HomeMy WebLinkAbout012-640-09-4201-SAN-2022-040 ` �.n'rcru;ti , County .
��' tndustry Services Division Sa.vyer
�'�� �� , �i J_I 1400 E Washington Ave 5����y p���t Noma:,r(to be filled in by Co.)
', `.i �� P.O. Box 7162 �
,, � -� Madison,WI 53707-7162 / 3 ��� / �
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� Sanit�ry Permit Application Stat�Transaction23umber �
In accordance with SPS 383.21(2},Wis.Adm.Code,submission of this form to the r�ppropriate govcmma�Uil unit � �
is rcquimd prior io obtninio�a sanitary pemiit. Note:Ap{�lication Forms for stttte-crwned POWTS are submitted ro �
the Department of Safety and E'rofessiunal Services. Personal informatioa you provide may he used fior secondury �'�Ject P�dclress{if difforent th�u�muiling address}Q
u ses in accardunce wiilt;the Privacv La�v s.15.04 i m Stnts. 9iK?6 Trapper Treii �
I. A lieation Informafion-Pteaye Print All lnformation
Property(7wner's Name Pascet#
Wiifiam Gtesson 012b40094201
Property Owaer's Maiiing Address � Property Locution
1918 RaEeigh Rd
Govt.Loi
City,St�te Iip Code Yhone Numbcr NW'/,,SE'/,, Section 9
New Richmond,WI 54U17 (circiconc)
"f40N ; R6EorW
IL Type of Building(check�il th�t apply) Lot�
� I or 2 Family Fhvclling-Number of Bedronms^ � 3 Subdivision Name
❑Pu61icJCommerciul-Dcscribe t7se _y___.___ Bloek#
Q City of
❑Stute Owned-Describe Use
! CSM Numbcr ❑ ViEtuge of
24/14i}t�G52E� � Town of flunter
[Il.T e of Permlt: Check onl one box on tine A. Com lete line 8 if� licable
A � New Systerri ❑ Replttcemcnt Systcm ❑'t'reaimenUHotdin�Tank Repl�cement Only ❑ Other Modiftcation to Existin�,System(explain)
g. ❑ Pcrmit Renewt�f �Permit Revision ❑Chtuige of ❑Permit"I'r�nsfi.r to New i.isi Prcvious Pcrmit Nwnber and Dnte Issuc:d
BeforcExpirstion Plumber O�vner 2l ^ 2� ef116 �`
J(J
TV.T e ofPO�iJTs System/Component/Device: LCheck all that apply)
�Non-Pressurued In-Ground ❑ Pressurizc�lln-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soi! ❑ Mound<24 ia of suitabie soil
❑ [iutdi���'C'ank ❑Otl�er Dispersaf Component(explain) ❑FretreatmenE I?evice(expi�in)
V.DispersalJ'Tre$tment Are�Infor�nation:
Besign Fl�w(gpd} Desi�n Soil Applicsttion llispersal Area Required(s� Dispersal Arca Proposul(s� Systcm Elevation `�3 0
450 Ratc(gpds� 643 652
.� � `i ,d '
VI.Tank Iot'o Capucity in
Gullons Total #of Mrutufacturer � � U� � � ,�
New'fanks Eaisting Tanks Gatlons Units � � ;; � ,� �' � "�
0. U v� v, v� w C� d,
Septic or H�Iding Tank ]000 (0�0 1 Wieser �
Dosing Chatnber
V[E.Responsibility St�ternent-1,the nndersiti�ed,assume respo i6ili ur iqsWif�tinn of the PO�i'TS ahowri on the ettached plans.
Plamber's Nume(Print) Plumbct's Signatur MP/MNRS Number Business 1'hanc Number
I)a�t�usCh 253808 7 i 5.�t l G.t 642
Yiumber's Add�ss(Street,City,State,7ip Codc)
t 11RN t'ront Street Spooner WI 54$01
VIII. oun !De artment tise Ont
(� p�b�l^ ❑ Disnpproved Permit Fce Date Issued tssuing Agent Si ature
Uvner Given Reason for Dcnia[ $�.� �t-- _�-d-
IX.Co ditions of Approval/iteaaons for Disapproval ��
�� � 1 � O�� C.�•
� 5
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C s-� ��- - ��"� 9'��
AtMcb to camplete plaas for thr tem and suAmii to the Coaaty oniq on psper uo eas than 8 t/z x I t inc6ee in sisn
NO RCFUNDS AFTER
SBD-6398(R03/14) ISSUE OF PERMIT
PAGE 1�OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manua/Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12),,.
