HomeMy WebLinkAbout028-542-12-5104-SAN-2023-163 :-�'`'"'"'`� Department of Safety c°°nty�� �
_ � � & Professional Services,
_ �, f = Sanitary Permit Num r(to be filled in by C �
�, �_ _ Industry Services Division
����,,,,,, . - (;� S I 0 L � �
Sanitary Permit Application State Transaetion Number �
In accordance with 5PS 383.21(2),W is.Adm.Code,submission of this form to the appropriate govemmeotal unit �
is required prior to obtaining a sanitary permit.Note:Applicatio�forms for state-owned POWTS aze submitted to Project Address(if different than mailing ad� uJ
the Department of Safety and Professional Services.Personal informadon you provide may be used for secondary ��f�Q�/�j �h „�� (�
puiposes in accorclance with the Privacy Law,s. 15.04(I)(m),Stats. f � � ti � ���� ���
I.Application Information-Please Print All Informallon
Property Owner's Name Parcel#
�Cl �• f l 11�r �f'�CIS C�'1 ��. "�i'�-l--� C��tS'— ��--��—J l�`�
Property Owner's 'Img Addre (,15`� Property Location
� W� ��1.l V W �. �� V vY �� / �-I�� �'y' Govt.Lot�—
City,State Zip Code Phone Number
�,.��t �a- ��• �� ������ �� J��� 0"'/�`� �/,, '/,, Section�—
IL Type of Building(c6eck all that appty) Lot# T N R �`J E or
�I or 2 Family Dwelling-Number of Bedrooms_�__ �j Subdivision Name
✓
Block#
❑Public/Commereial-Describe Use
❑City of
❑State Owned-Describe Use CSM N-u�m7ber � �Village of
V' � 1'i 1�b � /� / �Town of /�D j�.a7C� �-'�'^" __
IIL Type of POWTS Permit:(Check either"New"or"Replacement"and ot6er applicabte on line A. Check one box on line B.Complete line C i
a licable.)
A.
❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Dnit(eaplain)
B' ❑ Holding Tank �,In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Tra�sfet to New Owner
ist Previous Permit Number and Date Issued
Expiration $` ,��C{l �5' „ .�3�
IV.DispersallTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �
`/so . 7 � s 6 � S:
Capacity in Total #of Manufacturer
Tank Infomtation Gallons Gailons Units p � o '�„ �
New Tanks Ezisting Tanks � � � � � � � �
0
r� U �in v, v� ia. C7 LL
Septic or Holding Tank DD / S
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assume respoosibility for instaliation of the POWTS shown on the attac6ed plans.
Plumber's Name(Print) Pl 's Signatur MP/MPRS Number Business Phone Number
� � �q�s.�o� ��s s����
Plumber' Address( treet,Ciry,State,Zip Code)�
l�s7f l� i�-� � - �� }�a�-- t�� -� � �.� S�E�l3
VI.Co nty epartment Use Only
�A � ve ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
�%^' ❑Owner Given Reason for Denial $ `�•�0 7 I�� I�-3 ��.+�C����+-
Conditions of Approva1/Reasons for Disapproval D � 5��
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a � `+ JUL 2 6 Z023
� � �-3 - 1 ��-f �`���#--�3�� -- —�---_..___- SAV�lYER GOUNTY
ZONING ADMINISTRATION
Attach to complete plans for the system and submit to the County only an paper oot less than 8 1/2 a ll ioches in size
tvo AeFUN�a�r�R �`� ���`�
SBD-6398(R.03/22) �cg►��pF pEFs��T
PAGE 1 OF
In-Ground Gravity Plan
Index & Cover Sheet
Component Manuai 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 Pian
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 1 Description
Owner Name(s):�(LU'(C�. E���IUCL�y1'1 i���i'rLSC4'► )�h ne:"7lS-��- �.7i=3
OwnerAddress:w�I�,�U�dlcl� 5t- ('�1ip�y:i«1��C(� l�i. Z�p:�j���'/—��
Project Address: ���5 � 1;BtF Y'� ��a,�1,�� I,L��L
Govt.Lot: 1/4 of 1/4,Section�,T �v�-N-R� EQor Wp
Township: �p�l�:ef t(,i-�� Co�nty: �L[.tll,lc��('
Project Parcei tD#: ��`��.�j����— (��
Designer Information
Designer Name:��(� ���-l'V(,ty�(}t Phone:� �S_S�S�=��J��
e .
Designer Address:{ 7 '�� Z�P; ����
E-mail: , �Qa?J t�.!�
License Number: �����1�
Remarks:
" `—
Signature•_ Date:����
ginal signaNre required on each submitted copy.
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C��oas ►�
�+ �IV-GF�OUNC� C�RAVITY C�I��'E���L A��A ��� �eptfc Tank(s)Manufaoturer;
Uniform �levatian Trenches with Quic�c4� �tand�rd-U1l Chambers SepticTani<(s)Valume(s):
. 3-ft Trench (douvn-s�zing credi�) ,���a, �„ g�, „�„ ��, �M gat
Effluent F'flter Monufacturer.
