HomeMy WebLinkAbout008-937-11-4302-SAN-2022-041 Industry Services Division � Cbun�� �`
� 4822 Madison Yards Way J U w � �^ �
� $� Madison,WI 53%OS �anitar-Pcrmit Numbcr(to c fillcd in by Co.) �
$ P.O.Box 7162 �
Madison,N'1�3707-7162 �3gD��Y n
� w
Statc T�ansaction Numbcr
Sanitary Permit Application , _ �'
In accordancc with SPS 383."_'I(2),Wis.Adm.Codc,submission of this fonn to thc appropriate guvcrnmcntai unit �' Q
is rcquircd prior to obtaining a sanitary permit.Notc:Application fomis for statc-owncd POWTS are submittcd tu Projcct Address(if diffcrcnt than mailing add��css)
thc Departmcnt of Safcty and Prot�ssional Scn�iccs.Pcrsonal inPomiation you providc ma��b'r uscd for sccondai}� i � ��� � � ������ � �
puiposes in accordnncc�vith thc Pri�acy La�a.,. I 5.0 3(11(in).Stac�.
I..application Information—Please Print Atl Information
P�apc�ty O��ncr's\zmc � Parccl�'
/�/l i k e IO�'e s c�.i �'.9�r ��d�e.,LL�. ' 008--Q3�- 1 I -Y3�a
PropcRy Owncr's Mailing.Address � Propery Location
i �t4Z7 � 3 � t�, a �� ! �,�,,..� SwsE
City.Statc Zin Codc Phonc Ncmbcr I .,,�,,� ��
�rn �a�1 s � ��I 7 i/ �/5-$2 8' - I l d '� -�'�°.-'- ` `a. s,<<��,,,
[L Type of Building(check alI that applv) � Lot� T��_N R_ _____E o�
�1 or2 Family Dwclling � NumbcrofRrdro��ms � SubdiviSionNamc
Block�+
�Public/Commcrciel -Dcscribc Usc _
��City oP
�Statc Owncd Dcscribc Usc CSM Numbcr il!agc of
— [�r�,�„�,i�_+�u.'1-e r _
ltI.Type of POVb'TS Permit:(Check either•`New"or"Re�tacement"and otht�r appiicable on line A. Check one box on line B.Complete line C if
a licable.)
A. _ --
�1Vcw Systcm �cpiaccrocut Sy,[cm �Ots;er Mouiiicai �io E�istmg Sy;t�.m(c�p!�u�) ��Add��lionul Prrtrratmcnt Unii(c.Kplainl
C7t c�C� �i ���Y' �
B' �1lolding Tank In-Ground �At-Gradc �Mound ���Indi�idua]Sitc Dcsigi� Othcr Typc(cxplain)
(comcntional)
C• ❑Rcncwal Bcforc �Rc��ision �C'hanec of Plumbcr �Iransfcr to Ncw O���ncr�i ��'t Prc•,ioua Pcmiit Numbcr and Datc Issucd
C�:xpiration ��'�,�7 .3a O
!
I�'.Dispersal/Treatment Area and Tank Informarion:
De�lgn Fi�m (^_nd1 �� Dctii�n Sui;:lp�licauon Ratc(vi���;(i C;�;p:rcal;�.rc«Rcqcird tst� D�:.�;,�� �I,\���.i� ^r<��f r>('I '� ���,t.m I`.�.�a:r�n
3 o p �� , 7 � ' `I Z �f � �� `�30�' 9 3. c� `
Capaciry in Total #of Manufaeturcr
:!
Tank Infortnation Gallons Gallons Units � � � � �
Neu�Tanks Existing T:mks 'u � _ C � 'J �^ �
I .` :� v: n ✓; i` .: c_
Septic or Holdin�Tank �v QO ��� 1 I (J N�f.�u �
� r�
Do.incChamhrr � � �
V.ResponsibilitV Statement- 1,the undersigned,assume responsibiiitr for installafion of the POW7'S shuwn on[hc attached plans.
P!umbcr�,Vamc l�tl Plumh�' �ei�aturc �9P��1PRS\ inihcr Bu�incs�Ph.��,i�_Numbcr
� e �r � � 2 i�i ��- &6�' 7�7
Plumbcr's Ad ress(Strcet.City.Stata 7ip C )
W I 3 3 I S i(/L �,c� L !c. � � � �K,� 3
YI.Co tv/Department Use Only
O D� Prrmit Fcc Datc Issucd 'Tr«•�,�cr,t`;i<<ninur:
t�Ap r�c� J Di�.ippro��cd I Z 1'1 C�+ � � L
I �
� ❑Owncr Giv�n Rcason for Dcniai ���/ —7_��
Conditions of Approval/Reasons for Disapproval ` ,'�`
��" � '�\• 1 . ���Ol��/Q1�ci"G"i S�' v�
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CS � �-� l��� �-���i'� � , ZOZZ
. _ ,_,__ {;�r
:�ttach to cumplete plans for the s��stem and submic to the Countp unh on paper not less[han S t 2 s 1 1 i�iUfieti,,ii��v§F',!..3�b�'�i'�i'^I �%i i�'� �
SBD-6398(R.03/21?
