HomeMy WebLinkAbout004-839-08-5213-SAN-2023-180 ��"��"""�x Department of Safety �"ty �
=`r= &Professional Servicea, S i R
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Sanitary Permit Application sti�r�,,;�x� '�
In eccordence wit6 SPS 383.2I(2),�s.Ad�a Code,subm'ssion oftfiis fo�m to tl�e eppropriece gavemmenpl imit 'J �
is required prior to obtau�q a semtary pcimit No¢:Appliwtiw fmma for smtaowned POW7'S ere submilied to Project pddms(if difiamt W�meiiing
�he Departmrnt of Safity end Profasonal Services.Persoml mfoimarion yw pmvide may be used f semudary �
aus iu eccordence with the Privacy Law,s.15.09(lxm),Smu, � ,/
L Appllcatinn Infnrmsaon-Piea�e Print All Intormsffin 67 N C�YAN S R 0
Pmperty Owner's Neme p��#
A sa + ��A,cy �v,�u�s,� ' doy83 9a851�3
Propeny Owncr's Mailmg Add'ess Roperty Locatlon
� y�r7 `/d0 r"r �r, �o�L�a�s
City,Sta[e Zip Code Plrone Nnmber
�Eao�roaif !�J I 5i'75/ i. u,s«o� 8
II.TypeofBaildmg(che allthstnpply) Lot# T .3r N R 8 E
�I 1 or 2 Famiiy Dweping-Number oEBNmoms .3 ` Subdivieiw N�
Block q
❑PublidCo�mcial-DarnbeUse
�Cityof
❑StazeOwned-DexribeUw CSMNumbu 8•�67 ❑Villageof _
�Towvof__ �OUDfilAY
iII.Type of POR'TS Permit(Chxk ekher'�PTev"or"Replscement^ond otLer applicsble oa lineA.Check one box on Bae&Complete IIoe�C
a licable.}
A' �New
3ystam ❑Replacement Sysiem ❑01her Modificetion m Existing Sys�em(explain) ❑AddifionW p�etream�rnt Umt(upkin)
s. ❑xoia�gr�x ��-c��a ❑n�-c� ❑Mo�a ❑ma�ra„�snenos;� ❑atarrxc�v�)
(conveotional)
C• ❑RrnewN Before ❑Revision ❑Chaoge of Plmn6er ❑7�sfer to New Owna ��ous Prnnit Number and Dete tasued �J
Expvation �O' �
G27939- 9-,t9-ao�a
N.D reeUTreatmen[Ares and Tank 7nformation: �
Design Fiow(gpd) Design Soit ApPLcatiun Raa(SPd/s't) Dispusal Aree Requiad(s� Dispersei Area Rop�ed(s� Systm Elevarion
yso .7 q a.4�-
GY3 L 6 9S!Y� y ,o'
CaP+��h�n Toql #of Mmufacnua
Tmklnfartoetloo GWom Geiloa: Ume '-'
NewiWo ��q7� m� V� _ �y �g
� a
a� 'o',� �:,o a
sepu<mHata�c 000 -
/dC0 � (.�/FSEf �a,1ca �--
��gcn�x. !,po -
L06 / C6niS0
V.Responefbilky 3fstement-I,t6e o�er�igned,a.wm¢ � `
mpouaibUity inefa➢a8o¢ shown an Ne ettac6ea pLus.
Plumbers Name(Print) Plumber's Si MP,0.fPR&Number Busmeas phoue Number
ENT oKE ti-- �?1Y/49 7/S 9�a-yrsf
Ptum6ds Addeess(Saeet,Ciry,Smte,7'ry Code)
6�a. .6ox a Lo«Ax wr SY7.�6
ar.co tymepa.cm�v�o�y
li PeRoit Fa Dp{��� �yyyjp
�.A ❑Dieepproved B AB��Si�ature
G�i"i ❑o�«c���[�o�n� a Kt1o.6O 3 I<<�a 3 �,�c�u.P.e��f�u.,�
Conditions of AppmvaUReasons for Disappmval , �
"1 �I!� A ,ate___-��I1�a 3 �' '% �� .:, ..
