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HomeMy WebLinkAbout024-741-20-5210-SAN-2022-137 � ' Industry Services Division County� � 4822 Madison Yards Way �,(,,� � � _ ,�_ -. Madison,WI 53705 Sanitary Permit Num (to be filled in by G �= P.O.Box 7302 � Madison,WI 53707 � ��nj � 3�j � Sanitary Permit Application State Transaction N�r , In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit JJ is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POW7�S aze submitted to Project Address(if different than mailing adi � the Department of Safety and Professional Services.Personal information you pmvide may be used for secondary IQ/_�} a i '�Q�J�,(,(�jte. purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � {��`� /�i I.Appiication Information-Please Print All Information Property Owner's Name � Pazcel# �0� ���iC,l�l 0��C-"��ll� � -- 5'�la PropeRy Owner's Mailing Address Property cation I�,�1 N �I�J�'�.��e Lv� �a�'.'�o� � Ciry,State " Zip Code Phone Number 1��`�l�li���� W J'— ���`"�"� , DS�. ,�(`Section� II.Type of Building(check a11 that apply) � Lot# � GS m T "1� N R E o �l or 2 Family Dwelling-Number ofBedrooms Subdivision Name Block tt �ublic/Commercial-Describe Use ❑('ity of ❑State Owned-Describe Use CSM Number illage of ��03�, ����, ��la �T��,of �� � IIL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i a licable.) A' ew S stem e lacement S stem ther Modification to Existin S stem ex lain Additional Pretreatment Unit ex lain � Y � P Y � g 'Y ( P ) ❑ � P ) B' ❑Holding Tank �In-Ground �AAt-Grade �Mound Individual Site Design Other Type(explain) (conventional) C- ❑Renewal Before �Revision hange of Plumber �ransfer to New Owner �st Previous Permit Numbrr and Date lssued Expiration QS'^�-�/ ( �� �S' IV.DispersaUTreatment Area and Tank Information: Design Flow d) Design Soil Application Rate(gpd/sn Dispersal Area Required(s� Dispersal Area I'roposed(s� System Elevation � . �l oZ 0 - , �. zti Capacity in Total #of Manufacturer � Tank Information Gailons Gallons Units � � o b„ � New Tanks Existing Tanks ` o � � y p � � a U cn �, cn k. C7 P, Septic or Holding Tank /�Ov i "� ► l Dosing Chamber � � V.Responsibility Statement- I,the undersigned,assume responsibility for instaliation of the POW'fS shown on the attached plans. Plumber's Name(Print) Plu ignatur MP/MPRS Number Business Phone Number n � �`� � �?1 j-S 5�-��0�73 Plumb 's Address(Street,City,State,Zip Code) /U571/V T i'ti. ��- �Cu�-f�• u?�u��� �5��t3 VI.Coun /Department Use Ooly �App O Disapproved P��t Fee Date Issued Issuing Agent Signature ❑Owner Given Reason for Denial $ / ���da -� I�'+ ",.,�- ����� Conditions of Approval/Reasons for Disapproval __. _- --- -- . . D � ��''�'____-�------- :i r � � � CS� � � `�3`� au� � $ ao2� �;``� �� � � �� , s�,wrrER co T�a,T�o� Attach to complete plans for t6e system and submit to the County only on paper not less than 8 1/2 x 11 inches in size NO REFJNDS AFTER SBD-6398(R.02/22) ISSUE OF PERMI'T 6/27/22,3:58 PM Novus-Wisconsin Access rev. 13.1108 Redl Estdte Sawyer County Property Listing Property Status:Current Today's Date:6/27/2022 Created On: 2/6/2007 7:55:43 AM �'Description Updated: Z/18/2020 '� Ownership Updated: 2/6/2007 Tax ID: 25704 � ]OSEPH M&JULIE A GENDRICH HAYVJARD WI PIN: 57-024-2-41-07-20-5 OS-002-000100 Legacy PIN: 024741205210 Billing Address: Mailing Address: Map ID: :2.10 lOSEPH M &JULIE A ]OSEPH M&JULIE A Municipality: (024)TOWN OF ROUND LAKE GENDRICH GENDRICH S1R: 520 T41N R07W 10679N DOVE LN 10679N DOVE LN Description: PRT GOVT LOT 2 LOT 1 CSM 16/72 HAYWARD WI 54843 HAYWARD WI 54843 #4038 Rxorded Acres: 0.970 w Site Address * indicates Private Road Lottery Claims: 1 10679N DOVE LN * HAYVJARD 54843 First Dollar: Yes Wa[erbody: Placid Lake __,J property Assessment Updated: 7/16/2019 Zoning: (F-1)Forestry One (RRl)Residential/Recreatlonal One 2022 Assessment Detail ESN: 404 Code Acres land Imp. G1-RESIDENTIAL 0.970 88,700 288,000 �� Tax Districts Updated: 2/6/2007 2-Year Compariwn 2021 2022 Change 1 State of Wlsconsin ��d: 88,700 88,700 0.0% 57 Sawyer County Improved: 288,000 288,000 0.0% 024 Town of Round Lake Total: 376,700 376,700 0.0°� 572478 Hayward Community School District O01100 Technical College • Recorded Documents Updated: 9/3/2014 �Property History O WARRANTY DEED N�A Date Recorded: 6/28/1995 248678 556/24 � CERTIFiED SURVEY MAP Date Recorded: 8/1/1994 243162 tl1 https://tas.sawyercountygov.org/Access/mastecasp PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References: Version z�j', SBD-10705-P (N.01/01 , R. 10/12) _ . _ ✓ ' a . � 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): �J(��' Cj-�-D'�a^iC�, Phone: - - Owner Address: /��7���t i�ov� Ln _i-���ra�-�c,��=- Zip: '�r� `5�°'� Project Address: �(� (07�'l� �� j�y�, ��GLca t,��.�� u7..�- � `Lc�L3 Govt. Lot: 1/4 of 1/4, Section�, T ��N-R�E � or W ,Q Township: ��1�- �.GL-�� County: `�j�Gt.(,�1t�' Project Parcel ID #: � a`��-{- 7� I � � � "J�� Designer Information Designer Name: ��,I(�t-v1 .S--�G7,c�� Phone: l� �- �� Designer Address: �� /� � '�C� r Zip: �{. E-mail: �. . . !. . `�� i License Number: �9 g"�C Remarks: Signature: Date: � ��7 —�£�� riginal signature required on each submitted copy. N �a393 CTy p �c`'I.� � EtklnoYr� , wz 53�2� • ��s) �t�a2- 'fl"7d �sl�r.j � I "1� �945 Soi� Evaivarrer. � � ��• !�e L.a.H e Lo-r I, �sm�yoa8 , v,�6, p. �z S zo, T �Fi N, 2�w �w�n o� �2ou.�nd l�l�e SOu�Jy�r�. i WL PU4c�p LK . C,ow.,p.'� 02N-�yl-2o-SzlO e�ev. = A5"'� �. \ �� � BYYI=�DO� � �e oF 30" Q}�cu+t. � -'--= W 14�¢ �v�a o� FAs� S�dE�Cow ¢4.@ C-.�.� � \ _ � �`- ` / � EIwcL�orS : ► p1= roo.8' ez O g, 82: I00.3' 3/ Z y-r Qi3= l0l.O' � r �3 y`��'Zi�oce. � (i�{= 100.8' "` � ' � � /. B5= 49.5 � � i '�SmuSs�+ �D�D w� Ore..co F.'I+ev � sysfe.�,_ 9�.3' i �— �� `1_ D�K , �VMO flM� ) i \��� r /� 1 6a.age ; %p�.,ed���I ( PtiP�22oi�3 � a/z��os- a�Posee � i oa;��. f a o� 7 � � , — — ` ' /�'d.EaseM+.�+ ik��F_(a.,c �'1 ( N��F?OUi�[� C�RAVITY DISPERSAL �REA Septic �ani<(s) Manufecturer: �� L�.�e� Uniform Elevation Trenches wi�h �Z1203HP �undl�� S�ptic7ank(s)Vali.ime(s): 3-ffi Trench (down-sizing credit) � l� �,,a� £,{y� �3� � �.,� E(fluent Filter Manuf�cturc�r. .�..._�'..�.�'_ �'._��'__1�.�,�!..,.,_., —�..._..�k�_...+Y.._ G��'�az r-� �� � � 7"� �. .�..,�._.._ i � f- �� � � ��— inln. 1)" Effluent f'Uler MorJ�ll1' � � �-, U<�ot���xtNrr I Y) (typlcal) Cavcx —_ - _._�.____�._..__�.__........_.._....._____� .._._._ _..