HomeMy WebLinkAbout024-741-01-2205-SAN-2020-287 ,°/
�� -`- Industry Services Division County(` � n
- �� . 1400 E Washington Ave �Ct.t.�' 'L;,^ �J�
i '� . ' \� P.O.Box 7162 �
- . _' \1 c �C��' Sanitary Permit Number(ro be filled in
S r.Madison,WI 53707-71 2 ������ �
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Sanitary Permit App ication State Transaction Number �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this foem to the appropriate governmental unit (
is required prior to obtaining a sanitary pennit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin N
the Department of Satety and Professional Services.Personal infonnation you provide may be used for sewndary
u oses in accordance with the Privac Law,s. 15.04(l)(m),Stats. Sq�..�R_ �
L A lication Information-Please Print All[nformation �
PropeRy Owner's Name Parcel#
hb t'Y1 . � �l��������ns� n c�. p•Z� -��{( - C; I - Z Zc> �
Property Owner's Mailing Address PropeRy Location
� ��� � u L r " ' �' Govt.Lot
Ciry,State Zip Ca1e Phone Number N(,J y,. �i:.i,' �/., Section �
° I.UQ,�"N �� -�Ts T3 ��='fIOL �y/Z_3 arcleon
II.Type of Building(check all that apply) Lot# T�N; R�
L7 1 or 2 Family Dwelling-Number of Bedrooms � Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑ City of
❑State Owned-Describe Use CSM Number ❑ Village of
�,,ZS ���, �To,�,of '�:..�cl '�e.
IIL Type of Permit: (Check only one box on line A. Complete line B if applicable)
A� ❑ New S stem
y �Replacement System �jl'reatmen�'ank Replacement Only ❑ Other Modification to Existing System(explain)
B• ❑ Permit Renewal ❑ Pertnit Revision ❑Change of Plumber ❑Pennit Transfer to New ��st Previous Pertnit Number and Date[ssued
Before Expiration �Owner �3 � `�� `5 ��
IV.T e of POW'I'S S stem/Com onent/Device: Check all thlt a I
�,Non-Pressurized In-Grpund ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
❑ Holding Tank er Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dis ersal/Treatment Area[nformation:
Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(st) Dispersal Area Proposed(s� System Elevation ��•� L�-
�0� �1 �.57 �!G'D �Ys� `�1��/ � `,f �r'
VI.Tank Info Capacity in Total #of Manufacturer
Gallons Gallons Units ` o '� �
New Tanks Exis[ing Tanks v o � 2 u � R �
c, U v� vi v7 L-. C7 CL
Septic orffelding Tank
�Z.. Z L rf .�
DosingChamber -7� ..���
VIL RespOnsibility Statement- I,the undersigned,assume responsibil' r install ion of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber's Si MP/�Q+�RB Number Business Phone Number
' �(►1'LUS�4'�d�S (.°'S '1,17 71J��4I'">;J3��
P umber's Address(Street,City,State,Zip Code)
Q v . �� � � C'�:G j.� ��-�- S��Zi
VII[. o nt /De artment Use Onl
1 .Z3 Pennit Fee Date Issued Iss}i+ag Ag nt Signature
�,Ap ro ed ❑ Disapproved �
❑ Owner Given Reason for Denial $ C�'oo I)I�I 2�ZU �t/��l/�`�
IX.Conditions of Approval/Reasons for Disapproval
- � �o VE OF ps A�A
W i I ��L ERMI
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Attach[o complete plans for the sys[em and submi[to the County only on paper not less Ihan S I'2 x I I in �1 � ir' �?� �
I��i T �-'� q �'7 a � ' � � 2��-0 � ���.�����f J� �_��,1
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' OCT 2 2 2�20
SBD-6393(R.03/14)
SAI�JYEl� CG�"tl�Y
ZONiNG AD�liViSl"RATION
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�"�""'"'E? PRIVATE ONSITE WASTE TREATMENT county
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��'����$ ,���, SYSTEMS
� P � ( POWTS) Sawyer
�.\\ry � ��.i:;j
'' ��'-�^ INSPECTION REPORT sanitary Permit rvo:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � ` �-
Pecsonal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] ��- �L= �
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
�1i: � .`r�\�� \i�,�-.�. \��,�� �.r.Jf
insp BM Elev: BM Description: Parcel Tax No:
��c ��, �i3�, -�`( 1 -�, A - a�:S
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W,��L L��� \a�� '�5� Benchmark
Dosing
Aeration Bldg. Sewer
Holding St I Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO PIL WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �,;} 5 v� �S ' � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding Dist. Pipe •
PUMP/SIPHON INFORMATION Infiltrative
Surface
Manufacturer L�� Demand Final Grade
,��
Model Number �3 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 °� G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
— --- ----- _ __ __--— -- -- --
DISTRIBUTION SYSTEM X Pressure Systems Oniy
Header I Manifold Distribution Pipe(s) ' X Hole Size X Hole Observation Pipes '
Length Dia �Length Dia Spac I � Spacing ❑Yes ❑No �
SOIL COVER — — -----__— --- - — --- --
�Depth Over Depth Over Depth of Seeded/Sodded Mulched
ell 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� � a� ,��-�—_� \� ��'�
% -- -- ---J
Use other side for additional information Date � POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS ANO SKETCH
SANITARY PEAMIT NUMBER: ��- a�� '
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