HomeMy WebLinkAbout028-542-12-5106-SAN-2021-419 . �� � � . . .
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Sawyer County Zoning Administratior� .
10610 Main Street Suite 49 /r %?�?�
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SAWYER COUNTY SANITATION DEPARTMENT .
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: p hn�
TOWN OF: �p j� Ww�--
ADDRESS: � (`� �� /v "'`a�7' ' ` '-
I, �C�������_ ���nX , a Wisconsin
Licensed Plumber, authorized by the owner, do hereby acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, and private sewage system plan review due to inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381.01 (92),Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date inay result in the issuing of a citation,under Section 11.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR THIS AGREEMENT SHALL BE: I� `�( �
Signed: �-'� �/
Date: � l��� -2-�
Accepted by: �µ l/tii-��l�'��
Date of temporary emergency approval: l� ( ���- �
Rev. 03/26/13
-'�t""T"'�>; PRIVATE ONSITE WASTE TREATMENT counry
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�='�S SYSTEMS SaWyer
�s '��� ( POWTS)
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" �"�� ' INSPECTiON REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 21 _ c.�lq
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] �
Permit Holder's Name: ❑City ❑ Village � Town of: I State Plan Transaction ID#:
P��q ,��c,t�.,�s�..� � �� --
Insp BM Elev: BM Description: Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �.�,,3' (Oa.6 j� �op,4s�
Dosing
Aeration Bldg. Sewer 3,a � �9 r
Holding ,,�,�e ��p St/Ht Inlet �,�-(� � c� � `
TANK SETBACK INFORMATION St I Ht Out�et � �� �g�og�
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIRINTAKE
Septic NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man.
Holding fiy�' �h�' �p� .}..�o G�S� Dist.Pipe
PUMP 1 SIPHON INFORMATiON Infiltrative
Surface
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 Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters °� GP ❑ Chamber Model Number:
o EZFIow
CELL TO o Mound o Other
DISTRIBUTION SYSTEM X Pressure Systems Only
Header 1 Manifold Distribution Pipe(s) TX Hole Size X Hole Observation Pipes �
Length Dia Length Dia_ Spac _L j Spacing ❑Yes _❑ No
SOIL COVER ___ —
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges � Topsoil ❑Yes � No � ❑Yes ❑ No
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COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?�Yes 0 No �Q3 10 a- � �I ��� (`
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
A��ITIONAL COMMENTS ANO SKETCH
�Q'�'� ��`e � SANITARY PERMIT NUMBEA _ �Z / _ Y(�__
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