HomeMy WebLinkAbout028-642-30-1306-SAN-2023-217 - - Department of Safety c°°°ty c�
� & Professional Services,
�c:.�;;L ��� �
- f� � Sanitary Permit Number(to be filled in by( �
: Industry Services Division
C,� S I b t �' �
State Transaction Number W
Sanitary Permit Application _ �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ad �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �/��-� �� `?��,�,�� (,1��
I.Application Information-Please Print All Information � �� �`'�
Propeny Owner's Name Paroel#
L(Z/a1 � S�; Sf�," y-L n"Ly - L��IZ-3b - �3b�
Property Owner's Mailing Address PropeRy Location
�2-�� G IZi; �' �`�. Govt Lot
Ciry,State Zip Code Phone Number �-
.� �
��"C�,��h► vti:� j`/ic��� �11'�6 Z- - �`'lG�t� 51.4' %, lJ� ", Section a��
Ii.Type of Building(check all that apply) [.ot# T_ � 2- N R W�
f�il or 2 Family Dwelling-Number ofBedrooms 3 2 Subdivision Name
Block#
❑ Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number 7��� ❑Village of
'Z�� /l/ry ki Town of C�n�6�1r'-C�d.��C-�,
iII.Type of POWTS Permit:(Check either"New"or"Replacement"and other app(icable on line A. Check one box on line B.Complete line C if
a licable.)
A.
❑ New System � Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �;�n-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type�explain)
(conventional)
C. � ❑ Change of Plumber List Pre�ious Permit Number and Date Issuec
❑ Renewai Before Re�ision ❑ Transfer to Neu O�rner
Expiration � �Gt� 23 -l�s (1��,/Z�
IV.DispersaUTreatment Area and ank Information: {
Design Flow(gpd) Design Soil Application Rate(gpd;s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �
� SZ � �1 ��f 3 (r�?�' f�z,G '
Capaciry in Total #of Manufacturer
y
Gallons Gallons Units � U ;° �
Tank Information .n � , ` ,,, �
V'�•�c�1-uuks Lzistine 7�unks � � .o. � � � c`s cs
a v v� ti cn i:= J a
Septic cic-Elel�iing Tank !Q��n ���fl l L(,�I G S� " �
Dosing Chamber �
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Vame(Print) Plumber's Signature MP/N}�RS Number Business Phone Numb��r
��' ,� �/�,��-�� ".�� �;,�;� (��"7s'?Sl 7rS����i�-3s�3�
Plumber's Address(Street,City,State,Zip Code) �>
-�.� r��� ��� ������ ���.� s�� �
VI.Cou ty/Department Use Only
� 9 '� Permit Fee Date Issued Issuing A�ent Signature
A�� roved ❑ Disapproved
fl Owner Given Reason for Denial � ��� �I� I�3 ����
Conditions �r va Rcasons for Disapproval
f '�� ^ .�- �l � � 1 '�3 � `�,�(�1.�i'�5�5�1
i r, � ,•'
ir d �d�r`N ( � �1-�-_' - —.. _
h k# i u o ��. ..=z.m...._..__. � � �;�
---
Cs� a- l -- �3� ,_ ¢� � �.►�t � � AUG 3 1 ZOZ3
-,.,• „�--< (-�n? :�.:
�.:-.`,�:1: ._E . 'T'l
Attach to comple[e plans(or the s�stem and submit to the County only on paper not less than 8 v2 x ll inches in size
��� i �f:2
t�d0 F�LFUN��AFT�R
SBD-6398(R.03/22) �S�.1E QF'P�R�IIh`E'
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 / Description
Owner Name(s): �c���Cc I('�v►�� .�i� Phone: z-j a - 1(PS- I�v��
Owner Address: 5�4Z i�� �n�n�t� (�c i���5[-�•�.�,� �d��l� Zip: ���/,�
Project Address: �l�OUi ��;,�ti,��- Y.�r. ��,{-�;,�����-
��. Lot: 02 Sk.' 1/4 of �r� 1/4, Section �C� , T �FZ N-R � EQor W�
Township: Sp�G��v' t-G'�!� County: �Cc.u.f:J'�e,r'
Project Parcel ID #: �Z�—!o�f2.-3U��(�0�• GS�� �73X� � v.u�� p /l(�
Designer Information
Designer Name: �C�So 6-� ��Uf+f�-( Phone: �r 7 - 33.5�'
�_-�
Designer Address: P��. ��� � � CCc��,eF c;�-=- Zip: _ ,�`f����-/
E-mail: �'(,�l�.�i'���✓�./��'C'lS iC-�i'� ;'Li; ti�;;i�; ,....�;vrcl Iur aj,��r,,�.,u sl�nriE�.
License Number: ����5�
Remarks:
1--� �--
Signature: ' Y Date: � i l �' ���zj �rV�
Original signa re�equired on each submitted copy.
, t:�-!Ef:IC f3C}X 4S�PP�.jC�3LE. C`�I��(�.(3UX.1S 4?P!.N;.1ELt.
F SOIL EVALUATION s�1e �" _��' � PAGE 2 OF
� SITE MAP ° ��� 6a �� SYSTEM
PLOT PLAN
PROJECT NAME: �Fsicri F�ow S`'"
('C It gndJ �p� CPD
j i�t:�• ;v�7 _�c/�� Attacn desiqn flow calculations(or commercial plans.
