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Home My WebLink About024-641-24-2301-SAN-2023-309 � � Industry Ser�ices Uicision Count}� � -\^, �4822 Madison Yards Way SBWye� > � , SP - Madison,WI 5370� Sanitary Permit Number(to be tilled in by C ` : P.O. Box 7302 � ` Madison, WI 53707 �.s 1 �1 � � � — � Sanitary Permit Applieation S`a`e T`a°Sa`"°""°mbe` �,''� � o In accordance with SPS 38321(2),Wis.Adm.Code,submission of[his form to the appropriate govemmental unit � is required prior to obtaining a sanitary permit Note� Application fonns for state-owned POWTS are submitted to Project Address(ifdifferent than mailing add��,�� the Department of Safety and Professional Services.Personal infonnation you provide may be used for secondary 10766N Moose Lake Rd. Hayward, WI purposes in accordance with the Privacy Law,s. 15-Od(I)(m),Stats. I.Application Information-Please Print All Information Propem O��ner's Name Parcel# Brian & Deborah Rootkie 024641242301 Property Owner's Mailing Address Property Location 2800 Cleveland St. NE �„n o�,—{�— Cin�,State Zip Code Phone Number P`<<�1 Minneapolis, MN 55418 612-860-8021 sW ��"W '�, SeC11On 24 II.Type of Building(check all that apply) Lot# T 41 N R 06 E or W �Ior2FamilyDwelling-NumberofBedrooms � SubdivisionName Block# �� ❑Public/Commercial-Describe Use �City of �State Owned-Describe Use CSM Number �Village of �Town or Round Lake I[L T��pe of PO«'TS Permih (Check either"tie��"or"Replacement"and other applicable on line,a. Check one box on line B.Complete line C i a licable.) `�' New S stem Re lacement S stem ther Modification to Existin S stem ex lain Additional Pretreatment Unit(es lain � Y ❑ P Y ✓ g Y ( P ) ❑ P ) teel Tank Replacement B' �Holding Tank �In-Ground �At-Grade �Mound �[ndividual Site Design Other Type(explain) (conventional) C. �Renewal Before �Revision �Chanse of Plumber �Cransfer to Ne��O�rner List Pre��ious Permit Number and Date Issued Expiration N/y �`1� � IV.Dispersal/Treatment Area and Tank Information: , Uesign Flow(gpd) Design oil Application Rate(gpd/st) Dispersal Area Required(s) Dispersal Area (st System Elevation � 300�- 0.7 O.(o � �( 2q SZ� Existi + �'7 Existing $3.36 Capacity in Total #of Manufacturer v L',9 Tank Information Gallons Gallons Units � V v ? � •µq- Ne�r Tnnks E�istine Tanks y o ^.� ` � L `,�,' � a. U v� � cn [,. C7 0. Septic or Holding Tank 750 75� 1 Wieser � � Dosing Chamber � � � V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature � MP/MPRS Number Business Phone Number �ason Kuettel �,�� ; 675751 715-798-3355 Plumber's Address(Street,City,State,Zip Code) - ,' PO Box 66 Cable, WI 54821 e VI.C unt�/Department�'se Only �A�� ❑Disapproved Permit Fee Date Issued Issuing Agent Signature l� �l/� �,(i� ❑O�cner Given Reason for Denial $ `�O'� 'i I�` � `�:j 5 f�� `" �f Condif ns�A p oval/R�e�o�for Disappro�al — �, . -- � i� � �-��,a 3 '-~ �`�.' } ^�',`�- ' .� , �� . �._ + W �r� � �.�� I�t� 23 � '� ... r ��' � . �. � �_��. � ��?�' � � :��2� , 3�� _.---- _--____._..---- GS`��- � � �-13 � � 1':J1�<i��r�: � ! Atfach[o comple[e plans for Ihe system and submit to the County only on paper not less than 8 I/i s 11 inches in size aN�� SBD-6398(R.02/22) P�O f�'e�FU�'�J�A�r Tt'R t�SU�OF h''�RNlT 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 Rootkie Tank Replacement Owner Name(s): Brian&Deborah Rootkie Phone: 612 _860 _8021 Owner Address: 2800 Cleveland St NE. Minneapolis, MN Zip: 55418 Project Address: 10766N Moose Lake Rd. Hayward,WI Govt.Lot: SW 1/4of NW 1/4,Section24 ,T41 N-R06 E❑or W❑✓ Township: Round Lake County: Sawyer Project Parcel ID#: 024641242301 Designer Information DesignerName: �asonKuettel Phone: �15 _798 _3355 Designer Address: PO Box 66 Cable,WI Z�p: 54847 E-mail: tim@andryras.com License Number: 675751 Remarks: x� Signature: —'"F�" Date: ,i/��Li� Original siq�at re required on each submitted copy. , ��" D c.v v�e.v' : -- � / Le�: �C�4v` � . ( �el�o�!'c�0'1 fiC�{ RpoL ��e. Sc'cwla.crCa,P GZavvt� l-a �e c�� 1 � aan �c ��a� � s-r �� N oz�_ 6�r_ z� -. Z3do I'V�c '"t�l e� �a ci s , M �1 Ssy 1 g Sc��/N c� 5' z� T' �F� ►.