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Home My WebLink About026-939-12-5214-SAN-2022-098 � ��, County �� Safety and Buildings Division sawyer 1� �8 - 201 W.Washington Ave.,P.O.Box 7162 s�n��ary permit Number(to be filied in b� Pa - Madison,WI 53707-7162 /' � � C� ��j � � a Sanitary Permit Applieation state Transaction wumber � _ In accordance with s.SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govemmental 1 unit is required prior to obtaining a sanitary permit. No[e:Application forms for state-owned POWTS are submitted project Address(if different than mailing (� to the Departrnen[of Safety and Professional Services. Personal infortnation you provide may be used for secondary n u oses in accordance with the Privac Law,s. 15.04 1 m,Stats. -�� I. Application Information-Please Print All[nformation 6627N White Ln � Property(hvner's Name Parcel# Ellen Ullsvik 026939125214 Property Owner's Mailing Address Property Location 1934 Nakomis Ave Govt.Lot 2 City,State Z.ip Code Phone Number ya, '/4, Section 12 LaCrosse, Wl 54603 T 39N; R 9 W [I.Type of Building(check all that apply) Lot# � 1 or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name Block# ❑ Public/Commercial-Describe Use ' ❑ City of � State Owned-Describe Use CSM Number ❑ Village of �. � Town of Sand Lake III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ❑ New System � Replacement ❑ Treatrnent/Holding Tank Replacement Only ❑ Other Modification to Exis[ing System(explain) System B. ❑ Permit ❑ Permit Revision ❑ Change of ❑Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner /,��` ? Ex iration �'� IV.T e of POWTS S stem/Com onenUDevice: Check all that a 1 � Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatrnent Device(explain) V.Dis ersaUTreatment Area Information: Quick 4 Plus Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed{s� System Elevation 600 .7 857.1 870.2 92,91 stepped VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Uniu � o b u U � New Tanks Existing Tanks `'�y° c � L � � � � � o a� U iT :n �n u, Ci a Septic or Holding Tank �250 1250 1 wieser � � � � � Dosing Chamber ❑ ❑ a ❑ ❑ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumbers Signature MPiMPRS Number Business Phone Number Gerald Froemel �� 95011 l 715-558-1138 /i°- PlumbePs Address(Street,City,State,Zip Code) 13502W Froemel Rd Ha azd,WI 54843 VII1. /De artment Use Onl �.App � Disapproved 1'ertnit Fee Daie Issued Issuing Qgent Sign ure , ❑ Owner Given Reason for Denial $ l�•�� I �� ' I L""'"`"""i�v��Y IX.Conditioos of Approval/Reasons for Disapproval ; D � � � ��li� �� s -- o � s� — ,, N � � i Q C a � �� a �oZz ____._ . Attach to complete plans tor the system and submit to the County only on paper not less t6an 8 1,2 x i l inches in size , SBD-6398(R. 11/i l) �IPJa ApMIPJISTRATlO� NO REFUNDS AFTER ISSUE OF PERMIT Ellen Ulisvik Rev Trust Property Owners Name 6627N White Ln Property Address C�26939125214 Tax Parcel Number Sawyer County .�.�� 2 Gov Lot or Qtr-Qtr/Qtr S12 Section T39N Town R9W Range Page Index 1 Property Information 2 Data Entry 3 Plot Plan 4 Drainfield Cross-Section 5 Dose Tank 6 Maintenance Plan 7 Contingency Plan County Parcel Listing Gerald Froemel Plumber's Name � Plumber's Signature 950111 Plumber's License Number 715-558-1138 Plumber's Phone Number 06/01/22 Date Not an endorsement,written or implied for the following companies and products;DelZotto Concrete,Wieser Concrete Products Inc.,Skaw PreCast Co.,Huffcutt Concrete Inc.,Zabel Environmental Technology,ITT tndustries(Goulds),The Pentair Pump Group(Myers), Infiltrator Systems,ADS Products,Polylok Inc.,Orenco Systems Inc.,SimlTech Filter Inc.,Sta-Rite Industries, 1 Page 1 of 7 � � ��t In-Ground Soil Absorption SBD-10705-P(N.01/01)Version 2.,, Component Manual Used 4 Number o Bedrooms 4 Percent Slope (%) 114 Depth to Soil Limiting Factor (in.) 0.7 In Situ soil apptication rate 400 Estimated Wastewater Flow (gpd) 600 Design Wastewater Flow (gpd) 2 Number of System Elevations 92 Proposed System Elevation#1 91 Proposed System