HomeMy WebLinkAbout026-939-27-5521-SAN-2024-128 � " "F'�� Department of Safety c°"''ry �
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i & Professional Services, �
� $ Sanitary Permit Number(to be filled in by c
� �� �"� Industry Services Division
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Sanitary Permit Application StateTransactionNumber 1
-- R,In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate gocernmental unit
is reyuired prior to obtaining a sanitaro permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin ac O(�+
the llepartrnent of Sxfety�and Professional Sen�ices.Personal information you provide may be used for secondary �-�&� � �0.��� -. f-{O ���� �yF�
puiposes in accordance with the Pricacy Law,s. 15.04(1)(m),Stau.
I.Ap�l�ie��n`InformatiQn-�'lease Print Alt Information
Yroperty Owner's Name Pazcel#
���er Cv �5M ��� L� � l��S� c2�ci3c�7SS� 1
Property Owner's Mailing Address Property Location
�7Sc N,�bb a,-�� .4 ti�� Ga�.Lat �
City,State Zip Code Phone Number
�� (-0.v � ,�t ry .-s s �o y '�a, '/a, Section�
I1.'�e r���ilding(check all that aPP�Y) Loc� T � N R � E o�
�1 or 2 Family Dwelling-Number of Bedrooms � �`� 7 �- 2 Subdivision Name
Block#
❑I'ublic/Commercial--Describe Use ��
❑City of
❑Staie Owned-Describe Use ti� CSM Number ❑Village af
�e%� 2i3i �'To..mor 5��� L �KC
III.Tyge o€PfJWTS P�rmit:(Check either"New"or"Replacement"and ot6er applicable on line A. Check one bog Qn line B.Compiete tine C if
a ticable.
;�.
❑New System ❑ Replacement System �<�ther Modification to Gxisting System(explain) ❑ Additional Pretreatment Unit(explain)
R � ,�K
B' ❑ Holding'Cank �In-Ground ❑ At-Grade g yp ( p )
❑ Mound ❑ Individual Site Desi n ❑ Other T e ex lain
(conventional)
ist Previous Permit Number and Date Issued
C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner � �0 �
Expiration �— ���
IV.D�s ` ifFre�tmai�f Area end Tank�ntar�stion: M`'
Design Flow(gpd) Design Soil Applicaiion Rate(gpd/s� Dispersal Area Reyuired(s� Dis ersal Area System Elevation
��� . � - ,. Y�� y/o ����3 '
Capacity in Total #of Manufacturer
Gallons Gallons Units a��i U '$ N �
Tank Information � � � N •N
New Tanks Existing Tanks � eo « � N � � �
ci U 'v� �, v� i�- U G.
Septic or Holding Tank ��j,�c� ----�- j�C� I %v� ��� '�� x
Dosine Chamber
V.Responsibitity Stat�ment-I,Yhe undersigned,asaume responsibi�itp fae installaHon ofthe POWTS shown on the attached plans.
Ylu er's N Pr Plumbef Signature ..�...� MP/MPRS Number Business Phone Number
`�erry��id"�xcavating, LLC � , ��,�_�.�,��.�-2�t��,
��� ����,��
P'u`��oned�a�Ce; j`���� ip Code)
VL Ct►uu !Be artment Use Only
� �' Y ❑llisapproved Yermit Fee Date Issued Issuing Agent Signature
$ �//� i ( n -�'
❑Owner Given Reason for Denial /"�/•O� sl'��' I`�y ' � 1�tJ��'�',��-- ' �'����
Conditions of ApprovaUReasons for Disappro��al,
� ' I� t���� ��
� � '' S 'a-a at-( � L� `i� Ln�1 ,y �
+r �i��'��i� Date�---- �:
L ='-,�
�:hk# 3��� �.��...�.-- t��'� 17 2024 �..�
C �T �-N— d� 1 ) ��.t.�___..�_�c�:a�° _ �i,w�r�� cou�v;,;
��.
