010-171-00-0102-SAN-2022-244 Department of Safety c°°°ty SAWYER �
� & Professional Services, �
_' - Sanitary Permit Number(to be filled in by�
` _ . Industry Services Division � 3 � a 3 1 9,�
R7
Sanitary Permit Application State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropnate governmental unit NA �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing a� �
the Department of Safety and Professional Services.Yersonal information you provide may be used for secondary
purposes in accordancc with the Privacy Law,s. 15.04(I)(m),Stats_ 10567N PEN�SULA R�A�
1.Application Information-Please Print All Information
Property Owncr's Name parccl# ���- �'"1 � „ p�_ p I� '1
e�
HAROLD & ANITA EBNER TRUST
Prope�,�c��°����ESERVE PARKWAY �°p�`ty�`a`'°n
Go�t.�ot NA
City,State Zip Cocie Phone Number
WESTMINSTER, CO 80234 �e, �.se���on 23
II.Type of Building(check alt that apply) Lot� �r 41 N R �g C w
C�or 2 Family Dweliing-Number oCBedrooms 4 _ la.C� 1 t I�C,I, � Subdivision Name
� - r
B���k# ROUND LAKE PARK
❑Public/Commercial-DescribeUse NA
❑City of
❑State Owned-Describe Use CSM Number ❑V illage of
#612; V3, P278 ���f HAYWARD
ItI.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.)
A� ❑ New S stem
y �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holding Tank In-Gmund ❑ At-Grade gn Q� yp ( p )
❑ Mound ❑ Individual Site Desi Other T e ex lain
conventional) eo mat
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ "I'ransfer to New Owner �st Previous Permit Number and Date Issued
Expiration � � I _.(0� �/� p
6
IV.Dispersal/Treatment Area and Tank information:
Design Flow(�d) Design So'1 Applica ion Rate(gpd/st� Dispersa Area Req red(sn Disper, 1 Area Proposed(s� System E vation "7�25"'
600 07 1.6 �.O gS7 375 300 4�1� ,s 9 T.
Capacity in 7bta1 #of anufa � �
Tank Information Gallons Gallons Units ' y o 'b �
New Tanks Existing Tanks � o � � � p � �
n. U v� v v� i.i. C7 ti
Septic or Holding Tank 1200 NK 1200 1 WIESER COMB X
DosingChamber p0o QOO
O O
V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plu 's Signature MP/MPRS Number Business Phone Number
`r''�, G�. ���� ; /� [ 7tS�SS�I b73
Plumber's Address(Street,Ciry,State,Zip Code) , �
�
�05`7!� 1 tn�'�=/�.Qu.��-�t �4�tr�(�� � u� c�J�'�'`��
VI. u ty/Departmeut Use Only
� e ❑Disapproved Permit Eee Date Issued Issuing Agent Signature
�Owner Given Reason for Denial ���v•�� � �I�1 a� �:�(�Ltx�C.�'�'�9-
Conditions of ApprovaUReasons for Disapproval �- -- -
� � �_
� ��GI � �
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i�at� 1
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+.°'hk#� ��?3_..,
� S� �.2 — �o�—S �w w,o r t d �3350 .
Attach to complete plans for the system and submit to the County only on paper not ess than 8 t!2 x 11 inches in size n
�-(S /
NO RCFi1NDS AFTER
ss�-639s�x.o3i22> ISSUE OF PE'�tMtT
Dosi�D�
INDEX AND TTTLE PAGE
Owrwr Info
Projed Name: HERMAN&ANffA EDNER REVOC 7RUST
Owner's Name: (SAME)
OvmeYs Address: 11357 RANCH RESERVE PARKWAY
WESTMINSTER,CO 80234
Property Info
Property Address�. 10567N PENINSULA ROAD
HAYWARD.WI 54843 . . ... . ._.. .
Legal Desaiption: S 23 T 41 N R 6 W
Township Hayward County: SqWYER ,_ ._
... .. . ...... ...._.._.....
