014-942-35-3115-SAN-2022-064 � ` Industry Services Division County �
, �1A22 Madison Yards Way S8Wy2f �
- _' - Madison,WI�370� Sanitary Permit Number(to be filled in by Co.)
= P.O.Box 7302 1
Madison,WI�3707 �Q 3� U� � ^`
� "
Sanitary Permit Application State Transaction Nwnber N
� �
In accordance with SPS 38321(2),Wis Adm Code,submission ofthis form to the appropriate govemmental unit ('ti
is required prior to obtaining a sanitary permit.Note Application forms for state-o�med POWTS are submitted to Project Address(if different than mailing address' �J
the Department of Safety and Professional Services Personal mformation you provide may be used for secondary 12173N Wa ner Cir. Ha ard �
purposes in accordance with the Privacy Law,s. 15-Od(1)(m),Stats. 9 � � �
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
William H & Jane A Gross Family Trust 01 49423531 1 5
PropeRy Owner's Mailing Address PropeRy Location
PO Box 246 ���,,P,'��'�
City,State Zip Code Phone Number
Kansasville, WI 53139 715-634-3165 "E �%.SW �%, Section 35
IL Type of Building(check all that apply) Lot# T 42 � R 07 E or�'v
�Ior2FamilyDwelling-NumberofBedrooms 2 � SubdivisionName
Block# —
�Public/Commercial-Describe Use �
�City of
�State Owned-Describe Use CSM Number illage of
_ �Town of Lenroot
IIL Type of POV1'TS Permil:(Check either"New"or"Replacement"and other applicable on line.1. Check one box on line B.Complete line C if
a licable.)
1
�I�iew System �eplacement System � ther b�lodification to Exishng System(explain) �Additional Pretreatment Unit(explain)
LJ d Pump Tank to Existing Holding Tank
B' �Holding Tank �In-Ground �At-Grade �Mound Individual Site Design Other Type(explain)
(conve�tional)
C. �Renewal Before �Revision ❑Chanee of Plumber �ransfer to New O�vner List Previous Permit Number and Date Issued
EYpiration ���' �Y� � �� �S �
1V.DispersaVTreatment Area and Tank Information:
DesiQn Flo���(epd) Desian Soil Application Rate(gpd/s� Dispersal Area Required(st� Dispersal Area Proposcd(st� Scstem Eleva[ion
300 0.6 500 500 97.50
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � v �„ �
tizw'Canlis E�isting Tanl:s "` c � ` � � � �
c �
a U rn h v� i� U c
Szptic or Holdine Tank 2�0� 2��� 1 Rasmussen � �
Dosing Chamber 750 75� 1 Wieser � � � �
V.Responsibilit}'Statement- [,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber�s Sienatur �r MP/MPRS Number Business Phone Numbcr
�,.�:..�_,._
Jason Kuettel -:::.:��; 675751 715-798-3355
Plumber's,4ddress(Street,City,State,Zip Code)
PO Box 66 Cable, WI 54821
VI.Coun /Department Use Only
S' Permit Fee Date Issued Issuiny Agent Signature
�Ap ed ❑Disapproved ,� ✓
�yV ❑ONner Given Reason for Denial �Y�.oO y �� f�` �',��.��/Wj
Conditions of Approval/Reasons for Disappro�al `���,�
��. � ��i�����.��p,,1
�� CST �a ^ Q� ?, MAY 0 2 2022
U
�
�
Q
SAb'VYER COUN�
ING ADM�N�STRATtON
Attach to complete plans for the s�'stem and suUmit to the Counh�only on paper not less than R 1/2 x 1I inches in size
SBD-6398(R.02/22) NO REFUNDS AFTER
tSSUE OF PERMIT
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan .
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)_. .
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
William & Jane Gross Family Trust - 2 Bed Lift
Owner Name(s): William H & Jane A Gross Family Trust phone: �15 _634 _3165
Owner Address: PO Box 246 Kansasville, WI Zip: 53139
Project Address: 12173N Wagner Cir. Hayward, WI
Govt. Lot: NE _1/4 of SW 1/4, Section 35 , T 42 N-R07 E ❑or W❑✓
Township: Lenroot County: Sawyer
Project Parcel ID #: 014942353115
Designer Information
Designer Name: Jason Kuettel Phone: 715 _798 _3355
Designer Address: PO Box 66 Cable, WI Z�p; 54821
E-mail: Jeff@andryras.com
License Number: 675751
Remarks:
Signature: � Date: �z:./z� � Z
Original � n ure reqwred on each submitted copy. —�
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IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
Imin.12"
Geotextile � «,P;�,� TYPICAL TRENCH
Cover
SOILCOVER CROSS SECTION VIEW
12• � (No Scale)
min.trench ' ; . OBSERVATION PIPE DETAIL
depth L ,�•' • (No Scale)
�tYPical) —j� — —„: .'::'':` Screw-Type or •
/ Slip Cap(loose) W •W�• Finished Grade
(mulched&seeded)
• n..