NO RCFIINDS AFTER
ISSUE OF PERMIT
. PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/G1, R. 10/12) . . �
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
Owner Name(s): /vl 1 k � � (�QS � I Phone: - -
Owner Address: I q�i 27 I 3 �5 tl� Gt v e Zip: �N�N�
Project Address: i �SG 2 /V �ll o r,c� c��t,�� �ci�
Govt. Lot: Nt 1/4 of $� 1/4, Section ) I , T N-R E❑or W ❑
Township: �"GP G e I�IJG,'�-�Y- County: S 0..wy � �.-
Project Parcel ID #:
Designer Information
Desi�ner Name: �rr'•� �c.hp�� b e,-c� Phone: 7/-��- 665�7�7f1
Designer Address: � i 3 3 / � /� u-0� l-k �;� • Zip: 5 y71 �
f-�i l: �C�W Q �.c � a.t r � , w 1� s�j7.�;�. . _.. . ..
�icense Number: � 2 2 7/ 7/
Remarks:
Signature: � Date: 2!� � 2 Z
Original s nature r quired on each submitted co .
i
/ ..r�.ECK 9��X.+,S�PP��_tCABLE �.,=�K_���Y�5.>��:CA3_" I
i !�SOIL �VA�L9ATlO� s�a�e: �" =50' j�'"SYST'�-i�/I �',`�G� 2 ��� I
I S I T E M A P ° 5a 75 '0° PLO� PI��N �
, � _ �
� PROJcCT NAME: � otsicN F�ow: — =�� c�o �
; /y�{ !' �` �12.Sftgdd; 12.5✓
i
/'' P K e 1�` +(e S� � Attach des;gn flow calculatior�s tor commerciai plans. i
I PRO,:ECT.�DDRESS: f�O � /'✓ �t�q.��. t:CA � Pipz Material/ASTM Stzndard(-abies 384.30-3&384.30-5) �•.
,� n i
� ,s� Sanitary Sewer. u _� 5=��'�. � `-�� i
BM Symbol: � BN�clevation: ���. �l FT Force Man: V\ �
t !
� BM Descript;on: C��v'�� � 1'�A��� � �tiC� ��t ►'�� �q�p i n
J � ��
Incica;z ronh by �''�1PORTAh-.
� Siope Grad',ent�%; � �� �vei��ymoc,, ap :�ca�le;. � raw-y a�a�c�. Show gro.:�d c.�z::o^cen:o.:�s at s��?able in?ervals. I
� ef Tested Area: fl o.,che zp ro rte lir.e.
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IN-GROUND GRAVITY D{SPERSAL AREA SepticTank(s)Manufacturer:
exfs-fi n4fN uffc�tt�
� Uniform Elevation Trenches with Washed Aggregate
Septic Tank(s)Volume{s):
2���� gal gal yal gal
�a dd -�Effluent F Iter Manufacturer:
� egt
I 4 � fluent Filter Model#:
���
Geotextile Perforated Lateral min.12" Effluent Filter Model#: G '�� �
Cover—�I (rypical) (lypical)
SOIL COVER �____._,_____
�Z" I 0.5"TO 2.5"WASHED AGGREGATE
min.trench I '
depth ` • ° , (min.6.0"beneath distribution pipe
(typical) � � , -min.2.0"over distribution pipe and
covered with approved synthetic fabric)
°•. :
S stem Elevation/�•� ft. ,'
TYPICAL TRENCH Y �typical) OBSERVATION PIPE DETAIL
CROSS SECTION VIEW ipv�r'-�' c�� i n � e t �?. S � c"°S��e,
(No Scale) Slp Cap(loose) �. �":-- Finished Grade
Provide minimum 3ft �"'��°he°�See°ed�
S2p8f8t1011 b@�V0811 tfellCflOS. 4"0 PVC Pipe ,:'.i Topsoil Cover
Top of pipe to terminate (min.1 foot)
atorabovefinishedgrade . �
(4)1/4"-1/2"X 6"Sipts
(Show�location of inlet/outlet pipe connection on plan view.) @ 90 apart
TYPICAL TRENCH
Anchoriny Device Intlltretion
PLAN VIEW 4„� ^ Surface
(No Scale) Perforated Lateral
(typIC81) Observation Pipe ft
(center lateral in trench) (�YP���) (rypical) �
i� I �i
- - - -��- - - - - - - - - - - - - � - - - � D
� - - - - - -- -- - � —
� -------------------------------- ------------------------------ � A= � ft 'n
o m
L - - - - - - - - - - - - -- -�i�-- - - -- - -� — (typical)
- - - - - - - -- - - - - - - u,
a = g6 ft „ „ -I p
(typical) e a c h �/3 ' w 7� h c e rte r �1
�
� �eed Distribution Method:
Required Infiltration Area= y� ft1 p �, ��
`�3 4����f� T
Proposed Total Infiltration Area = _�=i n�r per trench x _� trenches = � • ft�
�l�� _'_'
� R.ESET�
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 shail
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= 3 G� 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 n�glect 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 efffuent 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 filterls) 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: SC-�o e.��e�G S o ; ( �e s T i h G Phone: 7 /S fS 6 8�- 7� ��
Local government unit: �A`�y e r l. o �c� n� �c� Phone: (71 S1 b3`"�� ���
Local government unit address: ��b�� �a� J� �x-� '"l`l _ZIP: �'"�0`�3
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 f�iled 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.
