HomeMy WebLinkAbout012-739-06-5216-SAN-2023-173 _�'' """`� Department of Safety c°°°ry� �
` � � = & Professional Services,
- �� �� - Sanitary Permit Nu r(to be filled in by( �
, _ , Industry Services Division
'��z � ;v-��' �� ` � � S s�
-�,,.,...,- _ �v
Sanitary Permit Application State Transaction Number ,
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit J
is required prior to obtaining a sanitary pemvt.Note:Application forms for stateowned POWTS are submitted to Project Address(if different than mailing ac �J
the Depariment of Safety and Professionai Services.Personal information you provide may be used for secondary `�O�W CjMa�� ��
pucposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. " �
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
CO b CcLb ih, LI.G 0 I oZ -739- a{o-�/lo
Property Owner's Mailing Address Property Location
D � ��I Govt.Lot_�
City,Sta[e Zip Code Phone Number(,.�h,�
�����5 ���L � I �a�'��S'��?9 /e, './., Section�-
II.Type of Building(check all t6at apply) Lot# T N R �7 E or
�I or 2 Family Dwelling-Number ofBedrooms � � Subdivision Name
Block#
❑Public/Comme�+cial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
���0� ��o�'� 1�,Town ofl�Ll�(��{'{i/�
iQ.Type of POW'1'S Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A' ❑ New S stem ❑ Re lacement S stem g y ( p ) ❑ Additional Pretreatrnent Unit(explain)
y p y �p Other Modification to Existin S stem ex lain
/t� l - / "
B' g ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
❑ Holdin Tank �In-Ground ❑ At-Grade
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration O_O�� �� '
IV.DispersaUTreatment Area and Tank Information: e
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(s� Dispe 1 Area Proposed(s� System Elevation
3�� �v� % ��r �•
Capacity in Total #of M ufacturer
Tank lnformarion Gallons Gallons Units p � o 'n„ �
New Tanks Ezisting Tanks � o � � v p � �
n, U �n �, v� i�.. C7 A..
SepticorHoidingTank �0�Q ��6a / r
/`� u
Dosing Chamber
V.Responsibllity Statement-I,the undersigned,Assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plu 's Signatur_ _ __.....__,.�._.. MP/MPRS Number Business Phone Numbei
,/�'" _� _.___-------- � �� 7�5� � 7
Plumbe s Address(Street,Ciry,State,Zip Code)
�V✓ '� � � �� 1.�/�- s�G
VI.County/Department Use Only
�Approved ❑Disapproved Yermit Fee Date Issued Issuing Agent Signature
��':" ❑Owner Given Reason for Denial $ L���� g�a �.-3 `' 'I��/i/'.�L�.-
Conditions of Approval/Reasons for Disappivval
r
� � � � .-�,�' �����' 1�
� �� ��� ; Date � �- 3 _, c�..=.� �
'��
iJ
�hk# ��'3 �� AUG ti 1 2Q23 �
� ,
--__ _ � �
�5T z3 --(pg �c�t#___��i�S__. _ .. _ savw. E� cc�i.�►�-�,:
iN .a� � ► • ,._;.,.
Attach to complete plans for t6e system and submit to the County only on paper not less than 8 U2 x 11 inches in size
h0 R�FUN��AFTER !�I�`1 �
SBD-6398(R.03/22) ISSUE UF�R�IR1T
PAGE 1 OF
In-Ground Gravity Pian
Index & Cover Sheet
Component Manual Design References:
�n-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): ( ��1/ C�� �,_[�C, Phone: �Odg -Io�J' - S��-L�"f�
OwnerAddress: � l�(�j �,Oy7)`5(1Y11q(( � t,IJZ Zip: J _?IJ��I
Project Address: �,_`�J�O 11.) (�,���- Q� ����� r �
Govt. Lot: � 1/4 of____1/4, Section� D�, T��N-R 07 E Q or 1N �
Township: �1l1r-�'�f,(' County: _ S�./A/U �
Project Parcel ID #: O�a "7�J�I� �(p — �a/�Q
Designer Information
Designer Name: ������� � Phone:��-�-���
Designer Address: Zip: 5��d�j
E-mail;
i_�
License Number: � 9�3(� �
Remarks:
Signature: �w Date: /���-,�j
' nal slgnatu required on each submitted cppy,
ow r�er : L�4 ( :
C o � b`� C�,���'i . LLC Q e.r L'o . ( ,�-t v��-��T`w �.
