HomeMy WebLinkAbout032-540-35-5209-SAN-2020-150ft.0, 's .i-Safety and Buildings Division201 W. Washington Ave,, P.O. Box 7162Madison. Wl 53707-7162dSTCountj-SouilAiy Pennit Number (to be filled in by Co.)^ ^ ,1Sanitary Permit ApplicationIn acootxlonce witb SPS 383.21(2), Wii. Adttu Code, submissioD of tbis fonn (o tbe apjvophsta govenunental unit18 required prior to obtaining a sanitary peimil. Note: Application fonns for statCHiiMtied POWTS are stitentted tothe Department of Safety and Profeasional Servies. Personal informatioo you provide may be used for secondarypurposes in accordance with the Privacy Law, s. i 5.04( 1 )(in). Stats.State Transaction NumberL Applkatton Infonnation —Pleaae Print All InformafionProject AcUress (if different than mailing address)552/wc5Property Owner's NameParcel#IL<i2 Hq^'LC19, Sl^frm/rfcH Tfeiu11. Type of BuUding (cfiecic all that apply)or 2 Family DweUing - Number ofBedrooms.D Ptdili^Commercial—Describe UseQ SiatB rhtmed - Describe Usely 1/1,0 n P I/O tePiopqty Owner's Mailing Address6^2 - SVO-^S-- S2o^Zip CodeZPhone NumberLot#Property Location'A, Vt, Section. (oudIb one)T /yO N: R £ Eorgr~j7Subdivision NameBlock#CSM NumberD City ofD Village of ^•^^Town ofin. Type of Permit: (Chedc only ooe box on line A. Complete line B if sppUcable)E0 New SystemD R^tiscemeni ^stem r?TreaiinenidieU^ Tank Replacement OnlyD Giber Kfodifiostion to Existing System (explaiiOB.0 Permit RetkewalBefore ExpirationD Pemtit Revision0 Change ofPlumberIV. Type of POWTS Syirtwii/romDonent/Dcvice: (Check all that applyD Permit Transfer to NewOwnerList Previous Pennit Number ^ Date Issued77-r)W3.l%/?7□ Non-Pressurizedln-Ground □ Pressurized In-Ground □ At-Crrsde □ \found>24in.ofsuilabie8oi] □ Mound <24 in. of suitable soil□ Holding Tank □ Other Dispersal Component (explain) 0 Pretreatment Device (explain)V-DigpersalfTreatmeot Arealnfonnation: fS&sV^vi'Sign Flow (gpd)Design Soil Application RAte(gpdsf)o nDispersal Area Required (sOH2%.(o'Dispersal Ares ISSfind 0'53^VI. Tank infoCapacity inOallonsTotalOallonsAofUnitsManufacturer0*£ SSh eCon-detcints1u. 0lPasticNew TanksExisdegTadj(Septk^ HNdmeTsak-7.*^1^i■■■Oositig Qiamberystem ElevationVn. P'^ponaibility Stat»™ent- l.thc mdere^ced. assume responsibfllcy for InslallaileB of the POWTS ibown ontfae attidied planaMPAimBusinPhiB^'sName (Print)Plumber's,-Numberess Pbooe Number(,3<236'7'ZPlumber's Address (Street, City, State, Zip Code) _t2,on>ca IaIj- .bVg'/J'Vin..Comttv/Departroent Use Onlyn DiiafqxovedD Owner Given Reason for DenialPennit Fee» Ljoo."^Date IssuedDL Condhioiis of f^proval/Reasons for DiupprovilIssuing Agent SignatureORIGINALNO REFUNDS AFTERISSUE OF PERMITJUL \ 3 2020^^.n,.j:pi«M|a«n.ia-fli»iT»tBBsndsnlnaHteih»CcBitiy«plyaopsi»eTi»orlasih»i8iasUtp«toto^^y^gp BOUNTYZONING administrationSBD^98 (R. 11/11)
CONVENTIONAL IN-GROUND POWTS DESIGNResldeutiai AppllcatioDIndex and Tide pageOwner's name;Owner's address:Site Address:Legal Description;Town;County:SubdiviBion Name;11/9UiK> c QUbtz/Hc/LoZ /yc.'fe-sszi Vv* mmn/jS3s--rm A/ gloiLot No. *7 Block No.,Parcel Identification Number: n 3^~Page 1Page 2PagyPage IndexIndex and TitlePlot Plan (May include septic tank and filter specs)Maintenance, Management and Contingency PlansPlumber Name:Plumber Address:(SfOCt^ Credential No.tsnz(2<-avUr s-ygyjSignature:Date:-y/zv/z^zo Phone No. '9/^'G3<Z-3S'?7Designed Pursuant to the:In-ground Soil Absorption Manual for POWTS Version 2.0SBD-10705-P (N.01/01)Page 1 of.
