HomeMy WebLinkAbout012-840-00-0400-SAN-2020-048 ,,`,��:�r,S�r:p�, i� Co�mty
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,�>;� '�s^ �! 1`� f }i..�'� Safety and Buildings Division �J Ci�� �r' •
, /s j ` 201 W.Washington Ave., P.O.Box 7162 Sanitar}•Permit Number(to be filled in by Co.)
',. `� PS ;;' '�\�*^'�- Madison,WI 53707-7162 �
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Sanitary Permit Application State Trsnsaction Number
In accordance�vith SPS 383�l(2),Wis.Adm.Code,submission of this fam to the appropriate govanmental unit
is required prior to obtaining a sanitary petmit. Note::�ppGcation forms for state-ocvned POWTS are submitted to Project,lddress(if different than mailing addcess) �
the DepaRment of Safety and Professional Srn•ies. Personal infamation}•ou pro�tide may be aced for secandary Q
ses in accordance�vith the Pri�•acy Law,s.I5.0 1 m,Stats. / /" � "� P(`�
I. �1 lication Informadon-Please Print�+111 Information L�'W �J U�SL� 1�-�c� �
Propert}�O�ener's Name Paroel 1t
��I.n � � � � ���k� T��st vl� ab�/ d o� ��
Property O�sner's blsiling Address ,1 Prqxrty Location
� " c� G SG�c����,' Wl co.a.La
City,State Zip Code Pha�e Number ,; ,, t 7
�+, ,, Sxtion
� �, 1 . 1� S'?�C�� -- (circle on
I.Type of Building(ch k all that apply) L«p T `�I�T; R�E \v
1 or 2 Family Ihti�elling-Number of Bedrooms J ���.t Subdi�ision Name
B��k� �v}�n5cli5 R�,Sa:t Ci,�ncQ
Public/Cmnmercial-Descnbe Use
City of
State O�vned-Descnbe Use CSM Number �'illage of
Trnvn of �-1�,��er
III.Type of Permih (Check only one bo=on line=1. Complete Wre B it applicaMe)
a' New S stem R lacement stdn Treatmen Tank R lacement Onl Other ht�ca►ion to E�istina S gtem e� lain
y eP �' � eP Y� ) ( 'P )
, B. Pe�it Rene«al Pem�it Re�•ision Change of Plumber Peemit Trsnsfer to New List Pre�ious Peimit Number and Date�ued
Before Fxpiration O�a�ner ���_ (
IV.T� of POt'{'TS S��stem/Com onent/Desice: Check all that a
�Non-Ressurized In-Ground Pressurized in-Ground Ai�'rrade btound>24 in.ofsuitable soil h4ound<24 in.ofsuitable soil
Holding Tank Other Dispetsal Component(eaplain) Pretreatment De��ice(e�pla'n�)
V.Dis ersaVl'reahnent:1rea Informallon:
Design Flo��(gpd) Desiga Soil:lpplication Rate(gpds� Dispersal Area Required(s� Dispersal Area Propased(s� Systcm Elevation Px,yt;�
G�SO � 7 (�l3 �x�5�cn �13.75
VI.Tank Wo Capacity in Total #of l�•fanufacturer
Gallons Gallons Units � � ' � =
Netv Tanks E�istrog 1'ad:s v j v ? a b' m �
a`,Li J� m v� fi, :j A..
SepticorHoldv�gTank � L�%b �- SK�w., rc �c��j�
Dosim�Chambar
VII.Responsibil3ty Statement-I,the unders'boned,essume respoffiibilih for installation of the PO\`TS shown on the stmched plans
Plumber's Name(Print) Plum Signature AiP;1IPRS Numbcr Business Phone Number
��'=ti� '��u�`� �n � � �'� � �1 �,.��1�.�L7 �l 5 al��-o2b'`��2
Ptumber's. s(Stmet,City,Statc,Zip Code) /
S�i�C�� / / i(��� Y' � �/V����l.�Gl � � V�� ,
VII Co /De arhnent Use On!
��`� Permit Fce Date Issued Issuing�ent Si atu�
SL/ �
O��vc Givrn Reason for D�ial `�• �,3U-�'0
LX.Conditions of ApprovaUReasons for Disapproval
� NO R�FUNDS AFTER
�� ' lSSUE OF PERMIT
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attx6 to oompkte plam for the rystem aod sabmit to the Couoty oals on paper nd less t6an 81/2:11 ioehes in siu .
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SBD-6398 R.11ill �
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APR 2 9 2��0
SAW`�ER C4UN�Y
ZONtNG ADMI�ISTRA71�) � L�
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'�°'"""�� PRIVATE ONSITE WASTE TREATMENT county '
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= � sa = SYSTEMS Sawyer �
,>�,1 �s ( POWTS) ,
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"°�������;� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION
Personal infonnation you provide may be used for secondary pueposes[Privacy Law,s. 15.04(1)(m)] �� - ���
Permit Holder's Name: � �� ❑City ❑ Village Town of: State Plan Transaction ID#:
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�-� �•����-�:�.�, `�\.C_�c_ u—�1�'C�
Insp BM Elev: BM Description: Parcel Tax No:
��. c.v �:�- � �'�--�-.�-.�\� C..1�-- ��S`� L,C.; -- �`-'1�;
TANK I FORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ������. � ��` ,-`;q� Benchmark _�,��; \v�,.��;
Dosing
Aeration Bidg. Sewer �1�.�b
Holding St I Ht Inlet `j� ;;;�,
TANK SETBACK INFORMATION St I Ht Outlet �j�,-75
TANK TO P/L WELL BLDG vE"T To ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Instaliation �
Contour
Aeration NA Header I Man. -
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Finai 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/L Bidg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
- --._ - _
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) X Hole Size ', X Hole Observation Pipes
Length Dia l Length Dia Spac ', Spacing ❑Yes ❑ No ;
SOIL COVER
-- _ __--
Depth Over I Depth Over � Depth of Seeded 1 Sodded Mulched
Cell Center � Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes ❑ No I � I -�y� i� � �,��—� ����� ,�
Use other side for additional information Date f POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
` AO�ITIONAL COMMENTS ANO SKETCH
, aAN'TAPv PFR�,1�T �i'J^,19ER �C7_'__����____
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