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006-440-19-5105-SAN-2023-100
�y� �;ci,,�rrrtny County - .X � _ �!� Industry Services Division /� Sawyer � : p t � / .��'C 1400 E Washington Ave ` �•� Sanitary Permit Number(to be fi11ed in by Co.; � ,s P 701 � # P.O.Box 7162 G�\�� _ �}� S = �� � 1� �� ti� Madison,WI 53707-7162 �Q / � �„� '>-„ � � � Ip �p� -,.. Sanitary Permit Application S�te T�'��'°n N°mber � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit 1��^'1�-O -C 0 is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing�9�ress) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Clover Rd N � u oses in accordance with the Privac Law,s. 15.04 1 (m),Stats. i. A lication Information-Please Print All Information Property Owner's Name ��ti;(�;',1 };,,� Parcel# QG(p- Yl(0^ l q -S(ps Joshua and Rabecca Gothem �i1�1-= �,_; 57-006-2-40-04-19-5 05-001-000050 Property Owner's Mailing Address Property L.ocation s2a.7 cty Hwy nn �o .Lot� City,Scare Zip Code Phone Number �p�, Section �9 New Auburn, WI 54757 T ao� N; R ba Wp II.Type of Building(check all t6at apply) Lot# �1 or 2 Family Dwelling-Number of Bedrooms � � Subdivision Name �_ > Block# ❑Pubiic/Commercial-Describe Use ' ❑City of ❑State Owned-Describe Use CSM Number ❑Village of 98'L a\ I ��3 �Town of Draper • III.Type of Permit: (Check ouly one boa on line A. Complete line B if applicable) A' �New System ❑Replacement System ❑TreatmenUHolding Tank Replacement Only ❑OtheT Modification to Existing System(explain) B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber QPermit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner �� IV.T e of POWTS S stem/Com onent/Device: Check all that a 1 ❑Non-Pressurized In-Ground QPressurized In-Ground ❑At-Crtade ❑Mound>24 in.of suitable soil �Mound<24 in.of suitable soit ❑Holding Tank �ther Dispersal Component(explain) QPretreatment Device(eacplain) V.Dis ersaUTreatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpds� Dispeisal Area Required(s� Dispe�sal Area Proposed(s� System Elevation 300 1.0 300 300 101.58� VI.Tank Iufo Capacity in Total #of Manufacturer Gallons Gallons Units � � o '�, o New Taciks Existing Tanks �° q y � a� `" � � ;? o ;3 � a U �n' � �n 'w c7 Ci. Septic or Holding Tank 750 1250 1 SkBW X Dosing Chamber 500 VII.Responsibility Statement- I,the undersigned,assuroe responsibility tor installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Darrell Frazer 221071 715-288-6225 Plumber's Address(Street,Ciry,State,Zip Code) 16317 160th St Bloomer, WI 54724 VIII. o /De artment Use Onl A rov Pernut Fee Date Issued Lssuing Agent Sign � p ❑ Disapproved /! ��o�� 6 2���13 ' � 77 y✓ ❑ Owner Given Reason for Denial IX.Conditions of.Approval/,Reasons for Disapproval a _�J� . . �P— �? � �' ��! �! a�7'� .. _ Y I�■ �� . ti C � � � Attach to complete plans for the system and submit to the County only oo paper not less thao 8 a 7 p�q�'o c�' ;,`j, l�n n CST �3— O53> � ,�-���������___- , � I �� sBD-639g(xo NL?R�FUNDS AFT�R "--� '� ���� 15 2�23 l�SUE OF PEFiMIT �-----------.--J �N11��- �:..:.���`.'�:��'r��i C�G'•JPJTY Z�tv�iVGl�Cif��ilN1;iTRi�TlON ���� 14. Place stone aggregate over the distribution network and the entire distribution cell until the elevation of the stone aggregate is at least 2 inches above the top of the distribution network. NOTE: If using stone aggregate go to step 17. 15. Install the leaching chambers and pressure distribution piping as instructed by the]eaching chamber manufacturer's instructions, pressure distribution design and applicable sections of ch. SPS 382, 83 and 84, Wis. Adm. Code. 16. Install an observation pipe in each row of leaching chambers. 17. If stone aggregate is used, place geotextile fabric conforming to requirements of ch. SPS 384, Wis. Adm. Code, over the stone aggregate. 18. Place cover material on the top of the geotextile fabric and extend the soil cover to the • boundaries of the overall component. 19. Complete final grading to divert surface water drainage away from mound. Sod or seed and ' mulch the entire mound component. VIII. OPERATION,MAINTENANCE AND PERFORMANCE MONITORING A. The component owner is responsible for the operation and maintenance of the component. The county, department or POWTS service contractor may make periodic inspections of the components, checking for surface discharge, treated effluent levels, etc. The owner or owner's agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or the department. B. Design approval and site inspections before, during, and after the construction are accomplished by the county or other appropriate jurisdictions in accordance to ch. SPS 383 of the Wis. Adm. Code. C. Routine and preventative maintenance aspects: L Treatment and distribution tanks are to be inspected routinely and maintained when necessary in accordance with their approvals. 