HomeMy WebLinkAbout010-841-29-1302-SAN-2023-196 _ ''' """`�' Department of Safety c°°"ty� �
� • - & Professional Services, �
� , �� -� Sanitary Permit Nu •(to be filled in by
,,, `., ; ; Industry Services Division
,.,,. �w'�" Cv � I C�r`i � �
Sanitary Permit Application State Ttansaction Number i
In accordance with 5P5 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit � .S
is required prior to obtaining a sanitary perniit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing a �
the Deparhnent of Safety and Professional Services.Personal information you provide may be used for secondary �p 33 y,� ����,�
purposes in accordanee with the Privacy Law,s.15.04(t)(m),Stats.
I.Application Information-Please Print All Informalloo ��
Property(hvner's Name Parcel# �/Q r Q+/�/�.�/3� r,��
M/d/ � U '7 i v�/ �
Prop Owner's ail' g Address Property Location
ay s � �-�'� �- �o�t.�or
City State Zip Code Phone Number
(�/�"�' �C.�.�f/ �'/., /Y's� '/,, Section�_�
....`j� Y `1 u
II.Type of Building(check ali that appty) Lot# T 7� N R a E or
,l$1 or 2 Family Dwclling-Number of Bedrooms Z. ' Subdivision Name
t3lock#
�Pablic/Commercial-Describe Use
❑City of
❑State Owned-Describe Use C3M Number ❑V illage of
a i//S� � �bo� �o.�of �,._.?�
III.Type of POWTS Permit:(Check eitber"New"or KReplacemeoY'and other applicable on lioe A. Check one box on line B.Complete line C if
a licable.)
A.
�,New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(expiain)
B.
❑ Holding Tank �In-Gmund ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain)
(conventionaq
C• ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner �st Previous Petmit Number and Date Issued
Expiration r--
IV.DispersaUTreatment Area and Tank Informallon:
Design F'low(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s fl System Elevation �
�� � � �` , s�
Capacity in Total #of Manufacturer
Gallons Gallons Units a o v �
Tank Information ,o �
New Tanks Existing Tanks � o � � � p � �
a U 'ri� �, v� w :7 p,
Septic or Holding Tank �7�-�,� /`a ( �� �, � �
! J
Dosing Chamber
V.Responsibility Statement-I,the undersigned,assume responsibility for installallon ot the POWTS shown on the attached ptans.
Plumber's Name(Print) Plum 's Signature MP/MPRS Number Business Phone Number
�" 4� �S''
Plumber' ddress(Street,City,State,"Lip Code) �
N ��z� �a��- � - s�
VI.County/Department Use Only
�Ap ❑Disapproved Permit Fee Date Issued Issuing Agen�5ignature
$ �� ��a, ��_3 -�,�_.tt.�.��f-f�r,�-:
. ❑Owner Given Reason for Denial '
Conditions o'f�Xpp'roval/Reasons for Disapproval � � �; �'f �;,
D �I����1 --�
, ������ '� � �ate 8 �t �3__�____.�� �.._.._
- �� -�.- � -.- --� ��,k# ��� AUG 18 2023
C s �" � � � � r:�:�t#R_^�'l I l� .� SAWYER COUrITY
� ' Zp�NG ADMINISTRATION
Attac6 to complete plans for e system and submit to the County onty ou paper not less than 8 t/�x ll inches in s¢e '�u n O
-1-1 0
h0 R�FUN�S AFTER
SBD-6398(R.03/22) I�SUE�F PERW11 f
PAGE 1 OF 4
In-Ground Gravity Pian
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 Dispersai Area Cross-Section& Pian View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map
Project Name!Description
Owner Name(s): �1,0�� L �Q/'I,C Phone:
Owner Address: �a� 1ti1 �j ,[ (Z� ��„p 4�ip; Jc���
Project Address: /Q_3�� 1�-�2a,-C�t�rm Tr 1-�-�i�i�1��r--�
,_�.____r.�„
Govt.Lot: �1/4 of ,la.�1/4,Section�,T_�N-R 0� EQor W�
Township:�,��(,�,�-�/� County: �ju,o,/'
Project Parcel ID#: (��O- S y�- a4- �3 o a
Designer Information
Designer Name:�1.�.(1,� �j�y�( Phone:�-5,��.�
Designer Address:� -]' Z�P: �'j C�g�i 3
E-mail• �`� �._ _
License Number: �gp 30�
Remarks:
-------�__
Signature: `� � �ate: �'�7��3
� �i inal si nature required on each submilted copy.
