HomeMy WebLinkAbout026-939-14-5218-SAN-2023-149 Department of Safety c°°^`� �
�_ &Professional Services, "�zi`�� e4� �
� � Samtary Pertmt umber(ro be�Iled i�by Co)
S . Industry Services Division
ir 5 1�5-7 �
5'anitary PePilllt ApPllCatl�n StareTrnnsactionNumber cN
In accordance with SPS 38311(2),W�s.Adm.Code,submission oFthis form[o the appmpria�e governmental umt I
required pnor to obtaining a sanitary permn Note�Application forms for sraterowned POWTS are submitred m Projecc Address pfdifferent than mailing addre�. ...[
the Department of Safery and Professional Services.Personal mformatwn you provide may be used for secondary �
purposes in ucordance with the Privacy Law,s.IS OS(Ixm),Stats. ,,y1 - ,/� / �
LApplicationInforma[ion—PleaaePrintAlllnfarmallon �/Z«iA%/i��'y771l1LS(L(� L��7�,
Prope+rty Owner's Yame Parcel I!
SreVZ.v'1 Syl WQ. �2�0—c13�/—��—SZ/t�
Property Owner's Mailing Address Property Location
z�( RO�1�-Vt � l��'Se (��1 L
Govt.Lot
Ciry,S1ate Zip Code Phone Number
C9Y'u- � �C��t' LL (vb630 �47-5 32-6�.Q(o '/•. v.,sec�ion �`{
II.Typ of Building(check all that apply) Loc q T � � N R �
�Ior2FamilyDwelline—YumberofBedrooms ��_ ( SubdivisionName
Block H
❑Public/Commercial—Describe Use
❑Ciry of
❑State Owned—Describe Use
CSMNumber ,g(7� ❑Villageof
/
'�r ��c�, �Town of ��r�/��!K� _
lli.Type ofPOWTS Permih(Check either"New"or"ReplacemenP'and other applicable on line A.Check one boz on line B.Complete line C i
a Iicablal
`�� ❑New System [l�!Replacement System ❑Other Modificatfon to B.eiseine System faxplain) ❑Additional Pret�eatmznt Uni�(expluiN
B' ❑Holdin�Tank �J In-Ground ❑At-Grade ❑Mound ❑Indrvidual Site Desi�n ❑Other Type(expla�n)
(mnventional)
�� ❑Renewal Before ❑Rev�sion ❑Chan,e of Plumber ❑Transfer m hew Owner �st�Pfrevious Permit Number and Dare Issued
Expiration •l 0 �—1(p� y/2-1/!p
IV.DispersaVl'reatmrnt Area and Tank Informatian:
Design Flow(gpd) Desien Soil Application Rate(epd/sq Dispersal Area Required(s� Dispersal Area Proposed(s� Syseem Elevation
ysa � � �y3 C�s�� 93:0�
Capaciry in Total M of Manufacmrer
Tank Infortna[ion Gallons Gallons Units `
new TarJ:s Ezis inp Taa4s `�� —
c`.U — y u.'J —
Sap�icw-NeH.n¢Tank �bC'(,' �00(t �
�UIES^
Dwing Chember I
V.Responsibility Statemenb 1,ihe uodersigned,assume responsibili inetalla'n ofthe POWTS shawn on the xttached plans.
Plumber's Name(Pcinry Plumber's Sig ,_, ,__.,-- MP/hH'RS�Number Busfness Phone Yumber
�5�,� d�ufffer �-�__ (�7s7s7 �,S--�46`�3s:i
Plumber's Ad�ress(Street,City,Staie,Zip Code)
f�C�_ E��u �G C��l e,C�z S"�fx u
VI.Co�n,tv epartment Use Onlv
�A 6v� ❑Disapproved Permit Fee Datz Issued Issuin�Agen[Signature
��.OwnerGivenReasonforDenial �ye.U� � I�N'�-3 �����-/"����-
Conditions of Approval/Reasons for Disapproval
0�lG�I�.�� a,�:� , ��y��� � �` � ����� a1��
d� Chk# f 3q�s . ,_,_ �,1 1UL 1 2 2023
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saw�vea couNry
ZONING ADMINISTRATION
Arrach to complete plans for the eysrcm and suLmit�o the Counry only on pap<r nor I.�u than B in c I I inehei in size �U_�r S�
NO F�FUNDSAFTER
sau-b�as�a os�zz� ISSUE OF PERNIT
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 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�V�i,1 S�'Lc.PWQ�-f Phone: �`�� - S3z - v48fo
Owner Address: 2�{ �'v��c�G �r�c� �.4.;i � �``Ys �, �LL Zip: G���C+3c�
ProjectAddress: (�Z1f� i•� M1�rYtc��1qSl��F ��:� � S��z.m�,��;,�f, c� � �(� 73
�. Lot: I LSm� � �`f 1/4 of 1/4, Section�, T 3 r� N-R�_E ❑ or W �
Township: ���L� ��. County: ��c,���z,,�
Project Parcel ID #: (72 �, � 93�f -/�F - S'� Z-I �
Designer Information
Designer Name: �c2S�+� �U< � � Phone: ��S'� - �4� _ 3;'S3 '
Designer Address: � C � ��� � � C cz� (�, (-�' z Zip: S'�� Z/
E-mail: -�-tm @ cc-.�d✓i-�r�cs ,c.em
License Number: (��S,7S�
Remarks:
�s .9 .�p.�
Signature: �'�Y �ate: �� // Z-3
Original sigrtature required on each submitted copy.
