026-939-13-5248-SAN-2022-143 ��""'"''��-: Departme�it of S�fety c°°"ty �
� _ & Professional Services, S�'' �� �
t , Sanitary Permit Number(to be filled in by Co. �
�� �� � Industry Services Division
l'� 3� � �lv �
State Transaction Number
Sanitary Permit Application � �
[n accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addre
the Department of Safety and Professional Services.Personal information you provide may be used for secondary J, �1
purposes in accordance with tbe Privacy Law,s.15.04(I)(m),Stats. �(�V�SE% l..��
I.Application Information-Please Print All Information �
Property Owner's Name Parcel#
Co�-t h�r�► •�� F �, �u s� d.2�'q 3 9 •I 3� S� Y�
Property Owner's Mailing Address Property Location
y3y� �r�,Mc4�-� �z Sa��� Go�t Lot �r-4 �
Ciry,State Zip Code Phone Number
(Vil!\2A l� (�'S ��� � �.5��9 ���- /`� "�5 /� '/4, '/4, Section ��
lI.Type of Building(check all that apply) � Lot# � T �9 N R O� E or
JZ{1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use — CSM Number ❑Village of
3?132? �g6`(� g�To,�,of__����-ak�
IIL 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 licablc.)
A.
❑ I�e�v System Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number a d Date Issued
❑ Transfer to New Owner
Expiration aO 'DS Sl�/(.ZO (q�2�I �����/�
IV.DispersaUTreatment Area and Tank Information: S �
Design Flow(gpd) Dcsign Soil Application Rate(gpd/s� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation �
�"I�� l• Co �/(o S -r7s !r 0 O ,
Capacity in Total #of Manufacturer �
Tank Information Gallons Gallons Units L ;; o � ^
New Tanks Existing Tanks �4 � U " y p c`�d c`�'a
o �' �
a U �n ti v� i�. C7 0.
Scptic or Holding Tank /$a f'— �5 �/ � ��,,�
vJ
Dosing Chamber �� � �`
.>v
V.Responsibility, Statement- 1,the undersigned,assu r ponsibility for installation of the POWTS shown on the attached plans.
ber's Name(Print)� c Plumbe s Si ature MP;'�1PRS Number Business Phone Number
�� lOtv� k ,v23 G rl:�� 7/.�- 7.j I- Cs��L�
Plumbe ' Ad ress Street,City ta ,Zip Code)
� ' l �o ���v�-�v,��►� L.�� :S�t 'l.
VI.County/Department Use Only
�A��o e� ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
�,� $�00,0' � )�, , �� n��;;,f,�.�.�2,�f-}���..�-
❑Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval D � ��S�r�
I� �
�
c5� �-� - i � a �uN a 2 �022
�
I IN�
�!�`J°YE� COUNTY
„Z�.t�l{�!G p,DMtNISTRaTION
Attach to wmplete plans for the system and submit ro the County only on paper not less than 8 ln x 11 inches in size
NIO RE�UNDS AFTER
SBD-6398(R.03/22) ISSUE OF PERMIT
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet �,SF .T,.,-G����
Component Manual Design References:
qvlav�ka
Version 2�", SBD-10705-P (N.01/01 , R. 10/12), _ , �ow.Q-
�.a(�v
Pg 1 of 5 2 � ` Index & Cover Sheet �"� '
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
MANUFACTURER TANK SPECS Soil Evaluation Report & Site Map
CSM SURVEY MAP CALCULATION SHEET
Project Name / Description
CARLSEN ELJEN SYSTEM
Owner Name(s): CATHERINE R. CARLSEN FAMILY TRUST phone: 612 _750 _2596
Owner Address: 4340 FREMONT AVE SOUTH MINNEAPOLIS, MN Zip; 55409
Project Address: 14993 W SUNSET LANE
Govt. Lot: P� 2 1/4 of 1/4, Section � 3 , T 39 N-R 09 E ❑or W❑✓
Township: SAND LAKE County: SAWYER
Project Parcel ID #: 026939135217
Designer Information
DesignerName: DOUGLAS E. MANTHEY Phone: �15 _ 739 _6868
Designer Address: PO BOX 796 DRUMMOND, WI Zip: 54832
E-IT1811: hOPpI1l2S p�C�'12C.�f18t.l1@t This space reseivec9 ti�r approval stamp.
License Number: MP230722
Remarks:
S ig natu re: � Date: 06/01/22
Ori al signature required on each submitted copy.