97.5 �• � • 4"0 PVC Pipe •'�� Topsail Cover
System Elevation= ft. � , m;�.i root
�t ICaI Provide minimum 3 ft Top oi pipe to terminate � �
yP � ' at or above finished grede •
separation between trenches.
�a�,ia•�-,i�.�x s^sbts
@ 90 apart
i*
TYPICAL TRENCH (Show location of inlet/outlet pipe connection on plan view.) Anchoring Device Infiltration
Surface
PLAN VIEW
(No Scale) 4��� Observation pipe shall be installed
at jundion between two units. 1 Q �
Perforated Lateral Observation Pipe
(typical) (typical) (typical)
--- - - -- ��--- - - - - - ------- - - - -
r-- - - - - - �
� =__=__ _______ _-___ __ ___ _______ ________ � A= 3.0 ft D
�----- - - - - -- -- - -��- -- - -- - - - - - - - - --- - J �tYPical) U�
r- B = 50 ft �; m
(typical) W
INSTALL PER TRENCH: EZ1203H Bundle Q
(typical) T�
5 10-ft bundles @ 50 fi� EISA/unit=250 ftZ (mfd by Infiltrator Systems,Inc.) (,j�
Install pursuant to manufacturers instructions.
+ 5-ft bundles @ 25 f� EISA/unit= ftZ
= Proposed EISA per trench= 250 ft2 Required Infiltration Area= 500 ftZ Distribution Method:
x 2 trenches = Proposed Total EISA= 500 ft2 branched manifold
RESET
PAGE40F4
In-ground Dosed-Gravity Management Plan �
IMPORTANT:
The owner of this in-ground dosed-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 Oqeratinq Limits:
Design Flow= 300 gpd; BODS 5 220 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 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(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:
Name of individual or company: AIICIC�/ RaSCTIUSS@Il 8c SOC1S, I►1C Phone: 715-798-3355
Local government unit: SaWy@I" COUllty ZOtllflg Phone: 715-634-8288
Local government unit address: 1061 O Malll St. #49 H8yWa1'd, WI Z1P: 54843
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.
Continqency 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.
PAGE50F6
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4"0 Vent Pipe
>10 ft from
Building ElecUical must comply with
12"Min.or 2.0 ft above SPS 316 and NEC 300
Established Flood Elevation Weatherproof Extend manhole riser as necessary.
(typical) Junction Box
Approved Approved Locking Manhole
IMPORTANT: VentCap with Warning LabelAttached
Anchor tank(s)as necessary � (typical)
�Conduil
pursuant to SPS 383.43(8)(g) a��Min.or 2.0 ft above
Established Flood Elevation
(rypical)
�Airtighl Seal
Finished Grade �
�uick Disconnect
� 18"Min.
CAPACITIES @ 20.28 gal/in �:� � . y ..�� � � � � (typical)
� Q . . , �
Depth(in) Volume (gal)
A 23.7 480 'k
Weep •�Approved Joints with
Hole Approved Pipe 3 ft onlo
B 2.� 40.56 q il Solid Ground
� (typical)
[C] 2.3 46.64 =
Alarm
D 12 243.36 B I��_o�
* 40 f [+] �_off • EL VATOION = ft
Pump 87 7
Pump Tank Liquid Level = in � �
�
° INSIDE BOTTOM
Force Main Diameter = 2 in Concrete
� B�°�k ELEVATION = 86•7 ft
. . . .•. - : .. �
Force Main Length = $� ft 3"Approved Bedding Material Beneath Tank
Vertical Head = ��•$ ft
Force Main Void Volume = 13.04 gal �
+ Min. Supply Head = Np` ft
[C] Total Dose Volume TDV = 50 gal/dose �
+ FM Friction Loss = 2•64 ft
(5X total lateral void volume<TDV<0.2X design flow) �
+(force main drainback volume) + Fitting Loss* = NA ft
*(min.supply head x 0.3)�
CJIIN. PUMP DISCHARGE RATE = 40 �
• gpm = TOTAL DYNAMIC HEAD = 14.44 ft
�
PUMP TANK: SEPTIC TANK(S):
Volume = 750 gal Total Volume = 2000 gal
Manufacturer: Wieser Manufacturer(s): Rasmussen (Existing)
Pump Manufacturer: Champion
Install approved effluent filter at the septic tank outlet
Pump Model: CPES3 immediatel upstream of the um tank inlet.
