HomeMy WebLinkAbout008-937-04-5205-SAN-2022-032 '�='-''� Indushy Services Division Ca��Y
4822 Madison Yards Way ;�; ,
,-^:,�_ = Madison,WI 53745 Sanitary Permit Num er(to 6e 511ed in by Co.)
. �� P.O.Box 7162 �
-__ - Madison,WI 5370?-7162 (p3 9 03 g L
Sanitary Permit Application State Ttansaction Number �
�--
In accordance with SPS 383.21(2��s.Adm.Code,submission ofthis form to the appropriate gove�nmental unit
is requiied prior tn obtaining a sanitary permit Note:Application foimv for state-owned POWTS aze submitted to Project Addiess(if diffencnt than mailing add�ess)
the Depaitrirent of 5afety a�Pmfessional Services�Persaral infonnation you provide may be used for secondary J�.�_ (7
puiposes in accordance with the Privaz,y Law,s.]S.(f4(1j(m),Stats.
I.Application Information-Please Print All Ieformation
Pro�rty Owne�r's Namc Pazrxl# p LT���.5/-�'(1/-5..2 US
� O tp��
Prope�ty Owner's Ma►1mg Address Property Location
58'�� W Ol. S (� - ��`� .�
City,State "Lip Code Phone Number
- .� l�i� j ��i � ��sc, s�on O�
II.Type of BeiWiag(c�eck all that applY) Lot# ` T�N R d E o
�!or 2 Family tlwe}{ing-Number oFBedrooms�__ Subdi�ision Name —
Block#
�ublidCommercial-Descnbe Use r
�iry of
State dwned-DescribeUse CSM Number illage of
- �Town of�����
III.Type of POWTS Permifi(Check eit6er"New"or"Replacement"and other applic$ble an line A. Check one boa on line B.Complete line C if
a licabl�)
`�" �Iew SysBem �eglacement System ❑Other Modificatioa to E�cistiag System(explain} Additional Pretre�etmea[L'nit(ezplain)
iFy
B' �F[oldivgTaak ❑[n�round �At-(',►ade �Mound IodividuaI Site Desig� Other Type(expiain)
'i--T (conventiaiai)
C. �Rencwal Before �Revis►on nge of Plumber ❑Transfer to New Owner ist F're�zous Permit Number and I?ate lssucd
ExpiraRon ��� . �
IV.Dispersal(Treatment Area aad Tank Infc►smation:
Design Fiow(gfd) Design Soil Appiication Rate(gpd(sfl Dispersal Area Requimd(s� Dispeisal Area Proposed(sf) System Etevation
Capacity in Total �of Mano6ctmer
�
Tank Infonnation Gailons Gations Units S, � o � �
Neiv T�ks Existing Tani-s y o u ` � � � �
a U �n � r� a. Ci o.�
�����T� � 0 31�c�
��� o o a
V.Respoosibility Statement-I,the oadersigned,assame re�oH�b7ity fer iastnllation af t�e POW'I'S shown on�attac.�ed planx.
