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028-542-28-6001-SAN-2022-138
" Industry Services Division County � 4822 Madison Yards Way � _ ,�_' - Madison,WI 53705 Sanitary Permit Num (to be filled in by Cc : p.o.BoX�3oz � 3c� I 3� � Madison,WI 53707 O � Sanitary Permit Application State Transaction Number , In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit w is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submiried to Project Address(if different than mailin add� � the Department of Safety and Professional Services.Personal information you provide may be used for secondary 1 r'1!„a,(p /� �� �"7[� purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. 6 o�ti I.Application Informarion-Please Print All Information L�(�I'Yl- �-��`��-- �j'�{�jl Property Owner's Name pitr;,z� tt � ��' [ , • � �, � � �1�11 �-_ Property Owner' ailing Address Property Location �O `�(� , Govt.Lot Ciry,State Zip Code Phone Number �� 1JJ`''f� �-v"yL'C- � �.�--�- � J6��W �� ��� l�" ~��7$ �/<, '/<, Section II.Type of Building(check all that apply) Lot# T �� N R C7 E or I or 2 Family Dwelling-Number ofBedrooms Subdivision Name Block# �ublic/Commercial-Describe Use �City of ❑State Owned-Describe Use CSM Number illage of �Town of S�1� �P � III.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' ❑New System nReplacement System �Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) Ll� B' �Flolding Tank In-Ground �4t-Grade �Mound Individual Site Design Other Type(explain) �FI (conventional) C. �Renewal Before �Revision hange of Plumber �['ransfer to New Owner ist Previous Permit Number and Date[ssued Expiration -17� �� g/5�9, IV.DispersaUTreatment Area and Tank Informallon: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation ( �-� �5� ` �� Capacity in Total #of Manufacturer Gallons Gallons Units a��i o 'fl ^ Tank Information � � U ;; � ,� New Tanks Existing Tanks y o a� � L p y � � n. U v� �, v� ir. C7 a, Septic or Holding Tank h! � � �, c V �J Dosing Chamber � � V.Responsibility Statement- I,the undersigned,assume responsibility for iestallation of the POWTS shown on the attached plaos. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number K n r� � � �7l��5�-1b��3 Plum er's Address(Street,City,State,Zip Code) 1(�5"I /�C ��t,�� :� � l��dlc-l�, i,� t,�c���8t( VI.Cou /Department Use Only �A�r ed ❑Disappmved Permit Fee Date Issued Issuing Agent Signature _ $ �e• �1 � �,9� ��/ ❑Owner Given Reason for Denial � � I� ,tr� �-C�� Conditions of Approval/Reasons for Disapproval T._, t--� --4-�s {,�r� �^� ��a � ���f ''"`1"� '� -• tt. r',� L/f��%�4 LJ` iG``: �� JUN 2 8 2022�� `: � C� ��7- o�`� __� � �S IN v � SAVVYER CCU�IT� ZpN1NG ADN1EiVi57f�ATl�i� Attach to complete plans for the systero and submit to the Counry only on paper not less than 81/Z a 11 inc6es in size SBD-6398(R.02l22) NO REFUNDS AFTER ISSUE OF PEAMI'f 9l27/21, 627 PM Nows-Wisconsin Access rev. 13.1108 Rea) Estate Sawyer County Property Listing Properly Status: c��nt Today's Date: 9/27/2021 Created On: Z/6/2007 7:55:50 AM � Description Updated: 2J25/2020 � Ownersfiip Updated: 2/25J2020 __ _ __ __ - - _ _ ._ . _ __. _ _. _ _ __ _ _ _ Tvc ID: 29912 IERRY E TENNEY CLAM LAKE WI PIN: 57-028-2-42-05-28-5 05-010-OQ0010 Legacy PIN: 028542286001 Billing Addr+ess: Mailing Address: Map ID: :10.1 7ERRY E TENNEY ]ERRY E TENNEY Municipality: (028) TOWN OF SPIDER LAKE PO BOX 15 PO BOX 15 STR: S28 T42N R05W CLAM LAKE WI 54517-0015 CLAM LAKE WI 54517-0015 Desaiption: PRT GOVT LOT 10 Recorded Aaes: 10.800 � Site Address * indicates Private Road _.