HomeMy WebLinkAbout002-940-04-1224-SAN-2021-023 , .
- D r��
/�� Coun �
/�/�. . Industry Services Division �2w -� �--
��i;, Os ,, �: 1400 E WaShingtotl Ave Sanitary Permit N txr(to be filled in �
�`-� R � P.O. Box 7162
I '�'� L $ �j Madison,WI 53707-7162 P !� 2� �/� /� z
� �`••-_� cST a-1 - C�IID l.,F' � �r �
I � State Transaction Number _
Sanitary Permit Application
in accordance�ith SPS 38321(2).W is.Adm.Code,submission of this form to the appropriate go�emmenral unit �
is requited pnor to obtaining a sanitary permit. Noce:Application farms for state-o�+�ned PbWTS are submitted to Ptoject Addrcss(iEdifYcrent than mailin O
the Department of Safely and Professional Servies. Personal information you pro�ide may be used for secondary
u s in accordance with the Priv L,aw,s.I5.0 1 m},Stau. `Sta��S.�f��i� � �
I. A fication Inforrnation—Pieasc Print All Information .1 �
Propetty Owner's Name Parcel r rr
s e �'. L� �trre. OOZ _q�t-0 -O�-I -. I 2.Zy
Pro{xm Owne s. ailing Ad ess Property Location
lb S rJ � !�r,e�, �' • � R-c� �K.�t
Cip•,S�acc Zip Code Phone Number , , 'I
�G� WC2.C`� (.(,/ J�y y3 3 Q' ��l.) /., �� /., Section b`1
$ 60Z—yDZ—� circleone
II.Type of Buifding(check•s!!thai apply) Loc� T � 0 N; R �� E o�v
�or 2 Family Dwelfing-NumberofBedrooms 2 Subdivision Name
Block#
❑PublidCommcrcial-Desaibe Use
❑Ciry of
❑Stace Owned-Describe Use CSM Number ❑ village of
3��33� �S`fq9 �Ta�,ar Qass l� �e.
tli.Type of Permit: (Check only one box on tine A. Complete line B if appticable)
A� �.New Sysiem ❑R lacement S em
ep yst �TreatmenVHolding Tank Replacement Only �Other Modification to Existing System(exF;ain)
B• ❑Permit ReneKat ❑Permit Revision Q Change of Piumba ❑Permit Transfa to New List Previous Permit Number and Dau Issued
Before Expiration Owner _ '
IV.T� of POWTS S stem/Com nent/Device: Check sil that a i
�Non-Pressurized In-Grourd ❑Pressurizcd In-Ground �At-Grade ❑Mound>24 in.of suirable soil ❑Mound<24 in.of suitable soil
� Holding Tank ❑Other Dispersat Component(acplain) (]Pretreatrnent Device(explain) -
v,D'u rsaUTreatment Ares Inforrriation:
Design Flow(gpd) Design Soit Application Rate(gpdsfl Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation�
y-S D .�l ��f3 6 12- Q 3.�1 S
VI.Tank Info Capaury in Total #of Manufacmrer
=
Gallons Gatlons Uniu a � V� �
Newtartics ExistingTaz�ks u o or ` ; � m ;
c.U �n y rn is. C7 i
Sep ot Holding Tattk �p Q O ��Q� �,�/'e�s�r
Dosinc_Chamba
V'JI.Responsibility Stacement-I,the uadersigned,assumc raponsibiliry tor instatiation of the POWTS sho�n on ihe att2Ched p12ns.
Plumber's Name{Print) Plum�`�' ature MPRv�RS Number Business Phone Nlumber
ROD L� �rt'-e \, zZ�ZI�'j -11�- 64'c[.-0i3(o
Plumber's Address(Sttcet,City,State,Zip Code) �
i 4S�4 �...1 s-� �. �� c� �a-r� �-c�l 5�-f 8��3
V1J . oa tv/De artment Use Only ?
Pe�mitFee Dat lssu Issui c ignature ��
p ro �� ❑Disapproved $ � � �
��v ❑.Owner Givm Reason for Denia! ��� � �U �"�'�� � " - ���
IX.Cooditions of ApprovaUReasons for Disapprova! ,.