�r li ll�' __ — � .,1�
� '�I�
��,W�� chk# ai4o a L'� AUG 1 0 2023 '�J�
Rcpt#__a s So ------J
C5��0���7 -____.___..--- _ .. .,:,';:-�C;'U"JiY
c:i!;'<:�.�i l�U;�IINiSTRATION
�m�nmmmvw�W..+r we�.m�nrom.ce�xyomsaoa•a���m.n�e,a:ii�m.�
N3m81
SBD-6398(R.03f12) NO R[FUNDS AFfER
ISSUE OF PERV:tT
Page 1 of 7
Private Onsite Wastewater Treatment System
Index and Title Page
ProjectName: .� ASoN � �//taty �aur.1 3-.tSa /,��,e wal�'�N/ �a�rs `,�Em�
Owner's Name: " •� ��
Owner's Address: _ N 5'//7 Y,�d rN Sr
/�-_ Ev_ opa� GlI SY75/
Legal Description: G.L. -„7!3 S 8� 37Ni 8 4J
MunicipaliTy: Town, Vt$age, City of G 6ud E.tA Y
County: .SAu re,�
Lot Number: /� Block Number: CSM Number: 8 Y(7
Subdivision Name: _ rpiy��S Q�
Pazcel I.D.Number: OOYB 3 90 8 S.t i3
Page 1 Index and Title Page
Page 2 Plot Plan with Cross-SecUon&Plan View ,
Page 3 Sepric Tank/pamp Cba�ber Cross-Section&Specifications
Page 4 Pump performance Curve
Page 5 POWTS Owner's Manual &Management Plan
Page 6 POWTS Owner's Manaal&Management Plan
Page 7 Filter Informarion
NameofDesigner: � oKE License#: _MP- ,77y/99
Signature: ate: Q- S- ,T073
Des__ i��ursuant to the followine POWTS Component Manual and DSPS 381 385:
In ground Soil Absorpuon Component Manuat for POWTS"Version 2.1 (May 2022-2027)
Attachment: Soil Evaluation Report
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Page 3 of 7
CON�INATION SEPTICIDOSE TANK CR03S�ECTION
mw+vhru�wo�r ro s.�n�>
FINAL GRApE �HOLE RtSER&COVER _
f�reem�masurcer�awytmm ta�sPs3ea.xma(e).�
^A"h°�°(s)torWop�Nahu�) �8mendhd�itaer�ne�y.}�
4'M1pn.Stlt 40 PVC T4Nc Vert
41Ba SrJ�./0 PVC TmY�VeM loobtl tY aEow
BUILDMGSEINER womaatrmwegrm.u,at• JUNCi1pNBOX °�R°����n
(wrsasaez.���»} aeoverea�Floca� (�reansasais
m,a NEc avo}
. . . . . . . _ . . . . I . . . . . . . . . . . . FORCE
-- �r AAAIN
��� „a. OPT'ION3
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amn__' '� `\
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I _.'._.'._._.'.'._._._ _-'.'. 1� .':.':.'. / � Fv0
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MINIMUM OF 3'pF SURqpLE BmDING BEf�A7H TMBC 8 M/WMIRd BURY DEPTfi OF gg'
��8���eN��Pdred Per 3P3 383.A3(�(9)
Tank Manuiadurar. GJ/ESE�t Ln,�cw FrE Daily IMastewater Firner(pyy�; GPD
SeptirJPumpS¢e: /�a/Goo aail++rfs N�berofdailytloses; S. � (/9.1?,
Alertn ManuFacturer. _ .SEPs,ee,.+ic s
AAodel Number: _ ro.T7! Foree main volmne: .7S g X ,ll3 geIIR- y, / g�
SlnitchType: /�JELNA✓la9L Af1t721dO5EVWUrt18: �Id.S9y _ y!/ �_ 8�,y/ �
(totel dose volume-votume ofiwce main)
Htluent Pump AAanufacturer. Li rr� Gi��r
�odei a�,,,y�. 9 Fc DOSE TANK CAPAqTIES•
Reserve above alarm .?o.G in= YS 8�N)
Min6num Oischarpe Rate_ .70.D GPM A�rtn float abo�on float d in=— 33.S 9�1(C)
ONOfffloatmeasurement 5.5� tn= 9o.S gel(g�
Vertical lift(PumP off to lateral invert)............ 8.S $ Off above tank bottom m— 3 Y. !
