HomeMy WebLinkAbout024-641-15-4416-SAN-2023-295 _ '`' Department of Safety c°""�' � �
>�� f � & Professional Services Sat✓yei- �
_ �. _' _ � Sanitary Permit Number(to be filled in by
,� = Industry Services Division �
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Sanitary Permit Application State Trnnsaction Number ►
r-- R�
In accordance with SPS 383.21(2),Wis.Adm Code,submission of this fortn to the appropriate governmental unit .�
is required prior to obtaining a sanitary pc;nnit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing a �/'`
the Departrnent of Safety and Professional Services.Personal information you pmvide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. �O n 3•'/� G�I D ' S
I.Application Information-Please Print All Informatioo � ��Q�
Property Owner's Name Parcel#
iac� 'c�!`r T/`�•sT O.Zy- 6Y!-/.S'- 51�10�'
perty Owner's Mailing Address Property a on
�y 16 w N/oose /.�,�Ec IC� Gav�a��-
City,State Zip Code Phone Number c ,r
!� A/IV/�� �✓.� .f'��PY 3 J� �h,•s€ '/., Section �•7
II.Type of Building(check xll that apply) Lot# T � N R 6 E o
�.l or 2 Family Dweiling-Number ofBedrooms 2 !� Subdivision Name
Block# ^
❑Public/Commereial-Describe Use
^ ❑Cityof
❑State Owned-Describe Use CSM Number ❑Village of
�- ,�Town of /���` j 1 k P
III.Type of POW'I'S Permit:(C6eck eit6er"New"or"Replacement"and other applicable on Gne A. Check one box on line B.Compiete line C if
a lieable.
A.
❑New System �`iteplacement System ❑Other Modification to Existing System{explain) ❑ Additional Pretreatmeni Unit(explain)
B' ❑Holding Tank �.in-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ype( p )
❑Other T ex lain
(conventional)
ist Previous Permit Number and Daie Issued
C- ❑ Renewal Befoie ❑ Revision ❑ Change of Plumbet ❑ Transfer to New Owner ?
Expiration UK�
iV.DispersaUTreutment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispetsal Area Proposed(s� System Elevation
3c�o . `7 y�g.s7 ys�- �s:oo
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � U V �, F y ^
New Tanks Existing Tanks � o }; v � � � �
a` U V� � v� ir. C7 LS,
Septic or Holding Tank "f� ^1 S'Q ' / ,<<S�C �
� '1/
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assnme respoosibility for installatlon of the POWTS shown on the sttached plans.
Plumber's Name(Prmt) Plumber's 5i ature � MP/MPRS Number Business Phone Number
J�_
�ena.1�1 Fi�e.•�. I �i� � �lSo// l 7i.s^SSb�-J/3�''
Plumber's Address(Street,City,State,Zip Code)
I ��o a w Fi�e�.�.,� � /Q� �i� �..�,�,� �✓l s'y�Y 3
VI.C u /Department Use Only
�Ap ro ed ❑Disappmved Pemut Fee Date Issued Issuing Agent Signature
�� ❑Ow+ner Given Reason for Denial $ C"��� t i � � I `� � " ��"�4t�"�����2
Conditions �p va easons for Disapproval �-- �., ��-,r;-:r.,���--�
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Atbch to compkbe plans for tYe system aad�abmit to tLe Coanty ouly oo paper not kss thao 8 1n:il inches ie siu
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I�C F��F'Ji`��P.�T�R
SBD-6398(R.03/22) ���3`()�{�fti�V;11
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soii 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 / Descrip#ion
Owner Name(s): p�c.c.ti ;eit� r���r Phone: - -
Owner Address: 7 yl6 w A'�scSe f a,lCP/1� /�� , r,�.Z' ,� Zip: ��$
Project Address: !0 93��1 c.r„ Ro� 5
Govt.tat:--- S � 1/4 of S t 1/4, Section /6 , T�N-R 6 E�or W Q
Township: RcwN 4 ��kr County: S�.�r��
Project Parcel ID #: d a�1, 6 y! - l5= �yo�
Designer Information
Designer Name: �t�tl� �-re��< ( Phone: ���- ��- 11 ��
Designer Address: l 3ra� 4' ��'��� �� «+/w"'''�r �`'-r Zip: SY�`�3
E-mai{: _ _
License Number: �SO J/ )
Remarks:
�
� C Date: !/-�- ��
Signature:.��
Original signature required on each submitted copy.
