010-182-00-0100-SAN-2024-003 -�C�ft 1 t��\ .
/�==-�� �';, Department of Safety c°°°`y �
`=�'.�a -, & Professional Services, 5 �`"�"' � �
�
� �� �
;��g P '�I Sauitary Permit Number([o bc tilled in by C
, g , Industry Services Division � 5, J �
�;; ` :Nl,i! � L � 9J
----;:,� _ ...�
Sanitary Permit Application sta`�T'�a°sa°''°°"°"'be`� �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit Q
is required piior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if dit�terent than mailing ac W
the Depairtment of Safety and Professional Se�vices.Personal inlormation you provide rnay be used for seconda�y
pu�poses in accordaiicc with thc Privacy I.aw,s. I 5.04(I)(m),Stats. �q���W p Od �K�
I.Application Information—Please Print All Infor►nation
Property Owner's Name Parcel#
Ga� � � K�:s�; M 3ae�ser� o� o - ��a-oo o�oo
Prope�Ty Owner's Mailing Address Property Location
I 1 $�b '7+''` P 1a ce NE
City,S[ate lip Code Phone Number
_� � Scction UI
st M;chcel , Mt�l 5537(0 __.. __
IL Type of Building(check all that apply) Lot# �I� �/O N R _U 8 L_=er
"�I or 2 Family Dwelling—Number oCBedroom;._ � � Subdivision Name
Block# TANCstC WCSOD L3PY
❑ Public/Commercial—Describc Use
--_ - - __ . ------ �
❑City of
❑Statc Owned—Describc Use CSM Number ❑Village of
�— 1�Town of--- -��G��C.r"d_----
III.Type of POWTS Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one box on line B.Completc line C if
applicable.)
A.
� New System U ReplaccmenL SysLem ❑ Other Modification to Existing System(explain) ❑ Additional Pretrcatmcnt Unit(crplain)
B.
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ [ndividual Site Design ❑ Other Type(explain)
(co�rventional)
C• ❑ Renewal Before ❑ Re��i,ion U Change of Plumber ❑ Transfer to New Owner
List Previous Pernlit Number and Date Issucd
Expiration
�
IV.Dispeisal/Treatment Area and Tank Information: ,� 3� Qv:CK 4 'l��J S G I,w,•.be rs W /a Se Y.s a�e�d
Desi�n Flow(gpd) Design Soil Application Rate(gpd'sil Dispersal Arca Required(s� Dispersal Area Proposcd(st) Systcm Elc��ation �
y��0 0 ,-7 Gy3 �s� � 97.ov
Capacity in Total #of Manufacturer
�
Gallons Gallons Units � o "° �
Tank Infonnation � v �
'� U V N N V
Ne�v Tanks Exiscin�Tanks � c a� — � � � r
— U cn v, �n u.. Ci fi
Septic or Holding Tank t O O� �, f OQ U � w i�,�►(" �p,��CrG�C- x
Dosine Chamber
V.Responsibility Statement- I,the undersigned,assume re nsibility fm�' stallation of the POW"1'S shown on the attached plans.
Plwnbe�'s Name(Print) Plumber's i �ature MPiMPRS Number Bu,iness Phone Numbe�
-r�J:s 3�+���t� �� �sas7� ��s-c3y-�r7�
Plumber's Address(Street,City,Statc,Zip Cade)
l y3tit, � S�� RQ� �� Na w���, w�r sya y3
VI. ou ty/Department Use Only
� � p� -e ❑ Disapproved $crmit Fe� Date�ssued Issuing Agent Sig�lature
❑Owner Given Reason for Denial ��' � � � �`�C�� �� �����-��_���.�-�a��l�-
Conditions�o�f A�proval/R�s�s ror Disapproval
. :' �
�+\ � , a.. � �. �-� .... _... z + :J i
�r i1��� ■'f�1� r� ..<+�..,. �I t �� - ��/y1
...�kil � I 1X ��� �f2�� � � P��A 3�y .....J
G 5� � d� SU �'�a L � �1U
�� — DL � �'�°�"'' : __ __ .o��-�----•—= r.; - , ,:���,.„!�"Y,
�;,:�.�,t�� -,;�i� ,, ��'��PT��d
Attach tu complete plans fm•the system and submit to the Coonty only on paper not less tl�an 8 I/�s 1 I inches in size
IVi ��y
SBD-6398(R.03/22) ��� ��'�����������
�u�#..:�iJr �=`cN��i
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Baetsen - Tanglewood Pkwy
Owner Name(s): Gary D & Kristi M Baetsen Phone: - -
Owner Address: 11888 47th Place NE; St Michael, MN Zip: 55376
Project Address: Tanglewood Pkwy (no fire #)
Govt. Lot: 1/4 of 1/4, Section �� , T 40 N-R �$ E ❑or W ❑✓
Township: Hayward county: Sawyer
Project Parcel ID #: 010-182-00 0100
Designer Information
Designer Name: Travis Butterfield Phone: 715 _634 _8176
Designer Address: 14346W State Road 77; Hayward, WI Zip: 54843
E-Cpal�: OffIC@@bUtt21�12�C�C�I"I��II'1g.C0111 'This space ce�ei-ved lor approval stainp.
License Number: 652879
Remarks:
Signature: Date: � ^ S"aY
Original signature required on each submitted copy.
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Septic Tank(s) Manufacturer.
IN-GROUND GRAVITY DISPERSAL AREA wieser Concrete �nc
Uniform Elevation Trenches with Quick4 Standard-W Chambers SeP�;�Ta�k�s��o,�me�s>
3-ft Trench (down-sizing credit) �000 gal gal gal gal
Effluent Rlter Manufacturer:
Best Filter
erti�er,t FncP�Modei#: GF10
mlo.,r
(typlcal)
SOIL COVER
i2"
min.trench
depth
t�vv���o � � � TYPICAL TRENCH
a CROSS SECTION VIEW
� 3S /No Scale
(�YPlcal) .. . V �
� a . Provide minimum 3 ft
System Elevation =9 7.0 0 ft separa tion be tween trenc hes.
(typical)
Quick4 Standard-W
w/End Cap OSSeNa"o"P'ae TYPICAL TRENCH
(Show location of Inlet/ outlet pipe connection on plan view.) Ryvi�a0
��ypIC2�� Installpermanufacturefs PLAN V�EW
inshuc[ions.
(No Scale)
� � /� — �� R��i6TF�+�I�VnT�
��� � ������'l��- - - - �� - - - - - - - �� - -� — - - A = 3.Oft
�. y'���/ " �Y�rafa.aaa+aa J (bPlcal) �
�
'r B = s� ft I m
(typical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (typica�) �
(m`d by InfiltratorSystems.Inc.) �
Ins�all pursuant to manuFacNrer's instructions. �
16 Quick4 Std-W @ 20 ft� EISA/chamber= 320 ft�
+ � Pairs of end caps @ 6 ft' EISA/pair= 6 ft�
= Proposed EISA per trench = 326 ft� Required Infiltration Area = 643 ft� Distribution Method:
x 2 trenches = Proposed Total EISA = 652 ft' branched manifold �
�
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 Operatinq Limits:
Design Flow= 450 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 priorto dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch setiings, eic.)
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;
c surtace 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: BUtt21f12ICI IIIC Phone: �15-634-8176 _
�ooai go�er�me�t �n�c: Sawyer County Zoning & Conservation Pnone: 715-634-8288
Localgovernmentunitaddress: �OO�IO Maln St, Suite#9; 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.
Contingencv 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.