HomeMy WebLinkAbout024-741-33-2302-SAN-2023-238 ' Department of Safety c°°°ty `�
- � & Professional Services, S��"� �r �y
` :� Sanitary Permit Number(to be filled in by� `
� Industry Services Division
. ��fl.P _3t� �
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Sanitary Permit Application State Transaction Number ;
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for stateowned POWTS are submitted to Project Address(if different than mailing adc �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. I�.04(i)(m),Stats. ���� (��
I.Application Information—Please Print All Information
�t,+
Property Owner's Name Parcel#
TvhrTau��� � �"ess�c.Q C. C�pla.il ortt-_��-��J,1j 'L:�7i
Property Owner's Mailing Addre s Property Location
����s �v. �oo � PI .
City,State Zip Code Phone Number �~
SC�;'�"�'S(�C�f,' � �fSZl�l� ��` 2�?(a� �C�C- 7
cS�i�� '/<, Nk+ '/., Section��3
II.Type oi auilding(check all that apply) 2 Lot# T � � N R
�D I or 2 Family Dwelling—Number ofBedrooms J i Subdivision Name
�---
Block#
❑Public/Commercial—Describe Use
`�— ❑City of
❑State Owned—Describe Use CSM Number ❑V illage of
�53� �'cu..�d �-�C�
�Town of
3 7 ���
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.)
`4� New S stem
� y ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
ist Previous Permit Number and Date Issued
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner r__
Expiration
IV.DispersaUTreatment Area and Tank Information:
Desia Flow(gpd) Design Soil Application Rate(gpd's� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevatio�
c�7 ��3 ?oa �{�,as�
Capaciry in Total #of Manufacturer
�
Tank Information Gallons Gallons Units 9 �, U '� u
New Tanks E�isting T�nl:s � � � � y � � �
a U cn y �n i�. C7 p.
Septic oF-F{eldiag Tank a��� �CCU ���I"t�C�
l r�`�
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsib' for inst lation of the POWTS shown on the attached plans.
1 mber's Name(Print) Plumber's�, e > _ , _,.-— MP/R�S Number Business Phone Number
� �� �-
�s�,� ����-f-e l y, ��s��5 r ?��=^1��'� 3�s7�
,
Plumber's Address(Street,City,State,Zip Code)
�0 � �� �� �c-���� u''r S�`�$2--1
VI.Count /Department Use Only
�Ap � J ❑Disapproved Permit Fee Date Issued Issuing Agent Signature/
�� Q Owner Given Reason for Denial � `� a� � '�'� � �� �'��L`"�L`JT����Z
Conditions of Approval/Reasons for Disapp�oval
` J � A �4°'_..`"�..��-:�A,�.;?.�,......._ ,�_. � �1�� �� ��\`� !��'�'1;
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5�+1��;.',r�� ., - ,� I�`�'+t
Attach to complete plans for the system and submit to the County only on paper not less than 8 1;2 x 11 inches in size �y I��
NQ R;FJt�DS AFTER
SBD-6398(R.03/22) ISS�I}E OF F'�R�/;iT
� �
,=���^ 1 Oi -
!n-Ground �ravity Plan
)ndex & Cover Sheet
Component Manua/Design References:
In-Ground Soil Absorption for PO!�/TS Version 2.1 (N1ay 2022-2027j
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Piot Plan
Pg 3 of 4 Dispersai Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Dzscription
O�,vner Name(s):�'o�V� (a-U�(r' �- �ssicc� C. C��(C'u� Phone: ��b -z�- 10(��7
O�riner Address: 1�fQ"/S �N. tao� pl ae� �Sec��c<.�e� (�Z Zip: �S�1�0
Projec� Address: ����Q����-��� ���w�i� w.= S`{�'S`�3
V I
�:�-��: � 5�:.� 1/4 of Nw 1/4, Section 3,3 , T �H N-R�E❑or W �
Townshi�: ��1� �.�Ke. _ County: �.c��e�'` ___
Project Parcel ID #: D2�{--�'f t �33 --23o Z
Designer Information
Designer Name: ��n �c;�e-{�{'�-� Phone: 7cS - 7�/�' - s'.��
Designer Address: �0� � Lo� cr,���e� t,�.� Zip: S�FBv
E-maii: ���N-rY'as,�ir�
Licens� Number: (�`�S�S�
Remarks:
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Signat�ire: D.�t�: f l� �z-3
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IN-GROUND GRAVITY DISPERSAL AREA wi�����nk(s)Manufacturer.