____ ottery Claims: 0 12626N FR 174 CLAM LAKE 54517 First Dollar: Yes Waierbody: Boos Lake . � Zoning: (F-1) Forestry One `--� Propert}► Assessment Updated: 9/10/2013 . _ . _ __ ESN: 2021 Assessment Detail Code Acres Land Imp. � Tax Districts Updated: 2/6/20Q7 Gl-RESIDENTIAL 1A00 15,000 10,400 - G5-UNDEVELOPED 4.800 1,200 0 1 State of Wisconsin G6-PRODtlCTIVE FOREST 5.000 37,500 0 57 Sawyer County • 028 Town of Spider Lake 2_Year Comparison 2020 2021 Change 572478 Hayward Community School District �„and: 53,700 53,700 0.0°� 001700 Techniql College Improv�l: 10,400 10,4Q0 0.0% Total: 64,100 64,100 0.0% = Recorded Documents Updated: 10/7/2014 � WARRANTY DEED Date Recorded: 12/5/1995 251735 567/165 '�r property History ._ _ _ _ _ _ N/A '� i� /' `J °�- i � � ,`-�-� ' .� "_ , ' ( ; `;_-:' , ` ' ,_� tas.sawyercountygov.org/Access/master.asp 1/1 PAGE 1 OF 4 In-Ground Gravity Pian Index & Cover Sheet Component Manual Design References: Version�@, SBD-10705-P (N.01/01, R. 10/12) , . . a `` Pg 1 of 4 index & Cover Sheet Pg 2 of 4 Plot Pian 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 I Description Owner Name(s): ,��°-ir'��l (.. , I f'i��. Phone:��S-`>�'SC?- 1,�� Owner Address: �� �(�L f� �'�Q11'y'� �C'�.(��'� (�.L- Zip: �, ��;G� -����S Project Address: �a(p�p (V �=(Z i 7�1 �'.La,�v�. �e� i�-- ��C�� � _ Govt. Lot: 1/4 of 1/4, Section �g , T�N-R('S E❑or W � Township: ��i<�:� �.GZ-� County: �►L�- Project Parcel ID #: J`�� �' d�-�S�- `��Z�-0 j�-o�-g"�'" Designer Information Designer Name: � Phone: 1���-��J�� Designer Address: �� Zip: ��c�C� E-maiL• �-��c.retcQ� �-4- License Number: '�R'�'��� Remarks: Signature: Date: _ (�j��-���o� inal signatur equired on each submitted copy. ��1 . 4J � �y � 1 C'-.`_ _. �- _ G (� , �- 1+ �. � � �� � �-� � �� — --� G � � � ` � � �. ..-'a � �'�'� �`-' r� + n a. `, _ r^i. - .; �,�-� � G �--- ._ i, v t . 6 � � � ' i� �� l" ��— -� �, , -t' �" 1 � ;�r�, ..� � �- �� �� ���� � � . // ;,�3( Q-"{�'�'//•='' A� 1 ^�.� ♦`` �I l.j%� �.I� ' _� ' �v V�-�!! '� J� �. �� � ��� `.�= 9 h � , � � � �� � o"� ? u� o� '�,r'� ,� �� � �` �' �. �� �ti > .:, " �} --, __�*._-� 1� �t - �. � � ��- ,� �}� � �� � � � L f`'— .� ��.. �� � t � {' � v� v~4v� �` u �.� .-. c1`,.",.i,+J N `�. .�,� •�'� �� 1� l� �� *� ,.- � � - � , � !1 � :�'• (� �. (��= `.,' _. �1 ��� ��., � {f't '� � � � C� y� � —�� � � L.�'_ � _ , � w _ ,. _ d � ��-_____ � � u`� t�� �� �\ � �1 � �, : . ,�� ` � �� `�� S_ y , Septic Tank(s)Manufacturer: IN-GROUND GRAVITY DISPERSAL AREA �',�_��s __ ,,.,_ _______ Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Valume(s): 3-ft Trench (down-sizing credifi) ��,gal ,_..�.., 98, 9a, ga, Effluen�t (Iter Manufacturer: �i''2 GJ r'�� %7;�� — �J�E' , I _ r Effluent Filter Model#: 1 �� �� 2 • �min.12" SOIL COVER (tvplcaq 12" min,trench depth , �tiP'�'� �'� � � TYPICAL TRENCH �` � • . --� �� �� �''��a� �<; CROSS SECTION VIEW �.--� 3a�� �` , •` �� � (No Scale) �IYPIC21) '° n .I a,. , a. . . � . � ° Provide minimum 3 ft System Elevation =,����-�t separatfon between trenches. (typical) Qufck4 Standard-W w/End cap (Show location of inlet!outlet pipe connection on plan view.) Obae(typlcal) Ipe TYPICAL TRENCH (typical) Install per manufacturefs PLAN VIEW �--,���'�` — ,. — :;,,�,.