HomeMy WebLinkAbout002-940-13-1405-SAN-2024-127 �
_- Department of Safety �°°°�y �. �
� - & Professional Services ` � Z
� S� � Sanitary Permit Number(t �be fillcd in by G
t Industry Services Division
.,.. � s ��� s
Sanitary Permit Application State Transaction Number �
� �In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing add
the Departrnent of Safety and Professional Services.Personal informadon you provide may be used for secondary G' ��� /�1 ^]��C� � „(�
puiposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. � � r ► �� I��'�
I.Application Information-Piease Print All Information
Property Owner's Name Parcel# ��L U O_f 2_Y i !�J
6 6Jlti �'G
, �c.c� � C
Property Owner's Mailing Address Prope�Location
L� L` �^ /' ���
J�� covc.�oc�_
City,State "Lip Code Phone Number �c�-
�� �' / �„/'1� S� Y.,_�'/o, Section�
, �, {L/L/
II.Type of B ding(check atl that apply) Lot# T � N R E o
�1 or 2 Family Dwelling-Number�fBedrooms � �/ Subdivision Name
Block#
❑Public/Commercial-Describe Use
` ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
��/ ZZ { �v�'`J V �I'own of �(�<�� � ��
IIL Type of POWTS Permit:(Check either"New"or"ReplacemenN'and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
`�� ew S stem
,,�N y. ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(expiain)
B.
❑ Holding Tank �.In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(eaplain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued
L:xpiration �
n�'v
IV.DispersaU7'reatment Area and Tank Informa6on:
Design Flow(gpd) Design Soil Application Rate(gpols� Dispersa►Area Required(s� Dispersal Area Proposed(s� System Gievation
�so . � �5"d 77 98.0 '
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � � o 'T�„ �
New 7'anks Existing Tanks � o � `�' � p � �
a U v� � v� w C: ci.
Septic or Holding Tank ��-� /�AL / /� r
C/C�
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installaHon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Signamre MP/MPRS Number Ausiness Phone Number
�.., " -� � �'/�
Y�
Plum er' dress(Street,City,State,Zip Code)
�` � `� '_� f� � u�� �'" -
.Coun /Department Use Only
�A p ❑Disapproved Permit Fee Date Issued Issuing Agent Signature
�7�✓ ❑Owner Given Reason for Denial $ ���� � I�3 ic��� 7'.•��,� �',���'.C'_L��'G�2ri��
Conditions of Approval/Reasons for Disapproval �
� � �a��t"�'j^�'�M��;l
� "E � � ��t�,/� i'-'' ��L.T :�-� s'�
�' ���� �� S � a �� _.....� �t.�,
L e
Dat
� �� _ �t 3 chk# as3 o MAY Z 1 2024 ; ��
Csl ;
�:; = � lo�s SAWYER CO'vs�"�"
..._.._�_,�.._.________.___.,,__ G ADMINISTRi-�T!��N
Ariach to complete plans for the system an ubmit to the County only on paper not less than 8 1/2 x I I inches in sae
NO RCFUND3 AFTER
SBD-6398(R.03/22) ISSUE OF PERMIT 3�y-�
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 Piot 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): L�{�'�, �., �'jt�(�,��K-;�e�`� C,2 Phone: - -
Owner Address:�,��js�i_����,�� �, (.�`.�('1�'��L. Zip: G,,��;?�
Project Address: �'�,�� �,(}�r(���5 �� �aLc�C.e►?�.l �
Govt. Lot: �_ _ 1/4 of 1/4, Section � , T �O N-R �1 E 0 or W 0
Township: �L�,�7 � �� County:
Project Parcel ID #: (�(�'�' ��� - fT���� �
Designer Information
Designer Name: Phone:��,��1�J��
Designer Address: c ' ip: ����_�
E-maiL• u'�k�?�. ��-=�
License Number: '��,�i�
Remarks:
:/�
Signature: Date: �r"�d V'r�y
Original 5ig re required on each submitted copy.
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p �v �t
Ur�ifiorrn Elevafiiar� Trench�e� wr"�h Q�ick4� �;tand�rd�U1l �h�mb�r�
Septic'i'anl<(s)Vnlume(e):
��ft Ttrench (dovvr�—SiZlrli C� CI"G���,} ,�Q,Q,�gal �, g�) �„�, 9a� »»�,9al
� � �ffluent Flltor M�anufaaturer:
� � �--, .a � _ v .
