022-739-08-5221-SAN-2021-039 :`�E�aena;`7, County - -
�r �'�� � Saw er
�,,�, Industry Services Division y
3 , 1400 E Washin ton Ave
�I��P ��� � � � P.O. BOx 7 62 Sanitary Permit Number(to be filled in I
i \ �
�t•'� S -; � \��� Madison,WI 53707-7162 � �� r�� O � �
��F��F�,"�,ra��Y ' � c sT a�- o�a v
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form tu the appropriate governmental unit � ,
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to
[he Department of Safety and Professional Services. Personal informa[ion you provide may be used for secondary Project Address(if different i5an mailin O
u oses in accordance with the Privac•Law,s. 15.04 1)m),Stats. 11330 W Hanson Rd �
I. A lication Information—Please Print All Information �
Property Owner's Name Pazcel#
Jay A&Katie L Rideout 022-739-08-5221
Property Owner's Mailing Address Propert�Location
S 7320 Lowes Creek Rd Pqe�
Govt.Lot 2,3
City,State Zip Code Phone Number '/4, '/4, Section 8 •
Eau Claire,W I 54701 (circle one)
T39N ; R7WF,orW
II.Type of Building(check all that apply) 3 ��� �ot# '
� 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name
❑ Public/Commercial—Describe Use F31och#
❑ City of
❑State Owned—Describe Use
CSM Number ❑ Village of
36/82#8394 � Town of Radison
III.T e of Permit� «'heck onl one box on line A. Com lete line B if a licable)
f1 [�New Sysic��� �Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System lexplain)
g ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer[o New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner ��k �
IV. T e of POWTS S stem/Com onenUDevice: (Check all that a I )
� Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
❑ Holding Tank ❑Other Dispersal Component(explain) ❑ Pretreatment Device(explain)
V.Dis ersal/Treatment Area Information:
Design Flow(gpd) Design Soil Application Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
450 Rate(gpds� 643 678 95.0`
.7
VI.Tank Info Capacity in
� �
a
a ons Total #of Manufacturer � � � � �U
Gallons Units L o ;; � � � � �
New Tanks Existing Tanks � U � N � y � a
Septic or Holding Tank ]000 1000 Wieser � ❑ ❑ ❑ ❑
Dosing Chamber 600 600 Wieser � ❑ ❑ ❑ ❑
VII.Responsibility Statement- I,the undersigned,assume responsibilih for installation of the POW'TS shown on the attached plans.
P►umbers Name(Print) Plumb r' Sign MP/MPRS Number Business Phone Number
R an Strand �---�----� 798301 715-558-1673
Plumber's Address(Street,City,State,Zip Code)
8959 N State Rd 27,Hayward.WI 54843
VIII.Cou t /De artment Use Onl �
� 3 � �.t
Ap ro ed ❑ Disapproved Permit Fee Da Issue ls ing nt Si nature_
❑ Owner Given Reason for Denial $ �(�Q'6� � � ZQZ
IX.Conditions of Approval/Reasons for Disapproval
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t:j �q`V '� No REFUND q ° � '��� .;_ ;�,,�, , . --1
� t�� I ��3 W-�� S�E OF p �ER .;� ; ,: i�
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Attach to complete plans for he system and submit ro the County only on paper not less than 8 ln x 11 inche m s�ze
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,:��"`' �""`� PRIVATE ONSITE WASTE TREATMENT �ounty
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'� '� ��o � `�� SYSTEMS
��! $ Saw er
\'���-��� ( POWTS) Y
°F's"�'y�`'' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMITj
GENERAL INFORMATION � � .. �j,3�
Personal infonnation you provide may be used for secondary purposes [ Privacy Law, s. 15.04 (1)(m) ]
Permit Holder's Name: ❑City ❑ Village �, Town of: State Plan Transaction ID#�
�qy a- V��°Q. IR�deo�,'� �q� i 5soti r--
Insp BM Elev: BM Description: Parcel Tax No:
�c�o.o ' N�;1 �- �101�� �a " �, o� C� S,� o�. ��r `'�d �� �� � - �3� - oB-5��� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �; _ � Benchmark aj,o i
Dosing � �o�,,,��n o
Aeration Bldg. Sewer , Q� '
Holding St / Ht Inlet 8( . S�-. �
TANK SETBACK INFORMATION St I Ht outlet �6 . 2� '
TANK TO P/L WELL BLDG vENrro ROAQ Dt Inlet
AIRINTAKE
Septic ±�� �/ �q � �.�2p/ NA Dt Bottom �3• �'� �
Dosing �� �� �< << NA Installation
Contour
Aeration NA HeaderlMan. ��',a `
Holding Dist. Pipe
PUMP / 51PHON INFORMATION �nfiltrative q�`o ,
Surface
Manufacturer Demand Final Grade
Model Number ( GPM ; _ �t$��$-�
TDH � Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia `� Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W � L � # of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate L_��l
P I L Bldg Weli ❑ IGP Chamber '" �l
INFORMATION Waters n AG � EZFIow Model Number:
CELL TO -}- �Sb ❑ Mound o Other �,t�
----. -- -- --- ----
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) � X Hole Size X Hole Observation Pipe�
Length Dia Length Dia Spac Spacing 0 Yes ❑ No
SOIL COVER
Depth Over Depth Over Depth of Seeded / Sodded Mulched
Cell Center Cell Edges Topsoil _ ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?❑ Yes ❑ No � „a � $ � � ` � - I 64� r� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710 (R.3I01)
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AOOITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: o�-� ��.��
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