— ._ .._. � ��. � _.._ � �. _ ._ — �� — — — — — — — —( Instructlons, 0 SCaI (N e) �.. r�i �. s .4 � ������'i',��T�� � � I 'l;urii�� �� �� i:� ��, � ���i �) �"�,;� � A= 3,Oft (___�� � � �� �, �. �� �, Ua;,, � � 9�,V��V'��_ — .._ � _. — — — ---- — — — — — — — — � `��iV;1�?�,k�.�.Y 1�1f�s����� �tYPical) � _" �'/`' �j�— — — — — — — — --J �, �" B _� ft �---------•-� I�TI (typlcal) Quick4 Standard-W Chamber W tNSTALL PER TRENCH: (typ�cal> � (mfd by Infillrator Systems,Inc.) Install pursuant to menufacturer's instructions. � �� �,�_, Quick4 Std-W @ 20 ft� EISA/chamber= �� ft2 + �_, pairs of end caps @ 6 w2 EISA/pair= 6 ftZ = Proposed EISA per trench=Q�.. ftZ Required Infiltratlon Area= ��, ftz Distribution Method: x � trenehes = Proposed Total EISA = �.,a, ft2 /�r�c�v,c_�, ..�,��, , `�c�l� � PAGE 4 OF 4 In-ground Gravity Management Pian IMPORTANT: The owner of this in-ground gravity system shall be responsi6le for its perpetual operation and maintenance pursuant to requirements of SPS 382384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),�sc.Admin.Code,this system shall be considered a human healttr hazard if not maintained in accordance with this approved management pian. Furthermore,all inspection and maintenance activities shal�be perfortned by a registered POWTS Maintainer in accordance with SPS 383.52(3),Wisc.Admin.Code. Maximum Disaersal qrea Oioeratinq Limiis: Design Ftow= .��(� gpd; BODS 5 220 mgL-'; TSS 5150 mgL''; FOG S 30 mgL-' lnsoection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors(i.e_odors,user complaints,etc.) o mechaniql malfunction(i.e.,pumps,valves,switches,floats,etc.) o material fatigue(i.e.,leaks,breaks,corrosion,etc.) o solids volume in anaerobic treaiment tank(s)and any dismbution appurtenance(s)(i.e.,disfibution/drop boxes) o negiect or improper use(i.e.,exceeding design capacities,prohibited activiUes,etc.j o e�erd of ponding in distribution cell prior to dosing o dosing irregularities-if applicable(i.e.,pump re-cyciing,float switch settings,etc.) o electrical components-if applicabfe(i.e.,wiring,connections,switches,controls,limers,aiarms,etc.) o distribulion lateral or Iateral orifice plugging (measure lateral distal pressure—compare to design specificafion) o surfaoe discharge of effluent or sewage back-up into sfructure served Mainfenance Checkiist MAiNTA1N EVERY 3 YEA12S{or when necessary) o Seotic and dose tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 W is. Stats-when the voiume of solids in tfie tank(s)exceeds one-third(1/3)the liquid vo(ume of the tank(s)or as required by loca!ordinance. Disposal of conte�ts shal!be pursuant to NR 113,Wisc.Admin.Code. o Effluent filter(s1 shali be inspected every 3 years and shali be Geaned when necessary to remove any accumulated solids according to manufacturer s spec�cations. A servicing period will always be greater than 12 months. System maintenance reports shall be su6mitted to ihe proper locaf govemment unit in accordance with SPS 383.55�sc.Admin.Code. Report any component fai[ure or malfunction to: Name of individual or company: � Phone���5'SS� �(97 3 Localgovemmentunit:�_�('�f]�,�`ZiTyU�.t Phone: ��`�'"(C�u�'(—�So�� Local govemment unit address:�(�JO/(�}'��yL�-��u.�.k i�9 l{Q t���Q�cu��P_ .�"7�t'�1.