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002-940-07-1104-SAN-2022-333
' Department of Safety c°°°ty , D ! & Professional Services, Z� - Sanitary Permit Num (to be filled in b: � = Industry Services Division �O 3�13 � ! � ... . - � Sanitary Permit Application s`a�T�"�a°r'°°N"_ee` �,,, In accordance with SPS 383Z1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit W is required prior to obtaining a sanitary permit.Note:Appiication forms for state-0wned POWTS are submitted to Project Address(if different than mailing W the Department ot�Safety and Professional Services.Personal infomiation you provide may be used for secondary !� /� purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats_ .f �G I.Application Information-Please Print All Information Property Owner's Name Parcel# G � 00�9�i0a'7�l� Property Owner's Mailing Address Property Location � �� �� �� City, tate Zip Code Phone Number � ,�'"T � ��� `��, ��'/a,�'�'L�, Section�� Vli.l.� ` � II.Type of Building(check all that apply) Lot# �C %� N R �/ E or �l or 2 Family Dwelling-Number of Bedrooms J __ � Subdivision Name � Block# `� ❑Public/Commercial-Describe Use ❑Ciry of ❑StateOwned-DescribeUse CSMNumbezµ.�?5� ❑Viliageof -t•r- (��, j �, ,/ _ L�,Cown of (h(:'^�.S lu-K� �: S � �'p�l I[T.T,ype of POWTS Permit:(Check either KNew"or"Replacement"and other applicable on line A. Cheek one box on line B.Complete line C if a licable.) A. ❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) B' ❑ Mound ❑ Indi�idual Site Desi ❑ OtherT e er lain) ❑ Hoiding iank �,In-Ground ❑ At-Grade gn yp ( .p � (conventional) C• ❑ Renewa)Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date[ssued Expiration Q�..a„� G� I� b� IV.DispersaUTreatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd:�st) Dispersa Area Required(st) Dispersal Area Proposed(s� System f{le��ation � C�C' qU Capacity in otal #of Manufacturer � "l�ank Information Gallons Galions Units � �? o � � New'ranks Existing Tanks � o � � � p �a v"s a U cn � v� w U a. Septic or Holding Tank �.nv �, _ C/ Dosing Chamber V.Responsibility Statemeot- t,the undersigned,assume responsibility for installatian of the POWTS shown on the attaehed plans. Plumber's Name(Print) . Plumb� ' Signature MP/MPRS Number Business Phone Number pu'L ��� � 7 / ! ` ���3 Plumbe s Address(Street,Ciry,State,"Lip Code) � ''� ��� T(lU�-'Vl�� � � "c� l�-� Gl)llG� (.�� `�� J Vl.C un /Department Use Only Pcrmit Fee Date lssued Issuing Agent Signaturc �APPro cd ❑Disappro�ed $ (.�0� ao �� '�7 I �� �� '�/Lt-���� �� ❑Owncr Given Reason for Denial � � Conditions of Approval/Reasons for Disapproval ��d���,,,a3� ,� � . Irr'�7 3� 1 �.�,..L.�,�c+� . . 09 p �� I� , � � 1 __�_�__._._�. � ..� � ��� � � ��� C� 1 ,. VU�r i.c�� `'��� fl� -- ���� 4 =..�--_ `� �Aw�rEa couN�nr �t�:K��oeecN~s�w�� Atlach to complete plans for the sys[em and submit to the County only on paper no[less than S V2 x t 1 inches in siie ��r.� NO R�FJNDS AFTER SBD-6398(R.03/22) ISSUE OF F�Ef�'�U117 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):��:�IL� C�Cd�1/'� Phone: - - Owner Address: � , �� L���('m�,� ��Q, �-�����r(� T Zip: � �'�t'3 Project Address: C�� Govt. Lot: ��1/4 of ��1/4, Section Q `7 , T� J�N-R O l E � or W,� Township: �1,� j,�L.