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006-439-02-2302-SAN-2021-093 �, q� Safety and Buildings Division Counry � '`�' 201 W.Washington Ave.,P.O.Box 7162 S � �2 0 s � � Madison,WI 53707-7162 Sanitary Permit Number(to be filled in t � , PS � � ti�l� Z ,,,� , _ . . _ �s� a o- �s�) � �'�� i � State Transaction Number � '" Sanitary Permit Application P„„� _ o�(a �c�oyyl - - In accordance with s.Comm.8321(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental C unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS aze Project Address(if different than mailinp G submitted to the Department of Commerce. Personal information you provide may be used for secondary �� u oses in accordance with the Privac Law,s. 15.04 1 m,Stats. �M�� I. A lication Information-Please Print All Information � I 1 �N �o �y Property Owner's Name Parcel# v�. �,� �? � .3 aaz3o Property Owner's Mailing Address Property Location �� � `�����y ,�,� Govt.Lot City,State Zip Code Phone Number �_, .►,_l , 2 W �4�—!J[.11L/,, Section �� �'1� circle one `C��N; R�,�or� II.Type of Building(check all that apply) Lot# �[1 or 2 Family Dwelling-Number of Bedrooms �� I Subdivision Name .J_- Block# ❑Public/Commercial-Describe Use ❑ Ciry of ❑State Owned-Describe Use CSM Number ❑ Village of ���7 36�33� �Town of �Nt'T�� IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) `�' �New System ❑ Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) B• Permit Renewal Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Ex iration Owner P �o-3t`� 12 '� �o�o [V.T e of POWTS S stem/Com onentlDevice: 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 Tanl: ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis ersal/Treatment Area Information: Design Flow(gpd) Design Soil Application ate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation� ��o . �,o y.�'o �.5� iar.o ' VI.Tank Info Ca acity in Total #of Manufacturer Gallons Gallons Units � � o � � New Tanks Existing Tanks � o �, � � A � � a U 'v� � v� i�. C7 0.. Sep[ic or Holding Tank / � �.� Dosing Chamber 0 � � VII.Responsibility Statement- I,the undersigned,assume responsibility for installafion of the POWTS shown on the attached plans. Plumber's Name(Print) Plu r's Signature MP/MPRS Number Business Phone Number Jerald Esterholm MPRS?31487 715-428-2938 Plumber's Address(Street,City,State,Zip Code) P.O. Box 28 Prentice, WI 54556 VIII. ou t /1De artment Use Onl � `�.� l Permit Fee � Date Issued Issuin A ent Signatu Ap o� ❑ Disapproved $ �,,/ �'0 4 ZN 20�1 E !7'" ❑ Owner Given Reason for Denial / IX.Conditions of Approval/Reasons for Disapproval � .,r '� . � � Alp R�F�Nt�s ` I� t� "��F(1;.� ����';�rj li�i,�1 j, ! '1 r� � l.f I \t [:.� �� �S�V E OF �FTER � �L i� � -__, �.1 � �1J i�� �`� �., � _ �� PER�M►T �S`�i D ,� Attach to complete plaos for the system and submit to the County only on paper not less than 8 ln x 11 mc es n s' e`e�t� SBD-6398(R.�J1/07)Valid thru Ol/09 ��� ��4� I U I \ � � �"�� � { � 1 I �1.��I �� Y{ �' ,L 'I ',' � .�+_:�4�C':�z r;..rf'�,^;�;'�:,L i:-ft:Ti�i� c� �g .� � �- �� � � �� � � � ��_ � - n „��Q y . ��af � � r Z � L .�-X .�' � O `�1 � � � (� �. 3� Q � � ��' t� � ��► ` � � � Q � � C� _� ` � � t�, i'� .