HomeMy WebLinkAbout028-295-00-0900-SAN-2023-259 � �-`'" `�� � Department of Safety �O°°�' �
l \�_' � v` $1',1-`� & Professional Services, ry s aw f y Z
� Sanita Permit Number(to be filled in b G
, f ,�' ( �� Industry Services Division
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Sanitary Permit Application S[ateTransactionNumber �
(n accordance with SPS 383Z1(2),Wis.Adm.Code,submission ofthis form[o the appropriate govemmental unit �f,
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing adi �
the Department of Safety and Professional Services.Personal inforn�ation you provide may be used for sewndary
purposes in accordance with the Privacy Law,s. I�.04(I)(m},Stats_ �C��� (p� VZ ra�� ��
[.Application Information-Please Print All Information
Property Owners Name Parcel t1
a �- F�4t.1Yr� � 0��-195-00 dgo0,I o0 0,J�op
Property wner's Mailing Address Property Location •
O p Govt.Lot
City,State Zip Code Phone Number
Le r+�,�+-1 , � �- G o`+3 9 '�<, Y<, Section o1T
II.Type of Building(check all that apply) � T y� N R ^E o
I�I or 2 Family Dwelling-Number ofBedrooms 4 U�r,�5 C/�v �, Subdivision Name
7
,�(pt�s ca.►,�,e.y) Biock# 7-oTEn por,E c.a,�cE Go��
❑Public/Commercial-Describe Use Sss S��1 Te�i��
❑City of _----
❑State Owned-Describe[Jse CSM Number ❑Village of
�ownof ,SP:G�[� l.cc)�e _
I[I.Type of POWTS Permit:(Check either"New"or'•Replacement"and other applicable on line A. Check one box on line B.Complete line C i
a licable.
4 ❑ New System p y p )
❑ Re lacemen[S stem �Other Modification[o Existme System(explain) ❑ Additional Pretrea[ment Unit(ex lain
TanK R� laeew+t.��'
B' ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(erplain)
(conventional)
�=• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner '�st Previous Pertnit Number and Date Issued
Expiration �� -I 6 K� � �� ���!
(V.DispersaUTreatmentArea and Tank lnformation: �krw..�f-ee► 0'�.r� l�eCo-��d
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area ReyuireJ(s� Dispersal Area Pe�pese�{sfj System lilevation
�39 0.� 9 � a o� fix,s�...� 4y.s�
Capaciry in Total #of Manufacturer
Tank Information Gallons Gallons Units D � o v �
New Tanks Existing Tanks � o v � � D m c�'o
a U tin �, rr� a, .7 a.
Septic or Holding Tank �,S V S.an��� r
C�,�j U 3 W�C Br �r�u t�1 �
Dosine Chamber � S�j d �O � Rh3�'�s�� x'
V.Responsibility Statement- I,the undersigned,assume responsibility for installafion of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's.'� r� MP/MPRS Number Business Phone Numbe��
h�o► v; c a3o�3(0 7i�-G y - 71
Plumber s Address(Stree,City,State,Zip Code)
) �aaa s µw � 3 t�� u,..� a w= s�ay3
VL County/DepartmeM Use Only
�p Pernlil Fee Date[ssued Issuing Agent Signature
�Ap ro� ❑Disapproved _ -�I
��•V ❑Owner Given Reason tbr Denial $ 1�`� '� f � �� � ��"�'����' " ���
Conditions of Approval/Reasons for Disapproval �--�
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OCT 0 4 2023
r-. i ;�k#_�l�8 —
G�j� a3 � I � s SAWYER COIJi�TY
��` 3;��j�3 ZONING/iDMIhISTRATION
Attac6 to complete plans for the system end su6mit to the County only on paper nut less ffian 8�2 a I1 inches in size � ��� i�
hC R�FJN�S AFTER
SBD-6398(R 03/22) IS�,1C OF P'�R�f
�'�n.�� �s'
PAGE 1 OF 5
In -Ground Dosed -Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Pian
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): Phone: - -
Owner Address: Zip:
Project Address:
Govt. Lot: .1 /4 of 1 /4, Section , T N-R E ❑or W ❑
Township: County:
Project Parcel ID #:
Designer Information
Designer Name: Phone: - -
Designer Address: Zip:
E-171a1�: `� ,. _ r�.��cr�,�ed inr +tpj��rsrn�a �(ar ip.
