HomeMy WebLinkAbout014-665-00-4900-SAN-2022-050 "` "'.�' Industry Services Division �aunh' '
4822 Madison Yards Way 1
,=M .�S P ' Madison,WI 53705 Sanitary Pernvt Nun r(to be filled in by Co.)
S P.O.Box 7162
,
Madison,WI 53707-7162 �O 3g D �'�p �
Sanitary Permit Application S�`e T��`'°°Nu'"be`
]n acwrdance with SPS 383.21(2),Wis.Adm.Code,submission of ihis Form to the appropriate govemmental unit �
is reyuired prior to obtaining a sanitary petmit Note:Application forms for state-0cvned POWTS are submitted to Projecf Address(if different than mailing address) �,
the Departrnent af Safety and Professional Services_Personat information you provide may be used for secondary f,;,,
purposes in aecordance with the Privacy La�v,s.15.04(1)(m),Stats. _ ;J
I.Appiication Informanoo-Piease Priot Ali Informahon v
Property Qwner's Name Parcel#
" ` " F � ". �rl� 0/�l`�o�--�- 9a6
Property rer's Mailing Address Property Location
- `/ - �-- �--�-
ity,3tate Zip Code Phone Number
t.C�a!�� (,(7� ���� t � y�-�-1�lk� �--� s��on ��
II.Type of Baiiding(check all that apply) ot� T �N R �� E o
�lor2FamilyDwelling-1VumberofBedrooms ; 1, �� Subdi�risionName
aiQ�k=
7 ����� ����
�ub(ic/Commeneial-Describe Use
�City of
❑State Owned-Descnbe Use_ CSI�i\vmber illa�e o£
i`^�own of w`1�C,C.��
�
III.Type of POW'FS Permit:(Check either"Ne�i�"or"Replacement"and other applicable on line A. Check one box an line B.Complete line C ii
a licable.)
�' ew S stem {''�� lacement S stem ther Modification to E�isrin S stem ex lain Additional Pretreatment Lnit ex lain
� Y I XIKeP Y � S Y � P ) ❑ � A )
L_l
B� �-lolding Tank ❑tn-Ground �At-Grade �Mound Indiizdual Site Design Other Type(explain)
Yd ��n�-�tional)
C- ❑Renewai Before �Revision hange oC Plumber �fransfer to New Owner ist Precious Permit Number and Date Issued
Expiration Wl� O J - �� ( �� .ZY 0��
N.DispersallTreatment Area and Tank Information:
Desigi Fiow(gpd) Design Soi(Application Rat�gpcl(st} Dispersal Area Rec#uired{s� Dispersai Area Propose�(s� Sysiem Elevation
r-- '� � �
Capacity in Total ,=of Manufacmrer
�
Tank Informalion �»�s Gallons Uniu � � v $ � l �
U J
Nc�v Tanks Fxi�a Tanks � o � � � � r c`"s
a. U v] w c/� �a. � C.
Septic or Holding Tank �Q� �R� !_� � i��
�JW �U
Dosing Chamber � �
V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POW'I'S shown on the attached plans.
Piumber's Name(Print) Piumber'� iena � MP/MPR3 Number Business Phone Number
��-�� 30l �?�5���k�73
Plumber s.4ddcess(Street,City,3tate,Zip Code)
l D 5�7i/y " � � ; i� ��k-�. u> �'� �
VL C ty(Department Use Ooly
1� Petmit Fee Date[ssued Issuin,Agent Si�ature
�A p ��e ❑Disapproved ��/ `
'!J r" '�7 Owner Given Reason for Deniat C�"�� �- ��- �
Conditions.of ApprovaUReasons for Disapproval ;�. ,� � �
�U1�d� �� D
` `` APR 1 1 2022
�` �ST No� ���dl
��
�� �
SAWYER COUNTY
ZON�{�1G ADMINISTRATION
Attach to complete plsns for t6e system and submit to the County only on paper not kss than 8 I!2 a 11 inc6es in sue
NO REFUNDS AFTER
SBD-6398(R.03121 j ISSUE OF PERMIT
Sawyer County Zoning & Conservation Administration �
````"�1, 10610 Main Street,Suite 49
� ,�,, i� Hayward, Wisconsin 54843
' ��� (715)6;4 8288
�-�� � � FAX(71 i)638 3277
i ���'» %
� � ,� �v_,a1 �c ':. ii o��i
� � i E mail: �or a �c�:>> � .�n r� „�
� i�``;~�� �� Toll Free Courthouse/General Informahon 1-877-699-4110
I �
f'��\������
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp o3 /3� / 20 2�
Parcel ID# O 1 �( - 6 6 S-o o - '-1 �j O o
ll. Plot Plan
� Property Lines �Benchmark BM ♦
� Site Address �North Arrow
� Structure IC Scale
�Well �<25' to Service Road
�Legal Description �[Nearest Road Intersection
�Setbacks to: Properiy Line�Vell, Structure, Water bodies, Roads
Ill. Required Plans
� Index Page with Original Signature
�Management Plan/Contingency Plan
�Servicing Contract
�Holding Tank Agreement fonn � ��� �� /�.o�
IV. Holding Tank Specifications
Cross-section—Manufacture, Gallons: �LP 3������/
Tank Anchor Calculations [SPS 383.43 8) g)]
Lockin�device, chains/locks
Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) and
State Statutes 101.862(2) and ]01.862(3)
� 3" Bedding Material < 1/2 "
V. Holding Tank Plans per Component POWTS Manual
�Version 2 SBD-10855-P (R.3/07)
Owner: �2���2 Plumber: ��h
Application Review Date: 03�3���0�.�
POWTS Reviewer: ��v,�„�%`�-�-�
Namc /�S� /�
6 �
Liccnsc#
Revised 4/11/2013
PAGE 1 OF 4
����ing Tank P��� �
�ns�e�c � ���er �n�e�
Componertt Manual Desigr� References:
Versian 2.0, SBD-10855-P {hl. 03iQ7; R Q1!121 , , .
