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Home My WebLink About002-940-25-5303-SAN-2023-162 _°' �"'"`� Department of Safety cOII°ry�� -r� � = & Professional Services, Z =� �;� Sanitary Permit Nu (to be filled in by Co.' ,, ; i Industry Services Division -�;�,,:,, . ��'�\ t� S i o�'� � Sanitary Permit Application s`are T�"�°`'°°N°"'be' �' In accordance with SPS 3A3.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit �' � is required prior to obtaining a sanitary permii.Note:Application forms for state-0wned POWTS aze submitted to Project Address(if different than mailing addnn � the Department of Safety and Yrofessional Services.Personal information you provide may be used for secondary �7 ��1 ��,, ( ( /� purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. � /�Q W I�`�� `�'�� I.Applicallon Information-Please Print All Information � Property Owner's Name Parcel Q' ,� ` � ..�- ppo2--��Q ... a„�5303 Property Ow�er's Mailing Add�ss Property Location ��1�O V� �Q.O1.� �o�t?� Ci ,State Zip Code Phone Number W(.G� (J�t W� .J I�V ��/ /�� IlJ3'�y"-3�j/� ( Dar. �Section� II.Type of Buildiag(check all t6at apply) � Lot tt T `l 0 N K �7 E or _�l or 2 Family Dwelling-Number ofBedrooms I�� — Subdivision Name . _'_ Block# ❑Public/Comme�ial-Describe Use ^ ❑City of ❑State Owned-Describe Use CSM Number ❑Viliage of `� �Town of�j}��__ 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 ❑ Replacement System �Other Modification to E�cisting Systetn(ezplain) ❑ Additional Pretreatment Unit(explain) �-c*� �cz�. /C B' ❑ Holdin Tank g �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) (conventional) C ist Previous Permit Number and Date Issued ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner Expiration 7�� I/ �7 t q 0 .�� O / 0 IV.DispersaUTreatment Area and Tank Information: T k Design Flow(gpd) Design 5oi1 Application Rate(gpd/st� Dispersal Area Required(s� Disp , Arca Rse�se�(s 5y m Elevation .s`v _ �� _ .,� s- apacity in Tohal #of ct er , , Gallons Gallons Units �07�3� °' � b Tank Information ,a i v � � � � New Tanks Existing Tanks � o e; � � p � � i U �n m �n u. C7 fi. Septic or Holding Tank � /�Q � � s, �✓. y /` Dosing Chamber V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW'I'S shown on the attached plans. Plumber's Name(Print) Plupb r's Signature MP/MPRS Number Business Phone Number � , ' � _ .. - ---� "7 Q I '15—��'-1jv73 Plumber's Address(Street,City,State,Zip Code) ��7 d N �T � `" � ��Q �arl�-- I�� -� J�� VI.Coun /Department Use Only �A � ❑Disapproved Permit Fee Date Issued Issuing Agent Signature , ❑Owner Given Reason for Denial $ ��•a a � I��3 �j�'��"`�`�-/ ,"wL�a" Conditions of ApprovallFZeasons Cbr Disapproval D ,,,�. � � , _:.��.. ...: ��"� � ( �&,;� �� 3.� JUL 2 6 2023 � � � �6._3�i.35 �, ,.� - 2 ,:-- r�#_ Ma.3�7�-1 _._ SAWYER COUNTY CS� �J� I � � ��y ZONING AD�IINISTRATION Attach to complete plan�for the system and submit to the Couoty only on paper not less than S v2 a 11 inches in size �� l0 R�FUN��A�TER SBD-6398(R.03/22) �;��1E 0�P��M1T PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manua/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):�Cl,� �`0��. �IrIX-`7�" Phone:' ��S -�� ` �� Owner Address: � �-f'�l� (� (�-��CX �`� �� UL��P� 5� 3 � Project Address: ��> Govt. Lot: ,� 1/4 of 1/4, Section�_, T�N-R�_E Q or W � Township: % � LLl.� County: G�'U�� Project Parcel ID #: �C�'`� �`�� J "��D � Designer Information Designer Name: ��!��1 . Phone:��>�- �� Designer Address: � 'Y� �C��-� Zip: �J �� ,,; E-maiL• License Number: �7�'O�� Remarks: ------_ Signature• Date: 7��'�� gi I signature required on each submitted copy. o��er : 1.��• Pa 2 Tf V S T.._.— sG W�►Gr 1.3� •1 �cc..5 S �.Gc�G _C'w�. l (4��w ��ll,c�,r�� Lr �!N : DOZ--a�O-- z$.... 