(See attached pump curve.) x p p
Controls/Alarm Manufacturer: SJE Rhombus Filter Manufacturer: Orenco
Controls/Alarm Model: HW 101
Filter Model: FT-0822
Float switches containingmercur�are prohibited.
.
., am ion _ 1�3-1/2 HP �
�� � � �- -�___� � EFFLUENT SU
�m . / MP
pEvery pump tesied�n woter to ensure pump
meets peformance curve.
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11/.�,�;?021 - Novus-Wisconsin Access rev. 13.1108
Real Estate Sawyer County Property Listing Property Status:Current
Today's Date: 11/30/2021 Created On: 2/6/2007 7:55:31 AM ,
�� Description Updated: 3/27/2020 � Ownership Updated: 3/27/2020
Tax ID: 18725 WILLIAM H&JANE A GROSS FAMILY KANSASVILLE WI
PIN: 57-014-2-42-09-35-3 01-000-000150 TRUST
Legacy PIN: 014942353115
Map ID: .9.15 Billing Address: Mailing Address:
Municipality: (014)TOWN OF LENROOT WILLIAM H&JANE A GROSS WILLIAM H&)ANE A GROSS
STR: S35 T42N R09W FAMILY TRUST FAMILY TRUST
Description: PRT NESW PO BOX 246 PO BOX 246
Recorded Acres: 0.350 KANSASVILLE WI 53139-0246 KANSASVILLE WI 53139-0246
Lottery Claims: 0
First Dollar. Yes � Site Address * indicates Private Road
Waterbody: Nelson Lake 12173N WAGNER CIR HAYWARD 54843
Zoning: (RRl)Residential/Recreational One
ESN: 400 � Property Assessment Updated: 9/26/2014
2021 Assessment Detail
� Tax Districts Updated: 2/6/2007 Code Acres Land Imp.
1 State of Wisconsin G1-RESIDENTIAL 0.350 135,000 55,200
57 Sawyer County
014 Town of Lenroot 2-Year Comparison 2020 2021 Change
572478 Hayward Community School Distrid Land: 135,000 135,000 0.0%
001700 Technical College Improved: 55,200 55,200 0.0%
Total: 190,200 190,200 0.0%
• Recorded Documents Updated: 9/11/2012
0 QUIT CLAIM DEED �
Date Recorded: 6/29/2017 407403 'L'J� Property History
� QUIT CLAIM DEED N/A
Date Recorded: 8/13/2012 380162
� QUIT CLAIM DEED
Date Recorded: 8/13/2012 380161
� TRANSFER ON DEATH DEED
Date Recorded: 4/5/2010 365855
� TERMINATION OF DECEDENTS INTEREST
Date Recorded: 3/19/2009 359099
� QUIT CLAIM DEED
Date Recorded: 2/14/2005 328570
tas.sawyercountygov.org/Access/master.asp?paprpid=18725 ���
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Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� _ � Y
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
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TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic e �,y� ��C�'0 Benchmark pp��r
Dosing W� ?�
Aeration Bldg. Sewer _
Holding St/Ht Inlet _
TANK SETBACK INFORMATION St I Ht Outlet p, r
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE 4��( �
Septic f �,r�.$' �-) �f�') NA Dt Bottom �,q '
Dosing ` � � � NA Installation
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Aeration NA Header/Man. Q�,7j-'
Hoiding Dist. Pipe
PUMP/SIPHON INFORMATION infiltrative �6�Q �
Surface
Manufacturer Demand Final Grade
ModelNumber GD� , GPM �� �l . `�'�'�c"��
TDH (�.Lift Friction Loss Sys Head TDH Ft
Forcemain L � Dia � '� Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N 3 L � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P 1 L Bldg Well Waters °� GP ❑ Chamber Model Number:
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CELL TO ¢- � ` ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) — - - X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac Spacing 0 Yes ❑No
SOIL COVER
- - - --- ---
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil _ _ __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
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