HomeMy WebLinkAbout032-539-02-5303-SAN-2022-135 �
_ "' Department of Safety c°""ty � �� �, � �
- � = & Professional Services,
a Sanitary Perrnit Number(to be filled in by Co.)
� �_ � Industry Services Division �
(�'3`�� 3 3 �
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmentai unit �
is required prior to obtaining a sanitary permit.Note:Applicarion forms for state-0wned POWTS are submitted to Project Address(if different than mailing addre
the Department of Safety and Professional 5crvices.Pcrsonal information you pmvide may bc used for secondary
purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �yr� f {�
1.Application Inform$tion-Please Print All Information ��y � 1 r I�1, I�
Property Owner's Name Parcel#
Y� ; � ;� Sc�l�i,}� �� c��� S3 C��� �3r 3
Property Owner's Mailing Address PropeRy Location (��'�;
�D• U�X LI � Govt.Lot �
City,State Zip Code Phone Number �
I, j �n I e j, 1 j , 1"1` ���� G L C%, %, Section^�
c,mt.� T w�—�_
II.Type of Building(check all th$t apply) Loc# T 1 N R E o W
�l or 2 Family Dwelling-Number ofBedrooms � � Subdivision Name
Block#
❑Public/Commercial-Describe Ux
❑City of
❑StateOwned-DescribeUse CSMNumber ❑Villageof
S 3y? � !�.�1 ' �To�,of � ►n�e�
IIL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on tine A. Check one box on line B.Complete line C i
a licable.
A. Y P Y Y�- S Y � P ) ( P
❑ New S stem Re lacement S stem Other Modification to Existin S stem ex lain ❑ Additional Pretreatment Unit ex lain)
a k 2 �'ut�,,�.e:'��
B' ❑ Holding Tank In-Ground ❑At-Grade gn yp ( p )
❑ Mound ❑ Individual Site Desi ❑Other T e ex lain
conventional)
C• ❑ Renewal Before ❑Rcvision ❑ Changc of Plumber ❑ Transfer to New Ou�ier
ist Previous Pcrmit Numbcr and Datc Issued
Expiration `�S O�c7 5- j3-�S�s
O
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(st) Dispersal Area Proposed(s� System Elevation �
3w �7 �la�t Y�a "°���rt:.� �s 3,S
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � �o '� �
New Txnks Existing Tanks � o a; � � � � �
a. U �n v, cn [i CJ fi,
Septic or Holding Tank �/' � � 5{r__ , 1'�fe ���
1\ lr�c+f/ /'
Dosing Chambcr
V.Responsibility Statement-I,t6e undersigned,assume responsibility for installation of the POWTS s6own on the attached plans.
Plumber's Name(Print) Plumb s Signature MP/MPRS Number Business Phone Number
C�r��� �, � � �i a���t o �r s�a��-a�s�la
Plumber's A dress(Street,City,State,Zip Code)
�'v�-l� �,o .5a� � ���-�r, (,c,/� �Ll£���o
Vl.County/Department Use Only
�A � ❑Disapproved Permit Fee Date[ssued Issuing Agent Signature
❑OwnerGivenReasonforDenial $ ��" '� , I� I �" ��C/�(�-�<�-TW��'`�y
Conditions of Approval/Reasons for Disapproval
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SAYVYER COU+V;
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Attach to complete plans for the system and submit to the County ooly on paper not less than 8 IR x 11 inches in size
SBD-6398(R.03/22) NO REFJNDS AFTER
ISSUE OF PEAMIT
. PAGE 1 OF 4
in-Ground Gravity Plan
Index& Cover Sheet
Componerd Manual Design Refersr�ce�
Version 2,� SBD-70705-P(N.01l01,R.10/12) , � •
Pg 7 of 4 index 8 Cover Sheet
Pg 2 of 4 Plot Plan .
Pg 3 of 4 5��;c. T4nY Cross-Sec�ion
Pg 4 of 4 Management Plan
Attachme�rts: E c
POWTS .ication f�Review
Soil Evaluation R �Site M
Proj�t Name/D�cript�on
m��� � T�,k �2��i�t�,�:��
a�er,�rne�si:111;Ke d� Sarkh 12�/an Pno�.• -
owne�naa�s: �o. ac��►�Is 1���-� �z�p: s-c��c�
Pro�eandar�: '�cs=i-N fnat .
