HomeMy WebLinkAbout012-640-06-1211-SAN-2023-164 _ °`�" Department of Safety co�aty �,
=�`\� _ & Professional Services, �
- �, _ = Sanitary Permit N n er(to be filled in by �
� l �_ , Industry Services Division
.,,� •, Co S � Cl �`�� �
y-, ,. .
State Transaction Number �
Sanitary Permit Application �
�
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemme�tal unit �
is required prior to obtaiaing a sanitary permit.Note:Appiication forms for state-0wned POWTS are submitted to Project Address(if different than mailing a j,
the Department of Safcty and Professional Services.Personal information you provide may be used for seconda 5�,/_� ��,��- �!`
purposes in accorciance with the Privacy Law,s. 15.04(1)(m),Stats. ��
I.Applicallon Information-Please Print All Information (,O(,(I'� —
Property Owner's Name Parcel#
� � �� Y�,v1-e C, � ' _r �«—(0�14—��' l�-i l
Prope Owner's Mailing Ad ss Property Location
� �d`�' Sfi, ��.�eP�
Ciry,State Zip Code Phone Number
�' �✓l� �wl, : .11--- ���0�.' '/,, %, Section ��
W i '
II.Type of Building(check all that apply) Lot# T '"!�� N R � E or
�1 or 2 Family Dwelling-Number of Bedrooms �+ �C Subdivision Name
Block#
❑Public/Commercial-Describe Use —
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
'�l t7(.e / �6�.G5� (�Town of 1T� 1:�9
1II.Type of POWTS Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one box on line B.Complete line C i
a licable.)
A. Y P Y � g Y ( P ) � P )
❑ New S stem ❑ Re lacement S stem Other Modification to Existin S stem ex lain ❑ Additional Pretreatment Unit ex lain
�v 1
B' ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design yp ( p
❑Other T e ex lain)
(conventional)
C• ❑ Renewal Befote ❑ Revision ❑ Change of Plumber ❑ Transferto New Owner ist Previous Pemut Number and Date Issued
Expiration g� � �I 6 �� ��
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpdis� Dispersal Area Required(s� Dispersal Area P sf� System Elevation
3c� o � r - �zx 3s� 9 -
• Capacity in Total #of Manufa urer
Gallons Gallons Units � o '�„ �
Tank Information � �
New Tanks Ezisting Tanks � o a� � � p � �
c`. U �n � �n iz. :� CL
Septic or Holding Tank �[ ?�G �/� �
/\
Dosing Chamber
V.RespOnsibility Statemertt- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plu 's Signature MP/MPRS Number Business Phone Number
/� � �. .__...__..............._.__ �
,(�. _.__�--�1_ � �/ 1.�-Lf V V��-/
Plumber' Address(Street,City,State,Zip Code) �
(�5 l N � I u�n " 7��Z Pcu�d�- � u�� u1� ��� 3
VI.County epartment Use Only
7 Permit Fee Date Issued Issuing Agent Signature
�Ap � ❑Disapproved � � ���
��� ;I�Owner Given Reason for Denial $ l�-W �'��f�� ���'��'e"�' ''""""�
Conditions of Approval/Reasons for Disapproval
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c s�- 23 - Los� �CRt# �`'�� �.� _________
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ZONIPJG Ai.)UIIPviS��i��,i�:;��
Attach to complete plans[or the system and submit to the County only oo paper not less than 8 li2 i I1 inches in si�e
I �'?I 3
NO R�FJND�AFrTER
SBD-6398(R 03/22) ISSUE O�P'EF�UflT
PAGE 1 OF ti
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: Enciosures:
POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s):����. �(�y�C, 1 ,r1�-ry1e� Phone: - -
Owner Address:9(�3 a�'f`` Sf: dS"�c�`klf �,U� Zip:,-�i�LO�-�Fal`�
Project Add�ess: '7 SZ)(�/�l ����YL�I' Dd"' �„�E (,��
Govt.Lot: 1/4 of_ 1/4,Section ��,T�N-R�E Q or W,Q
Township: -�t�.p��t-,�.0' County: �UP�
Project Parcel ID#: (��;-�—(��(�—(��f�,j
Designer Information
Designer Name:���__��Cl.� Phone:"�lS -S� �7
Designer Address:� �� C- Zip: C ,�
E-mail- � ,f:G.���, ,
License Number: ��f�;��
Remarks:
Signature:`� Date: ��a�0'"o�J�
Original slgnature requiretl on each submitted copy.
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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 mai�tena�ce 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�ot 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 Operatin9 Limits:
Design Flow= 3C'8 gpd; BODS<_220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL"'
Inspection Checkiist 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 of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cyciing,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 spec�cation)
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(s1 shall be pumped by a certified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the ta�k(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)shatl 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 govemment unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: �� Phone:���'�'����
Local govemment unit: l� Phone:�1��'7`C"�D v
Localgovemmentunitaddress: V i �Z�P J`��`�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 dispersai component may be
abandoned and replaced by a code-compiying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued,it shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
� ` �'-"`� PRIVATE ONSITE WASTE TREATMENT County
-�� �
� � o SYSTEMS SaWyer
��� �gps ( POWTS)
ry<\,`_r ;
"�"�^`'' INSPECTION REPORT sanitary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3� (�(,f
Personal information you provide may be useci for secondary purposes[Privacy Law,s. 15.04(I)(m))
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�ak lci J ��H'^2�Cl` w�Qf� rlk �—
Insp BM Elev: BM Description: Parcei Tax No:
\�O.C7r /" ���r1.41'.9�N' VD�V✓1 01��'��� ��t7^Io2 � l
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w i 2r�- -� Benchmark (a a,o �
Dosing
Aeration Bldg. Sewer q7,ay'
Holding St I Ht lnlet 9� 07 ' 7
TANK SETBACK INFORMATION St/Ht Outiet 97,0 ' `
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIR INTAKE
Septic fi(0 �-a�� � �$ � 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 Dla Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P�L Bldg Well Waters °� GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
—- --_ --__---- - - _ _ _ _-----
- __ ---- - - --- _--
DISTRIBUTION SYSTEM X Pressure Systems Only
—_. - --- -- - -------- -- -
Header/Manifold �Distribution Pipe(s) � X Hole Size ; X Hole Observation Pipes I
Length Dia Length Dia Spac ' Spacing O Yes ❑ No �
--- _
__ _ _.__.
SOIL COVER
- - --- — - _ - -- - _ _
Depth Over Depth Over Depth of Seeded/Sodded Mulched �
Cell Center Cell Edges Topsoil __� ❑Yes � No l ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision re uired?0 Yes❑ Na I �� 2 � � � / �/ �
q � I� C� � � to
3 -- -
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITAAY PERMIT NUMBEA:�__- I �o_�_
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