HomeMy WebLinkAbout002-940-15-2304-SAN-2024-099 "�="����� Industry Serviccs Division ���«��n' � �'
-���p 4822 Madison Yards Way� � �
- _ t - Madison.WI 53705 Sanitary Perniit Ni mber(to be filled in by°C
ps P.O. Box 7302 �
Madison.WI 5302 �p 5 � � ��`{ �
Sanitary Permit Application State Transaction Number 'O
hi accordanee with SPS 383.21(2).Wis.Adm.Code,submission of this fomi to the appropriate govemmental unit �
is required prior to obtaining a sanitary pennit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ad...___,
thc Department of Safety and Professional Services. Pcrsunal infi�rmation you provide may be used for secondary
purposes in accordance�sith the Privac��I.a«�,s. I S.Od(1)(m).Stats. ����
1.Application Information-Please Print All Information
�ertv O er's N•me Parcel#
°� � �t �,� � � 0�2- �d .,�s_ �3d�
Property Owner's Mailing Address Property Location
8 1 � � ��,�� � . Govt.Lot
C�tv State "LipCode hon Number ��
� W= S�1$t--��3 ��S '��`����a ��Q, 111 11� ��. s��r;�„
I1.Typ of Building(check all that apply) � Lot# � T �� N K 6 G o W
f� 1 or 2 Family�Dwelling-Number ofBedrooms Subdivision Namc
Block#
❑Public/Commercial-Describe Use
—� ❑City of
❑State O���ned-Describe Use CSM Number ❑ Villaee of
����� ����D� ��foti�nof � �--
llL 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.
❑ Nc��Sy�stem Replacement System ❑ Other Moditication to f�:!:isung S}�stem(e�plain) ❑ Additional Pretreamlent Unit(explain)
B' ❑ Holding Tank �'In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Desi n
g ❑Other Type(explain)
(conventional)
C• ❑ Rene�val Before ❑ Change of Plumber List Previous Permit Number and Date Is u�e� ���J
❑ Revision ❑ Transfer ro New Owner � b
Expiration 0�- ��� Y��O O�
S��o �
IV.Dispersal/Treatment Area and Tank Information:
Desien Flo���(gpd) Design Soil Application Rate(gpd/st) Dispe I nrca Required(st) Dispersal nrea Proposed(sl) Sy�r�^,�������'��p
5 0 ,� ��'13 �y 3 1^n�,.=70 `� 1 �'o ��
Capacity in Total #of Manufacturer
� �
Tank Information Gallons Gallons Units p � v '� �
CO D U f
New Tanks Exis�ing Tanks ` _ � ` � a c� ;y
a. U ✓; � ;n [r. :7 G.
Septic or Holding Tank b b� �/�
Dosing Chamber
V.Responsibility Statement- 1,the undersigned,assume responsibility for ins Ilation of'the POV1'TS shown on the attached plans.
Plumbe � Name(Print) ) Plumber�s S� a h1P/MPRS Number Business Phone Numbe
`� �j� :�.3rJ� 3.� 'IS C��! t,� 70
�,,'��' ;nb�►lD �/��oc
Plumber's Address(Street City.State. ip Co e)
1(�2� �3 S� v�; S��l��3
VL C unty/Department Use O y
Permit Fee I)ate Issucd Issuma��gent Sienature
�ved ❑Disapproved � - � �
� �� $�OD."' �s ��-��y ��,�,!,����.{-j-z�,2�.�-
❑O�cner Given Reason for Denial
Conditions of ApprovaUReasons for Disapproval
f���a�� �
� � � , � �t���l��c� t z '��
� S a �����
L � �r��� ��i�� �ate_ �� y _ � ,�
�
:hk# 5 Gi o _ ._ _ MAY 0 6 2D24 �---
G�� 2-� � � ( � *++ ���_�_.�....,_ SAWYE�i G J t!;'. ♦`�f.
;� Y'-t�.,.� ADMI�ilS"i�'itvi 31::i�
Attach to complete plans for the system and submit to the Cuuoty only on paper not less than 8 t/2 x ri inches in size
ss�-63ys�R.o2iz2� NO REFUND6 AFTER
ISS�UE OF PERMIT �3 � � }
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): Qa�cl� a' � ��� Phone��S �3 `1 _ a�--3�
Owner Address: �6 � d � � c�'�� 1�1 Z�p; 54848�i
Project Address: �� 1'`��..,
Govt. Lot: W 1/4 of �� 1/4, Section � , Ty� N-R�_E ❑ or W �
Township: �3'�a.c.. County: S
ProjectParcellD #: d �� �y'0 �s �� �
Designer Information
� � � _ ) 7 �
Designer Name: �� Md�� v '� Phone:l S _ � 3 �
Designer Address: � ` �� G3 w • Zip: Sy $� 3
,
E-mail: � S�oL � . , ;:��, .,,.«t� ,��,t� ���:�+ <<,� , �.�.�� �
License Number: � � b
Remarks:
Signature: Date:
S � z, l
Original signature quired on each submitted copy.
