HomeMy WebLinkAbout014-842-05-3302-SAN-2024-059 _ �' " Department of Safety c°°"ty �
� & Professional Services, �'���'� E� �
� Sanitary Pertnit Number(to be filled in by�
�= Industry Services Division � 5 �'Z S 3 f.�
.. . �
Sanitary Permit Application State Transaction Number �
_--_
In accordance with SPS 3R3.21(2),Wis.Adm.Code,submission of this form to the appropnate govemmental unit �,1
is required prior to obtaining a sanitary pemut.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing ad �
the Depariment of Safety and Professional Services.Personal information you provide may be used for secondary �
puiposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ����
I.Application Information-Please Print All Information
Property Owner's Name Parcel#
,-.^ �
� � � ` r7 � '� � � (� C. Q�
operty Owner's Mailing Addre s Property Location
1 � t l� �J � P,�—
City,State . Zip Code Phone Number L
� �,� �J� �) � -✓ I[;7�5�''J�{ 'J'��� ��/., �� Ye, Section�
Il.Type of Building(check all that appiy) Lot# � T N R E or
�I or 2 Family Dwelling-Number ofBedrooms � Subdi��ision Name
Block# —�
❑Public/Commercial-Describe Use —'
❑City of
❑State Owned-Describe Use_ CSM Number ❑V illage of
-- �,�ro�a or ��,-n.rc�� t—
llI.Type of POW7'S 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 ❑ (hher Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B� ❑ Holding Tank �In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site[�sign ❑ Other Type(explain)
(conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Trans(er to New Owner I
List Previous Permit Numher aud Date lssued
Expiration 'l�p�1�� ��I b tqgl�
IV.Dispersal/Treatment Area and Tank Information:
Design Flow(�d) Design Soil Application Rate(gpolstl Dispersai Area Required(s� Dispersa Area Pmposed(s� System Elevation �
�1 S � , 7 ` n f) ����
Capacity in Total #of Manufacturer �
"I�ank Information Gallons Gallons Units � � U v � '�
NewTanks f?xistingTanl:s c�i o :; � v P ,� ,�
i U �n v, v� i�. C7 G�,
Septic or Holding Tank � � o O /�� •7 ���: �f
�y a G
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installadon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumbe' Signature MP/MPRS Number Business Phone Numtx�r
�G�� � ��f ��� � %!���_���7.
Plumber' Address(Street,Ciry,State,"Lip Code)
iC�57 � ` ;'u,�r� ���` >;� ��i tl� �. �u �1 c(JL - �-1 _
VL C /Department Use Only
� A �ed ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
❑Owner Given Reason for Denial $��` � � I � '�y ����'��t"�'`�' �- ��`
Conditions of Approval/Reasons for Disapproval �...,—r-.
ts�.�''��;�/1'.�` {,��� '�r,,-°`�,,
��� � � ; � I U� ��n�,L tt,' �r:.R 6f'
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_ aPR o t za2�
�S�' 2`-(-� 3 ? �ak#__a`��3 ------ SAWYER COUNTY
�-S 1 � �, -\ S ���`� .�on�Mvc�,�r�wSTr�Tlan�
Attach to compiete plans f the system aud submit to the County only on paper not less than 8 1!2 x 11 inches in size
���� NO REFUNDSAFTER
SBD-6398(R.03/22) ISSUE OF PERMIT I t��I g 9
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):`��1(� y�A-� � �.���iCl`tCtrr��'Yl Phone: �Z-.�3�.- ��5��{
�
Owner Address: /yf�(��:�1�( `��i 2�1_ ���c.1 � Z�P� `�_t� „ ��
Project Address: S (��
Govt. Lot: �j� 1/4 of j� 1/4, Section C'�� , T�N-R d 1S E❑or W �
Township: �: l�,r't�L'�� _ County: ��.IEJ�d"
Project Parcel ID #: ('`)I� -- �/;�2 —�'!� �� �6�� �
Designer Information
Designer Name: ��1/�,�1 ��.��Q Phone:��_-S� �-�
L
Designer Address� �` Zip: ���CS���
E-mail: ���YI�t�. c�,�
m t�
License Number: �����X� �
Remarks:
6� - --- _ _.._..____ ._..:._..�.-..._
Signature: ' Date: 3`"��o��
riginal signature required on each submitted copy.
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'� � �-G RO 11 N C� G RAV I TY D I�F'�RS�lL AR�A Se tic Tani<(s) Manufacturer;
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o.
niforrn Elevafiion Trencf�es with Quick4 Stand�rd�V10 Chambers SepticT'ank(s)Valume(s):
3-ft Trench (down-sizjng c�edit} � ga�
r��;.�,.�ga� .,......_..» 9a� .�._,_.�... 9al
• Y�1�1_.. \A��I��AI��IIYLIN� ��
� 1 � �� r � ` t� ` �
Effluent f=llker Madal�F; „ ,,;�G'1,11e1,,,,�,,�—,,,�,�.,,,.
� m1n, 12" ��
SQIL COVER (typlaeq
12"
min, Ironch
dopth
�`�P'c°'� � ': • �' TYPICAL TRENCH
' ' � �'' ' � ''°��a ' < CROS5 SECTI�N VIEW
�'» - ttyp�i� .°a' '� �' . � , (No Scale)
H 4 � ' a
� � � 9� I'rovide minimum 3 ft
System �Ievatlon =,�'.�...., ft soparatlon batween trenchos,
(typic�l)
Gtulck4 Standard-W
W(typ cal)p (Show location of iniet / autle! �ipe conn�otlon on plan vlow.� �bg�(fyp ca,j�p� TYPICA►L TRENCH
Ineteil per manuPacluror's PLAN VIEW
tnslrucllnns,
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`.-�'/`' —' .�/`— — ___. __ � .___ .� ._ �.I �
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(typical) m
Quick4 St�ndard-W Chamber G�
INSTAI.L PER TRENCH: (typ�oat) a
(mfd by Inflltrator Systems, ino.) .�.�
+ ,,.„f,,,C..,�„ QUICk4 Std-W @ 20 fl� EIS/�/chamber = Z�,�, ft� Install pureuant to menufaolurers instructlane, �
�h ,._,.,.�,.,.,,w Pairs of end caps @ 8 ftz �ISA/palr = .,,,,,,,,,�„�„ ft2
= Proposed EISA per trench = ,��;� ftx I�equ(red Infi�tratinn Are� = � ftz Distributlon Method:
x ,_,,�,�, trenches = Praposed Totat EiSA = � ' �2 i���� , ; �'
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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),Wisc.Admin.Code.
Maximum Dis�ersai Area Oaeratin4 Limits:
Design Flow= ��C� gpd; BODS 5 220 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,corrasion,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 po�ding in disfibution 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 laterai distal pressure—compare to design specfication)
o surface discharge of effiuent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Seotic and dose tank(sl shall be pumped by a certified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of sotids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s}or
as required by local ordinance. Disposai of contents shali be pursuant to NR 113,Wisc.Admin.Code. _
o Effluent filter(s)shall be inspected every 3 years and shail 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 govemment unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or matfunction to:
Name of individual or company: K��j'� .7�{�� Phone: ����� 7S Z[%��3
Local government unit: ' Phone: ����(�'J,��--��
Local govemment unit address��[��n�/�(Li7l� .LC/'Yc � ��11L(.�'��IP: ��(,. �_
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 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 soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.