HomeMy WebLinkAbout010-941-28-4207-SAN-2023-221 _ �'' ° Department of Safety c°°"�'� �
- � ' _ & Professional Services, �
� t = Sanitary Permit Numb to be tilied in by�
�_ , Industry Services Division �
C�S I l� � � �,,�
,_ ___ ,
Sanitary Permit Application s`a`e T�°��''°°N°"'b�� �
ln accordance with SPS 383?1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit � �
is rcyuircd prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffcrcnt than mailing ac
the Department of Safety and Professional Services.Persooal information you provide may be used for secondary �Q �L-•a�..�
u oti�,�in accordanee with the Privac Law,s. 15.04(i m Stats. ����` � �� �K� ��
P rP ='= Y )( ), I
I.Application Information—Please Print All Information
Properly Owner's Name Parcel#
` , �I� . 4l4 -�g-yao7
Property Owner's Mailing Address Property Location
Govt Lot
City,Swte Zip Code Phone Number �w �� ��
5��+�, , S E ,/.,_�_—'/,, Section
II.Type of Building(check all that apply) a`� Lot# T� �� N R �� l�or
[�l or 2 Family Dwelli�g—Number of Bedrooms Subdivision Name
Block#
�Public/Commencial—Describe Use
❑City of
❑State Owned—Describe Use CSM Number ❑Village of
� U+ /. � ;7�.��1 �,Town of ���
p )� t Gr
iii.Type of POWTS Permit:(Check either"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 g y ( p )
❑ Other Modification to Existin S stem ex lain ❑ Additional Pretreatment Unit(explain)
�' ❑ Holding Tank � In-Ground ❑ At-Grade
❑ Mound ❑ Individual Site Design Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permit Number and Date Issued
❑ Transfer to New Owner
L;xpiration �� ,� Y�6 �� '7 a ODa
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Reqoired(s� Dispersal Area Proposed(sfj System Elevation
/
��so � o � s� �
, Capacity in Totai #of anu acturer
Tank Information Gallons Gallons Units � � o � �
New Tanks Existing 7anks � o � i y .o � ca
n. U �n v, cn w :7 G.
Septic or Holding Tank ��r��� b � E/ �
i
Dosing Chamber
V.RespOnsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached pians.
Plu ber's Name(Print) Plumber gnature _ _ _ MP/MPRS Number Business Phone Numbe-
Gt,VI S -- � ��30/ 7l s-s��'r—Ilo�3
Plumber's Address(Street,City,State,"Lip Code)
d 57/ I�l-T �a,�k- 1�. r� �E .3
Vl.Co t /Department Use Only
�Ap � ❑Disapproved Permil Fee Date Issued Issuing Agcnt Signature
� $YOo.°� `� 1� ��3 ���-z�-P-r'-��+�.�
C3 Owner Given Reawn for Denia]
Conditions of Approval/Reasons for Disapproval � '����;; .�
�` �� � �,
� ;--:,..y� `� ? �3 __ �
!��i�G I �� .�,a«�___�_. - 6 2023
L 0
<.n�,k#_��q s _ _ SEP
C� �3 " ��� i�^�t�. -_��a3� — _ SAWYER COUNTY
zpN1NG ADMINISTRATION
Attach to complete plans tor the syslem aad submit to the County anly on paper not less than 8 t!2 z 11 inches in size � a�—�(�
�
��!7t_i-�f`iVCt r1+ ��1"1
SBD-6398(R.03l22) I$.�'3�.1�QF(��j"
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 2I'1,�P �J, � TOC� S, �.l Phone: - -
Owner Address: f,'�,�(p7 ,l.�.(��C�117Q.i'z�Q., uJL Zip: S`-�$'��_
Project Address: L��,� w ��,5 !-�W U r0� �C-1 l�rZ�
Govt. Lot: �,� 1/4 of�_1/4, Section v� , T�N-R O�E Q or W �
Township: L� �u��'� County: �Q�(.���
Project Parcel ID #: 0 � � " -l'1�.. �-�f—�oZO�
Designer Information
Designer Name: l.�/1.1�1., ��"��X Phone:7� -S�-1f�J3
Designer Address: � Z�p� �����
E-mail: u�Qi'�, w'�
License Number: ����
Remarks:
Signature: Date: ���a'-�
Original'signature required on each submitted copy.
