HomeMy WebLinkAbout002-106-14-0800-SAN-2023-197 Department of Safety c°°°ty (�►
� & Professional Services, `����'l �4� �
t Sanitary Permit TI1 nber(to be filled in by �
�s Industry Services Division
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Sanita� PeY,mlt AnnllCatl�n State Transaction Number f
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In accordance with SPS 383.21(2),w'is.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sani[ary permiL Note:Application forms for state-owned POWTS are submitted to Project Address(if diffcrent than mailing .J
the Department of Safety and Professional Services.Personal infonnation you provide may be used for secondary
purposcs in accordance with the Privacy Law,s. 1�.04f l)(m),Stats.
I.Application Information-Please Print All Information �� �Z ����D�''e( ���5 �r' ���
Property Owner's Name Parcel#
�Mav-{� D � �- Pacr��l�i L, zes��f���-- �;cz - �o� --��- o��
Property Owner's Mailing Address PropeRy Location
�j�3 � (l� •�Ci.�,,C� Ci c'��-�' ,� �
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City,State Zip Code Phone Number C�c�L
SGi'v<<�� � lVl N� S 5 3 73' `��2-2r�i-S�tf� �}� D�_Section -� (
II.Type o Building(check all that apply) Lot# T�_N R Q' o W
(�7 1 or Z Family Dwelling-Number ofBedrooms � � -( Z Subdivision Name
❑Public/Commercial-Describe Use Block# ��,� ���� Fj�j�L7 �S� ���
j `� ❑c�cy oe
❑State Owned-Describe Use CSM Number ❑Village of
l�Town of ��55 ��
III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
`�' New S stem Re lacement S stem
� y p y ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Other T e(ex lain)
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design yp p
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Changc of Plimiber List Previous Permit Number and Date Issuecl
❑ Transfer to New Owner
Expiration
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd'sf1 Dispersal Area Required(s� Dispersal Area Proposed(s� System Elecation
`�SZ , `7 ��3 (�Sz� ��u S� -
Capacity in Total #of Manufacturer
�
Gallons Gallons Units a� o '$ u
Tank lnfoanation � �
U � � `' n v
Ve���Tanks Gxistiug Tank, -�y � r� � � � �
c U cn � rn :i.. C7 0.
Septic os-F{elding Tank i DC Q f L�,�j � �J��S '
t
Dosing Chamber
V.ResponSibilitV Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Naule(Print) Plumber's Signature MP/M-F-�S Number Business Phone Number
�l-S�:'� �l,c �� l�'-I.S r/S � �1 S'�74.�5�j;� �
� K +t�i
Plumber's Address(Street,City,State,Zip Code)
�.D UG``�- �' �' �'c���)�-�� �'-� S�E��'1-1
VI.Co n y/Department Use Only
�App o�� �� ❑Disappro�ed �ermit Fee Date[ssued [ssuing Agent Signature
y�/� � 's�a� I a 3 �'�/��r�G<�C
� ❑Owner Given Reason for Denial l`-�V- t �' ,-,`---�+
Conditions of Approval/Reasons for Disapproval [l i r. i ; � `.' '.�-��; ��
�-)`�
� . ,` _ -. _. _- , I
�-j � � �a���f���.�_ ---- L�23 _,;
����� � AUG 18
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�.5���— � � � ,_:,� .'' �� � sa'uv;,,_ , �
_, ___�..
;'.;�;'t'-�.._..__��. ___.__. ZONIfVG AUMiN�S"1t�ATlON
Attach to complete plans for the s��stem and submit to the Counq�only on paper not less than 8 vz x 11 inches in size ���
NO R�F,h�S A�7ER
SBD-6398(R.03/22) I$5'(J�Qr��,�-r
PAGE 1 OF 4
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: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
�
Project Name / D�scription
Ov�mer Name(s): �Clvk .�: °� Pa_rh���i L � Z�.r��I"n�� Phone: ��SZ - 2-�1 - S� 4�8 C��u�'J��
Owner Address: `7l 3� (Y1Cc.v� ��..r��c( ��G��% Sctu2q�, ��tti Zip: 553 ?�'
Project Address: `�'5 7?-� �'«rt <�r�i IleS Lc�C� Ur: �uGcr lI� cc'.� 5��'S�_3
.�t. Lot: 3''-��l g(�, I'� 1/4 of 1/4, Section �� , T �-{� N-R �� E❑or W �
Township: L�<<S� ��_ County: �t.c;,��e,r�
Project Parcel ID #: LC�2-ID�: - ��F -G�-c�� �-��n��p�sf ��cc��, � S� ��j�;��
Designer Information
Designer Name: •�t���„� �<�.t-�{�-�� Phone: 71.f - 7�t�' - 3���
Designer Address: �-� � C�� �(� ���-�, � Zip: s�-f�"2-/
E-mail: f��r�� c��c�lvu���S. �►'►'�
License Number: (�7S�S(
Remarks:
�
S�c�nat�re: Date: � �� Z3 _
Onginal siy ur_required on each submittsd copy.
