HomeMy WebLinkAbout014-842-14-3220-SAN-2023-310 Department of Safety c°°°n' �
D & Professional Services, �"�- `r �
� g p Sanitary Permit Number(to be filled in by�
g Industry Services Division �
L� �1 1��1 7 W
Sanitary Permit Application state'►'ransaction Number (.jJ
In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
the Department of Safety and Protessional Scr�°iccs.Personal information you provide may be used for secondary ��L��� � ��(�{.ri�� ��
puiposes in accordance with the Privacy Law,s. I�.04(I)(m).Stats.
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�oti„ t-t�:�, K�Ik� RW Tws�- o�Y- �wt_ �`�- 3Z2o
Property Owner's Mailing Address Property Location
�3� C . W�f�,�, sk �
City,State 7,ip Code Phone Number /����f��
b LM�eN�D"C �+l 1 s30�� S���i'6 �""'�;. SIA/ y<, Section �� _
II.Type of Building(check all that apply) �ot# � I �Z N R o� E or('�
�1 or 2 Family Dwelling—Number ofBedrooms Subdivision Name
�� N� ,N,S s�ock# '—�'
❑Public/Commercial—Describe Use
�" ❑City of
❑State Owned—Describe Use CSM Number ❑Village of
�7�3Y� �?I S`� �f`r�wm or l�,,.��
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.
��� �New System -� Replacement Sy°stem - Other Modification to F,xisting S}�stem(explain) _� Additional Pretreatment Unit(explain)
B' ❑ Holding Tank �In-Ground _J At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type lexplain)
(coAventional)
��• ❑ Renewal Before � Revision '�� Change of Plumber _' Transfer to New Owner
ist Previous Permit Number and Date Issued
Expiration Qy.. �9 II �Z �1,/
! 1
N.Dispersal/Treatment Area and Tank Information: w� ;h
Design Flow(gpd) Design Soil Application Rate(gpd/sY) Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevatio
-�3�° � 7 y2 S 5'Z 92' 95�� �
Capacity in Total #of Manufacturer
�
Tank Information Gallons Uallons Units ` o '� �
New Tanks Existing Tanks � c � " � A � �
o . �
a`. U cn v� ii. C7 a.
Septic or Holding Tank ��d �O 1 �'C},�
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for instsllation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Si ature MP/MPRS Number Business Phone Numbcr
ny��•.� 5�1..�(�FZ 1�'t�r-t� ��� S S8 - �qoy
Plumber's Address(Street City,State,Zip Code)
�G�qo 41 M�t4.�F f� S� lal�c.. w� Su�7G
VI.C un /Department Use Only
1 � Permit Fee Date Issued Issuing Agent Signature
�Ap ro� d ❑Disapproved
�j?�'✓ ❑Owner Given Reason for Denial $��'� �( � ��``���3 �' F'�'�`�����
Conditions of Approval/�teasons for Disapproval
€",! � �1�! �1 � �:iaiw_ �) `� 5_.__.._,_. �
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CS`� 23 _a�� 3��. _ _ __ _ , ��:�?�,r� � �� �a�" -
Attach to complete plans for the system and submit to the Caunty only on paper not less than 8 v2 x 11 idctrps+in site '
",;
sB�-639g�x.o3iz2) ;hall not b� �cre�t�.. 1 t�'��3
�� accessory s#ruct�r�;�
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil 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/Description
OwnerName(s): �O�n � ����' N"��`'�" Phone: - -
OwnerAddress: ��� � �dsOh 5'�" °G��a `" Zip: � S3o�d
ProjectAddress: �3y16�V ���yu�o� In F{,yuwZ �^ �r�v3
Govt.Lot: / 4� 1/4 of sW _1/4,Section�� ,T �Z N-R a B E�or W�
Township: �...�nroa-}- County: s�"`''Y��
Project Parcel ID#: ��y- g4Z-�`f- 3 ZtD
Designer Information
Designer Name: �y��.. ����z Phone: �Y� - Sr8- Sf�
Designer Address: ����u W r'`c�`"l� �1 Zip: Sy 91�
E'IT181�: �Y� >C�••�+L�9��/ble.r�. �ojt� ..,y�a�e resene�(nr�F,Pro��.l.ien����.
License Number: 1���12�
Remarks:
-:aaitable Living area
�hall not be created
Signature: Date: ��'21-Z�
Original � nature reA red on each submitted copy.
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Septic Tank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA w«J-�
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) �S0 gal 9a� gal gal
Effluent Filter Manufacturer
\ �Y/•cL
I
Effluent Filter Model#: �2�
in.�2'
(ryplcaq
SOIL COVER
iz.
m�n veo�n
cao°�n • TYPICAL TRENCH
a CROSS SECTION VIEW
�—34"
�tyP;�,� (No Scale)
� . . ' q Z,9�� Provide minimum 3 ft
System Elevation= ft separation between trenches.
(typical)
Quick4 Standard-W
w/EndCap ObservationPipe TypICALTRENCH
(rypicaq (Show location of inlet/outlet pipe connection on plan view.) (lypical)
Install per manufaclurefs
PLAN VIEW
i���uo�s.
(No Scale)
���#�-t4vl...a ,ew7es-----��--------�f----- .� �.wA .,.—.�1
' '..
I ° a I,I A=3.Oft
Lillffwil�i. s.•riiYY► _�� ��_ a YalmWu�ar•- �.a.J (�YPical) Y
B= `�Y rc �; m
(typical) Quick4 Standard-W Chamber W
INSTALL PERTRENCH: ��YP���� �
(mfd by InfltratorSystams,Inc.) -n
Insfall pursuant to manufacturers instructions.
�_Quick4 Std-W @ 20 fl�EISA/chamber= 12� ft' �
+ � Pairs of end caps @ 6 ft�EISA/pair= � ft'
=Proposed EISA per trench= 22C ft' Required Infiltration Area= yZ4 ft' Distribution Method:
x Z trenches =Proposed Total EISA= WSZ-- R' ��'��
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 it 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= 3 �� gpd; BODS <_ 220 mgL�'; TSS <_ 150 mgL-'; FOG <_ 30 mgL-'
Insqection 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 tatigue (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 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 one-third (1/3) the liquid volume of the tank(s) or
as required by locai 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: �Y�n �`-A"'r2 Phone: � �� - SSS'�oy
Local government unit: 7�v�r -✓ �'`'N�' [�• � Phone: 7�r'�jy-3�Z�P _
.
Local government unit address: I���6 �`�� ���'F ZIP: �/1"/� _
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.
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.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33. Wisc. Admin. Code.