Subdivisio�Name: ROUND tAKE PARK
Lot Numbec t Block Number: NA CSMll: 612
Parcel I.D.Numbec 57-010.2-47-0&235 15-112-000102 V 3,P278
Plan Transadion No.�
IndeX Pages
Page 1 Index and title Page 9 Plot plan
Page 2 Data eMry �o9e�� Fiker specifications
Page 3 GeoMal dist.cea drawirgs&calculalions � c<<
Page 4 Lateral and cell aoss section Q�r�z
Page 5 Management&cortlingency 7�<<3
Page 6 Maintenance 8 specifications 1�a9 c�y Aerial .
Page 7 Tank aoss sections �ag�15 Pump curve
Page 8 Distribution media ,��,d,�e„cs:smge.�w��zwt�or�
i-e��;,�,r,�;.�1
MARV JO HUPPERT license Number 1859-007
.._. ..._.... .
Date: OSl14/22 Phone Number: 715-426-1775
T6����
SignaNre: (,�
Desigr+u Stamp:
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- o18�a : _ ���o�
, ;F:�:CR FALL3�;' ��In Ground Component Manual Ver MAy ZozL
'h�'ry�''`�.,-,�rSIG��.��cey�`
%�umrnmtun�
Page t of 15
m�na ana Dosi�e Di�'�°"compon.�rt oesfgn
. , ,�r� ., ,_ . _
Stta I�ormation
R ResidenGal or Canmercial Desgn N ISD Required?
A00.00 EStimatedWastewxlerFlaal9Pd� .
1.50 Peakirg Factor(e.g. 1 S=1 W°b) .
600.00 Design Flox(gpd) �
' 2.00 Site Slope(%) q� � �-
�
. .b6.6YPre0.SYstem Elevation
� 47.00 Deptl�to Limmrg Factw(in)
t.60 In-situ Soil Application Rale(9P�)
98.60 Lowest Original Grade Ele.In SysMm Area(R)
99.50 Highest Original Grade Ele. In System Area
"g4.yi-�Llm'Nrg Factor Elevatlon((t)��� a��
1.31 DeDm Below Grade �
Dishibudon Cell Information
325 Cell WidM(fl) 3 Number of Cells
2.00 Dispersal Cell Design Loading Rale(gpMt�)
2 Influent Wastewater Oualiry(1 or 2)
D�ib1bUN011�IIfO�Ill�h011
E Center or Er�Manifold,Oist Box or Drop Box
0 Change Cell WidML Num.of Cetls or Manrfold System dosed Y
425 Lateral Spadng(k) _,
1.96 forcemain Dreinbad�(gal) Does the torcemain drain Dack7 V J
0.50 forcemain Filler Loss(ft)
2.00 ForcemainDiameter(in) I
12.00 Forcemain Length(ft) � � �1 `� L. _ l�w gY�,�
88.00 Inside Pump Tank Elevation(ft) �'— � �We�
3.50 System Head(/t)z 1.3_
1079 Vartiral LiR(ft) �—
7.39 Fnction Loss(ft) �
16.18 Total Dynamie Head(fl) � Oe��qne� �r�.s�erte�!na:or icse ac;f ss'err :e���ara,qpm�
Minimum Dose Volume(gal) �� (� / �,1- �
25.00 Sysiem Demand(9Pm) � �� I�. `fY�� :/I\"rif ?�y� a� l3l P�`�"`q /
� �f�',�
Manufacturer Information k (�
Treabnent Tank Informafion Effluent FilEer Infoimation � `
1200.00 Sep6c Tank Capaary(gaq see pump lank Flter Manufacturer r( �
Wiaser Concrete ManuFacturer see pump tank Fitter Model Number �
Dosa Tank Infomution Gallona/Inch Calculator � � -
800.00 Dose Tank Capacity(gal) ?otal Tank Capaary(gal)
2224 Dose Tank Volume(gallin) Total Workirg Lpuid Depth(in)
Wieser Concrete ProducLs,Ina Manufacturer ��galln(en0er resutl in cell DosaTaMcVolurtic)
Project HERMAN 8 ANITA EBNER TRUST Page 2 W 10
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� -..---�-.r>o'ft A 32 Basal Area Required 37
K 1 B 31 sal Area Proposed /��_ R' ���
S 1.0 L 3
W 13.7
Basal Area Calculation GeoMat Dis ersal Cell Basal Area Calculation
GPD Loadin Rate GPD Loadin Rate
600 1.6 usa�vaay 600 2.00 oausq roder
Total 37 Total 30 ���,.,_�...�.�i .