System h�d(dishal ptessure_x 1.3 ft): — g '—"—$— --.L---_9��A)
..�5 ft Foree main x L_H00 irktipo t�Or .3 ft ppgE TANK d1AEN31oNs•
Fiterfictfon loss.................... . . . : — ft ��� /SO in Width Q'/
. . . . ........_
Total Dynamic H�d �
��= �.8 ft Outlet height 3G m Gepo��nch 1L.7L
P�. YoF�
EFFLUENT PUMPS
9EC SERIES-4/10 HP
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p A C
B �
9EC{IA-SFS 9K-CIA-Af
��aiN�S
B
A � o
9K{IM
9EC-0A-SFS �(g'(;ppmm) 10.]'(ZIImm) B.4'R14mm) I
� 9FC-CIF-RF I 170'(280mm) � 87Iu6mm) � fld"(214mm)
I Ytt-0M I RO'(280mm) I �A9"R7bmm) � BA'(2Umm)
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� EPoxY-coatetl cazt iron/
�
� `ihermoNastic
Motor Housing Epoxy-coa[ed cast iron
35 ImpNlerMahri� Thermoplasticelaztomer
ImpellerType Nontlog
30 — —
Yolute EpoMy-coa[ed cast iran
g Mo[orShaft Steel
MechaniaiShaftSeal Nitrilewithcarbonanticeramic
m faces
Fasteners Stainlecssteel
u �y��� � Uppersintered�leeveandlower
ball bearin
p Powertord 5JT4V••SJTOW
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-a�m�c-0a-�me s�can o�oam
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Page s of ]
POR'TS OWNER'S MANUAI,AND MANAGEMENT PI,pN
Fll.E QVFORMATIpN SYSTEM SPEQFICp1TONS
Owner
T a.J Ru r tic Tank i
PermitN Oo0 ON
BESIGNPARAM6'PEgS S bcTankManufacturer G/�ESE,� Ga.�ca. ON
Number of Bedrooms Effluent Filter Msnufscquer OR E�JCO Q N
Number of Commercial Units _ Effluent Filter Model Fro8,7,-/9B O N
Estimated flow(Ave)(100�dlbedroom) DO T� �i GOO a1 O N
Desi flow WF � T�M°°�� W/E E.l O N
So (D )=estimeud x 1.5 YSo Pu Msnu£ecnaer
Soil Application Rate 7 �� M��� i 1'rt E /a/R,�r ❑N
Ec O N
InfluenNEfflueat Quelity(O NA) Monthl Av ��e��t Uoit (�NA)
Fats.Oil&Grease(FpG) <;p�� O Send/Gisvel Filter p PeatFiiter
Biochemicel Oxygen Demnnd(BODs) . <_220 mg2 O Mechanicel Aeration O Wetimd
Total Susp�ded Solids(TSS) <150 mg/L D Disinfcction O p��
Manufacmrer. Model:
Preheated EtHneat Quality(�NA) Monthly Ave�age ����IPtioa Componeat(O NA)
Biochemicel Oxygen Demand(BODs) 530 mg/L O In-g�omd(&a�ty) O In-gromd(pmssurized)
Total Svapended So�ids('('SS < O At- de
� 30 mg/L � O Mrnmd
Fxal Colifoctn(geometric mean) <_10 cfu/I OOmL O Drip-line O p��
Meximum E$luent Pardcle Sue Veitical Distance TenkBotfom to Sen.l��pa�; ft
i�����+' Horizo�lDistenceT s roServicePad; g
Calcolatlom: ���U°�t MfgJhfodd Namber: EI_Ftou /?d3N QuJOClS O NA
Soil Dispersal End Cap (pispe�sel Unit EISA)
AW + Anolica[ion nm = A„�Rm.' _ -
�$8 or(Trench Wi h� _ #U ' �r t o ��ch �
5'SD � =7 �y3 - So a Fr' _ /3 �s��o�fs �GSasr'
DESIGN CR1TEgIp
