026-939-27-5502-SAN-2020-069Industry Services Division1400 E Washington AvcP.O. Box 7162Madison, WI53707-7162CountySanitary Permit Number (to be filled in by Co.)Iss.Sanitary Permit ApplicationState Transaction Numberto accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unitis required prior to obtaining a sanitary permit. Note: Application forms for state^wned POWTS are submitted tothe Department of Safety and Professional Services. Personal information you provide may be used for secondarypurposes in accordance with the Privacy Law, s. 15.04(l)(ml. Stats.Inject Address (if diSerent than mailing addre^ ^s£)L Application Information — Please Print All IpformationProperty Owner's Name-^c..5o,o LI KParcelProperty Owner's Mailing Address .Property LocationGovt. LotCity, StateS7b.o^ , L-L.>XZip Coden. Type of Building (check all that apply)1 or 2 Family Dwelling - Number of Bedrooms,aD Public/Commercial - Describe UseD State Owned - Describe UsePhone NumberVi.'A SectionavLot#Subdivision NameBlock#D City of.CSM Number ^ ~fD Village ofSrown of_m. Type of Permit: (Check only one box on line A. Complete line B If applicable)A.D Now SystemReplacement System0 Treatment/Holding Tank Replacement OnlyD Other Modification to Existing System (explain)B.D Permit RenewalBefore Expirationn Permit RevisionD Change of PlumberD Permit Transfer to NewOwnerList Previous Permit Number and Date IssuedIV. Type of POWTS System/Componcnt/Device: (Check all that apply^'Non-PrcBsurized In-Groiuid 0 Pressurized to-Ground D At-Grade D Mound > 24 in. of suiutble soil D Mound < 24 in. of suitable soilD Holding Tank D Other Dispersal Component (explain) DPreireatmeni Device (explain)V. Dlaperaal/Treatment Area Information:Design Flow (gpd)Design Soil Application Rate(gpdsl)Dispersal Area Required (sf)c^sDispersal Area Proposed (sf)System Elevationq i.oVI. Tank InfoCapacity inGallonsNew TasksExistzsg TasksTotalGallons#ofUnitsManuGaclurerIi8IIHi51E Ou•3OhSeptic or Holding Tank/ocoiOOODofuag ChAffibcTVII. Responsibility Statement- 1, the undersigned, assume respoaslblllty for Initallitlon of the POWTS shown on the attaebed plans.BPlumber's Name (Pontljerry Ru1<3 Excavating, LLCKumbqls Signature ,,PlurRUf^^AfldKJftSVi*. CJW.^&tf Zip Code)Stone L^ke, Wl 54876-«SrMP/MPRS Numberusiness Phone NumberVin, QjUttty/Departmeot Use Onlyin, Goutity/DepP UDisapprovedD Owner Given Reason for DenialPermit FeeS / 1.^^ ooDate UsiudS-A/'Issuing Agent SignatureDC. Conditions of Approval/Reasons for DisapprovalNO REFUNDS AFTERISSUE OF PERMITORIGINAL,n.-nm|,l««pl«ii« Oipth» tyntfm and tuhmillo the CouBtv oftlv on paper sot Itia tlian 8 l/t a tl iatlllM MAY 1 2 2020 PSBD-6398 (H 08/14)SAWYER COUNTYtONINQ ADMINISTRATION
PAGE 1 0F4in-Ground Gravity PlanIndex & Cover SheetComponent Alamia/ Oes^ Refe/enees:Version 2.0. SBD-10705-P (N.01/01, R. 10/12)Pg1of4Pg2of4Pg3of4Pg4of4index & Ck>v8r SheetPlot PlanDispersal Area Cross-Section & Plan ViewManagement PlanAttachments:Endosuras:POWTS Application for ReviewSoil Evaluation Report & Site MapProject Name /.DescriptionOwner Name(e): ^ L&cs,OwnerAddiesa; ISy"SS"lu A!Project Addreee:Govt Lot; ^I r1/4 ofPhone:.an:Towiwhlp: ^>o^joAPrriectParceilD*:,1/4, Section 3- 7 . N-R Enor WCounty: Soso->Designer InformationJerry Ruld Excavating, LLC phane* 1!^ 2.«-(WaoBOeurtyllWYA Phon*.PtttewrAddresi! SliinaLaka,VWl54a7B gp! SH'e^CsDesigner Name:.C.gA%.>rcrf V^c-f >UcenteNumben feS.Remarks:This tyace reserved for approval stamp.Signature:ra^ndoRN31iffif3&B7copy.Date:
CHECK BOX ABAPPUBMLE□ soil EVALUATIONSITEMAPPROJECT NAMEPROJECT ADDROS: .■CHECK BOX ABAPPUCWaS.1-o4ff40«•[If SYSTEM page 2 OFPLOT PLANHS'oDEnONROW:..QPDAMaehdcNan flow cataJtfoiw tor oamnwrelElplaM.iBmBmBMDMoipiieR Teja C/arJer'<ap^ ^ T.FTnwed 8*11*01 dwolebiix Q•iBtmivJMMOeoa8»oiwaprtit»Pipe MbIbiW / ASTMSiandinl (TMiloi 884.afr3 A 384^anowB—r. ri/c- ScAgs^Ce^ c/g?Fawemn: hJ I_ lUPOWAWT;Show greund atandon ccnloun at KttUe Mmato.WCv.r•ftSe_\ S!-7.75'Z H7.75-«>f\ ^rfepert^ Ut4i^&Di —
