HomeMy WebLinkAbout026-118-00-3300-SAN-2023-055 �"'°"``�=, Department of Safety c°""�' ��
S R�:�; �'
� i� �t & Professional Services, �
�, � Sanitary Permit Number(to be filled in by Cc �
�; �'� � Industry Services Division
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State Transaction Number
Sanitary Permit Application _ �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit O
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing add vl
the Department of Safety and Professional Scrvices.Personal information you provide may be used for secondary ,�,{2��� ���������/�
purposes in accordance with the Privacy I,aw,s. 15.04(l)(m),Stats. 1 �
I.App�ication�Infar�msk#an-Please Print All Infortnatifln
Property(?wner's Name Paroel#
Q �K��cibSGai.J ��.�Il Gf� -�iC•C�
Property Owner's Mailing Address PropeRy Location
��/(p Ccc e n�ee �� /U� �,.�-�e
City,State Zip Code Phone Number
►�,y Section �
�v�-���� t'E�� / �ll�l SS�����
B.�'ppHe ufBa��lc�tg4�e���ll,thst gPP1Y) Loc a T �L rr x �. E o�
�1 or 2 Family Dwelling-Number ofBedrooms 3 3� Subdivision Name
h�� slock# i r vi e�J Ju�O� �
❑Public/Commercial-Describe Use /�/
—� ❑City of
❑State Owned-Describe Use ��:� CSM Number ❑Village of
__ �Town of ��i•�e� �k"�
IlI.T,ype of POWTS Permit:(Check either"New"or"RepiacemenN'and other appl'ecable on line A. Check one box on line B.Complete line C if
a licable.
:�.
❑ Ncw System ❑ Replacemeot System �Olkter Modification to Existmg Systen�plain) ❑ Additional Yretreatment Unit(explain)
�dc��t�o,��i N�ld�.v c��,/�
B' �Holding Tank ❑ In-Ground ❑ At-Grade
❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New O�sner q �{
.ist Previous Permit Number and Date Issued
Expiration � t' Z�} ����K- � 1
N`.Dis 1/t'reatment Area and Tank Information:
Design Flow(gpd) Design Soil ApplicaIion Rate(gpd/s� Dispersal Area Required(st) Dispersal Area Proposed(s� System Elevation
3c,�, ._.___ ----__ ___.. _.._ _ _
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � U �$ ` N �
New Tanks Existing Tanks � p « � y � � �
c� C� v� v, v� w C7 G.
Septic or Holding Tank `G �/��C� `?� �l,����. �
IJosing Chamber
V.Respflnsibility Statement- I,the undersigned,asgume responsibility for installallon of the P�WTS shown on the attae6ed plans.
Plumber's Nan�e(Print) Nlumber�s Signature MP'MYRS Number Business Phone Number
Jerry Ruid Excavating, LLC �� ��-�c z.�6,�. 7is-�-t�z- �.�ta�
Plu , t . ,ip Code)
Stone Lake, WI 54876
v�..coun� a����us@ o�iy
�App� � ❑Disapproved permit Fee Datc Issued Issuing Agent Signaturc
❑Owner Given Reason for Denial $ /�•� � 'f S � " 5 �� ��4������tiZ�''�--
Conditions of ApprovaUReasons for Uisapproval � ' � '1
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�.�� ' ��` �-����---- J MAY 1 5 2023
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CSl ��'�' � t ��'� -- �ONINGADMINISTRA710N
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Attach to complete plans for the system and submit to the County only on paper not less t6an 8 1/2 x 11 iuches in size -� �D'�?�j�
SBD-6398(R.03/zz> I�0 R�FUIVDS AFTER
1�SUL-OF PER1fll7
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Man.ual Design References:
Holding Tank Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicabie)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name / Description
��r � �cfe.