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Septic Tank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA t�' � Es�,2
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) ���'�' gal 9a� gal 9a�
Effluent Filter Manufacturer:
Of��cc;
I E(fluent Filter Model#� r � � ��'`
min.i2"
RYPicaq
SOIL COVER
iz
min.�rench
depth
mo��n • TYPICAL TRENCH
a CROSS SECTION VIEW
f 34
„yp;�a,� � (No Scale)
� , . r Provide minimum 3 ft
System Elevation = �3 ft separa tion be tween trenc hes.
(typical)
Quick4 Standard-W
w/End Cap Observation Pipe TYPICAL TRENCH
(rypicaq (Show location of inlet/ outlet pipe connection on plan view.) (typical)
Ins[allpermanNacturefs PLAN VIEW
instmctions.
(No Scale)
� - - - - - �� - - - - - - - �� - - - — — � 1
� I A = 3.Oft
(hv��q �
L - - - - - - - - - - - �� - - - - - - - �� - - - - - - - - - � D
S-/GG
g = ��,��� ft _ � m
�tY� Quick4 Standard-W Chamber W
(typical) O
INSTALL PER TRENCH: �mte by��e�c�a�o�syscems,��o.� �
Instatl pursuant to manufacturets instmctions.
��� ��� � Quick4 Std-W @ 20 ft� EISA/chamber= ��Fe ft� �3� �r��l 'A
+ � Pairs of end caps @ 6 ft�EISA/pair= � ft� (3 Pa«5 }C�'«�)
= Proposed EISA per trench = ft` Required Infiltration Area= ��3 ft� Distribution Method:
13= 2Gb -+ (, - ZL4
� � ` ZZe Y� � Zz� x � trenches = Proposed Total EISA = �cs � ft� C-����.j �11�rhe ���'
y = i � o -� (� = 1� �
� 4 ` U s�'� �Z RESET
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 Operatinq Limits:
Design Flow= �� 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 af ponding in distribution cell prior to dosing
c dosing irregularities - if applicable (i.e., pump re-cyding, 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)
c 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 malfunction to:
Name of individual or company: (-� KC�(fil,USS��'�`�f3�-� Phone: I�S��r�-�3�'S�
Local govemment unit: SCl l.u.�Q�-- �. ��L��� Phone: 7l S�-�3�/'3'��"�
Localgovernmentunitaddress: �(?Q,�L"C� Lt,�d- ZIP: �s�
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.
Continpencv 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.
__
"''='"'-�'=��>'- PRIVATE ONSITE WASTE TREATMENT co�nty
� �p
S � SYSTEMS Sawyer
`�'���� p,s �� ( POWTS)
�.�o _---ei�
"'�� � INSPECTION REPORT sanitary Pe�rnit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION p�3 ,� I(l q
Persa�a]infonnation you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�[Town of: State Plan Transaction ID#:
�i wca sa� �i� ^—
Insp BM Elev: BM Description: Parcel Tax No:
100'c7� �v c��\ 1 O�-�—`f�`�� !Y —.�02 l�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,.,��� ��t'� Benchmark lo�.p�
Dosing
Aeration Bldg. Sewer --
Holding St/Ht Inlet 4S,2s'
TANK SETBACK INFORMATION St/Ht Outlet 9'S. t�'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic .� � }�� G � .{�� ' NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. 5'�(,p�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative q3�� �
Surface
Manufacturer Demand Final Grade
Modei Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMA ION
DIMENSIONS W 3 � ' ` ` #of Cells3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate `��� �
INFORMATION P/L Bldg Well Waters a GP � Chamber Model Number:
❑ EZFIow
CELL TO �-�' ��.b �-ICSO ❑ Mound � Other /r;��
____-- -- --___ — __ — — ----`-r ---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) �ize , X Hole Observation Pipes
Length Dia � Length Dia Spac Spacing ❑Yes _0 No �
_-- -_-- --
SOIL COVER
--- ---- -- -— -
� Depth Over �epth Over �epth of � Seeded I Sodded � Mulched
Cell Center Cell Edges I Topsoil _ ❑Yes ❑ No ❑Yes ❑ Vo
COMMENTS: (Include code discrepancies, persons present,etc.)
�-�s�lf�.�f �3�Iz3
Plan revision required?❑Yes❑ No 03 l y i Ii _. /. , _ —j 6� ��� �
__ w
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN�7O SK)ETCH
SANITARY PERMIT NUMBER ______..__2 J_'1_��___
-t-o r�to�^�-75,�'�`-.L+'�.
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