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Sawyer County Zoning Administration r�
10610 Main Street Suite 49
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SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: �� t� . ����,y�,^ �C�f+�•S�
TOWN OF: �,�t��S-
ADDRESS: � � �«Ow �HqQ„� Ilri •
I, �9�'.—��� �D2� , a Wisconsin
Licensed Plumber, authorized by the owner, do hereby acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, and private sewage system plan review due to inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381.01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
� deadline date may result in the issuing of a citation, under Section 11.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR THIS REEME SHALL : << I �� ��
�;�
Signed: _
Date: ��� l� —�-�
Accepted by: ��_ (�i.�� _
Date of temporary emergency approval: �,p��q �� —
Rev. 03/26/13
,
� "T;'E�, PRIVATE ONSITE WASTE TREATMENT county
,=������sp SYSTEMS SaWyer
���-2,1 s ,.� ( POWTS)
��`�"`" `�'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � 1 �- �(�
Personal infonnation you pmvide may be used for secondary purposes[Privacy Law,s. 15.04(1)(in)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
`��n 'K��wr�so-,�1�-s� �-I�c� r—
Insp BM Elev: BM Description: Parcel Tax No:
(d�•�� � n� ��,� '�.�� �, cG o�� - ^13�'- ��- S 23
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic u,;e �n Benchmark ,� ` /Ot/•7S� oo.a�
Dosing
Aeration Bldg. Sewer -�
Holding St I Ht Inlet ,(,.��"� � , S'
TANK SETBACK INFORMATION St I Ht outlet � Y�,� �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic .} ` .��. � �3' 4. 13� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. �-�,o ' q 7.-� ►
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative fi��s,� � i
Surface �(S,�g
Manufacturer Demand Final Grade
Model Number GPM O�-{w�^'� l9, 3� �S•YS��
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 We�� Waters o GP ❑ Chamber Model Number:
o 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 ___ Spac I ___ �I Spacing ❑Yes ❑ No
SOIL COVER _ —___ _____
Depth Over �Depth Over ' Depth of — Seeded I Sodded Mulched
Cell Center Cell Edges I Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No ' � �jq � j(o
03 �� � � —_�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBEA _____ a � ��____
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