HomeMy WebLinkAbout002-940-01-5220-SAN-2022-025 :�;�="';'.;i,. Industry Services Division Counry
4822 Madison Yards Way �Q).�.
..,.��' ,- Madison,WI 53705 nST�-D/9 Sanitary Peimit Num er(to be filled in by Co.) �
s P.O.Box 7162 n
Madison,WI 53707-7262 ��9O3� ru
I
Sanitary Permit Application State Ttansaction Namber �
In accordazice with SPS 383.2I(2),Wis.Adm_Code,submission of this form to the a�ropriate governm�tai wut
is requi�ed prior W obtaining a sanitaiy permit Note:Applicarion forms for state-owned POWTS am submitted io Praject Addiess(if different than mailing address)
the Department of Safety azd Pmfessional Sercices.Personal infamation you pmvide may be used far secondary
Purposes in accorda�e we#h ttte Priwai.y Law,s. 15.04(t}(m),Stats. �GQ(M�
I.Applicatioo Information-Pfease Print All Iafermafian
Property Owner's Name Parcel# �p -Q� - O
i
G: �� Ca ��w�.�cr lr� � �c����
Propecty Own 's Mailing Address Proper�y Locatioa
y� a �o�r-t �. ��`�t�
City,State Zip Code Phane Number
��,W�-P/� � �� � ��3 l J r�CIJ��-v J`�� �K� DC Section U �
IL Type o#Bu�di[tg(c5eck all that apply) Lot# T �d N R � E o
�!or Z Family Ehvelling-Namber ofBedrooms 3 � Subdivision Narrre ^— y
Block#�
�ublic/Commen.ia!-Descnbe Use
ity of
tate O�wecl-Desc:ribe Use CSM Number illage of
3111 l� ��64(0 �'°`",oc (��Q.eSS C.G�l�.�
III.TyQe of POWTS Permit:(Check either"New"or�ReplacemenP'and other applicable on line A. Check one box on line B_Complete line C i
a licable.)
A" �few System � �Other Modi6catioo to Existing Sy (ezpJam} Additionai Pretreatment Unit(explain)
--•� 5'�T- l,�Q� o�,l
B� ❑Eiolding Tank �1mGround ❑4t-Grade �Mound Individual Site Design Other Type(explain)
(c�ventional)
C• ❑Renewal Befoie �Re�-isian ge of Ptumber �I'ransfer to New Own '���70���t Num6er and Date Ls�sued
�P� 8Y- oY� $"�3� 8Y
IV.DisQersaUT'reatment Area and Tank Information:
Design Flo�(gpd) Design Soil ApPl�cation Rate(gpolsfl Disper�j:1iea Requimd(s fl (s� System Eievation �
� 6 .� �' o C�' �oo -z7
Capacity m Totat #of Manufacturer
�
Tank Infoimation rr�ltons Gatlons Units � ` o j v
� c' � y '", va
New Tanks F_xivtiog T�L � o ¢� � � � r �
n. U �n �, v� cz. C7 w
s����T�,k �'C� C� lJ� � lL��(L�rc�.
nas�pg c;nam�r �� � � � �
V.Respoosibility Statemeat-I,tLe aade,-�g�ed,aRs�respoaebility for i�ta8ation ef the POWTS shown o�t�e attacked plaas.
Plumber's Nazne(Print) Plum re MPIMPRS Numher Business Phone Number
�� LH .��i��� �1� �3c�/ 7 l���S-��!3
P(umber's Addre�s(Street,City,State,Zep C.ode)
05�� N T(Jl�=� -l-v`E����-�iG-s� ��l/f�- C,�� 5 c�
VI.County/Department Use Only
� 3 (� ����roti,� Pertnit Fee Date Issued Lssuing Agent Signatuce
7�►'� �Qwner Given Reason for Deaial � I�U'�V .3-�sf-o2oZ.
Conditions of AppmvaUReasons for Disapproval
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SA ER COUNTY l_------ - ,
pNlivG ADMINISTRATIOM
_ __.,
' Attsch W comQkte plans for the s��stem and submit to the Couoh ooW oa paper nat kss t6aa 8 t/2 a ! size � `''
NO REFUNDS AFTER
SBD-6398(R.Q3/21) 15SUE 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
Owne� Name(s):'�y�,,�,r, �o- ��l�-���-�,��y�Phone:�-��-�_
Owner Address: �y(d�jQ {��jn,-(-- (,�c/; lin,,a t (� Zip: 5�'��
Project Address:
Govt. Lot: _� _1/4 of 1/4, Section�"'�, T�(�N-R �' E ❑or W�
Township: �j(��'��(�L1� County: ���r
Project Parcel ID #: �G��L� � �r 7��
Designer Information
Designer Name: � ��('� � �",�u� Phone:7/� -���'- �L'��3
Designer Address: � ; Zip: J���"�
E-mail: u�C�.�`��-��:�-
License Number: ��g��j� �
Remarks:
r
Signature: Date:
Original signature required on each submitted copy.
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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 Operatinq Limits:
Design Flow= Ll �� gpd; BODS <_ 220 mgL-'; TSS <_ 150 mgL"'; FOG <_ 30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
c 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)
c 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.)
„ electrical components- if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
c 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 (113)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:�l�C� � ~ � Phone: 'I/G;•-�-,��—�L,7�
Local government unit: Phone: �C -��iJ���-�"�C
Local government unit address: Y ZIP:;����
Any defective part of this system shall be repaired, replaced, or removed pursuant to S�"��83.51 (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.
