HomeMy WebLinkAbout024-741-17-3408-SAN-2023-282 _ ° Department of Safety c°"°ty c��, �
• - & Professional Services, Z
,, � . Sanitary Permit Num er(to be filled in by�
�'� �� Industry Services Division �
(.� �l ��� 1 w
SaT11LaIy Permil AppllCatlOT1 StateT�ansactionNumber �
In accordance with SPS 383?I(2),Wis_Adm.Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for stateowned POW'CS are submitted to Project Address(if different than mailing a QJ
the Department of Safety and Professional Services.Personal information you provide may be used for seconda )� �� /�_j„„� �Ujh�(j�,
purposcs in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � �,� Z�-��E.J ����
I.Apptication Information-Please Print All Information
Property Owner's Name Parcei#
� a �L � 0�`� ��7�1' l� 7 — 3Y4�
Property Owner's Mailing Addres Property Location
fC � V� � Govt.Lot �
City,State Zip Code Phone Number �7
✓�') 1 —�����I//�'�/Y�" y��l� y���a,�w� ���, .SCChOt] I /
II.Type of Building(check all at apply) Lot# T `/� N R d/ E or
f�I or 2 Family Dwelling-Number of Bedrooms Subdivision Name
i�
Block#
❑PublidCommercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number�3/Z�7 ❑Village of
it 32`��' �ro�,a,��11��1C. C.LL-1�-�
� " ' � � fc
iII.Type of POWTS Permit:(Check either"New"or"ReplacemeaY'and other applicable on line A. Check one box on line B.Completc•line C if
a licable.)
�� ❑ Additional Pretrearinent Unit
❑ New System ,�Replacement System ❑ Other Modification to Existing System(explain) (explain)
B' ❑ Holding Tank �In-Ground ❑ At-Grade €� YP � P )
❑ Mound ❑ Individual Site Desi Other T e ex lain
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to New Owner
Expiration ��- a7,� b � t
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd;'s� Dispersal Arca Required(s� Dispersal Area Proposed(s� System Elevation �
L �- , �' �S`" �t:�,i
Capacity in Total #of Manufacturer u
Tank Information Gallons Gallons Units � � v � � n �
New Tanks Existing Tauks L o t; � � ,a ,_? �e
a U ri, �n rn u., C� A.
Scptic or Holding'Tank !��Q �Q D �
Dosing Chamber � �� � �� . �
V.Responsibility Statement- I,the undersigned,assume respoosibility for installa4on ot the POWTS showo on the attached plans.
Plumber's Name(Print) Pl 's Signatur __ MP/MPRS Number Ausiness Phone Number
` j ^ i� 9�"��/ ` ...� z�/�07
Plumber's Address(Street, .iry,State,"Lip Code) :
., � ��. �
d�" � CZ �, � �
VI.Count /Department Use Only
�A�p� ❑Disapproved $ermit Fee� llate Issued Issuing Agent Signature
�� ❑Owner Given Reason for Denial `��O' ��'��y I � -3 �y�'�`��� '-
Conditions of Approval/Reasons for Disapproval �---�7-«� ;'—�����'���� �
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ZON�'�u�I7MINI�TRi�TIOi�
Attac6 to complete plaos for t6e system aod submit to t6e County only oo paper not less t�an 8 U2 x 11 ioches in size
.� `>�,��
NO RvFJtv��A�TER
SBD-6398(R.03/22) ISS�,1�OF��5�i �
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): lJ �Q��1 �c�.��(,?)1Gt�u� Ll.t f1.�1 Phone: - -
Owner Address: �y`�J /N(���L �J� �,�� �'iL����t�ip: J�l� ��
Project Address: /dCf`��l �C'�'l� P�l�•�`" �f�• ��f l.t-�1���� ��.�
Govt. Lot: � � E�/4 of ji� 1/4, Section / � , T �� N-R 0�E ❑or W�
Township: llU,.l'�� �G(.�- _ County: �JGl�(���
Project Parcel ID #: d�y� ���� � 7 `� ?��0 �
Designer Information
Designer Name: �1�(,L61 --� 4��� Phone:�/S� -��-!�
Designer Address:��'rJ�/j��l �(�.t4'��G� �a.1/�-I�. Z�P� J ���
E-maiL• ��)� ` . � . ..
