HomeMy WebLinkAbout032-540-28-5102-SAN-2022-243 :_�__ Industry Serias Division ��H � .
- ,��4 4822 Madison Yazds Way S-�((,�J �
'�;'��_ � : MadisoA�53705 $anilary PemtitNumber(to be fiikd ie by Ct
;,•.` 'j �` � P.O.Boz 7162
�,�,6`;.: �a;�4wiss�o�-�iez (r 3q a 30 �
Sanitary Permit Applicarion StateTcrosactionNumber �
In accordance wiW SPS 383.21(2),�s.Adm.Code,subvtission of this foim to the eppropriate govemmrntal wit ,,,�
is requited piioc m obminwg a sm�itazY Pemtit Note:AppGwtim falms for state-owned POW75 am wbmitted oo Projat Addreav(if�ffereat than miliqg ad W
t6e Dcperoamt of Sefely md RoCessoml Services.Personal infocmetion you Pmvide�y be uxd tor sccwdary
v�+�aoses in ecconievcc with the em.�ecy Law.a Is.oa(lxm).Sars. / �7 y�
I.Applintionintormatioe-PleesePrintAll[nformatiou �poCa�-�.t� �uJl�e/ �I�
Propeny Owuei s Neme Parcel ll
ames � n� Qe ou.�ro�ez 03� S�ID a� Sla
Pmperty Owner's Mailiog Address �I-ocaeoo
aZelwoo �.�1 �°w��z*a
City,Stete Zip Code Phooe N�ber
Len�i e�J . �� (nooaS ��s-ar�-�o�� �—'°���a8
�II7.1 Type of Boildiag(check all that rpply) � Lot# � T�� N R E
�x�l or 2 Femly Dwellmg-NumberofBedmoms Subdivisiou Name
y,� Block#
�b1irJCommaeisl-Describe Use ^
�Ciry of
tete Owned-DescnbeUu CSMNmnber illegeof
— �ro,m or /.J�Rte r
III.Type of POWTS Permi�(Check dffier"New'or"Replacement"rnd other spplinbk on llne A.Check one 60:on lioe S Comptete lice C'
a licable. r� �
A. �Iew Syslem 1 peeWscement Symem �Dlhtr Modificatw eo Existing Sys[em(exptam) Additional Pretru�e�n[Uoi[(«plain)
LJ ��k � �
B. �FFiolmng Teok Io-Gmund �AFGrede �Mamd Individuel Site Design Ot6a Type(uplain)
)
C. �Rmeual Before �Revision ge of Phnnber ❑I'taasfer4o New Oumer �10�p��N°mba a°d Da2��ucd
Expiration rp'o2t�� lO' 0�'7�0
N.DlapenaVfreotment Area md Tmk Ioformatlon:
Design Flow(�d) 1Jcsi�Soil Application Rete(gpNs� Dispmel ARa Required(s� spetsal Aree P�o�rosed(sQ Systan ElevaRm *
3� .? �ra� a�� �r;�; R l�s -
Cepeciryin Total #of Manufechrter
Teok InCo�metion Gailoas Galioav Units �u �'g4. .�
Nnv7eoka Fiis6n8T� y$ 3� 3 �� m
&U 'm vi i,.U e.
SepUcaHoMiry{Tmk � DU� L Sf-'�W f 7�
Dosiog Chambcr �
V.Respoosibilily Sbhmeet-4 me a�denigoee,anome mpendb�iry tor imh0atloa o[the POWTS s4own m the atnched pl�m.
Plumber's Neme(Pri�nt) Plumber' / MP/MPRS Nmober Buvoss Phone Numbw
�r�,. /il� i ao�Y�d�( ?lS`o� - `!v
P�umber'n AdJn.ss(Shat,Ciry.Smm,Zip Codc) ,p � .
�O � u�-cC � �lL�Pr �.cJ.�' S� 8�
VI.C n /Department Use Oely
A ❑Disepproved P�it Fx Date Iswed Issuing Agart Si�amrc
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Condidons of RpprovaUlteasona for Disappmvel � - -
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O�IGII�:�� ��o� � SFP o� zo2Z .
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��5� �� — I U/ �� �� �r�d � SAWYER CGUNTY
/ ppdA1NISTRATION
AmrB b campieh P�for t6e sysem aud ao6mit b He Cway�7�WPa ast kn thu 8 N t t I ivehe W�e
NO REFUNDS AFTER
SBD-6398(R 03/21) ISSUE OF PE�i1JIfT 3(y�9l�
PAGE 1 OF 4
In-Ground Gravity Pian
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
Owner Name(s): J�meS � t�i� i�a F.J e5Cc7c-cfo�CeZ Phone: �l5 - aUc - �o�v
OwnerAddress: ��3 {-�aze�4x.,-c�Q Ln, GZe�IU�e�i �L Zip: �odOaS
Project Address: Cpo2o5�-W �lwe�e�- �. ke 12�
Govt. Lot: �-�30 1/4 of 1/4, Section a� , T ` O N-R �EOor W �
Township: [,t���-�.�eJ County: �er
Project Parcel ID#: O 3 a J��D o2� S l D o�
Designer Information
Designer Name: ��'� � �, / /���� Phone:7l5 -a�ry - oZ�S�o2
�Designer Address: -SO�?' N ��hl�xl �-'� l,(/ i/� Lei Zip: S�(���o
�
�E-maiL• GQ�/l'�"Gtr�/h�n/IC� f Vr� CD �
License Number: �,�v���`C�
Remarks:
� �Signature: �� Date: "� ��
Original sig tu �required on submitted copy.
CHECK 80%AS APPLICABLE. CHECK BOX a5 APPLICABLE.