�_-- ��� sc�i�. c;c�vr,i, �� TYf'ICAL TRENCH [11 "� CROSS SECTION VIFW . . niin. lremclt ri • d�i�dh " (�vt���::,�) - � �-- - —_ __ __� � .zt ' ,. . :,,,' �NO SC���� pl3SCRVATIQN PIPL= DETAIL. �A �p . (NO SGiI�(/� fici�tw-IYPt�ni .._._ Sysl�ni Flc�vnflon = � � ° ' �' .' siq,cup (lopr�u) y w'•v•W+• ... I inl:;hod Giudu �fynlCr��� (�I'OVICIG I1111111TtUI11 $ (l Unulr.hud t6 F;oad�rd) . ,� . :•�,'. sep�ration bciw�en irenches. n"V1 PVC Pipo ••--• ;'.i • i ':.. , -- I op:.oil Cnver I ap��I plpn lo�nmilnnlu (min. 1 /nnl) �d�x;drovn Ilni�ihnd pr;rde • ' (4) V4"-UI..X(y'Slvin _- TYPiCAL TRE NCH (Show lur,�tion of irdcl / ouqol pipc r,onnecfion an �I�in vicw.) c>>uu ,�i,;��i ��� � Anr,hnun{� Duvir.a ..-_._: ;�', , "... .,•:r»f: . - Inflllr.tliun PLAN VIEW .�:� 5��<<.��:�� �n � Obsurvaliun pi�ro shall liu in��l�illud (No Scale) �iljunclionbu�wuunlwuunilf;. �l •" P�rC�r�at�;d Laler�l a��:;c:rva�inn t�ipU �-. _ (lyf�ic�l) (ryr,ir:�q (�vr��c:a�) .J-"^__`—��� ..� --..��.�M_ . ,_.�-�.:.__._ :� -__ _. _ —ir�- _ __ __. _ _� .-- — -- =�_� — ---- — - . _ .... _ __ .. _ _ _ _ . __. ._ ... __ r� ___ ____ _..�_ �, ; ,�.-.-:,_�_,-.. ._-__._-_--. __.-..__ _ --. �u�_ ____..._�,_ -_�T__.__..�_ . t __�____ _.._.._w__._._ __�.__ __ . � �-_��:�r___: -- ----___T- -_�_._._ _ ,f_. __ __ - _ __ _ ._ _ _ �_ _�___ _ = y� _.__._ __._ __ _ _.._____�.___ _ _._ �. _ _ c� ���:���> m _ _ . .. ._ ._,.. _� _ _ .._. .. . ___ .._ __ .._. ._ ._. .._._.. _ _ _ ___.___ ) � --- _ --- _ f..,_.._____._._.__�..____._ ------.------..... g - �/Q ft .___.._..______ ._.__..__.._.__ __._.._�_.._,,�� W (iyr,��flq � --�� �Z12Q3H Bundle INSI"�I_L F'ER TRENCH: � _ _.._...._____- (tYPical) -� _,�,_�,__ 10-ft bundles @ 50 fl' CISF�lunil = � ft' {mtd by Int��tr��tor systenis, Iric.) � Inst��ll pursu�nt to manufacturUr's instrur,lfons. + ,_,_„�,,, 5-fl bundles @ ?_5 fl' klSAlunit = _,,,.,,,,,,,,,,_, ft' � u = I"�r�pasetl �.IS� per trenr,h = ,�'._,,,.C�.. fi�' Renuir�d Iniillr�tion Arr.�� = �,., ft' Distribution M�thod: x ,_,�,,, trenches = Proposed Tofi�l FiS/� = 9�p tt�' �,���;�,� � f2�F:�a-�. ���/� F��S�T r � PAGE40F4 In-ground Gravity Management Pian 1MPORTANT: The owner of this in-ground gravity system shall be responsible for its perpetuai operation and maintenance pursuant to requirements of SPS 382�84,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code,this system shali be considered a human health hazard if not maintained in accordance with Uiis approved management plan. Furthermore,a!I inspection and maintenance activities shali be performed by a registered POWTS Mainfainer in accordance with SPS 383.52(3),Wisc.Admin.Code. � Mauimum Disoersal Area Oaeratinq Limits: Design Flow= ��_ gpd; BODS<_220 mgL-'; TSS_<150 mgL-'; FOG<_30 mgL"' Insuection Checkiist 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 materiai fatigue(i.e.,leaks,breaks,corrosion,etc.) o solids volume in anaerobic Veatrnent tank{s)and any distribu'uon appurtenance(s}(i.e.,distribution!drop boxes) o negiect or improper use(i.e.,exceeding design capacities,prohibited activities,efc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities-ff applicable(i.e.,pump re-cycling,float switch settings,efc.) o elecfical components-if applicabie(i.e_,wiring,connections,switches,controls,timers,alarms,efc.) o distribulion lateral or lateral orifice plugging (measure Iateral distal pressure—compare to design specification} o surface discharge of effluent or sewage back-up into structure senred Mainfenance Checklist hAAiNTA1N EVERY 3 YEAi2S(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 iiquid vo[ume of the tank(s)or as required by local ordinance. Disposaf of cnntents shali be pursuant to NR 113,Wisc.Admin.Code. o Effiuent filter(sl shail be inspected every 3 years and shall be cleaned when necessary to remove any accumulated soiids according to manufacturer s spec�cations. