HomeMy WebLinkAbout022-738-23-5102-SAN-2020-102 j�'�� � �N • �' -�
�� ,�: � Safefiy and Bufldings Dlvision �aw�r�T--
`�"t"� Q . �'� •«, � 201 W.Wash#ngtQn Ave., P.O. Box 7162 sanua�,pern�at Numt�er(to be fi31ed in t
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Sanitary Permit Applicatian ��TraasaotionNwmber
7a aoeocdartoa with SPS 353.21(2),Wis,Adm.Cade,�ian of ti�is faam to the ap�xnpriate goveramemffi1 vnit �
��P�'��8 8�'P�- Note:Applioation fo�s for stete-ovmed POVTTS nne submiued to Project Addre.9s{if different ffinn msilit —
t}�e Depertmmt of SaRaty and Profeesianal 3ernies. Petsoual'n�fmsmtion you�avide may be nsed for s�ondary Q
in acaaadanca with the Privac Law,s.i s.0a i m,staLs. \c�� � ���/b" !
L A iuformatioa—Pkase Print All Infarmativn
i Property Ov�z�er's Natne Paneei�t
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Pro oamcr a Ad� Looeuon
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Cit.p,3tate Zip Codc Plwat Number "�/S y., y.. 3ectia:► ��
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II.Type of Buil�ng(eluck all that sPPiqj � Lot H �
❑1 ar 2 FamiIy I?wellmg—Nnmber af Be�ooms Subdivision Name
Block#
❑R�blidCo�eroial—Deswrelx Use —
❑City of
❑Sffite Ownod—De�aribe Use C3MNumbar _ ❑Viliago of
�Tawn of �.S�U�
IIL Type of Permit: (Check onty one bo=oa line A. Comp�ede Iine B i[spplicable)
A' ❑New sysOcm c 3ystem ❑rr�mmr�Hio�nag Tenk Replacement Only ❑Odier h�odifiaatioa aa
Existin6 BYst�ca Caxpla�
�. ❑Permit Renewal ❑Permit Revicion ❑Change of Plumber ❑Permit Trsnsfer to New Liet Previoeas Pecmit N�unber aod Date lswed
aetoreaxpiranon owa� u� '�
IY.T d POWT3 S /Com t/Device: (�eck all tlrat I
�Na�-Pre�In-0rouad ❑Prassraized In-0round ❑At-('sm� ❑Movad>?A in.of suitabto sail ❑Mound<Z4 in.af suiUable so�7 '
❑Holdmg Tank ❑Other Dispeigat Co�mpo�nt(explain) �Pcetreatment Davice CaxPiain?
V. rcatmeet Area Informati�•
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3C)t7 o S .. e yd� .r
VI.Tenk Iafo CepacitY in Tota! #of Manufeatwcr
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New Taars F�ciatiog Tu � �� �
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Uosng CLmnber
��iI, 'b'' Statentent�I,t�e mde stsame tor iastallatlon of the POR+Tfi ahown oa f6e aad�ed hu�s
Plumber's Name(Print) Plum�er' gaeuae MP/lv�t3 Namba Busiasas Phaos Number�! S
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Plumbar's Addres�(3treet.CitY,3tata,�P�o)
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� ���Q� Pasmit Fee� Dace Issued sigsature �;Jd`xY"\
Q 4wrtnr Given R,easom for Deioual ��� u I U 2(�Z.V
IX.eonditiaas of Approva!/Re�mons for Disapprovd
�� � e/� P!O flEFUNDS AFTER
'��� iSSUE OF PERMIT
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SBD-b398(R l lll i)
s�v�.�c� coun��rY�
ZOfVitdG A�JMIhISTRAi�ON,
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-"'""`"``� PRIVATE ONSITE WASTE TREATMENT cou�ry .
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.��`�s = SYSTEMS Sawyer
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"'`��"y��`" INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT)
GENERAL INFORMATION \
Personal infonnation you provide may be used for secondary pueposes[Privacy Law,s. 15.04(l)(m)] ��3 � �c�;y--
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�_-U�C_\� �h.,_.�] �'�c�L.���;`\
Insp BM Elev: BM Description: Parcel Tax No:
��v L _c.'�. �.c���. c;-. '}c� � ���_G�� C�.�� '��`G �-�"- ��i�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � ,���- �5� Benchmark \ _\ia ��;� \�
Dosing
Aeration Bldg.Sewer ��, 31
Holding St/Ht Inlet �(�,p�,
TANK SETBACK INFORMATION St I Ht Outlet �j s,� �
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIRINTAKE
Septic 5;;'±- y��'_ "���,! NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION �nfltrative '
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/L Bldg Well Waters o GP � Chamber Model Number:
❑ EZFIow
CELL TO `j S'�' �5 � C-c �i C-�`> �-1— o_ Mound _ ❑ Other � � �� �` � —
DISTRIBUTlON SYSTEM x Pressure Systems Orny
- _ _ _-- --
�Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
ength Dia lLength Dia Spac I Spacing ❑Yes ❑No �
SOIL COVER
— — -- __ - —
Depth Over Depth Over ' Depth of Seeded I 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, ���\�7 ��'`
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
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= i' AOOITIONAL COMMENTS ANO SKETCH
- j� SANITARY PERMiT NUMBER _av_�c��-_
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