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Home My WebLink About002-940-13-2402-SAN-2022-168 °' ` Department of Safety c°""�' Cn _- Sw��y-�� : �_ - & Professional Services, Sanitary Permit Number(to be filled in by � ` � P= , Industry Services Division , �".��,.. � - (..0:3�( I C� �-C Sanitary Permit Application State Transaction Number �; In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit — is required prior to obtaining a sanitary pemiit.Note:ApplicaUon forms for state-owned POW'IS aze submitted to Project Address(if different than mailing p� the Department of Safaty and Professional Services.Personal intormation you provide may be used for secondary pp purpos�s in accordancz with the Privacy Law,s. 15.04(1)(m),Stats. I.Application Information-Please Print All Information -- Property Owncr's Name Pazcel# i��,�� F�� rt'e�n oo2 -g�/�� 3 _ 2�f �Z Property Owner's Mailing Address Property Location $ 7�d /✓ Y�P�S �� City,State Zip Code Phone Number � � �-��v.i� �✓t e-U �-� � '/a, �� '/., Section� J � II.Type of Building(check ait that apply) C.ot# � T y� N R �9 E or� �or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name Block#� � ❑Public/Commercial-Describe Use � ❑City of ❑State Owned-Describe Use CSM NumbEv ❑Village of �Town of �^S'r "�G III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on fine A. Check one boa on line B.Complete line C if a licable. a' IJ New System Raplacement System g )' ("'p ) ^ � 'P ) � Othzr Modification to Eaistin S stem c.a lain I� :ldditional PretreaUnent Unit ex lain T.n k e.,( B' ❑ Holding Tank -Ground ❑ At-Grade gn YP ( P ) ❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain (conventional) C. ❑ Renewal Before � Revision ❑ Change of Plumber -ist Previous Permit Number and Date Issued ,J ❑ Transfer to Nzw Owner Expiration ? 1 ^ I� 7 �-O 7 IV.DispersaUTreatment Area and Tank Information: ; ' Design Flow(gpd) Design Soil Application Rate(gpdis� Dispersal.1rea Required(st) Dispersal Area � System Elevation ,�F,So , ro 7.r0 6l S— �'x�s�'`> Qs" ` � � Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units � � v '°„ � � N � New Tanks Existing Tanks � o � � � `� ro G~i U V1 v� C%1 GL C.J P.. Septic or Holding Tank ��GO 160 c> < < � S{i � Dosing Chamber V.Responsibility Statement-I,the under�gned,assume responstbility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/n4PRS Number Business Phone Number � � 5��-L /S"/6/ Z �F�-s:�8 -�s% Plumbzr's ddress(Street.City,State,Zip Code) ?o rC,�v S{.�.�� lqk�- r�. , S'Y�-7,�c S�� /.,k w. VI.County/Department Use Only �A7 � ❑Disapproved Pzrniit F�z � Data Issued Issuing Agent Signature /�./ $ Y��. `� l�-� I;�-� �1�.f.,,.�,"�.J�,�-iT,t/i�l�:}- ijJ�� ❑Owner Given Reason for Denial i Conditions of Ap}sroval/Reasons for Disapproval � ��z¢�`��j��(} � ��A � � �-� �a ' ,�� _o ��;E� r ��' : � ate � � ,_ �aI �� 1�i�► � �:hk# � � �� JUL 2 5 2�22 C � r ' � ��I SAWY�R COUNTY , T �� - ��-D .�� w��,-�� ZONtNG AQVlINISTRATIUN Attach tn complete plans for the system and submit to the County only on paper not less than 8 1/2 i 11 inches in size SBD-6398(R.03/22) NO REF'JNOS AFTER ISSUE OF PEHMIT y o�� PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References: In-Ground Soil Absorption for POVVTS Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg3of4 - Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Owner Name(s): �^� � � � � �s. "��nh� Phone: - - Owner Address: g7�� YopP S r � Zip: ��8 Project Address: K�K4y � `�'f �Y $ ( 3 Govt. Lot: s E 1/4 of N u 1/4, Section f 3 , T�N-R 6 �1 E ❑or W � Township: 34SS �til�a County: ProjectParcel ID #: o6Z � �1 `/o - � ? -2YoZ Designer Information Designer Name: Dylan Schultz phone: �15 558 5904 Designer Address: �076N Stone Lake RD Z�P: 54876 E-mal�: dy�8f1SCf1U�iZ18�gIlldl�.00111 Chis space reserved for approval starz.p. License Number: � 516129 Remarks: Signature: Date: 7 — ZZ - 2 � Originals% e re uired on i mRted copy. Reset Page j Qlu �- pl�., 2�F�j pwher -. �-_eq�: � �o�alL � � Eoa. lCa`�C,�ec.-1Te•lney sc�.�c.- L`o.