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper locat govemment unit in accordance with SPS 383.55�sc.Admin.Code. Report any componenf fai(ure or malfunction to: Name ofi individual or company: ���'� ���� Phone: ���J�5��(073 Local govemment unit: Phone: �[S C7,��(—��' Local govemment unit address: n ZIP: ���� My detective part of this system sha)I be repaired,replaced,or removed pursuanf to SPS 353.51(1),Wisc_Admin. Code.Repair or replacement of failed or maifunctioning components shall�ompfy with SPS 383,Wisc.Admin.Code. No product fior chemical or physical restora6on ofi the POWTS may 6e used unless approved 6y the department in accordance with SPS 384,Wisc.Admin_Code. Continaencv Plan in the event fhat any failed treaUnent component of this POWTS cannot be repaired,it shail be replaced pursuant to a plan submitted to the appropriate agency for review and approvai. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersai component in a pre-determined area of suitabie soils. Svstem Abandonment (f use�of this POWTS is discontinued,if shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code. $t � ��.' `» � '- �� . �i'r:�� �'�A . � 4L. � �F\�Y: s?} '�.: � > _ ♦:q '"'_ ��� ..� 44, o S - � ���: ���.nt L .-� f ,. ,., ' X 'i�4 w � � �4�y,�ti ,� ,, � � '�:�, ,�`�, � ,f ` ����Aw ti � z�'+•�. s � R .�. 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''�5 " s '�'s:.Y-r �ob-:f � . �.. {�i�' ,Pt 'Y � �. . ..� � .,:4 �`.�, �ff.� 'x. fi F.' , °'- ``� PRIVATE ONSITE WASTE TREATMENT �ounty , ,� X'(;�,�,,,`.\''\ SYSTEMS ��,�SPs ��l Sawyer ��� ` �W% ( POWTS) k°F s'"�'"'`� INSPECTION REPORT sanitary Permit tvo: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2-� — I 3 � Personal infonnation 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#: � ��- �'e- c�-� � CR�— Insp BM Elev: BM Description: Parcel Tax No: �oo.o' 8qse. a'' �,.�l►` �P��. o�. � �Y�- d-5�-�10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic v.�c.��`,� � Benchmark 7 Dosing �( b,p� Aeration Bldg. Sewer Holding St/Ht inlet TANK SETBACK INFORMATION St/Ht Outlet ,l S- ' TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. 9<0 3 ' Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative � � � Surface Manufacturer Demantl Final Grade Q 7�.'�3' Motlel Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist. To Well DISPERSAL CELL INFORMATION DIMENSIONS W 3 ' � p` ' #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav $� Conv ❑ Aggregate P I L Bldg Well ❑ IGP ❑ Chamber INFORMATION Waters � AG p� EZFIow Model Number: CELL TO ��p .}.�a' ` -}-�' ❑ 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 Cetl Edges Topsoil_ ___ _ ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��.�� �( �.�I�-�z � �<< S �,y Plan revision required?❑ Yes ❑ No p3 �l �� C ' � 6 cl,��� � ���� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) ADDITIONAL COMMENTS AN� SKETCH SANITAAY PEAMIT NUMBEA; ��I ,�-] __, �� �w c�� �.-a1� �1/ �� -H ' �g� D � �� � �° C� E�x 9p' �Y�� , �—� ►�� , ,o . - _ _: ___:__ . _ o . . : . . . . . _ . . .y'_ .___._ r_ ............. .. _..."" 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