HomeMy WebLinkAbout026-938-14-5101-SAN-2022-012 � '`''-"`v;. Industry Services Division County �
_'� B :', 1 � 4822 Madison Yards Way Sawyer �
- $ ���:� r3�� Madison,WI 53705 Sanitary Permit Number(to be filled iii t
PS S� `" p�� P.o.Box 7t62 ,� ,r l�
=�;`' Madison,WI 53707-7162 �
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� Sanitary Permit Application s�te T`a°sa"`°°N°,,,ee` �
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fomi to the appropriate goveinmental unit Q� `"������O�"C� �..�
is required prior to obtaining a sanitary pe�mit.Notc:Application forms for state-owncd POWTS are submitted to ProjeG Address(if diffcrcnt dian mailin, �
the Department oCSafery and Professional Seil�ices.Personal information you provide may be used for secondary �� ���t L�t �
puiposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. �
I.Application Information—Please Print All Information
Propcity Owncr's Namc Parccl# ��
Johnson Timber Corp 3 �,,,,� �3) 026-938-14-5101
Property Owner's Mailing Address Propeity Location
9676N Kruger Rd Go�,t.Lot p��
City,State Zip Code Phone Number
Hayward, WI 54843 715-634-7241 ��, ��<, se�t,on 14
Il.Type of Building(check all that apply) Loc# T 38 N R 09 E or W
�I or2 Family Dwclling—NwnbcrofBcdrooms SubdivisionName
RV Park Block�
�ublic/Commercial—Describe Use__
�City of
�Statc Owned—Describc Use CS�t Numbcr illage of
�To��r,or' Sand Lake _ _ _
III.Type of POWTS Permit:(Check citlier"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
,4.
✓�Tew System �Replacement System ther Modification to Existing System(explain) �Additional Pretreatment Unit(explain)
B� �EIolding Tank �In-Ground �At-Grade �Mound Indi�•idual Site Design Other Type(exolain)
(conventional)
C• Renewal Before �Re�°ision �Change ofPlumher �Tran;fer to new O�vner
List Previous Permit Numbcr and Date Issued
Expi ration
N.DispersaUTreatment Area and Tank Information:
Dcsign Flow(gpd) Dcsign Soil Application Ratc(gpd/s� Dispersal Arca Requircd(s� Dispersal Arca Proposcd(s� Systcm I?Icvation
675 .7 900 1006 95.00
Capaciry in Total #of Manufacturer
Tank Infonnation Gallons Gallons Units p � o 'd o
New Tanks Fxis[ing Tanks y c � L y p � �
0
a J ci� � � i�. U n.
Sep[ic or Holding Tank 1585 1585 1 Wieser Concrete ✓
Dosing Chantber 9rJ� 9�J� � �/�/I@S@I'COI1Cret@ ✓ � � �
V.Responsibility Statement- I,the undersigned,assmne responsibility for installation of the POW'1'S shown on the attached plans.
Plumber's Vame(Print) Plumber's Signature MP/MPRS Number Business Phone Numbcr
Travis Butterfield 652879 715-634-8176
Plumher's Address(Strect,City,State,Zip C
14346W St. Rd 77, Hayward, WI 54843
VI.C u �/Departmcnt Use Only
�Ap}ro�ed ❑Disapproved Pcnnit Fcc Datc Issued ,suing A nt Signaturc
�w �`�O''`° � ' Z Z �
❑ON�ncr Givcn Rcason for Dcnial 7
Condicions of Approval/Reasons for Disapproval
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, ���� � 6 2022 �
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At[ach ro complete pla s for the system and submi[to Ihe County only on paper not less than A l/2 s I1 inche� °59�rk` '__'� �,..0,�:.1; . 9 �� ��
r�} (� � � z����r���;��,���:�v�S tRr�;1"ION
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sBD-639s�R.o3izi> ' � �I �V�—Z NO REFUNDS AFTER
IS3UE OF PE,RMIT
�""""-'^�;= PRIVATE ONSITE WASTE TREATMENT county
., ,.
%=j��o \\'�! SYSTEMS Sawyer
� $P � ��' ( POWTS)
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°`T"!"�^��'' INSPECTION REPORT Sanitary Permit No:
Safety and euildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a� ^ bl �
Personal infonnation you provide may be used for econda purposes [ Privacy Law, s. 15.04 (1)(m) ]
Permit Holder's Name: �s. 3 ❑ City ❑ Village C�Town of: State Plan Transaction ID#:
�a4,rso►-, �.�.�er' Cor �2v SG�.�. l.a�,c� 1a^,�� - a��-2croo� - L
Insp BM Elev: BM Description: Parcel Tax No:
�U l./ . a ( NA� l � � � �� "�25�-- ��.► 9�g"'.( c� .- �l� �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,iio�,sZr- — � �' Benchmark pd.o �
Dosing ^ co� �po q�j
Aeration Bldg. Sewer —
Holding St / Ht Inlet $� .S'7�
TANK SETBACK INFORMATION St I Ht Outlet �3 j,� '
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
f
Septic �{�` .��� ,{�aD ,�c� � NA DtBottom �'j
Dosing " 4 • , NA Instaliation
Contour
Aeration NA Header I Man. 9 �
Holding Dist. Pipe ,
PUMP 151PHON INFORMATION �nflltrative
r
Surface �lb-a2
Manufacturer �a Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L fi�..js Dia � `` Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N � L z� # of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate � �
SETBACK p I L Bldg Well OHWM of Nav � IGP � Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO ,� � .� � ,f,�„ fi�� ' ❑ Mound o Other ��
-- _ _ -- ---- ------ -- --- — -
DISTRIBUTION SYSTEM X Pressure Systems Only
T
Header I Manifold Distribution Pipe(s) ! X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac �_ Spacing ❑ Yes ❑ No �
- --- -- -
— -- - —_ -- —
SOIL COVER
Depth Over Depth Over Depth of � Seeded I Sodded � Mulched �
Cell Center Ceil Edges Topsoil _ __ _ ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
� -�l� 5�t3 � 2�
� 57���^-, �.3�
Plan revision required?O Yes ❑ No �
-
o� � a-3 1 � �� .� l �
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710 (R.3/01 )
AOOITI�NAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBEA: o�o�-�«
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