HomeMy WebLinkAbout010-941-33-1207-SAN-2022-289 :�'` Department of Safety c°°°�' �
- �aw1 �/ D
Y - & Professional Services, �
5 Sanitary Permii N mber(to be filled in by
� � �_ ^ Industry Services Division � 3� �� ` �
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Sanitary Permit Application StateTransactionNumber �
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 t �
the Depanment of Safery and Professional Services.Personal information you provide may be used for secondary � �,l
purposes in accordance with the Privacy Law,s. 1�.04(I)(m),Stats. �� �..�„I� Z
I.Application Information-Please Print All Information
Property(hvner's Name Parcel#
rx�<Me �n����t� �l � p � a9yl33�zo `7
Property Owner's Mailing Address Property Location
���� g}� �V� N� Govt.Lot
Ciry,State Zip Code Phone Number
�G�lr�w/�1 � /"1� �'s GZ) �� ��a� !V ��/a, SCCtIOiI " �_
II.Type of Building(check all that apply) Lot# T �"�� N R � E or�
�or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number O Village of
�o,�of �-�w,.r d
[IL 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 ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreamient Unit(explain)
B' ❑ Holding Tank -Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type lexplain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
F.xpiration � � ��,� � � �� �
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
yS� . � Gy3 Cs'Z 9/ - 93 ,s
Capacity in Total #of Mariufacturer
«:
Gallons Gallons Units � o 'fl �
Tank Information � � U � �,
New Tanks Existing Tanks ` � y � Y � � �
a. U cn �, �n c�, C7 0..
Septic or Holding Tank /Q�O O(J � �✓(t S�e.�
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
fi 5��,� If Z JSl6/z �..r-ss��-��
Plumber's Address(Street,City,State,Zip Code)
7U 7( /1/ ,S�'a^-G �.�,G /�� .S'�d K �4�►.G_ lr�� .S��(8� 7�
VI.Coun /Department Use Only
� Appi v ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $ `��'W �� I�� I �� ��i-�l��-�
Conditions of Approval/Reasons for Disapproval
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Attach to complete plans for the system and submit to the County only on paper not less than 8 Ui x 11 inches in size ' � � ��
NO R�FJNDS AFTER
SBD-6398(R.03/22) I�UE OF PE�tMI�
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
Owner Name(s): rX�F�tM� �.��h,`+c� ll c. Phone: - -
Owner Address: 32o'L g� �re, .�W , ��l�µ F MN� Zip; � s,jo z/
Project Address: /��
Govt.Lot: lV� 1/4 of�V�1/4,Section 3 3 ,T �/1 N-R �% E❑or W�
Township: �-y��-c' County: Sa✓y c�
Project Parcel ID#: D((�-- �yr-33- t2o1
Designer Information
Designer Name: Dylan schultz Phone: 715 558 _ 5904
Designer Address: �6880W Metcalf RD Z�p: 54876
E-mail: dylanschultzl8@gmail.com
,,:.
License Number: �516129
Remarks:
Signature: Date: �- �9-Z Z
Ori �al signature ired on each submittetl copy.
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7076N Stone Lake Rd
� � £X Stone Lake, WI 54g76
� s MPRS 1516129
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Septic Tank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA w����--
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credit) 60� 9a, 9a, gal 9a�
Effluent Filter Manufacturec
�o�Y�e��
I
Effluent Filter Madel#: �Z�
n.12^
SOIL COVER (rypi���
iz^
min.trencn
depth
�yP���� • TYPICAL TRENCH
— a CROSS SECTION VIEW
=— 34"
�ryP��> (No Scale)
� , . Provide minimum 3 ft
System Elevation= ft separation between trenches.
