HomeMy WebLinkAbout010-941-23-4226-SAN-2022-202 ' Department of Safety c°°°�' S'qvy.c/ �
��� � � & Professional Services, �
= � S : Sanitary Permit Number(to be filled in b}
,,, � �: . Industry Services Division
(0 3�I I Gl � c�,
State Transaction Number �
Sanitary Permit Application _ �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �
puiposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �a��
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
fi✓i���u,�., l.onZ BjO-- 9y/— 23- �ZZ6
Property Owner's Mailing Address Property Locafion
9 ��P T 3/V Ai/'�o/"y" r C r ....�e� N ws F,s�E, NES�
City,State � Zip Code Phone Number � �
�h k/c«-� � �c s"ygc.�3 '/., Y,, Section
II.Ty e of Building(check all that apply) 2 Lot# � T �j N R B 9 E or
or 2 Family Dwelling-Number ofBedrooms 7 Subdivision Name
Block# '—
❑Public/Commercial-Describe Use `
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
3 s�238 �831I .�°""°f�w`'�
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 if
a licable.
A.
❑ New System eplacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holding Tank n-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
Expiration g����3� ��I 1'] (�3
IV.DispersaUTrestroent Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
�s-o • 7 6 K� �a 9y.a.r-= 9s s—'
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units w c �o $ � � �
New Tanks Existing Tanks � a� � � p � `�
a` U 'v� � v� w C7 Ci,
Septic or Holding Tank d MV �(�'f � W�a�
Dosing Chamber
V.Responsibility Statement- I,the underaigned,assume responsibility for instxllaHon of the POWTS shown on the attached plans.
Plumber's Name(Pnn�t Plumber's Signafure MP/MPRS Number Business Phone Number
j)�(�,,,i SG�.� k"v 1 S-i �,r2 9 ?/�--�'s� -.�o Y
Plumber's Address(Street,City,State,Zip Code)
�0 7��/ s-�n� /�,�z r �. , S-Fo�,� lut� , t,v,' , .s`�ys� ��'
VI.County/Department Use Only
�.A v d ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
� $ yo�a° ��(�-(aa �v�Q�.�}r,�._
❑Owner Given Reason for Denial
Conditions of Approv 1 eason's for Disapproval �,--.-� � � \-��r,�j�--1
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Attac6 b complete plaos for the system and submit to t6e County only oo paper oot less than 8 t/i x 11 inches in size
NO REFJNDS AFTER
SBD-6398(R 03/22) I�SUEOF PE'R�AtT ��yys
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
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
OwnerName(s): �/�If :_M �-O�z Phone: - -
Owner Address: �bG`I3 � ������' n c� � u-y 4wa , w�� Zip: � -S�5'$s'�
Project Address:
Govt. Lot: 1/4 of 1/4, Section Z 3 , T y � N-R�E❑or W�
Township: I d� °'� �ax'^'"'d County: SNWy�
Project Parcel ID #: oi� � q�ll - z3 - y 2 z�
Designer Information
Designer Name: Dylan Schultz Phone: �15 _ 558 _ 5904
Designer Address: �076N Stone Lake RD Zip: 54876
C1y�df1SCf1U�tZiB�gfTIdI�.CORI � lxi> �ua�c teszned f�>t a�>> oc�� clain�
E-maii: � z� }.
License Number: 1516129
Remarks:
Signature: Date: �- 9- Z Z
Original ' natura r ired on each submitted copy.
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� � � 7076N Stone Lake Rd
Stone Lake, WI 54876
, MPRS 1516129
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Septic Tank(s)Manufacturer
IN-GROUND GRAVITY DISPERSAL AREA =_..., w,<<S,,r
Uniform Elevation Trenches with EZ1203HP Bundles SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit) ��ao
gal gal gal gal
Effluent Filter Manufacturer:
�' �Y �Y 'Y "� oe_._o ,_ �oly /o�LC
Geotextile I min.1Y Effluent Filte�Model#: �"� �Z�
cover I (hpipl)
SOILCOVER TYPICAL TRENCH
min.Vench1 � . CROSS SECTION VIEW
depth 1 L _ N
�ryp;�i� � .��.. . ,;' � O SC8I8� OBSERVATION PIPE DETAIL
(No Srala)
System Elevation= ft. �• '�"� � s"a"'-ryva°f •
•.• • Fm�snee caaa
��YPical) p suvi ceP O�sa� , .+�. .
