate with s.SPS Table 383.44-1 and 383.44-2, Wis.
Adm. Code
Table 2b
APPROVED PRODUCT MODEL NUMBERS AND DIMENSIONS
Product Square Footage Product Width Product Length Product Height
A42 12 square feet per unit 36" 48" 7"
843 16 square feet per unit 48" 48" 7"
Table 2c
APPROVED PRODUCT INSTALLATIONS AND SQUARE FOOTAGE
Product Square Footage Installation Width Installation Length Instail Height
12 square feet per unit 36" 48" 19"
A42 16 square feet per unit 48" 48" 19"
20 square feet per unit 60" 48" 19"
16 square feet per unit 48" 48" 19"
843 20 square feet per unit 60" 48" 19"
24 square feet per unit 72" 48" 19"
Eljen Corporetion
P<<ge 3.5 �� '�
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 if not maintained in accordance with this approved management plan.
Furthermore, al� inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersal Area Oaeratinq Limits:
Design Flow= �oc;� gpd; BODS <_ 220 mgL''; TSS <_ 150 mgL"'; FOG <_30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanical malfunction (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
o 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, etc.)
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)
o Septic and dose tank(sl 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 filter(s)shall be inspected every 3 years and shall be cleaned 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 government unit in accordance with
SPS 383.55 Wisc.Admin. Code. Report any component failure or malfunction to:
Name of individual or company: 1a11 I h�M�S�n d �n 5 �G lLC Phone: 7!5 ' �66 -v2���a
Local government unit: �4U,•�� �v�tti � �oit� Phone: ��-�S�/ - �a��
Local govemment unit address: �O Gl� �1c;� j�. su f e �l`1 �!-'���"+r-� ZIP: s��£5��3
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 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 shall 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.