--� � � t � . � �, � � � � ta � � �,J�� �- � t�t -�`o �- � -�1 � � � C' i� �, .� �a - H � J� �N., Q ,`�� i�� � �� � � � Q � o �� � � � _ - F � �� �..� � � � --'�-4 �`� :��—, t�� `T � .�?�} ' ' � � i!,�,,�' -P j-� �� a ,� � � ,_._ � .-- � e .,.p-1' � ,f i� � fio '� � -°`� �` s ' r D s� t�/,, J � .. �' �.' s- `-� (+ � ``��' „p � � , t t� tN c� � vJ { T1 �� C� � �' �,'r : �� ; � l� f, ,� � � i . � � � � � � �_ � � � � � � . � Q � r" � � � ;�' �1 � ; f► u c' � � (> f:ti�' -o � �� -� � , � � �, -ry---� � � � � " E — , �� -�-�` � � � �� J' 3� [� � � .� � � '.,� � � � i {�" t� �.�. �1 tT� : � � Q �' � � �+a� � ---� 6' � � � t � r � .: �, � � � � � � �,�� �r� �,� �a-- = �- � . � e____ — _ C � � �.� �D,� -� �` � � � � � � � �. � � �� �� ' � � ����� �i -� -� � � ` � `'3 � � � ` �'� .R f�` ' � --� � z -� � � �=� � �,�'.._„ � �� � �c � � �. � � � � � � � � c� x � -�, c � -- � ° � � �� � � � � -� ���' � � -�=- a � z � y � �: . r � -� � : � � --�� � �v � � ,� � � � -- . -� : X � � �--- � � . z � Q �p � � � � � � � � � � x � ..,� ---� -P� �_ � � � � � � � � � �: x �- C� /� .}� ct- �` .�.,� �,-� � � �, �� N s �i £? �_ � {� f � . � �J sJ ��y _ r� � �t �*�-��. .�. + ,..::✓ N �• �``' � � � � � � � �3 � � X � � �� � � � � , c��J �t- ..�� � � � � +.r'� `S— '�C � i� t9':�C�`� � � �Q �� � � � C3 ... a u � � � �-�' �� �� �a t� �� ,� .` ,,� � �h �► � va N � p� � � � � y� _' �.�. � C� � f`� � � i t� ff yC� � CF C1 �'� �� r� � f�` —�{1 � �� � �� J` �� � � � � n ���� -r1 C1 � �� � . . �, `" � �. � � c g c �" � `' � s � � z � -Q N .� � � � � � ru � � � , � � r-- Q v � � - � C� m c► �; � � _ _ --- � Z � ( � Ti � CJ a � � � I � � ��Q � -1' � � R � ��� I �- � � �, � c �-- -�, _ � ► �---� " �... � � � � �� � � ��� r �1 v�� cJ .� -� � . � � b —° c� i� � x .A` �� �.� -� P ` �\ �1 _ '� . 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K� rtt � < � � � `-`� ``� i N � a c...�� m� z QO W � �� r � \ � � - - - - -- � � --- -- C�� :.t,,.a,:;;,.; �,� -- PRIVATE ONSITE WASTE TREATMENT county � ''��a � SYSTEMS SaWyeT ���S�s = ( POWTS) \�N �_`P."� . • ` �"��� ' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� — �(� Personal infonnation you provide may be used for secondary pucposes[Privacy Law,s. 15.04(I)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �a�.� �Pqsa-e t l — Insp BM Elev: BM D�scription: Parcel Tax No: 1��v� �"�`L 5 a' \ �{`-.S� ,1�1�0�,� � 'I'o O�Co1n�.�`T^d ��p- Y�9 '�Z - d 3��C TANK INFORMATION w• ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark � p` a 3• 3•o' (oo-c�' Dosing gw� a .6� Y•Y� Aeration Bldg.Sewer ,�' � .YS' Holding �,� p�� -7� St I Ht Inlet (�•�. ' 6. ' TANK SETBACK INFORMATION St/Ht 0utiet 6.S ' q�.s-� TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom � p.�.' q�,g` Dosing NA Installation Contour Aeration NA Header/Man. Holding �� k ` �3� S3a' L� � Dist.Pipe PUMP/SIPHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade Model Number � ' GPM �'{Yl � O� Io�. TDH Lift Friction Loss Sys Head TDH Ft � Forcemain L Dia Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters ❑ AG ° Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other DISTRIBUTION SYSTEM x Pressure Systems Only Header I Manifold Distribution Pipe(s) � X Hole Size I X Hole Observation Pipes Length Dia Length Dia Spac i Spacing ❑Yes ❑No SOIL COVER Depth Over Depth Over Depth of Seeded/Sodded� Mulched Cell Center Cell Edges Topsail ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies,persons present,etc.) ��s���� �� � 7 ��-d � �� Plan revision required?