�� County: Project Parcel ID #: �� � `7 ��� �f� `-i' Designer Information Designer Name: ��-�,Q-1/1 G�Q.� Phone: ����� l�2.3 Designer Address:� � l� � l 'Y1 � �. Zip: �j �L� 3 — E-mail: ���:: � �,f ,�.� z ��>�;��� ,� �,�1�•„�� ��,, ���� License Number: �g,� �� � Remarks: Si nature: ` Date: d � '/ � '��- � � inal sign ture required on each submitted copy. r . t _ � �'�'v��GIC �u,v�CUtt tr � 58 S'oc.� .�'?C4.t 8 a t ��_ � . , , �� � ���5 L'tt►C-IP �:Ol. ( ' � $11�v�.eS, c.v� SV873 '_`�'„A`� �-7ts) �qS- Z((o( qy+w�. . a � s� � - ``,-� Roht�' r�d. o ,-- ��`�� ���f�� NE, NE, s 7, r�{a N, 2�i�.t! � roP� �=- - - _ �ti..-r. a L�T �� cSm # aS/�a! `� t�7S 8� p �t,�2 �,rs��� -�� Tocc,n.p{ l�ass Calr� ��� � � _ SCiwc�e,r c�� �- •r ,� (L�V'GC f � S7�Qd2-Z�'y0'OCt-�0��� �... �SW1tl @.��1 roc� ���orE,nca ol •oao- oaoo y0 �i I{er 4•�44 tl�c�g ��� l�Cm e �4. �3vY1 =fAD'� 1�1ai� w1ribbon Pro�os�d 1 Y1 9" �Iap1e Tr+�e, . '�w�c..c. . A�op . L�ou"Rc�G E ie.t)c�-�-�or�S a ._..-.._._.�...-- � �1= 940 83' 6z= R4.Sa' �3= 9 3.25' . � ��� D�iu�wo�.� SYs�en^ = 9°'S� . RLT. SY$, = 4Q.0 I . C��h t� Rd. a o�� � ' -= =_ PAGE 3 GF � ��� ' ,: � � � =_ =A =_ -� _ � f � L �` f~ G j � i � C � t' C*i ? ',' '�{-`<. �� � . _ �- � ` C � C �.� � _ -:=, c j � � o j rs � �t 1` . ..•.: '-f_", � � � ` � z � -- � : �1 r > = ' C, �1�f,��� ( _:t�_ „-' �� � ` �� j = � t::.�i�` � �= J: ,� Y ,,. '� � ' � _ - . _ = _`r � � \Rf` �, �`� - - - � � v =�_ __ _ . M T _ � \. _ .0 '� = � M �` ' - _ � �t T.' - r `� � -- it; � i v -_ >_= y= _ 'c . � _ : .T � r { S-_ __ = M= i C: _ ._ . - � � _ - = � Z �;' ,� O�, � ^".��t �I = i � �= i '1 F'!'!i `', f �� = � � c� - i ��- t F,:, �; '�1 >. _ \^� �i �� 1 {� i: �ii i i� � � � �, ` � � :.' � � � �,�,�� ;,, , .., = e ' i. L = � -'�., � = ,� {I; � � � M = � �;?� - o ? ttl � � L - :; - _ " ;;�� a = � '� }-. }- u = � - __ _ �i I i �'• , _ '•- �' r � � _ ~ - � -_ '�� ' �} � U � � v n 3 = _ - _ !i ��''�;�; � '�' }- � �- > _ •> __ -�" 'I '��� li � C LL � � � C •� ' :� i! �:i `-' ; � O tf: ; i � LL �" O - r " _ _ " '� ,�` ( N ` � � T ^ . '_' � � _ '_ ', i; . ; ;t � c� � � U = � � � � �j � Q? � :.: _ ' : � � �11 t�F `I � - � =a _.. :. :_ = ; `� _ `t `r � �•`� _' � t` ` � � ' '�� . _ _ � ('�t L � i�� S �c r �` '�y �':''�; ; t � ''� - /�� � � � �i�� �, R � '� a!I �����_� � _ _ ' 6\i � �j� � L.A� � � {T--. ��• ,� _ _ � \ '• :? il i4 � 1? X tJ f ; � � O � ;�_'; � �� � � � J � \ � "� '� � � � � "� �; _ � _ � " .a, � . " u�i ' ' � ` � � � '��i _ .�1 �r- �r-, � G '� � � . � � il i , � ; � .. � �: ; O: �-1 � i � � i � ' ; _ :n ;. � � � �',S�__�./���' ? i� :r i �j� �`t ; U i 2' �'', � L. t j � �� :r: :n i �r � � L . '�' � �-.-Q,-'-�-�� •� S„fi C: J ; � ( � _ � _ +�� �,' j �� ."7 i !1 -F� -i�r ; a j __y J ' i!� � ' . 1 ^ � � � � 1 � Li� >j; �7 _ � rT. ,� :��! ; � �i .... �. 1 - � 7 ,Y{� � ^ _ ?' 'v^, � i f: i,• �� L i ` �� t !! � � i.� .� v c � � i:i � �: O i'� � y � ^ ��?' r '� � 1; �/ L3�1 �� `�- J ;� i =j � � SL � -. z-.��- � � �i�{ .� �`��� �} � � '�' �I � � i�i� I z1 � S; � � � � � � jl:i . i �' �, �' � ''�!� v ,,:_.