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'' IN-GROUND GRAVITY DI�F7�RS�lI.., A�F'�EA _ ��� e ���nk(s) Manufaaturer:
U niform Elevafiian Trencf�es with Quick4 Stand�rddU10 Chambers Septic Tank(s) Valume(s):
, 3-ft Trench (down-siZing credi�} ��.�g�� � ga� .�,�„ ga� � ���
�ffluent Flitor Manufacturer;
� � �
�ffluent Filter Model #; ��� 2�
� min, 12"
SOIL CQVER ��yp1°°��
12"
min, trench
dopih
(lyplenl) `� �: d �� TYPICAL TRENCN
1 ' �a ' ''d ° CROSS SECTIaN VIEW
. �r 1�7p�C0�� ;�4 � 4 •� � t � (No Scale)
�� � 4 V
• I�rovide minimum 3 ft
System �levation = 9��t separation batween trenches,
�tYPical)
G�uicl<4 Standard»W
W(fyplcalj p (Show location of Inlet / outle! nipe connectfon on pi�n viow.� Obse�typlcal) IP� TYPI�A,L TRENCH
Inste�l per manutacwrore PLAN VI EW
Inetructlons,
(No Scale)
I ' ���,����,��SI �' ���_ y�� ..�. .��. .r. �� �.� ...+.� ��. �. �.�.. .�... �. ..../� .`. �r �...� ..."4���� YT'ti � N,Rii � "'�^R l� i'S�r. 1 I
Y � fJ� � _
t�:. ^` � ` �� �`�f:��it�� '' - ��,� ;I��l ll��a � �i ,., 1, �"( � �I��i�; �
�y�,¢ ,pGr � a, ���� � �f '� I� I . i� , �i� �i �� ' � A = 3,Oft
Fl� 7H��b� �:'f'� .:_.. Ja i �,
� _... .._ _._. .._. ,_., �� _... � .` ._.. � ._ _ .,�� .,. _... ..._ �i�� ab�t9 8,����,u li�.i� i.�,��¢.sh�'�;4ef�� � �tYP�cal) �
� , B ....�L.l�L.... �� �
(typlcal) I m
Qulci<4 St�ndard-W Chamber t�
INSTALL pER TRENCH: (typi�ai� (�
(mfd by InflilratorSystems, Ina.) �
T „o,„�,�.,�„ WuICk4 Std-W � 2p fl� E15/�/Ch�111be1' = �;Z d it` Install pureuant to menufaolurer's instrucllans, �
+ ...,.,�,.,�, Palrs of end caps @ B ftx E15A/palr = �,�,,,,, ft'
= Proposed EISA per trench = ,2„Z,,,�,�„n ftx Requfred Infiltratinr� Area = ,��� ft1 Distributian Method:
x � trench�s = Propnsed Tot�l EISA � ,���Oft2 �,,,�;�,� m.s., ` / ,
4� �,`� "�"°. �
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 heaith hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance adivities shall be performed by a registered POYVTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disoersal Area Oaeratinq Limits:
Design Fiow= ��D gpd; BODS<_220 mgL''; TSS 5150 mgL''; FOG 5 30 mgL"'
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,eic.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatmeM 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 specificatlon)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checkiist MAINTAIN EVERY 3 YEARS(or when necessary)
o Seotic and dose tank(s)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 filter(s1 shaii be inspected every 3 years and shall be cieaned 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;��(,���,{� Phone:�J�S�5����0�
Local govemment unit:����r1,�'(,� 7/J�� Phone: �I�S�(o3<-f— �So��-S
Local govemment unit address:� �(� '�'t , �� �jAj�_Lp�tP: 'rj��L�
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.
Continqencv Plan
in the event that any failed treatment component of this POWTS cannot be repaired,it shaii 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 soiis.
Svstem Abandonment
If use of this POWfS is discontinued,it shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
�"'�"'^ �r:, PRIVATE ONSITE WASTE TREATMENT County
=, ��o�p ,�; SYSTEMS
`�,�, � s _ ( POWTS) SaWyer
�i%4� L__/�•.,
"�'''''"'"" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �-� �'�2- l
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(in)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
D;�.fi1�� � H4Y�a� —
Insp BM Elev: BM Descr' tion: Parcel Tax No:
(Ob�� ' a � �I`�w,jh,, �.a� ,s��1 �10 '9Y�—�$���c�7
TANK INFOR ATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic „„ieyzr Benchmark (00,o �
Dosing
Aeration Bidg. Sewer 9'� Q r
�
Holding St/Ht Inlet 9?,p �
TANK SETBACK INFORMATION St/Ht Outlet c�6.-� r
TANK TO P/L WELL BLDG vENr To ROAD Dt Inlet
AIR INTAKE
Septic .�..�� � 8` ��p� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q 6.j'r
Holding Dist. Pipe
PUMP/51PHON INFORMATION Infiltrative
r
Surface �S•S
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 �N L t(y yf,� yy� �#of Cells�` Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate
�
SETBACK P/L Bldg Well OHWM of Nav � IGP � Chamber '�'� '
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO � ❑ Mound o Other
�(-S _ _t kSb
- � ---- ---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) � X Hole Size ,X Hole Observation Pipe�
Length Dia � Length Dia Spac 'I I Spacing ❑ Yes ❑ No �
—
SOIL COVER
_-- --- --
Depth Over Depth Over � Depth of Seeded I Sodded Mulched
Cell Center Cell Edges Topsoil _ __ 0 Yes ❑ No ❑Yes ❑ Vo
COMMENTS: (Include code discrepancies, persons present, etc.)
����l�f ���3��3
Pian revision required?❑Yes❑ No I�3 (� 2� �� ,
�
1 � � _ __ , �� �(�
_ -
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITAAY PEAMIT NUMBEA: 2 3��•2 I
�'
N,�Y.
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