HomeMy WebLinkAbout028-782-00-1000-SAN-2023-132 Department of Safety c�°°°ri' �
� � -- & Professional Services, S`�w `�
$ Sanitary Permit Number(to be filled in by �
PS Industry Services Division
(s, 51 � �-i � �
Sanitary Permit Application State Transaction Number f--�
In accordance with SPS 383.21(2),Wis.Adm Code,submission ofthis form to the appropriate governmental unit
is required prior to obiaining a sanitary permit. Note Application forms for state�wned POVVTS aze submitted to Project Address(if different than mailing addre,$)
the Department of Safety and Professional Services.Personal inlormation vou provide may be used for secondary
purposes in accordance with the Privacy Law,s. 1 i.04(1)(m),Stats. �� ���� f10��, Q �'
I.Application Information-Please Print All information �� f5
Property Owner's Name Parcel#
s�.so� ,��r�,s Qz�- �s2- ao'-oao
Property Owner's Mailing Address Property Location
�'✓(0047 C°`^�` HwY � Govt.Lot
City,State Zip Code Phone Number �y
'�'/'� d a/� S`I888 '/<, '/<, section
IL Type of Building(check all that apply) �ot# T yZ N R 6 E or
�'1 or2 Family Dwelling-NumberofBedrooms � �Q Subdivision Name
BIoCk# Te.,� �..�Ce �0 d C Cen c�61��0
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use _ — CSM Number ❑Village of
�'Town of SP,'c�<i /H�(�
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' 'U�ew System L�2eplacement System � Other Modification to Existing System(explain) ��� Additional Pretreatment Unit(explain)
B' ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound �' Individual Site Design ❑ Other Type(explain)
(conventional)
C. �:i Renewal Before �� Revision ^ Change of Plumber ^: Transfer to New Owner
ist Previous Permit Number and Date Issued
Expiration
IV.Dispersal/Treatment Area and Tank Information:
Uesign Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(st) System lilevation
3�V . 7 �Z� �JS Z 9'.S- O
Capacity in Total #of Manufacturer
Y �
Tank Information Gallons Gallons Units � ;? v � �
New Tanks Existing Tanks a`'i o � � ar t � �
i U rn � v� w :7 0..
Septic or Holding Tank '�s0 7,�(� � :Q�,�� �\
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Numbcr
0 (u.. S���I�Z /.S'/6/Z y �<s-3�Y J'S°y
Plumber's Address(Street City,State,Zip Code) ,
�6g�0w /`te�e.,�-� ('� , S'�K�. ��� I�.�� � S"�/S�T�
VI.Count /Department Use Only
1 Permit Fee Date Issued Issuing Agent Signature
�pPp V� �' ❑Disapproved -
�� ,❑Owner Given Reason for Denial $ ��'O� � I� i � �'� � .��I�������~y �
Conditions of Approval/Reasons for Disapproval �r,}n D
��:a:�:.�.a{..�-.�.E�7
�3 ��j r..�
r'-t � -�' i 0 g i ,. �U�`I 2 3 ZUL3
� �� � �� Chk#
/ �r;•tkP �..1.... aAWYER COUNTY
� � 2,_ O�� lv fY't�F ' _-._�_...,.— - ZONiS�1G ADAAINlSTRATI4N
c �L`�
Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x ll inches in size �,�'� ? ,,�4 J
NO R;F�1t�DS AFTER
SBD-6398(R.03122) ��$UE O���lY
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design Reterences:
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'tiSon M eY�rS Phone: - -
Owner Address: �600 7 GWn�Z x"Y � , �`�° , L`'i Zip; � S"Y�s�
Project Address: ��, I Ly 33N '►.�ss r �
Govt. Lot: 1/4 of 1/4, Section � y , T `f 2 rv-R 6 E Q or W �
Township: 50���" �N�� County: S�wY �
Project Parcel ID #: oz4 _ 782 - o01- o op
Designer Information
Designer Name: �� r"'� s` �� � Phone: ) �� _ Sra� _ �voy
Designer Address: �6��OW M`+`"�� � `� Z�p� syg��
E-mail: Y�� ScLI �'z �gn2-,` /. �'h
License Number: 1Sr 61 Z�
Remarks:
Signature:
Date: � - � S' z 3
Original si ture r quired on each submitted copy.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
❑ SOIL EVALUATION 0 Scale: �ao 40 so 80 �YSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: z DESIGN FLOW: ?a� GPD
(10 ft grid) 10
Attach design flow calculations for commercial plans.