Elevation#2 Proposed System Elevation #3 Original Grade#1 95.2 Finished Grade#1 Original Grade#2 93.7 Finished Grade#2 Original Grade#3 Finished Grade#3 Infiltrator Quick 4 Standard Chamber Type 15 Height o hamber (in.) 0 sq.ft. per chamber 2 Rows of Chambers 5.1 sq.ft. per pair of end caps 3 Distance Between Cells (ft.) 43 Proposed Number of Chambers Used 857.1 Minimum Distribution Cell Area Required (sq.ft.) 870.2 Distribution Cell Area Proposed (sq.ft.) Wieser 1250 ESeptic Tank ose an (if applicable) Llfetlme � T � �Effluent Filter �"'select only if NOT using combo tank Soil Boring SurFace Depth to Lowest Highest System Number Grade Limiting Elevation Elevation Elevation Elevation (ft.) Factor(in.) Acceptable 1 � 95.20 114 88.70 93.95 TR U E 2 .7 96 88.75 92.50 TRUE 3 4. 1 88.90 93.65 TRUE 4 5 Page 2 of 7 owher� �� EI�n �C. I (s�► (C ({e�T'r'us�- Saw,r- Co.� SQ�d La.ke Tw� 1� 34 �akawtis ��. �r1J : OZIo-939— [2- SZty L.� �r o s s�, c-c� ► s y b o3 ,� I 2 7"' 3� � R o�j c� 2, S Z 4 c.. �— S� le : (o loZ`7 t� W�'1��,e Lvt _� . � K- (.c� �;��•s (.� L a��e �-- ± 7Z� � — �r---�=--� �Z3a c-�1,�-e _. Sc.�� 1``=`��' � +ioo� a io � a, uo „►Jo+ -�'o scale„ J � " � S ��,Le IK �I� 0.�t� SO t I � `� �. 3 l e s-E a.c-e� a v�l� ! o� y5 ` .� �� ' X �+o� /, 8►�'l��v o P o�wl�L( , � Q� �r �n B l , 95.L� • �" �, o Z �i3.75' 8►� �oo' � 3 3. aY.9 ' c�,�ll ° � , � S o: �5 ♦ II _ Sc.�sf e�. u�trTr9Z� aL �a�"�f'o01K ir� 9a�ra��G �,,,pwMT►—�((� C�o �a,r Z 6 b �s�-sT ia t`ts=4�i` c�a � ��o � �b �"� . .� ho��a� a�'`� ��r v�5-2_ _ r � h � + �� !�i„��,y .SP�..r.L L..�.I �C C�c' �,�S ��i�'f S. � � � 3 � N � L ; i�i� � ��5�� Cross Section of a Two Cell In Ground Ccmponent Using Leaching Chambers Observation/Ve�it Pipes // � 95.20 Finished Grade ' �.-- — - � Finished�rade— 93.75 Slope 4% /I CeN'Seperation � .__ , \' �=--�J" t ,, _, � . � ,' � ,- '"� % ��` ��J �' x �� i Original Grade- . ��,��`,�, ' ! .k,-'�, ,.ffriginal Grade 93.25 Top of Chamber ____ _� _ ti',�,-' , ' �._ __ L«_;�_.'�Top of Chamber 92.25 . ., 92.00 System Elevation _____ /�• .. .: ,' ,__ '" System Elevation 91.00 .. • , � . . -.r__. ' .• .l'reotrr,ent�pnd'Dispersa�.Zone•. � . , : ` . ` . �, • . , . . , . , . , , ,.. . , . . • - -� -- ---- � - � . . ____�_..� � l imiting Factor Ubse�vot o�/Ven: pipes to be consti�cted ond capped w�th approved moteriols for the porticuler use. Dia rams Not To Scale _. - - - - -_ _ " ' ��I O � `-��i � � � _ � i z� I�NA dM�1�, �� O II� �� - _ _ ---._ _ _ — _. _---__ _ � � — 1 __.. , a _----- 5 � ---- . . _.. ._---. . . . -'`. '��1��,'i�V' ��IA�' s.'�Il �`. � .as�rr� �an�s er� �► ��w. � ��. � C" ) bservation/Vent Pipes to be located 1/5 to 1/10 the length of the distrution cel�measured from the end of the cells Page 4 ot 7 Ellen Ullsvik Rev Trust 6627N White Ln 2.69E+10 Number of Bedrooms 4 Septic Tank Wieser 1250 Estimated Flow(average)gallons/day 4 Effluent Filter Li etime Design Flow(peak),(Estimated x 1.5)gal/day 6 Pump Tank #N/ Soil Application Rate gal/day/ft2 0.7 Pump Type Influent/Effluent Qual" Monthly Average Fats, Oil &Grease(FOG) 30 mg/L Biochemical Oxygen Demand (BODS� 220 mg/L otal Suspended Solids (TSS) 150 mg/L , ��v 5." Servicing frequency of 12 months or less requires the Management Plan be recorded with the Register of Deeds. Maintenance Schedule Service Event Service Frequency Inspect condition of tank(s) At least once every Year Pump out contents of tank(s) When combined sludge and scum = 1/3 of tank volume Inspect dispersal cell(s) At least once every 3 Year Clean effluent filter At least once every ear Inspect pump, pump controls &alarm At least once every � Maintenance Instructions Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, Septage Servicing Operator. Tank inspection must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any backup or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals 1/3 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. A service report shall be provided to the County Zoning Department within 30 days of any service event. Start-Up and Operation For new construction, prior to use of the POWTS check treatment tank(s)for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank removed by a licensed Septage Service Operator. System start-up shall not occur when soil conditions are frozen at the infiltrative surface. Page 6 of 7 Do not drive or park vehicles over tanks and dispersai celis. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fat, foundation drain (sunnp pump)water, gasoline, grease, oil, painting products, pesticides, sanitary napkins, tampons, and water softener brine. Abandonment When the POWTS fai►s and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with Wisconsin Administrative Code SPS 383.33; -All piping to tanks and pits 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. -After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. Continqency Plan If the POWTS fails and cannot be repaired the following measurers have been, or must be taken to provide a code compliant replacement system: (Check One) "' The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation shall be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed to replace the failed POWTS. ' A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structures, lot lines and wells. Failure to protect the replacements area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. A suitable replacement area is not available due to setback and/or soil limitations. A holding tank may be installed to replace the failed POWTS. ��VI/ARNING!! Septic, pump and other treatment tanks may contain lethal gasses and/or insufficient oxygen. Do not enter a septic, pump or other treatment tank under any circumstances. Death may result. Rescue of a person from the interior of a tank may be di�cult or impossible. POWTS Installer Septic Pumper Name Gerald Froemel Name Scott Poppe , _ _ Phone# 715-5 - 3 Phone# 4- 4 �� POWTS Maintainer Local Regulatory Authority Name Jays Septic Agency Sawyer County Zoning Phone# 715-55 -11 8 Phone# 715-634-8288 Page 7 of 7 '"'`'"—'�'"��r,> PRIVATE ONSITE WAS1'E TREATMENT county ,'�� e$ '; SYSTEMS SaWyer �.�� Ps � ' ( POWTS) �� .,�; �'RUFF,____/.'��. �"'°��'�`' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �a — 6c�g Personal infonnaCion you provide may be used for secondary purposes[Pnvacy Law,s. 15.04(1)(in)] Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: ��ev, �«5�;k sa�. �-a� -- Insp BM Elev: BM Description: Parcel Tax No: �oo.o` � 6� �\� n2b-`�3`t- I 2-��I TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic w�� Sp �� Benchmark )p�,p� Dosing a(� � q�,� r Aeration Bidg. Sewer� q��9 ' Holding St/Ht Inlet �j S 6 � TANK SETBACK INFORMATION St/Ht outiet �tS. Y ' TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR INTAKE Septic k(o �� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. �f.J.o' Holding Dist. Pipe PUMP I SIPHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade Model Number GPM S l �l�o� TDH Lift Friction Loss Sys Head TDH Ft s, 4�,� � Forcemain L Dia Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W 3` L gp' � #of Cells o� Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate �� P I L Bldg Well ❑ IGP � Chamber INFORMATION Waters � AG o EZFIow Model Number: ❑ Mound o Other CELL TO -1'S� �--- �_ t�_- _— —. _ -- - Y� - -- __ DISTRIBUTION SYSTEM X Pressure Systems Only Header I Manifold Distribution Pipe(s) �X Hole Size X Ho el Observation Pipes Length Dia Length Dia Spac Spacing ❑Yes ❑ No - -- — --__—_—. SOIL COVER - - -�- _-- Depth Over Depth Over j Depth of Seeded/Sodded Mulched Cell Center � Cell Edges ; Topsoil _ ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��-►.�ll�, �I�S��-� �-� I Plan revision required?❑Yes❑ No i ��3 �� C' � _ j 6�� to —��- Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�DITIONAL C�MMENTS ANO SKETCH SANITARY PERMIT NUMBER: v�-�_ ��'g `�'� l�k��.l.k, ��s' a �� _ � �� a�x 0 . � y a , � y' S� q � ___ :_ . , � �'�. � �,,,�¢3��P ' - — ��SS'��T �`_ s� � .�� ti,y�,. ► . � �,�.�a�l�i�. . �� _ _ _ _ _ _ _ � �� 0 �� `�"� �,�- � --�—