HomeMy WebLinkAbout002-940-03-4106-SAN-2022-166 C/) _
Department of Safety c°U°cy �
o & Professional Services,
��Ctc�: e-r �
a p - Sanitary Permit Number(to be filled in by Co.)
E Industry Services Division
(� "� �'� 1 l9 � �
State Transaction Number �
Sanitary Permit Application �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note Application forms for state-owned POWTS are submitted to Project Address(if different than mailing addre�
the Department of Safety and Professional Services Personal information you provide may be used for secondary �'
purposes in accordance with the Privacy Law,s. li.04(I)(m),Stats. �G)LLL�/� �Q h����J �
I.Application Information-Please Print All Information � � J
Property Owmer�s Name � Parcel#
�-h�S 1� h��' c�1�� �h�v�s� iM. -�z�a oU�C— q�FO — 0 3 - �/o�
Property Owners Mailing Address Property Location
s�� S {i' ►'t'Ve W. AP7 ��7' Govt Lot
City,State Zip Code Phone Number j
�Z-Q�--i'�� � (�l+(1 �a(�� �3C � z.��� Q.S 1� �%,.s� '/., Section 3
II.Type of Building(check ail that apply) � Lot# T �b N R 9
�l or2 Family Duelline-NumberofBedrooms / SubdivisionName
Block#
❑Public/Commercial-Describe Use
❑Ci[v of
❑State Owned-Describe Use CSM Number et S^��J� ❑Village of
/O /��J Q�.To�m of 1— "s—�� - -
IIL Type of PO��'TS Permit:(Check either"Ne�"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.
.a.
❑ New S}�stem �2eplacement S�stem ❑ Other Modificntion to Existing System(esplain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holdine Tank �In-Ground ❑ At-Grade
� ❑ Mound ❑ [ndividual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Change of Plumber List Previous Permit Number and Date Issued
❑ Revision ❑ Transfer to Ne�c O�cner
Expiration �� - a3� /�������J
IV.DispersaV'I'reatment Area and Tank Information:
Design FIoN�(�pd) Desien Soil Application Rate(gpd/s� Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation
�� d '7 � �F3 noC q3's
Capacity in Total #of Manufacturer
Tank[nformation Gallons Gallons Units � ` o � ;
New Tanl:s Existing Tanks '� � y � � � � �
c
G C.1 V: n cn f.c. Ci G
Saptic oc-Fleldlag Tank ���� ���� ����/',/�
G�,
Dosing Chambzr
V.Responsibility Statement- I,the undersigned,assume responsibility r'nstallati n of the POWTS shown on the attached plans.
Plumber's Nnme(Print) Plumber's Signa MP/I�4PR��Alumber Business Phone Number
�u���► Ku�t�Cl ��s�s/ ��sl-����--3�.�
Plumb s Address(Street,Ciry,State,Zip Code)
� o , �;o� �,�, c�61�-, ��.� s�fb'2�
VI.Count /Department L?se Only
� � � Permit Fee Date[ssued Issuing Agent Signature
Ap Pov ❑Disapproved �/
��� ❑Owner Given Reason for Denial � (��� ? I�-� I�� ����-Q--��L�-�-
Conditions of Appto�aUReasons for Disappro�al �i'���'��,���,j?���
� �i `'�� �.._. - - i -'i; _] �i!^,'�jjJ 1JJ �"�`;1i
�,�
,� �ate�� `._ '_�_ i
���' ��o► „ k# �� � JUL 2 0 2022 :
L �.h ►�
�t� t#�ew ��Y,d '�-a(���i
�—S� �a -- � � ` P SAWYER C�UNTY
��ZQNtNG ADR.RiP3I�TRATION
Attach ro complete plans for the system and submit to the County onh�on paper not less than 8 i/?x 1 I inches in size
sa�-639s�x.o3izz� NO REFJNDS AFTER
ISSUE OF Pf�+MIT
�-�3`7
PAGE 1 OF 4
In -Ground Gravity Plan
lndex & Cover Sheet
Component Manual Design References:
Version 'l�.Q, SBD-10705-P (N.01 /01 , R. 10/12) � _ �
� • �
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� : � V'tS+O��ti� d �'I�t�eS� M � �R Z � a Phone : �30 - 23� - c�S18
Owner Address : 5z�{ S� {��. �,�; , '�.L-fc�{ S ea-�-�}-( e � �,c,� i� Zip : 9k1 / 9
Project qddress : R�f�FI xl f-�-i � �t �� �� � 2C� . �cLc� ward , c,�s �{�'{3
,
Ge�-tot: o� �1 /4 of 5 � 1 /4, Section 3 , T �-lb N-R � E ❑ or W �
Township: �QSS Lc�K� County: SQu,�4e�''
Project Parce! ID #: D�` 2 - �i �f-0 - o � -- �{ ( 0 �
Designer Information
Designer Name : �QS�c� �u � �e � Phone : 715 - 7�,� - 335��
Designer Address : P' 4 � �uG�c � (� ��Ol � , ��' i Zip : S 5�� Z/
E-mail : �� m �-Q.c�c��, ras : r_.e �r� _
License Number: �C �1 S75 �
Remarks :
�
� *_,.�Gc.a�.,,�:...b.,T..