GOvt Lot: 3 1/4 of 1/4,Sedion o2 .T ` N-R S EQor W
Township: �tJl�te� CouMy: s4�✓y�r'
Project Par�i 1D� 0 3a s3� o a 53a3
Designer I�ormatian
n�i�n� Cr�,�; ��Q�n Phone:�IS _�GW _pZ��/.�
o��ner adar�: Sv 6 -N ��mPso� I� (,J;n�r np: S�l 84�o
E-mat�: �Qoni-�mP�nllerr 1�'ve,C.�.�l r;,��::,�..�:_•�_.,:r,��:,,��:,F:�,:::,>:"-:,�.
I.ieanse Number: v�o�0�S�Z7
Remarks:
� � � s� -
s���- , ��: � �s aa
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CMECK BOX AS MPLICABLE. CHECK 80%AS APPLICABIE.
� SOIL EVALUATION o s��: �ao� � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLANp
PROJECTNAME: io, �esicNF�ow: JC(� cPo
m�t�m �� Atlach design flow calwlations for commercial plans.
PROJECTADDRESS: ��SLI�N m`L�/�l � Pipe Material/ASTM Standartl(TaWes�gq(�30.3&384.305)
BM Sym6ol'. � BM ElevaUon:
1(7!� �J(' � � SanilarY Sewer �/� � f UC�
For�Maln: /
eMoesoe�+�o�: �4� ��ft in t5'' Ke.,Z' f��ne
Inacate nann hy IMPORTANT:
Slope GretlieM�%) Well Symbd(nappiicae�e): 0 arewi�p ana�n Show ground elevation con[ours at suitable intervals.
Ot Tesletl A�ea: on iha approptlte line
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6AFFLE
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/ `�� WAftNINGDEA7HMAYOCCURIFiANKISENTEREO
� Q � WITHOUT PROPER EOUIPMENT
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�\ � 57.20 56.00 89.20 94.00
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� � 5670
6t75
TOP VIEW OF MANHOLE COVER sz�s
FILTER
� 12.00 �
3.00
�� � 25.50
4 00
� �27.00 �27.00� 23.50 Z3.50
S.T�24.00 24.00�� 25.75
� �—ifi.00— �.o�- TOP VIEW OF TANK (TAPERED)
—�z.00
INLET � � senweoo �
_"______________"'__ __ _ 1
OUTLE7� i i
� l�—59.23 �'
4/NCHPRESS 2.00 9'00 �g��� 41NCH � �
SEAL GASKET PRESS j j
INSTALLED SEAL � �
WHENPOUREO � GASKET i i
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BAFF�E � �
4170 1 1
FlLTER � �
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� s.00 T SECTION VIEW OF TANKAND COVER �3.0o OUTLET END VIEW OF TANK
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-tr Model Number. �OO SKAW PRE-CAST Phone: (715) 967-2277
Approved for. SEPTIC, SIPHON, HOLDING, OR PUMP 26255 105th Street, New Auburn
� n e im. ut et �m, Toll Free: 1-800-924-8625
Weight Liq. Depth Gal. /In. Max. Cap. Wisconsin 54757 Fax: (715) 967-2707
7930/bs. 46J" 44J" 41.70" 19.18 800 gal. www.skawprecasGcom
PAGE 4 OF 4
In-ground Gravity Management Plan
�onPoarrwr:
rne owner of nds In-�ound grov�y�sl,an be respon�le fw�s�rpeUml c�eradoo and m��noe pwa�,ent ro
requl►emeMs oF SPS 362.�4 Wisc.A�rYn.Coda Pursuant 1D SPS 383.52(2�.W�c.Ad�nin.Ccde.thi�syet�n�aA
bs con�dered a human health I�d�not mau�tein�in a�ordenoe wnh this�aoved mmmgem�P�n.
FarthermOta.aA irt�and�if�ellance�Hv�s�be Pe�ed�Y a re�er�d P0111/1B1W�YMr in
axa►darx�wHh SPS 38352(3),Wix.Adm�.Code.
