HomeMy WebLinkAbout026-939-20-5308-SAN-2023-018 Department of Safety c°°°�' �
6 & Professional Services, s�Wy� �
$� - Sanitary Permit Number(to be filled in by( �
g Industry Services Division
�3�i 3Nc� �
Sanitary Permit Application StateTransactionNumber �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit � �
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing ad �
Uic Department of SaPety and Profcssional Scn�ices. Personal intormation you provide may be uscd for secondary �� ��� $� ( /__
purposes in accordance�cith the Privac��Lati_s. 1�.04(I)(m).Stats. �Fs d `��� cp
I.Application Information-Please Print All [nformation
Pruperty(hvner's Name Parcel# �z0� 5-308
W���.n� '��q;� a26- 939'
Property Owner's Mailing Address PropeRy Location
� F?o �cal(Y P�'CL^( vn��' 3O7
Govt.Lot
City,State 7.ip Code Phone Number
Q 1"O A O � /h� s�3�6 '/<. '/4. Section �-O
I�ype of Building(check all that apply) ��t# T 3 q N R �y E or�
1 or 2 Family Dwelling-Number ofBedrooms 2 Subdivision Name
131ock#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
�i'own of s�wd �a�C�
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.
`�� �New System -� Replacement System _ Other Modification to Existing System(explain) —'� Additional Pretreatment Uni[(explain)
B' �� Holding Tank �-Ground ❑ At-Grade � Mound r Individual Site Design ❑ Other Type(explain)
`�(conventional)
r• � Renewal Before �� Re��ision � Chanee of Plumber �� Tra�isfer to New Owner�'ist Previous Permit Number and Date]ssued
Expiration
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 Ele tio (
3 �a . � �l Zy KsZ g�- 8�.0
Capaciry in Total #of Manufacturer
Gallons Gallons Units a o T� �
Tank Information .n v �
ro � � N �
New Tanks Existing Tanks ` � a� � � � � �
a U v: � v� u. :7 ci.
Septic or Holding'1'ank '�r0 7 SV '� W(��(� (/
/�
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 Si nature MP/MPRS Number Business Phone Number
1� ,,,,� 5��,��fz I�)G/Zq 7rr- rr� - fyrY
Plumber's Address(Street City.State,Zip Code)
`�o CN ��-vr� �v�l,Ge �� � S� ���i �"� S�j'76'
VI.County/Department Use Only
A� 0 3 Permit Fee Date Issued Issuing Agent Signature
� ❑Disa roved
� P� $ �o�.6� �,I� �a 3 "%�j�L.e���f,�-a-
❑Owner Given Reason for Denial
Conditions of Approval/Reasons for Disapproval r,� �
� ,��-�i�'' 1, �'75�r",
� :� �at��?�a 3 ��.�.: r, E -�t�_ __ �
. j 1
� ��GI� ��^ .-��;��
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�`,� Chk# MAR 0 � �'023 _ .
G�� �-�, — �`�� �c�s��s`�_�v,��Cn I a �., --_----.--_____.
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LC�( ErdG F�D`��� �i �v�:��i:;t�!
Attach ro camplete plans for the system and submit to the County only on paper not less than S 12 x 11 inches in size y�� 3 � `
NO R�FJhDS AFTER
SBD-6398(R.03/22) ISSUE OF PERMIT
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): Whitney Blair Phone: - -
Owner Address: 2670 Kelly Pkwy Unit 307,Orono, MN Zip: 55356
Project Address: �6457W Little Sand Lane
Govt.Lot: 1/4 of 1/4,Section 20 ,T 39 N-R 09 E❑or W❑✓
Township: Sand Lake County: Sawyer
ProjectParcellD#: 026-939-20-5308
Designer Information
Designer Name: Dylan Schultz Phone: 715 558 _ 5904
Designer Address: �076N Stone Lake RD Zip: 54876
E-mail: dylanschultzl8@gmail.com , ,, ,., „ ,
�. :.,.,��.
License Number: 1516129
Remarks:
Signature: Date: ��L�`23
Original si ature ir on each submitted copy.
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Septic Tank(s)Manufacturer:
IN-GROUND GRAVITY DISPERSAL AREA W<<zv
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) ��° 9a, 9a, gal 9a�
Effluent Filt r Manufacturer
��fo��
i StS
Eftluent Filter Model#�.