Signature : r`� _ Date : � i z 2
Onginal signature r2quir2d on each submitted copy.
C�rlsf�Ph�r °` -���rese i�t �f,zio Scc�e€ I " =`{o' t
Sz'-{ s�h �ve w, , /-1-,ot �(�'-F
sza+Ne, w�4 GS��9 N
(n 3 0 -2 3`f- o S-I�S .�,�e�.5�:.-���' �4-2 3 z
�c�i4�74 �Vzl��n�
��w-� N ��5h1��� Rd�
�.of NE, SE� S 3; T'-fO 1�5; (L�I�J
Lar l�csm �8/ns t 5-�33
—`bwn o�' �ss �e stied
Sa:-���.f��, li-'z
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� rE1c�s}�n� `Ca���Q�t'c�'��SC Stcel S.�a,n(C.
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e ��� �Fo �V l.�"Salce�e w�ne�-e (Y�ju�reaQ
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b i �V1.u�T n 1 �,�J1eS<..- �OoO ST. wI OY2itLC �`'�-P'
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63
�, 6m= ico'E-'C�x,1-lo�n �F
5���n5 cv� �av�aye.
�I eu a-h-�s �
t3l= R'l,Z 9
6�=R?��� '
Q 3_ a�(,z s' �c�c�� Kaei-�el
��s+• sys+�, = �3 �z '± �p�. �,s,sf
P�P�s�
d „� Sys+� = aa:s ���q�Zz
Cross Section of a two cell EZ Flow In-�Grounc� Dispersal Componeni
Gell Separabon
3 3 R 3'
� __��I'd �I Final Grade
'+ ' �' � z �`"�- � ) 'd
, z � y��i�j �,� y r'�� i,�
� ceuKi . ,�-����f� �t„ ., .�,'���i ' celi � '�r�"�v'�� GeotextileFabric
� — � � . r ::'� ���
�
,2�� o �� o , :`�- -
� � + � '� �
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� /�
— � �,�-� � =r�_. , r���
- c�< ��i�
� s
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Design Flow `{s� / Loading Rate • � = Required dispersal area �i �-3 Ce11 #�
System Elevation °I b:5
Required dispersal area �� / 50 (EISA) _ _ I 3 (number of �.inits) �
Final Grade�. ���`�
Geotextile fabric to meet Comm 84.30(6)(g) "� U S ey�G Ca� Cell t�2 �
Minimum of 12" of cover over top of cell ,3� X 7G � �C�S System Elevation: R 3.S
Two Observation/vent pipes to be provided per cell
C�� �n��\ Final Grade q7 'f�
Not to scale J
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
requi�ements 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), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= �(,� gpd; BODS <_ 220 mgL-'; TSS 5 150 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.)
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, 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 tanklsl 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 (113) 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 filterls) 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: {��t.�1,Vil Y.SCS�\�i-(SSC-dl °'��S Phone: '7rS �f� ��
Local govemment unit: �-��az� �� �'�-� Phone: �7� S��v3�"�Z"�
Local government unit address: (,ULLV � I,� "- ZIP: ����''
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.
Continqencv 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.
'""'""—'"'f���=�; PRIVATE ONSITE WASTE TREATMENT county
��;�.,
,=�'� o�� � '; SYSTEMS Sawyer
�����1 s ( POWTS)
.� � ,;:�,�
�:��F.:; !�.�
��'=«'�����' INSPECTION REPORT sa�itary Permit tvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _. �,��
Personal infonnation vou provide may be used for secondacy purposes[Privaey Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Pian Transaction ID#:
��`�� � ���� �,�� (.�(�. '
Insp BM Elev: BM Description: Parcel Tax No:
(c�.o ��`^-i b�5,�i D� ar�y�2 �o� � �l�f� --03- �ljC-�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W���� �u0 Benchmark �,o�
Dosing
Aeration Bltlg. Sewer �'�,a�
Holding St/Ht Inlet 4�',��
TANK SETBACK INFORMATION St/Ht Outlet �S: 3b '
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIR INTAKE
Septic �� ,t-� .��o �-�o � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. Qy,�y'
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative �
Surface R 3,3 S
Manufacturer Demand Final Grade
Modei Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR TION
DIMENSIONS W 3� L p � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
P/L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG � EZFIow Model Number:
� ❑ Mound o Other
CELL TO �}(o �'2� �(oa _ _.1V
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) ' X Hole Size X Hole Observation Pipe��
Length Dia �ength Dia Spac_ __ � Spacing ❑ Yes ❑ No �
SOIL COVER
Depth Over Depth Over Depth of � Seeded I Sodded Mulched �
Cell Center Cell Edges Topsoil __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
� �---- --
Plan revision required?�Yes❑ No �I � �'
�3 ;�3 �� I _ . �- _ 6� S�I;�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT Nl1M8EA�_ �� �-L�L• _,
C7E�'X C 0� .
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