Ownar Name(s): 1��'b r�, ��c�,soti Phone: - -
Owner Address: 3 7/ , C - �ne� r�l �U L ��� i� Mn, Zip: 5S��f(��,
ProjectAddress: y24:;S�N �ra.� herr-y i�r
Govt Lot: 1/4 of 1/4, Section £� , T 3£� N-R � E Qor W Q
Township: 5�..,� �4 k�. County: S �,� y�
Project Parcel ID #: p � �� (f3 c>c� 3� c�v
Designer Information
Designer Name: �erry Ruid Excavating, LLC phone: 7/S �
-�- 2_�(o�
Designor Address: Stone Lake WI �4876 Zip: 5��
E-mail: � c- ��U Q C e,�i7';�'- % j'z / N L'% This space reserved for approval stamp.
License Number: �`I �- °i G �
Remarks:
Si nature: �,_y-, L.�`�
9 Date: � - �o � 2 3
� O ginal signature required on eaeh submitted copy.
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W208 County HWY A i a; 3-3 3 71�, C4�,�eG �� N�
Stone Lake, WI 54876 fg,� � 1e� S�� R
c5' tl��� es.er M,v
rvr'/�5 1`��<,G..l
� � SS`�06
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' 9"min. abuve surrounding grade or 2 fl. abave
,,,...���sta611s6eJ regim�al Oood olevatlon, unlesa
�ccess porl is wa�er anJ gas tigbl -
. .Cover wllh warnb�g Iabo1 �
% apo lock I�access opening is Cover wflh warning lahel
J grnaler than 6 luch dia. _� Waterligbt)uncOnn Lox /anJ lock If access opaniny Is �
' —�- j �realer ihan 0 Incl� dla. �
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/Venl `�".... �l
0 Inch
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min. dia. ��—�-- 0 h�ch �
rohi. dla.
f'ower sonrce
�WLo�p(a SiWER � ------ -- '--- -
\ �L _'__
- � Maximum alarm on level set
a112"below tank Inlet Invert
Alarm Iloat or90°A o(tha Ilquld capacly
at Ihe tank below Ilie lank
Inlet Invert �
El.CcrK�ca� hf PE/7 .
A/EL 30o Aun /6
Cross-Seclionoffluldin Tanks �ti S�¢��s Z—" 3��l3Eooi,v4
- ANCHo2 TANIC as ,Jrcatcee./ T� Nr[d�k 6NoyANcy �
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ALAQA7 A4qG/uFAC IUil=R , S _D S �i2/T� '�
ALARM AIppEL Nu m/3�—Ii _! G'[�
fTL6�3ECT" �f� h�[�Z-'- . �.
�ur,aeQ to�,.�uid E,�c�avaEing, 6��—
_ W208 Countv HWY A
Stone Lake, WI 54876 /�7/�j�s_ 4,� y<� � �
� �v�ifbNE1.IT 1�1AI.�uAI. I�J�:.n�3cR �
PAGE40F4
Holding Tank Management Plan
IMPORTANT;
The owner of this holding tank(s) shall be responsible for its perpetual operation and maiMenance pursuant to
requiremerrts of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s)
shall be considered a human health hazard 'rf not maintained in accordance with this approved management plen.
Furthertnore, all inspection and mairrtenance activities shall be pertortned by a registered POWTg Mairkainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Estlmated Daily Wastewater Flow = 3 ��� gpd
Insoection 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., Ieaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited adivfies, etc.)
o electrical components (i.e., wiring, connecBons, switches, controls, timers, alartns, etc.)
o surtace discharge of effluent or sewage hack-_up into struc�ure.served
SERVICING FREQUENCY
o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 �sc. Stats.
when the wastewater in the tank(s) reaches,a IeveFaf or�foot below tha inlet imeR of the tank(a).
Disposal of contents shail be pursuant to NR 113, Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local govemment unit In accordanee wkh SPS 383.55 ws.
Admin. Code. RepoR any eomponent faflure or malfunctlon W:
Name of individual or company: SGo7T'S SG-/�Y� L 7iS- G�
Phone: `1 ' 7�. 7�
Local govemmerrt unit 5 � w yet- G�o . z-vti r.v� phone: �>S- E �N- $ 7.$P
Localgovemmentunitaddress: l(3(�� O YY1A.th� ST. sV�r� tiq i�w,,�dz�P: s�+ Su3
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 malfuncGoning components shall compiy with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoretion of the POWTS may be used unless approved by the department in
accordance wRh SPS 384, Wisc. Admin. Code.
