HomeMy WebLinkAbout008-937-19-5510-SAN-2022-128 �/!
vra•^n'"',�\ lndustry Services Division County Z7
r,;'"�', �_� 4822 Madison Yards Way -SQ cc' p r 'Z
;.
I,j �`s ` fv� Madison,WI 53705 Sanitary Perxnit Number(to be filled in by Co.)
` '• � �� % P.O. Box 7302 ��
1°` �� ^° Madison,WI 5302 l;1 �j� � .� �
ky)'`�'tiffT:�\.s�� r �
State Transaction I�tumber �
Sanitary Permit Application .—
In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit — �J
is required prior to obtaining a sanitary permiL Note:Application forms for state-owned POWTS are submitted to Project Address(if diff rent[han ailin�ddre p�
the Department of Safery and Professional Services.Personal information you provide may be used for secondary � D 4 p N �cy ��' � Y«^�_�.�
purposes in accordance with the Privacy Law,s. 15.04(i)(m),Stats. /� � / ' '/ �
1.Application Information-Please Print Al(Information ,u�%"c-!� c�c c)c•
Property Owner's Name / Parcef#
.�'-t e✓e h U> £� �t�.�� /'1? l�e t� P��� �o �j �/ 9 �S`/D
Property Owner's Mailing Address Property Location
� � . . / 7 V f'h � f • Gov�Lot 's
(0
City,State Zip Code Phone Number p
�/�Q / P L^q I�0 C !� ,(,�/� s �� 7�� 7/5�- ��.s ``O C.>�" S`�J %, /'�-'tC/�/4, Section_�1—
II.Type of Building(check al thaf appty) Lot# T�N R � 9 E o
�1 or 2 Family Dwelling-Number of Bedrooms -� Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑Ciry of
❑State Owned-Describe Use CSM Number ❑Village of
'QYTown of�c�/tfo cc./c"r 7tt'Ii'
IIL Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A.
❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
� �(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued
Expiration �1v1�, ?
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation i
�! S—O � a7 6 �!3 " C�7$ �_3 S_
Capacity in Total #of Manufacturer
Tank[nfottnation Gallons Ga(lons Units p � o � �
f0 U V U 4. Vl
New Tanks Euisting Tanks ` o a; � � ,n c^`� `c�
a. U ci� � in w C7 cL
eptic or olding Tank v �rz� _.._-_� (� V�l H U �"�'L Ci � �<,� �
Dosing Chamber __ `_ -- � _
V.Responsibility Statement-I,the undersigned,assume r poosibitity f installa6on of the POWTS shown on the attached plans.
Plu ber's Na►pe(Print) Plumber's � nature /" MP/MPRS Number Business Phone Number
� �� � > �
����„%, c�� 0 L�r�✓S 1 L�,t ��� ��>__2�'—e' � �:���s ;� �� ��'s� -:�;� � -�;3�
Plumber's Address Street,City,State,Zip Code)
.�` j � ' -�f -S i` -- --�a�,� ��, _ �. :'� � S`� `l b' I �
VI.County/Department Use Only
�Ap�i e�� �Disapproved Permit Fee Date Issued lssuing Agent Signature
❑Owner Given Reason for Denial $ C ��'a� ' �' �`�`^ �y�n f�`�_�����M1� ''
Conditions of Approval/Reasons for Disapproval D � ��5� �
f �,'� -�1
'1` '!
� I �� �.��� ���- I�1� JU� 2 9 ?��2 � _;
n �� ---
5A1!`�Y��:'� �"�
L�/��Id;7 F�.-LJ,'d;:i���.�;. .. . ..
