HomeMy WebLinkAbout010-941-33-2418-SAN-2023-038 :"� ""'`� Department of Safety c°°°ty�� Vl `
- � � � & Professional Services, � �
���_' � Sanitary Permit Num (to be filled in by �
,, _ , Industry Services Division
,v>��� �� 3� �3 S�7
,, . �
Sanitary Permit Application S`a�T�"��''°°N°"'beT ``'
ln accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate govemmental unit d
is required prior to obtaining a sanitary permit.Note:Applicaqon forms for stateowned POWTS aze submitted to Project Address(if different than.mailing �'
the Department of Safery and Professional Services.Personal infortnation you provide may be used for secondary �
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. c4�_
I.Applicallon Information—Please Print All Information `�
Property Owner's Name Parcel# U`��
:��-�G fiY1.�`— l�S
�133� �etg
Property Owner's Mailing Address Property Location
� `� f � Ga�,�r r .
C�ry,State Zip Code Phone Number �
�A ///7/� i )�� �ij(�55� �� '/,, 'v� '�a, Section �-
�r.�,�.. �N �/ 1. /�J G
II.Type of Building(check all that apply) Lot# T `7/ N K 0! E o
,�1 or 2 Family Dwelling—Number ofBedrooms � � Subdivision Name
Block#
❑Public/Commercial—Describe Use ..,,,
❑City of
❑State Owned—Describe Usc CSM Number ❑Village of
6 �� � r �j Town of��l��N(���
iII.Type of POWTS Permit:(Check eit6er"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A. ,�/
❑ New System Lr1'Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B� ❑ Holdin Tank In-Ground ❑At-Grade
g � ❑ Mound ❑ Individual Site Design ❑Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued
❑ Revision
Expiration �Q� 0�'/ �
U ✓ CJ
IV.DispersaUTreatment Area and Tank Information:
Desigo F►ow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sfj Dispersal Area Proposed(s� System Elevajion
o • � 3 6°► '
Capacity in Total #of anufacturer
Tank Informarion Gallons Gallons Units � � o v u
New Tanks Existing Tanks w � y � � y ' v,
� o � v p � �
n. U v� �, c7� is: C7 a
Septic or Holding Tauk �` n� lmoD J �
� � "%� � /
V.Responsibility Statement—I,the undersigned,assume responsibilirty for instsilation of the POW'CS shown on the attached plans.
Plumber's Name(Print) Pkitnb Si�,matur MP/MPRS Number Business Phone Number
�� 7� 3C�� lS
, _._..__.______ -��-1��3
�.
Plumbe s Address(Street,Ciry,State,Zip Code)
"iu ��.3Y1 - � �`�1� ay�-l�- � c.cJ�=,�
VI.C un /Department Use Only
�A� � 3 ❑Disapproved Pemut Fee Date Issued Issuing Agent Signature
�y✓ O Owner Given Reason for Denial $ YQ�•� �I r� I�'� ��
Conditions of Approval/Reasons for Disapproval
�� � � � �
� � � ���
�� «w"�►� :�:���
�-�'`�_,i�3-� APR 2 6 2023
5� �( '��0�5 � .�.._!!t�� .
� SAWYER COUNTY
ZONfNG qDM1NISTRA70N
Attach to complete plans for the s�•stem sod submit ro the County only on paper oot less than 8 v2 z ll inches in sae
NO REFUNDS AFTER � ���S`�
SBD-6398(R.03/22) ISS��0�f���Y
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): �U��l Y1 rn� T� �� Phone: - -
Owner Address: �� ��l� ��iYl.t"�-I � `L' ��t�� Zip: 5��1J�
Project Address: �J' �
Govt. Lot: 1/4 of 1/4, Section��, T �1 N-R�_E 0 or W �
Township: t-fc�U ��G:�ZX County: �,G(��t,��
Project Parcel ID #: Q�� g�7�J��� � � t�
Designer Information
Designer Name: ��..F� ��� Phone:2�-��� f��7�3
Designer Address:�0,��7I N�Tri1.t,�11��'l�.C���'%1�'Z� /��'�C.-� . Zip: S���..�
E-mail: �'��e:��'��` G�
License Number: '�9����
Remarks:
�' __.._.____..__
Signature: Date: ���fo`"�j
riginal signat required on each submitted copy.
