HomeMy WebLinkAbout010-941-16-4316-SAN-2023-190 f��,�`"�T"'r. Department of Safety c°��' �
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;x%;1! '�=�� & Professional Services �a�"'��— Z
ia; .,�'�� � '-� ' Sanitary Permit Number(to be filled in by i
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Sanitary Permit Application I State7'ransactionNumber �
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 permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different dian mailing a
the Department of Safery and Professional Services.Personal information you pmvide may be used for secondary
purposes in accordance widi the Privacy Law,s. 15.04(1)(m),Stats. /� ' � �
L A plication Infortnation—Please Print Al!Inf4rn►adoa ".'6�{.7 U.l �;L��J L�t`
Property Owner's Name j Pucel#�
'�/ ✓�- �f��-S C- ��-4 ST ����-��11-� .—L/�/�;
Property Owner's Mailing Address Property Location
L�• �C'X ` � � Go.�.i,ot
City,State Zip Code Phone Number �
L�,ii3 L'��-I� .��1��F 3 �
� '/<, ��-- Y., Section �
T�'.�'ype of Bufid#�e�(clteck sIl th�t�Ppi�') � t,ot# �� T � N R E o %
1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use
-- ❑City of
❑State Owned-Describe Use CSM Number • /�S' ❑Village of
'� i 5��� � �o,�of �a����,�,�� —
IIl.Type of Pfli'V'F�Permit:(Chec�efther"New"or"Replacement"und other applicable on line A. C'�ceck oAe 60�on line B.C`�mpiete li►►e C if
a licable.
A.
New System ❑ Replacement System ❑ Other Modification to Existing System(explain) � C Additional Pretreatment Unit(expiain)
B' ❑Holding Tank In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑Renewal Before ❑ Revision ❑ Change of Piumber ❑ Transfer to New Owner, ist Previous Permii Number and Date Lsaued
Expiration ' �� I � z� -- ���
!
N.I?is ersaUTreatment Area and�'ank Iniormat�on,
Desi Flow(gpol Design Soil Appiication Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(s� S stem Elevation
�f�2' 4 �7 ��3 �` � �/� -� z- �
Capacity in Total #of Manufacturer
Tank Information
Gallons Gallons Units � � o ',� �
New Tanks Existing Tanks '� c � r' « p b �
0
a U �n �, rn u.. C7 ' P,
Septic or Holding Tank 1 ,� t �HL
Cj�C� ��C,u � �,:�
Dosing Chambcr
V.Responsibility Statement-I,the undersigned,assnme responsiMlity for installation of the POVYTS showtt on the aEtacfied p}ans.
Plumber's Name(Print) Plumb i ture MP/tc�ilB Number Business Phone Number ����
C��-�=� -�(�7��t i��Z2 � y-3�'�7
Plumber's Address(Street,City,Statq Zip Code)
������ �,���f ,��,�� l-�������z►� t��v�- �����
VI'.�oun /Deperfmient Use O�tly
I 3 Permit Fee Date Issued Issuing Agent Signature
�APPJ� O Disapproved $ �� � 5'I � I �� ���,.1 c� ��tit,t�
��"' ❑Owner Given Reason for Denial z tn-t-c-c-t
Conditions of ApprovaUReasons for Disapproval D �����' i ,�, ,�r r�'
� ?e�J 4�, �
� � t�;a��_.������.�.. _ ,:
� �� ' �1,�0► _ AUG 17 2023 �
�
.:.h k# i H 3 3 O ,,.�. _..._.•��
1 ��,5 ' SAWYER CGv�`,i1�Y