IN-GROUND GRAVITY DISPERSAL AREAUniform Elevation Trenches with Quick4 Standard-W Chambers3-ft Trench (down-sizing credit)SOIL COVERSe Tanl<(g) ManutetuferSeptic Tsnk(t) Vdumefa):EfflMM Filter ManiMuferEffluent Filler Model«A -ir«nln gfwdtphIfyfiletl)TYPICAL TRENCHCROSS SECTION VIEW(No Scale)Systam Eiavatlon^.(typical)Provida minimum 3 ftseparation Patwsen trenches.OulcM StanOard-WwfEnd Cap/— (typical)(Show location of Inlet I outlet pipe connection on plan view.)B = ft(typloBi)OtiswvsOcrPt*oyp*c«IntttUpftrmtfiumm/ ir*ms8m.IA = 3.0(IW"TYPICAL TRENCHPLAN VIEW(No Scale)INSTALL PER TRENCH:Quick4 Sld-W@ 20ff ElSA/ehamOer = 3.^0 ft>Pairs of and caps @ 6 ft* EISA/pair = ft'^Qulcli4 Standard-W Chairtber(typical)(mTil tiy Inlintilf l/ine In ]Inealpuunt ID iHBiiAcSneri hesuetlora.I Proposed EISA per trench!Required InfiitrBton Arean C>^{3 ffDistribution Method:, trenches = Proposed Total EISA =
FILE INFORMATIONPOWTS OWNER'S MANUAL & MANAGEMENT PLANSYSTEM SPEanCATlOIBPage.Tank Manufacturer□ NAPermit#I^Septlc □ Dose □ Hokflngvol. /CtPOgalDESIGN PARAMETERSTank Manufacturer□ NANumber of Bedrooms3□ NA□ S^c □ Dose □ Hokflngvol.galNumber of Public Facility UrtitsgNAEffluent Rltffl-Manufacture"□ NAEstimated (average) flow'Soogal/dayEffluent RIter Modd A ~/CODesign (peak) flow o (Estimated x 1.5)qal/davPump ManufacturergNAIn Situ Soil AppOcaUon Rateaal/dav/f^Pump ModelStandard Irrfluent/Effluent QualityMonthly average*PretreatmentUnitfiNAFats, ai& Grease (FOG)^OmgA.□ Sand/Gravd RItw□ Peat RIterBiochemical Oxygen Demand (BODs)£220mg/L□ NA□ Mechanical Aeration□ WetlandTotal Suspmded Solids (TSS)£150mg/L□ Disinfection□ OtherPretreated Efflumt QualityMonthly averageManufacturerBiochemical Oxygen Demand (BODs)S30 mgA.Dispersal Ceil(s)□ NATotal Suspmded Solids (TSS)£30mg/L^NA^ In-Grmrnd (gra\^)□ In-Ground (pressurized)Fecal Odlf«m (gecmietric mean)SIO^ cfu/IOOmI□ At-Grade□ MoundMaximum Effluent Particle Size*4 In dia.^NA□ Drip-Une□ Other:Other;□ NAOther□ NA*Value9 typical for domestic wastowatar and septic tank effluentOther□ NAMAINTENANCE SCHEDULEService EventService FrequencyInspect contflUon of tank(s)At least once ev«y:'-t □ monthte)<A Byear(s)(MaaAnumSyeare)□ NAPump out contents of tank(s)fiSTWhai oxnbined sludge and scum equals onethird ()§) of taik volume□ Whoi the high wat^ alami Is activated□ NAInspect dispersal c^(s)At least once every:o □month(s)^Syear(s)(Maximum 3 years)□ NAClean efflumt fitterAt least once ev«y:\ □month(s)1 B-year(s)□ NAInspect pump, pump controls & alarmAt least once every:□ monmfs)□ year(s)(g|>IARush latorals and (vessure testAt least once every:□ m(mth(8)□ year(s)Other:At least once every:□ mtMitiifs)□ vearfs)□ NAOther:□ NAMAINTENANCE INSTRUCTIONSInspections of tanks and dispersal cells sl^l be made by an Individual caning one of the follovring llcer^es or certifications: MasterPlumb«r; Meeto- Plumbw Restricted Sewer; POWTS Inspector; POWTS Maintains; Septage Swvldng Op^or (pumpo'). TankInspections must Include a visual Inspection of the tank(s) to Identify any mtesing or broken hardware, Identify any cracks or leaks,measure the volume of combined sludge and scum and a check for any back up or pondng of effluent on the ground surface. Thedisposal cell(s) ehaJI be visually Inspected to check the effluent levels in the obswvatlon pipes and to chsdt for any ponding of effluenton the ground surface. The ponding of eflluent on the ground surfffi» miy Indicate a falling oondtion and requires the immediatenotification of the local regulatory authority.When the combined accumulation of sludge and scum In any treatment tank equals one-third {\k) or more of the tank volume, the entirecontmts of the tank shall be removed by a Septage Savlcing Operator and disposed of In accordance with charter NR113, WIscondnAdministrative Code.All other services, Including but not limited to the servicing of effluent flltars, mechanical or pressurized components, pretreatmmt units,and any sovldng at Intervals of 2 months, shall be performed by a certified POWTS Malntalner.A savlce report shall fcte provided to the local regulatory authority within 10 (kiys of comi^etlon of any service evait.QMW (12A)2)
