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HomeMy WebLinkAbout010-941-25-3405-SAN-2020-229:)Industry Services Division1400 E Wushinglon AveP.O. 1)0x7162Madison, W1 53707-7162CountylAJve-*".SaniUiry Permit Number (to be tilled in by Co.)Sanitary Permit ApplicationState Transaction NumberIn accordance with SPS 383.21(2). Wis. Adm. Code, submission ot'diis form to tlie appropriate governmental unitis required prior to obtaining a sanitary pcrmii. Note; Apgilieatioa forms for state-owned POW i'S arc submitted tothe Department of Safety and Professional Services. Personal iiifomiaiion you provide may be used for secondarypurposes in accordance willi the Privacy Law, s. 15.04(1)1in), Slals.Project Address (if difTerenl than mailing address)1. Application Information - Please Print All InformationProperty Owner's NameProperty Owner's Mailing Address/ W.-cUctlParcelCcaonVy Wtovj fi>City, SlateVAo.oooa.rd , UJXsotIVoperty LocationCiovi. Lotii. Type 01 Building (check all that apply)I or 2 family Dwelling - Number of Bedrooms -3Zip CodeSH-&V3Q Public/Commercial - Describe UseQ .Stale Owned - Describe UsePhone NumberLot#■&£ auJ Section ^(circle one)T V/ N; R_5_&or<©Subdivision NameBlock f□ City of.CSM Numberc^rA^n-73V6(. p.^O*-/D Vill^ofS^own of VAtxyr.sQrr4III. Type of Permit: (Check only one box on line A. Complete line B if applicable)D New SystemD Permit RenewalBefore ExpirationORcplnccmcnt SvsirmD Permit RevisionJ^Trcatment/howmg^fank Replacement OnlyD ChangeofPlumberD Permit Transfer to NewOwnerD Other Modlflcallon to Existing System (explain)List Previous Permit Number and Date IssuedIV. Type of POWTS Systcm/Component/Device: (Check all that apply"KNoit-l'ressiifi/cd In-Ground D Pressuri/cd In-Oround D Al-Grade D Mound > 24 in. of suitable soil D Mound <24 in, of suitable soiln Holding fank D Other Dispersal ComptMient (explain) D Pretreatmenl Device (explain)V. Dispersal/Treatment Area Information:^ 1^ » Ct« (i-lDesign flow (gpd)Design Soil ApplicfUion Rate(gpdsO0.-7Dispersal Area Required (si)Dispersal Area Rfopowd^sf)-7^System Etev^ionVl. Tank InfoCapacity inGallonsNew tanksExisting TanksTotalGallons«ofUnitsManufadurcrtSM gi/> <xMSiZ QSeptic or Holding TankDosing ChamberVOOC:)\CCiO^oncret-e.VII. Responsibility Statement* I, the undersigned, assume responsibility for installation of the POWI'S shown on the allached plans.Plumber's Name (Print)1 ^Plumber's /kddress (Street, Cjly. State, Zip Code)S Way 03Plumber's SiCDuturc>MP/MPRS Number.^30'S3C.Business Phone Number7/S--63V-/C-7<^<7VgV3VIII-iCouiity/Department Use OnlyD DisapprovedD Owner (iivcii Reason for DenialPemiil feeHco,Dale IssuedIssuing Agent SignatureIX. Conditions of Approval/Reasons for DisapprovalypUlKle^ORIGINALAttach to complete plans for the system and submit to the County only on paper not lets thantLi\y SEP 2 1 2020SI)D-6398(R. 08/14)c./ ,"yZONiNG ALiMifdiGTRATION In-Ground Gravity PlanIndex & Cover SheetComponent Manual Design References:Version 2.0, SBD-10705-P (N.01/01. R. 10/12)PAGE 1 OF 4Pg 1 of 4Pg2of4Pg3of4Pg 4 of 4Index & Cover SheetPlot PlanDispersal Area Cross-Section & Plan ViewManagement PlanAttachments:Enclosures:POWTS Application for ReviewSoil Evaluation Report & Site MapProject Name I DescriptionPhone:Zipr55$:^3.Owner Name(s):Owner Address:Project Address: nGovt. Lot:. 1/4 of S^ 1/4. Section05 .tMI N-R ^ Ef"!or w1^Township: Coun^Scxxwvv£^^Project Parcel ID #: CD\0 ^ ^Designer infoij^^ionDesigner Name: Phone:Designer Address: /(jJ: Zip:E-mail:License Number:Remarks:^lll^ s|\n(- reserved ior ivpinova! slJmieSignatureOrigindl signature required oh-€Ech submitted copy.Date: oCOIIUJ _I <c o cOi>%53 o j- (T T «•r J*> t' 2 - *0 U) > /» i" 0 U U) *0 V) auK3I a. 0 '2 3 >w2000 f£ w >■ 2 IC yo 7-ni._* o« >7 «0? 180- ^T0-I 0 r3 - 0 fO 5^ <r7cV*'dViI0 C3 £ eg I- < 7 UJ J y ~v>«v.vv «v >0 3-0 ro0JIT-0-0 -0V 4i> c 1 1 •3 t i o a o t.Ip1 ^V •» V]•.'.1 " - u.1 i ■< •<i s0 i tl.:5 {^ -0i 5I--:r?