HomeMy WebLinkAbout008-937-05-5205-SAN-2022-298 �
_ `' Department of Safety c°°°�'`�� �
� � & Professional Services,
� �� - Sanitary Permit Num r(to be filled in by C
= Industry Services Division � 3 � a`� � 9J
�
5�1111ti1I�/ PeY'Illlt t�pp�ICdt10I1 State Trausaction Number �
_� �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to thc appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ad
the Department of Safety and Professional Services.Personal in(ormadon you provide may be used for sccondary aa�o N cow��y �
purpo,es in accordance with the Privacy Law,s. 15.04(])(m),Stats.
I.Application information—Please Print All Information �jj��� � '19�� "�,����
Property Owner's Name Parcel#��_d(?g.,a_37 �_e5�5
U�� � �Lll Q.Y'GC �4/�-'�fiJ! �f ����'a—�c�
F�roperty Owner's Mailing Address Property Location
1—� '�"^�1� ���'1� F� �' Govt.Lot�
City,State Zip Code Phone Number
���..,���Q �L �O� �� '/4, �/,, Section ��
. vtr,
II.Type of Building(check all that apply) Lot# T�N R �9 E or
� 1 or 2 Family Dwelling—Number ofBedrooms � Subdivision Name
Block#
❑Public/Commercial—Describe Use
O City of
❑State Owned—Describe Use CSM Number ❑Vi(lage of
�Town of 1—E�1����
TIL 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 Nlodification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
ST. o��
B� g ❑ Mound ❑ Individual Site Design ❑Other Type(explain)
❑ Holdin Tank �In-Ground ❑ .At-Grade
(conventional)
C• ❑ Renewa]Before ❑ Recision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to NeH Owner
Expiration �� �+ �p �p/13��/
� i�
IV.DispersaUTreatment Area and Tank Information: 6O ` �
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Pe+r�osed s� System I�:Ievauon
CD �� 7 2 5 7 L� �' :r� �� � n � �-a qS a �
Capacity in 7'otal #of Manulaciurer
Tank Infotmation Gallons Gallons Units 9 � ,o v � � u
W V V j y Vi Vi
New Tanks Exis[ing Tanks i c y � � � �
�
n. U rn �, v� w C7 M1.
Septic or Holding Tank /O /_'p �� � T x
< (� s�
Dosing Chamber
V.Responsibility Statement— f,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plum r's Signature MP/MPRS Number Business Phone Number
� GZ-Vl, S-�'V'Q�(/t� � �7� � "7l S �J�S'`�b7�
Plumber's Address(Street,City,State,Zip Code)
1�571 I� T�n� �z t�a,Yl�- I�, t,��� �� � �L�3
VI.Coun /Department Use Oniy
l7 Permit Fce Date Issued Issuing Agent Signature
App ove ❑llisappro�ed $ �1
C�Owner Given Reason for Denial `�� i C I ���°�� ��^��
Condilions of Approval/Reasons for Disapproval ��:
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C �� � d� ' o�,�� : - � ��AW�r'ER COU�a r.,
,'t�NING qf�MINiS'-F;r;;�,'�i
Attach to complete plans for the sy slem and sub����Fu�DSyAFTER ot less[han S 12 x 1 t inches in sixe ^ ��{ ,
?S" '�
ISSU�OF PE.I�MIT
SBD-6398(R.03/22)
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 Pian
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): C� , � ��h(�Q �1 " ��f-Phone: - -
Owner Address: ,1���' � �.�1.�- L(rU,l� l�y'��Q�Q�l�Zip: �r�_
Project Address: � �L �-1�
Govt. Lot: � 1/4 of 1/4, Section�, T37 N-R �' E a or W �
Township: _��C��';�G�,Y County:
Project Parcel ID #:57�C)O�' ����-0�--�D J��-'J l'S�;= Un a �x��C�
Designer Information
Designer Name: ��� ��TY�-�Y�[ Phone:��s -`�l�J�..�
Designer Address:l(�i��� T�j��%'��,, � PG-�I��< Zip: ��
E-mail: �'�"`Z, � �e,l�,,�
License Number: ���'��
Remarks:
Signature: Date: 1�������
Original signature required on each submitted copy.