Ollke ofJUL'-^ 202Qs^yer County Zoning AdministrationSAWYER COUNTY10610 Main Street Suite 49Hayward, Wisconsin 54843(715)634-8288FAX (715)638-3277www Siiwvcn'niiiilvcov.iiruE-mail: yoiiiim.sccfoisawvercoiiiilvL'ov.oraToll Free Courtliouse/General Information 1-877-699-4110CniGIOLSAWYER COUNTY SANITATION DEPARTMENTTEMPORARY EMERGENCY TANK INSTALLATION APPROVALPROPERTY OWNERS NAME: fw. \TOWN OF:ADDRESS: _AI-X. -CMLicensed PlumbeP, authorized by the owner, do hereby acknowledge that I am receivingtemporary 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, 1 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 agenl, 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) SanitaryPerniils], of the Sawyer County Citation Ordinance.DEADLINE FOR THIS AGREEMENT SHALL BE:Signed:-> 07Cc9a Wisconsin'Accepted by:Date of temporary emergency approval: j "^ )Rev. 03/26/13
C7
4
(51
"0>^VV|
T
%){r'^'-
IbOZ. rtoel Ao-e.S-fao^U^B ljD[ ^"3567-• SSXi u-> f-Aa-T-'k"^ Rd -pc^rL-g^aj-.UJi«a"f-ev- ''^p■P/^J OS'L-S^^ — 3S —S^O^5' 35" r4c»J iS-OS-^L<.k7 C5K ^C.13+155*2-1 uJO7- i sof '-+ fss-/Jt)f hi^Cal^lOcIIr■i—<-<iec,V>2_b«i. fit.W'^5^8M«0o' -F^4^Si:i4« =HojO ys^ Cf9<~coi^iO/er5^'^ S:rs V/PtL*^C6C[c 5^^/ p/CTSh.^ Sy\ 'Oo , b^irktf Gjfw««- xAjooi S.3[. ^S.5',7 Scjs^-tfUA g|.'^-T* l^Xgrd-CS-gci. ig, Oevct"
POWTS OWNER'S MANUAL & MANAGEMENT PLANPage3 ^3FtLE INFORMATIONSYSTEM SPECIFICATIONSfkhJM c Ciinc^LPermit #DESIGN PARAMETERSNumber of Bedrooms□ NANumber of Public Facility Units□ NAEstimated (average) Flow2<ic>(gal/day)Design (peak) Flow = (estimated >c 1.5)(gal/day)In Situ Soil Application Rate(gai/day/fl^)Standard (Domestic) Influent/EffluentMonthly averageFss. on & Grease (FOG)Biochemical Oxygen Demand (BOOc)Total Suspended Solids (TSS)s30 mg/Ls220 mg/Ls150 mg/L□ NAHigh Strength Infiuenl/EffluentMonthly average(FOG)(BODs)(TSS)>30 mg/L>220 mg/L>150 mq/L□ NAPretreatad EffluentMonUily average(BODj)(TSS)Fecal Coliform (geometric mean)s30 mg/Ls30 mg/LslO"□ NAMaximum Effluent Particle Size/6 m dia.□ NAOther:□ NATank Manufecturer; "XofSSn ameptic □ Dose □ Holding Volume; (sal)Tank Manufacturer:□ Septic O Dose □ Holding Volume;□ NA(gal)Vertical Distance Tank Bottom{s} to Service Pad:Horizontal Distance Tank(s) to Service Pad:(ft)(ft)Specific servicing mechanics must 1)6 provided if verticel Is >15 feet orIf horizontal Is >150 feet. Specific instructions to be pro<rided on back.Effluent Filter ManufacturerEffluent Filter Model: 2^5^□ NAPump Manufacturer:Pump Model:IMAPretreatment UnitManufacturer:O Mechanical Aera^□ DisinfectionO Sand/Grad^ Filter□ Pea! Filler□ Wetland□ Other□ NASoil Absorption Syst□ In-Ground fgra'□ At-GradeO Drip-Line□ In-Ground (pressive)□ Mourxl□ Other;□ NAOther:□ NAMAINTENANCE SCHEDULEService EventService FrequencyPump out contents of tank(s)□ When combined sludge and scum equals one-third ()6) of tank volume□ When the high water alarm is activatedInspect condition of tank(s)At least once every;□ month(s)I] yearfs)(Maximum 3 years)□ NAInspect dispersal cell(s)At least once every;II monih(s)11 year(s)(Maximum 3 years)□ NAClean effluent filterAt least once every;3 monlh(s)□ year(s)□ NAInspect pump, pump controls & alanriAt least once every;□ monihfs).□ year(s>□ NAFlush laterals and pressure testAt least once every;□ month(s>□ yearfs)□ NAOther:At least once every:□ monlh(s)□ year(8>□ NAOlher;□ NAMAINTENANCE INSTRUCTIONSInspections of tanks and soil absorption systems shall be made by an Individual carrying one of the following licenses or certifications:Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).Tank inspections niust include a visual inspection of the tank(3) to identify any missing or broken hardvrare, Identify any cracks or leaks,measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soilabsorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluenton the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediatenotification of the local regulatory authority.When the combined accumulation of sludge and scum in any treatment tank equals one-third (5^) or more of the tank volume, the entirecontents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113,Wisconsin Administrative Code.All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,and any servicing at inten/als of S12 months, shall be performed by a certified POWTS Maintainer.A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.GMW-OOS (02/05)