Attach to complete plans for the system and submit to the Count}only on paper not less than S 1/2 a 11 inches in
� �
SBD-6398(R.03/22) ,�`��( �.p
CXECK BOXAB APPLIGBIfi CHECK BOX AS MPLIGBLE �
� SOIL EVALUATION o S�'�� �40' � � � SYSTEM PAGE 2 OF
SITE MAP PLOT PLArN� �
PROJECT NAME , i�a DE31GN FLOW: .JCJO GPD
Co��Q.C'$Y�-L 1-r � Attach tlesipn flow ealaletlona for mmmerdel plans.
PRaEciADDNEBS: S'ygYiV �4w•-^ }�6��y �f. N PipeMeteAel/ASTMStendartf (TaWea384.3038384.3U5)
e�ec 58nlhrySlNer. /
BM ByrMd: � B�M rEev/a�lbn: 1I �7
BM DserlpUm: )O'Q �'t 1-�51' Yfoni Y 2n)l� Faca Mrn: /
SIOWOredleidf%) � iw�uta�nnM IMPORTANT:
�7��: WeI18ymEd(CyipuuEle} Q aiawi�an.mw Show ground alevation conh�ura at aui}ebb in0ervale.
on eha.pp�rroe uro.
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Jerry Ruid Excavating, LLC
W208 County HWY A
Stone Lake, WI 54876
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. PAGE 4 OF 4
In-ground Gravity Management Plan
i�oxnwr:
The owner of thi8 in-ground pravity system 5ha11 be responsibie tor its perpeAial�eratlat and meirrtenance pursuerrt to
requiremertts of SPS 382�384.VIRsc.Admin. Code. Pursuant to SPS 383.52{2),Wmc.Admin.Cods.this aystem�ell
be eonsidered a humen heetth hazard'rf not mair�airred in accordarxe'Mth thfs epproved management Plan.
FuN�emare.all inspeatiw�a�m�tenance activ�ies Shali be perfortned by a tegia�fed POWTS NrlMdn�r fn
axordance wtth SPS�3.52(3).Wisc. Admin. Cade.
Mazi�m Dleosnai Araa Ooaratlna Llmlts:
D�sign Flow= 3or� 9Pd; BODe 5 Y10 mgL''; TSS 5150 mgL''; FOG 5 30 mgL',
Inawetlat Cf�ldlst INSPEC'T EVERY 3 YE/1R3
o type ot uee
o �e Ot system . .
o nuis�oe facWra(l.e.odors, user compieints, eta)
o medianicel malfunction(i.e, p�anps,vahres, swiDches,floats, eta)
o material fatlgue (i.e., leaks, breake, cortoafon, etc.)
o so1i�vd�ane in anaerobic treatrnerrt tank(s)arxi any�tribution ePPuRenance(s) f-e.,distributlon/drop booces)
o r�glec[or impr�er t�e(i.e..exceef6r�g design capedties.Prohibited adNiBes, etc.)
o exterR of p�dirtg in dlsMbutlon ceil prior to�sing
o dosing irtepu�-if appiicabie(i.e..PumP recydin9�floffi switch settings, ete.)
o elBCMCei Compo�-if applkebb(i.e.,wiring, Catnectrons,SwiDChes.corrtrots�timers.el�ms, etc.)
o tSstributlrn�Iffieral w I�eral wllice P�uggin9 (measure Iaferal�stal premure—compare to�sPedBcaticnl
o euAaoe discharge ot afNumrt or sewage back-up Grto�ructure sorved
NUuw'rNN EVER1r 8 rEARs lor when nacesaer�
O 9ao11C and doss Lnlda)sl�ali be ptanped by e cerdfled eaptege aeNbirg operator Iicensed tmder 8.281.48 Wis.
stets.wna,nre w�ume ot.onds m ti,e�,Iqs)�«ro-t�a(11�8�0�Iquw vok,mo a na ank(.)«
aa required by local ordnnnes. dsposel of�shall be pursuertt to NR 113,Wfec. P�nhi.Co�.
o at�ll be fnspeated everY 9 yers arxl ahall be deaned vrhen�ery to remove arry
ecaunulated aolids exading to merufecturer's spe��tiona A�ruj period wiY elways be grsa�r then t2
montlie.