�O L3 x l4(Q t��i�} ; O ( Z - �3q - o(o - SZ- ((p
f1/� o r�' tso►nU���e �w l 53i7( Lo-�- tZ. Cs�-1 s�6� � q�o
� 5%TP�'. f 2b�jQ W Co✓�Br- �c1
,-c' ���� L-a_K�'v 1�1
� �Q �� ��� �o
���
o �o so 30 4a
/-� ''°z � fi
� �� � L 8f'l l00 Woo � �►2�-�vr►'+�t trt, �Yo+'�� �-��til� c�.00�
3 �. ivo,8
�� � x Sys��� el. 46.8�' d�� t y-r` ��� ,
d� � N,�9. / 1�u��� �X 5^��c� Co ���Se�
/4f�m � �� l Y ;� �
`.`'ef� ' /r�/�-{✓' �- w (
�, 6� d.:�, -7'v��� � '�� �ci.GG S� -�---� �'t��
b
o� 1� A r �
� A
P ° Bn caa
^ C .0 �►�
_ ,
��
o ���
�,�g� � �. a
�— �
��Y
-} ( OQ
LIFTING STRAP -RISER CONNECTION(TYP.)
(TYP.) —� B
- +--1.6(38j
A A� ACCE65PORTftIM ��p CONTINUOUS
TANH TOP ELASTOM[TRIC
FI.E%IBLE RUBBER NAIf 6ASKET
_ OABNE7�TYR� � ,
b � � �y TANK
62.2 INTERIOR —SEAM CIIP
E�1,580t �sa�
TERIbR +--INLE7/
WIDTH TANK OUTLET AIIGNMENT —.TANKBOTTOM
I INTERIOR TEE DOVYEL(J4) HALF
�
— L
Q PIPE PENETRATION Q MID-HEIGHT SEAM
LIFTWG LUG B�
�7YP� SECTION DETAIL SECTION DETAIL
-.-- —127.0�3,226�EXTERIOR L[NGTH-------►
TOP VIEW
TANK EXTERIOR �_�qUID DEPTH 44.0�1,118) TOTAI CAPAC�TY 1,247 GAL 4,M0 L
LENOTH 127.0��,228 INVERT OROP 3.0(78 �M1`��HING VOLUME 1,070 GAL 4,050 L
(d 24.0(810�ACCESS OPENING WIDTN 82.2 ,6B0 FREEOOARU 10.2 280 COMPAflTMENT!�VOL. 713 6AL 2,700 l
WITH IOCKING LID(2) HIEOHT 4.7�1,7BB COMPARTMEN7 8 VOI. J57 OAL 1,350 L
RI 4(102J- 10.2(260)FREEBOARD 0 4(102)
PVC OR ABS PVC OR ABS
INLET TEE OUTLET TEE END OUTLET BAFFLE SLOT
p - �•Ti.l=. . �.,�-��,.. .
� INIET 9.64
AIR 6PAC O TLET
� 9.0 � � , ..._-- --_.- .
� � �78� BAFFIE P�R 0.2 f5I WALL —
� CODE - �THICKNESS �
�"- COMPARTMENT WALL L 18.0 8•�_ BAFFLE
PER 4/.0 � 54.7 [4�1 It52� 7oP
� � CODE � �1,118 —$ f1,389 j .� ^ 0e .
LIQUI� COMPARTMFNT 1 f ��b2
� 2�5QX2�51j OEPTH 0 E%TERIVR � qFFLE
� FIBEROLA33 O SEAM CLIP HEIGHT � sUPPORr--►{ poRT
UAFFLE
Bl1PPORT SLOT �'r(P. BEHIND I
Ryp,� � OAFFLE BAFFlB
LIFTING STRAP � SLOT
� �...__ _ .
2l�TOTAL VOI.— +-tla TOTAI VOL.-r� (nP.) -
� SECTION A-A' END VIEW SECTION B-B'BAFFLE DETAIL
� NOTES:
g 1.ALL DRAWING DIMENSIONS IN INCHES�MILLIMETEHS]OR AS NOTED.
