HomeMy WebLinkAbout014-842-10-3402-SAN-2023-205 Department of Safety c°°°ty� (/� �
c� ��,. �
6 & Professional Services, �
� t� � Sanitary Permit umber(to bc filled in by
= Industry Services Division
(� � I l�o� �
S�lI11t�1Iy PeY'1Tllt t�ppllC�t10I1 State Transaction Number w
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In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit ""�— �
is required pnor to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing< �
the Department of Safety and Professional Services.Personal informatio�you provide may be used for secondary �{
purposes in accordance�cith the Privacy Law,s. 15.041 I)I�n),Stats. —
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�'c��w 1�. �- LC)���ii M, . �Lc;C`S p 1�{- :Y�FZ - r L, --3 ef�'2-
Property Owner's Mailing Address Property Location
(3�?���c,� �c�mm��-U�(I e. (�
City,State Zip Code Phone Number ��
� (,'�6�YJ� Ll.',� �T y�-� "71�J—ev��fr `�iL��t.J S �7y<, �CL' '/.,. Section /Li
II.Type o Building(check all that apply) Lot# T � 2— N R � W
�t1 or 2 Family Dwelling-Number ofBedrooms � � Subdivision Name
Block*
❑Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�-
�Town of �-.2-(,•'�Vi'i��
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A.
❑ New�System �Iteplacement System ❑ Other Yloditication to Existin�System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �[n-Ground ❑ At-Grade ❑ Mound ❑ Indi�idual Site Desi�m ❑ Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Pre��ious Permit Number and Date Issued
❑ Transfer to New Owner �
Expiration �•tV�� �
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(opd) Design Soil Application Rate(gpd�sfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
'-�JZ `7 (�-�F'3 '�C�,� �SF�S �
Capacity in Total #of Manufacturer
v
Tank Information Gallons Gallons Units � ;; v �D � �
,r� V 'J :� ,j � U.
Ncw"ranks Lxisting Tanks y � °: � a� � �a ca
n, U v� � �n i: Ci P..
Septic ox.klel�ifig Tank ���� �aC�; � �j►�5"�` _ /�.
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibili f r install•tion of the POWTS shown on the attached plans.
Plwnber's Name(Print) Plumber's Si�na MP/�4PR9 Number Business Phone Nurnber
-�.,'�' �
,j��Ctc�i �u-�{-f-�( ~ �� (o7��7S1 7is'-�4�'�-33s s
Plumb r's Address(Street,City,State,Zip Code)
��0 � �iIX �(-> �c��r(� C�'.� ��'�
VI.C unty/Department Use Only
Permit Fee Date issued Issumg Agent Signature
�A ro � ❑ Disappro�ed � �p � '
� ❑Owner Given Reason for Denial (ba� ��� � '�3 r✓���-��-�/�.�
Conditions`of Approval/Reasons for Disapproval
� �-`���3 ��,,��-�,c;`���C`�
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� [ �� � Chk# 14013 - r ---`— � ;
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s�c�t� a�+����._.._.s._.. � A�JG 2 8 2023 _.
GST �3- 13 � - __ - =:
� _______--
;;t,dtiY c�? �' �,.
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Attach to complete plans Cor the s�stem and submit to the County onl�on paper not less[han 8 1/2 m s�ze� � �� �-�
I�fl F}i FUND�A�TER
SBD-6398(R.03/22) 15SUE UF PEF�ItIf
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
Ovvner Name(s): ��'hn�. -� �vtclu Fl( � �`��S Phone: �7 ls^- ��4���- ' �����
Owner Address: ( 3� �fu.' �����titi:c��,'���� ('� �y�?c�i;�.cc�� Zip: SZf�{3
T
Project Address: ° p �
�
Govt. Lot: S � 1/4 of S�c: 1/4, Section �� , T�Z N-R � E❑or W �
Township: �-�.;,•�i�:�'I— County: S�c-cv�-e.�
Project Parcel ID #: Gi�{—f��Z ��D ���{CZ
Designer Information
Designer Name: Jc�� (�c,�-�{�-'��z� Phone: 7l�- - 74.�' - ���5�
Designer Address: � � • L`�b 'K G`�C� ��(�j.�, (,c,�-� Zip: S�;�Z-/
E-m a i I: �"c�n��G�Y�a�-�c_S. t��ti'1 ,
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License Number: Co�S"7S�
Remarks:
--���
Signature: Date: 8 �.r L3
Original signature required on each submiit�d copy.