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) ��,
gal gal gal gal
Effluent Filter Manufacturer:
Q{'f_{�C(�
I min.12" Effluent Filter Motlel#: �Tw�'�
Geatextile I (typical)
Cover
SOILCOVER TYPICAL TRENCH
m��.�Ze��h1 CROSS SECTION VIEW
depth 1 L
�ryPi�i� —— ,�"e. : (No Scale) OBSERVATION PIPE DETAIL
/T� �No s��a�
System Elevation= 7�"Zsft. Y • s"aw-TyPa°` F�����sneac�aa
(typical)
' Provideminimum3ft s"PcaP�'°°�a� tm��=haassaaaad�
separation between trenches. a e Pvc a�oe ToPso�i co�a�
Top of pipe lo tertn�na�e (min.1 loo�)
at orabove finlshetl gratle
(4)1l4"-1/2"X 6"Slo�s
TYPI CAL TRENCH (Show location of fnlet/outle[pipe connection on plan view.) La 4o aPan
PLAN VIEW A��ho���9oe��a �����«a��o�
Observaiion pipa shall be�inslalletl SuAaca
(No S ca le) 4'� at ryndion between two uni�s.
Perforated Lateral Observation Pipe ft
� (typical) (rypicap �� (�ynica�)
r — �f————————— � �
� '__"_�_-___ � A—3.0 ft D
__ '__ _____=_ ______=' —
�---------------��-------------- -----� (�YPical) �
F= s= 'l� ft -� m
w
(typical) O
INSTALL PER TRENCH: EZ1203H Bundle �
(typical)
� 10-ft bundles @ 50 fl�EISA/unit= 3s� ft� (mfd by Infiltrator Systems,Inc.) �
Install pursuaM to manufacturers instructions.
+ 5-ft bundles @ 25 R'EISNunit= ft�
=Proposed EISA pertrench= 3s7� ft` Required Infiltration Area= �'T3 ft' Distribution Method:
x z trenches=Propoced Tntal EISA= '�r� fc` ��'"' �����
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 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 _< 150 mgL"'; FOG 5 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 vofume 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 on�-third (1/3j 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: �. �l.�.SYY�I,I..$��-//� �l- ��-�y�S Phone: '71�1- �7��'�� 33��
Local government unit: 5Q-:.��:.�' �,� �j • �✓��-Y1�- Phone: 7�•S-�3� '�Z��
�
Local government unit address: ��)Gt.�,� � W� ZIP: $�{�`,�
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1 ), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pr2-det2rmin2d area of suitabl2 soils.
System Abandonment
If use of this POVVTS is discontinued, it shall be abandoned in accordance avith SPS 383.33, �Visc. Admin. Code.
�'`"``�; PRIVATE ONSITE WASTE TREATMENT county
���o$p r� SYSTEMS
�=�� ` $ -
( POWTS) Sawyer
.� ry( `._ p�i/
' '"�'> INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 -�3g
Personal infonnation you provide may be used for sccondary purposes[Privacy Law,s. 15.04(1)(m)J
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�oln,,.�''q�r� t Je..iS�C�.C�l q� �� l.�� �
Insp BM Elev: BM Description: Parcel Tax No:
1���o � a�-' 104�.�, ��1 -�' �►ks�-�-�� o��f -7YI-33 -23a�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w�1�,sZf- ��aap Benchmark �oo,�'
Dosing
Aeration Bldg. Sewer �
Holding St/Ht Iniet �j9,Z '
TANK SETBACK INFORMATION St/Ht Outlet 5 8,95 '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic +-�b� N r/ N NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ci7 oS- �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative � ,�s/
Surface
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 3 L p' 7p' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
P/L Bldg Well o IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO
❑ Mound o Other
— ---
-- �a- --J✓ N �FS�__
DISTRIBUTION SYSTEM x Pressure Systems Oniy
- - - — —
Header/Manrfold Distribution Pipe(s) �� X Hole Size , X Hole Observation Pipes '
Length Dia Length Dia Spac I � Spacing ❑Yes ❑ No
C --- ----- -- _
-—- -- -_ _ -----
SOIL COVER ____
— - ---— — --- --
r Depth Over � Depth Over II Depth of �Seeded I Sodded Mulched
� Cell Center Cell Edges , Topsoil ___ 0 Yes ❑ No O Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��.,s1���� ���i► � 23
j��� � - - - - - —�I
Plan revision required?❑Yes❑ No p3 'I �� '� J � , ; � ���1 � _
�_ � __��'
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AD�ITIONAL C�MMENTS ANO SKETCH
SANITARY PERMIT NUMBER: __��__-�2 3�___
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