HomeMy WebLinkAbout010-941-33-1110-SAN-2023-220 �.vuuiy
llepartment of 5afety � I
; •: ; & Professional Services, �
Sanitary Permit Nu er(to bc filled in by( �
� '�: , Industry Services Division �
Co 5 1 c.y I l�
Sanita� Perinl+ AnpllCa+l�n State Tra��saction Number W
l. Y 6
In accordance with SPS 383.21(2),W'is.Adm.Code,submission of this form to the appmpriate govemmental unit �
is required prior to obtaining a sanitary pemut Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing a� ol
the Depariment of Safety and Professional Services.Personul information you provide may be used for secondary Mn /�,rn n�` �.e� I�'
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. V�� ���� G
I.Application Information-Please Print Ail Information
Property Owner's Name Parcel#
B ..�� dln�R�ll- 33�!llD�--//�9
Property Owner's Mailing Ad ress Property Location
� �� �Q�
City,State Zip Code Phone Number
� �/►r"q/C� W.� / l� �� ��'•—�ti%�-'/e, Section ��
II.Type of Building(check all that apply) Lot# ^ 1� ' N R�[i or
�l or 2 Family Dwelling-Number of Bedrooms � Subdivision Name
�
Block#
❑Public/Commercial-Describe Use �--
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
•�0 � / � �,I'own of ���
{..
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 it
a licable.)
A' +c ❑ Ke lacement S stem g Y � P 1
❑ New System p y ❑ Other Modification to Existin S stem ex lain Additional Pretreatment Unit(explain)
B' ❑ Holding Tank 8 In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(cxplain)
(conventional)
❑ Chan e of Plumber ist Previous Permit Number and Date Issued
C. ❑ Renewal Before ❑ Revision g ❑ Transfer to New Owner
Expiration
IV.DispersaUTreatment Area and Taok Informallon:
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Arca Required(s� Dispersal Area Proposed(s� System Elevation
� , �'y 2..
Capacity in Total #of Manufacturer v
Tank loformation Gallons Gallons Units � ;? � � =
U ,. �
New Tanks Existing Tanks � o .°3 ,,u�„ y � .� �
6. U c%� m V� �.. C.� f�.
Septic or Holding Tank /�D f QQ� � �/j �
<
Uosing Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility for installaAon of the POW"PS shown on the attached plans.
Plumber's Name(Print) Plumber' Signamre MP/MPRS Number Business Phone Number
� �1�0/ �5-��r-���
umber's Address(Street,Ciry,State,'Lip Code) �
d o5�� hE au� Pa,�- �e9. cc�a.v� u� s�-e�c
VI.Co n y/Department Use Only
Permit Fee Date Issucd Issuing Agent Signature
�Ap � ❑Disapprovcd $�hT���p l�, I� �a 3 71/����Gt.e-e�-�-1 �� "
❑Owner Given Reason for Denial ��C.J
Conditions of Appfoval/Reasons for Disapproval
(( t�
� - Uate��.�----------� D ���������-�'
�� � , �
���" hk#_.�--9-� 6 2023
� .� ��i �� r� SEP 0
..A; a°� � �i _-
Cs� �3-- � � s �_ �A��� �o�
Attach to complete plans for 1he system and submit to the Couoty only oo paper oot tess than 8 v2 x 11 inches
� ? ISI
SBD-6398(R.03/22) �Q F3�FI�N�$aFTER
IS�JE O�PER,�?iT
, 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):SCO-�{' �• �;��I,f1�.1� L. S�F-0�� Phone: - -
Owner Address: `0�77'�2 0�/�ST. ,. �� , Gc�_Z�P� `j���5
Project Address: 0'�► �( �,P� ���Gc��
Govt. Lot: �F_1/4 of N,� 1/4, Section�?�3 , T�� N-R�E�or W.�
Township: �iiA(,�1r/'t� County: -���'l�JLf�P�
Project Parcel ID #: B��� g�-1�— 33— �� 1 �
Designer Information
Designer Name: ��UQ,/'� � Phone:���-`� Llv2�
Designer Address:� � Z�P� 4��l�
E-mail: L�ald1` �
License Number: /"f��� �
Remarks:
, .
