010-941-20-1201-SAN-2022-264 ,���:;='-"'.�;�.. Industr�-Services Di��ision Co�mty �J
-�~, _ �1822 Madison Yards Wa}� S8Wy2� �
;�� ,, t� - Madison. WI �3705 Sanitan�Pennit Number(to be tilled in b��
�. E P.O. [3ox 7302 p
��''4;;-`—= Madison. WI�3707 � ,3� '�� p �
,.���.:,,::�`.
State Transaction Number �
Sanitary Permit Application '
ln accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis fonn to the appropriate governmental unit �
is required prior to obtaining a sanitary pcnnit Note:Application fonns for state-owned POWTS are submitted to ProjecL Address(if different than mailing,
thc Dcpartment of Safety and Professional Scrvices.Personal inionnation you provide may be used for secondary �08��� ���,�� p� �
purposes in aeeordance rvith the Privacy Laee,s 15.04(I)(m),Stats. «
L Application Information-Please Print All Information
Propert��O���ncr's Namc Parcel#
Shellee Lake 010-941-20-1201
Propert}�O���ncr�s Mailing Address Property I.ocation
10808N Gorud Rd �;��,� ,,ot
City.State 7.ip Code Phone Number
Hayward, WI 54843 '�� �� s��t��,n 20
I1.'Cypc of I3uilding(check:►II that apply) �.����s 1'41 N R 09 E or W
�I or2l�amil��D���elling-Numhcrofl3cdrooms 3
Subdivision Name
131ock N
�Public/Commercial-Describc Use
�City of
�St�te O�med-Describe Use CSM Vwnhcr �Villa��c of
����,��„�,f Hayward
IIL 7'��pe of PO��'TS Permih (Check cither"New"or"ReplacemenP'and other applieable on line A. Check one box on line l3.Complete line C if
x� licable.)
`� Ne��S�Stem Re lacement S stem Other Moditication to I�:xistin S �stem ex lain Additional Pretreatment Unit cx Iain
� �� � p Y � g Y- ( p ) ❑ ( P )
13' �1 lolding�Cank �In-Ground �At-Grade �Mound ❑Individual Site Design Other Type(explain)
(conventional)
�• Rene�cal E3efore �Rc��ision �Change of Plumber �Transfer to Ne�c Om�er
l ist Previous Pennit Number and Date Issued
F�piration K�Y�♦ � "7 z,� I��Q
IV.DispersalfTreatment Area and'Tank lnformation: .'2
Design I�lo�c(gpd) Desien Soil Application Rate(epd/st) Dispersal ca Required(sf) ispersal Arca P��(st) Syste Flevatioi�
450 0.7 643 96.50
Capacity in Total #of Manufacturer
�
I�ank Information Gallons Gallons Units � � ,o � �
New Tanks Fristing Tanks '� o y � � p � �
C. J v: � v� u. C7 C.
Septic or Holding Tank 1000 1000 1 WIESER CONCRETE ✓ �
Uosing Chamber � � �
V.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber' Signature MP/ti1PRS Numhcr Business Phone Number
Travis Butterfield 652879 715-634-8176
Plumher's Address(Strcet,Ciri�,State.7ip('ode)
14346W St. Rd. 77, Hayward, WI 54843
VI.C unt�/llepartmentIIse Only
�A ro�� C Disapproved $ermit Pee Datc Issucd Issuing Agent Signaturc
�y✓ y(�p � `� I a�..��� �.��c�.H��
❑Owiier Given Reason fbr Denial i
C'onditions of Approval/Reasons for I)isapproval �_ �j
•,}��i ��� .r��l�"
� � . � �a-�-..�._____. . � � J�
� .;;j'^^^ +� �. l ���\/�3�C_�l � �- � D
�i� �i� I �i�"g► +�J �� l cl"l�-I __ \.f�.-
:.�;. ��_ .��_m �. SEP 2 1 2022
1. .,n?:/ " .. .�0 Y��� � �J,J I _�
��
Qil/�� .,.__..-...:,.�,......._.....
