HomeMy WebLinkAbout010-941-21-2301-SAN-2024-001 _='''" �"`� Department of Safety �°""S�,, e�- �
_~ � & Professional Services, �` Z
= �.\_' = Sanitary Pemrit Number(to be filled in by�
,, _ _ Industry Services Division
� .��'� t� S I �l�S s�
... �
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 state-0wned POWTS are submitted to Project Address(if different than mailing ai --
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.
I.Application Iuformation-Please Print All Informatioo ���$�N w'��"Twe� �
Property Owner's Name Pazcel#
�i��;s �- T ti, �,�,e.r,e I O/D�5 y 1�1�3 0 /
Property Owner's Mailing Ad ss Property Location
���(�3 � �U!��`l.r�r "01 Govt.Lot
City,State Zip Code Phone Number ,, f`,
��iA� G�l/` G✓�J— ,sY�/!f� SW '/,, ///�/'/n, Section s��
II.Type of Building(check all that apply) Lot# � T � N R E o
�or 2 Family Dwelling-Number ofBedrooms ,� �' �� Subdivision Name
Block# �
❑Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�-��� \ �' ���� jaTown of �w+R/
III.Type of POW1'S Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
`4' ew S stem
,,�-�I y ❑ Replacement System ❑Other Modification to E�cisting System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑Holding Tank �.In�iround ❑ At-Grade ❑Mound ❑ Individual Site Design ❑Other Type(explain)
(conventional)
C• ❑Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued
Expiration
IV.DispersaUTreatmeat Area and Tank Ioformallon:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �
If,57� r �o +7.5-0 '7`��`' 7? !J '9.o�
Capacity in Total #of Manufacturer
Gallons Gallons Units � o � ^
Tank lnformation s� .. �
New Tanks Existing Tanks y a � � � � � �
a U v� �, v� iz. C7 �s.
Septic or Holding Tank /,rynv ���ru / / o�
[�y" �
Dosing Chamber
V.Responsibility Statement-I,the andersigned,assame responsibility for instaltation of the POW'i'S shown on the attac6ed ptans.
Plumber's Name(Print) Plumber's Signatu MP/MPRS Number Business Phone Numbcr
r'J'$-O//� ?/.5-SS�-Y/-=��
e�s. � �+'1 e �
Plumber's Address(Street,Ciry,State,Zip Code)
��J�.Z Ll/ / /OE�N'!-e//� �T�- F�at'/ �C.� ,�7�0-��
VI. ou ty/Department Use Only
�A ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $��`� �� �' � "�`�� ��"�`"���k������
Conditio o��o �ns for Disapproval �'-�5�-i`�,���';'�' ` � �:
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_ _ . __...._ ____�.._.. s�; � -.��
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zo�v��,��u�;:�.,���;�,���;�,��o�►
Attach to complete plans for t6e system and sabmit to the Cornty only on paper not less than 8 tn:11 inches in size )
I ���i' 1
SBD-6398(R.03/22)
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soit Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Pian
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): ln�.�r� ��e I , Phone: 7lS�- t�3� zoy�
Owner Address: �0763 � w;y �� �� Zip: ��$
Project Address: /��d��iV `✓��T�� l�.
Govt. Lot: S�✓ 1/4 of �w 1/4, Section�, T�_N-R � E�or 1M�
Township: �� County: ��-«
Project Parcel ID #: p/0 9`f� a-1 �3 d I
Designer Information
Designer Name: �r��� ���`l Phone:��� - �� �1��
Designer Address: �����-� � ��/` ����` Zip: S�l�`��
E-mail: ,�., . �"; , � ,;,, � .. . �.,
License Number: ��� ���
Remarks:
l
Signature• Date: ` �' 3 �'2�
Original signature required on each submitted copy.
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Septic Tank(s)ManufacWrer:
IN-GROUND GRAVITY DISPERSAL AREA �✓r'��i
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) 98, 9a� gal gal
Effluent Filter Manufacturer
�i ICe-�'�,,. ,f�
I [
Effluent Filter Model#: l�
min.12"
SOIL COVER �ryP��
12^
min.Vench
dep�h
cna��n • TYPICAL TRENCH
'.a .. CROSS SECTION VIEW
�ryP��� ^ (No Scate)
Provide minimum 3 ft
System Elevation= ft separation between trenches.
(rypical)
Quick4 Standard-W
w/End Cap Observalbn Plpe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (bp��0
InatallpermanutxNrefs PLANc.VIEW
Inslructlons. �rJO JC2�8�
�r — ,,,,{.----�j�-------��---- —,—
.��� r��r�� �i��l��14�' ��'-�ry����`��� �il�r������ A=3.Oft
. � a� ��r.■ ����1�4�� ---'��-------�f----�� U.��rw�y_ .IrM�e��rJ I (ryPicel) �
--- D
B= 7� ft �; m
(typical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: ��YP���� �
(mfd by InfiltratorSystems,Inc.) T
9 Instsll pursuent to manWacturer's instructions. �
�_Quick4 Std-W @ 20 fl�EISA/chamber= 3 ft�
+ � Pairs of end caps @ 6 ft EISA/pair= 6 ft'
=Proposed EISA per trench= 3 Sb ft' Required Infiltration Area= �'S� ft� Distribution Method:
x �- trenches=Proposed Total EISA= �7�- n' �
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground graviry 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.
Furthertnore, all inspection and maintenance activRies shall be performed by a registered POWTS MaiMainer in
accordance with SPS 383.52 (3), Wisc.Admin. Code.
Maximum Disaersal Area Operatins� Limits:
Design Fiow= �� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL-'
Insoection 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 treatrnent tank(s)and any distribution appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited adivities, 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(sl 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 onrthird(1/3)the liquid volume of the tank(s) or
as required by local ordinance. Dispasal of contents shall be pursuant to NR 113,Wisc. Admin. Code.
o Effluent fliter(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 govemment unit in accordance with
SPS 383.55 Wfsc. Admin. Code. RepoR any componeM failure or malfunctfon to:
r
Name of individual or company: �i,y f s�PTr c Phone: 7<3'SS 8'((3�_
Local govemment unit: ��. t i G Zo•�,,'c.� Phone: ���� �.3�7'�»�
Local govemment unit address: �+'.c .�: F/a,y,�,, f- � ZIP: s�l�*?
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 3&4,Wisc. Admin. Code.
Continqencv 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.