HomeMy WebLinkAbout024-110-00-1900-SAN-2022-332 _ � Department of Safety c°°°�' �
- • & Professional Services, � Z
- , _' = Sanitary Permit Num r to be filied in by
; Industry Services Division �
_,°� � 5�) D��--� R�
�
Sanitary Permit Application State Transaction Number `W
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the 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:..,..,,.,.,
the DepaRmcut of Safety and Professional Services.Persooal information you provide may be used for secondary f_�-�'�� 1 (,,��5����,
�� �" V�.O
pu�poses in accorcl:ince with ihe F'rivacy Law,s. I SA4(I)(m),S[ats. � f1
I.Application Information-Please Print All Information �t� �s'f�t
Yroperty Owner's Name Paroel#
�� `� .e� 1� C��� - ���-'a�"—�c%'�
Property Owner's Mailing Address Property Location
� � G�-L�,c---'
City,State "Lip Code Phone Number
�'(n � ( � ��rn�� � ���Section�
Y� ._�- �v v�
II.Type of Buil ' g(check all t6at apply) � �ot� �C�N R � E o W
.�1 or 2 Family Dwelling-NumberofBedrooms 1 9 Subdi�ision Name
Block# I ,Qj I Wa t`r �14v�d�
❑Public/Commercial-Describe Use
� ❑Ciry of
❑State Owned-Describe Use CSM Number ❑Village of
— �rown of _ 14:�.-i�
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
�. y ❑ Rep(acement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(crplain)
(conventional)
C• ❑ Renewal Befo evision 't'O ❑ Change of Plumber ist Previous Pernvt Number and Date Issued
❑ Transfer to New Owncr
Expiration �l�� ��_��S a� •• y� � (� 3 a,
IV.DispersaUTreatment Area an ank Information:
Design Finw(gpd) Design Soil Application Rate(gpd�sfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Ele��ation
� � - - o y �
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units L c b �
�
New Tanks Existing Tanks � � � � � � F �
0 2
a U ✓� y �n i�. C: ci.
Septic or Holding 7'ank J�� � � � ��
l ri� �'r�
Dosing Chamber � ' � �
V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
P(umber's Name(Print) Plu �r's Signature MP/MPRS Number Business Phone Number
0.-I�l� G�-l��1� � 7Gs -�io.�3
Plumber s Address(Street,City,State,Zip Code) �
� 05� t� �'rrwn ��-�-��- cl-d►�-- P�-A c��-� c�� � �$�3
VI.County/Department Use Only
� �� �S Pcrmit Fee Date Issued Issuing AgeN Signature
Ap ro e ❑Disapproved � ;
�� ❑Owner Given Reason Yor[�nial �.� �� l �» ��`� ���"-�•������
Conditions of Approval/Reasons for Disapproval +
�_I_ f 9�%,.�.�^ � � �
� ' � �,,:.:w. �
�� ' �jr; `-��# 1 �' � -_ NOV 15 2022
1
. •�.�aS�Fa,,._ In io r t�l �`�� �—
C,S-�-- 02 � -- .3� 1 � s��raY�� c�:,.:�,,-��;
ZUIV E f�J G ADM!!Li�i t�.�al'a01`d
Atlach to complete plans for thc s��stem and submit lo lhe Cou�ty only on paper not less than 8 t/2 x 1 t inches in sizc ������
SBD-6398(R.03/22) N�R�FJNDS AFTER
ISSU��F PEFi;v;IT
PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name I Description
� - (1��,
Owner Name(s): ...�1�`e- ��� Phone: - -
Owner Address: 6' �Pl �i � � Zip: (�i�C� (�I � � _
Project Address: �7 �a � " � �� �'-�-
Govt. Lot: 1/4 of 1/4, Section�, T�N-R�_E ❑or W �
Township: �j�An�� � �.��J County: �'�.� ��
�
Project Parcel ID #: �; ���^ l ��"��"l �� � -
Designer Information
Designer Name:�U ��4(�a�"� Phone: �S ���-��'��
Designer Address: �c`Z� I�l�119�-'Y���1C��4Q ��''�-�• Z�P� � ���3 -
��� �_ � �.�..��
� , � �
E-mail: ,
License Number: ��/��� �
Remarks:
Signature: `�� Date: I �—1 J--�-`�-
` � Original signature required on each submitted copy.
PAGE 4 OF 5
GRAVITY-DOSED -
SEPTIC / PUMP TANK SPECIFICATIONS
(No Scale)
4ro va�i��
>70 fl fiom
Building Electriral must mmpty with
tY Min.or 20 R ahove SPS 376 arW NEC 300
E�abtished Flood Elevation W���� Ex�e�d manhda riser as necessary.
(�ypipp AP��d Junction Box
��1�P Appmved Lodcing ManFwle
IMPORTANT: �with waming�abei Attached
Anchor tank(s)as necessary (ryP��l�
( )(9) co�a�a
pursuant to SPS 383.43 8 4'Min.or 2.0 ft ahave
EslabGshed Fbad Elevation
(bP��O
�Avtight Seal
Firnshed Grade �
�uick Disconned
78'Min.
