HomeMy WebLinkAbout012-740-14-2420-SAN-2024-034 Department of Safety c°°"ry �
-�� � & Professional Services �
a' � Sanitary Permit Number be filled in by C
= Industry Services Division
.. . �oS � �1 3� ..Q'c
,
State Transaction Number O
Sanitary Permit Application �,
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �— �
is required prior to obiaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different tha�address)
the Department of Safety and Prolessional Services.Personal information you provide may be used for secondary � /_/�� � C�� /��
puzposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. fQ7 �'��
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
�
r� L- � 5 O -��o-��-:2 Y�-_o
Property wner's Mailing Address Property Location
�� Y� 1�lJ" � Gp�i�6et
City,State Zip Code Phone Number
'lna �(./�O/ ✓��W%, M/ �'/,, Section�
� �� L
IL Type of Building(check atl that appty) Lot# T N R E or
�'1 or 2 Family Dwelling-Number of Bedrooms � Subdivision Name
Block# '-'--
❑Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
8�c 3g��g-Z `]�,Townof_t�i n,-f��'
IiI.Type of POWTS Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A' �iNew S stem
y ❑ Replacement System ❑ Other Moditication to Existing System(expiain} ❑ Addirional Pretreatment Unit(explain)
/
B.
❑ Holding Tank �jfn-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(expiain)
� (conventional)
C• ❑ Renewal Before ❑ Revision ❑Change of Plumber ist Previous Permit Number and Date[ssued
❑ Transfer to New Owner
Expiration
IV.DispersaUTreatment Area and Tank Information: �-
Design Ftow(gpd) Design Soil Application Rate(gpd�'s� Dispersal Arca Required(s� Dispersat Area Proposed(s� Syst m Elevation �
OD . /ODO fiq'�:d
Capacity in "I'otal #of M ufacturer
Tank Information Gallons Gallons Units � a v '�'„ M N �
New Tanks Existing Tanks � c a� � y � � �
4 U v� v, v� w C7 0.�
Septic or Holding Tank w
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation otthe POWTS shown on the attached plans.
Plumber's Name(Print) Plumb 's Signature MP/MPRS Number Business Phone Numbe�
� �-~ : _ _ 9 o i - ���3
Plumbe s Address(Street,City,State,Zip Code)
/u T 1�—� �e�� cc�— 5�
VI.Cou /Department Use Only
� ed ❑Disappmved Permit I�ee Date Issued Issuing Agent Si�ature
❑Owner Given Reason for Denial $ r ��•� ��� ��� �� "-" �� ���~
Conditions of ApprovaUReasons for Disapproval �--�
�-- "", �� �q � .:��. 3�y'�y D _�c�_`� �� �
�.� � D
„ �.�-(��-�l
�;;.: ., �.�� w tr.....�� ..�'1�.< _ . .
JAN 2 5 2024
�o`i
CsT�-`� - b � s sAvvY�R cour�rr
ZONING ADAP,�f�!�STRATI�d
Attach to complete plans for the system and submit to the County only on paper not less Man 8 I/2 x 11 inches in si�e
NO RCFUNDS AFTER
SBD-6398(R.03/22) �$$l�E OF pER�T ������7 p
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
Owner Name(s):�jl�� � L(11�r� .JC1Y�(C�01/� Phone: - -
OwnerAddress: �03� �(�CL4��"��. �/,�GG��G�Y�. c�Z' Z�p: �����C�l
Project Address: ��� ��,�'lil f�lGClt� � �G���
Govt. Lot: r 1/4 of St��E1/4, Section�, T��N-R�E�or W �
Township: ��1���� County: �'L[.Ct(-1��
Project Parcel ID #: a�� " ��� r ��— o�� � �
Designer Information
Designer Name: �l..l(��1 �� Phone:�. �S—��- ` 7,�
Designer Address:`(�'J /� Z�P� � �� ��
u�����
E-mail:
License Number: ���5 ���
Remarks:
Signature•
� ----�_ Date: ��v���cZ�
inal signature required on each submitted copy.
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SY�T��L�-�YiS7la�r/ 93,Z6 �
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�' Ssptic T�ni<(s) Manufacturer;
� � ������l�� ���1�f�� �������'��.., 1���'e� �itJ I Y�
Uni�'orrn �fev�tian Tre��f��� with �2uick4� 5tand�rddUll +�har��er� ��
Sentlo 1'�nk(s) Valume(s):
. 3�ft Tre�ch (daw�n-�i�in�c� crer�i�) t � 5Q
J�.�....,., N�► .H.,,.,.,,......, ��I ,......,,,..,., A�� .�..f,�,.Y. 9al
Effluen Filtor Manufacturar;
I _- � �o �
�iffu�r►t f�llter Madel 9�; �
� — mhi, 12„
SQIL CpV�R (typlaaq
12,�
rnin, tranch
(YP'L'Q�U
. _ • " ' TYPICAL Th�ENCM
'T ' ��" � ''"" � ' CROSS SECTI4N VIEVV
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nva����� , , '� '° (Na Scal�)
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•� ' 4 V
' ' ' I�rovld� minimum 3 ft
Systom �.IQvatlon =, 5 , � ft soparation bntweon trenches.