License Number:
Remarks:
Signature: Date:
Original signature required on each submitted copy.
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ToTen po�E �,co�6 - u,�,Ts 9,�d,i�
}�LOT �C..I�1�N SEG. �g , T�I�N� tZOc. W
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DISCLAIMER:This map is not guaranteed to be �G
accurate,correct,current,or complete and �
conclusions drewn are the responsibility of the
user.
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 shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3),Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow = 639 gpd; BODS <_ 220 mgL'; TSS <_ 150 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 compiaints, 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 (r.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution ceii prior to dosing
o dosing irregularities - if applicable(i.e., pump re-cyciing, 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(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 W is.
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 local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be Geaned 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: R8y VISOCKy Phone: 715-634-1679 _
�o�ai 9o�e��me�t„�;t: Sawyer County Zoning & Conservation pnone: 715-634-8288 _
�ocal government unit address: 10010 Main St, Suite#9; Hayward, WI ZiP 54843
Any defective part of this system shall be repaired, rep�aced, 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 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.
SYstem Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
PAGE40F4
In-ground Dosed-Gravity Management Plan�
IMPORTANT:
The owner of this in-ground dosed-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 Operetinq Limits:
Design Flow = gpd; BODS <_ 220 mgL"'; TSS <_ 150 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(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(s) 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 Iocal government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: Phone: _
Local government unit: Phone:
Local government unit address: ZIP: _
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 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.
�""``"'`�<;,.. PRIVATE ONSITE WASTE TREATMENT county
�� � ����o �'` SYSTEMS
' Sawyer
�g�s ( POWTS)
,`�`.� ``--,./,;
lH""''- ',`' INSPECTION REPORT Sanitary Permit No:
"'\� (ATTACH TO PERMIT)
Safety and Buildings Division
GENERAL INFORMATION � 3 � � �
Personal infonnarion you provide may be used for secondary purposes [ Privacy Law, s. 15.04 (l)(m) ]
Permit Holder's Name: ❑ City ❑ Village � Town of: State Plan Transaction ID#:
�\ k �-��e�v►�'� 1av�. ;�.v- �1�— —
Insp BM Elev: BM Description: Parcel Tax No:
�oa.o' Jl�;,� ..� ����, �- L l k o� l�'�� �a8- �gs_ oo -o�oa.. .
TANK INFORM TION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ".1 � �ra l �.� Benchmark ��,o�
Dosing
Aeration Bldg. Sewer " °� q�, �
Holding St ! Ht Inlet qy •a �
TANK SETBACK INFORMATION St / Ht Outlet q�.,,9 c
TANK TO P/L WELL BLDG vE"TTo ROAD Dt Inlet
AIR INTAKE
Septic .}�` ,�. �oe� .�-lo` r}cd NA Dt Bottom
Dosing NA Installation
Contaur
Aeration NA Header / Man.
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Gratle
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � # of Cells Type of System Distribution Metlia Manufacturer:
SETBACK OHWM of Nav � Conv y,� Aggregate
INFORMATION P � L Bldg Well Waters °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO n Mound � Other
- - _ -- ----- — _ - ------_— __ _- ---
DISTRIBUTION SYSTEM X Pressure Systems Oniy
Header I Manifoitl Distribution Pi e s �X Hole Size X Hole Observation Pi es —
Cength Dia � Length pO Dia _ _ Spac ! ___ ' Spacing ❑ Yes ❑ No
- — — p _
SOIL COVER_ _ _
Depth Over �Depth Over 'I Depth of � Seeded / Sodded I Mulched �
� Celi Center Cell Edges Topsoif _ ❑ Yes ❑ No � ❑ Yes ❑ 'Vo
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?� Yes 0 No 1��3 � � 2� � � �
--,
I__ '�_ _ - ..� 6� 5� ��
�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710 (R.3l01)
AOOITI�NAL COMMENTS ANO SKETCH
SAMTAAY PERMIT NUMBEA: 23^ �'�
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