Continaencv Plan
In the event that any failed c�mponent of this hpidln�t��k(s) ca�:� t he repaired, it shail be replaced pursuant to a
plan submitted to the appropriate agecy for 2vie:y�nd upprove'.
Svstem Abandonment
If use of this tank(s) is discontlnued, it shall be aband:7r,eti i ,.. or:!a��ce wiih SPS 383.33, Wisc. Admin. Code.
5/15/23, 11:14 AM Real Property Listing Page
R2dl EStdt2 Sawyer County Property Listing Property5tatus: Current
Today's Date: 5/IS/2023 Created On: 2/6/2007 7:55:45 AM
�Description Updated: 5/SO/2011 '� Ownership Updated: 2/6/2007
.. _... . . .__... . .
___ _.. _ .. .__---- ------
TaxID: 26766 DEBRA A]ACOBSON � ROCHESTER MN
PIN: 57-026-2-38-09-OB-5 15-140-003300
Legacy PIN: 026118003300 Billing Address: Mailing Address:
Map ID: -433.1 DEBRA A]ACOBSON DEBRA A]ACOBSON
Municipality: (026)TOWN OF SAND LAKE 3716 CAMEO PLACE NE 3716 CAMEO PLACE NE
STR: 508 T36N R09W ROCHESTER MN 55906 ROCHESTER MN 55906
Description: FAIRVIEW SUBD LOT 33 pp
Retorded Acres: 0.934 r Site Address * indica[es Private Road
Calculated Acres: 0.885 4285N CRANBERRY DR � � STONE LAKE 54876
Lottery Claims: 0
First Dollar: Yes � Property Assessment Updated: 7/6/2022
Waterbody: SissabagamaLake � -� � �-��-�� -�-�--� -�� �
2023 Assessment Detail
Zoning: (RRl) Residential/Recreational One
ESN: 423 Code Acres Land Imp.
G1-RESIDENTIAL 0.934 181,100 112,600
_� Tax Districts Updated: 2/6/2007 2-Year Comparison 2022 2023 Change
1 � �� �� �� � �StateofWisconsin Land: 181,100 181,100 0.0%
57 Sawyer County Improved: 112,600 112,600 0.0%
026 Town of Sand Lake Total: 293,700 293,700 0.0%
572478 Hayward Community School Distrid
001700 Technical College �
-C_8 Property History
• Recorded Documents Updated: 4/4/2008 N/A � �
QUIT CLAIM DEED
Date Recorded: 326543 QCD626/419 QCD326543
https:Nlassawyercountygov.orglsystem/frames.asp?uname=Enc+Wellaue� 1l1
�,,
' '"'E^ ; PRIVATE ONSITE WASTE TREATMENT Cou�ty
j��S� SYSTEMS SaWyer
� � ( POWTS)
L7�� �- :�
\H� `_ �!,,
"��' ' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 23 —d��
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#:
��, Ja�..`o5�� �� C�,� r'
Insp BM Elev: BM Description: Parcel Tax No:
�� •�' ��l a � R I � "j t�l/' 1 f� (�e� ��`O^W"33�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark ��o,a�
Dosing
Aeration Bltlg. Sewer
Holding t�,��ec,,�r cxsp St I Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet �-- g(, •7
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
D�sing NA Installation
Contour
Aeration NA Header/Man.
Holding .�..�o' �.Z � f � ,�2r� ��S- � Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number �pM h�- 1i•J `�S � �
TDH Lift Friction Loss Sys Head TDH Ft o4 �
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N � #of Cells Type of System Distribution Media ManufaCturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
P I L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO ❑ Mound o Other
- ---- -- _._ _-----____ _----—
DISTRIBUTION SYSTEM x Pressure Systems Only
___ ---
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length___ Dia_ __ Length Dia Spac Spacing ❑Yes ❑ No
- — — - --
SOIL COVER
f Depth Over �pth Over Depth of � Seeded/Sodded Mulched �
� Cell Center Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
���ll�d� 7��Y��3
� C3� �-i ��l
Plan revision required?❑Yes❑ No , d � � I � . ' 6R �
� Y l Y �_ �. l6
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER ____��_�QS�__
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