(typical)
Quick4 Standard-W
wlEndCap 06servalbnPipe -�ypICALTRENCH
(typicaq (Show location of inlet/outlet pipe connection on plan view.) (Hpi�O
Ins[allpermanulactureYs p�qN VIEW
instruc[ions. �(vO.SC8�8�
�' ���* "���'�� ——-��——— ��————�x+� �re�r —�
��n o� � �, d—..��,, I A=3.0 ft
�4W�'i9C ti-i�F��6'�'�s it1i�'f�Y'iYt��i� � J (�Ya�caq �
- ------�f--------��---- --- y
F e= n �-_; m
�ryP���� Quick4 Standard-W Chamber W
(tYvical) O
INSTALL PER TRENCH: �mta by��e�tratorsysterr5,���.� T
I� �O InsWll pursuent to manufacturefs instructions. �
Quick4 Std-W @ 20 Hz EISAlchamber= � ft'
+ � Pairs of end caps @ 6 fF EISA/pair= � ft'
=Proposed EISA per trench= � fl� Required Infiltration Area= �O�/ ft' Distribution Method:
x y trenches =Proposed Total EISA= �� ft' ����-
�
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
requirements of SPS 382384, Wisc. Admin. Code. Pursuant to SPS 383.52(2), Wisc. Admin. Code, this system shall
be considered a human hea�th hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3), Wisc. Admin. Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= �/.'Sv 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 surtace 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) 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: �4�M S��'��� Phone: 7 �S-�t11-3'7 0�
Localgovemmentunit: S�"rtr C�'�v z""^� Phone: 7�Y� �jf` _ �25'g _
Local government unit address: M'-� �C�" �� wcy � ZIP: SY8`f JJ _
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
�n 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 diswntinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
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9/6/22, 7:30 AM
Real Estate Sawyer County Property Listin� Property Status: Current
Today's Date:.9/6/2022 Created On: 2/6/2007 7:55:23 AM
� Description Updated: S/28/2007 � - Ownership Updated: 8/19/2022
Tag ID: 13170 ' �� EXTREME UNLIMITED FAIRBALTLT MN
PIN: 57-010-2-41-09-33-102-000- LLC
0000�o
Le�acy PIN: 010941331207 Billing Address: Mailing Address:
Map ID: .2.7 EXTREME EXTREME
Municipality: (O10) TOWN OF HAYWARD UNLIMITED LLC UNLIMITED LLC
STR: S33 T41N R09W 3202 8TH AVE NW 3202 8TH AVE NW
Description: PRT NWNE LOT 1 CSM FAIRBAULT MN 55021 FAIRBAULT MN 55021
19/283 #5709
Recorded Acres: 0.930 �- Site Address * indicates Private Road
Lottery Claims: 0 N/A �o � 4-}w � Z-Z So�`E-�-,
First Dollar: Yes
Waterbody: Namekagon River ���;, U ted: 11/9/2015
Zoning: (R-1) Residential One _w.,PrO��'.���ment P� ��
ESN: 444 2022 Assessment Detail
Code Acres Land Imp.
Gl-RESIDENTIAL 0.930 38,300 11,600
'-� Tax Districts Updated: 2/6/2007
1 ��w��� State of Wisconsin �y�r Comparison 2021 2022 Change
5'7 Sawyer Counn- Land: 38,300 38,300 0.0%
O10 Town of Haywaxd Improved: 11,600 11,600 0.0%
572478 Hayward Community School Total: 49,900 49,900 0.0%
District
�l�pp Technical College
�� Property History
-� Recorded _ _ _ _. _ _ _ ___. --_ . . _ _ _ _
Documents Updated: 8/19/2022 N!A
�� TRUSTEES DEED
Date ,��:��'k���
Recorded: 8/15/2022 —
-� QUIT CLAIM DEED
Date ;,�
Recorded: 8/12/2016 �3���'` \
-� WARRANTY DEED
Date Recorded: 2/7/2001 °`���Z
��- CERTIFIED SURVEY MAP
�ttps:j/sawyercowi.wgxtreme.com/ieProxy?uri=http://tas.sawyercountygov.org/ACCESSJREAL%20ESTATE(listing.asp?pid=13170&ui=0 Page 1 of
��/� '"'''`` PRIVATE ONSITE WASTE TREATMENT co�nty
?�o$ \���'� SYSTEMS
� Ps � " ( POWTS) Sawyer
',:�., ,�;
��A��_—�:/
°��s-=�„'�"'' INSPECTION REPORT sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� ^�/� �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J U
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
� U h�i nn�� L(.0 �a wq2�
Insp BM Elev: BM Description: Parcel Tax No:
(�.o � Na,1 �-�;b�,� 3b" �JaS � o�ag"w.�% oro-4��--33- �2�7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,e�T �p Benchmark �pp,� '
Dosing
Aeration Bldg. Sewer —
Holding St/Ht Inlet qS;��
TANK SETBACK INFORMATION St I Ht Outlet y, �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ,�� �/ ti NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �j�. Y r
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infiltrative
i
Surface 4 3� Y
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 ,3 L ' � #of Cells ,3 Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �,�( ,
P I L Bldg Well ❑ IGP � Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO '±'�o� fv �,/ � .�-Sb ❑ Mou nd o Other 7�
_ _ _ ---- - -- - _- -_ -- __ - -__--
_.. _ _. ----- --
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 � Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges I Topsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
��,r}al(� ��� ��a3
Plan revision required?�Yes ❑ No I ,
l���`�J C � __ J G��� �
Use other side for additional information Date POWTS Inspector's ignature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS AND SKETCH
SANITAAY PEAMIT NLIMBER:_ ��;�_______
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