HomeMy WebLinkAbout014-842-15-1216-SAN-2024-090 U
-' Department of Safety c°°°ry �j
-5�,��-�. �-�" z
• = & Professional Services, -
� - Sanitary Permit Number(to be filled in by('�i
�= Industry Services Division �
.: (� S � �l� d s
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to thc appropriate govemmental unit '"-- �
is required prior to obtaining a sanitary perntit.Note:Application forms for state-0wned POWTS are submitted to Ptuject Address(if different than mailing acdr d
the Department ot�Safety and Professionai Services.Personal information you provide may be used for secondary I �!„�� � i i„ i (� 1�
purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �f' V L'�•'�.'� � 1
L Application Information—Please Print All Information
Property(hvner's Name Parcel#
� �, � � o��-���- 5� -r�� �
Property Owner's Madi g Ad ress Property Location
C�vt 6ot
City,State Zip Code Phone Number �/ �
�� �i � ' �t'7�'i�.,�Ye, Section___�_�-
II.T e of Buildin check all h t a 1 `� Lot#
YP g( PP Y) I � T / � N R �� E or
� or 2 Family Dwelling—Number of Bedrooms Subdivision Name
Block# '�—
❑Public/Commercial—Describe Gse
'� ❑City of
�Siate Owned—Describe Use_ CSM Number ❑Village of
��"� S/��� �� �r ��
�8 �y #s��a �;To�,of I_�-���
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.
�.New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �[n-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type f explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to New Owner
Expiration 03 � y�� `l I� (�3
IV.Dispersal/Treatment Area and Tank Information:
Design Plow(�d) Design Soi]Application Rate(gpd/sfl Dispersal Area Reqaired(st) Dispersal Arca Proposed(s� System Elevation �
�
/��� r � L Z, � �' < .� '
Capacity in Total #of Manufacturer
�
Tank Information Gallons Gallons Units � U � '�°„ ^
New Tanks Existing Tanks � o � � � p � �
a U v� � v� w C7 A..
Septic or Holding Tank r �<
,x- 6
Dosing Chamber
V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POW7'S shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Numbc•r
1 � '?!S��' 7
lumb 's Address(Street,Ciry,State,Zip Code)
1�5�1 N�-T � i � Q'-C' 1�� � t-�t �CQ-� 1.L1� j����
Vl.County/Department Use Only
Permit Fee Date lssued Issuing Agent SignaWre
❑Approved ❑Disapproved �9 ..
❑Owner Given Reason for Denial $ /��� �I����� � �"1 �""""�a"
Conditions of Approval/Reasons for Disapproval
��� �'`3 l?�\`I-,r "r �.._.
i""� � �I ;��, �,.; I � � �._..`�'1 \J � '; !
�W �� � �� � e�,�`� �te���,v�e� � �-� 'a4 �':,
G � -�
� 6
�'°� �oe �,t�� .-- �.S o 3 APR 2 6 2024 � .,
C5�- z y -�� �°� �� .. �_. _ �
� � � �
i aq� savw�� couivT�•
ZONING AQMINISTRAi 1:riJ
Attach to coroplete plans for the s�s�em and submit to the Coanty only on paper not less than 8 I2 x ll inches in size
NO R�FUND6 AFTER
SBD-6398(R.03/22) ISSUE OF F'�R�1A1T ���q(o
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
�;�i� G,,
Owner Name(s): (hr Y�G-P� �, , ��,�1�C1�� �.� ��4/��e►1�Phone: - -
Owner Address:�1� ��� �T���[.' �K-�'; t9.�� Z�P� 5y g`���
Project Address: ����/� � �G�.-�,��PU • �'����
Govt. Lot: SG C 1/4 of l�k� NGI/4, Section � `� , T�N-R�E Q or W�
Township: L,�n,roc�-�- County: ��L(,t'sU��
Project Parcel ID #: � ��I �- �S'y� � l � �-� �/�
Designer Information
Designer Name: �(,,��1 �.��.-�'�X Phone: S�- ��=l�
Designer Address:�Q�,�J/ hl�o�rv�.�.�liC�1`�G til� p��'!� l�rk• Z�P� 5 � 3
(,-�!�(,C��,�.��.6�`-'
E-maiL•
License Number: ���� C
Remarks:
_._;._�is,.; .._i��.4oc�. r:_�:,;;;
:at�all not be created
m accessory struc#ure�
�� � _ Date: ���3�'��:
Signature:
riginal signature required on each submitted copy.