C S� O' 1 � � 'x�t#._.,�L4_L¢�1 ZON}f�IG ADMlNI�TRAI",{71'i"
Attach to complete plans for the eystem end submit to the County only an paper not less t6an S tR x 11 inches in size
� alr5
SBD-6398(R.03/22) NO R�FU�DS AFTER
issu�oF r��n�r
�
CONVENTIONAL IN-GROUND POWTS DESIGN
AesidenUel Application
Index and Title page
Owner's name: � I S /7 /'i �/7 SSL � �+`�`�S �
Owner's addtess: � � • �' X � ���
/'�/� i� W F��� Lti � . ��tS�f�
SiteAddress: I�� YJ ��-� ����� ��+��L
Legal Description: S �� — S� ��/ � ��v . � y� ��h� 1 �"_
To,�: l-�I�'cv�
county: ' _S�l.� YL� '
csr�r s/v�
Subdivision Name: Lot No. �/q' Block No. fi /5`/"L
Patcel Idenrification Number: �l� �4 � ��G' y3/�
Page Index
Page 1 Index and Title
Page 2 Plot Plan (May include septic tank and filter specs)
Page 3 Distribution Cell(s) Cross Section
Page 4 Maintenance, Management and Contingency Plans
�th SH�-tiC�a C.; R�:r}C. G5,7ATls .!/ST��✓6
PlumberName: (�f7�"`f �/f7�C y CredenriaiNo. �� � Z�
Plumber Address: / �s�-`�'N L�Cf�N� � ��17
��� �
,
Signature:
Date: � �/� �z��3 Phone No. '7/.y -��Y- �S '7�,
Designed Pursuant ro the: � /// �
ln-ground Soil Ahsorytion Manuel for POW7S Version SBD-10705-P(NAl/01)��_'Z'�
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I N-G RO U N D G RAV I TY D I S P E RSAL AREA Septic Tank(s) Manufacturer
W�2-.�f
Stepped Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit) SepticTank(s) Volume(s):
�n�� gal gal gal gal
I Effluent FiIn�Y�n�uf/a`cturer:
SOIL COVER �
min. 12"
�rypicaq Effluent Filter Model #: �a�
12"
min trench
TYPICAL TRENCH dePth
CROSS SECTION VIEW ��p�ca�� '
� ° .a a. Provide minimum 3 ft
(No Scale) � �cyPa�ai� a� , separation between trenches.
� ° " . ° ° r
Highest Trench �g 9 y Lowest Trench (as applicable)
r
System Elevations = @ 95��� ft; � �`��Ot ft; �- �3 'o ft; ft; ft
Quick4 Standard-W
w/ End Cap ObservationPipe TYPICAL TRENCH
(Show location of inlet / outlet pipe connection on plan view.) (tyP��aD
(typical) Install per manufacturer's PLAN VIEW
� instructions.
(No Scale)
.. �, .. v„.zr '�,�ar,s»+,^r»r.�s»�t3A��'�._"— — _ — �� — _ — — — �� _ — — —s��ne�m��an�r�xngm �v���*m4��
L �
I ' I A = 3.0ft
f A � ' a
��..,_ ���tww.�a.���_����i� �:.�;— — �� — — — — — �� — — — � ��� ��m�a,�.a��,�,_��=��� �typlCB�� �
B = �� ft — � �
m
(typical) Quick4 Standard-W Chamber GJ
INSTALL PER TRENCH: (typica�) O
(mfd by Infiltrator Systems, Inc.) �
, 2 � Q Install pursuant to manufacturers instructions. �
V Quick4 Std-W @ 20 ft� EISA/chamber = � ftZ
+ � Pairs of end caps @ 6 ft2 EISA/pair = � ftZ
= Proposed EISA per trench = � � ftz Required Infiltration Area = �'� 3 ftz Distribution Method:
x .3 trenches = Proposed Total EISA = ��� ftz �ea�
RESET '.
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6 r o �r �� �3��
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Quick4� Standard � r��r� s �-� �� ��+ r� � s .
