HomeMy WebLinkAbout010-171-00-2001-SAN-2024-022 �
Department of Safety c�uncY � ;
• - & Professional Services, Z j
� � - Sanitary Permit Num dr(to e filled in by� �
'= Industry Services Division � s I � �� s ;
..,.. , �
Sanitary Permit Application State T�ansaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
is requircd 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 Satety and Professional Services.Personal informadon you provide may be used for secondary G�n,/^, �
purposes in accordance with the Privacy Law,s. I5.04(1)(m),Stats. ✓�� ��
I.Application Information-Please Print All Information
Propeny Owners Namc Parccl#
�� � � � �� p�o� 4�1 --00 ����1
roperty wner's ailing Address Property Location
lJ�-�`C�l.. � �(�''- -
ity,State Zip Code Phone Number
,'(��// , ��j'�" �y��,/� �' I/��, Section��_
W(.�' C Vti l� v v
II.Type of Building(check all that apply) Lot# I�\ T � N R E or
.�Q 1 or 2 Family Dwelling-Number ofBedrooms �� 1� � � Subdivision Name
� d-V
s��k# u,� Pa�
❑Public/Commeroial-Describe Use __
❑City of
❑State Owned-Desc;ribe Use CSM Number ❑Village of
��t 33g �-3S9 8 �ow"of���_
III.Type of POWTS Permit:(Check either"New"or"Replacemeot"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A' ❑ New System �-Replacement System g y ( p ) P )
❑Other Modification to Existin S stem ex lain ❑ Additional PretreaUnent Unit(ex lain
B' ❑ Hoiding Tank �[In-Ground ❑ At-Gradc
❑ Mound ❑ lndividual Site Design ❑ Other Type(expiain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date lssued
❑ Transfer to New Owner
Expiration �3 � S" .�g q
IV.DispersallTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal rlrea Required(s� Dispersal Area Proposed(s� System levation �
G , � ' �
Capacity in Total tt of ManuFact�rer Y
Tank Information Gallons Gallons Units � � o � �
New Tanks Existing Tanks � o � � Y p ro c`"a
a U v� �, v� w C� P.
Septic or Holding Tank � Q�� � � �,
Dosing Chamber Q , /
V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plum � 's Signature MP/MPRS Number Business Phone Number
� _. _ _:. 9'� s�-�s' - 73
Plumber s A dress(Street,Ciry,5tate,Zip Code) j
sa N -, " . �� s����
I.Coun /Department Use Only
y Nernut Fee Date Issued Issuing Agent Signature
�Ap �dv �Y O Disapproved �0�. �� I ` J � n��
❑Owner Given Reason for Denial $ � � /`�y ���� ����—
Conditions of A rovaUReasons for Disa roval �' c�'�
PP PP D � � j(�7���
� � � ,, � �-�-1' �.J —= v5 ti _'`%'J�(�',1
tiR � � �
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Attach to complete plans for the system and submit to the Couoty onty on paper not less than 8 1/2 x I I inches in s¢e
NO REFUNDS AFTER
SBD-6398(R.03/22) ISSUE OF PERMIT ��9� 3
� �u\�
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):�i�n�.��'Sf�0�7, '�l`� p�t�,�lPhone: - -
Owner Address: f��a/� �L�°I,I�'1��C�.QLc. �. ���'�y��J,,�jZip: Jc�l�i��..�
Project Address: J��y1�
Govt. Lot: _1/4 of 1/4, Section o��j , T �'II N-R D�E ❑or W,�
Township: �-1�'l�ilU:.[lu''[� County: �xLI,C�CJ�O�
r
Project Parcel ID #: (��� '" l�l �'� ` ��
Designer Information
Designer Name: �1,��1, �}-!'j"��� __ Phone. /S���J'�`�'- L,�J�
Designer Address:� � � � Zip: �J' ���
����'i' tJ�-,G[.V�
E-mail:
License Number: ������
Remarks:
Signature: `� Date: ����vZ`�'
j Original signature required on each submitted copy.
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Pe�►-t,t�s�l� R d
IN-GROUND DOSED-GRAVITY DISF'ERSAL AREA
Uniform Elevation Trenches with Quick4 Standard-UU Chambers
3-ft Trench (down-sizing credit}
� �
._'""'.,'" TYPICAL TRENCH
(ryP+caq
SC)IL CUVER CROSS SECTION VIEW
��" (Na Scale)
min.Vench
dep�h
(�YPlc�l) '. a '
- ..... ._.. ._ 'v . .._.. .. -.. '. . .�9.. '.
. . i. ' . .Q a.
�'�"'_ 34" Q
(�v����0 , ' , � Provide minimum 3 ft
� . � " separation between trenches.