Q �U.���:�- ��.,�.�.� .
�M`�' ��/^ y '{ �
'�.� FM�'�"�t � 1�1 i� ~` fn 't.a,.ro P
� 4 �M �
.�."'��.�,J.1��'!r C 0. � Lt9Qa't� �T""�,J
�''�� $R�"�1 C",r"!��`d�� r��,�'' ��'`�'- '- �ry '��s -�_. ^ �� �
�t �i I �J-.�� C./ �4./�7 � � -`'� "a:�q
�-����, � ����s'�� S �3 �" �� � �a� �
� �or � �s m �� a7s� � � a��`
. . __. _ .,_ ... .. __. _ __ _ , _�__ _ _.._ ___ . __ _ . . ____._______.
d��
��� ,r
�
� � ��
'-� ' �....�__.__: _�..�
� � zk
. 1,'
,�,..,. ,.„, 4�..
�.�.�'b��- , 1�1 ��.,`. � = N o
,r�'- �rr �_�`
�;' (��°
��, c ��i_.���� ��.
�; � tW'�r �C ��'�
��tc�r�y�./ ��'�,f�'� .:� �"ca;^�'� t" ', �r v�, �.�,��;.« �
��'�«� G/
._.w_ ,__,..�,._.�..�...�.� ., .:. ,��}�'� � �
3 l3cr�. ..j�'.a . ``���• � '
�
�
�
.� I
�..
m..,.....�..,....._.,.......#�,.�.�. , �•-�
,:m... ..�,...�.�..u_.w..�.,.�w..�
� . �
w..�......��..�.._.,......�...�.�...�.�..,.�._., ...._._.__.�..�._____—.__ _ ._._—..,�.._ , _ _ _._' �'°�-,�, �'�/F_. _ ..�_.w.___-�.a_�.. .,__.______..____
, Sepdc Tank(s)Manuhacturer:
IN-GROUND GRAVITY DISPERSAL AREA _s/c,��/ r�,���� �=,•%r &,�,'h
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Vdume(s):
3-ft Trench (down-sizing credifi) /oD�l ae, 2 98, ge, 98,
EHluent Fllter Manufactur :
�_ � �rEv�c/J t3,fJ - �',/,�_
I
Effluent Fliter Model#: rt��22
min.17'
SOIL COVER QYPlcap
�z^
min.Irench '
dep�h
�tyP���� •" TYPICAL TRENCH
< CROSS SECTI�N VIEW
h 34„
��vpi�i�,;' (No Scale)
Provide minimum 3 k
System Elevation= ft separatlon between irenches,
(typlcal)
Quick4 Standard-W
wl End Cap �Show location of inlet/outlet pipe connectlon on plan view.) �hse�yPlllo�nl,Plpe TYPICAL TRENCH
(typlcal)
��———————��_ tl �n�pef inenufacturefs PLAN VIEW
ucllons.
(No Scale)
�1f!4V�rkYv��kh:kVa4k��.��i`---- --�i,�� yardds4h�a 494r'M'
���Ili �a � ii Ij i �r ,�,i� i I 'i�, id i �� A=3.Oft
Lr�W��rkl�������.�s�S�,�.�''-----�f--------y�---- a����a,k.���.,«�d�o� � caP��a�, D
F- a= �fL r� -� �
m
� (typlcal)� � Quick4 Standard-W Chamber W
� 5 6 <<YP��e�, o
INSTALL PER TRENCH: �r�td by��eu�AmrsyBtam9,�o�.) -�
Install pursuant to menufeclurer's instructlane.