� .� S �� ���
�'V'Q t. liiti(j �'%���;,,���
, ,�'�, �, �F� �s? , ,.�,s�;���F��pP?T F� I ;� D
�;r .. ����� '�. ��.� R.}��i ��",� FEB 0 9 2021
Artaeh to compiete plaat for the s�ssem aad submit to ehe County oaly on papar not!as dun 8 fn s 11 ineha ' ------"p�- i,
JAW��°�� f✓�.j;.�4''a��'
�(` �� � oi� � I I Z � � U� ��L � �ONING ADMINISfi-t�'3`i(7�fd
li
SBD-6398(R0313)
,� • .
'�<t"-��
U '
� �h
�n ` ��,
,����
� �,..,�� �. ,_ .-...�
� "'�� .�, �, `� \ �
t. ` '�-_-�� I
` � �'"2�'i'y.
t �� -�.
_ 4! ` Cb.
-� r_ :? \
�� �� I
a o �,
: ��: �
� �
,��� ..y
�
�. o �
; .
� c� `��!
�..._�-�
; �
� �
,t ��
� ;f �� -�' t` � ��`" c
�; ., c�
� � '-a � �
, ,�� � ���
S ��� . � ��'�� .
G k
��
r l
...,._r_ ,_�7
;
i
t , 1
` �4�iJ
j �.
�l ti_.
� ��.._._.._.._ ----- � -• . . .. _ .:� ,
�•F'!'"'`"f^�, PRIVATE ONSITE WASTE TREATMENT county
,,.�-
=��a$ \ SYSTEMS
��;�� P$ %` ( POWTS) Sawyer
�h �—,�;
"�'`�^� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION '�
Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] �y� — ��>�
Permit Holder's Name: ❑City ❑ Village '�Town of: State Plan Transaction ID#:
� �
"_�� �>�,�\c�— �--c��`�s� \�`>� �--c_�l
Insp BM Elev: M Description: Parcel Tax No:
��� �c� a'v� � � -..._��....�-�.�� � `���-�- - � �:,�=- c�c,�--�1,`"/� - �::`', - 1�a�1
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�� � ��� Benchmark �� `�_ ��� 3�
Dosing
Aeration Bldg. Sewer ��(o
Holding St/Ht Inlet �S y�j
TANK SETBACK INFORMATION St I Ht Outlet �j� ��
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic .5�} .— \�� NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. �j`"l `��
Hoiding Dist. Pipe '
PUMP 151PHON INFORMATION �n�iltrative
Surface �1.� �
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 Distrbution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ ,Aggregate
INFORMATION P I L Bldg Well Waters °� GP � Chamber Model Number:
❑ EZFIow
CELL TO �� � ��' � ',� ❑ Mound o Other ��`�v �-1 �
- — - _-- - - --- --
DISTRIBUTtON SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) i X Hole Size X Hole Observation Pipes i
Length Dia � Length Dia Spac ` i Spacing ❑Yes ❑ No J
- - - - - -- __
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center �ell Edges _Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
`�y`��.-v--- � "��G—�V+-L �`� I � � I oZc7� \
I
Plan revision required?0 Yes 0 No � �? �� I�-/ - ,L�� � 1� �� 1`�
�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER� �o-����-3
, ' ' :_ _ : _ _
, : , ; _..._.._ _.�_.. Y----,- -
_ _._. _ . _
. , _,__ . . _ .
; � i , �
, ,
_.., , ,..._...__. � __ __.
; .__ _, ._... ._ .
_ _.._. .
_ . :_ . ... _ .r __., .
: _ ,._ : ._ - , : �
' _ - , �
'- ��� ���
• � o
,�v.
�� �
�
i Q
�
%� /�I 3 �'�
�_-�� i A J�..
❑ �� 1 \Jl�
��� _\\ .- L .r�'�1���`�
.����
�C
� '
� JS
�G
�' ` �.f.
I �
I �S
1
I V
1
�
��� I
�� ,
�-- ��`-'`� � .
�_-