Signature: Date: 9�'�-3
riginal signature required on each submitted copy.
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$ oi0q4►33 11�0 � `
ft o��ay133 �I�.q
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P�O P
d�;�.e � 3 t��
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I �oo���+ ��.r�f
, Septic Tank(s)Manufacturer;
� (N-�R�URIC1 GRAVITY D15�'�R��eL A6���1 w �`.�,��f%
_ ............�...�.��..
U niform Elevatian Trenches with Q�ick4 �tand�rd�W Chambers Septic Tank(s)Valume(g):
, 3-ft 'Trench (down-sizing credi�) ��9a� �, g�� .,�,. ga� ._.�.ga�
�ffluent Filter Manufacturer;
� �
_ /�����r.z ��'.�-- t-v.�� .
Effluent FUter Madtll#: �,,,,.��,,��_,,,�,,,�
� min.12"
90�L CpVEfi (typlcal)
�a,�
min,Irench
da Ih ,
��yP�CAI) '• b TYPICAL TRENCH
' � �° � � ''°��4 �< CROSS SECTIQN VIEW
f--_______ sa„ . „ , �
(ryplcaq ';',�' o , , . ��0 �uCr��G�
•� 4� � q tl
• � � nrovide minimum 3 ft
System �tavation =,��;�,,,_ ft saparation batween krenches,
�tYP�cal)
Qulck4 Standard-W
w/�nd Cap (Show location of iniet/outlet pipe connaction on plan v(ow.) Obge�����al;Ipo TYPICA�L TRENCH
(typlcal) Instalipermanufacturore PI.AN VIEW
tnstructlans.
�, (No Scale}
�;"6r��,���,M������������R���;,;t���� ..__. _. ._._. �.. _.. ...,. _. .� _. ___. _.._ -��. .__. .�. ._ _....����� ����� ������ �������
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���'r����:���r t.�:�?��_��,�� �. _. .� ___. _ _. ,_ _ ,. ` _ ._... '•�.K �,���;'� �� � ' '1IAI ItYPlcal)
--- it ��1i1��&�4�C{td;.'I�'�pl�tl �
`�'/`` �'f-- — — -- _.._ .— _.._ ._._ nr,� �'
�-° B �.�?�._ f� --_� m
yp � Qulck4 Standard-W Chamber �
IN5TA4.L. PER TR�NCH; (typicai� a
(mfd by Inflltrator Systems,Ino.) •n
�netall pursuant to menufaolurers instruct4ona,
' „,,,,,,,.,7„�,. quick4 Std-W @ 20 fP EIS/�Jchamber= _3�� ft� .1�
+ ��, Palrs of end caps @ 6 �tZ E15A/pair= _,,, ,�,Z.,,o fta
=Proposed EISA per trench= .:�.�. ffix Requlred Infiltratlnn Area= ,�;��;,� ft1 Distribution Method:
x ,,,,,,,,�,,,, trench�s = Propnsed Totai EISA � ,��.,�„ ft2 /��^a�a� � ��, � 1,' ,-,�
.��� a�
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PAGE 4 OF 4
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 382-3&4,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 Disaersal Area Ooeratinq Limits:
Design Flow= �/�� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG<_30 mgL"'
Insaection 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 vdume 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(r.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribuNon 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 Seotic and dose tank(s)shail 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 locai ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effiuent fitter(s1 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 aiways be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance Mrith
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunetion to:
Name of individual or company: �U� S�i�(�C Phone: /«������
Local govemment unit: Phone:����3��(�a��
Loca�govemment unit address: IP: S��`-�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 maffunctioning components shali 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.
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 shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.