License Number: � � �
Remarks:
Signature: � �ate: / � `'��'�"�
� Original signature required on each submitted copy.
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IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard-W Chambers
3-ft Trench (down-sizing credit)
�
"''".,'" TYPICAL TRENCH
ca�+���i
- sc�i�covER _ CROSS SECTION VIEW
��° (No Scale)
min.tronch —
de pth
(�YPlr.al) ` °
- ..... .__.. ... . .�_. .. _.. . . .'4'' .
. . .. • . .4 a.
� I�Yn��� �e � a �a - I Provide minimum 3 ft
� � " 9'3�� separation between trenches.
System Elevation -.���'�ft
(typical)
QuiCk4 StBndard-W pbsorvadon Plpc
wl End Cap (Show location of inlet/outlet pipe connection on�lan view.) (lyplcal) TYPICAL TRENCH
— (lypiC81) Inslall por manufacturor's
Instructlons. PLQN V�EW
- -- -- - - - - - �' - - - - -_ _._ — (NaScale)
�Rs�M�rer►Nse�spv{��F�xete,. �— — �f -- — — —*#��rnnwunxe+�rNp�x���!
�f u, f , , I ��� I I� �P'= 3A ft
II` (typic�l)
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� - - - - -
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(typic�l) Quick4 Standard-W Chamber (Tl
(�YPical) W
INSTALL PER TR�NCH: (rn�d�y���i���ator syst�ms,i�o.� O
"— Install pursuant to rnainufacWrer's Instructlons.
�_ Quick4 Std-W @ 20 ft'EIS/�(chamber= � Uft� �
Ul
+ �_ Pairs of end caps @ 6 ft`EISA/pair= „�. ftZ
= Proposed EISA per trench= 3�6 ft' Required Infiltration Area= l% �1 Z ftz Distribution Method:
x �, trenches = Proposed Total EISA = �t' �i����� ��i co�
��..
�S�T
PAGE40F5
GRAVITY-DOSED
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4'9 Venl Pipe
>10 fl hom
Building Eleclncal musl comply wifh
12'Min.w 2.0 fl above SPS 316 and NEC 300
Eslablished Flood Eleva�ion W�(����f Exlena manhde nser as neoessary.
(�YPi�I) Ap�o� Junclion Bax
Vent Cap APP���Loticing Manirole
IMPORTANT: � �h Wamirg LabeiAttachetl
Mchor tank(s)as necessary �1ypi�'�
( )(9) �co�awc �
pursuant to SPS 383.43 8 � 4'Min.or 2.0 ft a6ove
Esla6lished Flood Elevation
(bvi�p
�AiNghi Seal'.
FinisFied Grade �
-- Duick Disconned
18"Min.
CAPACITIES @�gaUn �. �rywm'>
Depth(in) Volume(gal)
i
—�k \
A !g 3�� � Weep `Approved Joinls with
Hale Approved Pipe 3 fl onto
B `L'O ?�•� A Solid Ground
�> � IhiPicai)
[c] 1c�a. s� , _A�a,� '
� ��7. -B7� —°^
I[C, PUMP-0FF
* ` Pump _� ELEVATION= �i.:� ft
Pump Tank Liquid Levei=�in --f---
I
° co„�,��e INSIDE BOTTOM
Force Main Diameter=��in si� ELEVATION=- �� —ft
ForCe Main Length=�Q ft 3'Appmved B dtling Matenal Beneath Tank
Force Main Void Volume=�gal
[C]Total Dose Volume TDV = j , G� gal/dose
(<0.2X design Flow+force main void volume)
Vertical Lift= O ft
PUMP TANK: SEPTIC TANK(S):
Volume= �r=gal Total Volume= /,�9�gal
Manufacturer: .(�,`1s e/ Manufacturer(s): i,ci�'rS�/
Pump Manufacturer: 7 m .e /{r,—�
Install approved effluent filter at the septic tank outlet
Pump Modei: �J' 'i� (�a�tached pumpcurve.) immediately u�stream of the pumo tank inlet.