' Provide minimum 3ft cm���aaa��a�a�
j �{-ZS—qS •S separation between trenches. a�e Pvc r� ` :';,, roc���c��
Top of pipe to�ertninate �'� (min.1 toot)
at or above fnished gratle
(4)1/4"-1 'X 6'Sb4
TYPI CAL TRE NCH (Show location of inlet I outlet pipe wnnedion on plan view.) �9�O aaae
PLAN VIEW ^^m��9o�„� i^�m��^
4�� � Observafion pipe shall be inslalled SuRace
(No Scale) Perforated Lateral a�;u�������u��� 7D ft
Observation Pipe (ry���)
(typical) (rypica�)
- - �� - - - - - - - - - - - - - - - —
� - - - - - - - - -�- - - - - - �
I °__°__ __'____ _--__ °_____'= I A- 3.0 ft �
__ '__ __'__'_ -
�- - - - - - -- - -- - - - - �� - - - - - - - -- - - -- -- - - - � c�v���� �
m
F B = n =� c�
cryw���
INSTALL PER TRENCH: EZ1203H Bundle �
3sD caP��q �
� 10-ft bundles @ 50 ti� EISAlunit= ft' (mfd by Infiltrator Sysrems, Inc.)
Install pursuant to manufacturers instructions.
+ 5-ft bundles @ 25 fF EISAlunit= ft'
= Proposed EISA per trench = 3r� ft' Required InfiltraGon Area= �y� ft' Distribution Method:
x 2, trenches = Proposed Total EISA = dd ft' �'°�^�`��)'
�
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
7he owner of this in-ground gravity system shall be responsible for its perpetual 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 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 Disaersal Area Oaeratina Limits:
Design Flow= ��� gpd; BODS <_220 mgL"'; TSS 5150 mgL"'; FOG <_30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical matfunction (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., distributlon/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 Seutic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 261.48 Wis.
Stats. when the volume of solids in the tank(s)exceeds on�third (1/3)the Iiquid 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 fllter(s)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 Wlsc. Admin. Code. Report any component failure or malfunction to:
Dylan Schultz 715-558-5904
Name of individual or company: Phone:
Sawyer county zoning 715-634-8288
Local government unit: Phone:
10610 Main Street, Hayward, WI 54843
Local government unit address: 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.
� """�� PRIVATE ONSITE WASTE TREATMENT county
�;
'=�;�`�o$� SYSTEMS SaWyer
��� � s ( POWTS)
`��F,�-_---��
'"��'-���� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ,LZ —��
Personal infonnation you provide mav be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
W`�1dw1 ��N� HA wal�
Insp BM Elev: BM Description: Parcel Tax No:
�OV.d� a� CaY,C �i �C Cc��v'2�^ V�� "9Y�'��-3 '—i��-6
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w ;� � 0 oa Benchmark ���,� '
Dosing
Aeration Bldg. Sewer p�k �(�.75�
Holding St/Ht Inlet �(6.a5 '
TANK SETBACK INFORMATION St I Ht Outlet �s$3'
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIRINTAKE
Septic .��.c�` ,}.�ao` 37� fi3'7' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 4_).�S r
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative q,�6 ,
Surface
Manufacturer Demand Final Grade
Modei Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS W ` � (�S'` ;�S' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters o GP ❑ Chamber Motlel Number:
� EZFIow
CELL TO �Z� �'�' �(o o ��o�► ❑ Mound o Other
-- — -- — -�-- ___
DISTRIBUTION SYSTEM X Pressure Systems Only
— --
Header/Manifold Distribution Pipe(s) —�Hole Size X Hole Observation Pipes
Length Dia Length_ Dia _ __ Spac __ j_ � Spacing ❑Yes ❑ No J
SOIL COVER
- - - --- —
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center �ell Edges , Topsoil _ __ ❑Yes 0 No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���//� � �ti (a2
—T —�
Plan revision required?❑Yes❑ No �3� �� �3 � s � j � �� � �� �
��v �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
SANITARY PEPMIT NUMBER�_ __�o-�-�-0_3_ _
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