s � �a - ��� ��} SAWYER CC�� .���Y
� itVl���1'�TIUN
Att:�ch to complete pinns for the sys[em and submit tu the Coimty only on paper not less than 8 U2 z I 1 inches in size r� r�(�,/
I d�O'lL�O
sE;��-63�s�R.ozia2� NO R�FUNDS AFTER
ISSUE OF PEfiiMfT
PAGE 1 OF 3
In-Caround Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 3 Index & Cover Sheet
Pg 2 of 3 Plot Plan
Pg 3 of 3 Management Plan
Attachments: Enclosures:
---- ___
POWTS Application for Review
_ ___ Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): Shellee Lake Phone: - -
Owner Address: �0808N Gorud Rd, Hayward, WI Zip: 54843
Project Address: 10808N Gorud Rd, Hayward, WI 54843
Govt. Lot: 1/4 of 1/4, Section 20 , T41 N-R 09 E❑or W �
Township: Hayward County: Sawyer
Project Parcel ID #: 010-941-20-1201
Designer Information
Designer Name: TravlS Butterfield Phone: 715 _634 _8176
Designer Addres�: 14346W St. Hwy 77, Hayward Z;p: 54843
E-mail: OffIC@ C�X �JU�teffl2�C�C�I"I��If1g.001"Tl Tl�is space reserved tor approval st�imp.
License Number: 652879
Remarks:
Signature: Date: °f zl ZZ
Origi signature required on each submitted copy.
CHECK BOX AS APPLICABLE. � CHECK BOX AS APPLICABLE.
❑ SOIL EVALUAI"IOIV o s��e: 5�0 50 �5 �oo � �YSTEM PAGE 2 OF 3
SITE MAP PLOT PLAN
PROJECT NAME: z oEsicry F�ow: �{� GPD
�{�l e l l'P�. �Y"�— 12.5 g p
Attach desi n flow calculations for commercial lans.
PROJECTADDRESS: `Op 0� � �D/��.v� � Pipe Material/ASTM Standard(Tables 384.303&384.30-5)
N Sanitary Sewer: Y���� �J/
BM Sym6ol: -�- BM Elevation: /�1�.O FT _
Force Main: /
BM Description: ��'� f.'� � � DI�� �
Slope Gradient(%) Indicate north by IMPORTANT:
of Tested Area: Weli Symbol(if applicable): Q drawing an arrow Show ground elevation contours at suitable intervals.
on the approprite line.
$�r e(,�ec ��� /�
��d,vl5 �j?w`�'� `P f,G!'
(o&o8N Gvruo( R�
�.-�wc.rd �u>.Z. SY�Y'`l 3 � �S�a- �� �
l�%�� D/o9Y/��>�/
�V�..��NL` S v'v "T %/N k�9 w
� �'"� ' l� �,.�( ,h s7 �o�
i� - 99.0
� .
0
�
� /o� Ga � wl�S-t/' Co�c're� '1�.��C � � ,�,,1�
9� �Cs � �,//� I,
I�I
�
� ��
�
^ o
a
� �'oilil�•c7`- �,�V'.'•
� �1'c!/�e�n f'*e(�
0 0 ✓e w r .
� 4�
�
�n�x�� �,�..e ��D�
PAGE3 OF 3
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code,this system shall
be considered a human heafth hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Dispersal Area Operatinq Limits:
Design Flow= 450 gpd; BODS<_220 mgL-'; TSS 5 150 mgL'; FOG<_30 mgL-'
Inspection Checklist WSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisancefactors(i.e.odors,usercomplaints,etc.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatment tank(s)and any distributlon appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use(i.e.:exceeding design capacities,prohibited activities,etc.)
o extent of ponding In distribution cell priorto dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settings,efc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure Iaterel distal pressure--compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Septic and dose tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent filter(s)shall be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Butterfield, Inc. 715-634-8176
Name of individual or company: _. __ ____.Phone:_
Saw er Count Zonin 715-634-8288
Local government unit y Y 9 Phone:_
_ — ____ -- —
�o�ai go�e��me�t Un�t aaa�ess: 10610 Main St. Suite 49, Hayward, WI _ ZiP 54843
Any defective part of this system shall be repaired,replaced;or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code.Repair or replacement of falled or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Contingencv Plan
In the event that any falled treatment component of this POWTS cannot be repaired,it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
APPL.ZCATION FOR SAWYER CO UNTY
� SAN,TTARY PERMIT
� b
�AppZication # r'' � � ��" Da�e �,� �{�, � '-�
, r� �
� �-t ` '�,.�, �� � . ,,� .r /.�� x �
�'ee of S �0 < 00 received �: .� ``� " !'��, ' r . r<.�.<� � �, ,c��.-�-�_. �- ,-� �
Date County'"'C erk
� � ��'
' A�a� Zication is here�iz� made for a Sawyer County Sani �ary
Permit for �ork to be done on the premises described herein .
