HomeMy WebLinkAbout028-642-32-2102-SAN-2023-172 _ " Department of Safety c°°°ty �
- � = & Professional Services �
_' _ � Sanitary Permit Numb •(to be filled in by
,,, _ . Industry Services Division
`„ _ � sf � � � �
�
Sanitary Permit Application State Transaction Number �
In acwrdance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit fv
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing
the Deparhnent of Safety and Professional Services.Personal information you provide may be used for secondary 1 �?`� N ��M��,�7�A
purposes in accordance with the Privacy Law,s. 15.04(i)(m),Stats. �' �� '�`'f�
I.Applicallon Information-Please Print All Information
Property Owner's Name Parcel#
, ` � L.' � �u�f 0 a-S'- ��a-3a-�t o a
Property Owner's Mailin�Address Property Location
nS Dr; �---
City,State Zip Cod.e�n Phone Number /��
5���"7 r ►`rF y,, N.� '/a, Section��
[I.Type of Building(check all that apply) � Lot# T 'i P N R Q E or
�I or 2 Family Dwelling-Number ofBedrooms �� Subdivision Name
Block# -
�Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
� �Q Town of���(.,Vcr �
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on tine A. Check one box on line B.Complete line C if
a licable.)
A.
❑ New System �eplacement System ❑ Other Modification to E�cisting System(explain) ❑Additional Pretreatment Unit(explain)
B' ❑ Holdin Tank n-Ground ❑ At-Grade gn ❑Other Type(explain)
g �I ❑ Mound ❑ Individual Site Desi
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Chaoge of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued
Expiration �
��k,
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd�'s� Dispersal Area Required(sfl Dispersa(Area Pmposed(s� System Elevation
7 , � L/, �_ �
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � o ',d, �
New Tanks Existing Tanks � o � � � p � �
a U �in h in i�. C7 a
Septic or Holding Tank f�!!/1 /�� / ����� �, X
L�C./ l ( / \
Dosing Chamber
V.Responsibility Statement- I,t6e undersigned,assume respousibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber' ignature MP/MPRS Number Business Phone Number
s �/,� .�. . _.. __..�_.__ .._ � 7 �'�O ! 73
Plumbe Address(Street,Ciry,State,Zip Code) �
57 N T �Q �a.`I�- �. �
VI.County/Department Use Only
�Ap � ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $ _`0�1,p f� f 1��-.� ���v�
Conditions of Approval/Reasons for Disapproval �
� � a �� ���'';� , k;
� ii��� �:r�i� ���te �3 .�_._.._. � 'I
�5� �-3- lo� ��nk# a i3
Al1G 0 1 2023 �
� _..._ � SAWYER CGl1^'7"Y
�����i$$�„�a-�')s�� "ZONING ADMiNISI"HhTIUN
Attach to complete plans for the system and submit to the Coanty only on paper not less than S 1/2 x ll inches in size
n�o R`��n��a�r�R 3 cs�9
SBD-6398(R.03/22) ISSUE OF F'ERMIT
PAGE 1 OF�
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design Refe�ences:
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
Lj�
Owner Name(s):1.t7 i���Q.�1 D��UY�S�'jC.�B(T�'hone:
Owner Address: �0.'r, �{�J,o �PY� p�- i-.f, pWZip:�'�'�,�y_9�3C
-��-'1
Project Address: ��3� N (�,�V�,py�,�$r(Z�, ��r��p�'�� �
Govt.Lot: ��1/4 of�y�1/4,Section,3 a .T�l 02 N-R�E�or W Q
Township:�'j�l ����-� County: ,�,�UtI.PA'
Project Parcel ID#: l�v�- (p�02^��-c��Q�
Designer Information
Designer Name:��(�,01 �,J-t'�,01L� Phone:�-$�� l(n73
Designer Address:C(�'�j7`r117�� y%�CQ {� �L�, Z�p: S�Q��
E-maih CR�'��G,��.
License Number: �qp 3��
Remarks:
----..
signature: � '� � �t_—� Date: '1 3���.3
O�'� signature required on each submitted copy.