� �tfluent rllter Modal��; rd 22
• min.12"
SQIL COV�f'� (tYplanp
12"
min,ir�nah
dopih
urPiaAu . _ • " ' 1"YPICAL. TRENCH
_,_ ;_... . ,,n.� � CROSS S�CTICJN VIEW '
,Q �a
� _,'-- 34" ' .� , , '
�tYPl�l) ':'n� , � (No Scal�)
'� 4' ' q
V
' ' ' i�rov(d� minfmum�ft
System �I�vat(on =„,� ft son�ratlon bQtween kronohos,
(typlcal)
Ctulak4 Standard-W
w/h�nd Cap (5how (ac�t(an of Inl�t/outfet nine cnnncotlon on plan vlow,) O�e�(ly(11CflI� �ro TYPICA�L TRENCH
(lyplcal)
install per manufaoluror'o P�.AN VIEW
Inslruatlnne,
� ._. �,�.. � (Na Scale)
I�I�,{iy��aG'�j�,�1����t��li�����'�'��c..— —. _ ..... ._... _ _ .._.. _ �� _ �. _ ,��,�,�,��,���,���?���� � a:����
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-�j�-� -�j�-� _ _ _.._ � _.._ .�. _� �
��`° d = .,.��....�, fk � G�
(typlcal) �
Qulalc4 St�nderd-W Chamber f�
INSTALL. PER TR�NC{-I; (typ�oal) �
(mfd by Inflitrator 6yslems,Ino,) �
' „�.,�.,,,�„ QUIck4 Std-W �,di�A f�EIS/�/chamber= a 5�,',,,�,Q� f�- Inatall pureu�nt to manuFaalurer's(netructione, �
-� .,,,,,.,�,,,.,,,„, Palrs of end caps @ 6�ft7 EISA/palr= � �x
=Propased E15A p�r trenah = „�,� ft' I�equirod Inftitr�tlori Are�= O �{�
�� Distributian Method;
x �, trenci��c�s = Prapas�d l"oial EISA = „�7,�, fr2 �.��.�,/ ��..�,���
��RF�FTu �
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.
Furthertnore,all inspection and maintenance activities shall be pertormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disoersal Area Oaeratin4 Limits:
Design Flow= yS0 gpd; BODS 5 220 mgL"'; TSS<_150 mgL"'; FOG 5 30 mgL''
Insaection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(r.e.odors,user complaints,efc.)
o mechanical maifunction(i.e.,pumps,vaives,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 disfibution cell priorto dosing
o dosing irregulanties-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 piugging (measure lateral distal pressure—compare to design spec�cation)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Septic a�d dose tankls)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(113)the liquid volume of the tank(s}a
as required by local ordinance. Disposal of contents shali be pursuant to NR 113,Wisc.Admin.Code. _
o Effluent filter(s)shall be inspected every 3 years and shall be cieaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period wili always be greater than 12
months.
System maintenance reports shail be submitted to the proper local govemment unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company:�U�„� � 1/��� Phone:�(�j 7��{ �7
Local government unit: Phone: ���j�.����'��
Local govemment unit address: � 1Q � ZIP: s��`t
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 shaii 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 compone�t in a pre-determined area of suitabie soils.
�stem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
5/20/24,6:44 PM Novus-Wisconsin Access rev. 13.1108
Real Estate Sawyer County Property Listing Property Status:Current
Today's Date: 5/20/2024 Created On: 2/6/2007 7:55:07 AM
�Description Updated: 3/12/2019 � Ownership Upda[ed: 1/20/2020
Tax ID: 3147 DONNA M SMUSIQEWICZ CHICAGO IL
PIN: 57-002-2-40-09-13-1 04-000-000050
Legacy PIN: 002940131405 Billing Address: Mailing Address:
Map ID: .4.5 DONNA M SMUSKIEWICZ DONNA M SMUSIQEWICZ
Municipality: (002)TOWN OF BASS LAKE 5251 5 SPRINGFIELD AVE 5251 5 SPRINGFIELD AVE
STR: 513 T40N R09W CHICAGO IL 60632 CHICAGO IL 60632
Description: PRT SENE&PRT GOVT LOT 1 LOT 3 CSM
19/227#5680 � Site Address * indicates Private Road
Recorded Aaes: 5.000 g827N NOR WIS RD HAYWARD 54843
Lottery Claims: 0
First Dollar. No
Zoning: (RRI)Residential/Recreational One � Property Assessment Upda[ed: 5/29/2018
ESN: 406 2024 Assessment Detail
Code Acres Land Imp.
� Tax Distritis Updated: 2/6/2007 GS-RESIDENTIAL 5.000 31,000 D
1 SWte of Wisconsin Z_Year Comparison 2023 2024 Change
57 Sawyer County Land: 31,000 31,000 0.(1%
002 Town of Bass Lake Improved: 0 0 0.0%
572478 Hayward Community School District Total: 31,000 31,000 O.C�%
001700 Technical College
• Recorded Dxuments Updated: 3/12/2019 ,
O WARRANTY DEED �Property History
Date Recorded: 1/13/2020 422039 N�A
0 WARRANTY DEED
Date Recorded: 3/8/2019 416824
O WARRANTY DEED
Date Recorded: 8/30/20ll a08389
0 WARRANTY DEED
Date Remrded: 10/9/2002 304059
O COVENANTS
Date Recorded:9/20/2002 303957
O CERTIFIED SURVEY MAP
Date Recorded: ll/17/1997 264362
https:Utas.sawyercountygov.org/Access/master.asp „