START UP AND OPERAHONFor new construction, prior to uso of the PCDWTS check treatmoit tank(8) for the presoice of painting (uoducts, solvmte or othwchemicale that may Impede the treatment process and/or damage the soil cBspersal cell(s). If htah concoitratlons are detected teve tiiecontents of the taiid<(s) ronoved Ijy a s^rtage servicing operator prior to use.System start up shall not octarr virtiai soil concBtlons are frozen at the infiltrative surface.outages pump tanks may fill above normal hlghwater levds. When powm- Is restored the excess wietewater wrillbe dlsmarged to the dispersal cel!(s) In one large dose and may ov^oad them resulting In the backup w surface cyschatge of effluentTo avoid this situation have the contents of the pump tank removed by a Septage Servldng Operator prior to restoring power to theeffluent pump or contact a Ptumtrw or POWTS Maintainer to assist In manudly opoetlng the pump controls to restore normal levelswitWn the pump tank.Do not drive or park v^lcles over tanks and dispersal cells. Do not drive or park over, or othowlse disturb or compact, the area wifflin15 feet down slope of any mound or at-grade soli absrxptlon area.^ItnlnaHon of the following from the wastewater stream may Improve the pwformance and prdor^ the life of the POWTS:^blotlcs; ba^ wipes; cigarette butts; condoms; cotton swabs; degreasers; dmtal floss; diapers; disinfectants; fat; foundation drainhult and vegetable pe^lngs; gasoline; grease; harblddes; meat scraps; medications; oil; paln^ products;pesticides; sanitary napkins; tampons; and water softener brine. . . i— ■» kABANDONMENTWhen the POWTC falls ancVor Is permanently taken out of service the following steps shall be takoi to Insure that the system Is prtmeiiyand safely abandoned In comirflance with chapter Comm 83.33, Wisconsin Ackninistrallve Code: /• All piping to tanks and |dts shall t)e disconnected and the atrandoned pipe openings sealed.• The contwits of all tanks and dts shall be removed and properly cDsposed of by a Septage Servicing Opaator.• Aftw pumping, all tanks and pits shall be excavated and removed or thdr covers removed and the void space filled with son.gravel or anothw ln«1 solid material.CONTINQENCYPLANIf the POWTS falte and cannot be repaired the following measures have been, or must be takoi, to [xovlde a code comfrifemtreplacement system:□ A suitabie replacement area has bear evaluated and may be utilized for the location of a r^rlacemort sdl abson^onsystOT. The replacement area should be protected from disturbance and compaction and should not be lnfrlng«l upon byrequire s^badw from existing and proposed structure, lot Hnes and w^ls. FaDure to protect the replacemoit area winresult In the need for a new soU and ^ evaluation to estattllsh a suitabie replacement area. Replacemott systems mustcomply with the rules In effect at that time.A euit^e replacement area Is not available due to setback andfor soil nmltallons. Barring advances In POWTS technologya hdding tank may be Installed as a last resort to r^Iace the failed POWTS.The site has not been evaluated to Identify a suitable replacemoit area. Upon fanure of the POWTS a soli and sitew^uatlon mi«t be pwfonned to locate a suitable r^lacement area. If no replacanent area Is available a holeflng tank maybe Installed as a last resort to replace the faned POWTS.Mound and at-grade sdl absorption systems may be reconstructed In place fdlowing removal of the biomat at theInfiltratlve surface. Reconstructions of such systems must comply with the rdes In effect at tint time.«WARNiNG»f OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFRCtENT OXYGEN. DO NOTtank UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF APERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLEADDITIONAL COMMENTSPOWTS INSTALLERNamePhone ^90- - "3. H.o°tPOWTS MAINTAINERNamePhone3EPTAGE SERViaNG OPERATOR tPUMPERIName £>-e-/c>T^oPhoneLOCAL REGULATORY AUTHORITYName ^CL 7"Phone -7/^- ^-Q 3^-M®niuelte and Wauahara County Zoning and Sanitation aganbiao in ocmpiianee with ohaptarComm83.22{2)(b){l)(d)&(f)and83.64<l), (2) a (3), Wlaconain Administrative Code. ^