Pro sed 302.2 y.,-; a�;,. �
Number of Cells GeoMat Width 3.25
Cell Len th � �-���'�ft Lineal Feet of GeoMat Re uired 92.
.._..._''___
Min. Cel�Len 30. �neal Feet ol_ Mat Pro osed 9
Celi S acin 1.0 ND7'EMin S d�mension= P
�/4 �
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S stem Elevation �s
Limitin Fador
aration
. . �� ��u ia . .. . . . . . � _ . . ,. Remembe � . , . � -_ . _ . .. . .
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Project: HERMAN 8 ANITA EDNER REVOC TRUST Page 3 of�t'j
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Dose Tank Information
I.ucl.lnp mrcr��iih�wming lahel. —
IocAinc dcci.c and��atcr Iichi saal �
` . J..\'cnlcd(b.cr Y
lilcchical Ix�� . . '
,s p.�uir;ou ,
.md tiPS:Il�'_%VA.-A�' �
!l-. �{�, fini�hcJ Grade _:1d� .. !i-I� .:{{�� 1� 1�. .i.: .... �
Di�cV�mccl'
a"Clean uul Pipc ��.�.� OpGun;J ball�alrc
VA'{rn I�rmn 17eclri�sour�� � �,.�� � ��(>pGoii�l iN eJ af
__. . . . � dnscd
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J"liilci CJl l�ih.r ', � i
u:�in, i j . .__ r� Forcemaindiameter
13oss siop �' � I �r ns�i�i�o a vl �,� 2 in.
Jncl�valtr . � � nc:�a 1 r ma n,
� Ul�ll�'.ItikCl , `. .oliJgruund � ;
' ���mnh..l.,,.��n Pumco
I�'.q�nond.�l.c �
IIiL'h��atcralarm�., =
(,_$t_�, ni
Tl'ump On Ilunt�'� �. '''
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�Pump Off Plu:�t•I � Pwnp F� �� tion(k) �
� +I_ , 88.83 '
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971a..j...n�:•s•:::ga;.•:i��� k�• »n.•t�••,;::�:�'riii?�i:pas�:::::Eiij . a levation(ft)
...... � D
y•�•a:.a:.a s....a..:..: I3cddin_undcrlank::::� ••••.• .i;; ••^•.
ii:i:7:F;. '�ie..x�er�«•..............................................e#.i.:pG4;;,b7.;,F..�c;;;�ri;iEi�.;Fi�:;: SH.O �
Dimension Inches Gallons Wieser Concrete Products, Inc. �
A 21.19 471.16 f Capacity 800.00 I ' ' � �� �
B 2.00 44.48 Volume 22.24 gal/inch
C
D 10.0 222.40 ��,5 t �•�� ` p
Total 35.97 800.00 � �� S � �
Filter Manufacturer NEW SEPTIC SOLUTIONS \
Filter Model Number CLEAR WATER �� �t��. , �,/ I\.�.J �.�- .�a�.,,�- 1
r-� �
Alarm Manufacturer SJE Rhombus
Alarm Model Number AB TANK ALERT
Pump Manufacturer Zoeller Compan
Pump Modei Number 98
Pump Must Deliver 25.00 gpm at 15.64 TDH
Note: Switches containing mercury may not be used in this system.
Project: HERMAN &ANITA EDNER REVOC TRUST Page 7 of 15
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Diatribudon Cell Cross n �����l�
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Notes/ Maintenance Requirements
MANAGEMENTPLAN
This private onsi[e wastewater(POWTS)has been designed,and is to be installed and maintained in accordance with SPS 383,Wis.Admin
Code,the in-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treahnent Systems Version 2.0 SPS-1070SP
(N.01/01). GeoMat i�ground Component manual Version 1.
