HomeMy WebLinkAbout026-176-00-3404-SAN-2024-045 Department of Safety c°°"�' �"
0 - & Professional Services, ���y� �
$ Sanitary Permit Number(to be filled in by( �
Pg , Industry Services Division �
�S i � �-t L� �
,
Sanitary Permit Application State Transaction N^=r �
In accordance with SPS 38321(2),Wis.Adm Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtaining a sanitary permi[.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing atltlress�
the Department of Salcty and Professional Services.Pcrsonal information you provide may be used for secondary
purposes in accorJancc���ith thc Privacy I.a���.s. 15.04(1)(m),Stats. �
I.Application Information-Please Print All Information tl��Qr�
Property Oti ner's Name Y ����c-� .�,�-Q arcel#
�v�- e�e(o � Z-�-G `�� I 3 ��f m�- I 6.� Oo- 3 ys
Property Owner's Mailin Address Property Location
�� �d }( I L�s .
City.State , Zip Code Phone Number
�Y�� ��^�n.e � � /� �� (% �� 3 Y�' �Section Z � _
��v o
II.Type of Building(check all that apply) � Lot# T � N R � E or�
�l or 2 Family Dwelling-Number ofE3edrooms Subdivision Name ,,,,,�-.
sio�x# SK� -�- Poti,� � 13
❑Public/Commercial-Describe Use ---
❑City of
❑State Owned-Describe Use_ CSM Number ❑Village of
3 8/���� � `�7�� ,�To�,ot� S��� I�K�
IIL 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 licab .
A� ' ew System � Replacemen[System � Other Modification to Existing System(explain) �i Additional Pretreatment Unit(explain)
B� 'n Holding Tank �In-Ground -' At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type Iexplain)
(conventional)
C. I-1 Renewal Before ❑ Revision - Chanee of Plumber ❑ "I'ransfer to New Owner
List Previous Permit Number and Date Issued
F,xpiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow��pd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(st) System Elevation �
ys , � 7s� 77� a�• 7S`
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units D � o $ �
New Tanks Fzisting Tanks � o p; � � � ca c`�o
a. U in � v: ii. C7 !i.
SepticorHoldingTank /Q�V t�v0 � �/�tSt/
�
Dosin�Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility for instsllation of the POWTS shown on the attached plans.
Plumber�s Name(Prin[) Plumber's Signature MP/MPRS Number [3usiness Phone Number
� 1�.� S�l�� �fZ ls'�b�Z� 1�r-ss'� ,��ay
Plumber's A dress(Street Citv.State.Zip Code) I
����v �n/ M e���,� ,/' � S-��n c ��l�.-� �,.��� �'-I�7d
VI.Coun /Department Use Only
�Ap ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
� ❑Owner Given Reason for Denial $�w'� �I �': ?�'``+ ��'��-�t_('.<.c.�'-�s_ t-�-t�_'..^_t�
Conditions of Approval/Reasons for Disapproval
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r ��� � 3��.E,�a y ____�:; �
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' �" '�'� `� ``" `�` � � i s MAR 1 8 2024 '---�
C� l _�� ^ `� � ��, _ .. � ... .� ,r���=� ry� --
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Attach to complete plans for the system and submit ro the County only on paper not less than 8 v2 x 11 inches in size
sB�-639s�u.o3izz� Nd R�FUNDS AFTER ����,e:;
ISSUE OF PERMIT
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): �Y 9���,�,,,�1 L-L G Phone: - -
Owner Address: �s �oX �yY S�� ���^c w� Zip;-� 54�7,C
Project Address: M�Wt ��
Govt.Lot: 1/4 of 1/4,Section Z) ,T�N-R D`1 E❑or W�
Township: Ssn� �w�� County: 5���,1�
Project Parcel ID#: v2�_�'1b--oe - 34��
Designer Information
Designer Name: Qy'^� ������Z Phone: ��f- �Y�_ r�``/
DesignerAddress: I`��dw '"`�Tt�,�� f� S�'K ��t�c w� Zip: ,�yf17,6
E-mail:�T�ws�-1��1'�4 ��6= q�i���-��^ ��, , ...
License Number: �5�4�Z.� J
Remarks:
Signature: Date:
3- I� - 2`'�
Ori � I signature re ired on each submitted wpy.
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Septic T�nk(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA w•�St�
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) �00° 9a, 9a, gal gal
Eftluent Filter ManufacNrer
ooW lo,.k
� s2�
Effluent Filter Model#:
min.17'
(typlcel)
SOIL COVER
12•'
min.trench
�yaPen � •� TYPICAL TRENCH
< CROSS SECTION VIEW
�34� No Scale
(bvicai�,,� .. � �
Provide minimum 3 ft
System Elevation= ft separation belween trenches.
(typical)
Quick4 Standard-W
w/End Cap ObservationPipe TYPICAL TRENCH
(rypicap (Show location of inlet/outlet pipe connection on plan view.) (�yv��q
InstallpermanufacNrefs PLAN VIEW
instmctions.
(No Scale)
�Ts r*s..R, ,��� ---��-------��----�rset A�:R.xi +Ist:s �
o ' , � a A=3.0ft
���a�7tay__.iit'��`—---��--------��---=llt{111Yias� ...W.x�� (�YP�caq �
D
a= n �i m
(rypical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (�yP���� �
(mfd by Infiltrator Systems,Inc.) �
�(� �gv Install pursuant to manufacturers instructions. �
I Quick4 Std-W @ 20 fl�EISA/chamber= ft'
+ � Pairs of end caps @ 6 ft�EISA/pair= �° ft'
=Proposed EISA per trench= $� ft' Required Infiltration Area= 7�d ft' Distribution Method:
x 2 trenches =Proposed Total EISA= ��Z- ft' �r"`�f�
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 Dispersal Area Operatinq Limits:
Design Flow = �� gpd; BODS <_ 220 mgL"'; TSS <_ 150 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, 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 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 voiume 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(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:
� � c K��� Phone: � ��S �� —S y"y
Name of individual or company:� � —
' �rS-�3y- �2.%8
Local govemment unit: _ S hvY�r l�✓�i 2''���, Phone: _
Local government unit address: M�` i^ r�`u"� �"yw"G ZIP: ��� �`/3
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.
Continqe�cv 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.
Svstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33. Wisc. Admin. Code.