HomeMy WebLinkAbout012-740-24-4306-SAN-2023-234 ' Department of Safety c°°°`Y v`'
• & Professional Services, `S�'�'`' � �
. t Sanitary Permit Number(to be filled in by �
�: �: Industry Services Division
C�S ► � �� �
State Transaction Number �
Sanitary Permit Application '
In accordance with SPS 383.21(2),W'is.Adm.Code,submission of this Yorm to the appropriate governmental unit �— � I
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing W
the Department of Safety and Professional Services.Personal infonuation you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. 15.0411)(m),Stats. �� �� � �������� ��-,
I.Application Information-Please Print All Information
Propeny Owner's Name Parcel#
�i�cc-r l�s K . �u; �t z - 7�a -z�{ -�f 3a�
PropeRy Owner's Mailing Address Property Location
8(� D d�n � . ��--,
City,State Zip Code Phone Number c�� S�
l��t'L�Q 1 L �0��3�{� �30-8�6 �-�t3v7 s�' '/<, S� ';, Section Z� _
II.Type of Building(check all that apply) 3 Lot t� T N R � W�
�I 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
�'U-r'L'tC-V
QL 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 �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank � In-Ground�(:,S�O) ❑ At-Grade ❑ Mound ❑ [ndi�idual Site Design ❑ Other Type(cxplain)
(conventional)
C• ❑ Renewal Before ❑ Re��ision ❑ Change of Plumber ❑ Transfer to New�Owner List Previous Permit Number and Date Issued
Expiration (�V� K. �
IV.DispersaUTreatment Area and Tank Information: '
Design Flow(gpd) Design Soil Application Rate(gpdi�s� Dispersal Area Required(s� Dispersal Area Proposed(s� Systcm Elevation
�t�� �� s 9� 9a� �o y, s `
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units � � ^ "$ �
�c3 U .� �
Nc���Tank> Lsistin�_Tuuks L � u y � c3 a"�s
C. U c%7 "v, v] LJ. :7 G.
Septic otldelding Tank �O�Q � �1 ���5�� �,�„ n
wo
Dosing Chamber / � /_,�,^ �Nl�
lD �OW
V.Responsibility Statement- [,the undersigned,assume responsibilitv installa'on of the POWTS shown on the attached plans.
Plumber's Vame(Print) Plumber's Sign�4�ze��-�j �, �;,�� . MP/�9i'R8 Number Business Phone Number
��.s�'' .�
� �;,:.�:u•::'"- (0 7S�..5� �7 l S=��1 g-3 j�S�
�'asc,� �Cu��t r
Plumber's Address(Street,City,State,Zip Code)
�C . �G�:. G7� �Ct�OI-E 1.c1-L S��u
VI.C un y/Department Use On1y
�A �d ❑Disappro�ed Permit Fee Date Issued Issuing Agent Signature
��'✓ p_Owner Given Reason for Denial � ��� �1 �(`i ��� �����������
Conditions f A proval/Reasons for Disapproval
; 1 � � � ��, 2 � ��N � ��r�
r� { d/ i�
' �� �(��.L`��� —�—._. �R� c J ��-`j�r
Y �����r _�.._ ii
�� i o�� [� SEP 15 Zp �'�'
_:�►!�#_ .� 23
C`J��3 — � � 3 f,�,�:�� 3 v1�5 _ S�WYER CO�.��3�-�.
t�Nt;��AQMIlvlS'i RHl-ION
Attach b complete plans(or the s�stem nd submit[o lhe County only on paper not less than 8 v2 x i l inches in size , S�j�
1�✓D�u�R � fJ��LFUN�S p�TER
SBD-6398(R.03/22) ���E��f31�1T
��
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 5 Index&Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section &Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name/Description
Owner Name(s):U�ar1e5 (� .�Lcu.�nUa r�.Y+ Nu s� Phone: �3� -�;�C�- 43C 7
Owner Address: SI'7 Dv+�c�ev� `�. C��n�-�Ici,SL Zip: ��13`-f
ProjectAddress: 8(31N Wcz�c(Iu,�d Dr. l-�tcc,cuarc��G��T s�l84�3
Govt.Lot: SE 1/4 of�_ 1/4,Section a'{ ,T�N-R '7 E❑or W�
Township: � i.�s��e;� County: SQ���C�.�
Project Parcel ID#: pl2-��f-D-z'-4'- '-E30�C
Designer Information
Designer Name: JCLSo�� KU-e{'�e-� Phone: ?�S- 79�-�',�s3�
DesignerAddress: ��G, g� (o� (�q(o���_ Zip: S"�{�Z/
E-mail: i'iw��v n:��rusa5.c.om
License Number. (o�_C 7s/
Remarks:
�,:
�f/.�—s-�`�'._"
Signature: y`�'-✓ Date: 9�/i z3
Original gnature required on each submitted copy.
