HomeMy WebLinkAbout028-642-27-5408-SAN-2023-042 i:��:■�v;ti� County (/1
,;, Department of Safety ��� ��
=� � = & Professional Services,
: �, _ _ Sanitary Permit Numb to be filled in by Co.) �
� `, �_ _ Industry Services Division
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Sanitary Permit Application State Transaction Number � ;,�
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ln accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �— G %"
is required prior to obtaining a sanitary permit.Note:Application forms for stateowned POWTS are submitted to Project Address(if different than mailing address ..[, s
the Department of Safery and Professional Services.Personal information you provide may be used for secondary I �,���/�j �j;�� F7��r�(�(� � '
putposes in accordance with the Privacy Law,s. 15.04(1)(m),StatS. 11��
I.A p plication Information-Please Print All Information �-}U•t,t <.0(Jc.
Property Owner's Name Parcel�k
L C-l�a�dle� 2�� �'v�f- oa�-r��-a 7-��o�
Property Owner's Mailing Address Property Location
�V /� �-}'�I��.�.�FiuG J� � �'i c'�'-
Govt.Lot�_
Ciry,State Zip Code Phone Number
1,��+� �,1J�-�-`'' ! �, G��� �--� Section��-
II.Type of Building(check all t6at apply) Lot�# T � N R E or
�1 or 2 Family Dwelling-Number ofBedrooms / — Subdivision Name
Block#
❑Public/Comme�ial-Describe Use
-- ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
— t�,To,m or S D i 11,�� LQI.�K�e
tII.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one boa on line B.Complete line C if
a licable.)
`�� ❑ New System �.Replacement System g y ( p ( p )
❑ Other Modification to Existin S stem ex lain) ❑ Additional Pretreatment Unit ex lain
B' ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design yp ( p )
❑Other T e ex lain
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date[ssued
F,xpiration gY` �� �p l9 I g�
IV.DispersaUl'reatment Area and Tank Informa6on:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation
�S`D • l �l� .2`{�O .c��. --�
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Uniu s, � o � �
New Tanks Existing Tanks y o cUi � � p � �
a U vs �, c7� o» C7 CL
Septic or Holding Tank J�.'- /"� � � r-� � �
7
Dosing Chamber
V.Responsibility Statement- I,the�ndersigned,assume respousibility for installation of the POW'I'S shown oo the attached ptans.
Plumber's Name(Print) Plumber's Signature _,..__,..-------- -._._. MP/MPRS Number Business Phone Number
G� S-E'Ir'Q,n,d� --- �1 J'34l �l<s-S s�-lb�.�
Plumber s Address(Street,Ciry,State,Zip Code)
/
l 0 5�1i N �T�n � p�- �a-!1k P�. t.c�a..� c,cZ� S��-!
VI.County/Department Use Only
�A�ro e�3 ❑Disapprvved Permit Fee Date Issued Issuing Agent Signature
5 y � s I a a.� ,��p� �}��
❑Owner Given Rea.son for Denial ��• I ('i(,Z,�
Conditions of Approval/Reasons for Disapproval
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� S � 02 `��k# ����3-� ..� ..._.. _,� MAY 0 2 2023
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ZONlNC3 Ailrdt�,,,,,.,„., ,,�
Attac6 to complete plans for the system and�ubmit to the County only on paper not less than 8 1/2 x ll ioches in size
NO R�FUNDS AFTER 3 D 3 S �'
SBD-6398(R.03/22) Ia�UE OF PERMIT
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):����'^,�(� �/'V{ t � �� �yUSC'Phone: - -
owner�4ddress:yt'�0 ►yl�ra.iyv3a.E�.e S{-/�G +�r�nr L�t. r Zip: 553 Z o?
Project Address: �(D�N Pj"il-G��-I- L ,v� �R.,�,�ac�N i.el= S�`�g-�3
Govt.Lot: 1/4 of_ 1/4,Section�_,T�N-R�lo EQor 1N Q
Township; ^�p I(�,2f �ELI�.L Gounty: �,�,���
Project Parcel ID#:_fl a�- !��-/�-�7� �O� —�
Designer Information
Designer Name:��_�'�L/1�Q Phone:�S�$�(r�7%3
Designer Address:�OS�/N I(l�Uri�.t,L<�G�- �l�G'1�l�. Zip: 5��3
E-maiL• ���C�LZ�,, (.C�.Z�
License Number: �9�,� �
Remarks:
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Signature: Date: ��`' �'�
�r)gi al slgnature required on eacf�submitted copy.