..._..�.�.- / ` �
� f �� :� � ' ' � : . �... � � : I ,�;-. �; _, ,«,, .
�..3 �t` .� ,C�,�/�r___`�'l"C.x.�,�._._._.,�: r `1`= -�C. f�
Ou�ner Ad rtss " TeZephone
The �""��_ o f the �i � See . � � ;�. Tu�n . �,r'f�/' R. ��(�,�'
or �
Lot _____ BZock Subddivision __ ���} �(�
f r^�'�+ �,. .A.;.f J sa+ +� (�'' —.�—,.�.. '4E `a�?....f"e��r `f—' �''! ";Ff,� /� '�ZS�.�.
..... '�. .. '
Work con���a 7'o be per forme y
___ .__ p �
Number o f Bedrooms __ :�' Number o f Bathrooms _ , /
Dish�aslzer ,�-� Garbage Grinder �,.�
Automatic Washer 1.�--�
Soi Z Descrip tion ; � . ,.; , ,%
Septic Tank Size �"�_ gal .
Seepage Pit Hezght Dia�►eter „
` Seepage Treneh Length .:� .�;� Width �� Depth - ._
Septic ?'ank Permit � �� � � ,��
Percolation Test Form PLB 43 attaehed t�'
Yes No
ContempZqted completion date � � ,ZS-72— �
AppZiccztion Approved Permit #� � '�
<� ,
Sanitarian �, � � . t 1 �r , '3��. t �. K� " ��� " � �'--�
� � � Oraner7Agen I?o 2�2ed Date
Re ma rk s
Finat Inspecti , _ _ _
Sanitarian �eC.� ��' � �� 7 -- � �
Otvraer/Agent Notified (Date )
8emarks ___ (���---
* � * Se�d ox�ig^4nu�- and thxee eopies r.�ith � '� * � ``:-
fee a,� 5 �0. 00 ta .County Clerk �
�iaoonsia Depwrtmeat of Heslth and Sooiul Servioes
Plbs �b7, g��p Division ot Realth
SEPTIC TANK PERMIT APPLICATION
TYP� or U5E BLACK INK
I1. E1WtdEA OF PRQPSRTY
Hame Addrass (Street� City, Zip Cods)
��'3'" . ���,.,�, , ' � y:A��� '
�. v
r
$. LOCATI�1 OF PAOPERI'Y Wi-�RE SYSTfM WILL BE CONSTRIICTED ALTERED OR EXTIIZAED COtINTY _ `:��� ,,�,�
Cheak Oner �
�FTY VFLLAGE LEGAL DESCRIPTI�f
�,1_����.'TDWAI�S HIP �,,�
r''�'`,%'> rf'd :! / f ` f ,
f T r �
C. IS LOCAL PERPiIT REQUIRED FOR THIS WORK? t..-^^-�'YES Np /�;3� PERNIT NUMBER
D. SEPTIC TANK CAPACITY �_Gallons NEb! INSTALi,ATION _���".�' REpLACQ�gNT �' ppDITION
MATERIALSt Prefab Conorete poured in Placs Steel� Other
MIMBER OF T�NKS ?0 BE INST6LLEDs �',.L� '
E. TYPE OF QCCUPANCY
�heak One= One.os�w--Fami�y Residence v''� Co�ercial Ittdustrial Other
Speaify
Number of Persona to be Accommode.ted � N�ber of Bedrooms ��
F. APPLiANIIES, ETC: Food Wast• Grixider YES � NO Automntie Clothes Washer YES *-- HO
Dis2masher YES ..—�- NO Automatia Pototo Poelsr YES_:�I�W
Other (Speaify) .,,..--
G• MAS'P�R PLUMBER MAKING INSTALLATYOti
� /
Nama: !',,-r �-r_.�r-F f; __ s-'-r.►�i�oi�r�i�r Address a ,��.s��_ �. �_ � �i�,�,�,�T Lioenss Numbers
.�'�--` �
. ' , Kp � ,. .