Pl�mmber's Name(Priot) Plum 'i�ature - MP/MPRS Number Susiaess Phone Number
`� �/ - ���5'�301 /S-�'�-I(o
riva��s naa��su��c�c�,s�,z�caae�
05�� "'� �-'�c�,�c��� ����- f�9. �� i�:�=�— `� � �
VI.Cou ty/Department Use Onty
� � ���p�`� Permit Fee Date Issu� Lssuing AgenE Signature
S i�❑Owner Gir en Reasoa for Deniat Y��.�" 3 —3 t— a-.a-
Conditions of AppmvaUReasons for Disappmval _ _ _ ,_
, , � _�
D '�_'�1���?���;i� \1 �;��;
� � � � � � �
� �`��� ��-�► <<1 N�-1 �Q JAN 18 2��.� I�OV 1 6 Z�2�
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SAWYER COUNTY SA�,�� ��,�,��T�,
{�11NG ADMINISTRATIO� �����A�����i���„.����li
' Attach w comptete pluns for the system aod submit to the Couoty onW oo paper 0et kss thsn 8 tn:11 incdes in size
NO REFUNDS AF"fER
SBD-6398(R 03/21) ISSUE OF PERMIT �
Sawyer County Zoning & Conservation Administration
```"``1 10610 Main Strcct,Suitc 49
y�R Cp �� Hayward,Wisconsin 54843
.'�� �`G�I (715)634-R2R8
�Q! �,��I I�AX(715)63R-3277
�y i _ {� w�vwsawycrcountygov.org
� o =,� � „ i I:-maiL zonine.scc(n�suwvcrcount ov.org
��,,� =y_,. =y`�—,: Toll Frcc CourthousdGencral Information 1-877-699-4110
�js`oN��
Holding Tank Approval Checklist
L Sanitary Cover Sheet Date Stainp 1 � / �� /�
ParcellD# Do 8- �j37 - O �/ - Sa o �
II. Plot Plan �,�/->
_Property Lines Benchmark BM ♦
Site Address North Arrow
Structure Scale
Well <25' to Service Road
Legal Description _Nearest Road Intersection
Setbacks to: Property Line, Well, Structure, Water bodies, Roads
IIL Required Plans
�Index Page with Original Signature
�} Management Plan/Contingency Plan
�Servicing Contract ��30 I o��'2
�Holding Tank Agreement form @��;3 ��
I�IBI?-�
N. Holding Tank Specifications
�Cross-section—Manufacture, Gallons: 3 � �� �'"�P��
X Tank Anchor Calculations [SPS 383.43 8) g)]
Locking device, chains/locks
Alann and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) and
State Stahites 101.862(2) and 101.862(3)
�3" Bedding Material < 1/2 "
V. Holding Tank Plans per Component POWTS Manual
�Version 2 SBD-10855-P (R.3/07)
p c.� ,
Owner: �I°��� Plumber: I�. .�'`�'��
Application Review Date: << ���� � � � • ' �-=J`—� �$ � ��
�
POWTS Reviewer: �;�„�
Namc
6� S� �� :�
,�� ;..,��
Liccnsc# � /,:'1` � �'\\ � ' �
�� .
Revi � iS�6 � - � `
1 '__ .' ,
J�+�) ., 4,,.-�a '
�y\ � c',� �V a.t.
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�A�,1+Y'E�;��::��:':, ':;.�,
ZON�NG ADM►NIS�RATION
PAG� 1 OF 4
F��Iding Tank P�an
Inc�ex & �over Sneet
Component Manual Design References:
Version 2.0, SBD-10855-P (N. 03/07; R 01/12),,,
Pg 1 of 4 Index & Cover Sheet
�g � of A� F'14t Plar
Pg 3 af 4 Holding Tank Specifications
�g � ofi 4 (V�ana��ment �lan
Attachments: ; Enclosures:
� POWTS Appiication for Review
Soil Evaluation Report & Site Map (if applicable)
� Holdin� Tank Pum�ng Contract (if appficable)
-�----
_ __---- -- _ ---- - !-l�ldin� T�r� Agr��m�nt (it app�ica5le�
Project Name 1 Description
Owner Name(s}:��,,(���(�_� Phone: - -
CJsknet' A��rPc�- k���_�I---�� ����__ �.117�P�t.��f__ ��l�' �Y._S.?�---
Project Address: �
n �
��y�, !ot: �_ ?!4 of 1//1, S�rtic)t�_ Q�-' ���—N-1�-��1 _E �iC31 �'���
Township: �;(�.r°,cil�.�� County: ��A,c�?t1�-�
P.roject P�r��i �� �; �0��_______�`��Z�'
Designer Information
�eG�gt?�rName:��Q.O��._����Q_Q�_ __ _ _--- _- ___ PhQne. ��CJ �v�S l�I�_.