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Septic Tank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA w«�—
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) `7�' 98, ge� gal gal
EfFluent Filter Manufacturer:
I
Effluent Filter Model#: �l�rJ� �
min.12"
SOIL COVER (rypl�l)
12"
min.trench
depth
criP��n � •�� TYPICAL TRENCH
� • . -� � �� ��'��a� ��. CROSS SECTION VIEW
��,yP,�� .:... .: ... .. � . . (No Scale)
, • :.
. ' Provide minimum 3 ft
System Elevation = q� ft separation between trenches.
(typical)
Quick4 Standard-W
wl End Cap ObservatlonPipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (�vpi�0
Install per manufactureYs PLAN VIEW
Instructlons. �NO SCB�e�
�—, .. -�— ,�.
- - �--- - - - - - - �� - - - - - - - - - - �� ���►.�r,��; I A= 3,Oft
' .
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.,�... . { �� ' � ' 4'���;_ :'W Y i�Y W Y��� ' ��PICBI� V
�- - - =- - - - - - - - �� - - - - - - - 7'f-- - — - - - - - � �
�
B = ft m
(rypical) Quick4 Standard-W Chamber w
INSTALL PER TRENCH: (typica�> Q
(mfd by Inflltrator Systems,Inc.) �
2�� 2 Install pursuant to manufacturers instructions. �
�_ Quick4 Std-W @ 20 fi� EISA/chamber= ft
+ _�_ Pairs of end caps @ 6 f�EISA/pair= 6 ft2
= Proposed EISA per trench= '�a'�D ft2 Required Infiltration Area= y_ft2 Distribution Method:
x �— trenches = Proposed Total EISA = �_ �t2 G1�H'
PAGE40F4
In-ground Gravity Management P{an
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 Disaersal Area Oaeratinq Limifs:
Design Flow= 3� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL"'
Insuection 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, efc.)
o material fatigue(i.e., teaks, breaks, corrosion, etc.)
o solids vofume in anaerobic treatrnent tank(s)and any distribution appurtenance(s)(i.e., distribution/drop boxes)
o neglect or improper use(i.e., exceeding design capacifies, 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 Seatic and dose ta�k(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(113)the liquid volume of�e tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc. Admin. Code.
o Effluent fike�(s)shall be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacture�'s specifications. A serviang 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: �aY f .5�����c Phone: �f�`��"��3p
Local govemment unit: f`'�'�� �Ty ��:•�.s Phone: 7!S• �JY�¢�r _
Local govemment unit address: I�'��-:� lr Z�p: �YdV� _
Any defective part of this system shall be repaired, rep(aced, or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repair or reptacement 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.
Continaencv 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
ff use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33,Wisc.Admin. Code.
�z �
""''''` :; PRIVATE ONSITE WASTE TREATMENT county
\= �$ SYSTEMS Sawyer
P =.
''� �_s ( POWTS)
� �
=z"'���`''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 _�q S'
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. I 5.04(1)(in)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
��Gc��e-� �1�-s'�" l�o��� la� �
Insp BM Elev: BM Description: Parcel Tax No:
c�p,o� ��., c�-�'ba..� � c�.�- �.�'-6`(1 - (S`-�(YoS_
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ��� Benchmark �pp,p�
Dosing
Aeration Bldg. Sewer �;(,,(o �
Holtling St/Ht Inlet c�b Y r
TANK SETBACK INFORMATION St I Ht Outlet �b,a.. �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .(�p -�� )y� +� � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �.�o�
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative �S�o,
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia �Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N � L c( #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate '� .
INFORMATION P�L Bldg Well Waters °� GP g�C Chamber Model Number:
❑ EZFIow
CELL TO � -� ❑ Other
❑ Mound QY�__
----- ---�_ ---� � �---- �l� -------
- __--- - ------ -----
DISTRIBUTION SYSTEM X Pressure Systems Only
_ _ --- ---__
Header/Manifoltl Distribution Pipe(s) '� X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac ' , Spacing ❑Yes ❑ No
— - _ . -- - ---
SOIL COVER
------ ----- - --
�Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges ; Topsoil _ ___ ❑Yes ❑ No ❑Yes ❑ Vo
COMMENTS: (Include code discrepancies, persons present,etc.)
��i�s���� l( ��c ��3
i— -- ; i
Plan revision required?❑Yes ❑ No ' 3 I ' �_— __` __ _.�
I�a�1��; ��� (
Use other side for additional inforrriation Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBER: 23"o2�S_
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