_� _ ,-'
Sigisat�ro of Applioant: ,�"�� �. , _ ��
�� �
.. � t7P RSN
Addresss !�..�,/r.L �
-- �! .�. � �'''�%y'--e'
�• (To be Completed by Iasuing Agent) �D
� ��
Date of Application L.1 — :� �r�' �'` Fee Paid f ��r
Permit Iaeued (date)_ ;��f � 7� Parmit Number Ej� < (j
a '
Agent (Name) �� , . ,>Y�� � ;, r`> ,"i a�: E.€* Fori �;;j,c_>r<..P� 1
; .�
� ' To�n, Vit age, Ci , Co~unty, etc.
�SP�PY)
Note: The applioation oannot be conaidered for fiiing until all oP the above questions .e ansxered and the
fee paid. Agents xill foresard appiiaation, the fee of $1.OG for oaeh septie tazuc and the tnird oopy
of ths permit (oanary) to ths Division of Health. Cheoks aad mouey orders should bs �de payabl� to
the Division of Health.
Do not writ� in spa.ce beirnr - F6R DEP�IRTriENT USH ONLY
I. DATE RECEIVID A�CEPTED BY g��Ep
(Initials) (Date) See Corres,)
FEE RECEIVED YALID. Ho. PERMI4 N0.
es or No
REYIEWED BY APgROYEB DATE
(Initiais) Yea or No
COMPLETE �1'HER SIDE
ssPr� Taxx �xrsrr xo.
R Y P 0 R ? 0 li S 0 I L P = A C 0 L A T I 0 N ? Y S !
� IiD S OIL H OAI NGS
70
DIi/ISIQN OF gEAL?H � PLLT�ZNG SB�'tFt�li
P.O.Box :f09, qa,dison, itia. 53701 ,
Puraueint to H 62.20, i[1s. ��aiaistr�ativ� Code
P S R C 0 L A T I 0 ll T t 5 T
Test Bspth Ctisraotar oP So11 �Hours Water 7erC ?iwe Dro in T�Fater Level Inohes utes
N►sber Inahes Thialme�s in Inahsa Sines Hola in Hol• Interval Second to Next to La�t o Fsll
lst iiatted Overeti in Hiuutes Last Psriod Lnst Period period Onr Inch
Example
F - 0 36�� ?o Soil 10N C 26p 25 Y�a or No 30 1 2 1 2 1 2 60
� F✓,r, :f ` � _= F } 5 ,y .d r'+' ,r',
f
� _`�,,, .r �,'`tR c� i� !�' �:'".° /f:s
;t ` , . ;:
y:
:.i' 11,1? -° r a � e • ��...� �µ y �f� ,/r� .,'.=� !�.' .. I�r
/£` AJ t<
AECORD DATA FAOd1 MINIMUM OF 3 TEST HOLES
Co�eputs siz• of absorption ar�a in aoaord xith H 62.20 iiis. �iihfstrative Code.
S 0 I L B 0 R I N G S - Hinimam 36N Helo� Pro osod Abso tion S st�
Boring ?otal Depth De th to Grouad tiat�r De th to Bedrook
l�ber Inoh�s Qbserv�d =stiraated Obaerved &stimsted Ct�sraatar of Soil with Thiol�►esa in Inahes
�aapl�
B - 0 72N 72'� Hlaok To Soil 12p C 18�� Sand 18y tiravel 24��
t� � /�r• r .. ,� ,t
cz': ;,. ,„,, t� , �, � f�
f / .
_�..-.-- i_i''-� f� .�^I . . . . ,
- �
, �...1 !,� ` �i';�l� r . � ' , j �
R&�AD DA�� FROM IiIHIMIRS OF 3 BORE HOLffi
YPfi OF OC�UpANCYa -�.�
RE5IDElICEi Nuubar oP Bedrooma�i OTHER: (Speoify) Number of P�rsona �%
NASTE GRINDFRe Yas No�^^"� Diatnrashart Tas No �—' Automatic �lothss itasher: Yes No �^^"-
��
FFWENT DISPOSAL SYS'P�Ms NEFf t�7CTENSION ADDITION REPLi�tENT �^^'''`��
4ils Siz• No.Lin.Fset Tranoh Nidth Depth Nwabsr of Lines
f t r.� r� r�
Seepag� Beds Length -��' X3dth �:d- Depth ��Tila Size `O `No. Lines ��
Sespegs Pitt Insid� Di,aaeter Liquid Dspth
I� the undersl�ed, hereby oertiry that the peroolation tests r�ported on this torm wera made by me or ursder iey super-
vision in saaord with tho procadures and method spsoiPied in Chapter H 62.20 (13), Nisoonsin Adtinistrstiv� Code� aad
that tku data r�oorded snd location of test holes are oorreat to Lhe bast of � knoxledge and belieP.