MBXimW11 Q�Af89 OD@Ml�la L�niL;
DeNpt�Fbw m ��C� gpd; .BOpa 5 220 m�p:�; TSS 5 760��'. FOti S 80 mgL''
�cUOn Chael�t INSPECT EVERY 8 YEIUiS
o typB of use
o a�of syatem
o nuiser�ce facmrs(i�odors. �er comPleirds,e�)
o mecha►dcai ma{funcdon(La.P�s.valves.�6d�flo�,etc)
o m�erial fa�que ila.��ks.bresRs,cor►oeton,�)
o sWids voNane in ar�e�oWc tre��nk(��d anY�on appv�ensxe(s)C�e.,�On/drop boxes)
o negfect or improper use(ia,w�e�rg deat9��P�d m�tv�eG�)
o exG9td�pDr�ng kt r9stribuNon c�p�to doeing
c doafR9 ineg�az�fes-ff ePP6oebla(Le.,P�rt�B'c�9.floet swftcti�gs,eic.)
o elecUicei aomponar�s-i�aPP�c�e(Le..wVheg,.conn�s.awi�.�,�me�s.alarms.e�)
o di�tbution Iffieral or let�ai or�ice Wuggi�8 (measure lata�al�tat Pr�ure—compere tu de���)
o �lAaCe dis�efgs a�efllu�t or agw�e bfldc-up i�D struC4ne e�ved
1AAIM'AIN EVERY S YEARS(or when�ryr)
o �m�d doee�el shail be pumped by a CeAffled�e setvidng operatpr Gcer�d under s 281.45 Wis.
smrs.,rt�me vaume of soaaa in tn.tsMqs)ezceeds one�n�rm(i/9)me OqWd volume or uretank(s)or
�re�ired by tot�ii oRSnence. Dispoael aF coMeMs�ell be pursuent to NR 113.Wisc.A�rYn.Coda .
c u�� �nt Q�j��ell be inapeCtad e+verY 3 Yeers and shalt be deenad wfia��y ro r�nwe arry
accumulated aoGds axording�manuf�aer's specificadons. A se�vidn9 Pedod x511�ways be grea�r than 12
moMhs
bysstem�►aports al�dt be su�eif�ed to tl�e P�P��9�t untt M aocordsees�si8�
SPS 38855 Whc.At�min.t:oda�. Report�Y�onwd f�es or�adGu�4ion 10:
►�ameatinr�v�a��oan�e�y+: �n ljt;:� d-�ns �c Pno„�: �rs-ab6-�y�
�oce��re�nenc� 4�v er Cowt Z 2 �1e: 7 I S-�3�!— 8��f�
►.«�gw��aacaaa�e�: %W/o nl4�n 5't. Sµ; e YY N��'�u�( uP:_SY8�13
Any defecdve part oF ihls system shalf be rePei►ed.repl�1.or remoa�l p�uauent 6�SP3�3.51 (1).Ylfisc.Adrnin.
Code.Repair or repla�ement af te�I or malfum�ionin9�e�sl�ll comphrwi6i SPS 383,Wisc.A�nin.Coda
No product for d�emicel or physfcal restoradai ot ihe POWTS mey 6e ueed utdeas�roued py t�d���
ea:ordanw xr�f SPS 3B4,1Af18c.Admh�.Code.
m tne evwN that erryr feNed treatrnent c»�orrent af th�POWi3 cennot be repei►ed,R�all be�P���t to
a P�su6Mlted Eo Uie ePProP►iele a�enaY tor review and epprovei. A failed hrgrourW��Pp�erK may be
abendoned arui repl�oed by a code-oomPM�9���Por�t In a pre�deFermined area of�iteWe soils.
If use of this POWiS��u+ed.d sheN be ah�tbnad in amorder�w�SPS 988.88.VYtoa Admin.oma
/` ` ` > PRIVATE ONSITE WASTE TREATMENT county
�''�:.n_,�.;\,,.
;� � o$ 1�'� SYSTEMS Sawyer
�'�����j� ( POWTS)
'�z"'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� � 13�'—
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(i)(m)]
Permit Holder's Name: ❑City ❑ Village [,1�Town of: State Pian Transaction tD#:
M��(,�,. �-��,�,,�n Q a r� W��.� �
Insp BM Elev: BM Description: Parcei Tax No:
�oo.�' C� � �' i'ti. ��� '�t� IP�_ �3�- 53g -�.?-'�53�
TANK INFO ATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEU
Septic ��}1n/ g00 Benchmark ' oa,a'
Dosing Q� � ��,'�`
Aeration Bldg. Sewer � �6,g�
Holding St(Ht Inlet �'16,-�,�
TANK SETBACK INFORMATION St I Ht Outlet �
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic �,ZS' .r�.s` -7� '�-'7 � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P/L Bidg We�� Waters � G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifoltl 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: (Include code discrepancies, persons present,etc.)
�;�s����( �j���o�a
� � ����� �h
Plan revision required?❑Yes❑ No o� �$ � , � G�� ��
3 �-- �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: a-o�- (3S
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