1.This POWTS has been tlesigned to accommotlate a maximum daily flow of v� allons of wastewaler per day. The qualiry of
influent discharge into the POWTS heatment or dispersal component shall be equal to or less than all of the tollowing.
A monthly average of 30 mg/L fats,oil and grease
A monthly average of 220 mg/L BODS
A monihly average of 150 mg/L TSS
Wastewater shall not discharge to the POWTS in quan[ities or qualities that exceed these IimHs or that result in exceeding the enforcemenl
sfandards and preventative action limits specifed in ch.NR 140Tables 1 &2 at a point of standards application,ezcept as provided in DSPS
383.03(4),Wis Admin.Code.
2.The owner of lhis POWTS is responsible for system operation and maintenance.
3.Defects or malfunctions identified dunng maintenance described above shall be repaired in conformance with SPS383 Wis.Admin.Code,
and the pertaining county Private Sewage Systems Ordinance. The user's manual,provided to the owner of the POWTS includes the
names and telephone numbers of the properly lice�sed individuals to contact for such repairs.
5.No product for chemical o�physical restoretion or chemical or physical procedures for POWTS may be used unless approved by the Dept
of Commerce in accordance with SPS.384,Wis.Admin.Code.
6.If the POWTS is replaced,or its use discontinued,it shall be abandoned in aaordance wiM SPS 383.33,Wis.Admin.Code.
NOTES
Two Etfluent Filters to be installed where possible 1 to be installed in ST,arM or 1 in pump tank in order to insure paAicle size
less than or equal to 1/8". Filters should be cleaned once in spnng,and once in fall. Also,strainers in sinks in the building shall be
maintained,so that solids and fats are minimized to flow into system.
A minimum of 2 observation pipes per cell shall be installed. These pipes shall be located approximately at the end of each cell.
The plumber,or county shall see to R that a copy of ihese plans inGuding this page,maintenance folder,and maintenance agreement is
given to the homeowner.
This system may confain a dose chamber. If a pump,flwt,elecUiral outage causes the dose tank to fill,the homeowner should see to it tha
the effluent level in the tank is brought down gradually arW not all dosed to the system at once. One large dose could cause damage.
Contact a pumper or your installer if this problem occurs.
The homeowner is responsible for formulating a water conserva[ion plan Ihat will ensure the system is rarely overloaded. I.E.spread
laundry out over time,not 6 loads in 2 hours,while everybody showers,and uses the toilet,ETC.
CONTINGENCY PIAN FOR COMPONENT FAILURE
A.Septic Tank.Any shuctural failure resulting in cracks or leaks in the tank must be corrected by replacemeot ot the septic tank component.
Leaks in the joints between manhole risers or covers shall be repaired by replacing fautty seals with approved materials to make joints
waler-tight.
B.Outlet Filtec The outlet fitter shall be replaced or repaired when it is either no longer capaWe of preventing the discharge of partides
larger than 1/8 inch or when it has become permanently degraded by Gogging so as to interfere with the design flow out of ihe septic tank.
C.Dosing chamber and pump.The dosing chamber shall be replaced if any structural failure is found.Leaks in joints belween manhole
risers or covers shall be repaired by replacing fautty seals with approved materials to make joints water-bght.The pump and controls shall bE
replaced when they are no longer capable of functioning according to Ihe design plan.
D.Pressure Distribution Piping.Partial clogging of Ihe distribution network may result in unduly lo�g dosing cyGes.The ends of the
distribution laterals may be exposed and the threaded end wps removed.The pfping can be diswnnected on the outlet end of the pump.
The disfibu[ion piping may Ihen be back flushed to deanse any accumulaled matter from the piping. I[fs rewmmended that ihe dosirg
chamber then be pumped by a licensed plumber.
