HomeMy WebLinkAbout111-158-01-0200-SAN-2022-001 ` County
: `, �� `}- '� Satety and Buildings Division sawyer �
- �_ $' " �\� ,�� 201 W.Washington Ave.,P.O.Box 7162 g���ry permit Number(to be�511ed in
%, s - \� ��-' Madison,Wl 53 707-7 1 62 � � ``� ��� �
1� -�
Sanitary Permit Appiication ��Transactiort Neeaiber �
ln accordance with s.SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govemmentai �
unit is required prior to obtaining a sanitary permit. Note:Appliqtion forms for state-owned POWTS are submitted p�oject Address(if diffenent thsdf mailin
to the Departrnent of Safety and Professional Services. Personal information you pmvide may be used for secondary �
ses in accordance with the Priv Law,s. 15.04 1 m,Stats.
I. Application Information-Please Print All Information
Property Owner's Name Parcel# �
Wiliiam&Angela Pierre 111158010200 '
�ropeAy Owner's Mailing Address Prope�ty Locadion
4459N Paska St
Govt.Lot 2&3
City,State Zip Code Phone Number �/,, '/,, Section 12
Couderay,WI 54828
T38N; R8 W
II.Type of Euilding(check ali that appty) Lot#
� 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name
2&3
Block#
❑ Public/Commercial-Describe Use
I ❑ City of
❑ State Owned-Describe Use CSM Number � Village of COude1'ay
❑Town of
III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
A' ❑New System � Replacemcnt � TreatrnenUHolding Tank Replacement Only � Other Modification to Existing System(explain)
System
B. � Permit � Permit Revision � Change of ❑Permit Transfer to List Previous Permit Number az►d Date[ssued
Renewal Before Plumber New Owner �n1 i ' �
E iration �'�. �
IY.T e of POWTS S stemtCom neobDevice: Check all that a 1
� Non-Pressurized In�'iround ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil �
❑ Holding Tank ❑Other Dispersal Component(explain} ❑Pretreatrnent Device(explain)
V.Dis UTrcatment Area Information: uick 4 Plus
Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
300 .7 428.60 450.2 94 -q S' '
VI.Tank Info Capacity in Total #of Manufacturer �
Gallons Gallons Units p � �o� �
New Tanks E�cistiug Tanks � o �; � Y p c�`d `c�
a U v� y �n w C7 C.
Se�tic or Holding Tank '750 750 1 wieser � �
Dosmg C.'h��ber ❑ ❑ ❑ ❑ ❑
VIL Respessibility State�eat-L,the ee�ersigeed,asseme respoasibifity for installitioe of t�POWTS slwwe oe t�e'tt�ched plaas.
Plumber's Name(Print) Plumber's Sign e MP/MPRS Number Busi�ss Phone Number
Gerald Froemel 950111 715-558-1138
Plumber's Address(Street,City,State,Zip Code)
13502W Frcemel Rd Ha ard,WI 54843
VIII.Coun /De artment Use Onl
�A� v� ❑ Disapproved Permit Fee Date Issued suin g t Signature
�1�✓ ❑Owner Given Reason for Denial $ �v��� I � �� �'
IX.Conditions of ApprovaUReasons for Disapproval [� /,,C�] �'
� � F' � � � NO FiEFUNDS AFTER i
';, � _��� ;� �,�-;� LS l �� - ��I I�SUEOFPERMIT �AN 0 3 2022
�
� � � COUNTY
Attac6 to rnmpkte planc for t6e system and saboit to the Coaety oaty oo paper not Iess thae S 1n:11 ine6es.iA�ilzpNG ADM�N�S
LV�v�
SBD-6398(R. 11/I1)
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';;�='"''"�;;; PRIVATE ONSITE WASTE TREATMENT county •
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��=�'���Sp SYSTEMS SaWyer
���`$ :;; ( POWTS) ,�
�clF.`.-..__._ ,�♦'P.
r'��"��" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION � a � D� �
Personal infonnation 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#:
�Iliaw�. �lci �`�tTe_ Cc�d�s� `—
Insp BM Elev: BM Description: Parcel Tax No:
�D�,� � `Tv o�- �-� ` I l� , I S8-�I�-0�00
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W; -�� Benchmark /oo,p�
Dosing
Aeration Bldg. Sewer� 97 S- r
Holding St/Ht inlet q'��,3 �
TANK SETBACK INFORMATION St I Ht Outlet q7,p r
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic +lo� +�:..5� � �3-(� ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. ��,o �
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION �nfiltrative
Surface 4 S a�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFO MATION
DIMENSIONS W 3 � �`� �/Y #of Cells o� Type of System Distr�bution Media Manufacturer.
SETBACK OHWM of Nav � Conv ❑ ,Aggregate �� �
INFORMATION P 1 L Bldg Well Waters °� GP �C Chamber Model Number:
❑ EZFIow
CELL TO 6 � -}-�p' ,}.�j' �L�_ ❑ Other Q�
-- ❑ Mound --- --
DISTRIBUTION SYSTEM x Pressure Systems Only
Header/Manifold � Distribution Pipe(s) -- — — I -X Hole-Size — X Hole Observation Pipes�
Length Dia Length Dia Spac i Spacing ❑Yes ❑ No
SOIL COVER
-- — — -- — _ __
fDepth Over Depth Over i Depth of Seeded/Sodded � Mulched
Cell Center l Cell Edges Topsoil ___ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
���s�l�� � (Y�� 2
Plan revision required?O Yes❑ No 03�a�1 � � 6� � ��
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Use other side for additionai information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
' A�OITIONAL COMMENTS ANO SKETCH
. SANITARY PERMIT Nt1MBER: �o�.- 00 (
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