Iia i2"
ryp�caq
SOIL COVER
iz�
mm trencn
crov°�n • TYPICAL TRENCH
a CROSS SECTION VIEW
� 34�� No Scale
(�YPi�p .. � •.. � �
•' � �' Provide minimum 3 ft
System Elevation= �-� ft separation between trenches.
(typical)
Quick4 Standard-W
w/End Cap Observalion Pipe TYPICAL TRENCH
(typical) (Show location of inlet/outlet pipe connection on plan view.) (Np��O
Installp r anutacturers PLAN VIEW
i t uctions.
(No Scale)
�b �s: _- Rs� ----��-------��-- eec�rRa�•v:� s�s, �
11 ,� . � n A=3Aft
�� .:..Y (tyPicaq �
�l�loaW. a\ ���� �►k1110es�a '�.J
----------��-------��---- -- y
B= � ft �-_� m
(typical) Quick4 Standard-W Chamber W
(�YPical) O
INSTALL PER TRENCH: �rntd ey�ot�vam�systaros,�oo.� �
I I Install pursuant[o manufacturefs instructions. �
�uick4 Std-W @ 20 ft�EISA/chamber= 2L ft'
+ � Pairs of end caps @ 6 ft EISA/pair= ` ft�
=Proposed EISA per trench= �-�6 ft' Required Infiltration Area= ��- I ft' DiSt�ibUtiOn MOthOd:
x �^ trenches =Proposed Total EISA= �� ft� ��^��`T
PAGE40F4
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, 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 pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52{3), Wisc. Admin. Code.
Maximum Disoersal Area Ooeratina Limlts:
Design Flow= 3 �� gpd; BODS <_220 mgL"'; TSS <_ 150 mgL"'; FOG 5 30 mgL-'
Insoectlon 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, fioats, 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 capaciUes, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irreguiarities- 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 Iateral 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 Seotic and dose tankfs)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 Iiquid 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 fallure or malfunction to:
Name of individual or company: DylBn SChultz 715-558-5904
Phone:
�ocal government unit: Sawyer County zoning 715-634-8288
Phone:
Local government unit address: �0610 M8if1 St�@2t, Hayward, W I 54843
ZIP:
Any defective palt 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 compiy 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.
ContinaencV Plan
in the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursua�t 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 pfe-d8te�mifled 8f8d Of SUitBbi@ SOIIS.
System Abandonment
It use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
'"f��, PRIVATE ONSITE WASTE TREATMENT County
'���o$ SYSTEMS SaWyer
��;�;�� PS :� ( POWTS)
�ti �--e% —
"��' ' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 - 6l�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
�N���2 �-- Ca�r�2 QIqY' SuM� �� �
Insp BM Elev: BM Description: Parcel Tax No:
l pD.�' �va�) �rib�,,,, 3' � �'. s��. 2-�''wti� P� a�6 - -�'t39-�o —�'30�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,�„ -7� Benchmark (Oa.o�
Dosing
Aeration Bitlg. Sewer 9706 �
Holding St/Ht Inlet �j,�,q8`
TANK SETBACK INFORMATION St/Ht Outlet y�,�$ '
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIR INTAKE
Septic , ` ` fi�o� NA Dt Bottom
D�sing NA Installation
Contour
Aeration NA Header/Man. Qp ,p �
Holding Dist. Pipe
PUMP 1�IPHON INFORMATION Infiltrative
Surface ��O�
Manufacturer Demand Finai Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W ` � Y Y #of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �1 ,
INFORMATION P/L Bldg Well Waters a GP � Chamber Model Number:
❑ EZFIow
CELL TO �(b �� �' ❑ Mound o' Other �
-- —__ ___N __ �_-- — - - __ Y'�' _____-—
DISTRIBUTION SYSTEM X Pressure Systems Only
— _ _ _ _ _
Header/Manifold Distribution Pipe(s) II X Hole Size X Hole Observation Pipes
Length Dia Length _ Dia _Spac _ Spacing O Yes ❑ No
— -- - - -_
SOIL COVER
Depth Over Depth Over �epth of Seeded I Sodded Mulched
Celi Center � Cell Edges I Topsoil __ � ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���1(� s(�61�3
� --��
--� ; --- ---
Plan revision required?❑Yes❑ No I�v� �$ I y 'I ; - i 6� � j�
l �--- ----
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS AN� SKETCH
SANITARY PERMIT NUMBER ____ �.�^DI�______
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