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Septic Tank(s)Manufacturer:
' IN-GROUND GRAVITY DISPERSAL AREA ��,s .�,s�f,.r,�,�
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit) �[�ae, gel ae, ge,
EHluent Fllter MenutacWrer:
�', �J /'Jv'�.�..� �,'�1 -- tciL�
� /=TOS3 �2
Effluent Fllter Model#:
min.17'
SOIL COVER (�YP�`a��
12'
min.Irench
depth
�ryP'�'� • TYPICAL TRENCH
�'--34" '
a CROSS SECTION VIEW
nva��o (No Scale)
Provide minimum 3 ft
System Elevation=y6.�ft separatlon between trenches.
(typlcal)
QWck4 Standard-W
w/End Cap �Show location of inlet/outlet pipe connection on plan view.) �hse(�Piba1J Ipe TYPICAL TRENCH
�(typlcal) Instellpermenufacturere PLAN VIEW
————— —————— ——— � If1�IfUC110118.
(No Scale)
�G4'�'rtiV11�1{��ttiyXjl41�'�'��V�; �'/`�"� ��� �tutt�.a�ftu�apr,x,dit��:J
�i i�yi �Iryi� I�q � (�. ��Mn �Yra tk44w k'!k�!l!,� �A=3.Ok
�
L�YYY1�pw:�r:�i�R�.�'�————
� (bPlcel) 'Q
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I- e= .�_ ft � -� G�
(typlcal) m
Qulck4 Standard-W Chamber W
INSTALL PER TRENCH: ��yP10a�� O
(mfd by Inflllratar Syslems,Inc.) .n
Install pureuant W menufecWrer's instructlane. �
' /�? Quick4 Std-W Q 20 f�EISA/chamber= z 90 ftZ
+ �_Pairs of end caps @ 6 f!Z EISA/pair= �� ft'
=Proposed EISA per trench= '�`{� ft' Requlred Infiltration Area= �ft� Distribution Method:
x �-,��trenches=Proposed Total EISA=2 4 h ft' _C�h� T��,���
PAGE40F4
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.
Furthertnore, all 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 Operating Limits:
Design Fiow= /�� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance fadors(i.e. odors, user complaints, etc.)
o mechanicai 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- it 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 distai pressure—compare to design specification)
o surtace discharge of effiuent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s)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(s1 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��/,l,{�� ��� `�^ Phone: � ��-S��C/��
Localgovernmentunit: �'�Pi Phone: G(S'�'?J<<�a�
Local government unit address�( (i1�U ✓�t�r7f �u-(�� Ly��� C�L Z�P: S��J�
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.
Continaencv 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 dispersai 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.
� '`'"�:, PRIVATE ONSITE WASTE TREATMENT County
�=��`��o$ � SYSTEMS SaWyer
J�� PS �� ( POWTS)
�h `--{p%;
"�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 _ 6� �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m ]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�,�.�. G�a �A��� �.,.T�,,,fi S ;�- l�l� �
Insp BM Elev: BM Description: Parcel Tax No:
�•� ' ����, o� ►vw �.�,-�-��s;d� oa�—��� —2�--����
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � � �—dp Benchmark ��o �,,�
Dosing
Aeration Bldg. Sewer �' 47,� �
Holding St I Ht Inlet �;7 �
TANK SETBACK INFORMATION St/Ht Outlet -�, Y �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic fi�'p' }-S'b�' � � .�-- � NA Dt Bottom
Dosing NA installation
Contour
Aeration NA Header/Man. ��, � '
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative �
Surface �'�-f
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 �N '3 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters o IGP r� Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO �� fi ` � -�-� ` ❑ Mound o Other
-- '�— _ -- --__ _ _---- -- --- --- --- - __—
DISTRIBUTION SYSTEM x Pressure Systems Only
Header/Manifoid -_ � Distribution Pipe(s) -- X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
SOIL COVER
� De th Over �De th Over Depth of � Seeded I Sodded Mulched �
P p 1
Cell Center Cell Edges Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
�`�-►s��l�.� s(2 Y �� 3
� ���- -�- �-,1�,�,
-' __ � �- __� �
�
Plan revision required?�Yes ❑ No �� � ,2�, I .2 Y � � ���
�
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NIJMBER: � 3- �Y�__
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