AIAME if> ,� ��' r?C �'- f'*` �.f�u aG" TITLE r:�" �
�s or Print
REGISTAAPI�N N0. or MASTER PLUMBER LICIItSB N0. r'rJ ,��r
ADDRESS f'�:f�'`fr yc.�� v-c�; �r S G. �% �j ��l r..r
. � _ �-
. , �,. :
DATE �l�-- .�.� _.e
'" " SIGNA'i'�TTR6 -'_'�''�',c---�,� ,- >��_.� ,°
Fl� . . ._ . ._ . . ... _ .
. .. .. . ' ' � . .
�x t,. -i 1 �!w°'� .
� } .
� F
� � � .. _.._.,, . _��_��r . + {: - .
.� t
. . � �� � � : � '� '
� � � , -
. { � .k .. t . .
..-._.�.....�.. ..�....�.M.-.-...-�-.»-;d _..`.
...� t� 7 -�
�
�
4.
_ .....�., �^a+w.+w.en..u�ww...'a��...f.f.
� v
A . ,, f �
_ � a.�.,,,,..,,,�»,. t f
. . ... " F : �. .,
. � .. .. � -�r � { : . .r ,.
... . . -. R -.-..„.� .'.-..-...`.�._.,_...._.__�
� �k...,...�.r_,,,� _,,3 �
M�.
�
�
}
i
t
P
Indicate Lot size and shape, Zoeation of d�aelling !D), sep�ic tank
(ST)� septic field (SF) or seepage pit (SP1 and distance af anr�
portian of septic s�stem from dwelling9 r�eZZ and property Zine.
I f propert� Zies raithin 50 feet o f a Zake, river ar a stream so
indi�ate and sliory distanee there from.
If an�,� portion of the eontem�7.a��ed eonstruetion wiZZ Zie within
25 feet of d�elling, raeZZ� septic tan7t, septic fieZd or seepage
pit of adbutting ou�ner so indieate.
The undersigned agrees that aZZ r�ork performed and equipment
instaZZed shaZZ be in accordance with the Sanitary Code o,f Sau�z�er
Countz� and aZZ appZicable Zaws and regulations of the State of
Wiseonsin and recommendations of the Sau�z�er Countr� Sanitarian.,
:
..... '_ . n„{ � /1F .....i' . .._ ....._._
�.�_,�/ �T�'w.v'3�"':i�. �ii �^ ��.+J', ���{eR�".
:�6'
Or�ner, Agent t5ign�ature)
�"''"`"f^>; PRIVATE ONSITE WASTE TREATMENT County
���o ��` SYSTEMS
;;� ; \ \,, Sawyer
�, = ����
�,���SPs /�;' ( POWTS)
\�,_,�_--�%%
` '"-�""' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.2 _�,(ol.{
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. L 5.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
s���.� �t�— a ��, —
Insp BM Elev: BM Description: Parcel Tax No:
�00.0 � �la�� iN a-yN Oa �� OlU- 9�1f -ao - �a-� l
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,;�- ��acr0 Benchmark o�
Dosing
Aeration Bldg. Sewer s;g3 `
Holding St/Ht Inlet (o.o '
TANK SETBACK INFORMATION St/Ht outlet 6.3 �
TANK TO P/L WELL BLDG vENTro ROAD Dt Inlet
AIR INTAKE
Septic +Sb� '�5'�' �.` .���, � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP/�IPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade 5�,�
Model Number GPM
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
INFORMATION P�L Bldg Weil Waters ❑ AG ° Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
__-- --- --__ --- — —--
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia �Length Dia _ Spac _ _� _ Spacing ❑Yes ❑ No�
SOIL COVER
__------ — -
Depth Over Depth Over Depth of � Seeded/Sodded Mulched �
Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑ Yes ❑ �Jo
COMMENTS: (Include code discrepancies, persons present, etc.)
�` �,s}�/(�,� f l(����3
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�DITIONAL COMMENTS ANO SKETCH
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