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os ap�1 s Sf. 7�p� '�tay$ �.O bmo�
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'�'7°�rf��IS:52 ,.,;,ra -._ __ .__- /S � �� vlal/,�lb� � P�nt�U Iy1L(�
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�yd�as �auMp_
9 Oa '�� �>I+°�
�»107 �5��'�''9;'YM
Carlsen Eljen System
Part of Gov't Lot 2 S13 T39N R09W
Parcel ID 026939135�3�-
- 5 Bedroom Replacement
- DFR 750 GPD
- RDLR 1.6 GPD/SQFT— Insitu Soil = 0.7 GPD/SQFT
- System to consist of 25 Eljen B43 Units
0 750 GPD/1.6 GPD/SQFT = 468.75 SQ FT
o B43 Units with Installation Width of 72" = 24 SQFT/Unit
0 468.75SQFT/24SQFT= 19.53 Units (20 Units)
o Per Table 2 of GSF In ground Component Manual — Minimum
of 5 643 Units/BDRM
o Therefore System to Consist of 25 B43 Units
• 25 Units X 24 SQFT/UNIT= 600 SQFT— Proposed
Dispersal Area
- C33 Sand to be used for System as per Component Manul
� SEED AND LOAM TO PROTECT FROM EROSION
�—� GEO1EJCf�E FABRIC �
MIN 12"OF
CLEAN FILL .
�.. _ :: :.<< --�
_ :.:.:. .:: . :�::.: :::; : �„
�� SPECIFIEDSAND �
18" 3g'� �a,�
72"
B43 NATH 18"OF SAND TO SIDES
Figure 2. 643 Single Lateral In-Ground Cross Sections
�VENT CAP
12"1 W
`FINAL GRADE
�
_ DISTRIBUTION PIPE
Figure 9. Vent and combination observation/vent pipes
__ '� � �hS/��C�.�.YC �'� �� I . .
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PAGE40F5
GRAVITY-DOSED
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4"�Vent Pipe
>10 ft fmm
Building Electrical musl comply with
12"Min.or20Rabove SPS316andNEC300
Es�ablished Flood Elevation Wealherpmoi Extend manhole riser as necessary.
(rypical) APProved .lunction Box
Venl Cap Appmved Locking Manhole
IMPORTANT: I �wim waming Labe�a�acned
� (typical)
Anchor tank(s)as necessary �condui�
pursuant to SPS 383.43(8)(g) 4"Min.or2o�above
Esta6lished Flood Elevation
(typical)
�Airtighl Seal
Finished Grade �
�uick Disconnect
a. 1 S"Min.
CAPACITIES @ 25 gal/in e . . �`YP'��>
Depth (in) Volume (gal) a � �
A 18 450 * 1 we�P �nPv,o�ea�o��isw�m
Hole Approved Pipe 3 ft onto
B 'Z.O 50 A Solid Gmund
� (typical)
[C] 4 102 �
_Alarm
D 14 350 B �—o�
���� PUMP-OFF
* i P°`^P �_orr ELEVATION = 93.25 ft
Pump Tank Liquid Level = 38 in }
I
° INSIDE BOTTOM
Force Main Diameter = c°°0fe�e
�in s�o�k ELEVATION = 92.1 ft
3"Approved Bedding Matenal Benealh Tank
Force Main Length = 20 ft
Force Main Void Volume = 3 gal
[C] Total Dose Volume TDV gal/dose
��
(<02X design Flow+force main void voiume)
VerticalLift = 15 ft
PUMP TANK: SEPTIC TANK(S):
Volume = 950 gal Total Volume = 1�8�gal
Manufacture ieser Concrete Manufacturer(s): Wieser Concrete
Pump Manufacturer: Goulds
Install approved effluent filter at the septic tank outlet
Pump Model: EP0411 �seea«a�hed P�mP��rve.� immediatelv upstream of the pump tank inlet.
iControls/Alarm Manufacturer. SJE Rhombus Filter Manufacturer. Orenco
Controls/Alarm Model: 1025830 Filter Model: FT0822-146
Float switches containina mercury are prohibited
WLP1585/950
783a, TANK SPECIFICATIONS p �
DiMEN510NS � �
WALL: 3" � o
BOTTOM: 3� a a
COVER: 6"
MANHOLE: 24" I.D. PRECAST CONCRETE RISER �
HEIGHT: 53-3/4' O.D. �
' — -� '- — — � —���.. _='_=_�: LENGTH: 783-3/16� O.D. •r
�— — — — — — — — — — WiD7Fi: 101-3/76: O.D. _
�I I I I I (� BELOw iNLET: a3 O.D.