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IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
im�� ,z,.
GeO1eX"1e I I ��vP��ao TYPICAL TRENCH
Cover
soi�coveR CROSS SECTION VIEW
1z• (No Scale) OBSERVATION PIPE DETAIL
min.Irench
depth (No Scaie)
(hPi�q L —7- -- ,-1^� s��ew-ryaa o� F���sned c�aae
sry cav(ioosa) �m„i�ned s saeaed�
SystemElevation/io4��R � ' 4"BPVCPipe roPsouco�e�
(typicaq ' Provide minimum 3ft a;o°aeo'ar��snaag��da ����������
separation between trenches.
(4)1/4"-1/�••X 8"Sb�s
(,il 90 apari
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) n��no,m9 oe���e i�ru�ano�
PLAN VIEW Su�aCe
(No Scale) 4��g ooservaro„P�ae sn�u ba��s�auaa
al junction between iwo uni�s.
Perforated Lateral ObservationPipe ft
— (typical) (typical) —— (typical)
�� -------- ��
r-- �
� ______ __'____ �_-___ __ ___ ______' � A-3A ft D
-------
L---------------��-------------- -----J — (typical) �
'r B= Co0 ft -� m
(typical) G�
INSTALL PER TRENCH: EZ1203H Bundle �
(typical) �
�0 10-ft bundles @ 50 ft`EISA/unit= 3C70 ft' (mfd by Infiltrator Systems,Inc.) �
Install pursuant to manufacturers instructions.
+ 5-ft bundles @ 25 fl�EISNunit= fP
=Proposed EISA pertrench= 3�� ft� Required Infiltration Area= �a� fP Distribution Method:
x � trP.nr.hec-p�ppesed Totai EISA= Q���' tt° i�lr7uutcic� itec'�e��-�-va:��,y
RESET
PAGE50F6
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale) �
4"0 Vent Pipe
>10 ft from
Building Electncal must comply with
12" Min. or 2.0 ft above SPS 316 and NEC 300
Established Flood Elevation Extend manhole riser as necessary.
Weatherproof
(typical) Junction Box
Approved Approved Locking Manhole
IMPORTANT: Vent Cap with Waming Label Attached
+ (typical)
Anchor tank(s) as necessary �—Conduit
pursua�t to SPS 383.43(8)(g) 4" Min. or 2.o ft above
Established Flood Elevation
� � (rypical)
�Airtight Seal
Finished Grade �
Quick Disconnect
18" Min.
CAPACITIES @ � �� � � gal/in �: � � . , . .�� � � � � • (typical}
a. � � . . . �
Depth (in) Volume (gal)
A � O �j�; � , (y * � Weep � �Approved Joints with
Hole Approved Pipe 3 ft onto
B 2,0 3 � �Z A Solid Ground
(typical)
�C� ' l 1 � 3 z � :
II�Alarm
� � •� � 5� � �i '-� B �—On
f [c] PUMP-OFF ,
* + Pump �_off : ELEVATION = 93 , ��: ft
Pump Tank Liquid Level = 3 � in }
I
° INSIDE BOTTOM
Force Main Diameter = � in I Concrete
` + B'°°k ELEVATION = q(� • O � ft
• • .. 6. • .
