HomeMy WebLinkAbout008-937-20-3307-SAN-2021-041 � County
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� %��` ��': ��� Industry Services Division Sawyer �
i ��Fp' � �� �� �� �1�� 1400 E Washington Ave Sanitary Pcrmit Numbcr(to bc iillcd in � 1
"` `� � ��� � A P.O. Box 7162 � I
� ��;���' �1 �Q Madison,WI 53707-7162� � Z�O� f�� I
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Sanitary Pennit Applica ion s`a'e Tr�"�``°``°°"°°,�" �. I
fn accordance with SPS 383.21(21.Wis.Adm.Code,submission of this fonn to the appropriate govemmental unit � �
is mquired prior to obtaining a s�initary permit. Note:Applicatiun forms for statc-owned POW"CS are submitted to Project Address(ifdiffercnt than mailir
the Department of Safety and Profcssional Scrvies. Pcrsonal infomiation you provide may be used for secondary COUllty RC�. F ���� � �
purposes in accordance�vith the Privacy Law,s.15.04(I)(m),Stats.
I. A lication Information-Please Print All InTormation ��
Property Owner's Name Parcel#
Francis Hayes 008937203306
Property ON�ner's Mailing Address Property Location �
PO Box 66 �
�o�r.��,t
City,State 7_ip Code Phone Number S�l�/ �;, 5�1/ '�,, Section 2� �
BirChwood WI 54817 (circ(conc) �
T 37 N: R 09 E or W
II.�ype of Building(check all that apply) Lot# -- � _ _ �
J --i
J l or 2 Family Dwciling Number of E3cdrooms 3 Subdi�ision Namc i
— --- ,
Block# I
_'Public/Commcrcial Describe Use �
— ' City of -
CSM Number �age uf �
State Owned-Descnbe Use ,
I
T�µ„�,e gewater
__-------- --..---._.__. ._ _ ;
�lll.Tvpe of Permit: (Check onlv one box on line A. Complete line B if applicable) �
— � --____..
� A' � New System � Replacement System ��, TreatmenVHolding Tank Replacement Only ��� Other Modification to}ixisting System(expl�in) �
�
K• Pennit Renewal Permit Revision Change of Plumber Permit Transfer to New List Previous Permit Numhcr and Date fssucd
BMi�rc Expiration Owncr �-
`1\'." �pe of POWTS S��stem/Component/Device: (Check all that apply) ___- II
� " \rm-Pressurized In-Ground Pressurized In-Ground ' At-Grade tifotmd>24 in.of suitable soil Mound<23 in.of suitable soil . �
� I
I lolding l'ank ' Othcr Dispers�l Component(expiain)___ _�Pretreatroent Device(explain)__ ' �
--- _...--------
�V.DispersaUTreatment Area Information: �
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� Dcsign Flo�c(gpd) � Design Soil Application Ratc(gpdsfl Dispersal Arca Required(sf) Dispersal:1rea Proposed Ist) System Elc��ation �
450 .7 643 �5tf 6 Y(o 86.5� - $�.S� i
Vl.Tank[u�o Capaciry in Total #of Manufacturer T �
�
Gallons Galluns Unit, � � U � � u �
I ., u — � V I ;
� New Tanks Existmg"I�anks � c � � � � , �, �
G U i%� v V7 ti. �'7 I C. t
- -- ---- � --�1---- I
Septic or Holding l ank I �
1000 1000 1 Wieser X
Do+ine Chamber — +
— -- I
�V II.Kesponsibility, Statement- 1,thc undersigned,assumc responsibility fm-installation of thc PO�VTS shown on thc attached plans. __ �
� Plumber's Name(Print) Plumber's Signat l�e�/ MY:�MPRS Numher Business Phimc Number
Rick Brown �` �.�-- / 231251 ��s 419-0739 __ �
� �
� Plur.ib�•r's Address(Slreet.City,State,Zip Code) �
�PO Box 637 Spooner WI 54801 ;
r---- ---- - ----- - ------I
ti)tl.Count�/De�rtment Use Only ;
i----- � — — --- ------
, $�?��� Nermit Pce D�e lssued lss mg A >e t Signaturc l
� K .A�iru���d Disapprovcd � � � � i
�,: ' Y�,_ � °
� O�vner Given Rea,on for Derial �J �2 � _ �
�I�C.Conditions of Approval/Reasons f'or Disapproval 1 i� �� i
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L. �11'.�.1!S � ., i� �� ' ����__.�
Attach to complcte plans jar the s� tcm aud whmil tu the Count�onl�on paper nnt Icss than R 1;2 x 11 i o6i�i -- ---._. . �
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� �- I �4 , 3 �l5 202 i , t 2 ���� _.;
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Sf3D-6398(R0313) ' .. .
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''""'-'` �� PRIVATE ONSITE WASTE TREATMENT cou�ty
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%�;'� ■$ ����', SYSTEMS Sawyer
'��� Ps .'� ( POWTS)
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'>""��`� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ �� i 1
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. l 5.04(1)(m)] �
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
` ''_\c��C.�.�� ��t�'�� r=.tik.��c-'��
Insp BM Elev: B Description: � Parcel Tax No:
�v�,. ��; L:��,:_� ���� �c:� -�i 3-�- a� 3-3�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �;.,` .�_.-�,- � `, �, Benchmark �oc �.e la�.`�
Dosing
Aeration Bldg. Sewer �`i .�S
Holding St/Ht Inlet ���3."`;
TANK SETBACK INFORMATION St I Ht Outlet �7.-7S
TANK TO P/L WELL BLDG vENTro ROAD Dt inlet
AIR INTAKE
Septic i��+ ;a�'� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �' 7 �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative c�-L �
Surface
Manufacturer � Demand Final Grade _�
Modei 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 Bidg Well Waters o GP � Chamber Model Number:
a EZFIow
CELL TO 1��.-� Su k — ❑ Mound o Other (_,`�_v,� �-1
-- —_ ___------ -----_ __.__ —
DISTRIBUTION SYSTEM X Pressure Systems Only
- _ --
Header/Manifold Distribution Pipe(s) 1 X Hole Size X Hole Observation Pipes
Length Dia _ �Length _ Dia Spac !� _ Spacing ❑Yes ❑ No J
SOIL COVER
Depth Over � Depth Over i Depth of Seeded/Sodded Mulched l
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 '� �� � ����'f%�'�;�! � ���, �� � 1
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: a� '�� �
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