HomeMy WebLinkAbout024-741-09-5404-SAN-2024-030 '`� " `%,, Department of Safety c�°„`Y �
� � `�`� S a w e�'
; o �=' & Professional Services Z
I'I S� ' !_� � Sa��itary Pemtit Number(to be filled in by C
� '�� � Industry Services Division
'k ` ,,�� �oSl �la� s
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State Transaction Number �
Sanitary Permit Application n
In accordance with SPS 383.21(2),Wis.Adm.Code,submi;sion of thi,fonn to the appropriate goven�mental unit �—' �
is required p�ior to obtaining a sanitary pein�it.Note:Application foinis for state-owned POVdTS are submitted to Project Address(ifdifferent dlan mailing adme,;�
the Department of Safety and Profcs;ional Services.Personal infonna�ion you provide may be used for seconda�y
pu�poses in accordance with the Pri��acy Law,s. I 5.04(I)(m),Stats. � �3 l•j 3����M i r�Q b��•d �,n
I.Application Information-Please Print All Information �J
Propc�iy Ownc�'s Namc Parccl#
�o��-tv. � L:nc�c, u le� va�-I- 7'�l - 09 -SyvW
Property Owne�'s Mailing Address Prope�ty Location
700o Ed�� p�a;�ne Rd G��"L�� v
City,State 7ip Codc Phone Number
�Q�Y1 Pf`A��`i�� Mt� J�53y (O =_��� Section O C1 -
IL Typc of Building(check all that apply) Lot'� T�N R ��1 E�er
�lor2YamilyD�velling-tiumbcrofBcdrooms_ � � SubdivisionName
Block# .�--��
❑Public/Commercial-DescribeUse -
�- ❑Ci[y of
❑Statc Owncd-Dcscribc Usc CSM Number ❑Village of
csr� �a a4�►� �'r�,v�,�e_ .?aa.,c� LaKs
v.i� . al5 _
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Completc line C if
a licable.)
`�' �New System ❑ Replacement System g y� ( E ( p
❑ Od�er Moditication to Exiscin S stem ex�lain) ❑ Additional Pretreatment Unit ex lain)
B' ❑ Mound ❑ Individual Site Desi n ❑ Other T �(cx I�iin)
❑ Holding Tank �In-Ground ❑ At-Grade g yp� p.
(conventional)
C• ❑ Renewal Before List Previous Permit Numbzr and Date Issued
❑ Revision ❑ Change of Plumber ❑ Transfer to New�Owner
Expiration
IV.Dispersal/Treatment Area and Tank Information: y � y )v H,,,� �� i„� ,3 f�t �F a n
Dcsign Plo��(gpd) Dcsign Soil Application Ratc(gpd/s� Disper�al Arca Required(s� Dispersal Arca Proposcd(s� System Elcvation rj}tppl�C1 �
GUC� �•'7 858 9�8 �K 93.00, 9�.�s a4,so'
Capacity in Total #of Manufacturer
:?
Tank]nfonnation Gallons Gallons Units � � U '° � �
New Taiiks Existing Tanks � o � C ,a; � •t° `°
c. U � � v� w C7 0.
Septic or Holding Tank _
p�Jr� — �SO � r l^CO�nCPl�"!.'.
Dosing Chnmber
V.Responsibility Statement-I,the undersigned,assume onsibility f inst a on of the POWTS shown on the attached plans.