Chamber � ��s �Q���� ���d ��.�� -� Q'�f� I U���u
�r ��� The Quick4 Standard Chamber � ��� � ^ �
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POWTS OWNER'S MANUAL&MANAGEMENT PLAN P�_a_ •
FILE INFORMATION SYSTEM SPECIFlCATIONS
o`""8f�/SR /1%�}sst,�- �T/Zu'S T � Tank Manufadurer I.0 lt-5t/L ❑Na
��# �Septic p Dose p Holding Volume: �dcU�� (gap
DESIGN PARAMETERS Tank Manufacturer: ❑NA
Number of Bedrooms: 3 ❑NA ❑Septic O Dose p Hdding Vdume: (gaq
Number of PuWic Facility Units: ❑NA Vertical Distance Tank Bottam(s)to Sdvice Pad: (fq
Estimated(average)Flow: (geVdey) Horizontal 0istance Tank(s)to Service Pad: (iq
Design(peak)Flow=(estunated x 1.5): �9�ey� SPecific serviGng mechanics must be providetl It vertical b>15 feet or
5 U H haizontal Is>t 50 teet Specific insWdions to be provlded on back.
In Situ So�l AppGca6on Rate: �'7 (9aVdayret�) Effluent Filter Manufacturer: ��'rCUC�'
❑NA
Standard(DomesUc)InlluenUE�luent Monthly average Effluent Filter Mod�: � �
Fals,oa 3 Grease(Fo�) s3o mprl Ptanp Manufadurer;
BiocheMcal Oxygen DemarW(BODs) s220 mg/L ❑NA �NA
raa�Sus ded Saias rss s�so � P�p N1otle�:
High Strength InfluenUEffiuent Monthly average Pretrea6nent Ur�t
(FOG) >30 mglL Manufa�Yurer.
(BO�s) >220 mglL �NA ❑M��ical Aeratlon ❑Peat Fflter ��
SS) >750 m/L ❑Distnfxtion ❑Wetland
Pretreated Etfluent Monthly avarage ❑sanal�ravei FAter ❑Omer
(BODs) s30 mB/L SOii AbSOfp�On SystCm
(T&6) f30 mglL �NA ��n-Ground(gravity) ❑In-Ground awe)
Fecal CoWorm(eometric mean s10� U� O NA
Macimum Effluent Perticle Size k in dia. p Nq A�-�rede ❑atouna
❑DriPLine ❑Other:
Other: ❑NA Other: ❑NA
MAINTENANCE SCHEDUIE
Ssrvice Event Service Frequency
Pump out contenb of tank(e) ����mbined siudge and scum equals onethird{J§)of tank vdume
❑Wh�the high water alarm is activated
Inspx[caididon of tank(s� Atleast once every: mO"�sf (Maximum 3 years► p NA
0 v�ts)
Inspect disperael ceN(s) At least once every: ❑moMn�s} (Maximum 3 yean} ❑NA
,/1 0 year(s)
,/'Y Ciean etfluent filter At least once every: ����b� —�' 'C�2 ❑NA
r�
Inspect pump,pump conhois&alarm At leest o�ce every p rear"�S� �NA
Flush laier�s arM prassiae tesi At least once every: ❑moMh(s) ❑�
❑YaeKs)
o�' At le�ast once every: mD"�e> ❑NA
O yearts)
Other. ❑NA
MAINTENANCEINSTRUCTtON5
lnspeotions ot tenks and soil absorption systems shail tre made by an individuai carrying one of the fdiowing ticenses or certifications:
Mastar Plumber,Master Plumber Restricted Sewer,POWTS Inspector,POWTS Maintainer or S�tage Servidng Operator(pumper).
Tenk inapections muat include a visu�inspectlon of the tank(s}Yo identlfy any missing or broken herdwere,identlfy any cracks or leaka,
meesure the wlume of combined sludge and scum and a check for any badc up or ponding of eHluent on the ground surfece. The soil
ebsorpUon sys[em shall be visually inspeded to chedc the effluent ievels in the observallon�pes and to check for any ponding of ef�uerrt
on the ground suRace. The ponding of effluent on the ground surface mey indicate a feiling condition end requires the immediate
no6fication of the local regulatory authoriry.
When the combined accumulation of sludge and scum in any treatment tank equals one�third('h)or more of the tank volume,the entire
cordents of the tank sheli be removed by a Septage Servicing Operator(pumper)and disposed of in accordance with chapter NR 113,
Wisconsin Admimstra6ve Coda
Atl arher s�vices,induding but not fimited to the servicing of effluent flit�s,mecharacal or pressurfzed components,preVeahneM units,
and arry SaMcing�irrtervals of 512 moMhs,shall be perfortned by a certifled POVYfS Main[ainer.