Attach to complete plans for the system and submit to the County only on paper not less than S�n x 11 inches in size
NO REFUNDS AFTER
SBD-6398(R.02/22) 13SUE OF PEAMIT
PAGE 1 OF 4
In-Ground Gravity Plan
index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
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
�e f z �
� � 1 i ��q
Owner Name(s): ��t�c�F �, lN � /�tdh � Z Phone: 7�.s- - Y�}s - v n �
Owner Address: /1�3 yd�a / ��l�a r�oti Q��� �ip.S � 7 s v
Project Address: l �98 r�' J�o �,'s � %���Y k R�, .c��%�-�u,�c-��� ,
Govt. Lot: ,S S i.cl 1/4 of rvr-<✓ 1/4, Section�, T 3 7 N-R�E ❑or W�
Township: ���� G�/�a� ie County: S�si,�,i�
Project Parcel ID #: f�0 �93 7/ 9 SSiD
Designer information
�
Designer Name: � r��c�L`(% � � ��'F� S Phone: /,�--�3G-
Designer Address: ��t� �1�1�t .S� Sc,c a, <z��r 4/,�_ Zip: S �/ K �,� �
E-mal�:__�, !�i���fU G��p f h � lJ c� �-�y�Av��r �'C7��1 This space reserved for approvat stainp. •
License Number. +� .%�G.j �-S °/
Remarks:
�� /
Signature:� _ / �� � Date:
'Ongina signature required on each submitted(copy.
CH ECK BOX A&APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o s��: ��ao� � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: ��2 DESIGN FLQW: �i S O
GPD
s'�r �� h (i(,l� E YGt l�J /r/, �.e �f-Z P r Attach design flow calculations for commercial plans.
PRosECTaoost�ss: _10q � /'1/ ]0� (��5 � �ark K�• Pipe Matertal / ASTM Standard (Tables 384.30-38� 384.30�5)
BM Symbd: � sna�e�eno�: �0 0 . U �. � s�,�s�^ �( rt s c I. �l d � . -.---_
ar� n����,: ,�a t�f-a � o�� s,'r�l,'„9 �► �' Naure
Sto e Gredient % U Ind�cete norm by+ IMPORTAPff:
P � � � Well Symbol(ffappliceble): Q drawing an arv.v Show ground efevation contours at suitable intenrals.
of Tested Area: on the approprite Bne.
_ �
,
V �
�
��'� �� ,
� ��k�e �
�.
- ea _—
. .p
1 �
. - g
o €
��� � �$�.
, ;, � ��b�.
� ,, �t ���5� �
� 4�'`';, � ��
I 'E i�� ..� ,
o�---,
1 i o i���
I --
� � � �/ � %t
� &
� _.�6- S _�_--
� � '��
�
�,� �f
_ `��-�.,..�a,.s.._�--��
� � V'
li '
�, a 1� �
_ � � , �6 , c�
;
_ , �
r -
Septic Tank(s)Manufxturer.
IN-GROUND GRAVITY DISPERSAL AREA �l�����- -T�� .
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)VWume(s): ����,
3-ft Trench (down-sizing credit) �, gal gal gal
� EHIu t Filter Manutacturec
�C S�
I �1
�� Effluent Fllter Motlel#: ��r/� �`' �—�
mm iz
SOIL COVER �NP����
12'
min.trench
�Nw°�hu TYPICAL TRENCH
`'.e�'-. CROSS SECTION VIEW
��tyP��� , (No Scale)
. Provide minimum 3 ft
System Elevation=�-sft separation between trenches.
(rypical)
Qulck4 Standard-W
w/End Cap Observa[Ion Plpe Typ�CAL TRENCH
(typicaq (Show location of inlet/outlet pipe connection on plan view.) (�vp+�)
Installpermanufaclurets pLqNVIEW
��so-��n�,s. (No Scale)
r- ---��-------��--------- —�
� ----- '� T -
� A-(�rP�) �
l —"----------��--------��---- —� 1 �
B= � n � - I m
�h'P���) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: ��Y���� �
(mfd by Infiltretor Systems,I�.) T
Iretallpursuanitomanufacturefsinsfruclions. �
1�Quick4 Std-W @ 20 fP EISA/chamber= .�0 ft'
+ ��Pairs of end caps @ 6 ft EISA/pair= �ft�
=Proposed EISA pertrench=�ft' ���p Required InfiltrationArea= 6 y3 ft� Distribution Method:
x -3 trenches=Proposed Total EISA= �ft' r`1 P���
. � 6��8 `
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 353.52 (2),Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, alI 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 Operatinst Limits:
Design Flow= y�� 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, a�arms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure-compare to design specification)
o surtace discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(sl 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 filterlsl 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. RepoR any component failure or malfunction to:
Nameofindlvidualorcompany: ��Cc�� IC:<Z7 �'S � Phone: 7/S- '� 36 � ���/�
Local govemment unit: .S(1 % ( CG<<<< Z c�� '� Phone: 7/S - 6� `J l �� �c� ,
Localgovernmentunitaddress� /�( �(J 6�2'[cy�� �� � y` /-(a�G��c-�� l'✓,� ZIP: Sy �'y.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.