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IN-GROUND GRAVITY DISPERSAL AREA w ;���i���"`s, "'���`��`°����
Uniform Elevation Trenches with EZ1203HP Bundles
Septic Tank(s)Vo�ume(s)�
3-ft Trench (down-sizing credit) U� cG ga
gal gal gel
Effluent Fllter Manufacturer.
C'iY����w
Gaatex�ile � min. 12" Effluent Filter Model# ���'�'�-2—
Cover � (typical)
soi�coveR TYPICAL TRENCH
m�� ',e��n� CROSS SECTION VIEW
depth �
(ryp;�Tq � — — -�'e.,��• ;..� (No Scale) OBSERVATION PIPE DETAIL
� �p.�� (No Scale)
SystemElevation= �f4•5 ft. '• � si�cw��y��o� F. .snad� �e
��plCe�� � PfOVIC�BfT11f111llUfT13{t (mWched&seeaeCl
separation between trenches. a-mPvcaPe T�oso�co�P�
Top o�pipe lo�orminate (m�n_1 fno�)
a�or above finished gratle
(4)1/4"-V2'X 6"Slols
TYP ICAL TRENCH (show�ocation of in�et�outlet pipe connection on p�an vieev.) @�� aPan
PLAN VIEW A��na��9oa���e ��n��,z��o�
Observation oipe shau ba Installea SuAace
(No Scale) 4�� � a�;�����o�ea�waa��wo����_.
Perforated Lateral Observation Pipe ft
(typical) (rypicaq (Ypicaq
r — — — — — — — — �� — — — — — — — — — — — — — — —
� ______ _______ _-___ __ '_— --__---� �
- -- --- ---- —__ � A = 3.0 ft ^�
L - - - - - - - - - - - - - - - �� - - — _ _ — _ - - _ - - _ — _ � (typical) u,
I - B = �s � - I w
(ryplcal) �
INSTALL PER TRENCH: EZ1203H Bundle �
(rypical)
� 10-ft bundles @ 50 ft� EISA/unit = �C G ft� (mfd by Infiltrator Systems, Inc.) �
Install pursuant to manufacturer's instructions.
+ �_ 5-ft bundles @ 25 ft' EISA/unit= Z S ft�
= Proposed EISA per trench = ��'- S ft� Required Infiltration Area = �y 3 ft' Distribution Method:
x � irenches = Proposed Total EISA — �S�' n' ('41(���1���� �rtiC�el�
RESET
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 sha�l be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow = �.SZ� gpd; BODS _< 220 mgL"'; TSS _< 150 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 mechanical malfunction (i.e., pumps, valves, switches, floats, efc.)
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, efc.)
o extent of ponding in distribution 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, efc.)
� distribution lateral or lateral orifice plugging (measure fateral distal pressure - compare to design specification)
o surface 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) shalf 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 government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: J-� - �l',S�(1��SS�1 `� �Y►S Phone: '��S`- 7 �� -���3 "J
Local government unit: ��%�-�1�'' � ` �'%►'�-u'� Phone: �� S ' �' '�� -' �`��'`
Local government unit address: \ ��L ZIP: .�'�L��(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.
Continqency Plan
In the event tnat any failed treatment component of this PO�/�/TS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for revie�,v 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.
System Abandonment
If use of this PO'd�/TS is discontinued, it shall be abando�ed in accordance with SPS 383.33, Wisc. Admin. Code.