Pg 1 of 4 index & Cover Sheet
�g 2 of � Plot �I�n
Pg 3 of 4 Holding Tank Specifications
�g 4 of 4� IV�anag�men4 �lan
Attaehments: ; Enclosures:
; POi�ilTS Application for Review
` Soil Evaluation Report & Site Map (if applicable}
Holding Tank Pumping Contract (if applicable)
� Ha1di?�� T��k ,�, ree�nent �i'� ap�lica�le�
-----------�_ --— - ------__�
Project Name / Description
Owner Name(s):���I °1,�-�. � �r�1, �� �U�'� Phone:�f���-�
De�n�� �f.������: !I(�-��`�i�1Ct/"�����i�� _ j��1.� ---
Projec#Address:
� :_
���¢. $c�t: ��i�: �f ?/�, ���tit���_. T�ozi�-R �1_E'l�.�c:r 1��1�;
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Township: �--�(/�(Z�� County: �C�(�—P"
�'�'�S�rt P��n�� 1� �_ —� L`'� ���_�-..�� `" `ti��0
Designer Information
�����t�p� A�����: ��_--- --- -- ��;�:,P: ���=-,SS�lb_��
Designer Address: (� , Zip: J ��"��
�,.pY?3t�: L��-!�� U�, ��"
License Number: ���� / --`---- —
f�e��;k�:
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PAGE 3 OF�4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2_0 ft above
Junction and Approved Estab6shed Flood Elevation
Alartn Box ��YP���)
Vent Cap
Electrical must comply with + Approved Lodcing Manhole
SPS 316 and NEC 300 4'DJ Vent Pipe with Waming Label Attached
--Conduit >10 ft from (►yP)��) 4"Min.or 2.0 ft above
Buiiding � EstaWished Flood Elevation
(tYPica�)
�_ �Airtight Seal �
� a Finished Grade
18"Min.
�tYPical) � °
"� o
. °' '8 .
1 a e.. . .. d ' ' .
Inlet Inietinvert
--Watertight
Apprnved Joints with � P��9
Approved Pipe 3 ft onto Max. 12"or 90°/a of total volume
Sdid Ground �f�re than one tank
a
' Alarm-0n
e
a
HOLDING TANK
VOLUME = j 3 � � gal �� ,
a ' . d . - -a � . . . a n
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: Lt%L � vv -� �� � � � �' ��
Anchor tank as necessary
pursuant to SPS 383.43(8)(g)
Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-Ibs.tank.wt]x 1.5
Bailast Weight= [ n� . u.ft. x 62.4 Ibs/cu.ft)- Z� ���i� Ibs]x 1.5 = �j, �//�3�`lbs
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 of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52(2),Wisc. Admin. Code, this holding tank(s)
shall be cansidered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shall be perFormed by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc. Admin. Code.
Estimated Daily Wastewater Flow= ��f� gpd
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches,floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
o neglect or improper use(i.e., exceeding design capacities, prohibited activities, etc.)
o electrical components(i.e.,wiring, connections, switches, controls, timers, alarms, etc.)
o 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 113,Wisc. 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 malfunction to:
Name of individual or company: �T - Phone: 7�Sr� S S�-%�l�
Local government unit: �����-F�,�� �r,;�,;� ���,�:��Phone: �/j�� �.��j���s�'
Local govemment unit address:/���,?,. �:t<< , G>>�-- S';,�� �/���IP:>�����
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1),Wisc.Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin. C�de.
ContinQency 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.
Svstem Abandonment
If use of this tank(s)is discontinued, it shall be abandoned in accordance with SPS 383.33,Wisc. Admin. Code.