O"A[-Grade Compopent Mamm1�rpppf(�' (p�g�or Gjavity.Vecsion 3.0(May]A22�202�
❑"Design of Pressuie Distnbution Networks for$epric Tnnk-Soil Absoeption Systems." Pubtication 9.6(SSWbg Manuat)
❑"EZ Flow Mound Componmt Manual"Ve�sion]y15/2017(Apri1 20 1 8-2023)
�"In-Ground Soil Absoiption Component Menuet for POWTS"Vetsion2.1 (May 2022-7A2�
O"Momd Compoaent Manual for POWT'3^Vasion 2.1 (May 2022-2027)
�"Pressure Distibution Component Iyanual for pp�y'['�,»V�on 2.1 (May 2022-2027)
O Oth�:
MAIIVTENANCE MONI7'ORING SCHEDUy&�]►fpINTENppCC, pNp�pNAG&MENT
Servlce Eveot �«�
/'ms ect dis �rsal xll s clean 51ter At lmst once ev . � 13 months �3 ears O Other:
Ins 8c conhok, umit qt Ieavt once . O months �3
Flush and test late�als eazs O NA
At least once . O monihs O 3 eazs �N?,
,gTA�T UP AND OPFRs170N: For new conshucvuq yriar to usi�8 � p�� ��k ���t�s for the
producta or other chemicals tlut meY impede the he&meot ( ) presence of painting
tho wntents of the P��e and/or damege the dispecsei cell(s)- If hig6 conemtations are deteMed have
mnk(s)mpoved by a sepfage se[vicing pperaWr prior ro use Syetem ctsrtapshalinotoccnr when aop coadiHene are frozen
at t6e ioftltrative sarface.
'1Le property owner is iespppsible for the opetatipn end maintepanc�of the POW1'S �d su{wtiq,mon of roqui�od�epp�, 77ie y��,�
quality of the westewater sueam will effect the performaace md longevity of your POWTS. The iasmlletion of wehs-s°vin8 BPPGa�es a�
fixtuies along with PromP�tepail of leaks teduces the wastewater volume. Also the bcine or waete from water softeneis. 'aoa iemovel units,
ot6er clesr wecet hea�ent devices and fou�etioa dnins should be discherged W the growd surface wLmever
iaclude le�mdry westa,showets,djyhwater,ac. posstbte.Note: this does not
1'his syetem is designed to handle domestic shength was[eweter,however.t�diaposel of food based greases,olls.vegefabidfruit peels,
seeds,bones,end food soHds,auchas those produced yy a garbe$e dis�sel should be minimized.Toilet fissue is the onl
� be dise6elged into the system.Othar aon-biodegcadable items.wch as beb Y PaP�tLat should
deoral floas, and coann swabs, should not enter the Y R'iPas,tamPoa4.samtarl'naPkins coadoms.cigazette butts,
syatem. ChemiceLs, such as petroleum Produe�, Psint, disinfectants.Pesticides,
antibiotics,solvents,ete.,shouldaotbeflushedinWthesystemba��tl�ey�nee��y�eYourPOw,l,Sandc�o��e� ow
drinkingwatersupply. Maiu�inateBu�ersteadYflowbysPrmdin818mdcYa'ashin tluou y
altsYstem componmts.Compaction ofsnowoverthe g 8���e week Avoid vehicle traf5c over
disP�rsat unitmay cause it to freeze up.