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PAGE 4 OF 4
In-ground Gravity Management Pian
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,�sc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin. Code, this system shall
be cansidered a human health hazard if not maintaineti in accordance with this appraved management plan.
Furthermore, all inspection and maintenance activities shafi be perfarmed by a registered POVYTS Maintainer in
accordance with SPS 383.52 (3),Wisc.Admin. Code. ,
Maximum Disaersai Area Operatinq Limits:
Design Flow= ;5[X� gpd; BODS_<220 mgL"'; TSS 5150 mgL"'; FOG 5 30 mgL"'
inspection Checklist INSPECT EVERY 3 YE�►RS
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, efc.)
o materiai fatigue(i.e.,leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treafi�errt tank(s)and any distribution appurtenance(s} (i.e.,distribution/drop 6oxes)
o negiect or improper use (i_e., exceeding design capacities, prohibi#ed activities, etc.)
o extent of ponding in distribution ceN prior to dasing
o dosing irregularities-fi applicable(i.e., pump re-cycling,float switch setFings, etc.)
o electricat components-if applicabte (i.e_,wiring, connections, switches, contro(s, 6mers, alarms, etc.)
o distribution tateral or tateral orifice ptugging {measure iaterat distai pressure—compare to design specificafion)
o surface discFtarge of effluent or sewage bacic-up into sfructure seroed
Maintenance Checklist IIRAINTAIN EVERY 3 YEARS (or when necessary}
o Sedtic and dose tank(sl shall be pumped by a certified septage servicing opera#or licensed under s. 281.48 Wis.
Stats.when the volume of solids in the tank{s}exceeds one-third{9/3)the tiquid vofume of the tank(s)or
as required by locat ordinance. Disposal of contents shalf be pursuant to NR '113, Wisc.Admin. Code.
o Effluent filter(s)shali be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacturer's specificatians. A servicing period will always be greater than 12
months.
System maintenance reports shalt be submitted to the proper tocaf government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individuai or company: ��� ��7�'�./'� Phone: ���JJ1C>CS L�?�
�ocal govemment uni� Phone: ��,�"—�3�'�07�
Loca! govemment unit address: �! - � c IP: �`c�3
Any defective part of this system shall be repaired, replaceci, ar removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacement ofi failed or malfunctioning componen#s shaii compEy with SPS 383,Wisc. Admin. Code.
No product fior chemical ar physical restoration of the POWfS may be used unless approved by the departmenf in
accordance with SPS 384,Wisc.Admin. Code.
Continaencv Ptan
In the event that any failed#reatment companent of this POWTS cannat be repaired, it shalt be replaced pursuant to
a plan submitted to the appropriate agency for review and approva(. A failed in-graund dispersai component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
�vstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in ac�ardance with SPS 383.33,wsc_Admin. Code.