ttYplc�l)
G1�dal<4 Standard-W
wl hnd oap 5how (nc�tiai7 of Ini�t / Qutlel i c coi�nectlon on plan viaw,) ��gtl(lyplcalj�p� TYpIC�L T�ENCI-)
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Insta�l por monulacluror'o PI..AN 1/I EW
Insfruntlons, A�
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' fj` �jI��(, �`ay�}� �' If �l � Ill�ji�l� i� ,l � � I r�1��1 �I , �� � A = 3,0 ft
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(typlcal)
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INSTAI.I� PER TREf�1CH; (typlcalj �
(mfd by Inflltr�tor Syslemo, Inn,) «.n
� � -4,,..�, Aulck4 Std-W @ 2p fk� ElSla/ch�mber = �;� �" �rietall pureuAnt to msnuf�alurar'� instruatians. �
A
+ �,....,„ Pairs of end caps @ 8��t� E1SA/palr = --� ftz
= Proposed EISA �aer trench = ,,�,�, ft� Requlrod InfUtration Area � � J {�� Distributian MetF�od:
x ,,,.�„ trench�s � propased T'otal EISA = � � � ¢ �_ (/�, //�/� - `1U' \
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PAGE 4 OF 4
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 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 Disaersai Area Oaeratinq Limits:
Design Fiow= 6 0!� gpd; BODS<_220 mgL"'; TSS 5150 mgL"'; FOG<_30 mgL�'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,eic.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,eic.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatrnent tank(s)and any dishibution 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 w lateral orifice plugging (measure lateral distal pressure—compare to design specfication)
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 tankfs)shail 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 shali be pursuant to NR 113,Wisc.Admin.Code.
o EfFluent filteNsl shail be inspected every 3 years and shall be deaned 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 locai government unit in accordance with
SPS 383.55�sc.Admin.Code. Report any component fallure or malfunction to:
Name of individual or company: , I Phone: �I S-5 S g-I 61'3
Local government unit: Phone:���'fQ����v`�vC�
Local govemment unit address: 1� (.L�zIP: ���✓
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 wiih 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 shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
a6andoned 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 shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
W1250—MR
TANK SPECIFICATIONS � o
o a
8�_8�� a
�
DIMENSIONS: � o
WALL: 2 7/16" °� a
4" CAST-A-SEAL 4" CAST-A-SEAL BOTTOM: 3"
COVER: 5� w
MANHOLE: 24" I.D. PRECAST CONCRETE RISER a
�� � HEIGHT: 64 1/2" �
�� �' :� � LENGTH: 8�-8" >
ii ��
ii , �� WiDTH: 7'-2" �
ii m'L�Q. � � �� BELOW INLET: 53"
� '� � "�y ' \�� LIQUID LEVEL: 47" �
`� i � � WEIGHT: 7,220 LBS. �
0
i� � � � u c°�i � E
�,�� �-- � � -'��� INLET AND OUTLET: =� �' o 0
��� FILTER OR ii� 4" CAST-A-SEAL BOOT OR EQUAL GASKET � m o �
��,,� BAFFLE /� � � w ;
�� INLET AND OUTLET BAFFLE AND FILTER: a a � w
��� ���' NISCONSIN, SEE DETAII $10 u�i o o �
----- (OTHER STATES SEE CHART) W a
�
LIQUID CAPACITY: 26.81 GAL/IN W �
TOP V1EW � �
HOLDING TANK: � � �p
OUTLET HOLE PLUGGED
ACTUAL CAPACITY: 1,340 GALLONS 0 � �
� � I
� �OADING DESIGN: 6'-0" UNSATURATED SOIL � N
a
� � M
a o TANK CAN BE USED AS: � I
� SEPTIC / HOLDING / PUMP OR SIPHON � 3 O
x o�
� COVER: MIX DESIGN #8 (NO FIBER) �
--- , �_ TANK: MIX DESIGN #10 (STRUCTURAL FIBER) � �
---- �° . ' � --- �
MLET - OUTLET CUSTOMIZED TANKS: 3
N i FOR CUSTOM TANKS CONTACT WIESER CONCRETE
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REVIEWED 8Y N v
� PUMP PAD REVIEW DATE 3 W
N
DRAWINGS SUBMITTED
SIDE VIEW FOR APPROVAL
APPROVED BY: SHEET N0.
APPROVAL DATE: � /
OF
PRODUCTS NEEDED BY: / �
TANKS ARE MANUfACTURED TO MEET OR EXCEED ASTM C-122� REOUIREMENTS