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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� � ( 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. _—% �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;��: �.=- �,.�-��. _ -_--"""-.--�_ . Sic�na#ure: --- �. Dat�: ����6 �( i ' � '-� ' i i � � � � � _ , t � �� I � I i ; � � � I � I � � � i ( , � � � i � ' � � � f � i � I I � I ._ _ ...�. .� ,�... .�� ..,_ _ _. -,- .- ._. _ , . ,_ �_...t.. _ _ .,, � , C� � � ' ' I � - _. ,� _.. _. , � , , � , ' i � � � � I - ' � � ,:� ; ',v t. I i ' � � � 3;i�� � "� � 1 i I � _ � � -- �� &� i t r ' • *� -6' i ` ¢ I I � ! � I � � � I 6 fi j i I ! I � 1 I i i � it I � � ` i i i I i i - � j I i �' I I /��. ` � � j � r'� � I i � , j�l�" ' , � � � : � �' � t � �•`� � �� � � i �c�r• � ! I I � ; / � ��. I I r I I � � � ; � i � rrlvc � vr �+ 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 tas.sawyercountygov.org/Accesslmaster.asp ��� �i _*��,��:�•�aA F��� Y� .� � `.y� *��'�,�.�,,�'���..�°�' ',qy..�``r .�:4{' b ".�FA' ��.-,.� y�! ���"•*,r .... - ' . F �� � '.� ,w". y�i,� , -'�t4 F .����wM;�i,�4�}�g�,y� �w � 1� t+°F,:. ..� � �tt� , or, +ap � . i�"'K,�t�"^"`" ��� � �. ,� ' r. F�`� ° �°i.(� �� 'XY � �� {I ��4 d j�s�i. "'�. "4 ��: ,`�-�'� ���G �, �.: '� -y 1' � .:.�'� ¢ .S# �v' F I�4 ,�y` ,y� �''�• � _,� 4 �w. 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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� � �Sa ,p/ ; � C - - -�-- ---_ : _ ;_ __�_ ,___ ,_ __ , / . -�--- , ' �: _ , . :. . �� . �. . , i ,..,��' � i 3�lko . . , . , , ! , ; _ - - _ _ : � . . �__ ,_ _ ;.. _ _ _.. _ � ��J � �` ' � _ . - - - - - . • -- - — - ; � � , ---� � , . ._ ; . _. ' , � . i�o . . , .._ ;._..... . �.. ._ ._t �� � __ __ , , . . � : . ,. . .: . ' i � , , . _ ._ . . - -- - �- ; � . . . / ���' ` . : : � 3 �3�. �. U��� � �- ��� �n��� r$�3� �-Pd-- ��`� � ( ,( � . _ fi 61 I'1 ay� O