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Home My WebLink About028-642-29-4302-SAN-2022-320 -��''"""�� Department of Safety c°°°h' � - `\� - & Professional Services, �''�'"�� _ �, j . Sanitary Permit Number(to be filled in by� , �_ , Industry Services Division � % � ;�=� Co 3� �� 9J '~-.,;:�,..,� Sanitary Permit Application s`�`e T`�"��`'°°NanieeL w In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form ro the appropriate govemmental unit � is required pnor to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ac._._..G the Department of Safety and Professional Services.Personal information you provide may be used for secondary purposcs in accordance with the Privacy Law,s. 15.04(I xm),Stats. ,�j'�,SN /�Q,u Mq i e �` R� I.Application Information—Please Print All Information Property Owner's Name Parcel# Ma�: l� caa8- �tia-a5 y3oa Property Owner' Mailing Address Property Location 0 Mounf AsY+ Ln NW Govt.Lot City,Slate Zip Code Phone Number l�o ch t 5-E-e r, MN $$�7� � 5%a +.�i,_�F__'/4, Section�9 IL Type of Building(check all t6at apply) a Lot# � T N R d(. £^o W g[I or2 Family Dwelling-NumberofBedrooms Subdivision Name Block# — ❑Public/Commercial-Describe Use — ❑City of ❑State Owned-Describe Use CSM Number ❑V illage of _ � I .ZY� ��I �T'ownof�S�i�r'�.AX�---- IIL 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 odificatron to Existing System(explain) ❑ Additional Pretreatment lJnit(explain) � B' ❑ Holding Tank �In-Ground ❑ At-Grade gn ❑ Other"Pype(cxplain) ❑ Mound ❑ Individual Site Desi (conventional) C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permit Number and Date Issued ❑Transfer to New Owner �/ �p Expiration �r' V�� (a/ Q � IV.DispersaUCreatment Area and Tank Information: � ' X ' �c`a� n � � Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Prepese${�f System Elevation 3 O O o.'`� y a9 C f� � y O f E at,� 9 a . o a �{ Capacity in Total #of Manufacturer � Tank Information Gallons Gallons Units � U U �, � New Tanks Exis[ing Tanks � o a� y � � c`�a `ca n. U �n � rn u, C7 0. Septic or Holding Tank �CO �CU � 1 ,1 J GSe�. �G�� X' .7 �7 lN Dosing Chamber V.Responsibility Statement- 1,the undersigned,assume responsibilily for installation of the POWTS shown on the attached plans Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Numher �a � ��.�s3r a c.� -- s-s$ �� Plumber's Address(Stree,City,State,Zip Codej 9c�dSN StQ� 2oad a� i��r�� w = Sy�y3 Vl.County/Department LTse Only Permit Fee Date lssueci Issuing Agent Signature ❑ Approved ❑Disapproved � ❑Owner Given Reason for Uenial $ l�� I I�� <^=� -- " � Conditions i pproval ��4!��1��-.'�i('��%�j r� � ^� � I '�``J�? r}'f Y� ' ` �r �rlI � i L)u�", .......�_�-�_�3� � `�'� "'v`"'.+�� .;, i ��T' � �.hk# �.�- e,.__�_ - �.�� CT 21 2022 � J 1 �� — oZ oZ� �rn}�+N�,�.,__ln.,lprirl,��-fc.�3 ��1�.�'�r`L�< k �.`�lTY �: � ....�1;{�-_i r"..,.,.... ..�,!t2L,-;?��i� Attsch to complete plans tor the system and submit to the County onty oo paper not less tl�an 8 I2 x 1 I inches in size �7�(�s I J SBD-6398(R.03/22) NO REF+INDS AFTER ISSUC OF PE�iM1T / f /� � /� � � N �/ � .c�� z � �/ d �� W rn / L./ � �/ / �J �� c � � . � Q . ,��Q0 � � 2� �� a � 3 3 '� � r ' iR_ cs r U` 3 r�i o * VP � � � � �' � ° i��` •y � r � T �' 'k OJ � � � 6 � � �� "�+� ► M � .`� tp� ' _C) /�' �'/ O � �^`d� 3 n � j � � �Q��, .� . C� Q � �' ,� � °' � u tf � � , � � ao ,� n ^e° • � � � .� �`> : n � ;c C` � � � � W � .� * � �' � ,a � �- u ✓ �. E $ � Y � �/ J � � � o ta r �, a v+ tn v �i 3 O N { � � u � n o G � � � � 7. Q/ U � D 01 m p s m Z v p - � � a A � t� D ,O £ i * 0 ln -1 2 m �l ��J fimp u °' z a�7 � 3 ` o � 1� . � � � � � � � � � � �c� L�'_'� i � 9 p �W � � � Q � � � � � PAGE1�OF�Ic 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 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 Dispersal Area Operatina Limits: Design Flow= 300 gpd; BODs� ZZO mgL-'; TSS <_ 150 mgL''; FOG <_30 mgL-' Insaection 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., distnbution/drop boxesi 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 Septic 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 filter(sl 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 govemment unit in accordance with SPS 383.55 Wisc.Admin. Code. Report any component failure or malfunction to: Name of individual or company: ROIl81d A SpfeCk21S Jf Phone: �15-558-6472 �o�ai 9o�e��me�c��c: Sawyer County Zoning & Conservation phone: �15-634-8288 Local government unit address: �O6'I O M81f1 SL, 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. Continqency 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. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. �;�''`�"'f�>':r;,r� PRIVATE ONSITE WASTE TREATMENT co��cy o SYSTEMS Sa,W er �', $P \iJ`� Y '�-��` s- /r ( POWTS) \�'k�R` FP`/ �i'"""-"`' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� —��Z� Personal infonnation you provide may be used for secondary pwposes[Privacy Law,s. I5.04(l)(tn)] Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: a� , ��So� s ;�- �►� -- Insp BM Elev: BM Description: Parcei Tax No: 'Q� .D� Nc+�ll W � `o �O`1 ls`A— Q� b ��.� r� t"" `3�� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic w;e�r -75-p Benchmark �pp,p� Dosing Aeration Bldg. Sewer R3.q6' Holding St/Ht Inlet 93,�j � TANK SETBACK INFORMATION St/Ht outiet �3.�3 ' TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic fi�� k� ,2e �- � NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist. Pipe PUMP/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 � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv � Aggregate INFORMATION P/L Bldg Well Waters ❑ AG ° Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other ---- — ----__---_ -- — DISTRIBUTION SYSTEM X Pressure Systems Oniy Header/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/Soddetl Mulched Cell Center Cell Edges �_Topsoil _ —��Yes ❑ No ❑Yes ❑ ho COMMENTS: (Include code discrepancie�persons present,etc.) �� _a7D ��S�i 1l� � �� s �►��1��.�}-�,,l Plan revision required?❑Yes❑ No �3 �3 �3� _ _ � _ � �cj'� (� Use other sitle for additional information Date POWTS Inspector's ignature Certification Number SBD-6710(R.3/01) A�OITI�NAL COMMENTS ANO �KETCH SANITAAY PEAMIT NLIMBEA� �� r � �' L��-(.��. 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