4" CAST-A-SEAL ����4" CAST-A-SEAL LIOUID LEVEU 38� � w
II I� WEIGHT: TANK 13.010 l85 N ' o
I ���� I WEIGHT: COVER 9.300 lBS
� � � � l i �' � INIET AND OUiIEi:
:.. 2
4 / ' / 4' CAST-A-SE.4l B00T OR EOUAL
� ��P� 1 � �� 1� �� 3 S a
.�I \ J FILTER OR II �N�ET AND OUTLET BAFFLE AND FlLTER: 'r g �
II IIII NASCONSIN, SEE DETAIL g10 z g �
BAFFLE IE (OiHER STATES SEE CHART) s � .
�� ����
I I I I —� LIOUID CAPACITY: 41.67 G4.1/�N (SEPTIC� � � J
�_ _ _ _ _ _ _ ____ _�� __ _ __ 25.00 CALIIN (PUTAP �y� � �
lOnDiNG DES�GN: 8'-0' UNSnTURAlED SOIL ~ '�
W
� `'
TOP VIEW TANK CAN BE USED AS: � o �
SEPTIC/SEPTIC, SEPTIC/PUAAP � �
O � �
OR SEPTIC/SIPHON �7 o I
`s �
N
COVER: MIX DESIGN �8 (NO FIBER) M
4" VENT TANK: Mlx OESIGN y9 (SMALI FIBER) W � �
L
. � CUSTOMIZED TANKS: i �
g ,o FOR CUSTOAI TANKS CONTACT NAESER CONCRE7E W u�
a — — .. — � �
rc
n
n
MLET = T T `
� — II — — -
' I J
v�'i :� 3" � � � �.� I � rn z
' � i
� a
.�. _- - - - - - � -� �� - - - - -.J � �
- 1 � ~
� a
DRAWINGS SUBMITTED v"',
SiDE v�Ew FOR APPROVAL
APPROVED BY: SHEET N0.
APPROVAL DATE: '�
/oF 1
' PRODUCTS NEEDED BY:
T.�NKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REWIREMENTS
� [� GOULDS PUMPS Submersible
i�� _ _
Effluen� Pump
; . ,
EP04
� - - 3 � 71
_ . .� ;_ EP05
l�
/ � - ��.
� _ �
��-
�-�-�. �.
APPLICATIONS • Fully submerged in liigl� ■ EP05 impel►er: Thermoplas- ■ Bearings: Upper and lower
grade turbine oil for tic enclosed design for heavy duty bali bearing
Specifically designed for the lubrication and efficient improved performance. construdion.
following uses: heat transfer. ■ Casing and Base: Rugyed
• Effluent systems thermoplastic design provides AGENCY LISTING
• Homes Available for automatic and superior strength and corrosion
• Farms manual operation. Auto- re5istdnCe. S�' CanadianSWndardsAssaiation
• Heavy duty sump matic models include � Motor Housing: Cast iron
• Water transfer Mechanical float Switch for efficient heat transfer, Goulds Pumps is I50 90U1 Registered.
• Dewateriny assembled and preset at the strength, and durability.
fadory.
SPECIFICATIONS ■ Motor Cover: Thermoplastic
FEATURES cover with integral handle and
• Solids hantlliny capaf�ility: float switch attachment points.
'/a" maximum. 0 EP04 Impeller: Thermoplas- � power Cable: Severe duty
• Capacities: up to 60 GPM. tic Semi-open design with rated oil and water resistant.
•Total heads: up to 31 feet. pump out vanes for mechanical
� Discharge size: 1'1i' NPT. seal protedion.
• Mechanical seal: carbon-
rotary/ceramic-stationary,
BUNA-N elastomers.
• Temperature:
104`F (40°C) continuous METERS FEET � "" "
_ _ . _. _._ ,--- -
140°F {60`C) intermittent �o � � I t I i i
- --�- -- .....: .
_� .
