HomeMy WebLinkAbout002-136-03-1600-SAN-2023-155 /�c'"''``� Department of Safety c°°"ry N
��j� � & Professional Services, � � �
' �_ � Industry Services Division Sanitary Permit Num (to be filled in by �
� . l.i�S � �i� � �
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Sanitary Permit Application S`a�T�°�°t'°°N°"'ber '
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary pemvt.Note:Applicadon forms for state-0wned POWTS aze submitted to Project Address(if different than mailing a
the Ueparhnent of Safaty and Professional Services.Personal information you provide may be used for secondary ���� �l ������,� �,�
puiposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats.
I.Application Information—Please Print All Information l-t.��
Property Owner's Namet Parcel#
� .�urd .r aaa �����3��0
Property Owner's Mailing Address Prope�ty Location
'���7 a' T \ � . Govt.Lot
City,State "Lip Code Phone Number `1
�^ -� l,� �(t� O /s ' � " ��, , '/,, '/a, Section ✓��
�.C.{� �.J 1'
II.Type of Building(ch k all that spply) Lot# T �� N R Q E or
�1 or 2 Family Dwelling—Number ofBedrooms � /�--1 g Subdivision Name
r
Block#
❑Public/Commercial—Describe Use �
�Ciry of
�State Owned—Describe Use CSM Number ❑Village of
�Town of l/C�� ILJ�-'P
!
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. C6eck oae box on line B.Complete line C if
a licabie.)
A' ❑ New System �Replacement System g y ( p ( P �
❑ Other Modification to Existin S stem ex lain) ❑ Additional Pretreatment Unit ex lain
B' ❑ Holding Tank �In-Gmund ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Pre�ious Permit Number and Date Issued
❑ Transfer ro New Owner ^�
Expiration u y�1,[y���N /
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd�'s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �
� � � � ` , 5
� Capacity in Total #of Manufacturer
Tauk Information Gallons Gailons Units p � U � F � v
New Tanks Existing Tanks � o y � v L � �,y
o`. U �in m v� ii C7 Ci,
Septic or Holding Tank 5 J/Q L/� � `
`7
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assame responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) P►umb igmature MP/MPRS Number Business Phone Number
� � �9�3c� � ��S--sS����..�
Plumber's Address( treet,City,State,Zip Code) /
l�"� �v ��;n � � �c�.. Pa��c-- �. � �.�-�1� �.�-- s�c��
VI.Coun /Department Use Only
�Ap7p 1 ❑Disapproved Permit Fee Date Issued Issuing Agent Signatuie
�y�� '�71�wneCGivenReasonforDenial $ `��"� , ���(G �3 ,��`��,f'�V(/w„z
Conditio o�p roval/Reasons for Disapproval � � �.�,a,,, ��� �,
` � ;��.�_..__. �a� �a3 �.� -�-��� -�
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N�,
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E �-�IS ��
..hk# JUL 1 � 2023�
�-sT �-3- D�� ���t�_�3�r � _..�.._ _ _,
�AWY�R COI.+N�%
�����(�a�A[?MlNIS i riAll:;}P!
Attach to coroplete plsns for t6e system and submit to t6e County only on paper not less thso 8 li2 x I1 ioches in s¢e
�1 S�
SBD-6398(R.03/22) NO REFUNDS AFTER
ISSUE OF P'�RMIf
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): ���i�1G�-f"ti�J��-(,�1 6 l��� Phone: - -
Owner Address: `�5 �(��5�": �-� � Z�P� � ��d
Project Address: � �?N � r�? - �. `' W�
Govt. Lot: 1/4 of 1/4, Section_�(�, T�(�N-R�E❑or W �
Township: �';1.�"�� �d=-� County: �'Lc.�;�
Project Parcel ID #: �o�- � 3(c� b� 1(�0 a
Designer Information
Designer Name:�� �,��'� �2Z�'�C� Phone: ��S =?�1�73
Designer Address:� ��-�. . Z�P� ����
E-maiL- �_���'-� :� , ;,,
License Number: �����
Remarks:
� ._��.___.
Signature: j Date: 7���33
riginal signature required on each submitted copy.
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,+ Septia Tank(s)Manufacturer;
IN-GRC)IJNCJ GRAVITY C�l�PE6�S�L AR�A �1�:.��.1��.�.�,�-�,�
._..�„�.�.,.
