HomeMy WebLinkAbout004-839-08-5313-SAN-2020-258 � Industry Services Division Co,mry _�� i
\��I� �`J `�� 1400 E Washington Ave Sf,�,�,�,•y{f� �
c—�.� � P.O.Box 7162 Sanitazy Pecmit Number(to be filled in! �
Madison,WI 53707-7162 , �� � ,
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Sanitary Permit App ication 3tateTraacactionN� G
In accordsace with SPS.383.21(2),Wis.Adm.Code,submission of this fo:m to the appropriate govemmeatal uait , j
is required prior to obtai�nmg a sanitary pesmit Note:Application farms for stat�owaed POWTS are submitted to Project Address(if differeat than mailin� �
the DepsRmeat of Safet7+aad Professional Services.Petsonal mfocmation you provide may be usod for secoadary '-TQ.�`� � ( �,
oses ia accordaace�vid�the Priv Law s.15.04 1 m Stats. J
L A iication Inianaation—Please Print All Information ��
Property Owner's Name � Parcel#
1��,�,�..►,� � ��.f-�, �T��1(�es ooy- 83�'-0�-�3 �
��cy o��s�ng aea� ��cy�aon
I(7 H�.ar—i��.ti. ,� ��, ��.� `2 �3
City,State Zip Code Phone Numbet ��� ,�� S�� �5
�v t'�Scs-�% �,JL S�{C 1�e..' (circle oae
II.Type of Bnilding(check all that apply) L�# T 3� N; R �3 E or�VV'�
�1 or 2 Family Dwelling—Number of Bedrooms � � Subdivision Name
Block# �
❑PublidCommercial—;'�escribe Use
❑City of
❑State Oaaed—Des«ihe Use CSM Number ❑Village of
�`�21$ �O i� �Towaof C_c,�cl-cl�=-`i
III.Type of Yermit: I;Chock only one boz on line A. Complete line B if applicable)
A.
New Syatem ❑Replacemmt System ❑Trea�neaUHolding Tank Replacen�eat Only ❑Other Modificarion to Epsting System.{explsia)
B• ❑Permit Reaewal ❑Pecmit Revisiaa ❑Change of Plumber ❑Pemiit Traasfer to New List Previous Pamit Number aad Date Issued
BeEore Expisation Owner
IV.T of POWTS!� m/Com entlDerice: Check all that a 1
�Non-Pnssurized In-Cnouad ❑Pzessiuized In-Grouad ❑At-Grade ❑Mound>24 ia.of suitable soil ❑Mound<24 in.of suitable soil
❑Holdiag Taak ❑Other Dispetsal Componeat(explain) ❑Prctreatment Device(explain)
V.Dis real/Treatmont Area Information:
Desiga Flow(gpd) Lbsiga Soil Applicatian Rate(gpcls� Dispersal Area Required(s� DisPersal Area Proposed(s� S3'stem Elevation
LfSc� - �� C��t3 �s-�, �, �t.�,
VI.Tsnk Iafo Capacity in Total #of Maaufecturer
Crallons Gallons Units � � � �g �
]Vcw Tanks E�asting Tanla w Qc y � e� a`� � ¢
�V �
'v� � � w C7 P,
Sep6c or Holding Taok ���� �QCSC^. � 1..>i E%.`'r.d— �
Dosiag Chamber
VII.R�poasibility Statemont- I,the nndersiQned,assnme responsibility for installation of the POR'T'S shown on the attac6ed plsns.
Pl s N e Plumber's Si� MP/IvIPRS Number Business Phona Number
erry�u ccavating, LLC �� �.����� �,s_ y�t�_ 2Y�,�
� Stone Lake�W'VI 54876p c��
vIII. u n me arta�ent use onl
� � �O Pemiit Fee Date Issued Issui�g S'
� ed ❑Disapproved S r� 6� �CJ J
❑Owna Given Reasan for Denial �V. I� 'r� ��(� �
i�
IX.Conditions of ApprnvsUReasons for Disspproval
� ,� P1p A�FUNDS AFTER
�:�;�� l' �6�� 1SSUE OF PERMIT
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. ' i ' f .rr1. ��•,�r`'� S f'�[� r�, r
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Athch to compkte plam tor the system end aabmit w the County only on p�per aot las than 1n r I�11�ti�fd'idsdi?�--=_____:
�C,� � L� � �] ���15 2vG� �_'�' �� O��i � ^� �` ::
Z � / 8 �.L20 ,•_
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SBD-6398(R.08/14) ..:':�:`;:'��.�:� :�i.=i�-..;.�..t
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'"�'`'"''`'E��;; PRIVATE ONSITE WASTE TREATMENT county
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(�`,'� a$ �;�'; SYSTEMS Sawyer
`';�� Ps ( POWTS)
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" ���� INSPECTION REPORT Sanitary Permit No:
Safety and Bwldings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��; . `�5�
Personal infonnation you provide may be used for sccondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village ,�Town of: State Plan Transaction ID#:
�� '\c'._�C_ `—Y �—i'G-."C� \ - �Y�� ....` 'i���.
Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W,�� ����J Benchmark , � ,�.�
Dosing
Aeration Bldg. Sewer �j�.�
Holding St I Ht Inlet ��5,��;
TANK SETBACK INFORMATION St I Ht Outlet ��3 �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic k��' �� ,� ,� � NA Dt Bottom
Dosing NA Instailation
Contour
Aeration NA Header/Man. �j 5; �
Holding Dist. Pipe �y.�
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer -- Demand Final Grade
Model Number GPM
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 Bidg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO � ± ,�.; � ^;� _��� ❑ Mound o Other — L,�-v,,� �
DISTRIBUTION SYSTEM X Pressure Systems Only
---- - --- — — —
Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac j _ � Spacing ❑Yes ❑ No J
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SOIL COVER
Depth Over Depth Over T 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 re uired?�Yes ❑ No i � �� - _ �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: �-�='- �-��
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