HomeMy WebLinkAbout004-146-11-1600-SAN-2023-306 %' Department of Safety cOQ°ry SAWYER �
� & Professional Services,
�, �_' Santtary Permit Number(to be filled in by C
, � Industry Services Division �
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Sanitary Permit Application State Transaction Number O
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit NA �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addres�)
the Department of Safery and Professional Services.Personal information you provide may be used for secondary BAG WAKI DRIVE
purposes in accordance with Che Privacy Law,s. 15.04(1)(m),Stats.
I:Application tnformat�on—Piease Pcint All Infarmation
Property Owner's Name Parcel# ��t{ _ I — I I_1 �p
THOMAS J. & RACHAEL A. GREEN 57-004-2- -08-24-5 15-180-111600
Property Owner's Mailing Address Property Location
352 E SAMUELSEN D RIVE
ca�c.Loc NA
City,State Wj Zip Code Phone Number
EDGERTON, 53534 _�_�____�l,,, section_ 24
iL Type of Buiiding(check ail Yhat apply) � � � Lot# T 39 N R 08 �or W
�1 or 2 Family D3welling—Number ofBedrooms 3 �6 &�� Subdivision Name
Bio�k# LAKE A-SHE-GON HEIGHTS �
❑Public/Commercial—Describe Use
— -- --- �1 ❑Cityof _
❑State Owned—Describe Use CSM Number ❑Village of _
NA r�T�„�,�r COUDERAY ______
III.Type of POWTS Permit:(Check either"New"or`•ReptacemenP'and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A' New System p• � y, � p � Additional Pretreatment Unit
x
� Re lacement System � � Other Modification ro Existin S stem ex lai❑
(expl��)
B' ❑ Holding Tank X In-Ground ❑ At-Grade ❑ Mound ❑ Indi�iduai Site Design ❑ Other Type(explain)
(conventional)
C. ❑ Change of Plumber ist Previous Permit Number and Date Issued
U Renewa]E3efore ❑ Revision ❑ Transfer to New Owner
Expiration
IV.Dispersali'I'reatment Area and Tank Information:
Design Flow(gpd Design Soil Application Rate(gpd�s� Dispersal Area Required(s� Dispersal Area Proposed(s�
450 0.7 642.86 �p 96.00; 95.50 95.00; 93.50'
Capacity in 1'otal #of Manufacturer
Gallons Gallons Units � o 'o u
Tank information p � �
New Tanks Existing Tanks � o y � � � � �
ci, U �n v: ri� i.z. C7 P..
Septic or Holding Tank 1 oOQ �QQQ 1 WIESER X
Dosing Chainber
V.ResponsibiUty State�entr.l,the andersigned,assume resp ihitlty f f taliaHon of the P{?WTS shown on the attaehed ptans.