- USE BLACK INK ONLY - � I I `lJI ,I II)II�,�lI,I)
POWTS HOLDING TANK AGREEMENT 8 �x64038695 8
RELEASE ��9682
Owner's Name(s)as shown on deed: PAULA CHISSER
REGISTER OF DEEQS
2� I. -(� SAWYER COUNTY, WI
1�� ��� � Q--- L,LC'. �i Wt, �.Jt QS2' 06/14/2022 02:47 PM
Parcel Identification Number: RECORDING FEE 3Q.C1U
(12 Digit Legacy ID) Q � 8 -.� 3 �- i I - Y 3 � �
PAGES: 2
Legal Description of Property:
- SEE ATTACHED SHEET -
Return To:Sawyer County Zoning and Conservation Administration
10610 Main St.Suite 49,Hayward,WI 54843
��`^"a�d �-�\ entered into a POWTS Maintenance Agreement for
Holding Tanks on ���� a� �oo� (date of Agreement) ���77�
(document number) for Property located at �1$��1� Wno�a\e, 1Q� ,
(address) and as described and attached hereto.
This release, signed by an Authorized Sawyer County Zoning and Conservation
Administration Staff, relieves the owner and property from said Agreement as they have
obtained a sanitary permit to install a non-holding tank POWTS. The current owner, their
heirs, successors and assigns agree to abide by Wisconsin State Statute 145.245 (3) relating
to pumping of this new system.
Authorized Signature: , � ACKNOWLEDGMENT
State of: �n/�,�v n 5 ��
Authorized Name and Title (Print): County of: �c�w�c�
��cwe�tq..c?,S'� �o�.�n'�" �i�'ari�h �„�.N N,,, Subscribed and sworn to before me on this I�day
Date: r `��,�Z'� Ws�iBY,,� � �n� i�r�l u� ('20 ��
0 61��t� �a� r`�-�`� . ' . k' •, _
Drafted by: s :��O RY Not�yy Public Signature: 1 _
�(`i c W2�1 ct�eT— i � -'' �`G a�I� Notary Name (Print): ct � �s z/r LJS�',
,',, �•. ��mmission expires on: '� c�l/�b _
�, ;p�'.y''• .... G `, '
��`''��OF„�5`'°�
Personal information you provide may be used for secondary purposes[Privacy Law,§ 15.04(I)(m)J Rev.03/26/13
!
�he •Wl/2 of the I�l/2 of the N1/2 of the SWl/4 of the
SE1/4 , Section 11 , Township 37 North, Range 9 West ,
Town of Edgewater , Sawyer County , Wisconsin .
�� `- ``� PRIVATE ONSITE WASTE TREATMENT county
/f*t1`` \^'��' SYSTEMS
'�� �SP ��� Sawyer
��'�,��j�' ( POWTS)
A `_. �tP
`�s"<'�`•= INSPECTION REPORT sanitary Permit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2 /
Personal inYonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)J �"� b�l �
Permit Holder's Name: n.�;� ❑City ❑ Village � Town of: State Plan Transaction ID#:
i Lo C.C. �'```x'\ ��.4'�- r'
Insp BM ev: B escri ion: Parcel Tax No:
loa.a' c��. ��l.,�, ex5�., c�.lo 1.,� ? va�- a 37- !I - Y3o�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic exu�,� �{� �� Benchmark jpp.p�
Dosing
Aeration Bldg. Sewer
Holding St I Ht inlet
TANK SETBACK INFORMATION St/Ht Outlet �,78 '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Installation �6 � �
Contour �
Aeration NA Header/Man. 4�f.( '
Holding Dist.Pipe
PUMP151PHON INFORMATION Infiltrative �3��►
Surface
Manufacturer Demantl Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W ` L $6� #of Cells Type of System Distribution Metlia Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P I L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELLTO t��� �i-�.S" ,}�' N o Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
- — - --_.
Header I 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 l Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��S�ll� � ��Y��
� ��� �'� Ca��,
--
Plan revision required?�Yes ❑ No � �
o� o �. , ��/�
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT Nl1M8EA: oZol� O�(I
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