PROJECr ADDREss ;f�15Ui1 {�72r},��j'ti ,C� Pip�Material/ASTtv1 Standard(Tables 384.30-3&384 30-5)
� N Sanitar Se..�e�
Bhd SymCa !$i- Bh1 Elevatiun �-� �' FT � �
p ii�lj� L,;7�o,-� ForcuAla�n /
8Fd Cescn I:an 1 �l� i ^' ����-
Siope Grad:enl(°,a� i�a,w+c-oer;r, Iti1PORTANT:
of Tes�ednrr;a ��?�� U/2115yrI1bOl(if.lppliCaole; Q �rav,nq,3,,;,��o.�- Show yrnund elevation contours at suitable interoals.
on Uie appruV�ite lire.
��.-��.,r•c__ �tc �rY��� ..i�z��-�?<-� 7
���>�ic��� : ��j �so�� �;zc3�=� r �� c ,�, ;,.� y.t j �.t;_> ,
�C LV�r-t_ : �t�;`'E c_�� �_ LS,V� z_�i���o /� 7�r'�`;
I � ��> j`-� Z.^-' iZ-C��,i.-�
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Septic Tank(s) Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA �� � �-s��
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) `��� ga, gal
gal gal
Effluent Filter Manufacturer:
a tr��-C>
i ��-�,� ��
Effl�ent Filter Model#:
—min.12"
(typical)
SOIL COVER
12„
min.trench
depth .
�ryP'°a'� �: � � TYPICAL TRENCH
' � �' �� �� ��°��a �<: CROSS SECTION VIEW
F �tYP���) ':�e�' ' a .", .. . . (No Scale}
a
� '' Provide minimum 3 ft
System Elevation = C��' ft separation bstween trenchss.
(typical)
Quick4 Standard-W
w/End C8p Observation Pipe
(typical) (Show location of inlet/outlet pipe connection on plan view.) (typical) TYPICAL TRENCH
Install per manufacturer's PLAN VIEW
instructions.
(No Scale)
r- - - ,� - - - - - �� - - - - - - - -�� - - - - - - - -
������� � � � � ����� � A= 3.0 ft
����.�%
� — — —�— — — — — — �f— — — — — — — — ��-- — — — — — — — —,� ' � �tYPical) �
D
I-- a = ft m
(typical) Quick4 Standard-W Chamber GJ
INSTALL PER TRENCH: (typica�) O
(mfd by Infiltrator Systems,Inc.) —n
Install pursuant to manufacturer"s instructions. �
� � Quick4 Std-W @ 20 fi� EISA/chamber= z2� ft2
+ �_ Pairs of end caps @ 6 ftz EISA/pair= _� ftz
= Proposed EISA pertrench = Z-� ftZ Required Infiltration Area= �"�-4 ft2
Distribution Method:
x 2- trenches = Proposed Total EISA = ��Z ft2 �v�w�dh 'CT�a����-
S
Septic Tank(s)Manufacturer '
IN-GROUND GRAVITY DISPERSAL AREA ���������
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) IcrU 9a, 9a, 9a�
gal
Effluent Filter Manufacturer
�%�2.t�1 C.,�;
I
Effluent Filter Model#: �TUr^.Z�
la�z•
SOIL COVER (rypicap
iz-
min.irench
tlepl�
�ryP'°a'� • TYPICAL TRENCH
a CROSS SECTION VIEW
i^_ 34,. .. , �
avv����i ;� (No Scale)
\ �� Provide minimum 3 ft
System Elevation= �Z g separation between trenches.
(typical)
Quick4 S[andard-W
w/End Cap Show location of inlet/outlet Ooservatbn Pipe TYPICAL TRENCH
(typical) � pipe connection on plan view.) Rvviwq
Installpermanufaclurefs PLAN VIEW
�n5��uc����s (No Scale)
Ir— — ------��-------��----- - - - - — �I �A=3.Oft
�------------�j�--------��---- -----� ctyP��o D
'r B- �•!�(o fr _I m
(typicaq Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (typical) �
(mfd by Infiltraror Systems,Inc.) �
�I @ �-�- ff� Install pursuant to manufacNrefs instructions. �
Quick4 Std-W 20 ft�EISA/chamber= 2
+ �Pairs of end caps @ 6 ft�EISA/pair= _� ft'
=Proposed EISA per trench= zZ4' ft' Required Infiltration Area= ��-3 ft' Distribution Method:
x -� trenches =Proposed Total EISA= 4��� ft' �vuauav �-�ci'�ti'�
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), Wisa Admin. Code, this system shall
be considered a human heatth 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= `f S<: 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, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, efc.)
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 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 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) 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 acwrding 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: �� �SVr'�c,t S S C_�� `� ���,S Phone: ���- ���� �� ���5�
Local government unit: SC�I�J l_(� , �(i1,C,(, Phone: 7�S -����- �`�� _
Local government unitaddress: �c�f�.UL�o'L�i � � � � ZIP: 5�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 compry with SPS 383,Wisa 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 Plan
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 soils.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.