HomeMy WebLinkAbout002-840-18-5403-SAN-2024-051 _ '' Department of Safety c°°°ry � �
• _ & Professional Services, , �
- S' Sanitary Permit Number to be filled in by�
= Industry Services Division
(� sl ��l� �'
. ,
Sanitary Permit Application 5[ate Transaction Number
_ �
In acwrdance with SPS 383.21(2),Wis_Adm.Code,submission of this form to the appropriate govemmental unit �-
is required prior to obtaining a sanitary pemut.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing address)
the Department oC Safcty and Professional Services.Personal information you provide may be used for secondary /„7C� � N(�/•-W`� �,,
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �V � '�
I.Application Information-Please Print All InCormation
Property Owner's Name Parcel#
a,�l � ���rm Tru..s�- d�a-�Ya-iS--s�o3
Property Owner's Mailing Address Property Location
Pa �3 !o Go�t y
City,State 'Lip Code Phone Number
� �7 wC I ' 1 37 S��a V " �� � `� i"�� � �('Section � �
II.Type of Building(check all that apply) `� Lot# T �0 N R�E or
�1 or 2 Family Clwelling-Number ofBedrooms 7 Subdivision Namc
F31ock# '�'
❑Public/Commercial-Describe Use ��
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
� �Town of�c5 �-LCJ�^�
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.)
A' ❑ New S stem Re lacement S stem
y. � p y ❑ Other Modification to Existing System(explain) ❑ Addiriona]Pretreatment Unit(explain)
B' ❑ Mound ❑ Individual Site Desi ❑ Other T e ez lain)
❑ Holdin�;'Cank ,�In-Ground ❑ At-Grade gn yp ( p
(conventional)
C• ❑ Renewa.l Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration �j�,v�� �
iV.Dispersal/'I'reatment Area and Tank Information:
Design Flow(gpd) Design Soil�\pplication Rate(gpd/s� Dispersal Area Required(s� Dispersal Arca Proposed(s� System Elevation
s-- �c� � � � I
Capacity in 'otal #of anufacturcr
Tank Information Gallons Gallons Units p � o 'd„ �
New Tanks Ezisang'Panks � o � � � p �o �
a U �n �, rn u, C7 f�.
Septic or Holding Tank � �,.�- / ,` _ G �,�, �`
v
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW'PS shown on the attached plans.
Plumber's Name I:Print) Plu r' Signature MP/MPRS Number Business Phone Number
___._.�— 9�` ol 7�5���
Plumber Address(Street,City,State,Zip Code)
lc�5��n.IT �• . � �
VI.Coun /Department Use Only
v ❑Disapproved Permit Fee Date Issued lssuing Agent Signature
Y�/" ❑Owner Given Reason for Denial � `w`� �'`��'�`�� �K����� '" ^���
Conditions of A.pprovaUReasons for Disapproval - � 1��j r`,r;--�,
�t �''"'' � °�' L � �>� :? � � �,'.
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ZOl�ING ADM(Ni5'i F�,��i:,J�
Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 x 11 inches in size
SBD-6398(R.(13/22) NO REFUNDSAFTER �2�`��
13SUE OF PERMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manua/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 Pian
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Ptan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): �1�11e �� /'y►,�'�tJ� � ►r(,(,S-{" Phone: �o�✓O-,3ilD -g�
Owner Address:�� ,�(�L ��/O � 7'/U Zip: ����'a
Project Address: $'(07�1 N. I�l�n,u�s � � � t � U�
Govt. Lot: y 1/4 of 1/4, Section � g , T �O N-R �f E�or W �
Township: I�R��S.5 �,CLK.� County: s�,rl,/��
Project Parcel ID#: dd oZ " 8"�((� �� � '� �J���
Designer Information
Designer Name: �1�J� Phone:�j�-Ci��`�73
Designer Address: (� /`I� ZiP: 5��3
u�t'/ L u1.�.
E-maiL-
License Number: ��/ ��� �
Remarks:
Signature: Date: 3`'�� �`�
�Ori nal signature required on each submitted copy.
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lJni��rm �I�vatiaa� Tren�F��s �ith t��aPGk4� 5fi�n��rdWU10 �h�rrik��r� �
Septla r�nic(s)Valume(e):
. 3�ft �"rer�ch (dowr�-�i�i�� crer�6�)
-�9e� .�-........,. gai �.,_,..�, Ap� ..�...,�,9al
�ffluent Filter Manufaciurer;
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SOIL CQV�fa t Yplaal) �
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min,Irench
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. _ � A TYPIGAL, T'REIVCM
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Systam �.Iov�tlon =�� ft sop�ratlon batwaen tronches.
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w/�nd Cap 5how looaklan of Inl�t/outlet t�e aonriocllon on lan vlaw, p�An��atlon nlpo
(�vp�o��) � �i n ) c�vn�C��� T'YPICA�L. TF��NG!-I
�nstoN p�r manu�ac�uror'o pl�q� VIEW
Instruaflons,
(No Scale}
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µr ��YPlcai)
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INSTAL.L. PEI� TRENCH; (typ���i) �
(mfd by InflllratorSystems,Ino.) ,.,r.'
� G�uick4 Std-W @ 20 f� E15/�/chamber= ,�S,��a� ft� Inefall pureuAnt to menuf�alurer's instruatione. �
� �.„.��, P�irs of end caps @ 8'�tx EfSA/palr� _��„ ��2
=Proposed E15A ner trench = � � ft" Requlred Infiltration Area=/� / {��
-�..Z..m. Distributian Method:
x �„ trenchos � Propas�cl Tofi�l EISA = �%,,��ft2 ,�-��y�,, ,, �
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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 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 Dispersai Area Oaeratinq Limits:
Design Flow= �S C� gpd; BODS<_220 mgL"'; TSS<_150 mgL''; FOG<_30 mgL"'
Insaection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanical maifunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrasion,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,prohi6ited adivities,etc.)
o extent of ponding in disfibution cell priorto dosing
o dosing irtegularities-if applicable(i.e.,pump re-cyciing,float switch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution laterai or lateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surtace discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Seotic and dose tanklsl shall be pumped by a ceRfied 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 Wnk(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code. -
o Effluent fiiter(sl 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 wiii always be greater than 12
months.
System maintenance reports shail be submitted to the proper locai govemment unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individuai or company��Q,/1�)`�(�lG� Phone:��5�S�—/+���7
Local govemment unit: Phone:�LS—(�jJ3�U aYP18
Local government unit address: U � ,SU,G 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 with SPS 383,Wisc.Admin_Code.
No product for chemical or physicai restoration of the POWTS may be used unless approved by the department in
accordance wfth 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
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.