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Home My WebLink About028-642-27-5507-SAN-2020-274 \��„w nn� C011itty /�' n :� 0 _ ��,I a4 ��'� � Safety and Buildings Division sawyer U � S P - � � / 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in t � a r ' � M dison,WI 53707-71 �� C,� zv - 22 1P2�7 q'7`7 � Sanitary Permit Application S`�T�"�°`'°"N°"'h" - � � In accordance with s.SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit is required prior to obtaining a sanitary pertnit. Note:Application forms for state-owned POWTS aze submitted project Address(if different than mailinr � to the Department of Safety and Professional Services. Personal information you provide may be used for secondary t� ` u oses in accordance with the Privac Law,s. 15.04 1 m,Stats. � � v I. Application Information—Please Print All Information su�'�' � Property Owner's Name Pazcel# —*'� John Cerman 028642275507 Property Owner's Mailing Address Property Location 12718N Judith Ann Dr PQr� Govt.Lot 5 City,State Zip Code Phone Number '/a, Ya, Section 27 Hayward,Wl 54843 T 42N; R 6 W [L Type of Building(check all that apply) Lot# � _ � 1 or 2 Family Dwelling-Number of Bedrooms 3 `� Subdivision Name � -\ \ Block# ❑ Public/Commercial-Describe Use ❑ City of � State Owned-Describe Use CSM Number ❑ Village of �at g �� Town of Spider Lake III.Type of Permit: (Check only one box on line A. Complete line B if applicable) � `� � New System � Replacement ❑ TreatmendHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) System B. ❑ Permit ❑ Permit Revision ❑ Change of ❑Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner o� a Ex iration �— � l� �� O d IV.T e of POWTS S stem/Com onenUDevice: Check all that a 1 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑Other Dispersal Component(explain) ❑PreVeatment Device(explain) V.Dis ersaUTreatment Area Information: Quick 4 Plus Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation 450 .7 642.9 650.2 94 ��.c�_ o( S,(o� VL Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units � o '� ^ New Tanks Existing Tanks � o � � � � � � a U i� ti r� i.,. C7 a. Septic or Holding Tank 1000 \'�s 1000 1 Wieser � � � Dosing Chamber ❑ ❑ ❑ ❑ a VIL Responsibility Statement- 1,the undersigned,assume responsi6ility for installation of the POW"I'S shown on the attached plans. Plumber's Name(Print) Plumber's Si e MP/MPRS Number Business Phone Number Gerald Froemel 0 950111 715-558-I 138 Plumber's Address(Street,City,State,Z.ip Code) 13502W Froemel Rd Ha ward,Wl 54843 VIIL Co nt /De artment Use Onl � �O 1 Permit Fee Da�e Issued [ssu� A nt Signature j l A prove ❑ Disapproved � ��►'v ❑Owner Given Reason for Denial $�"(�V•� �� 2 CS Z(iZl7 �� / ' .� �, G Wvv IX.Conditions of ApprovaUReasons for Disapproval � �� C � ;, �GF�N'�S RM � � �� .� N� E OF QE � �� I ��L �SSU �' G 0�' OCT 2 2 202a Attach to complete plans for the system and submit to the Couaty only on paper not less than 8 1/2 x 1I inches i�� Uu'�"Y SBD-6398(R. 11/I1) zOi�11NG ADMIMSTRATIO�'E3 CP � 42�4 ��IZ`� Zo2� �- T � I %°""T"f�>;� PRIVATE ONSITE WASTE TREATMENT county ,yi�asP ��T� SYSTEMS Sawyer `�;�� $ � ( POWTS) �F�fr _ =�;:, =��'-'%' INSPECTION REPORT sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION � Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] �� Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �:� C��a-� 5- .� �. � Insp BM Elev: BM Description: Parcei Tax No: 1��. �� -�-<-�� S � �c-�� -�,�1�-- ��-SS�� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �;�,�j� �"��v Benchmark 1�`.v�; \o\.� Dosing Aeration Bldg. Sewer �S .71 Holding St I Ht Inlet `! �,�;"3 TANK SETBACK INFORMATION St I Ht Outlet �j'�.� , TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic �� /��- \� � NA Dt Bottom Dosing NA Installation . Contour Aeration NA Header/Man. �'S. �� Holding Dist. Pipe � PUMP 1 SIPHON INFORMATION mfi�trative Surface `��r ,% Manufacturer r- 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 Bldg Well Waters °� G � Chamber Model Number: ❑ EZFIow CELL TO \�; 'a- �`��'� �c;-� 1D� � _ o Mound o Other �� y — —— — -_ --- — ___._ ---- DISTRIBUTION SYSTEM X Pressure Systems Only Header/Manifold Distribution Pipe(sj �X Hole Size X Hole Observation Pipes Length Dia Length Dia Spac � Spacing ❑Yes ❑ No � --- — SOIL COVER Depth Over Depth Over Depth of Seeded/Sodded � Mulched � Cell Center Cell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) �- �5�..t.--- �..��-�� a��5 ( a-�-��. •�i_ �,��.� -�`� . a-r '� ��C `� � ��.�-- �c��7 �.'��.—,�2�. �o:��, ti.� . � �� "�1��_�.�•-� C_.r��v��\�� we�.,�� c,--`��{c , � �L; 1 ��c�.s-� � Plan revision required?�Yes 0 No � a„ , --� i ^3 � _ ;� f�,,_— � ��%�� `�1 Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS AND SKETCH SANITARY PERMIT NLIMBER: �� c�7`� � �.c_� �-�-�i--�� -`1�1�� -�> / ; �� v�� . , + �l� __ � . � '�� . T � �� '.� � / = J `J 1� J / J � � T � � V � i� �V�� 0 _� / ( \� � `. .f, � �� , / �� ( �� F�� \� \� �` \ � \ \ � --- ___---- ___ --- - __ __ -__— --. � �--- ��-�,�� .