Plumbei's Name(Print) Plwnbe�' �.,nature MPMPRS I�umber Business Phone Number
Ti�c.�:s B�}}ec-�rt �d Gs�8'79 7�5 - (o3N-B17(e
Plumber's Address(Street,City,State,Zip Code)
1y3�1�w S�-a�e Ro4c� 7''1 Wa wo.rd, ws stiati3
VI.C unt�/Department Use Only
� pE �o ed ❑Diyap��roced Permit Fec Datc Issucd �ssuing Agent Signatw�c
�!-f�.� �����-��( �'�tic`�p� t�7ivt.�
❑Owncr Given Reason for Denial
Conditions of Approval/Reasons for Disapproval
— �`�
��GI�� � � ` ' � � �
"��„ . q� � �����. � ������:%���
�� �
''`# 3 3 g 3 - FEB 2 8 202�4�---1
��`T� �3 - o��> s-�� ___-------_-�
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` � �u�.;� i,(�U+��T
Attach to complete plans for the s��srem and submi[[o the County only on paper not Iess than 8 u2 s I I irt���q!s!����v�;i�;:::�r•�`+�� '
ss�-639s�x.o3izz� N�?R�;�t1N�A�7��i
��SU�����RI�1fi <�s l � 3
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
Busklein - Hummingbird Ln
Owner Name(s): Morten & Linda Busklein Phone: - -
Owner Address: 7000 Eden Prairie Rd ; Eden Prairie, MN Z;p: 55346
Project Address: 11343N Hummingbird Ln
Govt. Lot: 4 1 /4 of 1 /4, Section 09 , T 4 � N-R 07 E ❑ or W ❑✓
Township: Round Lake County: Sawyer
Project Parcel ID #: 024-741 -09 5404
Designer Information
Designer Name: Travis Butterfield Phone: 715 _634 _8176
Designer Address: 14346W State Road 77; Hayward , WI Zip; 54843
E-mal�: OffIC2@bUtt2lfl@�C�C�CI��111g.0011`1 Tliis s}�ace re�erveci for appt-oval stai�ip.
License Number: 652879
Remarks:
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�'ogg : b�e �'u �ui-t expan5 � on
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Signature: � Date: �� ��� - � 3
riginal signature required on each submitted copy.
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P��a d�y
I N-G RO U N D G RAV I TY D I S P E RSAL AREA Septic Tank(s) Manufacturer:
Wieser Concrete Inc
Stepped Elevation Trenches with Quick4 Standard-W Chambers
Septic Tank(s) Volume(s):
3-ft Trench (down-sizing credit) 1250
gal gal gal gal
Effluent Filter Manufacturer:
� Polvlok
SOIL COVER
min. 12"
�'�P'°a'� Effluent Filter Model #: BeSt GF� O
,z„
min. trench
TYPICAL TRENCH depth •
CROSS SECTION VIEW «P��a�� ��. ° �
— � • ' ' '�°�.a � a, Provide minimum 3 ft
(No Scale) � �cyPc�al)`4� •a• • • • . . separation between trenches.
' ° , . a ,. . e.
<
Highest Trench Lowest Trench (as applicable)
System Elevations = 93.00 ft; 91 .25 ft; 89�50 ft; ft; ft
Quick4 Standard-W
w/ End Cap Observation Pipe TYPICAL TRENCH
(typical) (Show location of inlet / outlet pipe connection on plan view.) (typical)
Install per manufacturer's PLAN VIEW
instructions.
(No Scale)
— - - - - - - - �� - - - - - - - �j�- - - - -�.�r��e�����w�+�.��'� �
� "� w ' ° "� �' �
A = 3.0 ft
L- — - — — ��i�l�niar�`�cY���.��i.�."' '� �tYPical) �
- - - - - - - �� - - - - - - - �� - - - = - - - - - - D
g = 63 ft —� �
m
(rypical) Quick4 Standard-W Chamber C�J
INSTALL PER TRENCH: (typica�) O
(mfd by Infiltrator Systems, Inc.) �
Install pursuant to manufacturer's instructions.
15 (�uick4 Std-W @ 20 ft� EISA/chamber = 300 ftz 'P
+ � Pairs of end caps @ 6 ftz EISA/pair = 6 ftz
= Proposed EISA per trench = 306 ftz Required Infiltration Area = 858 ftZ Distribution Method:
x 3 trenches = Proposed Total EISA = 918 ftz �
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),Wisa Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= 600 ypd; 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 priorto dosing
c 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 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 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: BUtt21 f12Id II1C Phone: 715-634-8176 _
�o�ai go„e��me„t�n;t: Sawyer County Zoning &Conservation Phone: 715-634-8288
Local government unit address: �OO'I O M8111 St, Suite#9; 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,Wisa 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.
Contingencv 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.