� Bqss L.4�c.etwP 6 g1s0 N yb��s �c� l�(QJ Ft ObL-a40 - 13- 2`{OZ L-4a,� �4r�� w � Sy �`�3 ss�n�w 5 t3 ru�� 2o9�-�J -1l$ - 63�{ _ S-I15- 20 .7-�iac �ccroe � � �,�,wu.. C)r4s'S _q Z� � ` � r �� ` A _ -� � �ad� � � o � q a ' 36� �x 3 3 Q �cac � -ti ' BYt�o0 O�h 3 6P�� S Gar �ev �-s�[ . 2 � 7 �oo� 1r�tY/ Lpo . � � r,5� . CF g ra ue. sys . 3 . x ¢K'F � � 0 �1.� 3 ��°e�5 � � � I isn ��o bo�Ebms.d.:,� b`l9"5 �Ql�e B I. 95. z5' 2. 96. f' � II� S �� G 3 . �s• 1 ` S fS'IGIZ1 . � so:ls, sy54�w, ele�. a�.s' My � �,:�s�.;5 s.T �.a t R5' PAGE40F4 In-ground Gravity Management Plan IMPORTANT: The owner ot this in-ground gravity system shall be responsible for its perpetuai 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 heatth hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be peAormed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Oaeratinq Limits: Design Flow= Y-� � gpd; BODS <_ 220 mgL''; TSS <_ 150 mgL''; FOG <_ 30 mgL"' Insaection Checklist 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, tloats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatmerrt tank(s) and any distribution appurtenance(s) (i.e., distribution/drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited adivities, etc.) o exteM of ponding in distribution cell prior to dosing o dosing irregularities- if applicabie (i.e., pump re-cycling, float switch settings, etc.) o electricai components- if applicable (i.e., wiring, connections, swiiches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pre�ure—compare to design specNication) 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(sl 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)shali be inspected every 3 years and shail 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 compo�ent failure or malfunction to: Nameofindividualorcompany: DY�'r` �c��Z Phone: ��S -ss�"S9o� Local government unit: s�.� r�/ 4r�4�y z��%'-} Phone: 7`� ' G3�— &Z38 Local government unit address: ��` S�""'� ��y�'^� V' ziP: -�YY43 , 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 wiih SPS 383, Wisc. Admin. Code. No product for chemical or physicai restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Continaencv Plan In the event that any tailed 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 dispersai component may be abandoned and replaced by a code-compiying 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. Reset Page "T""�� pRIVATE ONSITE WASTE TREATMENT county , r;� ��o$ SYSTEMS SaWyer �� s� � ( POWTS) .\kUF`-�L�`�� '"'"�^'� INSPECTION REPORT Sanitary Permit No: Safety and Buiidings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2� r 16� Personal infonnation you provide may be used Cor secondary purposes[Privacy Law,s. 15.04(I)(m)] Permit Hoider's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: �� d- �V� � �tSS L�a� �' Insp BM Elev: BM Description: Parcel Tax No: l�o�o' s;�;� s vG�� czx�� - q�(o_, -� Y� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic , �p Benchmark (Oc�.o' Dosing Aeration Bldg. Sewer — Holding St/Ht Inlet q ,$� TANK SETBACK INFORMATION St/Ht Outlet q Y.S� TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIRINTAKE Septic k� � -I�,S` � ` +� ' NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist. Pipe PUMP 1 SIPHON INFORMATION Infltrative r Surface Q2,3S 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 I L Bldg Well Waters � A P ❑ Chamber Model Number: � G ❑ EZFIow CELL TO ❑ 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 -�epth of Seeded I Sodded Mulched Cell Center � Cell Edges I Topsoil __ __ � ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, p rsons present,etc.) � S� � �,.s�/� ��nl�--� -�q .. ri r � �. ��.,�,��--b��r C�s�°�� b�� -- � Plan revision required?❑Yes❑ No � 3 �? i L— , 6��'� > � Use other side for additional information Date P WTS Inspector's Signature Certification Number SBD-6710(R.3/01) A��ITIONAL C�MMENTS AN� S�pKETCH SANITAAY PERMIT Nl1MBEA�.___�"2�6_______ O ��" 36y c. a�'� �x � G^cQ° � �Q I �� I ��W ia)n.f' � �.�1Q�� ,�� .�,.�"�( � � ar ��'� S� I �� '(�o �'�'Q''�`' ��Sr,IS I �A1--- �•-