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Home My WebLink About002-106-14-0400-SAN-2022-013 /°�,�,1274j�`` Indushy Services Division County `\a� V,%; 0� �,I�` � /`� � 4822 Madison Yards Way Sawyer � = �aPs ,"<' '',,.7�� Madison,WI 53705 Sanitary Pemut Nmnber(to be filled in � -::�' /� � P.O.Box 7162 ��r' ? �-� � Madison,WI 53707-7162 . � ��r-� � �� C;2� �_.. �,srrmn�� . Sanitary Permit Application State Transaction Number f� In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit �� is required prior to obtaining a sanitary pennit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailinr � the Depai7ment of Safety and Professional Services.Pcrsonal information you provide may be used for secondary 7564N Court Oreilles Lak `�/ puiposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. I.Application Information-Please Print All Information Property Ownei's Name Parcel# �� Brian R & Holly M Duffy, Timothy Hartnett 002-106-14-0400 Property Owner's Mailing Address Property Location PO Box 590 G,�r r„f City,State Zip Code Phone Number � Hayward, WI 54843 �_154,�Section 31 II.Type of Building(check all that apply) Lot# T40 N R O8 E o �1 or 2 Family Dwclling-Number ofBedrooins 2 �'�-S Subdivisiofi Name ��o�k# t.B�-� l� �l �ublic/Commercial-Describe Use I� �1• ❑City of ❑State Owned-Describe Use CSVI Number illage of � OTow�of Bass Lake __ III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if a licable.) A ❑New System �eplacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) B' oldin Tank � g �In-Ground �At-Grade �Mound Individual Site Design Other Type(explain) (conventional) C• ❑Reuewal Before �Revision ❑Change of Plumber ❑I'ransfer to New Owner �st Previous Permit Number and Date Issued Expiration u�r�- ? V`' � IV.DispersaUTreatment Area and Tank Information: Desio Flow(gpd) Dcsign Soil Application Rate(�d/s� Dispersal.Area Required(s� Dispersal Area Proposed(s� System Elevation 300 .7 429 45 2 94.00 Capacity in Total #of Manufacturer Tank Infoimation Gallons Gallons Units � o v � New Taiilcs Existing Tanks �' � '" U � 0 y � y p ia � a. U v� �, v� w c7 a. sepc��o�xoi��g Taak 1060 1060 1 Infiltrator ,� Dosing Chamber 540 540 1 Infiltrator � 0 Q ✓ V.ResponSibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) PlumUer's Signature MP/MPRS Number Business Phone I�iumber Travis Butterfield 652879 715-634-8176 Plumber's Address(Street,City,State,Zip Code) 14346W St. Rd. 77, Hayward, WI 54843 VI.Co�nty/Department Use Only �A ed ❑Disapproved Peimit Fee Dat Issued iss ng ge Si�naturc �Z✓ ❑Owner Given Reason for Denial � t��°�� 2 2 � � � Conditions of Approval/Reasons for Disapproval t:�--1 � � i �� 3� �i--1!�+�r�'�W 1�'�1 r�� ;; , ;;' 1 t�5� � ` �;, ;�_ .. �. �.� �f�i Y� ` i`�4( � �� ' , .. 1 � . � • � �ti 4.1� � ��. [_';�J �"�,43 � 2 2722 r �� Z. '�____-------__-------� ,�,� � " CO�NTY Attach to complete plaus for the system and submit to the County only on paper not tess than 8 t/z x 11�nct�ea j��M��f� s�C �' 1 ^� �v�� 3s ��.o3i > �'��' �L � Z,.�� G VG�-� NO REFUNDS AF?ER ISSUE OF PERMR ' ��H � ; ' `��'�'` PRIVATE ONSITE WASTE TREATMENT county -Pc�—_/�'`Yi; �:/ ,?cr ��'o$p ,`� SYSTEMS Saw er �� s )�, ( POWTS) Y ,�� \k"`rs�'��` INSPECTION REPORT Sanitary Permit No: �_s�>_T Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION � � � (� l3 Personai infonnation 9ou provide may be used for secondary purposes[Privacy Law,s. 15_04(()(m)] Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: ;��iav� J-Hb�� '�-- � �S5 La�L�- Insp BM Elev: B Description: Parcel Tax No: (trv.o' ��a,�- l�„� o., c a`` �-��,e o,k� �,� a r s.S, �2 _io6_ 1 _ oyoo TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic f �'� Benchmark �op,o� Dosing �� Aeration Bldg, Sewer 40.o� Holding St/Ht Inlet �q,S� TANK SETBACK INFORMATION St I Ht Outlet �q, � TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet $q, 1 AIRINTAKE Septic -�"� -�� .�� -�5" NA Dt Bottom g�,2 � Dosing � � � , NA Installation '� � 't'S� �' Contour Aeration NA Header I Man. `�'J�b� Holding Dist. Pipe PUMP/SIPHON INFORMATION Infiltrative Y �� Surface Manufacturer q Demand Final Grade Model Number �� GPM 1'I� � � . Y(�a � TDH Lift Friction Loss Sys Head TDH Ft Forcemain L�� Dia " Dist.To Well DISPERSAL CELL INFOR TION DIMENSIONS W 3 L �f #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate '� ,� , INFORMATION P 1 L Bldg Well Waters � IGP � Chamber `�� ❑ AG ❑ EZFIow Model Number: CELL TO ❑ Mound o Other -- -- - ---- �---- DISTRIBUTION SYSTEM X Pressure Systems Oniy Header I Manifold Distribution Pipe(s) 1 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 Mulchetl Cell Center Cell Edges Topsoil _ � �Yes ❑ No �—❑Yes ❑ N� COMMENTS: (Inclutle code discrepancies, persons present,etc.) �� (a� Plan revision required?0 Yes ❑ No �� ,� �3 �— , /�� (� . .. �'� b � Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AO�ITIONAL COMMENTS ANO SKETCH �IL SANITAAY PERMIT NlJMBEA: a1- C�13 _. � 5 �� S, �.� Q�c} X�� Sl �I� ,�8�1 �f,.,�. 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