Pli�mber's�7ame(Print) Plumber's Sign• re MP/MPRS Number Business Phone Number
DANIEL BURCH o 2s3soa ��s-aib- �6nz
Plumber's Address(Street,City,State,Zip Code)
N59�1 C.T.H.K,SPOONL-R,WI 54801
VI.C n °lDepartment Use Only
�f A r� ❑Dis�pproved Pennit Fee Date Issued lssuing.Agent Signature
❑Owner Given Reason for Denial � 1 w'� �� I� � I �3 �� I��c•�.�.'r"��
Conditions of A roval/Reasons for Disapproval �--��--- � �, �
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Attach to complete plans for the system and submit ro the County only on paper not less than 8 l/2 x 11 inches in size i
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SBD-6398(R.03/22) NO R�FJNaS qFTeR
IS�JE OF P'ER#l!!T
t��G i�
PAGE 1 4�4
In-Ground �Gc�vity Plan
�ndex & Cover She�#
Component Manua!Des�grn References:
In-Grouttd Sail Absorption for P01NTS Versian 2.1 {May 20�-202T}
Pg 1 a#4 lndex 8 Cover Sheet
Pg 2 of 4 Plat Plan
Pg 3 af 4 Disper�al Area Cross-Section & Plan V'rew
Pg 4 cff 4 Management Ptan
Attachmer�ts: En�losures:
SuNey Map POWTS Application f4r Review
Tax Statement Svil �valuation Repo�t 8� Site Map
Project Name 1 flescription
Owner Name{s}: THO(NAS J. 8 RACHAEL a. GREEIV Phone: _ _
���q��s; 352 E. SAMUELSEN QR., EDGERT4N, Wt Z��,• 53534
Project Adtltess: BAG - WAKI DRIVE
Govt,.�.ot: � 1/4 of il4, Section �4 , T 3g tv-R �8 E�ot' Vil Q
Tovrnship: COUQERAY G�,�y; SI�WYER
P�oj�c#P�tcei iD#• 57=4d4-2-39-(�8-24-515-180-111600
Designer fnformation
p�#�,�r M�: MARY JO HUPPERT Phor�: 7�� - 426 _ 1775
Designer Address: �5720 FIREFLY LANE, WEBSTEf2, WI �p, 54893
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IN-GROUND GRAVITY DISPERSAL AREA SepticTank(s)Manufacturer:
WIESER
Stepped Elevation Trenches with Quick4 Standard-W Chambers
Septic Tank(s)Volume(s):
3-ft Trench (down-sizing credit)
���� gal gal gal gal
Effluent Filter Manufacturer:
� POLYLOK
SOIL COVER min.12"
«P'��� Effluent Filter Model#: 525
12"
min.Vench
TYPICAL TRENCH depth •
CROSS SECTION VIEW (ryP'�I) '. a '
___ ___ _- -------- ..,.. .
� ' � � a 'a, Provide minimum 3 ft
(No Scale) � sa•-.----� a• •• • separation between trenches.
(typical) a , . .
.. . a,. . a.
e
Highest Trench Lowest Trench (as applicable)
System Elevations=(a 96.00 ft�95.50 ft� 95.00 � 93.50 ft, ft
Quick4 Standard-W
w/End Cap ObservationPipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (typical)
Install per manufacturers PLAN VI EW
instructions. �NO SCa�@�
r— — — - - - - �j�- - - - - - - - -�j� - - - � � — � � �
�f,.`�d�� a ��s � ,�`"�; , ���*��4���f, �
, �
— �A= 3.0 ft
� ' +r ,�` . ,, �� �tyPical) �
I_._ _�, ,tk+�+�.��- - - - - - �� — ��- - - - - ,. . _ ���,����`�-��,�� �
1 @54 & 3@30 _I �
B = ft m
(typical) Quick4 Standard-W Chamber GJ
INSTALL PER TRENCH: �ryp���� O
(mfd by InfiltratorSystems,Inc.) �
Install pursuant to manufacturer's instructions.
13 Quick4 Std-W @ 20 ft2 EISA/chamber= 260 ftz �
X�. 4 X Pairs of end caps @ 6 ftZ EISA/pair= 24 ftZ
21 X 20 3��C�4�C���Xtrench= ftz Required Infiltration Area= 642.86 ft2 Distribution Method:
� ' �1 �� X�fX 4 trenches = Proposed Total EISA = �, ft2 branched manifold �
- ��Y" THOMAS &RACHAEL
GREEN
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 382384,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 Ooeratinq Limits:
Design Flow= 450 gpd; BODS<_220 mgL''; TSS<_150 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 volume in anaerobic treatment tank(s)and any distribution appurtenance(s)(i.e.,distnbution/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 Seqtic 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(113)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(sl 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:
Nameotindividua�orcompany: DAN BURCH PLUMBING phone: 715-416-1642
�oca�government unit: SAWYER COUNTY ZONING pnone: �15-634-8288 _
Local government unit address: HAYWARD, W I ZiP 54843
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.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shalt 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,Wisc.Admin.Code.