J
• {� � �
-�"�����'. Officc of
� _
�` � � �"� �� �Sawyer County Zoning Administration
10610 Main Strcet Suitc 49
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Hayward Wisconsin 54843 ���'~-�'�''�'"1
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� �R CO �� (715)634-R2R8 � �f 7 � ; �
=t1� G�/� FAX(715)63H-3277 �;��._ i�_�'j`_;i �
%Q/ a� wwwsawvcrcount�ov.ore � f �J�
�fq� � ��[� 1:-mail:zoningscc(ci�saw�crcount ov.org ��� � � � ) /
I � `��_ _ _ � � Toll Frcc Courfhouse/General lnformation]-877-699-4110 �Z' ��
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� SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
, „r , •
PROPERTY OWNERS NAME: � ' �L � tif' <<� ��;���,� , --'� ' �
� . �-�
TOWN OF: �7(,���� C1-�-�J
ADDRESS: I� ��� �U� �' IC� G�i �� ��-'1� ��.5���
I, ���ttJs� tG , a Wisconsin
Licensed Plwnber, authorized by the owner, do hereby acknowledge that I am receiving
tei��porary 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 inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage systein is found to be failing as de�ned in s. DSPS 38].O l (92), Wisc.
Adin. Code, corrective measures will be taken as such that the private sewage system
coinplies 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 the
deadline date may result in the issuing of a citation, under Section 11.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR T I GREEME BE:
� �� �� �
Signed:
Date: ������2 �Z 1
Accepted by: �A�
Date of temporary emergency approval: � ��- �,�- �
Rev. 03/26/13
3/14/22,9:06 AM Real Property Listing Page
R2al EStdte Sawyer County Property Listing Property5tatus: Current
Today's Date: 3/14/Z022 Created On: 4/29/2010 10:12:15 AM ,
-_�
�'Description Updated: 6/8/2011 '� Ownership Updated: 5/20/2011
---
Tax ID: 40748 DWAYNE E R&CATHY A GORMANSON HAYWARD WI
PIN: 57-002-2-40-09-01-5 05-002-000200
Legacy PIN: 002940015220 Billing Address: Mailing Address:
Map ID: :2.20 DWAYNE E R&CATHY A DWAYNE E R&CATHY A
Municipality: (002)TOWN OF BA55 LAKE GORMANSON GORMANSON
STR: SO1 T40N R09W 14630W POINT DR 14630W POINT DR
HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT GOVT LOT 2 LOT 1 CSM 31/110
#7696 MFL CLOSED
Recorded Acres: 11.680 � Site Address * indicates Private Road
_ _
Calculated Acres: 11.713 14630W POINT DR * HAYWARD 54843
Lottery Claims: 1
First Dollar: Yes i...-) Property Assessment Updated: 6/4/2815
Zoning: (F-1) Forestry One 2022 Assessment Detail
ESN: 406 Code Acres Land Imp.
G1-RESIDENTIAL 1.790 18,700 380,400
� Tax Districts Updated: 4/29/2010 y�/g-MFL CLOSED-BEFORE 9.890 20,800 0
_.. _ _ __ _
1 State of Wisconsin Z005
57 Sawyer County
002 Town of Bass Lake Z-Year Comparison 2021 2022 Change
572478 Hayward Community School District Land: 39,500 39,500 0.0%
001700 Technical College Improved: 380,400 380,400 0.0%
Total: 419,900 419,900 0.0%
+� Recorded Documents Updated: 10/28/2014
� WARRANTY DEED �
Date Recorded: 1/17/2000 281932 696/188 r :, Property History
O MFL AMENDED ORDER Parent Properties Tax ID
Date Recorded: 9/25/2014 392399 57-002-2-40-09-01-5 05-002-000010 2676
� NOTE
Date Recorded: 6/24/2014
O CERTIFIED SURVEY MAP
Date Recorded: 4/27/2010 366Z16
p MANAGED FOREST LAW-MFL
Date Recorded: 12/18/2003 318102
O NOTE
Date Recorded:
HISTORY O Expand All History White=Current Parcels Pink=Retired Parcels
O Tax ID: 2676 Pin: 57-002-2-40-09-01-5 05-002-000010 Leg.Pin: 002940015201 Map ID: :2.1
40748 This Parcel Parents Children
https://tas.sawyercountygov.org//system/frames.asp?uname=Kathy+Marks 1/1
,'�;t'=`"'"E��; pRIVATE ONSITE WASTE TREATMENT county
!%�
���Sp ��',, SYSTEMS SaWyer
;�,., � s %r ( POWTS)
\AIFl)'Gt1V.�p�
' -- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� � �j 2 �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
Q h.e �}- ��n �c,�4�n S�✓1 ��S S ��--2
insp BM Elev: M Description: Parcel Tax No:
�c�.a' o� �jn''c.I�` �o��(f%� �oa_`lyU � ol - S��o
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � � (O(�,� Benchmark �/.�,` (Oy.a.,� (C7�•a'
Dosing � �'� pc� -
Aeration Bldg. Sewer �`
Holding St 1 Ht Inlet 7.q � �b.3�
TANK SETBACK INFORMATION st I Ht outlet �.a ' �j�,��
TANK TO P/L WELL BLDG AIRINTA�KE ROAD Dt Inlet $ , l ' �16 ( '
Septic �-�� -}$a � s'� �F(S� NA Dt Bottom l a,(�� �( �.6'
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist, Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Welf
DISPERSAL CELL INFORMATION
DIMENSIONS IN L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P I L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia 1 Length Dia Spac _ _ Spacing ❑Yes ❑ No
SOIL COVER
� Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges �Topsoil � ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
���//e�( gl � � l�� 1
�s1� 3`�- �Y?� � , � . �P��'e�'�' 6 n�
�
Plan revision required?❑ Yes❑ No 03 �g �� � � lj�j ,� ��
C�l �_ � �- __�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITARY PEAMIT NUMBER; o�a —���
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