I
�.. Eiflu�nt Fliter Madet#; _� Td �2 2
mtn.17' '��—
SOIL CQVER (lyplaeq
�z��
min.�renoh
dapth ,
��yP�G��) �� ° ' , TYPICAL TRENCH
' � ��° � � ''°��4 �� CR(JSS SECTI(JN VIEW
;---- aa„ . ., , �
(tYplc�p •:'e, q . � �NO S'Cc'��@�
.r ., e,. � a'v .
� �'rovide mfnimum 3 ft
System Elevation = s. �fit separatlon botween trenches,
(typic�l)
Qulok4 Standard-W
w/knd Cap (Show locatian of Inlet/outiel pipe connection on pl�n viow,) �b��(typlcal) IpQ TYPICA►L TRENCH
(tYp�cal)
Install per manufacturore PLAN UIEW
Instructlnns,
r ��� "�� s ���� ���Jj�(;��J'�.,— .^ �. ___. ..�.�,. _. ..� _. _. �.. _. �. .�•�.. _. _. r ( (Na Scale)
)�Nf 1 A"'^'id"� ��IY5q1��'�A������Tf ���!1%�I
�.' �'�,',��'�������'�`� ��1liJ1.'�i � :,,���,���, �ii)'�I;(�iI�Il�ih,ll��lI���U�li �ij�i�,l�_`�`� A= 3,Oft
l._,, �d��l`4�?i�:'p`N ..���i:� ,�� � ,{ ` I�YPical) �
— ..� �... .�.�. �.. �... �...� �.�. .._. ...... `.. �,,,, _.,, 'bii'� �;�h W�.1P fl���.�iiNlW�iK��ii�t`�'�tik�4dl1
--�j�- -.. .��.... ._ ._ __ _ __ _ ._ _I �
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(typicai) Qu(ck4 Standard-W Chamber W
INSTAI.t. PER TRENCH: (typi°aq Q
(mfd by inflitrator Systems,Ina) ..n
' Z,� � 2 Inetall pursuant to manufaaturer's(nstrucHans. �
� ..�. Quick4 Std-W @ 20 f� EIS/�Jchamber= �.,,,, {t
`� .....l_.�, Pairs of end caps @ 6�(tz�ISA/palr� ,�,_„ ft'
= Proposed EISA ner trench = .,�s� ftz Requfred Infiltraklnn Area= �?��{t� Distribution Method:
x � trenches = Propased Total ElSA � ���.,�, ft1 �r_��h �,.r M ,'�'o/�
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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,ail inspection and maintenance activities shall be pertormed by a registered POVYTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disaersal Area Operatinq Limits:
Design Flow= �/�Q gpd; BODS<_220 mgL"'; TSS 5150 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 compiaints,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-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 tankls)shali 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 Geaned when necessary to remove any
accumulated solids according to manuFacturers 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:��-�Q� _J�Y�✓� Phone: /�5�5��3�
Local govemment unit � Phone: /�.�—�C7�-L'-0 �O
l.ocai govemment unit address:�vlUl�►I u.LCK. T�t!-L'9C � l.(YYCE��(9�ZIP: �'L��
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 wfth SPS 384,Wisc.Admin.Gode.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shail 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��ty
` SYSTEMS Sawyer
���.�SP_S 'J ( POWTS)
. q ?�j
""� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 _ ��3
Perso�al infonnation you provide may be used for seco�dary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�c�cs�L► �.�- T�.. S ��r- l�� —
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insp BM Elev: BM Description: Parcel Tax No:
vo .a � L�hc . �5�. .�,,, '��.,����C' b��-SY� - (�-S(o
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ^,� �6v� Benchmark OO,o �
Dosing
Aeration Bltlg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet �,,S'�
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. Q(o,S' �
Holding Dist. Pipe
PUMP I 51PHON INFORMATION Infiltrative i
Surface �a�3 �.S.�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATIO
DIMENSIONS �N L C� � � y #of Cells Type of System Distribution Media ManufaCturer:
� Conv ❑ Aggregate 1
SETBACK P�L Bldg Weli OHWM of Nav � �GP � Chamber � , `'
INFORMATION Waters � AG ❑ EZFIow Motlel Number:
CELLTO �-�b �� .+-5b` -r-�� ❑ Mound o Other ���
------ - - ----- --_ ----------
DISTRIBUTION SYSTEM X Pressure Systems Only
� __ � __ ------ ---- __T_ ._—_
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes�
g p Spacing ❑Yes ❑ No
engt ia Len th Dia S ac ,
SOIL COVER
_ _ _ -- ---- --- _ -- --- _-- ---
De th Over De th Over TDe th of Seeded I Sotlded Mulched
Ceil Center �el�l Edges Topsoil � ❑ Yes ❑ No l ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
��,��� ��9' �� 3
� �-`^r C�� 1 S �"e/"��^�� ,S` 1 •
.J
Plan revision required?0 Yes ❑ N� I� 2 ; ��' I , —_ J /
��i��- 2 � � 6�.�(b �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NIJMBER:____�3���0�___.__
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