Designer Address:��'J7�1� ��/�,e.ry��i�.c��7RQ �Ctl/1��-� Zip: s�g"�3
�art;�i 1: E�-�,�-��� �-c�
- --- _ -- ----_ ---- __— - ----
_ __ _--
License Number: __���_��_ ____ ______�___
�ema;��:
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Sic�na#ure: --- �. Dat�: ����6 �(
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HULDfNG TANK SPECIFICATiONS
(No Scale}
Weatherproof 12"Min.or 2.0 ft above
Junction and Approved Established Flood Eleva6on
Alarm Box ��YP���)
Vent Cap
Electrical must comply with � Approved Locking Manhole
SPS 316 and NEC 300 4"PJ Vent Pipe with Warning label Attached
f—Conduit >1Q ft from (typical) 4"Min.or 2.0 ft above
Building � Established Flood Elevation
(typical)
Airtight Seal �
} _- � a Finished Grade
�
18"Min.
(h'Pical) '• ( , .;, . . ° � ,
' � •' • '9 .
1 � � . � � , .. 4. ' � • .
Iniet � Inlet Invert
---Watertight
Approved Joints with � P��9
Approved Pipe 3 ft onto Max. 12"or 90%of total volume
Solid Ground ' if more than one tank
a
° Alarm-On
:
:
HOLDING TANK
VOLUME ����� gal �e
a � . e . • •, . � � • . � . .
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: WIESER CONCRETE
Anchor tank as necessary
�, pursuant ta SPS 383.43(8)(g)
Ballast Weight= [(cu.ft.tank.voi x 62.4 Ibs/cu.ft)- Ibs.tank.wt]x 1.5
Ballast VVeight= [(���.r�,+�—=cu.ft. x 62.4 Ibslcu.ft) - ibs] x 1.5 = ��1 s
PAGE40F4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s) shall be responsible for its perpetual operation and maintenance pursuant to
requirements o` SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this hoiding tank(s)
shall be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, ali inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), VVisc. Admi^. Code.
Estimated Daily Wastewater Flow= ���� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
., type of use
,. age of system
., nuisance factors (i.e. odors, user complaints, etc.)
.. mechanical mal`unction (i.e., pumps, valves. switches. floats, etc.)
o material fatigue (i.e., leaks. breaks, corrosion. etc.)
.. neglect or improper use (i.e . exceeding design capacities, prohibited activities, efc.)
., electrical components (i.e.: wiring; connections, switches. controls, timers; alarms. etc.)
„ surface discharge of effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wisc. Stats.
when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank�s).
Disposal of contents shall be pursuant to NR 1 i 3.�Nisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfiunction to:
Name of individua� or company:�V� ��(�,�� Phone:�{ ���C� C ��`,
Local government unit: Phone:�l��[�3�—t�c��
Local government unit address' � ZIP: ���.��
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1). Wisc. Admin.
Code. Repair cr replacement o`failed or malfurctioning components shail comply with SPS 383. Wisc.Admin. Code.
No product for chemicaf or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continqencv Plan
In the event that any failed component of this holding tank(s) cannot be repaired, it shall be replaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
System Abandonment
If use of this tank(s) is discontinued. it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
FIOLDING TANK SERV[CING CONTRACT
Contract Date: _/�/d t>�a. �
This contract is made behveen the Holding Tanit O�vner and the Pumper.
Holding Tank Owner's Namc: Pumper's Name:
I�lo-r�.c.�esf S�.r'-Ea.��
J`i-•�'`� v l� 1� i � w
r
Parcel Identlfication Number: �7
(12 Digit Legacy ID) ��_-�-3 / - � � _ 5 a �5
1. The owner agrees[o fi�e a copy of this coahact a�ith tiie governmental unit,Sawyer County,
which has accepted and recarded with the Office of the Register of Deeds,the Mtuntenance
Agreement for a Hvlding Tanlc�•equired under the Sawyer County Private Sewage System
Ordinance for the issuance of a Sanitary Permit for the installation of a holding tnnk(s).