�Yes� No �3 (� �, � -- � J (��1 ��� �---�/� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AD0ITI�NAL C�MMENTS AN� SKETCH sa�a.T�Av �Ffl�;T ;�u�vt�=�, �D- 31 ----- �---- ` � a� N�M� ,��' ��svl��� � a _ __ . _ . � ���t�� p��� � � � d 36 , � � ,�� . _ _ _ ; _ : __ __ . q' ti'-� �"`' 3��� � � � .� Q � ��7 I t"�l�I ��� ��� $'Y'� , TJ�¢�`^�--�� '� , � � k3� ��� sa�_� � - �I �$� �� �, . � � _ . � ;� � �� � .---� � � � 4 � � � � � ���s � � � � � � ' ��� �'�-- � I l��`� � i � � � . I �c.�G �► ���T., � � � i I ;�--- _ � , ___ _________� � ; �--_------_-� � i � � ' L�� I�D,f� ' ' � �`'" ' ���� ��, ��p.o � � �� � � �� o � � r� 1 � ; ' ��' � 1� ; � ,�� 7 �;� ,,� � �d1.Z3 � � r � ;I ��� � �a ` �, .�`� �--- ������ �, � �`°� c� K ��� `r f (�i : \`a . �- �."' �- � �� �� � � ��� ��` "`"`` PRIVATE ONSITE WASTE TREATMENT county � ����os � SYSTEMS � = � P = Sawyer ``�; �S _, ( POWTS) ��`�=F" ``�� INSPECTION REPORT Sanitary Permit No: _,,,�,,,. Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� — �(� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. l 5.04(I)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �a�.` l'as�e.. � l — Insp BM Elev: BM D�scription: Parcel Tax No: ��.�' �"�`� Sa� �`—.S� ,�'•I�G� - � b�Co�nC.'-To'^r� . ��- '�39 -o� - �30� TANK INFORMATION w • ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark � 3,p� o3,p' (OO.c�� Dosing �3 w1 a .b� Y•Y� Aeration Bldg. Sewer ,� � ri YS� Holding � �� ��-� 7� St I Ht Inlet (�•�. � 6. ' TANKSETBACK INFORMATION StlHtOutlet b •S ' q�.S` TANK TO P/L WELL BLDG vENT ro ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom 1 p.a1 ' q�,�` Dosing NA Installation Contour Aeration NA Header I Man. Holding fi�� �- ` �3� �3�' � a � Dist. Pipe PUMP/SIPHON INFORMATION � Infiltrative Surface Manufacturer Demand Final Grade Model Number GPM �Wl � 0� r lo�. � TDH Lift Friction Loss Sys Head TDH Ft � Forcemain L Dia Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P/L Bldg Well Waters � G ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound � Other DISTRIBUTION SYSTEM X Pressure Systems Only Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length Dia Length Dia 3��e __Spac __�_ _ _ � Spacing ]�'Yes ❑ No SOIL COVER _ � Depth Over Depth Over Depth of Seeded/Sodded Mulched Cell Center Celi Edges Topsoil_ _ _ ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) Mu�..,�. ,�:��s.-��- ��,5���e� 1� � 7 ���-d �,l ����l ��� �`��_-�� ����,,.,�..�— I��-�1?1� � �� Plan revision required?❑Yes❑ No �3 �� �1 � —��-`�� - � C� '�l � �� ; Use other side for atlditionai information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITIONAL COMMENTS ANO SKETCH SANITAAY PEAMIT NUMBEA __ �O — 31�____ a - � . 8 n� � , � �c, . („ � � ��. � ` � � 1 ��(�CH\' � \ \ �'^� `.1�I�� w� � c �O � ` ,,,��la���p�� � 36 • �3� . 9� . ry,� . ��c 3 Q�� � � � 'c Q � �$�ll`�� k��" �'�- �nn� � TJ �e��`r � � 1� � k3� ��� S A�----