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�� Saw er Coun Zonin Administration w
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° 10610 Main Street Suite 49 �.,
' ' �������� Hayward, Wisconsin 54843 j��1��
� �R Cp (� (715)634-5288 ��, ����' � �
�Sl,� � ���I� FAX(715)638-3277 �' �` � ,�
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jN� � � `i�C% F-mail:zonin�tiec(n,�sawvcrcountygo�'-c�rt; ��� � �y� �=� �
� o � o� Toll Free Courthouse/General Information 1-877fi99-4110 �`�` U t l
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SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: ���� _ � _ �h �ot ��'� I/� �q�,��i��,.,5�-'
TOWN OF: ���cc�
ADDRESS: `� ���� C"'- �`^-} �
I, � ��1�u�,,, l� ���„�� , a Wisconsin
Licensed Plumber, authorized by tl�e owner, do hereby acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, and private sewage system plan review due to inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381.01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with a11 applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date may result in the issuing of a citation, under Section I 1.3 [2) Sar�itary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR THIS A�C.�EME ALL BE: � b v_
� . _
Signed: °� r�� r.• . _-r---"'-
Date: �,�� I �
Accepted by:
Date of temporary emergency approval: � (6��-�
Rev. 03/26/13
� LB67 ''c�tmCr �� � � AYY �.xc�/�e� ,�vP, �1/. S,dc
s�.��r �„d o,,,�,�, ��.��,� P..,., . 1+4681
Q i 4 � Pcrmit APVlma�wn Cnunry P?rmn = 6-23�
lui Pnvn�e Domestic SnwaSlc Systmns Coaniy �`! .S8Yfy0S
csT 6-289
'DENOTES STATE APPROVAL RE�UIRED q
Date Aprwoval Recelvud irom Sta�c d RequlrcA State Plan I.D. _ �� � 137 � �g� �$
' � 2 - 9Ck. ( •dC
a. 'owNea oF aaoaeA�v Roger L. Vanderbilt MaJ:ny a�ia<<�+�.
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�o��- Uf.ih e.r � � � �- 20.��� � �� r��,u,<:,nd 1.1�sc. S �FS_l2.
a �o nory ----�----=ti, s����o�, .5, r 37N. n �( LL �o�� w ��,�= c��v _
SubAivislon Nnmc, nrarust nnd lake oi Lmdmnik f31kS VJlage
�y �-G��� f 1of ,�_a � ,U�..y f ,,,�:.,,,�,,,, �d��u.a��-
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�. TYPE OF OCCUPANCY-. 'Commercial 'Industn;d 'Othcr Ispralyl 'Var,,�nr.•
����a�e tdmllY J� Duplea Nn nf Pedroomv a No. al Pcn��m, 3
D. TVPE �OF APPIIANCES. ��snv:ashcr x YES � NO Food l'l.�a�� Gnntler YFS X NO = ��� L'.�rt-iuoms �
Av�omatic Washci K V[5 P�O O�hn (sPeclfY)
E. $EPTIC TANK CAPACILV 7.�0 ioial yallons No. nl t.��iF.. �
'HoIJInq lank capaclty 'futA Qallnnz Nu. ri. �._i..
New Installaiion �( l�ddn�.�n R�,pL¢rin�..n P��.L,li � �. -
'Pouretl �n P�au• S;e�l X O�n..� i ,. '��-
r Fff-�.UENT UISPpSAL SYSTEM' Pemnl;�i�un R.ne �1) � 7'� S ), �j . � �� .lbaail� , _ ,330 �. .
Ne�v �( AUdiM1un Replacemeni 'FJI Sp3oii
SucpageTrench: No. �In. Feet Wid',h Dun��� iil.� D.�pi;� N��. nf T�rm+n�.
�rul�a9c Bed�. Lenqth '�8� Width /a'2� Dep�h [���� iilu UcP�h �{:s� Nn. ol Linur. a . .
$eePa9c Pit Invdu diamc�ci L�qmd DePih Tilc Sir�. �j(••
Percent slope ol land_ . � jb Dis�ance ir�m Critic„I �,Inp- ��
i, �hc untlenlgnud, do hmobV �,.��i�v thal �hr mluunat�on I ha�� n�nort���l . in . . <ud .v4h S.�c'�nn lqi7J0
:'Jivconsin Admin�rtia;��..; Cude, and ;hai I Irrvc sl.cJ ihe eHluent d��po�al rystem tinm �hr FH 175 ;�rep.n�•el
by Ihc Ccrtifiyd I I��,� �
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ohtained fmm __v /� � �r XC l�+a. I��luldeil.