Force Main Length = f 30 ft 3"Approved Bedding Material Beneath Tank
Vertical Head = iN , ft
Force Main Void Volume = a I � I q gal
+ Min. Supply Head = — ft
[C] Total Dose Volume TDV = � � � , � 9 gal/dose
3 � u�, 3+ FM Friction Loss = � ? .t
(5X total lateral void volume < TDV < 0.2X design flow)
+ (force main drainback volume) 5(�CS�SL�U t pp + Fitting Loss" = ft
*(min. supply head x 0.3)
MIN. PUMP DISCHARGE RATE _ � S gpm = TOTAL DYNAMIC HEAD = % �- �� t
PUMP TANK: SEPTIC TANK(S):
Volume = C2liQ gal Total Volume = � �� � gal
Manufacturer: � ����L Manufacturer(s): �-Z � `
Pump Manufacturer: ��-��d�
Install approved effluent filter at the septic tank outlet
Pump Model: C-c(�� S .� (See attached pump curve.) immediatelv upstream of the pump tank inlet.
Controls/Alarm Manufacturer: S,J-� Filter Manufacturer. ��Y'f:;,��c�
Controls/Alarm ModeL f D��
Filter Model: �-T�� z�Z
j Float switches containinq mercury are prohibited.
.
' 3��� 1/3-1/2 HP
fiam ion , . . � � .� �
-.. , p �_ �_ _� � EFFLUENT/SUMP
��p Every pump tested in water to ensure pumb .
■ meets peformance curve.
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PAGE40F4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-gravity system shali be responsible for its perpetual operation and maintenance
pursuant to requirements of SPS 382-384,Wisa Admin.Code. Pursuant to SPS 383.52(2),N/isc.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 shail be performed by a registered POWTS Maintainer n
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= �}SD gpd; BODS<_220 mgL-'; TSS 5 150 mgL''; FOG<_30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
o rype 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 distributian cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settinga 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)
c 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 operetor licensed under s.281.48 Wi;.
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)shail 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[he 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: t{. 1K0.SVv�t-ISSe_V��- s6✓i S Phone: ?U� ��t Q' 3.�5 S�
Local government unit SQ,W" c�• � Phone: 7�5�-fo 3�(—�L��
Local government unit address �t U 0.�'Y�� W� ZIP: ���icf�
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,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.
Continqency 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.
System Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,N/isa Admin.Code.
�"'�"``� PRIVATE ONSITE WASTE TREATMENT counry
�
>
t`7, ? a$ ,�� SYSTEMS SaWyer
�����,� �$ � ( POWTS)
� �_ ,��
\h'"` V��`� INSPECTION REPORT Sanitary Permit No:
,,,
Safety and Buildings Division
(ATTACH TO PERMIT)
GENERAL INFORMATION �3 " �3�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction�D#:
�qt�S �.�.�w+Pl��t �'{c.�...�' —
Insp BM Elev: BM Description: Parcel Tax No:
,
�oo.� � -� Slq� o�� - �Yo-aY- �3o6
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,u;,ey�r - �� Benchmark ��p,a�
Dosing "��J�o 6a
Aeration Bldg. Sewer � '
Holding St/Ht Inlet Q y,� �
TANK SETBACK INFORMATION St/Ht Outlet �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Se tic k ` �d� �-�c� .��` NA Dt Bottom �j Q�,r �
P
Dosing « 4 4 } NA Installation
Contour
Aeration NA Header/Man. 1 oS 3�
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative �
Surface �a`��S
Manufacturer Demand Final Grade
Model Number CS 3 GPM �{�`` {��'• (06.O�
TDH (�„ Lift Friction Loss Sys Head TDH Ft
Forcemain L �� Dia ,Z'` Dist.To Well
DISPERSAL CELL INFORMA ION
DIMENSIONS W ' L (�p' ` �` #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P�L Bidg Well Waters o IGP ❑ Chamber Model Number:
❑ AG � EZFIow
CELL TO � •I-(dn� 'f'� +toa ❑ Mound o Other
- -- --- - - -- - __-- --- -_
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size ; X H� Observation Pipas
C Length Dia � Length Dia Spac ! Spacing ❑Yes ❑ No �
-- -- - -- -----—__- — - --- — —--_
301L COVER
- —
De th Over De th Over De th of Seeded/Sodded Mulched
p � P p -
Cell Center Cell Edges ' Topsoil ❑Yes ❑ No ❑Yes ❑ 'Vo
COMMENTS: (Include code discrepancies, persons present,etc.)
��s���� l o�Y �23
� — ��-- — __ _� �
� � �
Plan revision required?❑Yes❑ No I, �3 �or � II � �����'� � ��i'���,
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NUMBEA ____�"�3`''�_ ____
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