HomeMy WebLinkAbout014-941-01-2105-SAN-2024-089 �`° Department of Safety c°°"ry �
-� \� = & Professional Services, �`" �� �
,_ � = Sanitary Permit Number(to be filled in by�
� �, r= , Industry Services Division
�'-�,. ,���` 11'S I "1`1�] �
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Sanitary Permit Application Sta�e T�����on N=mber o
In accordance with SPS 383.21(2),Wis.Adm Code,submission of this form to the appropriate governmental unit a7
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing a� �
the Department ot�Saf'ety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. ��"'���
1.Application Information-Please Print All Information
Property Owner's Name Parccl#
rQ� -+- e�d; coo ei'
or�73A� o1Y�-gy/- OI -�(oS
Property Owner's Mailing Address Property Location
1 I 5�.3 N U..S. w . 3 .
City,State Zip Code Phone Number �� `
��� ��� Q w� sy�t� 3 �%, N�✓ '/.. Section
f
II.Type of Building(check all t6at apply) 3 Lot# � r N R 7 E o
�.41 or 2 Family Dwelling-Number ofBedrooms Subdivision Name —
B1ock#
❑Public/Commercial-Describe Usc
.— ❑City of
❑State Owned-Describe Use____ CSM Number ❑Village of
�7�0
�� ¢�� �row�or ��+•e.T�
;a�.��,� '.3g .3�
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.)
'�� �New System ❑ Replacement System g y ( p ) P �
❑Other Modification to Existin S stem ex lain ❑ Additional Pretreatment Unit(ex lain
B' ❑ Holding Tank �..in-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C- ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to New Owner
Expiration �
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
4s� , 6 �S"� ��� 93 so '
Capacity in Total l4 of Manufacturer
�
Tank Information Gallons Gallons Units � �; � bc, �
New Tanks Existing Tanks ` U � � "
� � Y U � � � �
O.. U V� � [n Gi Ci L1-
Septic or Holding Tank /��O ��� ' w�Q�e/� X
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW'1'S shown on the attac6ed plans.
Plumber's Name 1 Print t Plumber's Signatur MP/MPRS Number Business Phone Number
�.�1� `roe•yie � � �'j5�1// �/�=SS�-I/38
Plumber's Address(Street,City,State,Zip Code)
13 So� w �oe,�►,e/ Rd l� wa��,.�•�/.l SygS�3
VI.C n /Department Use Only
�q Permit Fee Date Issued Issuing Agent Signature
�A t64 r ❑Disappmved $ ��D �yp y I���� Z(.� '�C2-f-u.�(�e.•��,c^-
�� ❑Owner Given Reason for Denial ►
Conditions of Approval/Reasons for Disapproval
'�'�� � ��q'"ii� / ; T_ ^'�
�'^-1,,, �• ti r �c, �1i�
ti a 9 a Y._._. � � �r� �U �-��';
�.___1____.. ...�.��.V._ �
�� ►Y I 3 .. APR Z 3 2024
C� 2 ��- �s l � ��
SAWYER COUNTY
Attach to complete plans for the system and submit to the County only on paper not less than S t/2 x 11 inches in s'
���;��� �VO R�F�NDS q
SBD-6398(R.03/22) �SS(lE QF P�R��TR '-'f SCi'�C.�
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): Cr� � I�e ��; �p� ei Phone: 7f5 ,53� - / 73 �
Owner Address: 1 � 5 S�3v f.t .S. l�y 6 3 Z�P; 54848
Project Address: S� �/e� �;,� s i fl 8� l4 s��h<�
Govt. Lot: � � 1 /4 of N w 1 /4, Section ► , T �/ / N-R �I E ❑ or W �
Township: �2M �e o �'" County: -S�y ��
Project Parcel ID #: N�w Pq �iel �d '� T[3a 51�
Designer Information
Designer Name: GP�t jd o . F.� -�e i Phone: � �� =rS�r _ // ,��'
Designer Address: / 3 .S°� '� ���^� � � ��1��'�i wl Zip: Syfy �
,
E-mail: ( �, v�o �.r►s ( '�� i�.�,: I . eo ."�J . �;. ;� .��e,-��ec' �,l�t ,� .� ��t��: �ar�`
License Number: '�f 3—O /� (
Remarks:
Signature:��� l Date: �'- � 2 ` � v
Original signature required on each submitted copy.
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Septic Tank(s)Manufacturer.
IN-GROUND GRAVITY DISPERSAL AREA '���s��
Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Volume(s)
3-ft Trench (down-sizing credit) �oa gal 98� 9a� gal
EHluent Filter Manufacturer:
�:-�er;...c LT Yd
I EfflueM Filter Model#: LT��
In.12"
SOIL COVER (ryplcep
t2'
min.hench
depth
�rya��o • TYPICAL TRENCH
— `. "a • CROSS SECTION VIEW
�—34�� No Scale
(�YPical) w � �� � �
• � � Provide minimum 3 ft
System Elevation= �/3.'�ft separation between trenches.
(typical)
Quick4 Standard•W
w/End Cap OoservanonPlpe TYPICAL TRENCH
(rypicaq (Show location of inlet/outlet pipe connection on plan view.) (�yvi�q
InstallpermanufacNrefs PLAN VIEW
insimctions.
_ � _ �� (No Scale)
�—�F.� — 4;4.————��-———————��— ,C �
�l��i..�l.r� ��I1��.r-.. ----��--------��---- rtr�4�ierrr �l�tr.s JI �A=3.Oft
����.+.. +4V:4`�r �r rr �r���i.rttrssW (�vvicap D
� B= �g ft -� m
(typical) Quick4 Standard-W Chamber W
INSTALL PER TRENCH: (ryplcaq �
(mfd by Infiltretor Systems,Inc.) -�
/� ?PO Install pursuaN to manufacturer's instructions. �
Quick4 Std-W @ 20 ft�EISAlchamber= �° ft'
+ � Pairs of end caps @ 6 ft�EISAlpair= 6 ft'
=Proposed EISA per trench= 38� ft' Required Infiltration Area= �s� ft' Distribution Method:
x 2 trenches=Proposed Total EISA= ��a ft� ��+^^ �i.►�—f�w�
�
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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 Disaersal Area Operatinq Limits:
Design F►ow= y� 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 specificatien)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Seqtic 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 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 government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: ��Je�y'i� Phone: 7/.�'-�5�—I� 3 B
Local govemment unit: .S�i,�.o� c-X�� Ze�.�;� Phone: 7��- 63y- y1tP'
� /
Local government unit address: �/�+-�� ST lr�e,,,.,,+�/� � r.✓Z ZIP: -S4't`�'3
i
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 orphysical restoration of the POWTS may be used uniess approvedby the departmeni 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.