�,�.�c: �
I�e;�� E. � M �c�4e� E . ���va.r� I� F l�,�u►+� 4�r- Ca. Leinrao� Tw �
t�0 Bk. Z43"�- / `1 /
��r.� o t�4 —£3�-t Z-- �S— 1 Z.�(o
�r-��t-� e �4ke�c,� � S`i 8P�? s�..��N�, N w J N� � i s -r �c Z� rz o e w
�S���c: 1 3(o'i Z i.l 1�4(,��.� �-I L.o'� ► Z CSF�( l$/-T y � S�l t z
J��l�y �d
��Sa
Z (�o� l 2
N
�
M SGa�e (���{b
� —
� �'I . .o :e a. yo
��bitabl� L�vfng are::
.hall not be createc� � ►���L s:-�t �v CoK-E���s
� ,:-•,.<�cCr.r+, ctr°���fi�;�
c: /�
� �jNtD6 �a'E'+,0►41 O} Cptrtelr-
�. I'�4CT4� ��aS���as
�yrc��/s-E'a�.gc � 8 �. R4.3(�
I � �
n�ro�vSP�. �� Z. �Ic(.Z(o
3. �4.oq'
� Pro� b�� ❑ ° � ,Z So.�sr s�.ej. 9b'IS�
•
�rati.ge 96.5 — �l�'�
$M 100 :ip
�
� , ' -F n e w
�,� 4 bd d ►- � � s�u£ Lo�4�,�a� o
�
3 y 4 l'! � gQ��t�S�trra�C ��d1 �(.6��kn
.S'
v+ .
� Z
��,� f
� �
� �
� �
�} �}`O �
� _ J �
�S, ''
0
'� �1 V"�I'�,����!9.aI +.71,ia'y 1I f 1 Y I..B��f�M'ti���, /"'b,N'��:� /L / Septfa T�nlc{a)Manufaaturer;
�FP 4�k��ry �
�..�I"61�'C,)fl�"6 ���'l/�tlC�f�i T�"@P1(��'IG� WI��"1 l�I.,I�CEC�� r��c'1i1(��p"t���/ �:�"I�PYI��f�S saptia7'ani<(s)Valurne(s):
���� ��'G�1Ch (C�CC�IIUY'���IZIB�� �6"�0�&1;� ���� ,�..�,....�.. �a� � g�� ....,�.�.,,gal
�ffluent�Iltor Menufaaturer;
� � �
I w� . .'
� �filunnt Fllter Madal��. ����,N„�,,,,�
—�In,12„
. sai�.cov�r� �yr�Gpt�
- 17."
min,lr�noh
dopih
c�vp�apu ��: y'' TYpICAL. TREIVCN
� ' ' � '' ' '''��'a�'� C{�OSS �uECTIQN VIEUV '
, ,
, .
. , ,
�. - aa°--�-- ( � �� �
r (typlcaq :'n� 4 tl , � ��O u�C�IG'�
•� ' q V
• � � ,;� I�rovldA minimum 3 ft
Syste��t �I�vatian =�:,�;,:�'fk son�ratlon bakwaei7 ti•onohos,
(typlc�i)
C1u(cic4 Standard-W
W��n� ��p (Sl�ow ina�tian df inlet/outlet pine c�nr�ootlon on nl�n viow,) p���(tynicij��'0 r�rpicn,� r�cr�r�a
(tY�loal)
Instali por manu(aoluror'a P�,�(v V��W
Inslrucflana,
(No Scale}
�-� � ,,;� _._. ^ __.. �... _. _._. _._. _ __.. ._.. _. �./ --- �-- , �';�!;����
, � ��`���'� � /� ;�',�'��q��;���.'�k���h �
�� � � ��� �� � �� � �� ( �I,i,lr, i � r � � r�. i
t,����7�`,��d�� �� ��;'��'i�ir�'� �!IaN fl�ll�111,II��I��II�,r��4�i�+(�����,r������'���,;� A= 3,p ft
I_..... ._.._ ...... _._. ..._.. ..._. ...._. __., ..... .,�.. .._. ,..... .,.... ..., .,..,» .._.. .�..w ..... ._.. ..... � '�!'t�� ,.s��i:r�s��`wcl�,���V�ll����,3����:��'�tG��i;�r.�l�� �lypl pl) �
�`�'�- -... .��-. _. __ ____ ..___ �_ __ ._I �
� a = �...,.. �� I r�r�r
��yp����� Qulcf<4 8t�ndord-W Chamber G�
INSTAI.L. PEI� TR�NCH; (typlaal} �
(mfd by Inflitr:atar 6ystoms,Ina,� .•�•�
- ,,,,, �,,,,.,.,�., pufok4 Std-W �ia Zp f� �ISI�/chambar= .�� fk` Ingtc�ll pursuAnl to manu(aalurer'�InstrucNone, �
•h � Pairs of errd caps (a7 6`��t'�ISA/pair� w� ft�
� Prapased EISA per trench= �°�"��„"�,,,�„ ft' IZequired Inflltr�tinr�Area= �,�,�� �t� Distributi�n Met�torl:
,
x „�2,��„ trenches = Propas�r� Tpfial �ISA = �5,Z, �2 ,�,��,,,/ ,�z,,�,����"�
�
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 pertormed by a registered POWfS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dis�ersal Area Operatinq Limits:
Design Flow= /�l`� 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,etc.)
o mechanical maifunction(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 negiect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o extent of ponding in disfibution celt priorto 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 Seatic and dose tank(s1 shall be pumped by a ceRified 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,Wisc.Admin.Code. _
o Effluent filter(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 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 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: ���,� �y'p U.f U� Phone:����5 0 ��G'J:3
Local government unit � � ' Phone: �I�7"V/�7����"✓�
Local government unit address:�m(�IY�, ,]( �(di, / �.�, ZIP: J`L 7
Any defective part of this system shail 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.
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 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.