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Piot Pian
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
Owner Name(s): W I�1 il�.n� �L�S`'^' Phone: - -
Owner Address: t ��� I�.d !�E( G-t�1 12�� ,�I��c�M� a u '�� Zip: ��I J i 7
Project Address: �� �l� ��HP P�rL fi�A«
Govt. Lot: ��,I 1/4 of�1/4, Section � , T � � N-R_�E Q or W�
Township: �v au ri�L County: s;i�^'�G '1-
Project Parcel ID #: �J i �16`f ��9 `��J I
Designer lnformation
Designer Name: Dan Burch Phone: 715 _416 _1642
Designer Address: N5921 Cty Hwy K Spooner WI Zip; 54801
E-mal�: BU('Cr1p�Uf11bII1gIf1C@gfTtal�.COfT1 This space reser>>e�l for��pproval stamp.
License Number: 253808
Remarks:
Signature: Date: �'" f K '� �
Original signature required on each submitted copy.
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Septic Tank(s}Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA wieser
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s):
3-ft Trench (down-sizing credit) �oo0 9al gal gal gal
Effluent Filter Manufacturer:
Polvlok
�
EfFluent Filter Model#: 525
min.12"
SOIL COVER (rypical)
12"
min.Vench
depth
��vp��o �� < � TYPICAL TRENCH
—-- •-�.- •� �� .� '°�.a �<. CROSS SECTION VIEW
���,,p��> .:.�. .: ... .. . : . (No Scale)
n . a,. . �.
. " Provide minimum 3 ft
System Elevation —94 � separation between trenches.
(typical)
Quick4 Standard-W
w!End Cap Observation Pipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) ([ypical)
Install per ma�ufacturers PLAN VIEW
instructions.
(No Scale)
� ��.� ���:� — �.,- - - - �� - - - - - - - �� - - - — _— - - -�
� , �� . �� �. „:� �d , E,E _ ��� �A= 3.0 ft
� �I"i�i< �frG� — — — — — — — ��— — — — — — — — �� — — — — : — — — "— � � (tYPica�) �
�� B = 64 ft —i G�
m
(rypical) Quick4 Standard-W Chamber W
�tYPical) O
INSTALL PER TRENCH: (rntd by�nt�tretorsysterns,Inc.) -n
Install pursuant to manufacturer's instructions. �
16 Quick4 Std-W @ 20 f� EISA/chamber= 320 �Z
+ � Pairs of end caps @ 6 ft2 EISA/pair= 6 ft2
= Proposed EISA per trench= 326 ftZ Required Infiltration Area= 643 ftz Distribution Method:
x 2 trenches = Proposed Total EISA = 652 �2 btanched manifold �
PAGE�4 OF 4
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 shatl be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= �'� � � 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 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: DaCI BUI"CIl Phone: 715.416.1642
Local government unit: SBWy@I' COUflty ZOtling Phone: 715.634.8288
�ocal government unit address: 1061 O Main St. #49 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.
'„�'`'"'-`"E"%; PRIVATE ONSITE WASTE TREATMENT county •
�,:,
��`aa SYSTEMS Sawyer
��� Ps : � ( POWTS)
\���--=,<``�
""�"�"� INSPECTION REPORT Sanitary Permit No: � `�^
Safety and Buildings Division (ATTACH TO PERMIT) ��
GENERAL INFORMATION � ' . 3p y
Personal infonnation you provide may be used for secondary pu�poses[Privacy Law,s_ 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�'l ll���41�`� 4�ti�n� �
Insp BM Elev: BM Description: Parcel Tax No:
lOo. o � l a Ylb� � at�5�. c�lo" (M4 �� ad - 6Yo -c�7 - �f.2Dl
TANK INFO MATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w;� �pp Benchmark �vo,o'
Dosing
Aeration Bldg. Sewer q9 � �
Holding St/Ht Inlet '� �
TANK SETBACK INFORMATION St I Ht Outlet 97, � '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic +3o N ( 3� -F-�3' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �S,o`
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM �!S � �`/.o �
TDH Lift Friction Loss Sys Head TDH Ft s q�,o �
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR TIO �'e v �br'
DIMENSIONS W 3 � (o #of Cells Type of System Distribution Media ManufaCturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��� I
INFORMATION P 1 L Bidg Well Waters °� G � Chamber Model Number:
❑ EZFIow
CELLTO -�-�" fi o� N .}-'S'c7 ❑ Mound o Other Q�f
- -- � -------- -- -------- -
DISTRIBUTION SYSTEM X Pressure Systems Only
� Header/Manifold Distribution Pipe(s) �X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac ' ; Spacing ❑Yes ❑ No
- — ___.
SOIL COVER
Depth Over Depth Over �Depth of Seeded/Sodded Mulched
Cell Center �ell Edges i Topsoil _ �— ❑Yes ❑ No � ❑Yes ❑ No �
COMMENTS: (Include code discrepancies, persons present,etc.)
� �5�-a�G�i �� ��9(��
Plan revision required?❑ Yes❑ No p���2� � , �' 6 s � r(�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
• AOOITI�NAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBER:______ 21--_3O�__ __�-��-
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