HomeMy WebLinkAbout010-118-00-4108-SAN-2022-131 (�'1
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�''=�"'.;�. [ndustry Services Division County �
- -18�2'�ladi,on 1'ards w'a} SaWyef
� ,�S - Madison, W I 5370� Sanitary�Pennit Number(to be tilled in by C'o.) p 1
� PS P.O. Bos 7302 7.�
- Madisun. WI 53707 (�3�j i 3 U �
Sanitary Permit Applicatiion — s`are��`ansa�"°n""r"e" — �.,
In accordance�cith SPS 383.21(2),Wis.Adm.Code,submission of this fonn tu the appropriate governmental unit �— -�
is reyuired�rior to obt�ining a sanitary�permit Note: /�pplication fonns tbr state-o�cned POWTS are submitted ro Project Address(if different than mailino addre�
[hc Uc��artment ul'Sa�et}�and Professional Sen�ices. Personal infonnation you provide ma}�he used for secondary ������ �+��t� C+���� p�
purnoscs in accord<ancc�vith the Privacy La�c s_ 15 04(I)(in),Stats `� �� «
L Appiication Information-Nlease Print:111 Information
Property�C)�cner�s Name Parcel tt
RICHARD G WINN REVOC TRUST 010-118-00-4108
Property�O���ner's!�1ailfne Address Property Location
5501 BRUCE RD co�t.�.�t
Cih-,State Zip Code Phone Number
LUKA, IL 62849 _ ��4, ___�.; �e��,,,,, �s
II."C��pe of Building(check all that appl��) ����t� I�41 N R 08 E or W
�l ur2 Pamil��[)�rellina-NumherofBe�lrooms�_____ �R� ��� 41 g SubdivisionName
Rlock#
�Public/Commercial-Describe t�s��_ -
❑Cit��of
�State O�cned-I)escribc Usc CSM Number �Vill��e of _
���,�����r HAYWARD
IlL'I'}'pe of POWTS Permit: (Check either"Ne��"or"Replacement"and othcr applicable on line A. Check one box on line 13.Complete line C if
a licablc.) _
`� �Ncw S titem �Re ilacement S�stem �Other Modihcation to l-sistin S}�stem ex lain �Additional Pretreahnent Unit(ex I iin
✓ 7'= I >� � ( P ) P� )
�' �Holdin��fank �IrnGround �At-Grade �Mound ❑Individual Sitc Design Other�I�ype(e�plain)
(com�entional)
��• ❑Renewal Before �Rcvision �C'hanee of Plumber �fransfer to Ne��Owner�'�st Previous Permit Number and Date Issued
f[.ipiration
IV.Dispersal/"I'reatment Are�and 7'ank Information:
Design l�low(gpd) I)esign Soil t�pplication Rate(�pd/si� I)ispersal Area Required(sl) Dispersal Area Proposed(s�) System Glevation
600 0.7 858 904 94.50
Capacitv in Ibtal #of Manufacturer
u
l�ank Information Gallons Gallons Units � � o ti �
;� V U
New Tanks f�isting Tanks � � v � i � :� �
_. :.J �:i: r s .._ .. -
Septic or Holding Tank 1250 1250 1 WIESER CONCRETE ✓ �
Dosing Chamher � � �
V.Responsibility Statcment- l,the undersigned,assume ponsibility f��ins laf n of tha POWTS shown on the attached plans.
Plumher s hame(Prin[) Plumber �_nature MPih1PRS Number E3usiness Phone vumber
Travis Butterfield 652879 715-634-8176
Plumher's Address(Strect City_State_Zip Code)
14346W St. Rd. 77, Hayward, I 54843
�'L Coun �/Departmcnt Usc Onl��
Permit Fec Date Issued Issuing Agent Sigiature
�,n� o�"� ❑ Disappru�cd
❑Owner Given Reason for Denial $ Y�"•� ��� � °�a ����
(�onditions of Appro��aURcasons for I)isapproval � t���-�'
� �i/ ,_;,.
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� � �`- (�] It� 3 JUN 2 7 2022 �
, C ,S ) 1 ( ^ J COl)NT7�
� �� I �� ER
SAWY
Zp�,}�G ADM►NISTRAT{O
:11tach to complete plans fur tl�c scstem and submit tu the Cuun[y onh on paper not less[han 3 112 c 1 I inches in siic
NO REFUNDS AFTER
s��-63�x�R.oziz�> ISSUE OF PEAMIT
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version�, SBD-10705-P (N.01/01, R. 10/12) , , ,
P 1 of 4 �� � Index & Cover Sheet
9
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): RICHARD G WINN REVOC TRUST phone: - -
Owner Address: 5501 BRUCE RD, LUKA, IL Zip: 62849
Project Address: 12634W SOUTH SHORE RD
Govt. Lot: - 1/4 of �1/4, Section 26 , T4� N-R 08 E❑or W ❑✓
Township: HAYWARD County: SAWYER
Project Parcel ID #: 010-118-00-4108
Designer Information
Designer Name: Travis Butterfield Phone: 715 _634 _8176
Designer Address: 14346W St. Rd. 77, Hayward, WI Z�p; 54843
E-mai�: office@butterfielddrilling.com r�,�5 5���,��t-�;�t,-�d r��:a��}�,�<����� sta��F�.
License Number: 652879
Remarks:
Signature: Date: �PJ� a���
riginal signature required on each submitted copy.
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PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground graviry 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),Wisa Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= 600 gpd; BODS<_220 mgL-'; TSS<_150 mgL-'; FOG_<30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
c nuisance factors(i.e.odors,user complaints,etc.)
„ 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: BUttel"fl@Id, InC. Phone: 7�5-Fi34-H176
Local government unit: SeWyeC COUIIty ZOnlflg Phone: 7�5-E34-8ZS8
�oca�9o�ernmentunitaddress: �0610 M8ir1 St. Suite 49, Hayward, WI 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 compry 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.
Contingencv 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.