(�f.C�6�1 p�r--� �Q'(
�7 (7 } ��
�U.U�� �-� L�4� R`�. � f eGbjCcC�� s�w��r l�/ C74S5 �...a.���`��_
g 1 0 d r J E-Ec�.w I� }{�U�h �. � s
� �tn� : ooL—. �i�C�— ds�_ Z3dy
I-��.��Q..� �, t,�r s`-E 8`+3 . sw J r�f w � �s Z-- �v r..7 R.0 4 c.�
� ( S- �3`C_�Z3 0. La-� �-f Cs v( �ZZ�z�ro �
�zl�
{,3 z.��
i
, �
�' -�' l t5 �� �
. — _ ,_,_, ;
_£Y,Sqs-�ew. �
�`,� ``� V � � Q�,
• D �a�dG T .
�
�x
� ,p.
�ti �/? � —�. P
� detF`- SN1toa 2
e
3 b� 3
t�
W
_ g�� gQ,�� -
,u�e�� -
a �-�..
� �
� � _
� ��� $[��e I� �FO� N
tlo� ,
� e te � yo yo
L�-�} }9.�fl a�.
� 87a t t,/ � _ - .
_.—:3�. � _s�
�^� ��GK� . �. ...--.-t'ZCieal;.C^ .__�CLL1Gv�_�L�.�... . .
� � ' .' -_-..__.-`---•--�----._,_ ..
� �!'LG�D
��.s� o� cn�.�L�la�- •b � �'x�`a�
. k _. _ ...e�S��--"'�
B t, a S��aS` � ....
Z• �6.sS ` � � �� !J 'r�
3. �i b.�' . _ D
Z Sa�ls,s�s�,��. �L. 43` MAY 0 7 2fl24
L��.�.�e ��'— �3.zs'� SA1fiFFYERCOUNTY
� �y� •5"1� Ov'���-f' �6,2$` ZONING ADMINlSTRATION
Septic Tank(s)Manufxturec
IN-GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard-W Chambers � SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) I-1Doo -
gal gal gal gal
Effluent Fil�er Manufacturer:
� S�S
Effluent Filter Model#�
min iz
SOIL COVER (rypicaq
,p,
m�n.trencn
tlepth
«vo��n � •� TYPICAL TRENCH
a CROSS SECTION VIEW
r 3a•
�ryp;�e,� � � � .. (No Scale)
•' � �'a Provide minimum 3 ft
System Elevation= 1 3 ft separation belween lrenches.
(rypical)
Quick4 Standard-W
w/End Cap ObservationPipe TypICAL TRENCH
(rypical) (Show location of inlet/outlet pipe connection on plan view.) IryP���O
i�scau Pe�ma��ra�m�ers PLAN VIEW
��"�"�°�s (No Scale)
� �,------��-------��--------- —� 1
I ;: ,� a=s.on
� .�... .��-- � ��vP���� �
-- -----��-------��---- ----- y
a= +7b� n -I m
(rypical) Quick4 Standard-W Chamber W
INSTALL PERTRENCH: (typicap Q
(mfd by InfiltratorSystems,Inc.) �
l� 3Y i�s�uP��s�a��coma��ra�n,�ers��srN�no�s �
Quick4 Std-W @ 20 fl�EISNchamber= � ft'
+ � Pairs of end caps @ 6 ft`EISA/pair= �� ft` �� I
=Proposed EISA per trench= 3 S ft' Required Infiltretion Area=� ft' Distribution Method:
x a` trenches=Proposed Total EISA= �n` g��
�SET
��Y
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 Dispersal Area Operating Limits:
Design Flow= _1S� gpd; BODS <_ 220 mgL"�; TSS <_ 150 mgL-'; FOG <_ 30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o rype 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 ta dosing
o dosing irregularities - if applicable (i.e., pump re-cyding, 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 W is.
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 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: `� ' So�"' �\ ��""" k� �L� Pnone: � �5 63� 1 61� _
� Local government unit: S�'^�"�� � �-�"`��1 Phone�s' 6 3� �� _
Local government unit address: I�o(O/�'�a,l� �1� , }{qy�^,c,���' S�{gY 3 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.
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.