HomeMy WebLinkAbout026-938-17-5721-SAN-2022-276 ��` """�% Department of Safety c°°°n'
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_ �\�_ : & Professional Services, ,
Sanitary Permit Number(to be filled in by
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Sanitary Permit Application StateTransactionNumber �
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In accordance wilh SPS 38321(2),Wis.Adm.Code,submission of this 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 diRerent than mailing adc �
the Department of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(I)(m),s,��s. yo ry�N M�si<y Po�n+ �n
I.Application[nformation—Please Print All Information
Property Owner's Name Parcel#
Tho�+0.s S��a�►s oa�- 938- ,� S�a1
Property Okroer's Mailing Address Property Location
aaas� c�.,�� ��+�.: r}5 G�-��e ��o�t �ot �
City,State 7_ip Code Phone Number
EV G C'`�.0 C� �'� g�y 3q '/4, Y4, Section ��
/
II.Type of Building(check all that apply) Lot# 3 T 3 N R 09 Ee W
[�1 or 2 Family Dwelling—Number ofBedrooms a Subdivision Name
Block#
❑Public/Commercial—Describe Use
❑City of
❑State Owned—Describe Use CSM Number ❑Village of
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vo�. C. -30$
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 S�stem Replacement System ❑Other Modific�tion to Existmg System(explain) ❑ Additional Pretreatment Unit(explain)
�o�� e n
B' ❑ Holding Tank ❑ In-Ground ❑ At-Grade S YP ( P 1
❑ Mound ❑ Individual Site Desi n Other T e ex lam
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issucd
❑Transfer to New Owner I
Expiration 7��+ I��p � ��� �
IV.DispersaUTreatment Area and Tank Information: �;y}�n /S�'3 �'+a:n F.t 1 d
Design Plow(epd) Design Soil Application Rate(gpd/st) Dispersal Area Required s� Dispersal Area Propese�{c� System Elevation
3ov o. � ��q �so
cx•sf��g 9� •7S
Capacity in Total #of Manufacturer y
'I'ank Infonnation Gallons Gallons Units ,a � v � ;
New Tanks Existing Tanks � o y ` Y � c`"e c`�a
a U v� � rn w C7 Ls,
Sep[ic or Holding'Cank ` O O O _ ��O � r C��
Dosing('hamber
V.Responsibility Statement— I,the undersigned,assume responsibility[or installation of the POWTS showo on the attac6ed plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
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Plumber's Address(Strce,City,State,Zip Code)
9aosn s+n.�c Read a� �Q WAfC�� W Y J�y8y3
VL C n /Department Use Only
�Ap ❑Disapproved $�rniil Fee� Date Issucd Issuing Agent Signature
❑Owner Given Reason for Denial �� � I���a �^�'^'�^'�^�'I '""__-"
Conditions of Approval/Reasons for Disapproval
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PAGE40F4
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
requirements of SPS 382384,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 Oaeratinq Limits:
Design Flow= 300 gpd; BODS <_ 220 mgL''; TSS <_ 150 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 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 Seatic and dose tank(s)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 filterlsl shall be inspected every 3 years and shall be deaned 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: ROn81d A Spl'2Ckels Jf Phone: 715-558-6472
�o�ai 9o�e��me„t „�;t: Sawyer County Zoning & Conservation Pnone: 715-634-8288
�oca� government unit address: 10610 Main St, Suite 49 ; Hayward, WI Z�p: 54843
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 counry
��� �'� SYSTEMS
`�;f�SPS '��� POWTS Sawyer
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INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� _���
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�,,as S��s �+�1. C�I�.� —
Insp BM Elev: BM Description: Parcei Tax No:
loo,�' Nq�� fin`b�„ 1�, l�" w� le�- 0�6 - q3g- t� -���-�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W;�- � l� Benchmark �bO.o �
Dosing
Aeration Bldg. Sewer qa.64'
Holding St/Ht Inlet q� ,8� �
TANK SETBACK INFORMATION St I Ht outlet q�,61'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �-Z� � � ��` �.��t NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 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 INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P/L Bldg Well Waters � G o Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
- - - ------__ _
--__
DISTRIBUTION SYSTEM x Pressure Systems Oniy
-- _ ___ --
IHeader 1 Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia �Length Dia Spac � Spacing ❑Yes ❑ No
SOIL COVER
- - - ---- ---- --
IDepth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �ell Edges � Topsail ��Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
�F��ll� �dl�-f aa
� S). ,�-e��ee,w�e�.'�b��y
-- _ —__- ---
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Plan revision required?0 Yes ❑ No � � - � � 69 � ��,
03 ; o� �3
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA:__ �o� ^ v27�o_
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