HomeMy WebLinkAbout010-941-30-2101-SAN-2024-101 /`"�''"`� Department of Safety �°°"�' �
�� / ��_A & Professional Services, �a�'`' �� �
� � r<( Sanitary Permit Number(to bc tilled in by('o �
� � �� �./ Industry Services Division �
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Sanitary Permit Application s`a`e T'�a°sa°"°°"""'be' ,
In accordance with SPS 383.21(2),Wis.ndm.Code,submission of this fonn to the appropriate governmental uuit �� �
is required prior to obtaining a sanilary permit.Note:ApE�lication fom�,tor state-owned POWTS are submitted to Project Address(if different than mailing add��„��
the Department of Safety and Professional Services. Per;onal information you provide may be used Yor secondary
pmposes in accordance���ith the Privacy Law,,. I�.0�(I)(m),Stats. � ��'�� W �' ��Y ��`) � ��
L Application Information-Please Print All Informatioo
Propeity Owner's Namc Parcel#
1�� L3 �i� �c� e c-�}e T cv C7l O- 9`'11 - 3 p- a 1� I
Property Ownei's Mailin�Address Propeity Location
o � 39 y `"
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City,Sta�e Zip Code Phone Number
Mo���s+o w n r1 nl ssos�l _Nt= �i<,_►.��,.��,�, se����„ 3a
II.Type of Building(check all that apply) Lo�� � �I�__�N R 9 Eer
�71or2l�amilyDwelling-NumberofBedrooms 3 SubdivisionName
Block# �
❑ Public/Commercial-Describe Use _
❑City of —
❑State Owned-Describe Use CSM Number ❑Village of
^-- '�Town of-- 1��W oard
IIL 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
applicable.)
A. —
❑ Neti�System ❑ Replacement System �Other Moditication co lixisting System(explaiu) U Additional Pretreatment Unit(explain)
Tq�K �c 1G.cemer�� 0��
n.
❑ Holding Tank �[n-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before List Prc��ous Pennit Number an Date Issued
❑ Re��ision ❑ Chan,e of Plumber U Transfer to Ne��Owner
E:xp;���t�o�� � �~1�l , � (e �°��
IV.Dispersal/'I'reatment Area and Tank information:
Design Flow(gpd) Dcsign Soil Application Ratc(�pd/st) Dispersal Area Required(st) Dispersal Area P�yese�l-(�f) System I?le��ation
y�� �• � �y 3 Gay ex;s}, 9�. �e�
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units p � o 'g �
New Tanks Existing Tanks � ❑ � `'' � p � `"
a � r
n. U in � cn ti. :7 G.
Septic or Holding Tank � �� ��Q I V Q <<"C.OnC/C�C �Y►C �
Dosing Chamber
V.Responsibility Statement-l,the undersigned,assume res nsibility for insh la on of the POWTS shown on the attached plans.
Plumbe�',Namc(Print) Plumber', � naturc MP/MPRS Number Business Phone Numbe�
'��,�; g (��F}er�:'e lc� �sa�� 9 7/S- Co3`/-817Co
Plumbe�'s Address(Strect,City,State,7.ip Code)
IY3y�w S�k l��d �? �/�. wG�d, wL s� 9 y3
VI.Cou ty/Department Use Only
�A 'c �ed ❑Disapproved Pennit Fee Date[,sued I„uin�Agent Signature
�� ❑Owner Given Reason for Denia) �� '�•� �I ���� ���������
Conditions of Approval/Reasons for Disapproval
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Attach to cumplete plans for the system and suhmit to the County onl�•ou paper not less lhan 8 I/2 x 11 inches in size
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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 Dispersal Area Operatinq Limits:
Design Flow = 450 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.)
c solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution /drop bozes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell priorto 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 1�3, 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: BUttet-f12Id IIIC Phone: �15-634-8176
�o�ai go�er„me„t �,,;t: Sawyer County Zoning & Conservation phone: �15-634-8288
�ocal govemment unit address: 10010 Malrl St, Suite#9; Hayward, WI ZiP 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.
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.