�„��Quick4 Std-W Q 20 fl�EISAlchamber= �� ft� �
+ �„Palrs of end caps @ 6 f�EISA/pair= �_ft°
��/ =Proposed EISA per trench= v o 6 ftt Requlred Inflitration Area= 6�i3 ftZ Distribution Method:
�. D
�� x trenches=Proposed Total EISA= �ft� R.-av��l� ,�.,a�a%-fd��
k� 6��
�i�.� �
PAGE40F4
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 Disoersal Area Operatinq Limits:
Design Flow= 450 gpd; BODS 5 220 mgL''; TSS 5150 mgL"'; FOG 5 30 mgL''
Inspection 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., distribution/drop boxes)
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 specfication)
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 irt 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 filteNs►shall be inspected every 3 years and shall be deaned 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. Adm1n. Code. Report any component failure or malfunction to:
Name of individual or company: RyBfl Stf811C� Phone: 715-558-1673 _
Local government unit: SaVNy@f COUtlty Z011iflg Phone: 715-634-8288
�oca� government unit address: 10610 Maitl St Suite 49 Haywa�d WI ZiP: 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.
Continqencv 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 dispersai 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.
,
i � �_ I �
F�� 1 ��4MQ8 � � ��te�nal ��fluen� �'�It�r �;��rn �e►� ����
x� � 'Y � T E M S
Scale; i° _ �'
;---�ibPrglass Caslceted Lid with
� Stainiass Stoel L�olts
Madel
/f
,--W--.-----Fr�ter Carfridye 1lanclle
�__._._.._._______.__..._ % ,/
_,_,� ��:;._...,.__..�._._._._____- _-____._.__�__ --...__._._�_-;r':,ir ��,..
��n-�.�» .�z � ��-�- S��eclfy Rlsc�r Hoic�ht to Match
Ground S��rface
Modr-.i
_._....__..._ _._--__ __ .._..I�_ _.._ r _ �
_L __ _ _..._, .�! �~ ,�_.w._.____ 18" (Jin. l;rade !i'ing (cou�ling)
�---�- .-�,� � � .__..�.._.___._. ,�" pVC' Solvent Weld Fitting
�::�� � ( _�,
Liquid_l,ev+�l __.Sz_____ __ ,�- y�_.___�__.�-�--....
_._ !I_. 1�-_-__-__= � Efilui;ni f)ischarqc
J �,
�
� �„ , �„
W� ___.._ _:.�:_:.�_ ;��--
New or Exis4ing Bfotube Effluent �iiter
5eplic fnnl; .�-`. tE3" -_.-•». Modr�i
�._,--- — _./
'"ti
`--------------�---Extemal Eftlueni Filter dusin
(arder t F3" r,jic7. riscr & !id
sepuraiely to bring basin
up Ea gracl�)
..._____.____ ...�__._._.__________._.. N OT L;
' --------.__�_.�________._.__._..__..__..__._._....___..._.___---.._._.___.. t3a�in rrray bP retrofittetl inio
t�xisting d'+sr.hc�r'ge line witho�af
additior�pl iittings or fle�:ible �
GaIJ��lI�C�S.
rIDW�-TD—FT�-05
Il�1 7fl`�1 (lrrarirn �:��r.lr�mc Inr �iA\1 � n �n�l �7� �
4/26/23,721 AM Nows-Wisconsin Access rev.13.1108
Real Estate Sawyer County Property Listing n�eKy sma�:cu,+��c
Today's Date:4/26/2023 fXeated On:2/6/2007 7:55:23 AM
=i
'=�'�P�� Updated:7/24/2012 +�OrrnershiP Updated:7/27/2021
..__�_-------�----......_._._.____---
_.._---------- ---------------------
Tax ID: 13259 7USTIN M TOLES HqyWqRp yyI
�N� 57-010-2-41-09-33-2 04-000-000180
Legacy PIN: 010941332418 Billing Address: Mailina Address:
Map ID: ,8.18 ]USTiN M 70LE5 )USTIN M TOLES
Municipa8ty: (010)TOWN QF HAYWARD 9948N QNDY AVE 9948N QNDY AVE
STR: 533 T41N R09W HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT SFNW LOT 1 CSM 6/275#1265
Recorded Acres: 1.150 �Site Address *indicates Private Road
Lottery Claims: 0 ------.—_._--.._----------------------
Frs[Dollar: yps
9948N QNDY AVE * HAYWARD 54843
Zoning: (RR2)Residential/Recreational Two
ESN: qq4 �Pmperty Assessment Updated:11/9/2015
--------------------.