A service raport sha0 be provided to the ioca�regulatory authority with(n 30 days of completion�any service event.
GMW-006(07/(15)
Page �
STAR7 UP AND OPERA7iON
Far new Construdion, prior to use of th@ POWTS ch�sck ire�alment tank(s) for the presence of painting produds, solvania or ott�
chem+cats or sedimeM that may impede the treatrnem process and�or damage the saii absorption system. If high wncentrations are
detected have the contents af the tank(s) r�noved by a SepEage Servicing Operator(pumper} prior to use.
Pump tanks may fiN above normai highwater (evels prlor to startup or due to pump failures. Start up ar restoration of powsr uRder these
conditions is not recommended, as the excess wastewater will be �sc�arged ta the soii absorption system in one large dose causing an
ove�toad that may result in the badcup or surface discharge of ef�ue�t and damage to the sysiem. Ta awid this situation have the
contents of the ptxnp tank removed by a Septage Servicing Operator (pumper) prior to r�stonng power to ths p�anp or can#a� a Plumber
ar POWTS Mairrtainer ta assist irt manuatly oper�ir�g the pump corrtrois unU'I normai efflusnt levals are restored within the ptanp tank.
System s#art � st�ap not aocur when soil conditians ars fruzen af the infrltra�five surface.
Do not drivs or parSc vehicies over tanks or the soll absorpdon system. Do not drive or park over, or otherwiae disturb or compad, the
area witt�ir� 15 f�t dowr►siope of any maund or at-grade soil absorption area.
Redu�tian or et�mina�on of the foilowing from the wastewater stream may improve the performance and prolong the iife of the treatment
tanks and sail absorpaan system: acids, arrtibiotics, baby wipes, cigarette 6utts, condoms, c�ton swabs, degreasers, dental flass,
diapers, dislnf�ectants, fats, foundatian drain (sump pump} discharge, fruit and vegetable �eelings, gasallne, greases, herbiades, m�t
scraps, mecfications, oils, painting produds, pestiade�s, sanitary napkins, solvents, t�npons, and water saRener brine discharge.
ABANDONMEIdT
When the PONVrS fai{s antilor is permanently taicen out of seMce the fotlawing steps shall be taken to Insure U�at the system is properiy
and safeiy abandoned in canpliance with s. Gomm 83.33, Wiscansin A�iminist�ative Coda
• AI! pipir�g to tanks, pits and other sal a�orption systems shaU be discannected and �e abandoned pipe openings sea(ed.
• The con#ents of all tanks and pits shall � removed and properly dispos� of by a Septape Servicln0 Op�ator (pumperj,
� Aiter p�xnping, alf tanks and pits shaN be excavated and removed or their covers removed and �e void space fitled with soil,
gra�el or another inert satid material.
CONTlNOENCY PtAN
!f the PWVTS fails and cannot be r�airBd the fotlowing measures have been, or must be taken, to provide a code compliar�t
replacecnent system:
❑ A suitable replacement area has been evaluated and may be utitized for the loca�on of a replacement soil absarption system.
The reptaceme� area should be protscted fram disturbance a�d compadion and should not be infinged upon by requlred
setbacks from existing and propos+ed struetu�e, !ot lines and welis, Failure to pratect the r�lacement area wfil resutt in the need
for a new soil and sits evaluation to estabiish a suitable replacement are�a. Replac�meM systems must cornply �vith the rules in
effect at the �me o#their permit issuance.
❑ A suitabte reptaoement area is not availabte due to setbadc andtar soil timitations. tf the soi! abso�ion system c�nnot be
rehabilitated and barring advanc�s in POWTS technofogy, a holding tank may tie installed as a last resort.