START UP AND OPERATIONFor new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or otherchOTicals Of s^iment that may impede the treatment process and/or damage the soil absorption system, if high concentrations aredetected have the contents of the tank(s) removed by a Septage S^dng Operator (pumper) prior to use.Pump tanks may fili above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under theseconditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing anovenoad that may result in the bacltup or surface discharge of effluent and damage to the system. To avoid ttiis situation have the^® rOTOved by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumberor POWTS Maintainerto assist in manually operating the pump controls until normal effluent levels are restored vwthinthe pump tank.System start up shall not occur when soil conditions are frozen at the infiltratlve surface.Do not drive or park vehicles over tanks or the soli absorption system. Do not drive or park over, or otherwise disturb or compact thearea within 15 feet dovm slope of any mound or at-grade soil absorption area.Reduction or eliminaUon of the following from the wastewater stream may improve the performance and prolong the life of the treatmenttanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, d^reasers, dente! floss,diapers, disinfectants, fats, foundation drain (sump pump) dischaige, fruit and vegetable peelings, gasoline, greases, herbicides, meatscraps, medicaflons. oils, painCng products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge.ABANDONMENTWien the POWTS fails and/or is permanently taken out of service the foliovring steps shall be taken to Insure that the system is prajerlyand safely abandoned in compliance with s. Comm 83.33. Wisconsin Administrative Code:• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (pumper).• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soilgravel or another inert solid material.CONTINGENCY PLANIf ttie POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliantreplacement system:□ A suitable replacement area has been evaluated and may be utilized for the looatlor^ of a replacement soil absorption system.The replacement area should be protected from disturbance and compaction and should not be infringed upon by requiredsetbacks frcm ewsting and proposed structure, lot lines and wells. Failure to protect the replacement area will result In the needfor a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules Ineffect at the time of their permit issuance.□ A suitable replacement area Is not available due to setback and/or sdl limitations. If the soil absorption system cannot berehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.□ The site has ncrt been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluationmust be performed to locate a suitable replacement area. If no replacement area Is available a holding tank may be installed as alast resort to replace the failed POWTS.□ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrativesurfece. Reconstructions of such systems must comply vrtth the rules In effect at that time.WARNING- TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACKSUFFICIENT OXYGEN TO SUSTAIN UFE. NEVER ENTER ANY TANK UNDER Af^ CIRCUMSTANCE. DEATH MAYRESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.ADOmONAL INSTRUCTIONS:POWrS INSTALLER POWTS MAINTAINERName PoLNamePhonePhoneSEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITYNamePhoneName <ZhPhoneThis document was drafted by the staffs of the Green Lake. Marquette and Waushara Courrty POWTS regulatory agendes In compliance vrith secUonsComm 63.22(2)(b}(1)(d)&(f) and 83.54(1), (2) & (3). Wisconsin Admirtistrative Code.