2. The owner agrees to have the holding taak(s)serviced by thc pumpe,�and giarautees to
permit the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access road or drive so
that the pumper can service the holding tank(s)v��ith the purriping equipmen� The owner
fiuther agrees to pay the pumper for charges incurred in servicing the holding tank(s}as
mutua(ly agreed upon by the owuer and pumper.
3. The pumper agrees to submit to the Governmental Unit,Sawyer County,a rtport for thc
servicing of t6e holding tank{s}as required under SPS 383_55,Wiscons�n Administradve
Code and the Sawyer County Private Se�vage System Ordinance. T6e pumper further
agrees to include the following in tize report:
a. I'he name and address of the petton responsible for servicing the holdina tank;
b. The name of the owner of the holding tank;
c. ?he site address of the holding tank
d. Tlie date the holding tank was sccviced:
e. The volumes in gallons of the contents ptimped from the bolding tank for each servicing;
f. The disposal sites to which tlie contents from the holding tanic were delivered
4. This agreement will rzmain in effect until the ov�nier or pumper t�rminates this contract. In
the event of a change in this costtract,the owner agrees to file a cnpy of any changes to this
service contract or a copy vf a new service enntract unth Sawyer Couaty within ten(10)
bu.siness days from the date af change to this service contract_
(��wner's Name: (Pri.nt) ( OWl1CF'S SIg118t11iC:(Onty one owner signature required) �
1 '
�
j LLvrtaS b� d.e�
i �' C���— i
IPumper's Name:(Frint) Pumper�s Signature:
� i r p
!NOF�-�(�ES`(" Sa�N�T9�' � Vti�c.¢/U� —J
` Pumper's Registration Number:
� �3� �
- � � �� �'J���
Rev_U3/26/ 3 D
MAR 3 0 202Z
SAW`�ER COUNT�
ZONING ADMINISTRATION
�� ,�� � .
� ,. `.61� .�03
�"' � � \�• Officcof
� Sawyer County Zoning Administration
;.. ., . _
10610 Main Street Suite 49
���.���� Hayward, Wisconsin 54843 ;�'�;��,,�
+•�
,��
� ER C 0 (� (715)6348288 �,���%'���
/ �/ ��G ,I FAX(715)638-3277 /�j� f /�j
�Q� �..� �`,��� www.sawycrcountv�ov.org � �'��S
�{�( �� I�� E-mail:zonin�.sec�?sawvercouot�2ov.org /-� ��
�,o�� �_�� �_ :.,� Toll Free Courthouse/General Information 1-877-699-4110 oC.� C�
� o D
����'�co����= Zo���!-FR � 2 21
��.. N�A�Mi�i�R��
SAWYER COUNTY SANITATION DEPAR'TMENT �ON
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: ��`� � �'',.�\�.�.s�.
TOWN OF: �� e,"X_�
ADDRESS: \�`�!�� w �--%1 �--1��,.� �� \�.�.�,.,.,_�<�Z .i t��
I, �•��c„�-�, �-�'�'�,�� , 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 may 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: `l\ 1 \ 1 ��\
��1 — _ _ R r
Signed:
Date: � � � �j a—\
Acceptedby: ��%`'� r�-�'"`� - ��-�'�>��
Date of temporary emergency approval: �� l � � �c�—�
Rev. 03/26/13
I 11�1111�111'lll'�'I11�11 � �
1
8 0 5 �= u 5 '•
-USE BLACK INK ONLY - i x:=t035v5C�
' POWTS MAINTENANCE AGREEMENT 437185
PAULA CHISSER
For Holding Tanks REGISTER OF DEEDS
SAWYER COUNTY, WI
Owner's Name(s)as shown on deed: O1/18/2022 01:37 PM
� RECORDING FEE 30.00
' �J �e 2
I Parcel Identification Number: ��ry /1 PAGES: 2
i (12 Digit Legacy ID) V V �-���- ��-����
I
Legal Description of Property:
-SEE ATTACHED SHEET -
I
I We acknow!edge tha�2palica[ion is being made for the installation of a holaing tank(s)on the
property described on the attached sheet.
