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Home My WebLink About002-940-27-5316-SAN-2023-059 I�� ,�^�Y , �. Count�� r,� Department of Safety ,�` S<« y c.r' Z l; � & Professional Services, ; ti � Sanitary Permit Numbcr(to be filled in by �'g w� Industry Services Division 3� �� ' �i 13 ��Y � � 1 �)�1h r�:tl.- Sanitary Permit Application StateTransactionNumber d In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit � is required prior to obtaining a sanitan permit.Note:Application forms for state-owned YOWTS are submitted to Project Address(if different than mailing a -�� the llepartment ef Safety and Professional Ser��ices.Persrnial information you provide may be used for secondary �5 G.��,C �- ��Ce��t 6'�-� /:� purposes in aeeordance with the Pricac��I.a�v.s. 1�04(1)(m)_Stats. I.Applicatiaa Information-Please Print A(1 Information Propert�'(hvner's Name Parcel# ��/ I 'p SG.�. .�,� �.,�,.�K � ov��+ uc��z .�� Property Owner's Mailing Address Property Location I Z� S V�/0.S�'�rN� O•v •'1 �`L�- � iT / � Govt.Lot � City,State 'Lip Code Phone Number t�l� J S �C�/ '/4, Ya. Section Z' 7 � ry e,c o l.�S IL''fype af$�iiding(eheck all that�pply) ' n Lo�� T y b N R `� E or ; �I or 2 Family Dwelling Number ofBedrooms oG �- Subdivision Name W 0 Block tt r-- ❑Public/Commercial-Describe iJse -� ❑City of ❑State Owned-Describe Use CSM N mber y�.��q ❑Village of 3Y 3 Y� '�r � �o.��,of a�s�> ��..�� III.Type ofPOWTS Permit:(Check either"New"or"Repiaceme�nt"and other applicable on line A. Check one box on line B.Complete line C if a licable. `� ❑ New System ❑ Replacement S�sG:m �Qther Modification to I:xistinb System(explainj ❑ Additional Pretreatment Unit(explain) iy4,✓�k � �4.L.0 -�.z�- B' ❑ Holding Tank �In-Ground ❑ At-Crra3e ❑ Mound I❑ Individual Site Design Other Type(explain) (conventional) C. ❑ Renewal Before ❑ Kevision ❑ Ch;�nce ofPlumber ❑ Transfer to Ne��Owner� I.ist Pre�ious Permit Number and Date Issued Expiration �� j �Q�� 1Y.D3s ersalf'i'reatmeot Area and Tank Infermarion: Design Flo�d) Design Soil Application Rate(gpd/st) Dispersal Area Required(s Dispersal Ama � System l;lcvalion �3� � �- �� (o �s ��y ' Capacity in Total N of Manufacturer � Tank Information Gallons Gallons l_Tnits s, � o �° � U NewTank� Ex�sting'Canks � o �; 2 y � m ro � - = - U :i: v, v: .:.. .i G. Septic or Holding Tank ._�� v � �� `�^�`n� �C�CL Dosing Chamber V,�e9pana�bilit�Statement-I,the undersigned,assume respansibttifil'for installetion of the�'OWTS shown on the attached plans. Plumber�s Name(Print Yli cr s Sienature M��MPRS Niimber }3usincss Phone Numbe� Jerry Ruid �xcavating, LLC� �,� � z�,,,� � :� ��s �t �2-- z�/�`� Plum d ,C i . t te. ip Codc) Stone Lake, WI�54876 vI.C' u ty/Depnriment Use Only �,Ap r v� ❑Disapproved PcrmitFee Da�c[s5ucd Issuing A�ent Signamrc ❑Owner Given Reason for Denial $ �Q�•� S�`�'S �"` �' ��t�-�2��--�?/i�t�- Conditions of App��aUReasons for Disapproval ��.��y��,p �� , D � � D �{ i ,�-.�rr,� S �3 '� 3 �� G I�� _ z � zoz3 �►� �>3��.-- MAY �'hk# �S�°' Cj 1 �� Q� `% __._ SAWY�P COUNTY � i`_�� a �pNING ADMINISTRATION Vt�1� Attac6 to camplete plaus for the system and submit to the County ooly on paper not Iess than R li2 x 11 inches in size NO REF�NDS AFTEF� � �� '� SBD-6398(R.03I22) ISSl1E�i�PEf�M�T PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References: In-Ground Soil Absorption for P01NTS 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 �,ti� Owner Name(s): S h�.a��,ti l-�..;� Phone: ��- - OwnerAddress: �zl s, wAx,��:,�,T�,� ,4v�- 177��;;� �<,,�ci;"s hL.� Zip: 55'-lc( Project Address: �S`��c �n,�_ I�w.�rac.