HomeMy WebLinkAbout014-842-17-1301-SAN-2022-021 ""�"'��-� Industry Services Division Counry -
4822 Madison Yards Way �`�`�' � ,� �
: �,�j ��� Madison,WI 53705 Sanitary Permit Number(to be filled iR I
�_ � 1�\� P.O.Box 7162 /� �
_ �\�, Madison,WI 53707-7162 �� O 2,��)
1
Sanitary Permit Application StateTransactionNumb^er
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In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin�
the Department of Safety and Professional Services.Personal information you provide may be used for secondary �- �
purposes in aecordance with the Privacy Law,s. 15.04(1)(m),Stats. ����� �5 � ��,��5e�'� , �--.•
I.Application Information-Please Print All Information �j �/
Proper[y Owner's Name - Parcel# �_)
�j�'� � (����5 ���- � l�`�'-�ZI� �� � � —
Property Owner's Mailing Addre s Property Location
1 ���j W �;;�.,�-� �{ ,I( R�
Govt.Lot
City,State Zip Code Phone Number � /
� l,,I c.r ���" 5'y�`��j �� �/<, �V G '/a, Section�—
11.T e of Bui din check all that a 1 I.ot# Z ,
YP g( PP Y) � T � N R C�' � E o W
,1., 1 Subdivision Name
Qrl or 2 Pamily Dwclling-Number of Bedrooms
E31ock#
O Public/Commercial-Describe Use
� ❑City of
❑State Owned-Describe Use CSM Number ❑Village of
-� �Town of �-t�l �U�' i'
IIL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one boz on line B.Complete line C if
a licable.
A' �New System ❑ Replacement System g y ( .p ) ( ,p )
❑Other Modification to Existin S stem er lain ❑ Additional Pretreatment Unit eY lain
�' ❑ Holdin Tank ImGround ❑At-Urade
g ❑ Mound ❑ Individual Site Design ❑Other Type(explain)
conventional)
�=• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner
List Previous Permi[Number and Date Issued
Expiration
IV.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation
'3-0� . � y �/6 �I,� � � �'
Capacity in Total #of Manufacturer
�
iank Information Gallons Gallons Units � L o ,9, �
New Tanks Existing Tanks '� c � � Y � ;� �
0
a` U v: � v� u. C7 0.
Septic or Holding Tank �� ��� ( � ! �5��_
V�/
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume re onsibi ty!o installallon of the POWTS shown on the attached plans.
Plum er's Name(Print) Plumber's Si ature MP/MPRS Numbcr Business Phone Number
' ,2;Z �j� r � �.s�I `�c;-$ 'I������ �- ��; �1 Z
Plumber's Address(SVeet,City,State,Z.ip Code)
�j �t�.� �i.�ht- ,IT . h � . �� `�'�CY�11�f `a� 5�i 0 i.`�
VI.County/Departme t Use Only
� Z Permit Fee Dat �lssue [ss � g ent ignature
App o e� ❑Disapproved - �
�� ❑Owner Given Reason for Denial $ `�'� � I � 22 �
Conditions of Approval/Reasons for Disapproval
_._....�..�.�-• �U� [� � ��'��''=-�E�
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� C`�I � 2— �)� i'�' �
� �� ' �� ��� FEB 1 4 2022
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SP,W�'�R Cv�J1�TY
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Attach ro complete plans for the system anJ submit to the County only on paper not less than 8 In x 11 inche m size
�L P I � G�� �.� � Z� ��;J I �l;wZ NO REFUNDS AFTER I t°q�'� S
SBD-6398(R.03/21) 1 3 SUE OF PEflMIT
,�� �
//�i''�'-"``;,,y PRIVATE ONSITE WASTE TREATMENT county
���� o�p ��� SYSTEMS SaWyer
���,� s , ( POWTS)
�H f�---,,�i,
��'—°�'�' INSPECTION REPORT sa�itary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.�.-0�- I
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(cn)]
Permit Holder's Name: ❑City ❑ Village �,Town of: State Plan Transaction ID#:
�� �a L.�-L �2.h Cba �
Insp BM Elev: BM Description: Parcel Tax No:
��.� I�." W �Q� �IY-BY� -(� -(3�J
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic i,�,i e 7� Benchmark [.��p' p ,b' o�,�`
Dosing
Aeration Bldg. Sewer �3,0 � �of, O'
Holding St I Ht Inlet �,� ' q$.$`j'
TANK SETBACK INFORMATION St I Ht Outlet �",33 � `� •67�
TANK TO PIL WELL BLDG VENT TO ROAD Dt Inlet
AIRINTAKE
Septic .}�oo� fi�-� ].o` f�D� NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. (�.p � � �-p'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infi�trative � �
Surface ��� ��-�
Manufacturer Demand Final Grade
Modef Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
QIMENSIONS W � � � g #of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate '-'—
INFORMATION P I L Bidg Well Waters � GP � Chamber Motlel Number: �
❑ EZFIow
CELLTO i-(o0� -1-a,� '� � N ❑ Mound _ o Other _ Qy � —
DISTRIBUTION SYSTEM X Pressure Systems Only
_ _
Header I Manifold Distnbution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia � Length Dia Spac Spacing 0 Yes ❑ No
--- - —__-- --
SOIL COVER
__ -- -- -- _ __ -- --
De th Over De th Over De th of Seeded/Sodded Mulched
Cell Center �Cel�l Edges Topsoil __ ❑Yes 0 No ❑Yes ❑ No
COMMENTS: (Inclutle code discrepancies, persons present,etc.)
��s�lle� ab �23 la-�
Plan revision required?❑Yes❑ No
o z t� �-3 ���;. � , �t� (�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS AN� SKETCH
SANITAAY PEAMIT NUMBER: �,�2_�s��_
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