� Any defective part of this system shail be repaired,replaced,or removed pursuant to SPS 383.51{1),Wisc.Admin. Code.Repair or repiacement of faifed or matfunctioning components sfiall comply with SPS 383,Wise.Admin.Code. No product for chemica�ar physiqi restoration of the POWTS may be used uniess approved by fhe department in accordance with SPS 384,Wisc.Admin.Code. Continqencv Pian In the event fhat any faiied treatment component of this POWTS cannot be repaired,it shail 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 dispersai component in a pre-defermined area of suitable soils. Svstem Abandonmerrt If use of this POWTS is discorrtinued,if shali be abandoned in accardance with SPS 383.33,Wisc.Admin.Code. :, �y �,�, �. �, ..y �;, .,� �L�.j�; �:��i �a t�` �}4�1i!}���da°'x HZ � -_:i i i.�i ( d��C���q�. b �.,a}, � 1• ,f :�� �4+�' i 1��.4 � 1 . . 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't.�">`:+�. `��'',`?�.�+r� '� a ,��-+a��� _„ �-�\'4fe \�,,� y 1 r ,�„ i.• ,�. ,Tyia * �i tis�,� ae.`. ��^���` � ` t �•�F� Y `�-� a �"��t \ "t"�'�t� � '�'µ�"�•��;�y\ ��t�����}': �,. � �7f3�`���4 ���t .����',��. '�R'�1 ,..o.�y���a�C�� � �r�v A� :�' ��� 3�x.;. � ��''^�"e'" �1�c = �1�' ��: b ��`tiEp��` ,�a�*�; � t t ' � ��� r' � '�;'; ' � �� ���AT�c;��"IR�'3ti `a���`" �.��1 �r.�.� $j,'.i*:z�" b.. Soil Pro�ile Sheet Owner.�'ev�y�.e y Soi l Toster:_ f-{;Sd ��I ` t SystemElc�at�on: `�'3. � LoadRatP: �'� SystemRang=:93o5� 9S.c�� � � �-- �Ga .... ...... .. .... ...... � .:.... ...... ... ...... � ..... ...... ...... ...... .. ...... .... c ...... .....: - ...... ...... �� ... ... '_a7.OS , _— ... ... ... ... ... ... � ...... ...... ...... ...... ._.... ...... ...... ...... . ...... ...... . —96. S`t �6 ... .:.... ...... ..... , ..... .._.,. ...... ...... -qS• $� ps .:' .`� ... ... � .. .. .. ... � � ...... ...... ..... ...... .. ... 9Y ...... ...... ..... ...... � V ? ..... ...... R3� : ::: _�3,os� �— -:- .. ` (/ ... ... n � .. ... . ,93 oI �—_ .. ...... N C C ...... ...... . ... s ..:. � �� .... .. .. , . . ... . ... . . ... q ... ...... _qa. �� ' .. .. ... ..... ...... +3, ..... ...... 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S �dQ�-- 1s•1.Ce_ — Insp BM Elev: BM escription: Parcel Tax No: ���o` ��,,,,, o�ss��� o�B- s`��-�-��6ao1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic • •� app Benchmark pp,p r Dosing Aeration Bldg. Sewer + ��(6� Holding St I Ht Inlet Rs;q y TANK SETBACK INFORMATION St I Ht Outlet S;�S► TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR INTAKE Septic �pp` �` �3 p� � p� NA Dt Bottom Dosing NA Insta�lation Contour Aeration NA Header/Man. q .�-� Holding Dist. Pipe PUMP/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 INFO TION DIMENSIONS W L Y � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv o Aggregate �--�1� INFORMATION P I L Bldg Well i/,�aters o GP �C Chamber Model Number: ❑ EZFIow CELL TO �}-- pb� *�j� � ��j� ❑ 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 ❑ N� SOIL COVER Depth Over Depth Over Depth of Seeded/Sodded Mulched Cell Center I Cell Edges �Topsoil 1 ❑Yes ❑ No ❑Yes ❑ No� COMMENTS: (Include code discrepancies, persons present,etc.) ��,.�(I��I � (�s12� Plan revision required?❑ Yes❑ No �� �1 J � G� / J 6c���� � �'ti Use other side for atlditional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS ANO SKETCH SANITARY PEAMIT NUMBEA: �o� — I�g Q�`� . � � LG�` � �°� . , , . :. . . . ,-_ : _ :__ - . _ . . , _ . . �"j� - _: _ . ,_ � i : . _.__ ; ,3�C�S . �'-1,.'�`�� ��� w L $�„• "3�'sa,�� ' � " o,� � �� - ��j �——� _ - - - �- � - �` �i` 3D �,c • ��.�� a� ��, k� �,� 4��5 x W��i� �` L �����' �(�ba-bN ����� T �� l�Y � —�P�—