E.Soil AbsorpUon Cell.The discharge of sewage or wastewater to ihe ground surtace is stnctly prohibited due to the human health hazard
created by the effluent.All failures created by surtace discharge shall immediately be reported to ihe appropriate county.The pump shall
then be immediately disconnected to prevent further discharge to the ground surface via the soil absorption cell.The ewsting sep�ic tank anc
dosing chamber shall be used as a tempo2ry holding tank until the necessary repairs to the sal absorption cell can be achieved.The
replacement shall be initiated only afler any necessary plan approvals have been oblained from the
appropnate plan review authority and the required sanitary permit is obtained from the county.
Project: HERMAN &ANITA EDNER REVOC TRUST Page 5 of 15
In Ground System Maintenance and Operation Specifications
__ _ _. __ .
Service Provider's Name�RED'S SEPTIC SERVICE & REPAIR Phone 715-934-4912
POWTS Regulator's Namerawyer County SPIA - Zoning Administration � Phone 715-634-8288
System Flow and Load Parameters
Design Flow - Pea 600 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow - Average 400 gpd Maximum BOD5 30 mg/L
Septic Tank Capacity 1200 gal Maximum TSS 30 mg/L
Soil Absorption Component Size 100.75 Maximum FOG 10 mg/L
Type of Wastewate Domestic Maximum Fecal Coliform 10E4 cfu/100 mL
Service Frequency
Septic and Pump Tank Inspect and/or service once every 3 years
Effluent Filte Inspect and clean as necessary at least once every 3 years
Pump and Controls Test once every 3 years
Alarm Should test periodically
Pressure System Laterals should be flushed and pressure tested every 3 ears
In Ground Inspect for ponding and seepage once every 3 years
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap
and are secured in as shown in the GeoMat In Ground Component Manual Ver. March 20, 2017.
2. Dispersal cell media conforms to GeoMat products approved for use with the GeoMat In Ground Component
Manual Ver. March 20, 2017. Media is covered with an approved geotextile fabric.
3. All gravity and pressure piping materials conform to the requirements in SPS 384, Wis. Adm. Code.
4. Scarification of basal area is accomplished with a rake or other tool.
5. All disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration.
Lateral Turn-up Detail
6-8" Diameter Finished Threaded Cleanout
Lawn Sprinkler �de Plug or Ball Valve
Box �
Lateral Ends at Last Orifice Where
Variable Length Cleanout Begins
Long Sweep 90 or Two
�_45 Degree Bends Same
Diameter as Lateral
� -
Distribution Lateral Lateral Cleanout
96.15 Feet
Project: HERMAN & ANITA EDNER REVOC TRUST Page 6 of 15
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�C�NEW SEPTIC Address:N6643 Blue Lagoon Lane
S 0 i u t i 0 H 5 City,State,Zip:Caxo,Wi 54250
Telephone:608-333-3610
C LEAR F LOW Email:info@newsepticsystems.com
Website:www.newseDticsolutions.com
F I I_TF R
INSTALLLATION AND SERVICE INSTRUCTIONS ��� ____ _{�
�
MODELNO. NSSCFF324 �' --�"--
FILTRA710N 1/16" (.062"diameter holes) �� �
FLOW RA7E 83.8 gallons per minute @ 1psi. �1
TDH Increase the total dynamic head loss by .OS feet
of head to overcome friction loss from the fiker _..-----�
INSTALUITION
7he NSSCFF324 Clearflow is made to frt on the dixharge port of any pump with
a 2-inch NPT diuharge.The fiher wn be adapted to frt pumps with a smaller L_J
diameter discharge.Install the fiher in a position where it will be easy to service. ��:�-��
1 � � i
• Place a 2-inch Schedule 40 PVC male adapter(MIPT x socket)on the end of fiRer. ; ("�l-�
• Measure the amount of Schedule 40 PVC(tail sec[ion�needed between the fiher � `+}`. ,.,� ^
' �./7sa��
and pump.Cut tbe pipe to the desired leng[h and insert into the pump&fiker. � � :< <y��
• The fiker housing has a 2-inch Camlock coupling connection to the force main. ; �
� ,
� DO NOT REMOVE FILTER IP WATER LEVEL IS ABOVE FILTER CANISTER ' +
� 5
The length of time required between service intervals is unique to every application. ��
As such,we recommend the filter be checked within 12 months of Installation to �
determine fu[ure service in[ervals. Systems with known or suspected high volume � REM ra. , PARI NUMBFR �
usage should be checked six months after installation. �', ' _ ♦��"Botly __-�
DO NOT USE PLUMBING NMILE FILTER IS REMOVED . Z___�c°"'i°"..