2. Inspections of the mound component performance are required at least once every three years. These inspections include checking the liquid levels in the observation pipes and examination for any seepage around the mound component. 3. Winter traffic on the mound is not advised to avoid frost penetration and to minimize compaction. 4. A good water conservation plan within the house or establishment will help assure that the mound component will not be overloaded. �1 �' V � � 1 ��" �3 o �<< � l. 23 of 44 Desi n flood frequency 100 Max flowa e under(cu ft/sec) 4900 Max flowage velocity(ft/sec) 10.0 Draina e area(sq mi) 259.0 Vertical navigation permit clearance(ft) � Horizontal navigation permit clearance(ft) � Min lift clearance(ft) 0.0 Scour critica! Stable-within footing limites (5) Scour calculated Pier protection Navi ation control No navigational control on waterway(0) Hi h water elevation(ft) 1382.4 Record low water elevation(ft� � Recor�ater elevation(ft) Boat access location Inspection save cancel PatBrownSCZAC-61 �310060f3 home go � Saw — --_ — -- —� � 8-57-054 CLOVER RD over CHIPPEWA RIVER 31 General Inventory Main Abutment Pier Span Geometry Approach Sufficiency Capacity Expansion Join� Appraisal ADT : '-.��. ��1 �, ^ ,�-• f�., ..� - ���`Y`. "'�s-ryd.t� _ � . ;�-yyy .. � r�/ r:-y�s� � r ��,a'r ��� � �: ��.Ys. .fr,. ��. � �,}��-� �� a `�� �. �., 3�'�' .� _ F _�j�� .:.e •� � ��' - 4y .�' L '�{` .T-�sd*��'�`�,.n � ' . � {n�Sh^ +��� �}� f .t"h��' ,�R �� ;y> l. � W .' .. �•��� _ . .' . �; . 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N .. ,.-. ,. �6�, P•-y���,�".�= .� � ;- ,: " ' � � ",X � �, „ �`' fa. � ,,. `'%�, ., _. a� � � . r►.�'^ , �r .,F. .� . n.t. , , . ,. . _. ..., � . ... . i�`'"T`'f�'��� PRIVATE ONSITE WASTE TREATMENT County ,;,-�—- > j �'�Sp� ,�'�, SYSTEMS Sa.WyeT' � ( POWTS) 'tio '`--- �-��� INSPECTION REPORT Sanitary Permit No: Safety and Bwidings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2 3_l� Personal infonnation you provide may be used for secondazy purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village �-Town of: State Plan Transaction ID#: 5os��w �- Qe�..e-cw ��� �Q� P� ��'�300� 1 ^� Insp BM Elev: BM Description: � Parcel Tax No: (O d. p� I`J�� , ,-. � �' � � � 00(E,- `-�KO — ��—5-(o.� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic 1/�/— `�� Benchmark �va,o � Dosing —�,�,�� �� Aeration Bldg. Sewer -- Holding St I Ht Inlet 2 � TANK SETBACK INFORMATION St/Ht Outlet �. TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR INTAKE Septic �.�j� N NA Dt Bottom 92,�'� Dosing « << r� 4 NA Installation � Contour (0��b Aeration NA Header/Man. Holding Dist. Pipe ��s' PUMP 151PHON INFORMATION Infiltrative � Su rface ���,'� Manufacturer � Demand Final Grade Model Number 1�� (,� GPM TDH � Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist. To Well DISPERSAL CELL INFORMATION DIMENSIONS �N � L � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv � Aggregate P I L Bidg Well ❑ IGP ❑ Chamber INFORMATION Waters ❑ EZFIow Model Number: ❑ AG CELL TO ,�.2� -}�jp � Mound_ � Other - — — --- — --__ --- — —__-- — DISTRIBUTION SYSTEM X Pressure Systems Only --__ ----__—----- Header/Man�fold — �` Distributio Pip�s) « � ► , X Hole Size� X Hole 23 ' Observation Pipes —I Length � Dia 12� Length���Y� Dia 1•S Spac� � p,�$g �, Spacin� �Yes ❑ No J SOIL COVER �epth Over '� � Depth Over � I Depth of ?—� Seeded I Sodded � Mulched � � Cell Center , Cell Etlges � � Topsoil , ❑Yes ❑ No . ❑Yes ❑ Vo � COMMENTS: (Include code discrepancies, persons present,etc.) ���f� �l�1 �-� � Plan revision requiretl?❑Yes❑ No I,�3 7���I � � 6�j��� Use other side for atlditional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITI�NAL COMMENTS AND SKETCH SANITAAY PERMIT NUMBEA:_.�3^ (� ��b�. � �� ��- �33 � �5..�. ,��d�� 7 , � • ��. � ���� � � � � _ �.SK � �� , T� I� ����''`-s'�_ � � � � ? � �►� � ��� . 1 ��ir��- t ` �° w(I'��(I�f1 � `E �aw� ��,� � � �� , F(P ��� �_ , -� _ _ � .�` c�,, ���.�. �P ��