SPS 388.55 Wi�o.Admin. Cod0.�Roport M�jr�opmponarR� maNu��o�n�unit in�wlth
I�me of ir�vidual or camperry��v-7 Q.,�d �Y�••aa�wxx� Phone:75� 44��'2�-(v`1 '
wal govemment unn: SG Z atrone: 7/5-�c 3 Y-a2��
t.ocel gavertenerrt u�it address: ���n Mo.�„� 57 F4.�r�v�c.,.i z�P: s Y�`t 3
Any detective pen of n,fs system s►,el�ue repalred, rea�aced,or remwed p�,rsuarrt ro sPs 383st (t).w�sc.Admin.
Code. Repair or re�a�nt of fatied or maHurwfionin9 comPoneMs sheli oompy with SPS 383.VVisc.A�nin. Code.
No product fw diemical w physbal restoratbn of the POWTS maY be t�ed unless spproved by the depertr��ent in
accord�ce with SPS 384,Wlsc.Admin.Code.
Co�asnc�t P�n
In the event Shat any failed treetrnent compo�nt of this POVVSS canrwt be repeired,k shell be rep�Ced pursuant to
a plen submitted to the�+�late�CY for review end ePP�. A tailed in-ground d�e�al compmront maY be
abar�foned and repleced bY a code-comPh�9 d�Persal cor�O"eM in a Predetertnined ar�of suiteble e�s.
SY�S11f AbslldOnfllefl!
If use of this POVYfS is.dfscontlnued,it shall be abanConed in acoordence with 3PS 383.33.Wlec.l�min.Code.
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� R�al Estate Sawyer County Property Property status: �urrent
Listing
Today's Date: 4/30/2024 Created On: 2/6/2007 7:55:49 AM
'�' Description Updated: 10/8/2021 Ownership Updated: 2/20/2024
.._,. �..e_ , .._.. � . ....�..���_._ .....�. ., _..n.�,� .� __�__________�_ _�__� ._,�_� 2 .��,��.,��..� � . .�v..e�,.�.....�....�
T�tx I0: 29116 ' PETER A COPPERSMITH LIV TRUST ST PAUL MN
PIN: �� 5?-025-Z-39-fl9 27-5�05 OC}5-
a0t?i� Billing Address: Mailing Address:
Legacy PIN: {1�6�392755Z1 , PETER A COPPERSMITH PETER A COPPERSMITH
Map ID: . :5.21 LIV TRUST LIV TRUST
Municipality: (026) TOWN OF SAND LAKE 1758 HUBBARD AVE 1758 HUBBARD AVE
STR: S27 T39N R09W ST PAUL MN 55104 ST PAUL MN 55104
Description: PRT GOVT LOT 5 LOTS 2-1 & 2-2
CSM 10J91 #2131 Site Address * indicates Private Road
. Recorded Acres: 2.140 �._,...... . ..._...._� _..._ - ---. _ . _.__�.,.. ._..... . ..__W_____._,�._....w_.. �._
5484N HAM HOLLY DR STONE LAKE 54876
Lottery Claims: 0 --
First Dollar: Yes � U dated: 4 2 2020
Waterbody: Ham Lake Property Assessment ��� � P ���/ /
Zoning: (RR1) Residential/Recreational One 2024 Assessment Detail
ESN: 423 Code Acres Land Imp.
G1-RESIDENTIAL 2.140 99,800 99,500
j� Tax Districts Updated: 2/6/2007
-....�. 2-Year Comparison 2023 2024 Change
1 State of Wisconsin �nd: 99,80Q 99,800 0.0%
57 Sawyer County Improved: , 99,500 99,500 0.0%
026 Town of Sand Lake TotaL• ' 199,300 199,300 0.0%
572478 Hayward Community School District
001700 Technical College
�� Recorded Documents U dated: 9/23/2014 Property History
pm,_�,m_� _„.. ��mm. .� �� � .� �,,. .�_m,. .�m ..u _ ,��„r,�„r��..a,��� �..�,,.,� ,ob�,.w..__
� QUIT CLAIM DEED �'�'�'�'����'�� N/A
Date Recorded: 1/12/2024 44$iS3
0 WARRANTY DEED
Date Recorded: 10/17/2023 446899
� WARRANTY DEED
Date Recorded: 10/29/2020 427591
0 WARRANTY DEED
Date Recorded: 10/10/2005 334093
fl CERTIFIED SURVEY MAP
�Date Recorded: 5/10/1984 191224
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