HomeMy WebLinkAbout026-938-07-5303-SAN-2021-057 �///���� Industry Scrvices Division Co�mty �
� '� 1400 E Washington Ave �,���-�-�`�
� • �1� P.O.Box 7162 Sanitary Permit Number(to be filled ia t
a` M 'son,WI 53707-7162 � ��� �
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Sanitary Permit Application StateTraasaetionNumber ,�
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forni to the appropriate govemmental unit �' G
is required prior to obtainiag a sanitary pelmit Note:Applicarion focros for state-owaed POWTS are submitted w Project Address(if differeat than mailin
the Department of Safety and Professionai Servixs.Petsonal infamatioa you provide may be used for saandary ��c 5��`J `^� 1-�`��c�t.t.iw/ �
in�w�w�u� r..� s.i s. i m s�. J
L A llcatfon Informatlon—Please Print All Information �
A�operty Ownc's Name Parcxl# .
£: 1/�-�` 5 2..�. �- �.��-�r�� L L � o �q 3�,c� = 3�3
property Owner's Mailing Addte,ss Property I.ocarion .
5�-(�!`1 �'3 l�t1C �.. � Gc�vc.Lot �;3, (-�
City,Stste Zip Code Phone Number ,�� ,�� S�� '�
s' (circle one)
rL�x� L' o—t i`"� ,l `'�?C I T 3�'U N; R�E or�
II.Type of Bnilding(chock all that apply) � �#
�or 2 Family Dvvelling—Number of Bedrooms Subdivision Name
Block#
❑PublicJCommercial—Deacribe Use
❑City of
����_���U� CSM Number ❑Village of
8-Towa of f?c.n.�•� L,c,.../�- '�
III.Type of Permit: (Chock only one boz on line A. Complete line B if applicable)
A. ❑New SYstem �x��t sysc� ❑Trea�eat/Holding Tank Replacement Only ❑o��r�zion w�s sr�(«r�>
List Previous Pecmit Number and Date L4sued
B. ❑permit Reaewtil ❑Pecmit Revisian ❑Chaage of Plumber ❑Petmit Transfc to New ?
sef'on E�ion owaa l,��,�( .
1V.T of POWTS S m/Com ent/Device: Check all thst a !
�Non-Pceasurited In-Gmund ❑Preswriud In-(3rouad ❑Ai-Grade ❑Mouad>24 in.of suitable soil ❑!Viound<24 ia.of suitable soil
0 Holdiag Taak ❑Other Dispeisal Component(explain) ❑Pretreatment Device(expisia)
V. nal/I'reatment Area Iaformstion:
nesiga Flow(gpa) Desiga soil applicffiion R�dst) Dispecsal Area Required(a fl Dispersal Area Proposed(s� System Faevation
��� � � ��7 � ��� '� ����
VI.Tank Info Capacity ia Tota1 #of MaauFscturer
G�allans Gallans Units � � �'g �
New I'�lcs Ta�Ics w c u �' a� a`� `�' �v,
�B �3 y � � '�'-,� a
s��xo�T� t Z �� ��S° l ��.eS�' �
�c�b" 7.5�
VII.Ros onsibility Statemeat-L,the andereigned,assnme responsibilfty tor inst�llation of the POWTS ahown on the attached plans.
Plumber's Name(Print Plumber's Si� r MP/1v�RS Number Business Phone Number
Jerry Ruid �xcavating, LLC �� �z�ca��� `7�s-���-��c��
� Stone Lake, WI 54876��
VIII. o n /De artment Use On
� � ����� aetmit Fee Iasued t Si�ahae
❑o����x�f�� `f o�.�� 4 q, 202� O.��t
IX.Conditions of ApprovaUReasons for Disapprovai
�� � � � �'��'1 t7/��G�
' a ,'� ��I = , NO A�FUNIDS AF7ER � `�'�,,,�1�i" �' E � jl
� �� �u-�� lSSUE OF PERMIT _ ' ��� L!-=-� .f�� I I
;� � i� ,3f
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Att�ch to compkte plao�for the sy�tem and snbmit to the Connty oniy on p�per aot las than S 1B z inches tn
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SBD-6398(R.08/14)
�,;�"`""—'""^%:, PRIVATE ONSITE WASTE TREATMENT County
:��'�? �$ SYSTEMS SaWyer
�„�� p$ ( POWTS)
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INSPECTION REPORT Sanitary Permit No:
Safety and Buiidings Division (ATTACH TO PERMIT) i
GENERAL INFORMATION �� _ ��`�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Pian Transaction ID#:
�
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insp BM Elev: BM Description: Parcel Tax No:
�`=c _ ��_. �=`��-,-Z. ��X �;�(� _ �i 3� ��7— �3c�.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �.�� L,L:� 'i�� ��`, Benchmark �;;�;._,� lo\ `I2�
Dosing
Aeration Bldg. Sewer �j'-1 , �
Holding St I Ht Inlet G 3�j�
TANK SETBACK INFORMATION St I Ht Outlet �{3.�7
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic �lu � i�� � S � NA Dt Bottom �`i.��
Dosing NA Installation
Contour
Aeration NA Header/Man. �;�j .�
Holding Dist. Pipe •
PUMP 151PHON INFORMATION �nfi�trative �,3 �
Surface
Manufacturer �.��,�._ 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 �istr�bution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P/L Bldg Weli Waters o GP � Chamber Mode�Number:
o EZFIow ,
CELLTO �-/�; i �/� .� ("3 iC�a- ❑ Mound o Other ���j� � 5
- - ---. _ -- ----— -
DISTRIBUTION SYSTEM X Pressure Systems Only
Header I Manifold Distribution Pipe(s) I 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 ❑Y'es ❑ No �Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
SyS��--- �.���\�� \� � `� �� �
Plan revision required?❑Yes❑ No '� r� �a Z✓'������ --� I \��'� �� '`-`
Use other side for additional information Date � POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
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A�OITI�NAL COMMENTS AND SKETCH
SANITARY PERMIT NlJMBEA: a� �dS7
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