� 20 ��v (o ( Z - S6� - �bz� s��e : I b7b6nJ M oose L.Q-ke fZ.li- -- 4t�oo�. c,ak��— � - �; �� .�--- � z�o' i d � I �--� SG�I� l`_ �fo� �,� day roo�, �. o �u �!1 30 V O � �'3Y � ♦ sn�oo l��'i'Qryt o� 3 . � � . � $e9j Ew DvJ Gorne�c-bc�a� � 56 �.°onnLE-- a d . a � . 8?.3�t � 2 y � �3 z. �a9', 3y ` 8��. W�t�tll 7 so w/ o�t.t.r�c.o 3_ 8 e. $7 . ��1� RN .,N�� _��r�.� , (o So;� s 8 � �1'fenclt l v ��e�,-- 86` $�,00 Tre.��Z �u,c �- B�ES � �x 3b� � s i � r� � q 3.�y . � �� ga�� r��-�o�, �Qk ;, ��-- r��„ � z� � � � t � -- ls� 16 -z3 ' p �P 0 �° �. � �.t>�-� � MP (o� S'7S1 11 '1 L �'Z7 �U � -' �#' �o�bb� � ,�� 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 Operatinq Limits: Design Flow= 300 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 dishibution 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 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 local government unit in accordance with SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to: Name of individual or company: Andl'y RaSI1lUSS@Il H�SOns, IIIC Phone: 715-798-3355 Local government unit: SaWy2f COUllty ZOnlllg Phone: 715-634-8288 �oca�9overnment unit address: 10610 Main St.#49 Hayward,WI Z�p 54843 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. ContinqencY 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 353.33,Wisc.Admin.Code. _-__ °''�' " PRIVATE ONSITE WASTE TREATMENT county > '��o SYSTEMS `, ,,�SPs _ ( POWTS) Sawyer kv �j r! '"v� INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION 2�,-3p`� Personal infonnation you provide may be used for secondary purposes[Privacy i.aw,s. 15.04(1)(in)] Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#: .��,��, �- ►Q.�-��, �.,� �. R�� l� � insp BM Elev: BM Descriptio�: Parcel Tax No: (Oa.o` ��'�n, �'G aw��u� �tir c..� �r Oa�_��l(—�Y-•�3� 1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �,�„ef.�- -Z Benchmark �pp�p� Dosing Aeration Bidg. Sewer �(�,q� Holding St/Ht Inlet ��, ' TANK SETBACK INFORMATION St/Ht Outlet � TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet AIR INTAKE Septic �-�.,5 .}�� ,5'" �� NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. �(,2 ' Holding Dist. Pipe PUMP 151PHON INFORMATION Infiltrative 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 �N L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav Conv ❑ Aggregate INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber Model Number: ❑ AG ❑ EZFIow CELL TO ❑ Mound q� Other � � -- ----- -- ___ __— — -- _ __ --------- - DISTRIBUTION SYSTEM X Pressure Systems Only �eader/Manifold j Distribution Pipe(s) �Hole Size X Hole Observation Pipes j Length Dia LLength Dia _ _ Spac � � Spacing ❑Yes ❑ Nc � SOIL COVER ------ -- — - - — --— - — Depth Over Depth Over Depth of Seeded/Sodded Mulched Cell Center Cell Edges Topsoil__ ❑Yes ❑ No � ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��s�(1��, t2-(�3��3 �F 5-�, ,,-c� ,o,,t.� �( -ex:�� , 1��.! _�i ! �- ; I Plan revision required?❑Yes ❑ No jo3 as��-`"� � � � � _ _ II G`� �� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITIONAL COMMENTS AN� y�KETCH SANITARY PERMIT NUMBER' 23 '' d 1 c�— UI�� gl� �- --.__ , . . �'�4�° . � , �� J � De`'� fi�.S� / � \ � �� 7�IL �G� � � � ��5 �'� �� . �� 6� . w �oS- P �� 6� �.� �-��. � . 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