PLunbrr's Si9natmc�� � � �'MPH Wd _—�J��� Phn �. d �/s jsy388�.
plumhci's Addreu �,�r�G. . / �nY .�(i$ �a.urq b�i' c.._ .��($%O
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� PLAN VIEW: P o .1 �;V.r¢,i t elo:i ot ry�trm tmciude d rrrnnn ol slone anA all dist�nres in acmrq ontl•
H67 J0 in:l tl iy elq_
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Do No� Wrl�c in Spacc Bulo�v FOR O[PARTM[NT USE ONLY� �
Date of Application 1Q-].3-'T( _Fees Pald�. S�ute 1.�Q.. . ..Cnu"ty1Q.QQ_. ���eQCL011@I_.Z�� l�(6 . . -
Permit IssuedlR�Ca'!1 Idatc110-13-'Z6__. .. Issuing Agent Name $Obyfl Kept1$Tt. - D'j.A . . . . . _ .-
Inspection Ycs ✓SID �O '1.3'7Ce Valid# Da�c Rrc'J ...
1. county �white copyl �(� 3. owner I9reen copY1 DIVISION OP HEAITH, P.O. eOX 309, MADISON, WI 53701
�
Department of Zoning and Sanitation �
Sawyer County •� _
, ,_
Inspection Report
. - ..
Owner G r PY' 1��� t Address ��� i �1 rG h WOOGt�, l�i/�S • 5 `�$�
7
Description p r'�. O � �r-a f fi• �-o't. 2 j�^ S �• s , 7 3 7,1 `► � �l1/
l� "` 7 � �`
Name of business
Builder Address
Plumber �- �� y, �r i ��� Address
Inspection
(t� Private ( � Public Property Sanitary installation
Dwelling Privy
Violation Mobile home Setbaek - lake
Garage Setback - road
( ) Sanitary ( ) Zonin� Setback - lot line
p ...__. .___.. _.._..�..,��I_I
F, � ��30�
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�---- ..- ---- _ .__. _. _._._g�_r_._.__-___.._--�-- �
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Discussed with owner 1 yes no
Discussed with bu3.lder yes no
Discussed with plumber yes no
Date ] OI13�7'(
7""7"' "
�
Signature of Officer
61 —� /1 J
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Index y
o (
Soil Test Data Sheet �
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Owner Roger L. Vanderbilt � �
fi
Address Route 1 fD
Birchwood WI 54817 K �
Certified Soil Tester LeRoy Sandridge
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Date soil test received October 5, 1976 �
�t
Land Use Permit No. 6_318 0
Date issued October 11, 1976 K
r
Sanitary Permit No. 6-230 �
Date issued October 1'i, 1976 �
H
Plumber LeRoY Sandridge µ
N
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Zone District RR-1 �
Unrecorded deed formerly Mary J. Reuille I li v
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/;t�'ft'' � PRIVATE ONSITE WAS�E TREATMENT county
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�7�5 PS\\\��! SYSTEMS
'�" Saw er
�`'� �_r% ( POWTS) Y
�Ri�"���V'°' INSPECTION REPORT
Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ �,��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
Qa ¢. �- �a�bo�sa 1J�,�r-b���' wa.�' �
Insp BM Elev: BM Description: Parcel Tax No:
�A'��O � a� c��,Cro..�--� -�'�la Dog_�37-OS- S�U�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,, pbp Benchmark �op,o'
Dosing
Aeration Bldg. Sewer r�.g'��
Holding St/Ht Inlet q�1�'
TANK SETBACK INFORMATION St/Ht Outlet 4'�.9s�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic k�' ,�-�� +��` t�o r NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist.Pipe
PUMP/SIPHON INFORMATION Infiltrative
Surface 9.S a�
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 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 Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil_ __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
� �S�I� �`16�a-�
� s�: ���--�lY
Plan revision required?�Yes ❑ No , O3 �o �3 � — —� Gc��� o �
Use other side for adtlitionai information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
�
A�OITI�NAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: __��-�_ `��_
^— C,�(� Cl�.+a�— v
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