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Home My WebLink About012-640-20-5407-SAN-2021-154 �o�e"RT"'�Hr �/�,,'� Industry Services Division County � '�'� �, 4822 Madison Yards Way 53705 Sal"Ye� � '' � pgP -,, � �{`�� p0 Box 7162 S:;!itary PermitNumber(to be filled in I , � $ �, � � n � Madison,WI 53705-7162 � � � �. � 2` `— � No cs� � l� I �1�� - ��SS10!.'nl,5f� � . Sanitary Permit App ication Sta'e P,an Re"'eW N°�"be` N In accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit PWTS- �"'�"' is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS aze submitted to , the Department of Safety and Professional Services.Personal information you provide may be used for secondary Project Address(if different than mailin� �„ purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 8491N River Rd ` � I. A lication Information-Please Print All Information U� Property Owner's Name Parcel# � Menard Inc O]264020� �S'Y�7 PropeRy Owner's Mailing Address Prope�Location 4777 Menard Dr �c- Govt.Lot_4_ City,State Zip Code Phone Number � �, Section 20 Eau Claire,WI 54703 (circle one) II.Type of Building(check all that apply) ' Lot# T 40 N; R 06 W �1 or 2 Family Dwelling-Number of Bedrooms 2 1 Subdivision Name Block# ❑Public/Commercial-Describe Use ❑ City of ❑State Owned-Describe Use CSM Number ❑ Village of ��(� 3...�(�Oq � Town of I{unter III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • A' �New System ❑ Replacement System ❑ TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner — N.T e of POWTS S stem/Com onent/Device: Check all that a l - ❑ 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) ❑Pretreatment Device(explain) V.Dis ersaUTreatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation � a� N/A N/A N/A N/A VL Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units p ` o � � New Tanks Existing Tanks � o � � Y p � � a U ii� � tn u. C7 G, Septic or Holding Tank 2000 2000 1 Wieser Concrete � Dosing Chamber VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumher's Name(Print) Plumbe ' nature MP/I�1PRS Number Business Phone Number 652879 715-634-8176 Travis Butterfield Plumber's Address(Street,City,State,Zip Code 14346W St.Rd 77,Hayward,WI 54843 VIIL Count /De artmeot Use Onl b �� Permit Fee Da e Issued Issuing A nt Signature �App o e ❑ Disapproved $ - `y�'1/ ❑ Owner Given Reason for Denial �W� "' 7� Z�Z� � IX.Conditions of Approval/Reasons for Disapproval �j a�+ ��-� � � �� ,��N 0 2 2�21 � � f:i � �� G�� :� �� . _ � _ �� [ � ��:��v�.��:�.s�aTv Attach to complete plans fur the system and submit to the Couuty only on paper not less than 8 tn x ll inc�i�� ' �C� � �q'��1 � �� I Z b2� �sa��u��us a�-rE� ISSUE OF P�RMIT SBD-6398(R.04/l9) -'��`'"T"��>;; pRIVATE ONSITE WASTE TREATMENT counry ,y.:�- r�;��a$ �i `; SYSTEMS SaWyer ��;�� s � ( POWTS) � � %� .NG`j'>�I l��•�P:' ' °''' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �-` � �� Personal infonnation you provide may be used for secondary purposes[Pnvacy Law,s. 15.04(l)(m)] Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#: Y�� . ��s— � '�1�10�$�7 Insp BM Elev: BM Description: Parcel Tax No: I�o.o` �J�;� ;�, �a`' w1q l� oia- 6�0-�0 - �-y�-� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic eK;�s�� i,J -- I �-S'D Benchmark IUO.o� Dosing _ ��pu -75-O Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St I Ht Outlet TANK TO P/L WELL BLDG AIR NTA�KE ROAD Dt IT� o-►'f( ,Sg ' Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header I Man. Holding Dist. Pipe �9.6a� PUMP 1 SIPHON INFORMATION Infiltrative � surface `�g•�S Manufacturer q �y� Demand Final Grade _ Model Number ��, . GPM TDH�5 Lift Friction Loss Sys Head TDH Ft Forcemain L �36a� Dia �" Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W j.�.S' � Gj$ .a � #of Celis Type of System Distribution Media Manufacturer: ❑ Conv ❑ Aggregate /�►,� SETBACK P/L Bldg Well OHWM of Nav � IGP ❑ Chamber �/Vl� INFORMATION Waters � AG ❑ EZFIow Model Number: CELL TO �- $ ��a �� .f-�a o` � Mound �{ Other __ ------__ .-- -- -- --- - — -- DISTRIBUTION SYSTEM X Pressure Systems Only Hea�der/Marnfold �, Dist9bution Pi e s ,� -- p —, 'i X Hole Size ,� ; X Hole � Observation Pipes pO Len th — Dia �- Len th y7 Dia__� S ac o,l�..5 j Spacing �•° �1 Yes ❑ No SOIL COVER - —_ - - Depth Over �� Depth Over u Depth of �v Seeded/Sodded Mulched 1 Ceil Center �� Cell Edges �� i Topsoil Yes ❑ No ,�J Yes ❑ No � COMMENTS: (Include code discrepancies, per,s resent,etc.) N : ��f��1 02 1 � �-� � �.� I(Q� - s��-r �T� � a�S� - o��J� _ << ( �� - � � � ,- Plan revision required?❑ Yes O No 03 2� �17 I ` /q J / 0 0.� ,-- - V � �b Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) Jl`�tt'��` , . . � � \ w� �� ,.'—�= �. �, �,�c�`' . � � �� f' ��''� � �,, ��-' � �� c � � �'� __ _ __------.�- ___ �.. ` ___.� � __ �_ �--__.__ � � g ------_ _ ___ ,'"-------_..____-- - � �.q'''T `� : , � ` ___ _ , ____-- - _ __ � _ �_ ___ �� -- . � � � ' 1 ; `� �L ��- A .l�w� ,� + '�� ` Y , ; � i � �� `'� `-R.` � � �` ,�,�,, �� ' �, \ - "' �`�,�t r�- � _� ) 't 1�''�'� � �, � � ��•`�` # � � �� j �, �b� � • � .,..._..�... � � � i ..r--`".. � .��r.^ � { � � �' ��'��C �. - \ � r, �, - D n� - '`� � ,p ' .� � � � �� ,� �� , 3 _.- i �� _ _ - __- - �..� � `� � � l �� • � �� '� �' �=--� � �� , - �� ,--.---n._�__ _ � --' - �', � / � �� _ � _�...__ , �� ,, , ��: �- �,�� . � �� _ � _.. . �_ I��B3 � / ° ___�.-__ __-w-- �- �/ A��ITIONAL COMMENTS ANO S ETCH SANITARY PERMIT NUMBER: _pZ��_ _ a�� -o^" � \ , I ��' _ ._ ' ' ' ' .__ : ! �u �'.v�n. �-3 6� � * , � �� .�� a � .�1 s��'� � � �'P ��,,.' o � �ani r �+