PROJECT ADDRESS: ( �y33N �a SS r� N Pipe Materiai / ASTM Standard (Tables 384.30-3 & 384.30-5)
Sanitary Sewer: 'S�' YG /
BM Symbol: � BM Elevation: /�b FT
/� Force Main: /
BM Description: �"1� �t �G�
Indicate north by IMPORTANT:
Slope Gradient(°�) Well Symbol (if appiicable): 0 drawing an arrow Show ground elevation contours at suitable intervals.
Of TeStBd A�a: on the approprite line.
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Septic Tank(s)Manufacturec
IN-GROUND GRAVITY DISPERSAL AREA �D' w'�Sv
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) 1s� 9a, 9a, 9a, gal
Effluent Filter Manufacturer:
� �cc(�
� s�
Effluent Filter Model#: �
n.12'
(ryPi�ry
SOIL COVER
i2"
min.trencn
cyoP�n • TYPICAL TRENCH
— — a CROSS SECTION VIEW
�—34�� No Scale
mP���> , � ,.. ( )
� Provide minimum 3 ft
System Elevation= 4S.o ft separation belween trenches.
(typical)
Quick4 Standard-W
w/End Cap OhSer'a"°°P'Pe TYpICAL TRENCH
t ical (Show location of inlet/outlet pipe connection on plan view.) (Na��O
�YP � InstallpermanuFacNrers pLAN VIEW
instmctions. �nJ0.SC8�@�
� ��+> sR;...��----��--- --��----- — T�.z��
„ • -..F
�_. � '-..p . , --, �.,i i a ' I A=3.Oft
�.. . •i►�v• ..� iiiiaia�g� (1YPical) �
L ra.s. ------��-------��-- — -----J G7
B= 4� r, -I m
(typical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: �tyP��� �
(mfd 6y InfltratorSystertu,Inc.) �
I I Install pursuant to manufacturefs instructions. �
Quick4 Std-W @ 20 fl�EISA/chamber= Z�-0 ft'
+ � Pairs of end caps @ 6 ft EISA/pair= � ft'
=Proposed EISA per trench= ZZ� ft� Required Infiltration Area= �2� ft� Distribution Method:
x 2 trenches =Proposed Total EISA= ySL n' (�'�^"�
�
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, 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 Oaeratinq Limits:
Design Flow= 3�� 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, fioats, 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(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(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 matfunction to:
Name of individual or company 9��n ) °�"'� ,U __ Phone: 7��'��� �'�5`y —
Local govemment unit: S�`�u C"�n �� Z�^«y Phone: �`r- C�S�- �Zd'� _
Localgovemmentunitaddress: �U��D !�w`n S�'/zt-�' ZIP: �XS'�j _
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.5� (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.
System 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
�;�� PS � ( POWTS) Sa.Wyer
\h� � ��.,
' �^'' INSPECTION REPORT sa�itary Perrnit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.�j� �3 a
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
��,��, � Ko1l (Me.�rS 5 ��- t�,1,c.�. �
Insp BM Elev: BM Description: Parcel Tax No:
�p� Q � � o� �� oa�-��,�-01)- (OOp
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�e��r- '7� Benchmark /oo,c� `
Dosing
Aeration Bidg. Sewer �-
Holding St/Ht Inlet q'�,S'
TANK SETBACK INFORMATION St I Ht Outlet ai�. 3 �
TANK TO PIL WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic ��'� -� d� �-.S� -I-S � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q6,p '
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �
Surface 4�/.
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 3 � �a o ,30 #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG �f EZFIow
CELL TO -�-5`' �a.' �- �- ` ❑ Mound o Other
- --- —�--— �
---- ---- _....__--—- --- ---------
DISTRIBUTION SYSTEM X Pressure Systems Oniy
Header/Manifold �Distribution Pipe(s) X Hole Size-- X Hole Observation Pipes�
Length Dia Length _ Dia _ Spac ' i Spacing ❑ Yes ❑ No
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��i.s��� �(�9 �23
� ' 3 b�—I�� � ___ — � �
Plan revision re uired.❑ Yes ❑ No —� � j G� �
p � � �-- — -
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER:___���_130�_.__
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