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IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s) Manufacturer:
t�; �Es��
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) ����,
gal gal gal gal
Effluent Filter Manufacturer:
. � 0�"ei��;
I min.12" Effluent Filter Model#: � � ��'�"�'
Geotextile I (typical)
Cover
SOILCOVER TYPICAL TRENCH
12„
min.trench • s . CROSS SECTION VIEW
depth L
(typical) — — — ,-��,��.�� �.:� (No Scale)
• � � OBSERVATION PIPE DETAIL
• �,�� • (No Scale)
System Elevation = Q�.� {t. �' ' • ; Screw-Type or �,•�,��,• Finished Grade
Provide minimum 3 ft Slip Cap Qoose) .�.
(typical) � (mulched&seeded)
separation between trenches. 4°m Pvc P�Pe �' ` Topsoii Cover
Top o(pipe to terminate (min.1 foot)
atorabovefinishedgrade . '
(a)va•�-vz��x s��s�ots
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) @so apart
PLAN VIEW AnchoringDevice Infiltretion
4�� � Observation pipe shall be installed Sur(ace
(No Scale) atjunctionbetweentwounits. �� ft +
Perforated Lateral -
Observation Pipe
(typical) (typicaf) (cypicai)
- - - - - - - - - - - - - �,�- - - - - -
— — — — — — — — — —
I =_____ _______ =-___ __ ___ _______ _ __ — �
__ � A = 3.0 ft �^
� - - - - - - - - - - - - - - - �,�- - - - - - - - - - - - - - - - - - - - � �tYpical) UJ
_ � m
'r- B = �7� ft W
(typical) O
INSTALL PER TRENCH: EZ1203H Bundle �
(typical)
� 10-ft bundles @ 50 ft� EISA/unit= 3SZ; ftz (mfd by Infiltrator Systems, Inc.) �'
Install pursuant to manufacturers instructions.
+ 5-ft bundles @ 25 f� EISA/unit= ftZ
= Proposed EISA per trench = �352' ftz Required Infiltration Area= 4��f_3 ft2 Distribution Method:
x �- trenches = Proposed Total EISA = Y��L ftZ �e�;c��r !�'L�.,i{�1��
RESET
PAGE40F4
in-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shali 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 shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= �� gpd; BODS <_ 220 mgL"'; TSS 5 150 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, 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 ce�l prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.)
� electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, efc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure- compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAI�ITAIN EVERY 3 YEARS (or when necessaryj
� 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 government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company:����:Fn.i F ��+15 Phone: �Z�J��y���'yS=�
Local government unit: S�c.r� (..� , ��y:�,� Phone: 7t� -�����y3�
Local government unit address: A;i�;���(,4 � ZIP: ��i'y�
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), �Visc. 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 that any failed treatment component of this PO�l�/TS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for revietiv 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.
Syst2m Abandonment
If use of this POVVTS is discontinued, it shall be abandoned in accordance with SPS 383.33, N/isr. Admin. Code.
��` "'-`"E^� PRIVATE ONSITE WASTE TREATMENT county
= ��o$ SYSTEMS
p ( POWTS) Sawyer
�,r�1 S �
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' �'�' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 3 --�-0�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�a�,� � ��„� I,c.�o5 1-�,�� �--
Insp BM Elev: BM Desrription: Parcel Tax No:
do.o` �� d�- �-�� ��Y--��c�-- t�- 3�(��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�;�Q�f' � Benchmark �oo,o�
Dosing
Aeration Bidg. Sewer �.( �
Hoiding St/Ht Inlet qb,� '
TANK SETBACK INFORMATION St I Ht Outlet qg.�S- `
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic -��a� �-ls� f��'� �-,�-� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. Q5;3 �
Holding Dist. Pipe
PUMP 151PHON 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 INFORMATION
DIMENSIONS W � � �� d #of Celis Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters °� GP ❑ Chamber Model Number:
� EZFIow
CELL TO �!- �J'� rJ ❑ Mound o Other
- ---__--- _ _-- - ---- --- -------_..
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) I X Hole Size X Hole Observation PipE;s
[ Length Dia � Length Dia Spac Spacing ❑Yes ❑ No �
- - _ _ _—�-- - --
SOIL COVER
— —-- -- — —�— -__ -- --- - - -
( Depth Over Depth Over Depth of Seeded!Sodded Mulched
Cell Center �ell Edges � Topsoil � ❑ Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
����� � (.�cl�-3
Plan revision required?❑Yes❑ No ��03 I( � �' �� '� �j9 � �
� _�� � � � �
� -,��--��s��`=�-
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL C�MMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: ��"�O�
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