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Home My WebLink About032-540-31-5701-SAN-2023-051 V) "` Department of Safety councy �� e & Professional Services, �� - . :P Sanitary Permit Number(to e filled in by j, '; ; . Industry Services Division � 3 �u � k � . � Sanitary Permit Application State Transaction Number � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropnate governmental unit �� is required prior to obtaining a sanitary pernut.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffcrcnt than mailing� the Deparhnent oFSafety 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. �� ) }7 I.Application Information-Please Print All Information � ��"�C�' � !�� Property Owner's Name Parccl# �� S �� o��sL •3 -S�v� Property Owner's Mailing A dress Property Location��, �. ` X �S� Govt.Lot � City,State Zip Code Phone Number 2 / 9 1 /'�� ^1 �7 � / �, eF + ��-/�qC� !1�(p ^ p��Z� � ----�--'/4,-----%., Sechon _�_ (N G � II.Type of Building(check all that apply) ►-ot# T � N R • E �.1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name Block# -- ❑Public/Commercial-Describe Use ❑City of _ ❑State Ovmed-Describe Use CSM Number ❑V illage of _ �Town of W b��'t�'y1- — 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. y -L-� P Y � g Y ( P ) � ( P ) ❑ New S stem e lacement S stem Other Modification to Existin S stem ex lain ❑ Additional Pretreatment Umt ex lain B. �� ❑ Hoiding Tank ,,�In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain) (comentional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued Expiration �`-�` �7� ��•'� ��'t IV.Dispersal/'1'reahnent Area and Tank tnformation: Design Flow(gpd) Design Soil Application Rate(g d/sfl Dispersal Area Required(s� Dispersal Area9�r�r�(sfl System Elevation �l�t� o.� Z ��- �t� ��:7rt� ��,� G ,s�� Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units � V U �, � New Tanks Existing Tanks � o � � y p R ro a U in � cn i.,. U n. Septic or Holding Tank 1 � c� ylC e �"Q c�.r�. �! 1 �J (.. /� Dosing Chamber V.Responsibility Statement-I,t6e undersigned,assume responsibility for installation of the POW1'S shown on the attached plsns. Plumber's Name(Print) Plumber' Si�mature MP/MPRS Number Business Phone Number � �) �t�4.� � �(.ur S�r� � �� c ��'L!� ��LS'o2�(a'o2�S��c� Plumber's Address(Street,City,State,Zip Code) v�"v�-- �l �0 n J�.,F' L�1 ��t��e�� ,C./-�- ��l�C C� VI.County/Department Use Only �A tb ❑Disapproved Permit Fee Date[ssued Issuing Agent Signature ' ❑Owner Given Reason for Denial $ ��•� 5 I( �'1 �3 ��""'""-��"�� Conditions ofApprova�t/Reasons for Disapproval o � �� f�'� �ate S 10 2 3 ��.,,�„�..._. � ` ` ,� � �I IN� i��t� _,�..___.� ..�. � MAY 1 0 2�:_: Chk# - � ST �� . ��s �,r�s-# _i�?I Z�, � — �_.__ ..,. �u;vif�lla A��v�i� .�:� � Attach to complete plans for the system and submit to the County only oo paper not less than 8�R x 11 inches in size "3�y� 3l� NO REFtJNDS AFTER SBD-6398(R.03/22) ISSUE OF PEF�MIT 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 t��'�l Are�x. �t'�lw�� -�'��c Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Owner Name(s): � !/�l�'f"�`�/ J l`��J'ct.�-�Phone: ?15 -(��v� - oZ�l'�Y Owner Address: �. �. L�D7� aZs 3 �i��-�� , C� Zip: �Lj�`j�-i Project Address: ro��'l.c' � �r��e � � Govt. Lot: � -- 1/4 of — 1/4, Section�_, T yll7 N-R��E Q or W � Township: � d l�,�e� County: j ��i,/`��/' Project Parcel ID #: (�3 � J`�� 3� 5 7C�f Designer Information g � t ��C�' �l� Phone:��S -o7lv� - ' �L Desi ner Name: �c.� Designer Address: C�� ' � �� s � Zip: s�`�� E-mai�: c�Qv(1-�-l��rtP5�1/�Ilt�� 1��e. C�r� ,. , _. ,,, t ._ , , , , ��F,,lr, License Number: ��L� ��(� Remarks: �� C,n �� m�-� v� , /%� � Signature: Date: �— ��✓ Original sign re required on each ubmitted copy. CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE. ❑ SOIL EVALUATION o sca�e: 40 40' � $o � SYSTEM PAGE 2 OF SITE MAP PLOT PLAN PROJECT NAME: 2 DESIGN FLOW: �`°`�-� GPD (tOftgrid) �p � � Attach design flow calculations for commercial plans. PROJECT ADDRESS: �1�� .�L�E Pipe Material/ASTM Stand�(Tables 384.3__�.30-5) /'�2 2� N Sanitary Sewer. _/ / BM Symbol: � BM Elevation: � J'i•� FT �O^ � ` �,y'� �"5`� Force Main: / BM Oescriptlon: 4� �� -� ' � Slo e Gradient % Indicate northby IMPORTANT: P � � �,5� Well Srjmbol('rfapplicable): � drewing an arrow Show ground elevation contours at suitable intervals. of Tested Area: on the approprite Iine. � (� ( I I '�1' I w I —�y——� p,l�' _�� I � � _� S,T r►3�;t�• I _ 3 _� �,� � I � � � � S, � � ` �� ,� �� C \ ,� I I �--J \ � � .. � Oj � / �� ❑ �� . �e�� x �� I I I I I ( I I I I IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer S�-4.rrJ P�''� �stSZ` Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s) 3-ft Trench (down-sizing credit) �,�,� gal gal gal gal Effluent Filter Manufacturer: 13eS� � min.12" EHluent Filter Model tk: L7`T d�—O Geotextile I (rypical) Cover soi�coveR TYPICAL TRENCH min.tench� > CROSS SECTION VIEW depth L __ N (rypi�� —T -��,..'