HomeMy WebLinkAbout014-841-06-4219-SAN-2021-031 ;�"` � Industry Services Division County
1400 E Washington Ave .S a...�y e r �
,�=P = P.O.Box 7162 Sanitary Permit Number(to be filled in t,
`, = Madison,WI 53707-7162 '� �
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Sanitary Permit App ication State Transaction Number N
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit ,
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin.
the Department of Safety and Professional Services.Personal information you provide may be used for secondary O
u oses in accordance with the Privac Law,s. i5.04 1 (m,Stats. � � f g p 3 N �� 1(,� �p�
I. A lication Information—Please Print All Information � v�
Property Owner's Name Pazcel#
�t�nr�: �cr �1 (�vc�S�man�1 O I�f - 2y 1 - O G ti a � 9
Property Owner's Mailing Address Property Location
►y�y W No rd: � t,� Govt.Lot
City,State Zip Code Phone Number N� y,, �j� '/<, Section �Ce
H4 vra r� w= }/(j 4/3 (circle one
� T�N; R O 8 ,F�or V
II.Type of Building(check all that apply) Lot#
�1 or 2 Family Dwelling—Number of Bedrooms 3 � l Subdivision Name
Block#
❑Public/Commercial—Describe Llse
� ❑ City of
❑State Owned—Describe Use CSM Number ❑ Village of
— ,3.7 I? ���� �ro�,oe L e r.�-o 0 3
III.Type of Permit: (Check only one box on line A. Complete line B if appticable)
`�' New System ❑ Replacement System g p y g Y P )
❑TreatmentlHoldin Tank Re lacement Onl ❑ Other Modification to Existin S stem(es Iain
B• ❑ Permit Renewal ❑ Pertnit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV.T e of POWTS S stem/Component/Device: (Check all that apply)
�lon-Pressurized[n-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
❑ Holding Tank ❑Other Dispersal Component(explain) �ment Device(explain) Getawtiet�' 3�I G�
V.Dis ersal/Treatment Area Information: .Z �s t �� �-+ S'•�. 5�X 7�.� P E C t/
Design Flow(gpd) Design Soil Applicatio Rate(gpds� Dispersal Area Required(s� Dispersal Area Propos d(s� System Elevation
ySv '� �. o l.� aa� ��.�5 �k aas 6�3 9�.��� ���� ��N
VI.Tank Info C acity in Total #of Manufacturer
::
allons Gallons Units p � o ,'o, u
�M 8 O New Tanks Existing Tanks � o � � Y � c� `�
TA 1J�� n.c� �n � v� u, :7 a
Septic or Holding Tank � Q O� � V� (^�1� SG� L/1G
Dosing Chamber G D Q � G O�
VII.Responsibility Statement- I,the undersigoed,as me respons' ility f installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plu 's Sign e MP/MPRS Number Business Phone Number
�i�Jts 13���-tr�,,eld Gsa�79 �7�S-G3�1-817(�
Plumbers Address(Street,City,State,Z.ip Code)
ly3yl,cJ �-��k 2e..d �7 l�� Q,�.z� ws .s�-�ati3
V[I1.Co nt /De artment Use Onl
�A�p�ved� ❑ Disapproved Permit Fee Date Issued Issuing ent SignaYure
�L✓ ❑Owner Given Reason for Denial $ `�`� �'S ���� �+
IX.Conditions of ApprovaUReasons for Disapproval
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Attach to complete plans for the system and submit to the County ooly on paper not Iess than S 1/2 x 11 i;c�¢s Qai�e , � I�, �!_ '
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"`��''` `'-, PRIVATE ONSITE WASTE TREATMENT county
-" '�sP � SYSTEMS
=-� s ( POWTS) Sawyer
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q�""""`"`�'?` INSPECTION REPORT
Safety and Buildings Division Sanitary Permit No:
(ATTACH TO PERMIT)
GENERAL INFORMATION �.I — O� �
Peisonal information you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
J�-�^��r ��t�e I�^u^^� . . �.en t'�a-�. �
Insp BM Elev: BM Description: , Parcel Tax No:
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� �a � : ( � �:bb��. .� 1�� '� p;�� ���uo�
TANK INFORMA ION � ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATtON• �- BS HI FS ELEV
Septic , �D„� ���o Benchmark 3.�(.� �p2�.16 ��p,p�
Dosing •• �• ���
Aeration Bidg. Sewer y
Holding St I Ht Inlet �� 7
TANK SETBACK INFORMATION St/Ht Outlet �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet'
AIRINTAKE
Septic �� +SO � � I`� NA � Dt Bottom ` P ��. (
Dosing NA Install�tion'' ' • ' �
Contour ���"f �� ��e'j�
Aeration NA � Headsr/Man. g�
Holding , Dist.Pipe :
PUMP/SIPHON INFORMATION Infi�trative �
Surface � �p�`J s
Manufacturer � ,� Demand Final Grade
Model Number � 3 �� GPM
TDH(�j}Lift Friction Loss � Sys Head ,r TDH t
Forcemain L L/p Dia ��` Dist.To Weli 4 �•
DISPERSAL CELL INFORMATION
DIMENSIONS �N j'� � L �/�� #of Cells ( Type of System Distribution Media Manufacturer:
SETBACK � Conv ❑ Aggregate
OHWM of Nav �p t"�.`
INFORMATION P�L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG ❑ EZFIow
CELL TO f- p' `11 f} ❑ Mound �—Other
_ _ _ _— _�__�
--- _ _ _ _ _ --- ---
I TRI UTION SYSTEM x Pressure Systems Only
--
— _ ---- --
Header I Manifold Distnbution Pipe(s) X Hole Size � X Hole Observation Pipes '
Length Dia Length Dia Spac Spacing ❑Yes ❑No I
— _ _ —.__ --
SOIL COVER
_— - _ —_ _ _ ___ —__
Depth Over Depth Over Depth of Seeded I Sodded Mulchetl
Celi Center � Cell Edges , Topsoil � ❑Yes ❑ No � ❑Yes ❑ No �
COMMENTS: (Include code discrepancies, persons present,etc.)
s� ��5���� $�s/� �
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Plan revision required?❑Yes No � I I�I q
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Use other side for additional information Date S Inspector's Signature Certification Number
SBD-6710(R.3/01)
At701TI�NAL C�MMENTS ANO SKETCH
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