' I
�
� Returr Tc:Sawyer County Zoning and Conservation Administration I
i ^O6'IQ Main St.Suite 49,N2yward,WI 54843 i
As an inducement to the County o`Sawyer to Issue a sanitary permit for a holding tank on the above-described property, the owner is
responsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to ail
applicable requirements of SPS 383,Wis.Adm. Code relating to ho!ding tank management, including the following:
1. The owner agrees te contrac;with a person who is licensed under Ch. NR 113,Wis.Adm. Code, except as provided by
Section 281.48 (3)(d), Stats.,to have the holding tank properly serviced and to file a copy of the service contract with the
governmental unit. The owner further agrees?o file a copy of any changes to the service contract,or a copy of a new service
centract,witn the governm2ntal uni;v��ithin ten(10)business days`rom the date of change to the service contract.
2. The owner agrees to contract with a person licensed under Ch. NR 113,Wis.Adm. Code,who shall submit pumping reports to
the governmental unit in accordance�vith SPS 383.55,Wis.Adm.Code,for the servicing of the holding tank. In the case of
exemption under Section 231.48(3)(d), Stats.,the owner shall submit the report to the governmental unit. The governmental
unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the
holding tark is not being properly maintained.
3. If the owner faiis to have the holding tank properly serviced in response to orders issued by the govemmental unit to prevent
or abate a human health hazard as described in Section.254.59., Stats.,the governmental unit may enter upon the property
ana service, or cause the tank to be serviced. Pursuant to Section 145.20(4)Wis. Stats., a governmental unit may assess the
owner of a private sewage system for costs related to the pumping of a septic or holding tank.The charges will be assessed
as prescribed by Section 60.0703,stats. The owner agrees to pay ail charges and cost incurred by the governmental unit for
`����n��"""'N�n�ection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate
�.•OpK�YN,�,y"}�man health hazard caused by the holding tank.
,��. .... .. � ��1�
r Q'.•'_
-` �,•'N��.q T'i��gr�ement wi�l remain in effect only until the governmental unit responsible for the regulation of private sewage systems
' ruf�� at eitner a soil absorption system that complies with SPS 383,Wis.Adm. Code,or a municipal sewer serves the
t -���pE,.y��r addition,this ac,reement may be cancelled by executing and recording said certification with reference to this
� A ag'2Eme3:'r.suci�manner wl-�ich wi'I permit the existerce ef±he certification to be determined by reference to the property.
:Ni'•. �/eL�G , s
�� S Th� • c,{�Eem2nt shal! be bir.ding upon the owner,the heirs of the owner,and assignees of the owner.The owner shall submit
'�.� '••....
�,, 0� ••''+��ement to the register of deeds, and the agreement shali be recorded by the register of deeds in a manner which will
�''•., �VISG�:�.h�ex;stence of the agreemer.;to be determined by ref2rerce to the property where ihe holding tank is installed.
'"��uuuuu�
-On:y c�:e owner �aiure requirad- ACKNOWLEDGMENT
� Owner's Signature: '� v Cc�✓1 �
i
tate of: �� ; S S r�
� '-- County of: 1��/U/�/
Owner's f�ame (Print): ` Subscribed and sworn to before me on this
VGr^'QS p l ��P.--, , � day of �C�C(�VIn hP r , 20 Z �
Date: j By(Owner's Name): .Tarn('�i IC�f'C��1
� a' �' ' a 1 Notary Public Signature: b �
� Drafted b; public Notary Name (Print): �i'val��.rn !�I- �JOe='�
� _�G w��S O 1 ��A,� �' My commission expires on: (L' -ZS � 20 Z S
Personal inrormation yc� prcvide may be used for secondary purposes[Prvacy Law,§ 15.04 Q)(m)] Rev.03l26/13
That part of Government Lot Two (2), Seetion Four {4), Township . .