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'� �N-�ROUND GRAVITY DI�C'ER��L AR�,� ��`�����nk(s)Manufaaturer;
� ..��. _
Uniform Elev�tiar� Trencl�es with Quick4 �tand�rdwW Chambers SepticTank(s)Valume(s):
3�ft Trench (dawr�-sizing credi�) �s•r� g�+ � ga� �, ga� .�.�e�
�ffluent�Iitar Manufacturer:
�� � /
N_H r !'• ��i7•— Tr�l�Y
- r r.�..�.,wr�
. I � �G...i��6:i�
` Effluant Fllter Model i�; � ��
• ! � min.iZ"
SOIL COVER (lYplaaq
1?."
min,tronch
dopth
��yPi°°'� �� 4 ' TYPICAL TRENCN
� ' �Q � ' A'4 ° CROSS SEC71�N VIEW
�`—`itvp��� °4� '° �. � �. (No Scale)
~ 4� � d
• Provide minimum 3 ft
System �levation =,�� separation bakween trenches,
(tv�iC�i>
Gtulolc4 Standard-W
w/�nd Cap (Show location of Inlet/outlet nipe connectlon on plan vlew.� pb�e(typlcal) ip� TYPICAL TRENCH
(typfcal) Instell pet nianuPacluro�'s p�.AN V)EW
Instrucllons. �NO 5'Cc'��@�
�� � .�. � ����, ,. ..... _.._ ..��. _.... _.._ ._._ ._.., ,. ._.. ..._. ..�/� .__. ...... ;;��F�`�l�'���t1 G�'�4t�4�4' �� ;�'1��
��i�',�.t��e���t�f '�t, �� �i�� i:li,a'c��'il�ll�Iliili�l+ ���d���������li�``� A= 3,pft
�����Ti; pl�_... .._.. _...� _._. .._. �.. .._. _... ..r ...._ _._. .� _.. ,_,,, _... <� ����,���'����t�'��ti��t'r�V������tlD:�',"i�;sti�� ��YP�cal) �
_ --.. -- .�'f- .��-- — ._._. __ _ .__ ._ ._._ _� �
I o = ��.. �� i m
(typlcal) Quick4 St�ndard-W Chamber W
INSTALL PER TRENCH: �typ�Qa�� C7
(mfd by Inflllrator Systams,Ino.)
Inetall pursuant to menufaafurer's instructlans,
�= ,,,�,�,,,_„ Quick4 Std-W @ 20 f�EISA/chamber= 2 O ftz .p
+ ��, palrs af end caps @ 6 ft2 EISA/pair= ,_,,,,.,,�„ ft2
=Prapoaed E15A per trench= 2� ffiz Requlred Infiltratlnn Area= -� � ft1 Distribution Method:
x „�,,, trenchos = proposed Tatai EISA = �s�2 ft2 /� �QH�` ��� ,��
���
PAGE 4 OF 4
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 Disaersal Area Operatinq Limits:
Design Fiow= �d�`J 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 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 boxesj
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 Seotic and dose tank(sl shail 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 filteHsl 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 accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company: ��.Y1 ��hY�'LU LL+ Phone: ��S �SS���73
Locai govemment unit: Phone: ��S�3�L'�p o2 '�
Local government unit address:{� �� � �� : S�g�c�
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 in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitabie soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
�" "`"`�- PRIVATE ONSITE WASTE TREATMENT co��ty
����o �� SYSTEMS
�"� s� ���; Sawyer
,:,,`l s v; ( POWTS)
��,h�`�--t�>
"`F INSPECTION REPORT Sanitary Permit No:
.�s.,,<,�,,�,
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.3 _ � �(�
Personal infonnation you provide may be used for secondary purposes[Privaey Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
��l G 6 �� r�G --
Insp BM Elev: BM Description: Parcel Tax No:
���' �C S� �. � �oa-r' Olb —�(� ��q —(3Q�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �„��e�s-- � Benchmark (p�,��
Dosing
Aeration Bldg. Sewer --
Holding St/Ht Inlet �7,� �
TANK SETBACK INFORMATION St/Ht Outlet .�j '
TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet
AIR INTAKE
Septic .}�` ,{�a,p fi ,� �-��� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 46.9 �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative S� �
Surface �
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS W � L �{y/ tl� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � �
INFORMATION P/L Bldg Well Waters � GP p� Chamber Model Number:
❑ EZFIow
��-� '+'i0o ❑ Other Q Y�..
CELL TO �od _ _ ❑ Mound
- -- - - - -- - -- ---- _ __
DISTRIBUTION SYSTEM X Pressure Systems Only
----- - - ----- - - -- ---
Header I Manifold Distribution Pipe(s) X Hole Size � X Hole Observation Pipes
Length Dia Length Dia Spac , Spacing ❑Yes ❑ No
--- --- ---
SOIL COVER — --- ---- -- -- ----
— - ____ _--- - - _ _
De th Over De th Over , De th of Seeded/Sodded Mulched
P P P
Cell Center Cell Edges j Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
`����� (a�� a3
l
�3 �� �_ � �
Plan revision required?�Yes ❑ No i � I ' G� � � �
L---� L_ —�/-1'-�- -- --__�
Use other side for additional information Date aaa-� POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: 2�— (�� __
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