� i-- :�� PAGE 4 OF 4 In-ground Gravity Management Plan IMPORTANT: The owner of this in-ground gravity system shaii be responsibie fior its perpetual opera6on and maintenance pursuant to requiremenfs of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),�sc.Admin.Code,this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthertnore,all inspection and maintenance activities shali be perfortned by a registered POWTS Maintainer in accordance with SPS 383.52(3),Wisc.Admin.Code. Maximum Disoersal Area Oneretina Limits: Design Flow= ��'� gpd; BODS<_220 mgL"'; TSS 5150 mgL-'; FOG<_30 mgL'' insaection Checklist INSPECT EVERY 3 YEARS o type m use o age of system o nuisance factors(i.e.odors,user complaints,etc.) o mechanicaf malfunction(i.e.,pumps,vaives,switches,floats,etc.) o material fatigue(i.e.,leaks,breaks,corrosion,etc.) o solids volume in anaerobic treafinerrt tank(s)and any disfibution appurtenance(s)(i.e.,distribution/drop boxes) o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.) o e�ent of ponding in disfibution ceii prior to dosing o dosing irregularities-if appiicable(i.e.,pump r�cyciing,float switch settings,etc.) o electrical components-if applicabie(i.e.,wiring,connections,switches,controls,fimers,alarms,etc,) o disfihution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification) o surtace discharge of effiiuent or sewage back-up into structure served Maintenance Checkiist MAINTAIN EVERY 3 YEAi2S(or when necessary) 0 5entic and dose tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 V1'is. Stats_when the volume of solids in the fank(sj exceeds one-third(1/3)the liquid volume of the tank(s)or as required by loca(ordinance. Disposal of contents shali be pursuant to NR 113,Wisc.Admin.Code. o Effiuent t"ilter(s)shaif be inspected every 3 years and shall be deaned when necessary to remove any accumuiated solids according to manufacturer's spec�cations. A servicing period wili always be greater than 12 months. System maintenanee reports shall be submitted to the proper locai government unit in accordance with SPS 383.55�sc.Admin.Code. Report any component failure or ma(functian to: � I�,_ •- '1 Name of individual or company: 11 _��Z�'LLY�X Phone:�(��S�FS—���=� Local govemment unit Phone: ��S��4�J�—O a�� Local govemment unit�ddress•� ��ln YYI�L/Y� r ,�cEG -uir,[YOl7[i[ei�ZIP: S��`�� Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin. Code.Repair or replacemeni of failed or malfu�ctioning components shaii compiy with SPS 383,Wisc.Admin.Code. No product for chemical or physical restorafion of the POWTS may be used uniess approved by the department in accordance with SPS 384,�sc.Admin.Code. Continaencv Pian in the event that any faled Veatment 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 dispersai compone�t may be abandoned and replaced by a code-comprying dispersal component in a pr�determined area of suitable soils. Svstem Abandonment If use of this POWfS is discontinued,it shall be abandQned in accordance with SPS 383.33.Wisc.Admin.Code. 11117/22. 