Page � of 7
INSPECITONS 8c AiNTFNA (�; �p�ti� shell be made by an individuel canying one of the following licenses or
certi5cations:Master Plumber,Mester piumyQ gestri���,n�pOWTS Meintainer,or Septage Secvicing ppeea�ur(pei tl�e aUached
Maintenence $chedule)- Tank inspections must include a visusl inspection of the tank to identify any missjng or bmken haMware,
identify any cwcks or leaks,meaqar¢iha volume of combined sludge and scum and check for any backup or poeding of eflluent to the
ground surface aod test all electrical equipment such as pnmps md alarms.My defects ahall be piomp8y corrected &xposcd openings
greater t6an 8 inchcs in diaznetcr shall be sausd with effecdve locldng devices to prevent accidental or unauthorized entry tbe tanks.
When the combinatioa of sludge and scum in sny isNc exceeds�n�-��1/3)or more of the tenk volumq the entire conten�of Uu
tenk ahall be removed by a Septege Servicing ppecamr ead di��of ia eccocdance with Ch. NR 113.Wisconsin Admin. Code.
Specific aetvicing mechenics must be provided if vectical is>15 fat or if horizontal is>150 fat and iffiWcfloas to be pmvided below.
'I'he wtlet filtet(s)shall be inspected eud cleaned to removeany accumuteted solids accordingto mmufacp¢efs speciScations.Solids
was6ed from the filter shall be retained ip the tank.Filter cleauing roay be necessary at more frequent intervals than stated�n�e
maintenance schedu(e to kxp the system ope�ating,
Alacros should be tested on a regulaz basis by the home owner. If an alerm souads. contact an individust licensed to service POWTS,
1Lere is normally a 1 day rese�ve imder:eg,ta�opeisating conditiuns,bowever water should be cooserved unpl any prob�ems wi�y�e
system aze con�ected [o prevent back-up of sewage into the dwelling or surfacing.
ABANDONMEr?'r•Whep�e ppqrrg�j���ar is pe�manwUy takep out of urvice the followia
the system is properly and safaly abendoned in compliance witb Ch,SPS 38333,Wisconsin qdmin,C��e-. �1��en to ensure that
' �P�Ping to tsnks and pits shaq be disconnecud and the abandoaed pipe openings sealed.
• 1'he contents of all tanks and pits shall be removed and proarly disposed of by a Septage Servicing Opefator,
• After pumping, a(I tanks snd pits shall ye excavated and removed or their covers removed aod the void space Slled with so7,
glavel,or other inert solid material.
CONTINGEN - p�• if the POWTS fails and cannot be repaired the following measures have beeq or must be takeq ro provide a
code compliant replacement sys[em:
{� A suitable replacement erea has yeen evaluate��d�,�utiliud for the location of a replacement soil absorption system. The
Rplacement atea should be protected from diehubeuce and compactioe and should not be infringed upon by requ'ued setbacks
from existing and proposed shucture,lot tines and wells.Fail�ae to protect the�eplacemeot erea cenders it unusablo.Replacement
systems must comply with the nlles in effect at the time of replecement.
O A sui[able replacemrnt azea is not available due to setback and/or soil limitarions. Ba�ring advances in ppqrts techno�ogy, a
holding tank may be inyKa(led as a last resort to replace the failed POWTS.
O The site has not been evaluated to idenrify a suitable replacemeat erea Upon feilure of the POWTS a soil and site evatuation must
be perfoimed to locate a suitable replacement nree. If no replecement erea is aveilable a holding tspk may be iastal���8�
resort to roplace the failed pOWTS.
O Mound and at-geade sod absoxption systems may be recuuyhu�teA in P�gc�following removal of t6e biomat az the in5lhative
surface.Reconstuctions ofsuch systems mustcomp�y with ttie Iules ia effectat that time.
}Y�NG!!!! SEPTIC, PUMP, AND OTfIER TREATMENT TANKS MAY CONT[AN LETHAL GASSES AND/OR INSUFFICIENT
OXYGEN.DO NOT ENTER A SEPTIC,pUMP, OR OTHER TREATNIENT TANK UNDER ANY CIRCUMSTANCEg. DEATH
MAYRESUGT.RESCUE OFA PERSON FROM THE INTERIOR OFATANKMAY BE DIFFICULT OR IMPOSSIgLE.