•S ^ J * K ^1cl •J C9 <£ /< 2 O 'o « I <n 5 < r ^* 'it *- Jo ^ 5 ^0 t j« s vu 2 0. M-' 1 r o I D to to £o>l 4 Ji (Hlki; ofSawyer County Zoning Administration10610 Main Street Suite 49Hayward. Wisconsin 54843(7l5)W-t-f(2SKl-AX |7l5K)3S-3277WWW.SJIWVtTL'OIIIUVtJOV.OrL!E-niail; /oiiiini.scclii sawvercounlvL'ov.iir);I'dII l''ree Coiirthousc/Gcncral Inrocmatinn l-!t77-6y9-tllO(^\\SAWYER COUNTY SANITATION DEPARTMENTTEMPORARY KMI'.RGENCY TANK TNSTAI^LATION APPROVALPROPERTY OWNERS NAME: WpI*/? Idt Wev\W \TOWN OF:ADDRESS: ^ IK%0\aJ . Hvxy ^, ^Licensed Plumber, authorized by the owner, do herc^acknowledge that I am receivinglemporary approval to install a septic tank/holding tank without a soil and site evaluation,or existing system evaluation, and private sewage system plan review due to inclementweather and/or health and/or safety emergency.Further, I acknowledge that a soil and site evaluation, or existing system evaluation, andprivate sewage system plan review will be conducted by the deadline stipulated by thepcnnit issuing agent, or as soon as weather conditions or circumstances permit. If theprivate sewage system is found to be failing as defined in s. DSPS 381.01 (92), Wise.Adm. Code, corrective measures will be taken as such that the private sewage systemcomplies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,within 90 days of this agreement.I further acknowledge that failure to comply by obtaining all necessary permits after thedeadline date may result in the issuing of a citation, under Section 11.3 {2) SanitaryPermits]^ of the Sawyer County Citation Ordinance.DEADLINE FOR THIS AGREEMENtXhALL BE:bllSigned:Date: j jAccepted by:Date of lemporary emergency approval: p<bRev. mi26lU In-ground Gravity Management PlanIMPORTANT:The owner of this In-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant torequirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wise. Admin. Code, this system shallbe 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 inaccordance with SPS 383.52 (3), Wise. Admin. Code.Maximum Dispersal Area Operating Limits:Design Flow = ^50 gp^j. bqDs S 220 mgL ^ TSS ^ 150 mgLFOG ^ 30 mgL*^inspection Checklist INSPECT EVERY 3 YEARSo type of useo age of systemo nuisance factors (/.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 dosingo 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 senredMaintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)o Septic and dose tankfst shall t)e pumped by a certified septage servicing operator licensed under s. 281.48 WIs.Stats, when the volume of solids in the tank(s) exceeds on»>third (1/3) the liquid volume of the tank(s) oras required by local ordinance. Disposal of contents shall be pursuant to MR 113, Wise. Admin. Code.o Effluent fliterfsl shall be inspected every 3 years and shall be cleaned when necessary to remove anyaccumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12months.System maintenance reports shall be submitted to the proper local government untt In accordance withSPS 383.55 Wise. Admin. Code. Report any component fellure or malfunction to:Name of Individual or company: Rsy ViSOCky Phone: 715-634-1679Local govemment unit: Sawyer County Zoning & Conservation phore: 715-634-8288Local govemment unit address: 10610 Main St, Suite 49 ; Hayward, Wl ap. 54843Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wise. Admin.Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wise. Admin. Code.No product for chemical or physical restoration of the POWTS may be used unless approved by the department inaccordance with SPS 384, Wise. Admin. Code.Contingency PlanIn the event that any failed treatment component of this POWTS cannot be repaired. It shall be replaced pursuant toa plan submitted to the appropriate agency for review and approval. A failed In-ground dispersal component may beabandoned and replaced by a code-complying dispersal component In a pre-determlned area of suitable soils.System AbandonmentIf use of this POWTS Is discontinued. It shall be abandoned In accordance with SPS 383.33, Wise. Admin. Code.