Controls/Alarm Manufacturer: �j,L, Filter Manufacturer: !Jr�-,r.� G1•n -f���3
Controls/Alarm Model: i��/ Nu
FilterModel: F�"��p�2
Float switches containinq mercury are prohibited. �
PAGE40F4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-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 pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Disaersal Area Oueratinq Limits:
Design Flow= _�/ 5'U gpd; BODs� 220 mgL-'; TSS_< 150 mgL-'; FOG 5 30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
c type of use
c age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanical malfunction (r.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 exteM of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.)
o eledrical components-if applicable(i.e.,wiring, connections, switches, controls, timers, alarms, etc.)
c 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 (1I3)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 filterlsl 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 6e submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin. Code. Report any component failure or malfunction to:
� c-� �"
Name of individual or company: y/}��� �� Phone �l 7�.J���Y✓�,� !
/� c��� �
Local govemment unit: {� � � Phone:��s VJ h� cS ��
Local govemment unit address: � �L .JI• J � zIP: S'c d `L�
ur.�
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 POVVTS may be used unless approved by the department in
accorda�ce with SPS 384,Wisc.Admin. Code.
Continaencv Plan
in the event that any failed treatment component of this POWTS cannot be repaired, it shali 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 suitabie soils.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
W '� ncNu I,ArKt,l � Y t.uttvt - - .
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_�: �; r�i�us I ,o z� So +o sn en � ia ec �equi�ements.
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o FLOW PEA MINUTE --------�-T_ .--
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CONSULT FACTORY FOR SPEClAL APPLICATtONS
• �iec;ncai a3ternators, tar duplex sys,ems, are avallab:e and • Mercury t,oat stivi2C�8S �:8 8V3il8416 !0� CO�tfOtlffl9 Si►1g18'8rt0
suppl,ed with an alarm. ,�ras phese syste.Fs. �
n Mech2n„^,ai aRarnators, tor duplex systems, are avaliable whh or • Do�bia piggyback rrrercuy :ica; sw;:ches ara avaiiabl6 fo=
wi�hout z!arm swn�hes. var�ab�e Ieve� to�g cyc�R cc�:•��s.
SELEC7tON GUiDE
Sianda�d ati models - YJelQilt 39 lbS, - ' ti. E�ta�rat tsaet operateC 2 pa e -ec^ani;.at switch.�o o�aernat conuot requueC
-- ----- -------- ----_.__. l� N.P. 2. Sin9le P�BOYDack meaury f�oa: swi;ch w doubk P�98YDack mercury. ttoat
_^.
98 S�rias Centroi Ssieet{on switcA_ Reter:o fkt6t7).
. _. _. —� �--
� ' A��to VoitrPh Mod�� Amps ,}�Sim..�i��: ! Du t�z , 9. Mechanfcal e;ternator 10-0p72 0• �.�-60T5.
—--
�'i,3 - . t tS t Auto 9.0 I � pr 1 6 7 — �. See f�!a)S2.fcr corraci mode.ot £Iecuica Niernator. "E•Pak".
'�?r 'iS t t.orF � 9.0 �_O�2 3 fi i 3 Cr � d S S. Mercury unsor fbal switc`: t�0225 used as s ca�trcl act�va:or, speciFr
_ ___ __.- ._ __ __� _ dupaax{J}or (�) tba; system
"� , 23i, t Auio � �.5 1 or 2 6 T -' 6. Four(�) hofe"J-Pait".junci;on bcx, for w;etarUght connecLon or wired•in s�m•
• ----r--_ _
£4� : 2zD �1 , No�� s.5 2 or 2 4 8 . � or 4 3 5 plex w dupbx operetio�, tD�,'�tC2.