._..----------._.....-------_..
2023 Assessment Detail
�T�a�� Updated:2/6/2007 �e Aves Land Imp.
1--�-�--------------- --- Gl-RESIDENTfAL 1.150 20,9D0 63,400
State of Wisconsin
57 Sawyer County 2-Year Com
010 Town of Hayward ��O° 2022 2023 Change
572478 �nd: 20,90U 20,900 0.0%
Hayward Commun'Ry School District ImP��: 63,400 63,400 0.0%
001700 Technical Colfege T��. g4,3pp 84,300 0.0%
-a Retorded Do[uments Updated:3/12/2012
....-----' ------- -- -
__—-----
�WARRANTY DEED � � a� �
Da[e Re[orded 7J23/2021 433499� � ���H��ry
__ ...._.. -—--_- ...__--_._ _---..__.------
N/A
0 ORDER CNANGE OF NAME
Date Recorded:8/20/2020 425829
0 WARRANTY DEED
Date Recorded:2Ji7/2012 377223
�CERTiFIED SURVEY MAP
Date Recorded:fiJ18/1979 170046
G���
�o}�l,� t� ,�L�d
� r��t
https:lttas.sawyercountygov.org/Accesslmastecasp ���
` ` �'"t` PRIVATE ONSITE WASTE TREATMENT County
>
������$�� `'� SYSTEMS SaWyer
� � ( POWTS)
�, s _�
H �—r%
`"z„"` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 3 — Q3`g
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#:
��5�'�. To��S }-�aYwa�aQ ._
Insp BM Elev: BM Description: Parcei Tax No:
� �"I � �� a�.�a2t = �O�.o t �(C7-�Y�" 3�^'��l O
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � � S�, �o00 �-�` ,6 Benchmark ,Z �vp,o�
Dosing
Aeration Bidg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St I Ht Outiet q`7, � �
TANK TO P/L WELL BLDG vE"TTo ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. qb.S7 �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative 9S�,� �
Surface
Manufacturer Demand Final Grade
Model Number GPM � �n/ a.7,o r
TDH Lift Friction Loss Sys Head TDH Ft � �`, 6 .$ '
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N � L �{t�` q� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate �.-�,,
INFORMATION P/L Bldg Weli Waters � IGP � Chamber Model Number:
❑ AG ❑ EZFIow
CELLTO .�-�,.. �'l�p �-� /V ❑ Mound o Other �Y�
- -- - - —--__— _ _-- -- -- -- ---------
--
DISTRIBUTION SYSTEM , x Pressure Systems Only
Header/Manifold Distribution Pipe(s) �X Hole Size X Hole Observation PipE�s
[ Length Dia Length Dia Spac I Spacing ❑Yes ❑ No J�
- --- _ --
SOIL COVER
-- - - - - -- -- -
Depth Over Depth Over � Dep oth f Seeded I Sodded Mulched
Cell Center Cell Edges ; Topsoil ❑Yes ❑ No ❑Yes ❑ No
I __--
COMMENTS: (Include code discrepancies, persons present,etc.)
��,.>-}��/� y���s(�-�
�` '�e P�9«^^e.�'�-- �'e�� �- -���r-c wL ,
Plan revision required.�Yes❑ No .��� �y ' ----- - � �- . - -� 6���� �
� � �I
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITAAY PERMIT Nl1M8EA: b3�
_--��------
� �o\ �
�P< <-- ����' �
��S
,
���c>
� s'
i 9 �� e �o�
� y
�
q !
� �- _ :. . ; , . _
� �
� � ���`"
� , �;D �
,��' � �` ��\ �-Sa�
,
�
�
3��r.
� �
��,2
a,,�N
��
��Y �
lb
-�--