`�iJ The slte has nat besn evaluata�d to idenbfy a suiiabfe repiacement area, Upon failure af the PtriIVTS � saN and site evalugtion
must be pett�emted io locafe a stritable reptacemar�t area. !f na rsplacomart area is avai{abte a hdding ts�nk may be insiaq�d as a
last resort to reptace the fsiled POt�ffS.
❑ AAound and at grade soif absorption syst�ns may be reconstructed in place following remova! of the hiom� at the inflltrative
surface. Reconstrudions of such systems must comply with me rules in effect at that time.
WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAiN P4ISONOUS GA33fS OR LACK
SUF�IGiENT OXYGEN TO SUSTAIN UFE. NfVER ENTER ANY TANK UNDER AMl ClRCUMSTANCE. DEATH MAY
�� RESUt,T. ESCAPE OR RESCUE FRO�A THE iNTER10R OF A TANK MAY NOT 8E POSSlS1.E.
ti�
AGDi?70NAL INSTRUCTtONS:
POWT8 tNSTALLER PQYVTS MAINTAINER
Nan,e n� ' �.�1 �Z9B r.�, � t�ame 5'C.�,`�"✓\� S�~�'✓7�:
Phflne /.� -- � ' - ..s ✓�� Phane ( r"j- — 6�' — 7� /"--r
SEPTAt3E SERVtCtNG OPERATUR PUMPER LOCAL REGULATORY AUTHORITY
Name � c:,z (( 'S ��''�1 / G Name /�i.�'S�tG� � �� ��Nitti%,E�
Phone �7/� _ ���Y�.`-- �Z ��f Phone (5 - ���' �,2� �,
This docum�t was drafted by the staffs of the Gre� Lake. Marquette and Waushara County POV+fTS regulatory egendss in compEiance w�tl� sectlons
Comm 83.22(2)(b){t)td)8�(fl and 83.54(1), (2} & {3),Wtsc�r►sin Administrattve Code.
"'"`''E� PRIVATE ONSITE WASTE TREATMENT �ounty
�, ��o� `�� SYSTEMS
�S P S awyer
���:,:,� s .� ( POWTS)
,,� �_ ;.
�k �=�
°j '"�T INSPECTION REPORT Sanitary Permit No:
Safety and euildings Division (ATTACH TO PERMIT) q
GENERAL INFORMATION �3 ^' I (b
Personal infonnaYion you provide rnay be used for secondary purposes[Privacy Law,s. 15.04(I)(in)J
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
L� •t 55� �`^�� K`�Yw� �
Insp BM Elev: BM Desc;ription: Parcel Tax No:
(o�.a' IV�t v R��o �� ta �- oto 4Y�_ 6� �(3l�O
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic INiQ., ��soO Benchmark (8p,p r
Dosing
Aeration Bldg. Sewer v,�,(� '
Holding St/Ht tnlet c{�,�} �
TANK SETBACK INFORMATION St/Ht Outlet q9•G �
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIRINTAKE
Septic � N A 4-�S� fi1S� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. c�`7 p r
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative �
Surface �6 -�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MAT ON
DIMENSIONS W �� �� ' #of Cells3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate �1�
INFORMATION P/L Bldg Well Waters °� G 1�.. Chamber Model Number:
❑ EZFIow
CELLTO -f-�� �'�(D __ N �_ h/ ❑ Mound o Other (�Y�
-- -- — -- -- -_ -- — _--
---- -- — -
DISTRIBUTION SYSTEM x Pressure Systems Only
--- — _ ___-- ---- �- _—_ _
Header/Manifoltl Distribution Pipe(s) X Hole Size X Hole Observation Pipes �
Cength Dia � Length Dia Spac , ' Spacing ❑Yes ❑ No
_ -- - --- --- -- y --
SOIL COVER
__ -- — --- — --- —
�CDepth Over Depth Over ;i Depth of Seeded/Sodded Mulched
eli Center �Cell Edges � Topsoil � ❑Yes ❑ No ❑Yes ❑ �o
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?�Yes 0 No �p 3 �S- �ay � , � I ��7�t (o
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
AOQITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBEA�_�_3=�__
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