� 1,EXTERIOR OF ACCESS OPENIN�LID INCLUDES THE FOLLOWING WARNING IN
F ENGLISN,FRENCH 8 SPANISH:"DANOER DO NOT ENTER:POISON GASES:' x ISOMETRIC
r 3.TANK MARKINGS WILL INCLUDE:MANUFACTURER NAME,MODEL NUMBER,LIqUID � �
CAPACITY,DATE OF MANUFACTURE,MAXIMUM BURIAL DEPTH,WLET,AND OUTLET. VIEW ���h,�����rl •I-�^��i��^C.��t
A.MA%IMUM BURIAL DEP7H 15 48 in[t,219 mmJ. «
y tanks
� 6,MINIMUM BURIAL DEPTH IS e In(162 mm�.
g 8.MAXIMUM VEHICLE LOAD IS 4,60D-Ib�10-kN)AXLE LOAD. 8 INFILTRATOR SYSTEMS INC.
y 7.TANK IS FOR NON-TFtAFFIC APPLICATIONS. 4 Buslnese PeAc Rd.Old Saybrook,CT 08475
� B.AIRSPACE IS 18.6Yo. (800)221-4438
9.OUTLET TEE IS COMPATIBLE WI7H EFFLUENT FILTER. �
� tU,INTERIOR LENGTH TO WIDTH RATIO IS 2.�:1(11B.8dNCH INTERIOR LENGTH/ SIDE INLET/ INFILTRATOR IM-1060 TANK
61.7-INCH INTERIOR WIDTH�2.9). OUTLET(TVP.) 2-COMPARTMENT CONFIGURATION
� 11,FREE VENT AREA BETWEEN TOP OF BAFFLE WALL AND BOT70M OF TOP BAFFLE
SLOT IS 39.7 In'. oreNnOy:EMB ��e:OB/D5/2013
12.BAFFLE WALL TNICKNESS IS 0.91 In(8 mm). Say:r,orrosca�e cneuedhy:DFH Sheac 1 011
0
i
I
I
�
IM-1060 Generaf Specifications and itlustrafions
���P UFTING LL'G R5F1t CONNECi10N
;MlCW ._(<TQTAU (TYRUU
The IM-1060 is an injection molded two piece mid-seam
plastic tank.The IM-'I080 injection mo(ded plastic design �� � i � �
ailows for a mid-seam joint that has precise dimensions a
for accepting an engineered EPDM gasket. Infiitrator's ` oo � oo �
gasket design utilizes technology from the water industry � ° Q = � � �
to deliver proven means of maintaining a watertight seat. °� � °o ���
The two-piece design is permanently fastened using a "^DTM
series of non-corrosive plastic alignment dowels and i i �
locking seam ciips.The IM-1060 is assembled and sold '
through a network of certified infiitrator distributors. I t27D[3226)FMERi0R1FNGh1 —_�
,
Must be backfil[ed and instailed in accordance with TOP VIEW
Infittrator Water Technologies, Infiltrator IM-Series Septic
Tartk General Installation Instructions and for shal(ow O1TtFf
ground water condfions reference the Infiltrator!M- i
Series Tank Buoyancy Control Guidance.
c
Please visit www.infiltratorwater.com/images/ptif/ n�,
ManualsGuides/TANK01.pcff for the latest iriformation. �,�
$AM CLIP I
:. +.,.f (7'WIGU �
uFnr�srxaa
,Working Capacity 1 Q94 ga!(4�41 y � m"""�'
Total Capacity 1287 ga!(4872 y � END VIEW
Airspace 16.5% '
� �-��h 127"(3226 mm) r o<��oz� ,--mz<tsio�accessovEwr,wswm�waawcuosw
wc oR rss
�Width 62.2"(1580 mm) j w'�TT� ,o.�tzso�vF�mo,v� o<noz�vvcoe
A35 OVTLET7¢
� Length-to-Width Ratio 2.3 to 1 ,N,� � � ,bs�,,
j _ a�soa� ; ��
Height 54.7"(i 389 mm) � � n i i � � i o�
Liquid Level 44"(1118 mm) � � ; i �
aa.o
Invert Drop 3"(16 mm) 5�--� "'uai„D w�
m�cau °�TM' �' mr�cau
Fiberg(ass Supports 2 j �rr++s,�
wa.iwt�
i �� i i� i REQu�AED
� Compartments 1 or 2 �
� Maximum Burial Depth 48"(1219 mm) i SIDE VIEW
I Minimum Buria!Depth 6"(152 mm) I
! Maximum Pipe Diameter 6"(152 mm) %
�W21 ht TANKTOP CONTINUOUS
F 9 320 ibs(145 kg) HA�F ��I c�,4sKET
TANK
INTERiOR - SEAM CLIP
ALIGNMENT �-�
DOWEL � TANK BOTTOM
4 Business Park Road FiALF
�. P.O.3ox 768 .
Otd Saybrook,CT 06475
1 N F f�T R AT�R� ��-�� �`860�$"_70°' MID-HEIGHT SEAM SECTION
,-soo-2z,-aa�
V�cL@:'`.......,.v. '.. www.infilfratorswater.00m .