CAPACITIES @��gaVin �y.. �hw���
Depth(in) Volume(gal) �
/ * `
14 Z� ` �^jv � I WeeP ' `—APWoved.idnlswith
Hale Apqove0 Pipe 3 R oMo
B 2.� 3Z A sa�ac�«,�a
cryv��n
[Cl I 1
_Alarm
� B
� � }[C, i —on PUMP-0FF 4�• g�
*Pump Tank Liquid Level= G in � �mP —� ELEVATION= ,�-�'- , ft
° INSIDE BOTfOM
Force Main Diameter= in �°"°'e`e
� B�� ELEVATION= �7� ft
Force Mein Length=��R 3'Appmved Beddirg Malenal Berieath Tank ��, $Z�
Force Main Void Volume= .C�L gal
to3.�y
[C]Total Dose Volume TDV =��j��gal/dose
(<0.2X design flow+{p�main void volume)
r
Vertical Lift=-�1�ft �.a
PUMP TANK: SEPTIC TANK(S):
Volume=��gal Total Volume= /�r��� gal
Manufacturer. G[/.'vf�!- Ma�ufacturer(s): �i/,`.e��:F�:
Pump Manufacturer: Z p,�.//.P,r
install approved effluent fiiter at the septic tank outlet
Pump Model: q� (�atlatl�ed pumpwrve.) immediately upstream of the pumo tank inlet.
Controls/Alarm Manufacturer. 5J L Rl�,.....h;,< Filter Manufacturer: ��j ��x
Controls/Alarm Model: /!� / �G' Filter Model: /- f c� � r.2.
Float switches containing mercury are arohibited.
PAGE 4 OF 4
In-ground Dosed-Gravity Management Plan
IMPORTANT:
The owner of this in-ground dosed-gravity system shall be responsi6le for its perpetual operation and maintenance
pursuant to requirements of SPS 382384,Wisa 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, aii inspedion and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Disoersal Area Oaeratinq Limits:
Design Flow= Lj�`� gpd; BODS <_ 220 mgL''; TSS 5 750 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 any distribution appurtenance(s) (i.e., distribution/drop boxes)
o neglect or improper use(i.e., exceedfng design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell priorto dosing
o dosing irregularities-if applfcable(i.e., pump re-cycting, 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 Seutic 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 ordi�ance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent fiiter(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: wt�s S���i r. S,�r.�.'c � Phone: 7/�1�y- 9�>/a
Local government unit �S�o.��� ����� ��� : "� Phone: 7/S` L — �'i
Local govemment unit address: � v, ; � r IP: ✓�- y�� 3
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 physfcal restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc.Admin. Code.
Continaencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a pian 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.
Mack
Septic Systern P(ot Plan
North ,%� lulie Mack
�o���a�a #### Wolf Island Rd
�,'\har Lot 19 Big Wo1f Island
�;�o`'`` �� S19 T41N R5W
�c a,oQ 57-024-2-41-05-19-515-223-OQ1900
�'ii�P Town of Round Lake
T,.a! Q.68 Acres
�to
�o�f�sla'�
d� '�a
'r
�d�,
�J
d
�
0�
proposed pp
3 bedroom ho e o,
WieserlQdO/�p. � °�
w/ prenco 8" Bfotube ffiter / r
l ,�f r�
r•
�:'� :"
�. 1.
� Bench Mark = Top of iran property stake �� ``.. `''
,� i �r $ °la
Elev = �00' ` '�
� ' �„ `,.
�. ;�
Scale 1:40 � �' r'
r,
�-- � a^�'�
�
QSQ'
O
NOTES: �d`�
- No weli o�
- Moose Lake elev. � 91'
- Verify lake setback prior to drainfield installation
- Al! vent, observatian and conveyance pipes
4" ASTM D1785
Page 2 of 4
IN-GROUND DOSED-GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with EZ1203HP Bundles
3-ft Trench (down-sizing credit)
_��
I
Gaote�clib min.12'
c�,a, � - (ac�m9 TYPICAL TRENCH
so�coveR CROSS SECTION VIEW
1z (No Scale)
mm,trench OBSERVATION PIPE DETAIL
tlBplh � �ND SWb)
(NWmq �- � — .<�� sa.w.ry�o« Fwv,oao�aae
s�o cao Paoael �m�tm a s eeeaea�
System Elevatlon=97 fi. 4'OPVCPbe rov�ocow�
(ryp)cal) ' Provldeminlmum3ft T000iv�c�mm��aro cM�.+iooq
ro
ei or eeow i���,oa p�,aa
separation between trenches.