• Fasteners: 300 series � " " - " � ����� � ; � ' �'
stainless steel. i--- : - ---��'--- "` —► �--SGPM " '
9 30 � __ i,.__ . �_ �
• Capable of running ' � ! ..._---.. _........_l.._. ,� _. _�.✓ .- -Y
_....---.... ............. ...... ... .-�---��- � zs�r
. ._.. . .
dry without darnage to s ! i i _•_____�_____-;------- ______ ____
components, Zs —_�--- . _ _----:-__,__ _� +
--_-,--__. _ ,
� � ----�—�- —.._._. . . ._ 1 _ ......._...� . ........ .--- -±- --_ - � - � -
. -
... .. ....:........... � � _ .. _. �
Motor: x - - I L � ____;-----i ----- - --4--__.___
___�_____
• EP04 Single phase: 0.4 HP, � 6 zo � � --�� ���'- -- � �
115or230V, 60Hz. 1550 ...__... .i----�---.. ... ......... .........- - � -._._�......... ........._;.....--�-- . _.........�._..... . - --
� _._�........---
RPM, built in overioad with 5 � --�---'-- -- ---� ---� ---- --- ---- .
o �s ---� —__ _ �� _
automatic reset. � � ; i I � �
Q4 .__........t........---- �--- -�-•- -i--- -•-.... ......... ..` --�-......_. . - EPOS -_...
• EP05 Single phase: 0.5 HP, o I j..--�--.-• ��- - ! �_____
115 V or 230V, 60 Hz, 1550 '' 3 io - -- :�� - ' 4� � I
RPM, built in overload with --—�---�-' --........ .:::..:'.:�- - .._ ._ - --- ----- -...._...--.---._..... ..... EPoa --- -- - _ - --- ----
� , �
automatic reset. z � _.3____ __
; — -----; — — i _ -��
• Power cord: 10 foot � - � �
standard length, 16/3 � �
t _-�-----..... ............ --...--- -..��...-.:_:::. _.....- - �........._.. ......._...±- -____.. ... _ ..... ._-----
S1TOW with three prong .�__ � _ __� --1._- --� ----'
grounding plug. Optional 20 ° °o io Zo ao ao so GPM
foat length, 1 G/3 SJTW with
� � � � � '
three prong grounding plug o Z a 6 a to �t m'�,
(standard on EPOS). cAPnanr
Goulds Pumps
� ITT Industries
� 2002 Goulds Pumps
Effective September, 2002
63871
PAGE30F .7
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 pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= 750 gpd; BODS<_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 filterlsl 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: NOf PI11@S PIUlllblllg Phone: 715-739-6868
Local government unit: S8Wye1'COUllty Z011111g Phone: 715-634-8288
�oca�government unit address: 10610 Main Street Suite 49 Hayward, WI ZiP 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.
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.
� "—T";`�;, pRIVATE ONSITE WASTE TREATMENT county
��°' �� � ��' SYSTEMS
,x :�p ���
_�, �SPs ��; Sawyer
'�� ��;' ( POWTS)
��"" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��_ ( (,{3
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �1 Town of: State Plan Transaction ID#:
C� I�►PSi�,�.Cat'15o"1 �i"�I}/� �4� W W�-- �
Insp BM Elev: BM Description: Parcel Tax No:
(oo•o' S E� c��,-�- a�F-,��� B��„ 5s�d�w o�6.��3�_ i 3 _ s�2 Y g
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic t,�,�e.��- _ t S'$S Benchmark , )oO.o'
Dosin9 r-ca�+�jo �t'S�D bYh 2 �. 9`(•K? �
Aeration Bldg. Sewer �1 .61�
Holding St/Ht Inlet 9p.9'1'
TANK SETBACK INFORMATION St/Ht Outlet p,�'
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic +�p� �?fl` �' �-�� ` NA Dt Bottom 2i7,S�
Dosing �� n �, �i NA
Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe �3,7'
PUMP 151PHON INFORMATION Surf cte e `�� �
Manufacturer o � Demand Final Grade ,
Model Number �
N GPM rj3 C33 �Z•B
TDH `7 Lift Friction Loss Sys Head TDH Ft � �. Q3 ,47�
Forcemain L �h lS� Dia 2�� Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS W ' � �g .ti—�j #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �'(^e�
INFORMATION P/L Bldg Well Waters ° GP ❑ Chamber Model Number:
❑ EZFIow
' ' ' ❑ Mound � Other � �{3
CELL TO +.S — +_�-- '��� t 5�-- -- —--
DISTRIBUTION SYSTEM X Pressure Systems On►y
-- . i-- -r—
Header/Manifold Distribution Pipe(s) ' X Hole Size ! X Hole Observation Pipes
Length Dia Length Dia Spac__ j Spacing ❑Yes ❑ No�
SOIL COVER -- --- ---- — — --- -
- — --- ---
Depth Over Depth Over ' Depth of Seeded/Sodded Mulched
Cell Center Cell Edges I. Topsoil _ � ❑Yes ❑ No �Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
��.,s�ll�.� 1 a(�$ � �-�
Plan revision required?� Yes 0 No � �O 1 2 � �
� i �
� 3 �� �—L � �����
___ --- --
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
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