1PLB67Slate and CountyPernitt Applicationfor Private Domettle Sewage SystemsState Permit # —County Permit #County ggyyer108067-048•DENOTES STATE APPROVAL REOUIREDDate Approval Received from State if RequiredCST 5-24State Plan ID. # -€jOfg-ga>u> i/fA. OWNER OF PROPERTYMailing Address:tu'///e^AA PJJy pAifoA/loY^—B. LOCATION: Section ^a;, T^N, Rj£l E for) JfiL Lot# —i—Clty.nearest road, lake or landmark VillageTownship V-C. tYPE OF OCCUPANCY; •Commercial.Subdivision Name,Qovt Lot 2•Industrial.'Other (specify).'VarianceSingle family r( Duple*.No. of BedroomsNo. of Persons.D. TYPE OF APPLIANCES: Dishwasher YES Jf NO Food Waste (Srinder YESX_NO # of Bathrooms-/.Automatic Washer ^YES y NO Other (specify)E. SEPTIC -TANK CAPACITY.'Holding tank eaoaeitvNew Installation V'Poured in Place..AdditionSteelr> Total gallons No. of tanks .Total gallons No. of tanks._____ ReplacementPrefab Concrete.Other (specify).F.31 V Total Absorb Area_5*^g__sq. ft." y.?s-.Tlle Depth.No. of Trendies.EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_New sT Addition Replacement 'Fill SystemSeepage Trench: No. Un. Feet Width DeathSeepage Bed; Lenath ' Width / _ Depth Tile Depth No. of Lines —Seepage Ph: Inside diameter Liquid Depth Tile Size y"Percent slope of lond___^2__L__ Distance from criticol slope/£j.^I, the undersigned, do hereby certify that the Information I have repotted is in accord with Section H62.^,Wisconsin Administrative Code, and that I have siied the effluent disposal system from the EH-115 preparedby the Certified Soil Tew, ./ y - .name C.S.T. # and other rnformattonobtained from (owner/builder).Plumber's Signature jgSKMPRSW#'s ntyJ-Ufs vPhonePlumber's <PLAN VIEW: Provide sketch below of system (Include direction of slope and all distances in accord withH62.20, including well).•s-snpI,.0.<51/3J/a'.I _I;ITT"Db Not Write.in Space Below - FOR DEPARTMENT l»E ONLY tk nn „Dite of y^ieation 10-6-77 Fees Paid: State 1.00 County Ig.OO DatePnmit fflritiil 10-6-77 Isswtw Agent Name LorX OagrylIrspection Yes^Jdw-^ ^6 Oune. i'ill Valid# D«e Rec'dhitA'V'eoDv)county (whitt'7eopy)3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 310 June 197709, MADISON, Wl 53701
Sawyer CountyInspection ReportAddress //Jt s/k/nfirhz-u^.Description a/p.^. ss- 7Z,h. i>o^fj/i/ff-ZeOwnerName of business _Builder ^S-g./^- acL/A^^r''Plurober D» T^oinp<io{v^Inspection(fc^ Private ( ) PublicViolation( ) Sanitary ( ) ZoningAddressAddressPropertyDwellingMobile HomeGarageu'l Sanitary installPrivySetback-lakeSetback-roadSetback-lot lineIKS tv"tV «»-p KvyVn-g ^ ~Discussed with ownerDiscussed with builderDiscussed with plumber) yes) yes MvO yes i )nononoDateXLSignature of Officer