12:16 PM Real Property Listing Page R2dl EStdte Sawyer County Property Listing Property5tatus: Current 7oday's Date: 11/17/2022 Created On: 2/6/2007 7:55:06 AM � Description Updated: 3/26/2020 '� Ownership Updated: 10/13/2010 .. . . . .. .... ..... . ... . .... . . . ___-. _ TaxID: 2917 PATRICKJLANCOUR HAYWARD WI PIN: 57-002-2-40-09-07-1 01-000-000040 Legacy PIN: 002940071104 Billing Address: Mailing Address: Map ID: .1.4 PATRICK J LANCOUR PATRICK 7 LANCOUR Municipality: (002)TOWN OF BA55 LAKE 9203N ROHLF RD 9203N ROHLF RD STR: 507 T40N R09W HAYWARD WI 54843-3545 HAYWARD WI 54843-3545 Description: PRT NENE LOT 4 CSM 25/221 #6756 ro SCENIC RIVERWAY l" Site Address ' indicates Private Road Retorded Acres: 9.490 9203N ROHLF RD � ��� HAYVJARD 54843 Calculated Aaes: 9.492 Lottery Claims: 1 �lJ property Assessment Updated: 9/13/2012 First Dollar: Yes Waterbody: Namekagon River 2022 Assessment Detail Zoning: (RRl) Residential/Recreational One �ode Acres Land Imp. ESN: 406 G1-RESIDENTIAL 1.000 14,000 147,900 G6-PRODUCTIVE FOREST 8.490 14,400 0 -� Tax Districts_ _ _ Updated: 2/6/2007 Z_year Comparison 2021 2022 Change 1 State of Wisconsin Land: 28,400 28,400 0.0% 57 Sawyer County Improved: 147,900 147,900 0.0% 002 Town of Bass Lake Total: 176,300 176,300 0.0% 572478 Hayward Community School District O01100 Technical College �Property History .� Recorded Documentr Updated: 3/26/2020 N�A � � � WARRANTY DEED • Date Recorded: 12/30/2004 327678 CERTIFIED SURVEY MAP Date Recorded: 6/2/2004 322041 ORDER Date Recorded: 8/19/1994 243520 il1 htlps:/lta s savryercou nlygov.org Isystemlfre mes.asp?u na me=Eric+W el laue r � .yr �...: - ' � �Pv. :, �� ,� ..t r� � F7„p` ,. sL��� �' � d ' �f y'� '�"f� `��.�t '�G o"r ��.,�"� "ry .� Yt5'k'. �i.� •- � f r' . c�5 3�'>; `^� r� -�i��.V3 �n ?s ds `� iM� > .! �,q. 1� . �^�f� _ - .f4� f e 9�' , 1' ,�('' � f� � ?J��ttr� �� �t� r . r h'�:� a � ! ��������F [' F'tJ': {� .l� -. ] �y c� `a'� .. r 4z¢TN � a ��y�r'?�'..�`-i�'�''"{ :�a�.,/'�5 y�� e .Y. �W9��yr� �Y �r r .,� . ,. 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L5.04(l)(m)] Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#: �a�Y,1 CV �H C C�►� � �-- insp BM Elev: BM Description: �,` Y1�KM�u.t� Parcel Tax No: �c�o-�' lU�,,� Q � -� b� s`� �Sv- (, oba_ ��to -b7- �l o Y TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic . � � Benchmark ,� � oo•� ' Dosing Aeration Bldg. Sewer Holtling St/Ht Inlet TANK SETBACK INFORMATION St/Ht outiet ,q ' TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. 7,3 � Holding Dist. Pipe PUMP/SIPHON INFORMATION Infi�trative Surface g•S � Manufacturer Demand Final Grade t �o ` 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 Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters � IGP o Chamber Model Number: ❑ AG � EZFIow CELL TO �" {-�j� r/ ❑ Mound o Other - - — — --__.--- -- -- ----- -- -- — --- -- _ DISTRIBUTION SYSTEM x Pressure Systems Oniy - --- -— - --- Header I Manifold Distribution Pipe(s) i 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 _1 ❑Yes ❑ No �Yes ❑ N� COMMENTS: (Include code discrepancies,persons present,etc.) ��,,,5}��� r,(�.3��-� � � �-���e�..-�- cel�s o..,� Plan revision required?�Yes � No 03 �3 �3 [ __� ,(��j �� U � Use other side for additional information Date OWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A��ITIONAL C�MMENTS ANO SKETCH SANITAAY PERMIT NUMBEA: �� �_,�_ � . . �"�'`9� : . _ : 3 C��.�, . 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