HomeMy WebLinkAbout010-130-00-0500-SAN-2020-266 � Industry Services Division County ( n
` I`� I � �� 1400 E Washington Ave S ca�.��y-e.� v '
, P.O.Box 7162 Saaitary Permit Numbez(to be ed ia 1 �
`\��� �,�' Mad�son,WI 53707-7162 Z
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Sanitary Permit Applic tion StsteTransacc�onNumber � �
In accordsace with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit `
is required prior to obtainmg a sanitary pesmit Nate:Application focmg for atate-owned POWTS are submitted to p:oject Address(if di$erent thaa mailia
the Department of Safety and Professional Servias.Pessonal mfocmatian you provide may be used far secoad�y �d 7� � �,, ,�t n.» �
oaes ia accordance with the Priv Law a.15.04 1 m S�. �.���r �
L A tication Information—Please Prt�All Information
Pzoperty Owner's Name Parcel# b
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Froperty Owner's Mailing?,ddress Propaty I,ocation
'�0 13 01t t 3$ (3ovt.Lot
City,State Zip Code Phone Number ,/y yS �� z�
�G.� 4�c.�-�- l:i.i J�—c(�i c�,3 (circle onel
II.Type of Bnilding(check all that aPPly) Lot# T �l N' R � E o�d�,
�1 or 2 Family Dwelling—Number of Bedtooms � � Subdivision Name
Block#
❑PublicJCommercisl—Deseribe Use
❑City of
����_��U� CSM Number ❑Village of
�Town of }-��-'�i �-'�v i'�.
III.Type of Permit: (Check onty one boz on line A. Complete line B if applicabie)
A. ❑New System �Replacemeat System ❑TreatmenUHoldiag Taok Replacemeat Only ❑Other Modification to
E�s sr�(��)
B• ❑Permit Renewal ❑Pe�mit Reviaion ❑Change of Piumber ❑Permit Traasfc to New
List Previous Pocmit Number and Date Lssued
s���aon o�� g _ Ia '�
1V.T of POWTS S m/Com ent/Device: Check all that a
Non-Press�aiud In-Ground ❑Pressuriud In-Grouad ❑Ai-Grade ❑Mound>24 ia.of suitsble soil ❑Mound<24 ia.of suitable soil
❑Holding Tank ❑Other Dispersal Component(axPlain) ❑Pre�ment Device(explain) .
V.Dis rsaVfroatment Area Information:
Design Ftow(,gpd) Dasign Soil Applicatioa R�d4� DisPecsal A�a Reciuired�s� DisPersai Area Proposed(g� S7'stem Elevation
H So � �- (� �-r 3 �s Z `t�n 3 -- `�.�•y
VI.Tank Info Capacity ia Total #of Maaufactura
Gallans Gallons Units � °t�'', ��g o
New Tan10 &xistmg Taal� w � y `' q '�
r�� n � � wv a
Septic or Holding 7so1c /OOC3 • /�'C� � 1.t�l t,S�!' x
Doaiag(,'hamber
VII.Res neibilitq Statement-I,the nndersi�ned,ssanme reaponsibilfty for installation of the POR'TS ahown on the attached plans.
Plumber's Name(Print Plumber's Sigaature NSPJMPRS Number Business Phoae Number
Jerry Ruid �xcavating� LLC � -��•���� �,s--:�� �_ �:�oq
Pl , iP coae�
Stone Lake�WI 54876 ,
VIII.eo n /De rtment use ont
� � �9 0� ❑���� Petmit Fce Date Issued ent Sigaffiiue '
�'�`' �owaer Gi�rn xe�on for neaisl a `�O7` -`� �GJZ� 2v L u � � "C�� 1.
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IX.Conditions of ApprovaUReawns for Disapproval _ ,
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�, EFUN� � � � ; : � �, �
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Attac4 to compiete plaot for the tystem end submit W the Connty only on p�per mt les than 81/2 s IQ incha du _- --_ _,;r" '
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SBD-6398(R.08/14)
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'�"`''"'''^`%'; PRIVATE ONSITE WASTE TREATMENT county
���� ,��.\`� SYSTEMS Sawyer
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`,:�,� rs ..:� ( POWTS)
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' ""� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� a��
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
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Insp BM E v: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�� � w� Benchmark �j � }�j,(�
Dosing
Aeration Bldg.Sewer '� �-�
Holding St I Ht Inlet �j� �9
TANK SETBACK INFORMATION St/Ht Outlet �j g,�,;�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �Ic`'� ��'�'� • : NA �i�= Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �� `�.. �i �.-
Surface ;���.�. .'�i �t�,,�
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
P/L Bldg Well ❑ IGP ❑ Chamber
INFORMqTION Waters � AG Model Number:
o EZF�ow
CELL TO a� ' k 1��� '�c��'_ � o Mound o Other
--- _ — -- -- - -_ - -
DISTRIBUTION SYSTEM X Pressure Systems Only
- -- -- -
Header 1 Manifold Distribution Pipe(s) i X Hole Size — � X Hole ObseNation Pipes
Length Dia Length Dia Spac � Spacing ❑Yes ❑ No
- --- - ---
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Teil Edges �opsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Inciude code discrepancies, persons present,etc.)
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Plan revision required?�Yes� No `� `� �� ! %���-��� — j 1���? ��
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3l01)
ADOITIONAL COMMENTS AN� SKETCH
SANITARY PEAMIT NUMBEA:� -a.(�(�-,
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