Syst�m Elevation =� ft
(tYpical)
Quick4 Standard-W Obsorvation nipe
wl End Cap (Show locafiion of inlet/outlel pipe connection on plan view.) c�y�'��a�> TYPICAL TRENCH
— (rypical) Inslall pqr manuf�cturor's
��s<<�����ns. PLAN VIEW
(No Scal�)
�aR� ��,�;���r�mrw��'+R�ee.— � .._._ � �� � — — — -_ _._ — ��r_ __ � _ ._��,��r—Me�wa,ir.r�w+rrr��r�e�1
� p' � I wl�' I�I �A= 3.0 tt
p,��kw�VruMw+� .a;6r,aarJ (tYPic�l)
I�tlt�►�t M�b_h'i M N�1 K i�11:1I1�Ili1W� _ � ._. _. .� _. ,� r. � _..... _. � _. � _.. �. ._ _._ -- -- —
I �� � D
�..�-- ---- B — � fr --"'� G)
(typical) Quick4 Standard-W Chamber ('Tl
l�vn��,�i� c.�
INSTALL PER TRENCH: (�n�d�y��ret�ator sy5t�ms,�n�.) O
(nstall pursuant to m�inufaclurer's inslrudions.
�� Quick4 Std-W @ 20 fl'EIS/�lchamber= � ft' �
Ul
+ _,� Pairs of end caps @ 6 ft�EtSA/pair= _� ftZ
= Praposed EISA per trenc,h= .�,�.� ft' Required lnfiltration Area= ��flI Distribution Method:
�.��� �
x _,� trench�s = Proposed Total EISA= ��i r.� ft' ��br.�,-������`� _
E,$�T
PAGE40F5
GRAVITY-DOSED
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4'0 Venl Pipe
>70 ft iram
Buildirg EleWiml musl mmply wilh
12 Min.or 2A fl abwe SPS 316 and NEC 300
Esta6Fshed Flood Elevalion Wy�therproof Extend manhde riser as necessary.
(HWral) A�w� Junction Bo:�
IMPORTANT: ��� �`�`����A��
Anchor tank(s)as necessary � � �ry���
�—Conduil
pursuant to SPS 383.43(8x9) 4•htin.w 2o n a6ove
Estana�,ea Faod Eie.-auon
(hp�0
�Airtight Seal
Finished Grade
- Cw�VaM1e/
*a�Uscarmed
CAPACITIES @��gaUin y.. ,
' a
Depth(in) Volume(gal) W����
I
A � � *T , Min.Depth=��in
I � I �nPa�r�u�>
B 2.� 3� A i WatertightGaskel
�C� � , jI I
J1�. Alam� �����
D Q TB-�— ��_o„
[� c] PUMP-0FF
*Pump Tank Liquid Level=�in � � —�" ELEVATION= � ft
cne x
varva
° �„�,� INSIDE BOTTOM
Force Main Diameter=�`in s� ELEVATION= ��ft
Fotce Main Length=�ft 3�App�°�ed Beddirg Malenal Beneaih Tank
Imaortant:Bury force main below frost line or insulate
as necessary pursuant to SPS 382.30(11)(c),W.A.C.
[C]Total Dose Volume TDV = Z�gal/dose -�- Q� � ��j.3`� g q�, (��
�
(<02X design flow-NO DRAINBACK w/check vaNe)
Vertical Lift=��.ft
PUMP TANK SEPTIC TANK(S):
Volume= � � gal Total Volume= /,���> gal
Manufachuer. Cr/,P ��! Manufacturer(s): L����� rGl�
Pump Manufacturer: 2,cv�//,v�'
Install approved effiuent fitter at the septic tank outlet
Pump Model: li 3 ��a���mP�,�� immediately u�stream of the�ump tank iniet.
Controls/Alarm Manufacturer. �S J� l�h,�.-.,�i.� Filter Manufacturer: �
Q�-- ��6�_
Controis/Aalrm Modei: /�/ /,s9 1.Z�,�l..-�
Filter Model: /C7�p ��?2
Float switches containing mercury are prohibited.
�
�
� W PUMP PERFOR<<�ANCE CURVE
MODEL 151/152r153
so
14 45 753
72 40
I
35
� �� 152
� 3D
a
0 8 25 151
� �
t-
� g 20
15
4
id
2
5
0 � ,
10 20 3D a0 SD 60 70 SD 90 100
�ALLONS
LITERS 0 4D 3D 120 160 200 240 280 320 360
FLOW PER A1INUTE
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 inspedion and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersal Area Oaeratinq Limits:
Design Flow= y5—� gpd; BODs� 220 mgL''; TSS <_ 150 mgL''; FOG 5 30 mgL''
Insoection Checklist INSPECT EVERY 3 YEARS
c type of use
o age of system
o nuisance factors(r.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., distribution/drop boxes)
o neglect or improper use(i.e., exceeding design wpacitfes, prohibited adivities, etc.)
o exterrt of ponding in distribution cell prior to dosing
o dosing frregularities-if applicable(i.e., pump re-cycling,float switch settings, et¢)
o eledrical 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 surtace discharge of effluent or sewage back-up into struciure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tankls)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 local ordinance. Disposal of contents shall be pursuant to NR 113, Wsc.Admin. Code.
o Effiuent filterls)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: � lA ,/1 .�I"Y,�/� Phone: �LJ�'SJ''�S'�1o7 3
Local government unit: Phone: /�S �J3�'J�v�00
Local govemment unit address:�1,�� �/, �KL �9 �� ZIP: ✓ 4-CJ`G.�
Any defec[ive part of this system shall be repaired, replaced, or removed pursuant to SP�83.51 (1),Wisc. Admin.
Code. Repair or replacement of fai�ed or malfunctioning components shall comply with SPS 383,Wisc.Admin. Code.
No product for chemical or physical restoration of the P01NrS 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 dispersai 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.