•�..:' � O SC8I8� OBSERVATION PIPE DETAIL � (No sw�e) S stemElevation= ft. � s"a""-TYPBOf F��n��sneac�aa Y . , srPcevOoosa� (typical) Provide minimum 3 ft �m��=hed g sa�eaa� separation between trenches. a o Pvc P�� Tovso�ic��a� Tov or v�Pa ro�am,��a�a cmi�.i roop at or above tinished grade (4)1l4"-1/"%6"Slots TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) c��aoan PLAN VIEW A��o��9oa�� ,�a��, 4�� ,� oesarvam�P�ve snan ba��sr�oae s�nars (No Scale) a�;��o�ba�waa��wo��. ft Perforated Lateral onservation Pipe — J — (typical) (typical) (typicaq �---------- ��- --------�� I�---------_'-___ �A=3.0 ft � -- -- --- __ ___ _______ _______= I ------��-------------- -----� cty��o m s= '— n �I w cryw�n O INSTALL PER TRENCH: EZ1203H Bundle -n (1vPical) � � 10-ft bundles @ 50 fi�EISA/unit= �— ft' (m�d by Infltrator Systems,Inc.) Install pursuant to manufacturer's instructions. + — 5-ft bundles @ 25 H'EISNunit= — ft' ��5��,�, =Proposed EISA per trench= — ft' Required Infiltration Area= b�`'� ft� Distribution Method: x � trenches=Proposed Total EISA= ft� 17��^u��.� PAGE 4 OF 4 In-ground Gravity Management Pian IMPORTANT: The owner of this in-ground gravity system shall be responsible for its perpetual operation and mainte�ance 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 performed by a registered POWTS Maintafner in accordance with SPS 383.52 (3),Wisc.Admin. Code. Maximum Disqersal Area Operatinq Limits: Design Flow = 3�U gpd; BODS 5 220 mgL''; TSS <_ 150 mgL''; FOG 5 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 I drop boxes) o neglect or improper use (i.e., exceeding design capaci[ies, 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 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 tanklsl 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 (113)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: �al� / �1Af'��D- �J17A�5 FXL Phone: �J �S-a�vCd� ��a Local govemment unit: �4iJ�21 C�.vt'�� ZD/��n�, Phone: 7lS- (03�1'c�Sa`�� { J J ' u Localgovemmentunitaddress: L�G��D rnr^��l �J'�. Sua�� t(� C7�4.��ZIP: 5 -L��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. 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 compone�t 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 co��ty � � o�� SYSTEMS SaWyer \�SpS ( POWTS) �`"'""�� `� INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �3 —�jS � Personal infonnation you provide may be used for secondary pucposes[Privacy Law,s. 15.04(1)(m)J Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: `��N,o� 5 �Cob,c� w��,�r- Insp BM Elev: BM Description: Parcel Tax No: (�o .o' � o� v� p3�-S�ro-31- ��0( TANK INFOR ATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �j �a Benchmark ,�j de' Dosing Aeration Bldg. Sewer Q q 38 ` Holding St I Ht Inlet �($•�'7� TANK SETBACK INFORMATION St I Ht Outlet �P 3a ' TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet AIR INTAKE Septic ,�� ,�—�' 7` .� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist. Pipe PUMP 151PHON INFORMATION Infiltrative 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 �N L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv y� Aggregate INFORMATION P�L Bltlg Weli Waters � IGP ❑ Chamber Model Number: ❑ AG ❑ EZFIow CELL TO ❑ Mound o Other _ ___-- - —__—_ -- _.—_ _— DISTRIBUTION_SYSTEM X Pressure Systems Only �_ � _— P � ) -- - —._._ Header/Manifold _ Distribution Pi e s �X Hole Size X Hole Observation PipE� Length Dia Length Dia Spac i I Spacing ❑ Yes ❑ No SOIL COVER — _ _— --- — __----- - - -- — Depth Over Depth Over T—Depth of Seeded I Sodded Mufched � _Cell Center TCell Ed es I Topsoil __ __ _ � ❑Yes ❑ No � ❑Yes ❑ No C OMMENTS: (Include code discrepancies, persons present,etc.) �,5�►�/� �� - 3 -� S;T. o,�� I T �� -- —-�-� Plan revision required?O Yes ❑ No 0 3 I �I � 02 � � L�' I�--G'n/-�. — � ��'�d � � Use other side for additional information Date POWTS fnspector's Signature Certification Number SBD-6710(R.3/01) AOOITI�NAL COMMENTS ANO SKETCH SANITARY PERMIT NUMBEA: �3-oS I_ __ _ 3 �� , _ . � �� - >.� ��,,.�� p�c'�„ �s' �s� 6� �� - - - �5�� S K� � D� , n��„ w�7� ��;�vGy � �-t. � ��. l% '�— s e�i�—