Continaencv 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 aba�doned in accordance with SPS 383.33,Wisc, Admin. Code.
Ofticc of
Sawyer County Zoning Administration
10610 Main Street Suite 49
�������� Hayward, Wisconsin 54843
�Ea �o��� ��is��3a-Hzss
�S1; .LI� FAX (715)63R-3277
� Q/ .1 � www.sawycrcountygov.org
�tq; -'3" ` < � E-maiL zoningsec(ir:sa�tiycrcountyeov.org
� �, , �� ,�-� � � Toll Free Courthouse/General Information 1-877-G99-4110
� �y_,';!:r ' �
I!'G ���
��jSCpN��
������
SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: .S�}CV'�n 0.�� A my Fe '�" Ze r
TOWN OF: i�,°421�°VF'G �
ADDRESS: I (� � $ I� �O ( �� PA r � �p.�c�
,� 0..�I- L f L a�A.+, - ��- Tamesl, Pl�r�ael'
I, W , EkC �'�q , a Wisconsin
Licensed Plumber, authorized by the owner, do hereby ac nowledge that I am receiving
temporary 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 system is found to be failing as defined in s. DSPS 3� 1 A 1 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements ofchapter 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) Sanita�y
Permits], of the Sawyer County Citation Ordinance.
DEADLWE FOR T S AGREEME T SHALL BE: �/ 3D/a�
Signed:
Date: �j��/ ��
Accepted by: �� �Z���S� •
Date of temporary emergency approval: �� 1 a�
��� J ^ ( � ;n S�t� Rev. 03/26/13
�
J2%�- ` � PRIVATE ONSITE WASTE TREATMENT county
;,,...x�.,, :y�
�� o \����, SYSTEMS Sawyer
(r� �Sps �J ( POWTS)
�� � ,�,�l
\F'S1""// INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� �. (��
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�� �► �.�-� �-��w� -
Insp BM Elev: BM Description: Parcei Tax No:
I
(Dc�.� �W( l � r.., �.s���� a���.,s� ooH- �73�7- �`�—S S'10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,� a� Benchmark � �pp o�
Dosing j�a � �7,g'
Aeration Bldg. Sewer 9S,g�
Holding St/Ht Inlet �,'7s�
TANK SETBACK INFORMATION St/Ht Outlet q ,� �
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic a�o' .{-6S'' ` .E. � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ►y,s- �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION infiltrative
Surface R35`
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weli
DISPERSAL CELL INFORMATION
DIMENSIONS W ?j� L�' g6' � �� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �.� I ,
INFORMATION P I L Bldg Well Waters � GP � Chamber Model Number:
❑ EZFIow
CELLTO �-S �,2t�� ��oo _ ❑ Mound o Other �Y�
— -- __ --- -
DISTRIBUTION SYSTEM X Pressure Systems Oniy
--- ---- -- -- -—
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 Cell Edges �Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
��,�1� � ���
Plan revision required?� Yes 0 No jD� 2� �� � - � - ��f��� �
l
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
AOOITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA: 2oZ - I��__
�
. . . , . I
r---' ��`�-�, ��,,,
��� �t y 1Ktu(C��I
, \
i . _. -- �__ : _. �, _ __�_ .�_ __„ ,__ � 1a-� � �,e
- _ . t � ���.:,
�
_ _: __ :
_ _ _ , � _ ___
.
. . �- . . : t _ ._ .
� � 36 . - -
�`��^ . _ : .
4
O
l
6`Y 1 1
� L �
,
�, �x�
q� CQ� a) $�„2 ,
, � p
�5 � �
k I ► ' w`a�
� I �� (r
�-� I � I �i `'''�Q°`�
� �
I I
.�� �--
Dc �S�
�
��--
a� �
�o
�- ,��a� �.
c o ����
�---