� SOIL EVALUATION o s��: �ao� � 80 � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: oesicN F�ow� � cao
1. 10'
EMEr�,��/ �c�nF- ( (�,5-�rL(f Attach design flow calculations for commercial plans.
o•—�� p [�
PROJECT ADDRESS' �/�D p—W RUAtk,' (.,� e Pipe Material/ASTM Sta/n�dard(Tables 384(.�3I0.'3 8 384.30-5)
f1 N SantlarySewer -!�� l rv�
BM Symbol: � BM Elevatbn: /�'v FT
T�� �� ���� FwceMain: 1
BM Descnptlon:
slo eGraa�errt(%) mai���onnoy IMPORTANT:
P N� Weil Symbd(rfapplicable): � a,�wmg a�a� Show ground elevafion contours at suitable intervals.
of Tested Area: on t�e appropme Yne
w�ter L4ke
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Sawyer County Zoning Administration
L06I0 Main Street Suite 49 � ��
/��
�.,,�� Hayward, Wisconsin 54843 r
�
���.a_ '���1� 1735)634-3255 � r
�� ; ��I FnX(715)G38-3277 �� �������
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� �;t, �� =.r ; � � T'nil Frce CnurthousdGencral lnfonna�ion 1.877�i99-i1t0 �� 9O�
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SAV4'YER C�UNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TAVK [NSTALLATi�N APPROVAL
PROPERTY OWNERS NAME: �°�+�e5 � � f� �-�-a. � �SCc�u,rc��ez
TOWN OF: Gt� i�I�c�✓-
ADDRESS: �p�DS— (,(f � c-c/t��1' �. �=t.F—e �rX
i, �✓'c.�. c S %�c')/��1'� , a W'isconsin
Licensed Plumber, au horized by the owner, do hereby acknowledbe that 1 am receiving
tempoi�ary approval to instaEl a scptic tank�holding tan.k without a soil and site evaluation,
or existing ystent evalua�ion, and private sewabe system plan review due to inclement
r.veather and/or health and/or safety emergency. .
Eurther, I acknow�ledge that a soii and site evaluation, or existing system evaluation, and
pricate sewage systen� plan review �rili be conducted by the deadline stipuIated by the
permit issuino agent, or as soon as weather conditions or circumstances peralit. [f the
private sewa�e system is found to be failing as defined in s. DSPS 381 .01 (92}, Wisc.
Adm. Code, corrective measures will be takcn as such that the private se�vage system
complies �vith all applicable requirements of chaprer DSPS. 383, Wis. Adnn. Code,
within 90 days oE this agreemcnt.
I further aclrno�s�ledge that failure to coi�ply by obtaining all necessary pernlits after the
deadline datc may result in the issuinb of a citation, uuder Section 11,3 [2j Sanitary
Per•mits], of the Sawyer County Citation �rdinance.
DEADLINE FOR IS AGREEViENT SHALL BE: l � .J� ~� �
Sib ed:
� ����
Date: D - �l a �
Accepted by: ��. �
Date of tc�porary emergency approval: O ( -?� I p� �
Rev. 03i 26/i 3
� � � �
I'G/� � P_j � „ � �J
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shail 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 perfortned by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersai Area Operatinq Limits:
Design Flow= ��LJ gpd; BODS 5 220 mgL''; TSS<_150 mgL''; FOG<_30 mgL''
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance fadors(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 a�y distribution appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacifies,prohibited adivi6es,etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float swftch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connecHons,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure-compare to design spec�cation)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Seotic and dose tankls)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 fliter(sl shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturers 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: y�on��ontP$�n d-SetiS E� Z� Phone:?l S'026 6-cZ�S`la
Local government unit: J4 kl�� �Du�� Z�1L�M Phone:?lS"(0 3�t'-����
Locaigovernmentunitaddress: �0��0 n?k�n SL. S'^,�e k�( �"'� a1`*��l ZIP: S�g`l3
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 approp�ate 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 POVYfS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
'-"'`�'="f": PRIVATE ONSITE WASTE TREATMENT county
,:_� -,�-.
(i'��� � �1 SYSTEMS Sawyer
s )
'����� Ps /�~f ( POWTS)
�k F_�-,y�=%
='s151"=`''"- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� � 2.�3
Peisonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑Gity ❑ Village �Town of: State Plan Transaction ID#:
�c fw�t-S T�1T�`�'1"�t �C.o4�r'���� W�,��.�LS— r—
Insp BM Elev: BM Description: Parcel Tax No:
i
�a0'� a ��� o32 -S�1�-�-g-Sfb�
TANK INFORMA ION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic gBp Benchmark oO.o�
Dosing
Aeration Bldg. Sewer qr6�
Holding St/Ht Inlet 9 rY �
TANK SETBACK INFORMATION St/Ht Outlet S- r
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .�-�` ��' � ' +c6 ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 9�,q �
Holding Dist. Pipe
PUMP I�IPHON INFORMATION Infiltrative �
Surface `��•Y
Manufacturer Demand Final Gratle
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv �Q Aggregate
INFORMATION P I L Bldg Well Waters � IGP ❑ Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO ❑ Mound o Other
- -- -- ___— ---- - --- —._.
DISTRIBUTION SYSTEM x Pressure Systems Only
-- _ — --- -_____ —
Header/Manifold Distribution Pipe(s) �' X Hole Size X Hole Observation Pipes�
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No �
—
SOIL COVER _ _- — ---_- _-- _
- - --- -
Depth Over i Depth Over Depth of - � Seeded 1 Sodded � Mulched �
Cell Center � Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
������ ��3� I �2
� .S�—� t.e�\�r-e r`,r``�' o r�y
�
Plan revision required?❑Yes❑ No
�3 �� � _��. G�� � �� � ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBEA: a-o1—i�-�
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