ADDIT'IONAL COMMENTS:
POWTS INSTALLER '/ POWTS MAiNTAINER
Neme: � NT /faCE M/�- dd`//49 Neme• � P�u
• i.J G
� Phone: 7/T 9L1 �//�r Phone:
/S - i3S
SEPTAGE SERVICING OPERATOR er ? LOCAL REGIJLATORY AUTHORiTY
Name: Name:
.JA E �o. Za„i ,��
Phone: Phone: 7/S LJ9'-dZD"
l�i. 7 as 7
--L.
Maintenance Instructions �
��
Biotu6em EtflueM Rlter �
How to Clean Your Effluent Fiter
7o ensure your effluerrc fiiter is fancpanir�g prope�, ��ould be inspec0ed every year.Under normai conditions,your
efHueMfil[erunll function tor several years before cleaning is neceasary.The fitershould 6e cleaned when it becomes
clogged enough Lo resUjct�a�al flows out ofthe septic tenk At a minimum,the filter should he cleaned wheneverthe tsnk
is pumped
Mos[people preferto have a sep6c tsnk service providerlske care offikermai�Menance and cleaning.Y0u cen find s
saptic tenk service provider in ttie yellm„p�g� under'Sepvc Tenks&SystgmS•Or you can cor�ct your cnuMy heakh
departrneMtor a Cu2
If you wish to inspect end/ar clean your elfluentfD[eryaurself,be sure w drass proper{y,Wear fulFiength pams end shirt,
shoes,gloves,and goggles or glessas_Then followthase instru�pons
1. Aemove the access lid royour�ppc��by unscrew-
ing the stainiess s[eel lid 6ops wilh hex head wrench �
provided.if \ r �w*' i
Y°�'���d is abo++e gmund,itmll be easy m ' — �
find_ffitisburiedbeluwground,findthemarkerthat G� ,s5„ '
indicates its IocaOon. d ,,,,� . - � 4;;,; ''`',�" i�' �
.:� ."' �'.; F
2 Remove tha fihgr cartridge by graspi�g�Q�e handle �
and lifting it out aF iLc housing(see phom 1). , -
>; : "��
3- SP�aY the cartridge ti6es with a hase�o remova arry �� "' :a��
material sticiang in them(see photp 2/,Ensurethe three `
orifices in the optional flow modulaation pla6e inside the �j
�li+ ._ . �a�
filter are clear of airy debris.Make sure the rinse wate� � " � `�';;�
runs back into the tank,6U[do no[allow spfids rt�sp�rial P�1Dro 1.Remove the fiker cartridge 6y fi(ting it out otits
m faA irroo the open fii[er housing. housing.
4- Firmly placa the cartridge back inm t�e ho�n . --
9 `y�T -
5. Some etfiuerrti�ters come witli an elarmthet activate$ ~ "� �����:��'y.
;.. a s��'.
whenlhefifterneedscleaning.lfyouhaueanalartn, �'3 ' •r � ' ��S d ��<-
check m make sure h is woricio � '�
with a s6ck An audible hom�ou d spund.Thealarm :� ~ � '
panel is normally mou��y�e side oFthe house or ' -� ! `��
in the garage. �"
�:
' I � �a
Not�lfyoureffluerrtfitoerdoesn'thaveanalarmsystem � -
B�d You would like one,cail your local sepU�sy�
ins(aller.
6. Record me date that yo�i�p��a�or deened Photn 2 Sprey the ca�bidge tubes with a hose.
yourfilter on the fimi ffiat{oqo�yy�u checked the
alartn or madearry other uyserveeons a6outthe�nk
or system,Nclude 7hat(�ttormgpon under°Noms.•
7- Attech access Gd by placmg it on the riser me[cldng
the openings in the lid wrth the bolt catr;hes,ir�sert Gd
balls i�mo catches and q9hm.n wilh hex head wreooh
P��ded.
xe�rsh,
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