7. Tv+� ,2} h;,ie "J•Pnk", lor we!e^.i�M conzec!�on o�sD:ice.
. CA�TiCH
r,x �:.lu�.r.s:i.x:an ii0�tbnai ZDN.et ypC:+t's tettt b u4A�p on ComO:nat±on S:ater. F►+i.Sf�; An ina4t4tlon d cm'vo1�. Wol�ctwn Oe�.ce� and wrt�nq �Aouid W dons Cy � qw+��
�''t�Ci�, �lt`t.'Y Swfl:ltls. FAcg:)); E�K`JiCa! AlfitnilM. FMO�AC: M.lCMfttJ; /�.".et�� 1wd I+e�n�+d �IeNULit AJC �ledrw�� �nd �I�ry wd�� �tiwid W IWlow�d inclW�
��85. �.a^. °�c+ekie 'M�S'? C:r`A'Sae�.ape 9u:r.f. FAA04l7;i�+d S�mpi�a ConLd 80�, Inp th� fwwl r�unt Mai;ona! E�.cVm Coce (MEC) �n0 U+� Oscup�t.wut S�t•ry •.�d
��'u - i.��n� Aai (OSr4A;
RESERVE POWERED DESiGN
For u�usuai conditions a reserve safety tactor is eng��2ered into ine design at every Zoefler pum�.
--------- — -------�--- — --- - ---------- - -
. MAII T0:P.0 80X 16347
� Q � r���� �` La+sv+t'r. XY 4J250-03�J "fanutdCttJrCIS O( ry
L SHlP Td:3280 D+'0 M�N^r�(�n: �� ..
ic.�°sak. KY 6C2 f 6 ,QUa!/1Y�U�t/GS �N�-f /9.�9
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"""'`�:;; PRIVATE ONSITE WASTE TREATMENT co�nty
�=, �$p ,�; SYSTEMS Sawyer
� s � ( POWTS)
H `_ �'
�' '"` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 .- �'g a
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
L�=�'u� ���t��,�e_l.. �t�� `��.1� �� �—'
Insp BM Elev: BM Description: Parcel Tax No:
�•� r � � 5��� o� -�Yl �l ? � 3Yog
TANK INFORMAT N ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �„�Q� - ��,o Benchmark p�,o�
Dosing �- ��w,�o �,00
Aeration Bldg. Sewer � � /
Holding St/Ht Inlet � .� 3 �
TANK SETBACK INFORMATION St I Ht Outlet --
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .�+�p� �-�' � ` '}-�S' � NA Dt Bottom �,� �
Dosing �� �� k r, NA Installation
Contour
Aeration NA Header/Man. �Y, � �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative 43� ( �
Surface
Manufacturer `� Demantl Final Grade
Model Number �� GPM M°�, �; �Q�3 �
TDH fc�� Lift Friction Loss Sys Head TDH Ft
Forcemain L t''� Dia �`� Dist.To Well
DISPERSAL CELL INFO ATION
DIMENSIONS W � L `y � #of Cells Type of System Distribution Media Manufacturer'
SETBACK OHWM of Nav � Conv ❑ Aggregate �l
P/L Bldg Well ❑ IGP Chamber Model Number:
INFORMATION Waters � AG � EZFIow
CELL TO _ _��u�- �1-(� __'�tcSb�_ __ _a_ Mou nd _ ❑ Other ���
- ---
- ----- - _ __—.
DISTRIBUTION SYSTEM X Pressure Systems Oniy
--- — --__ _ --- __ _ --
Hea�der/Manifold l Distgbution Pipe(s) X Hole Size X Hole Observation Pipes j
Len th Dia � Len th Dia Spac �� j Spacing ❑Yes ❑ No �
- — - - - ' -- — -
SOIL COVER
— --- -
Depth Over �epth Over ' Depth of � Seeded/Sodded � Mulched �
Cell Center Cell Edges �, Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision re uired?�Yes❑ No � ���
q "3 �� �y � � �- — -- ! ��Sa �6 �
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: v�-3 "�$2
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