Thirty-seven (37� North, Range Nine (9} West, described as fotlows:
Commencing at the center of Chetac Drive on the line between
Government Lots 1 and 2; thence Westerly, along the center �ine of
Chetac Drive, 839 feet, to the point of beginning; thence South 435 feet; '
thence West 75 feet; thence North 435 feet to the center of Chetac Drive,
thence East along the center line of Chetac Drive to the Point af beginning
10/13/21, 1:39 PM Novus-Wisconsin Access rev. 13.1108
Real Estate Sawyer County Property Listing Property Status:����t �
Today's Date: 10/13/2021 Created On: 2/6/2007 7:55:15 AM
�Description Updated: 6/17/2021 '�Ownership Updated: 6/17/2021
Tax ID: 8128 ]AMES R OLDEEN BIRCHWOOD WI
PIN: 57-008-2-37-09-04-5 05-002-000050
Legacy PIN: 008937045205 Billing Address: Mailina Address:
Map ID: :2.5 ]AMES R OLDEEN )AMES R OLDEEN
Municipality: (008)TOWN OF EDGEWATER 15873W OL HAYS RD 15873W OL HAYS RD
SfR: 504 T37N R09W BIRCHWOOD WI 54817 BIRCHWOOD WI 54817
Description: PRT GOVT LOT 2
Recorded Acres: 0.800 � Site Address *indicates Private Road
Lottery Claims: 1 15873W OL HAYS RD BIRCHWOOD 54817
First Dollar: Yes
Zoning: (RRl)Residential/Recreational One Updated: 6/28/2021
ESN: 430 '�-� Property Assessment
2021 Assessment Detail
� Tax Districts Updated: 2/6/2007 Code Acres Land Imp.
G1-RESIDENTIAL 0.800 1,300 105,900
1 State of Wisconsin
57 Sawyer County 2_Year Comparison 2020 2021 Change
008 Town of Edgewater �nd• 1,400 1,300 -7.1%
650441 Birchwood School District Improved: 92,900 105,900 14.0%
001700 Technical College Total: 44,300 107,200 13J%
*� Recorded Documents Updated: 1/27/2009
0 WARRANTY DEED t'J�'Properly History
Date Recorded: 5/23/2007 346632 N/A
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/°t'""T `` PRIVATE ONSITE WASTE TREATMENT county
�Y r\\y"�` SYSTEMS
' ° Saw er
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`�`=:�����°� ( POWTS) Y
rs�'"-��-''' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��� D3�
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: State Plan Transaction ID#:
5�S O�� � r-
Insp BM Elev: BM Description: Parcel Tax No:
���•D� �� ��-- s�� aog-�3?-oY- �.��5-
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark 3-.�1 � p ,2�� �.of
Dosing
Aeration Bidg. Sewer 5;8� ' 97�39�
Holding �,,,,� � \�p St 1 Ht Inlet ,R � �1'l.3)'
TANK SETBACK INFORMATION St/Ht 0utlet _
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe
PUMP 151PHON 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 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bidg Well Waters °� GP ❑ Chamber Model Number:
o EZFIow
CELL TO ❑ Mound � Other
DISTRIBUTION SYSTEM X Pressure Systems Only
-
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac Spacing ❑Yes ❑ No
SOIL COVER — — -------___ _ ____
De th Over De th Over De th of Seeded/Sodded Mulched
Cell Center 1 Cel�l Edges Topsoil ❑Yes ❑ No � ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
� �,s�►ll,��f' I��� �a 1
� �r. .
Plan revision required?❑Yes ❑ No �� � �3 � � /'9��� �� �
— -- - --- L
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AN� SKETCH
� SANITAAY PEAMIT NUMBEA: oZ2 --a3�
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