(4)1!q'-1/]'X B"Sblc
�90 epan
TYPICAL TRENCH (Show locatlon of Inlet I ouUet � cnnnectlon on lan New. ��'
P PB P ) nnrnwnp oewce �nmram
PLAN VIEW 50"°�°
(No S cale) 4��� oesor.ero�pipo snao w ivim:ea
Pertorated Laterel °1�i1d10npBh"""1NOun1�' 10 H
Observatlan Plpe
(�YPical) (Haicaq ��
-- — -- ----�f------------ — — —
'____�______:—_-_,_ -p
__ ___ ___:___ _______= I A-3.0 ft
�— -- — -----�r-------------- -----� cha��> D
� _ G)
� a= 70 n -; m
cryw�o w
INSTALL PER TRENCH: EZ1203H Bundle Q
(bPicel) TI
� 70-ft bundles Q 50 fP EISA/uNt=�ft� (mfd bylMllrator Systems,IncJ �
Install pursuantto manufacturefslnsWeUons.
+ 5-ft bundles @ 25 ft EISA/unit= ft'
=Proposed EISA per trench=�sn ft` Required Inflltreflon Area=643 �� Distribution Method:
x 2 trenches=Proposed Total EISA= 7�� ft' branched manifold �
ftES�.T-
11N5/22, 3:03 PM Real Property Listing Page
Redl EStdte Sawyer County Property Listing Propertystatus: current
Today's Date: 11/15/2022 Created On: 2/6/2007 7:55:39 AM
�Description _ Updated: 10/27/2022 � Ownership Updated: 10/27/2022
TaxID: 23454 JULIE A MACK HAYWARD WI
PIN: 57-024-2-41-OS-19-5 15-223-001900
Legacy PIN: 024110001900 Billing Address: Mailing Address:
Map ID: -1.19 7ULIE A MACK ]ULIE A MACK
Municipality: (024)TOWN OF ROUND LAKE 10769N EVEREIT RD 10769N EVERETT RD
STR: 519 T41N ROSW HAYWARD WI 54643 HAYWARD WI 54843
Destription: BIG WOLF ISLAND LOT 19
Recorded Acres: 0.680 � Site Address * indicates Private Road
_ ._
Calculated Acres: 0.795 6922W WOLF ISLAND RD HAYWARD 54843
Lottery Claims: 0
First Dollar: No �..� property/lssessment Updated: 7/18/2019
Waterbody: Moose Lake 2022 Assessment Detail
Zoning: (RRl) Residential/Recreational One �ode Acres Land Imp.
ESN: 402
G1-RESIDENTIAL 0.660 104,500 0
� Tax Districts Updated: 2/6/2007 Z-Year Comparison 2021 2022 Change
1 State of Wisconsin Land: 104,500 104,500 0.0%
57 Sawyer County Improved: 0 0 0.0%
024 Town of Round Lake Total: 104,500 104,500 0.0%
572478 Hayward Community School District
O01100 Technical College
�� Property History
�+� Rewrded Dowmentr Updated: 6/2/2021 N�q � -������� �
WARRANTY DEED
Date Recorded: 7/30/2021 433642
MAP OF SURVEY
Date Recorded: 1/7/2019 19415-21
QUIT CLAIM DEED
Date Recorded: l2/21/1981 181438
hrips:Ntas.sawyercountygov.orglsystem/frames.asp?uname=Eric+yyellauer 1/1
��� ```�\r PRIVATE ONSITE WASTE TREATMENT county
// `^`t"` ' SYSTEMS
����? °SP ' ��� Sawyer
\t�� s ;� ( POWTS)
��;
�°`�`—� �`� INSPECTION REPORT sa�itary Permit No:
FS.SIU.`�P�,
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � �_ �3
Personal infonnaCion you provide may be used for secondazy pu�poses[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
���i e, �la c� �,.,,�d —
Insp BM Elev: BM Description: Parcel Tax No:
iofl.n � �op o-� ��.., ,� s�� o�-�- I l�- o�- (�oo
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w��s � �Ooo Benchmark �ba,��
Dosing _ �Y„�� �
Aeration Bldg. Sewer --
Holding St/Ht Inlet q , �
TANK SETBACK INFORMATION St I Ht Outlet �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic S� U �✓ NA Dt Bottom ��,(S�
Dosing ,< << << <, NA Installation
Contour
Aeration NA Header I Man. �g,
Holding Dist. Pipe
PUMP I SIPHON INFORMATION Infiltrative �.���i
Surface
Manufacturer ��' Demand Final Grade
Model Number �('g GPM Ni 4 '�T, `T I.( �
TDH '1 Lift Friction Loss Sys Head TDH Ft
Forcemain L �p` Dia �.`� Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS �N 3 L o 7a� #of Cells a Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P�L Bldg Well Waters o IGP ❑ Chamber Model Number:
❑ AG �: EZFIow
CELL TO S N � -� ❑ Mound o Other
— - --- __— ---_ _____—___ ---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifoltl 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 l Cell Edges Topsoil __ ❑Yes ❑ No ❑Yes ❑ ho
COMMENTS: (Include code discrepancies, persons present,etc.)
� ��
s� ��� I(� �� (a ( aa
� �`_ �c�
Plan revision required?❑ Yes � No �a l�— a3 G� � 6��(�
� - --- —__� �
Use other sitle for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOtTI�NAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: �S3!�
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