US PatEnts 4.759.661;5.017.041:5.756.C88:5.336.017:5.40'1.�18:S.001.459:5.51�.903:5.716.163;5.588,779:5.839.Sd4 C:anadian PaterrG;�.3y,95g 2�pp4.55y pyig p�g�p�d������.
Q�dc4.arx?SdeWmdrl are registered trademarks of Infittr�or Wat�Tectmologies Infittrata is a regL�etl tratlemark in Franca tr�ittra�Wa;a Techndogies is a regfsteretl tradeJnark in Mwce.
Coritota.MivoleaMing,PdyTuff.ChamberSpa�er.Mt�riPOR.PosiLDGc.QuickCuL QtnUcPlay.SnaPLOGk and Str-aigMLOCk are trademark5 of Irtfdtr�or Watpr Tedvttlogies_
PolyLok is a tratlemark of PoyLpk.Inc.TUF-TITc is a regi5teretl t2Cpmark of 7UF-TTiE,INC.Utt+a-A�b is a tratlemark pf IPDC Inc.
�20'161nfittrator WazerTechnologies.LLC.qIt righ5 r��veC.printetl�n ll.SA
IM02"16
• f ' • • • ' � '� . �
i �� �
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 shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersal/�vea Operatinq Limits:
Design Flow= �C�� gpd; BODS 5 220 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 complaints,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 I drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o extent of ponding in distnbution 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 surtace discharge of effluent or sewage back-up into structure served
Maintenance Checktist MAINTAIN EVERY 3 YEARS(or when necessary)
o Sentic and dose tank(sl 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(113)the liquid volume of the tank(s)or
as required by locai ordinance. Disposai of contents shail be pursuant to NR 113,Wisc.Admin.Code.
o Effluent fiiter(s1 shall be inspected every 3 years and shall be deaned 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:�/,�,i� � i {�� Phone:'Y��J S��i!/��
Local govemment unit: Phone:"/�,�!�/`��b ��
Local government unit address: �: J yC)`f-./
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.
Continqencv Pian
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 soiis.
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 county
;��� ,
_;`l���S �T; SYSTEMS Sawyer
� ( POWTS)
�� ti �;
' �'"> INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 _ I /�
Personal infonnation you provide may be used for secondary pucposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village (�'Town of: State Plan Transaction ID#:
C.o`� �b�, �(-c, I�.�� �
insp BM Elev: BM Description: Parcel Tax No:
(c�.�� w��� p�,���, � �,�-a�e,., d�.r ol�-=735'-6(o—S3f(�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,��- �p Benchmark ,p�
Dosing
Aeration Bldg. Sewer --
Holding St/Ht Inlet 9 •Y �
TANK SETBACK INFORMATION St I Ht Outlet , z `
TANK TO P1L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic S fio2'' � ¢-8 � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
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 �N �2 L j r— #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P/L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound � Other
-- - - --- - — -- ----- __ __-
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold --�Distribution Pipe(s) - X Hole Size � X Hole Observation Pipes �
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
SOIL COVER
� Depth Over �Depth Over , Depth of � Seeded/Sodded T Mulched �
Cell Center Cell Edges I Topsoil ❑Yes ❑ No � �Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
� -+'t^S1�I� � � ����
� S;�-, r�e�l . ���,t.
Plan revision required?0 Yes O No I�i p�?I ��t/'� � — �i
!J _ _ C 6��16 �
Use other side for additional information Date P WTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT Nl1MBER:______�.�_(7�__
�_ �'/�2� �� �--
�
�
, ;
: . . ._ __. ,_ . ; . . _ , , :
__ ; _ _.
, I
_. ;__ 4.. .. . __ _.. ._ . .._... ,_ __..._ ,__.. : .___._,.._. .. _ . , ; -- - . . , , __ _...
, �
�
� ' , ' , , i
. . : . . , _, _ . e : ; ; ; ; . _ _
,
_ _ .. : _-- _ _:_.. _ _ _._ ,- . _:._ —° —'--— : _ , .. : . _.T.. _ , _ , _ ; �_�-- -- — __ -
'
; ,. _.._ ,_.. ._ ..__. . _...... _ . ,.. . _ _. , s_. . .. : ,...._. . �. .._ _ _.i .
, , ; , ,_
i i , i
2 � -
v�� Q\�� ' , m"Z �^'l � —�
�-2S �� �, �
—}�►�' � ( ��,� �
� � /`�
�� �b I c� �
� — �
���
��
Ca�,� � .
�
�,r��_� a„_