5303 4-t-��,v�� ,�1 s`��`�3 Go� I�-3 � �` rt"�4o � Ro�Tw ��5-- 63�f-36'76 _ . „'- G r�n�.s�-o ne ��e ,` �_ �� t�� --�.� '_'� 5��2 ["=40� loo� � � r � e tp 30 � y� . 1 t��tao,.5w Corrte� bo4.r�- bo�o� � B ( . a�,iz� �.(,, �, � x�s�:h S S T ;,,� {-�t� �� I �� x�'sf�� s.�sf el. �r5.24 �.r _ � � �-a.kt �1��. � �' ..._,_. �_. v�' Du.K � c,,t _ � �- � a ,,jell _ _ " �N�oo _.... _.:_.___ :..._w .._.;.� ,._...... .._. ___� _...,._ ._.__,a._., o � _ _ � - � �x � p _ _ 5��= �� _,._ _ . ,:, .. _,.... , _ _ _ _. i�¢"� � �� f 81 �5(�e� . ...._._ .._..�_._.. � _ ., � _ _ _ _ _;_ _ � .._....�.�.. �. ►� ►a u3 � f l I�� . �� is �'^ 7 l0 '`3� _ . ��,1"' 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 Dispersal Area Operating Limits: Design Flow= ��%� gpd; BODS 5 220 mgL"'; TSS 5150 mgL"'; FOG<_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 specification) 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(sl shali 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(113)the liquid volume of the tank(s)or as required by locai ordinance. Disposal of contents shall be pursuant to NR 113.Wisc.Admin.Code. o Effluent filterls)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 aiways be greater than 12 months. System maintenance reports shalt be submitted to the proper local government unit in accordance with SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to: Name of individual or company��1/!'-n. .3�1� Phone:��G'�� Local government unit: , Phone:��.�—(J�'f �� Local government unit address� �(� ��u'��iP:��I�`�✓ — 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. Continaencv 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 inyround dispersal component may be abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils. SYstem Abandonment If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code. "�"T:'-'"�:�, PRIVATE ONSITE WASTE TREATMENT county ,'_;� � � SYSTEMS Sawyer � � p$� r �'��__s >; ( POWTS) ��""''-'='-=��s? INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) r GENERAL INFORMATtON � �-- � b a Personal infonnation you provide may be used for seco�dary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Vil�age [�Town of: State Plan Transaction ID#: �GV 1e�� `Tc�,.s � Qass �� insp BM Elev: BM Description: Parcel Tax No: � 00 ��` 5w c��,�-�o� (��"^,, �� . r�� - ��to -��=�3� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic w;��...� �� Benchmark (cp C,r Dosing Aeration Bldg. Sewer - Holding St/Ht Inlet q(o,Y� TANK SETBACK INFORMATION St/Ht Outlet 6 � r TANK TO P/L WELL BLDG vE"TTo ROAD Dt Inlet AIR INTAKE Septic ¢�� ' t ` f I � NA Dt Bottom fi Dosing NA Installation Contour Aeration NA Header I Man. Holding Dist. Pipe PUMP 151PHON INFORMATION Infiltrative �3 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 Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate P/L Bidg Well ❑ IGP ❑ Chamber — INFORMATION Waters � EZFIow Model Number: ❑ AG CELL TO ❑ Mound o Other -- — — -- -- __---_ _ - ---- -- - --____ DISTRIBUTION SYSTEM X Pressure Systems Only - ---_ _ _ __-- - _. Header/Manifold �Distribution Pipe(s) X Hole Size X Ho�le Observation Pipe� Length Dia Length Dia Spac �� Spacing ❑Yes 0 No —__ SOIL COVER — - — _— - Depth Over Depth Over I Depth of Seetled/Sodded Mulched � — --- Cell Center Cell Edges , Topsoil _ �❑Yes ❑ No 1 ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) �-�.��C�Q g<< ��-� � �i - ,�-��j'o�,� ;o t� _—_ .- - - Plan revision required?0 Yes ❑ No �L�� i ! � ' � � � �I �_ � � �� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) ADDITIONAL COMMENTS ANO SKETCH SANITARY PERMIT NUMEEA:______�_�'_I(Q_�__ _ '�- ��s�..-�. C.,� � D�.��, �6�,� . .__ . _ � � � , _ �� ` �,��°� , �' �� ,q,, , � �,,�^ • � ,, � �� 6 �� P�� !/Y , � �g-�` ---j �� 1 ¢'`'''��I is� I � � �� aa5� \� �� G��` � � -,� ,