ClE/WING TNE SCREEN DO NOT ALLOW SOLIDS TO FALL INTO FILTER CASE l e��c�
� � ��tage Gastet _.�
• Unurew the 4-inch cap and remove the screen from the filter housing. � , 'x,�„��
• Taking proper protedion,dean the screen using a hose with a spray connettion. �
• After deaning,inspec[the screen for damage or corrosion.(Replace if necessary.)
• Place the ureen back into the fiker housing and screw the cap back on,taking care ���, : .3�`
not to cross the threads. . ��
i
I �
4uALfTY
The fiher housing,cap and toupling are made of heavy-duty ABS injec[ion molded i
plastic.Injection molding insures[he first part made and the ten thousandth part ! ' �
are virtually the same,insuring consistently high quality in every part. I
I
The stainless steel screen is made of 316L((L stands for Low-meaning low carbon) i
316L stainless contains molybdenum,an alloy which increases strength&hardness � :�z ,
and enhances resistance in areas high in sah air and chbride,giving it the nickname
'marine grade's[ainless steel. i itern No. sw-F��e Nome�F�e rame�
: . .._. __._ . . _ _.
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EBNE0.A1TpCNMENT
""�='��'-�"�`"<�� PRIVATE ONSITE WASTE TRE�ITMENT county
% �,.�,
, ;
;��=�� o$p ����1��; SYSTEMS SaWyeT
����'��� s� %�� ( POWTS)
\�UFT`. �P/
�s—,°"-,''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �a � � y�
Personal infonnation you provide inay be used for secondary purposes[Privacy Law,s. 15.04(l)(m)�
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�� �'M q WC�� ^
Insp BM Elev: BM Description: Parcel Tax No:
(6���� y r,,,, � ��r� O(0-�I'�(^ac�-010�?
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�,j�s-_ 2,.0o Benchmark lOo,a�
Dosin9 —co,,,1� g�
Aeration Bldg Sewer ��. �
Holding St/Fit Inlet �g,q6'
TANK SETBACK INFORMATION St/Ht Outlet 4�76 `
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic h�S' �ts` � � .F.g` NA Dt Bottom 4��
Dosing " " �� Y NA Installation
Coni:our
Aeration NA Header/Man. q8 8,g
Holding Dist. Pipe
PUMP/SIPHON INFORMATION Infilt�ative G,7 �St
Surface
Manufacturer Demand Final Grade �`� Y�
Model Number `� GPM 'b e33 �f'� �S
TDH �{ Lift Friction Loss Sys Head TDH Ft H;� �; Q9.,3j� �
Forcemain � t 6a` Dia �" Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W �y L ' #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav 6� Conv ❑ Aggregate �v(M4�"
INFORMATION P/L Bldg Well Waters ❑ AG ° Chamber Model Number:
❑ EZFIow
CELL TO d-'$" •f-(c� .fi1pa' ❑ Mound o Other
_ -- — --- -- --
DISTRIBUTION SYSTEM x Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
I Length Dia Length Dia Spac Spacing ❑Yes ❑ No
. . —
.
L�.---- —-
_ -- -- __ - -
SOIL COVER
---- ----__ _ --- -—
IDepth Over Depth Over i ptDe h of Seeded/Sodded Mulched
Cell Center Cell Edges ! Topsoil _� _ ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies,persons present,etc.)
�IE'�/�( osl(�(�3
-- - -
� -�
Pian revision required?❑Yes ❑ No i d o5- � � � � G�'��,�
�L_� �--- ��-'u�'�� - � _.
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITI�NAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NIJMBEA:___�.�.-�?��____
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