Uni orrn El�vation Trenches with Gtuick4 �tand�rd-W �hamb�r� SepticTank(sjVolume(aj:
. 3�ft Trench (dovun-sizing credifi) �Q ��, � gQ, � ga� ����
Effluent Flltor Manufacturer:
G eN '
I �
� Effluent Filter Model#; r��'�� �- `'�
--min.12"
SOII,COV�R (lyplcol)
12��
min,tronch �
de th
�'yP�°°'> • °�' TYPICAL TRENCH
� J i' � �-� • � ''"�' ��< CROSS SECTIQN VIEW
r� ItYpical} ��a� .,, ,�°, ' �NO u�Cc'��G,
ti e� • e' �
• � � y Prov(dA minfmum 3 ft
System �levation =�� separation between trenches,
(tvni��i�
Qulalc4 Standard-W
w/�nd Cap (5how loc�t(on of inlet/outlet nipe connect(on on plan vlow,) �be�(typicaij��0 TYPIC�►L TRENCH
(typioal)
Instaii por menufacturers PLAN VIEW
Instruotlnna,
r��'������{����,.� ' r�..._ ._ _.. _. ..�.�., _ _. _ _ _. ._ ._ .,�� .�. .� � _ (No Scale}
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I a = � �� � ^� �
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(typlcal) Quick4 Standard-W Chamber G7
INSTAI�L PER TRENCH; (typ1°��� O
(mfd by Inflllrator Systeme,Ino,) •n
Insfal!pursuant tn monufaclurer's instructlnne,
' ,,.,,��,_ Qufck4 Std-W @ 20 fl� EISA/chamber= 2 2� ft2 .�.`a
+ .�,�, Palrs af end caps @ 6(�EISA/palr= y��, ft'
= Propased EISA ner trench= �;�,� ftz Required Infiitration Are�a= �� ft� Distribufiian Method:
x � trenches = Proposed Tofiai ElSA � ,�?E:,,�, ft2 s_N,Jc� ,
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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.
Furthertnore,all inspection and maintenance activities shail be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= /.�"Ci gpd; BODS<_220 mgL''; TSS 5 150 mgL"'; FOG<_30 mgL"'
Insr�ection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user compiaints,etc.)
o mechanicai 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 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 tank(sl 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 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 filterts)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 accordanee with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: �r�=�� Phone: /�S�S�'��07�
Local government unit: Phone:��—�J��—v�
Local govemment unit address:��i7�(� �}'�(llY1�1�� �L`�' ��y�� �IP: ��7'z�
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code.Repair or repiacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemicai or physicai restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Continqencv Pian
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 dispersal 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.
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� ������� i Hayward, Wisconsin 54843 �%� ��
��R Cp��� (715)634-8288 /G1J
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/ �'; ���—� ; o � Toll Free Courthouse/General Information 1-877-699-4110 � �� f
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STRqTY
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SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: �a � �-�a��y v, l�q i S-��
TOWN OF: �S$ � �
ADDRESS: � 7"(�N ��2v� �
1, � ` '• !�/CC- l.�iv> > � "� , a Wisconsin
Licensed Plum er, authorized by the owner, do hereb acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, and private sewage system plan review due to inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381 .01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date may result in the issuing of a citation, under Section 11.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR THIS MENT SHA ( 30� �ot 3
-- -_______
Signed: '< - �� �-• j��.
Date: �� �b ��.��--3
Accepted by: �
R / �� �—�
Date of temporary emergency approval: � 3 �l �a--�._
Rev. 03/26/13
;
, �""`�;;; PRIVATE ONSITE WASTE TREATMENT co�nty
,�iip �
- SYSTEMS Sawyer
;��Sps ,'r ( POWTS)
k ���,;
"�� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3- � �
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
E�.ah ���ro�r► I+�+;s-jiT (,�tss (s�(� �-
Insp BM Elev: BM Description: Parcel Tax No:
�DD .Q� Y� OT 5���/� O� ��..2IIl �a�' ���^(S3- ��OC�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � p� Benchmark ��,o �
Dosing
Aeration Bldg. Sewer g,o �
Holding St l Ht Inlet �(,�� '
TANK SETBACK INFORMATION St/Ht Outlet �6,6 '
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .F{o� .��5 � .��.p �-�o� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ��,o�
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative i
Surface �`��
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L �� #of Cells j Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �l ,
INFORMATION P/L Bidg Well Waters � G � Chamber Model Number:
❑ EZFIow
❑ Mound o Other
CELL TO �{-5 +-�r .{-S'a /�/ Y�
-- --- - --- - -.
DISTRIBUTION SYSTEM X Pressure Systems Only
g � 9 pO — p — X Hole Size X Hole Observation Pipe�
Header I Manifold Distribution Pi e s I
Len th Dia Len th Dia S ac � __ Spacing ❑ Yes ❑ No_ �
SOIL COVER
--- -
Depth Over Depth Over h of Seeded I Sodded Mulched
Cell Center � Cell Edges � Topsoil _ ❑Yes ❑ No ❑Yes ❑ Na
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
����I� ���g1�3
��-T �, ,�----
Plan revision required?❑Yes❑ No ,i p3 �� �, ZY�� ����'� � ��i � l�
�_� �__ J
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBEA:__�_� _ � ��__
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