� �' Govt Lot: 3 1/4 of 1/4, Section z 7 , T `-(� N-R `� E❑or W Q Township: 13<<s<, L.. �Ke County: S�wYe� Project Parcel ID #: ��>2 a '-(@ 2 �7 S 3�> l Designer Information Designer Name: �erry Ruid Excavating, LLC Phone: �'� -� S.Z_ 2 y ��r n Designer Address: StnnP i a�� W! gq87a Z�p: s `{ g 7(� E-mail: � G v � C�- �% G t+�T V!y l e/� N�� This space reserved for approval stamp. License Number: 7 �t � `c � � Remarks: Signature: �,.�- ��,� Date: �`_ � `7- � > � O g al signature required on each submitted copy. Reset Page CMECK BOX AB MRJG�ffiE CXECK BOX�8 MR1G1&E � SOIL EVALUATION o �'�� '90' � � � SYSTEM PAGE 2 OF SITE MAP PLOT PLAN PRaecT ruMe 7e, oesim,�.ow: �i'S-c oao �,,,,V Athdi deaign flav edwlallom tor commercW plans. �cr�oo�as: �SyLn T�_�-.v�� .L.� P�n�eeBe�iasn�sre�damRaaesaea.3o-sesaa.sas� iGG- �% N sNtrrsm,er. `-1'�Sc.{� � �lb Po�— BM Byn�Eol: � BM 6(�atlbn FT Fvcm Main / BNDuG,otlm: �C�f� 01 C'cs��•��c,.� Ve.✓`-- i„�„9,�nM IMPORTANT: gI�p��++�PX) C� wail symm(u.wucaeie). O m.�.+�.+.m.. Snow ground elevatlon canbwe et su�mbie Ir�Oervam. OttMO�tl Ati: on Ns�ODAV�ir Y �� _ � �. cc� 1 — — k�oor,c.. �t 7.s—z _ S ��s tc� 4�. H`f �,l �-�-�-e. �i. �G 3 i3r�l ��,o,r, i� I _- — __ - __--- -- - ——� _—-- CJ�.y�I• s� L� `�, — Jerry Ruid Excavating, LLC W208 County HWY A Stone Lake, WI 54876 � 5� _ ��,Z�6a ��2e�' 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. Furthermore, ali 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 Oaeratina Limits: Design Flow= `"�S C� 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, etcJ 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 Seotic 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: Nameofindividualorcompany:��r�� `� �� `�`"�'�—`' r��i Phone: -7�� z��'� Local government unit: s � � Phone: ��S " � 3�(— ��-S Local government unit address: I i:�I(; 1�1�' �N 5� N�`��Y��-t`d° `�'1-- ��P- '�� 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. 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 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. Reset Page , � " "''"" �, PRIVATE ONSITE WAS�E TREATMENT county -�;��o$ ,�� SYSTEMS �,�� PS ( POWTS) Sa.Wyer '- � �— „�;.; �ti�F, __i�� >>�",�'�`'- INSPECTION REPORT sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION ,�Z3 �- �� 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#: 5��su�, L��,k �tiSs �41�e_. --' Insp BM Elev: BM Description: Parcel Tax No: a o. �` � o� c.T . ��,� oaz -�Y�- ��-S3�(� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �;Q�- Benchmark (pd,o� Dosing Aeration Bltlg. Sewer �S �G,((� r Holding St/Ht lnlet 4S;� � TANK SETBACK INFORMATION St I Ht outlet �t;-� ' TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR WTAKE Septic �jt a� � f�-� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header I Man. Holding Dist. Pipe PUMP 1�IPHON INFORMATION �nfiltrative �, Y , 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 W L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav 6� Conv � Aggregate INFORMATION P/L Bldg Well Waters o G ❑ Chamber Model Number: � EZFIow CELL TO ❑ Mound � Other --- - --- — — --- --- -- ---- - DISTRIBUTION SYSTEM X Pressure Systems Only Hea�der/Manifold -T Distgbution Pipe(s) - — _ p '�l X Hole Size PHole9 Observation Pipes—�'� Len th Dia 1 Len th Dia S ac S acin ❑Yes ❑ No � SOIL COVER f Depth Over �Depth Over i Depth of - 1 Seeded/Sodded 1 Mulched� � Cell Center Cell Edges � Topsoil � ❑Yes ❑ No � ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) �=�1(.� l al3 /� 3 �_ .s� ,�Q�1. o�.`� �— - - _-- _ --- Plan revision required?�Yes � No I � � io3 �Y 2�i _ � G� �(� - _� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITI�NAI COMMENTS ANO SKETCH SANITARY PERMIT Nl1M8EP'.__ 2��5�_ � w��;�� L k, ti � � -� � � - / �� . t � � __ , , . ; ._ . _ ,. ; _ _ _ __ _ �' � ' d�Gk �,� I Sl� ��,�,,�-. � .J , � �'I �� I� S-� .�'t 3' �i°�� , i i �e��. �— w�' 6' .� l.J �� S�i o w �e,�,� _ 6 � � � � q� "``(� .�r �— ��--