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�' IN-GROUND GI�AVITY DI�F'�R��ll� �qF��A ��`, ��Pt�Tank(a)Manufaaturer;
""e"*°'e �rer �
Uniforrn Elevatian Trencl�es with C�uick4 �tand�rddW Chambers BeptloTank(s)Volume(s):
3�ft Tre�ch (down�sizing credit} ��, �a� �,�,,, g�� ,�„ ga� �____,ga�
�ffly�nt Filtor Manufaaturer;
.�.,.z�.� .,�.�- T�>��. .
I �
Effluent Fllter Modol��:
� —min.12"
SQIL COVER ��Yp����
12„
min,lrench
dopth
�`�P'°°'� ��� 4�' TYPICAL TRENCH
' � ,' , ''"�,a'�< CROSS SECTIQN VIEW
34" ',d �
�(typlCal) ;'4' , . (No Scale)
•� 4� ' q V
• � nrovide minimum 3 ft
System �levation = 9�ft sop�ratlon botween trenches,
�tYPical)
C�uicic4 Standard-W
w/�nd Cap �5how location of in�et/outlet nipe connectlon on plan v(ew,j ��8�(typlCalj�p� TYPIC/�L TRENCH
(�Yn(cal)
install per manufacluror's PLAN VtEW
Instructlons,
(No Scale)
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i-" D = --`�;�-. ft � Gy
(typical) m
Quici<4 St�andard-W Chamber t�1
INSTALL PER TRENCH; (typlcal) a
(mfd by Inflitrator Systems,Ino.) •n
Install pursuant to menufaalurer's instructions,
'� � Quick4 Std-W @ 20 ft� EISAlchamber= � ft� .�
+ ,,.,,,,,��, Pairs of end caps @ 8 ftZ EISA/pair� �„ ftz
�Propased EISA per trench W ,;�,,�,�. ft2 I�equlred Inflltratlnn Are�= �Y,��tx Distribution Method:
x __�_r„ trench�s = praposeci Tofial EISA � ��,� ft2 /�'r�q->�� �-�,�. ,l;/�
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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 382-3&4,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 POVYTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disaersal Area Operatinq Limits:
Design Flow= �f�(� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,efc.)
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(r.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 surtace 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 govemment unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: 1'll,a��, �� Phone:��5����N��
Local government unit: Phone: /���3�6�
Local govemment unit address� IP: �� �
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.
""`�� PRIVATE ONSITE WAS1'E TREATMENT county
�
�- ����5 SYSTEMS Sa,WyeT
�����,� �s ,w ( POWTS)
�i �.-"r��j
' "-'`� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3� '��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Viilage I�Town of: State Plan Transaction ID#:
W�1�.��,,'l�.�s �'��c�,� Ca..`T�. S s�s—�1�. `_
Insp BM Elev: BM Description: Parcel Tax No:
to��a' �� ���os-- 0��-6�r2 - 32 -�ioa
TANK INFORMATION EI.EVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �yi.�,�- Benchmark �,d�
Dosing
Aeration Bldg. Sewer �
Holding St/Ht Inlet q�,s-�,
TANK SETBACK INFORMATION St I Ht Outlet c�6 ,��
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIRINTAKE
Septic -f-Sp .�--�5� ��� �S$ � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q j:S
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION infiltrative �
Surface `�Y S
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MA ION
DIMENSIONS W 3� � Y �(' �/}� ` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ���
INFORMATION P/L Bidg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO -f-(b '�(c> �-�b �}-'$a ❑ Mound � Other �Y�
_- — - ----- —--
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution—Pipe(s) - - X Hole Size ' X Hole Observation Pipe�
Length Dia �Length Dia Spac Spacing ❑ Yes ❑ No
SOIL COVER
- -
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center I Cell Edges '�_Topsoil ___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���I� `��a���3
_ , , --- - __ -- --
Plan revision required?�Yes� No �3 II , �Y � .. � 6�'���
L
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADDITIONAL COMMENT5�1�0 SKETCH
SANITARY PERMIT NIJMBER______ j - 17
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