HOLDING TANK SERVICING CONTRACT
Contract Date: 1 / �
This contract is made behveen the Holding Tank O�vner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
��, �,� �, �,{� 5 � G .f � Q� -�
Parcel Identification Number:
(12 Digit Legacy ID) ���-��5 - � �-��� �
l. The owner agrees to file a copy of this contract with tl�e governmental unit, Sawyer County,
which has accepted and recordcd with the Office of the Register of Deeds, the Mainten�uice
Agreement for a Holding 1'ank required under the Sawyer County Private Sewage System
Ordinance for the issuance of a Sanita�y Permit for the installation of a holding tank(s).
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantces to
permit the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner a�recs to maintain the all-weather access road or drive so
that the pumper can scrvice thc holding tank(s)with the pumping equipment. The owner
further agrees to pay the pumper for charges incurred in se�vicing the holding tank(s) as
n�utually agreed upon by the owne►-and pumper.
3. The pumper agrees to submit to [he Goverilmental Unit, Sawyer County, a report for thc
servicing of the holding tank(s) as rcquircd under SPS 383.55,Wisconsin Administrative
Code and the Sawyer County Private Sewagc System Ordinance. Thc pumper furd�er
agrees to include the following in thc report:
a. The name and address of the person responsible for sen�icing the holding tank;
b. The name of the owner of the holding tank;
c. The site addcess of the holding tank;
d. The date the l�olding taiilc was scrviced;
e. The volumes in Qallons of thc contents pumped fi-om the liolding tank for each servicing;
f. The disposal sites to which thc contcnts fi•om the holding tank were dclivered.
4. This agreement will remain in effcct until thc owner or pumper terminates this contract. In
the event of a change in this contract, the owner agrees to file a copy of any changes to this
se►-��ice contract or a copy of a new seil�ice contract witl� Sawyer County within ten (10)
business days from the date of change to this service contract.
OwneC'S Name: (Print} Owtler'S Slailatlli'e: (Only one o��'ner signature required)
c
�.��i E I �2 ��c�,���, ' �
Pumper's Name: (Print) Pumpe►-'s Si;nariire:
,,-t-�- d�'�LLc�--
�
Pumper's e�istrati n Nu ber:
� �
Rev.03/26/13
� .
<
��� r`,; .
`�� �v Office of ,
��` ��� � Sawyer County Zoning Administration �,
� 10610 Main Street Suite 49 � �� I�� � ��
������`� Hayward, Wisconsin 54843 (���� r��
� �R CO �� (715)634-8288 � �
����� �V��� FAX(71�)638-3277 �°�
�Q `��j �iu-�'.sa���ucountveo� oi `� �� e�_ _L�
�V7 - �� E-maiL zonin ac�lu�sa�cYcrcounh���i��.�� _ ��� �
��c \ o � Toll Free Courthouse/General Information 1-877-G99-4110 , ,,�����
-r�=:,�- cl� �x,; �� 4i
�jGL� '- � ,a.
'; ``� ;..
/I \�pN� ,��J
�
SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: ��^�n�c� �e`r�- '��--
Towlv oF: Le� ��c-
ADDRESS: � !5��`f 9'�✓ �' �\S �� _
I, �� ��� , a Wisconsin
Licensed lumber, 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 l l.3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
' DEADLINE FOR T IS AGREEMENT SHALL BE: �� (3b �o��o� (
r" ?
` � __
Signed: oC __ .. .. _._ _.
, � l
Date: 'r � ��Jb 1 ����
Accepted by: ���= �.�—�
Date of temporary emergency approval: 3 1 3� I��01- �
Rev. 03/26/13
Illiil ' '!�'i��]�IIII�li� -
I��I�I�I,�I�Illl
8057802
Tx:40.�7320 '
-USE 8!ACK lI��C O�lLY- 438576
� P��ti3S N(AIN�'�t�AN�E A��REEMENTi PAULA CHISSER
i REGISTER OF DEEDS
�, For N�Idir�g 7anks SAWYER COUNTY, WI
04/11I2022 ]1e72 AM
owner's Name(s)as shown on deed: RECORDING FEE 3{).00
' � �_J�i' 1( �I �4' �� �(�`-( ��� j PAGES: 2
j P� ,,el loenirfica:ion Number: I^ /�1 /� \ �
� (12 Digii�egzcy IDj ���-� W�- V �-���/ �) �
I
I
� Legai Description oF Preperty: �
� -SEE�4�'1'ACHE� SHEET-
iWe acknct+rie�ae th�:application i,being made;or the installation oi a hofding tank(sj on the i
property dsscr�bed on!he attached sheet.
I
I Raturn To:8awyer County Zoning and Conservation Administra?ion i
'f0610?.7zin 5?.Suite 49,Hayward,Wf 54843 i
i
As an inducement to�he Coun:y of Sawyer to issue a saniiary per.mit for a holding fank on the above-described property,the owner is
responsib!e for the operation and maintenance of the hoiding tank, locking device,alarm and access,and agrees to conform to afi
appiicable raquirements of SPS 383,Wis.Adm.Code relating to hoiding tank management,including the following:
1. The owner agrees tc cor?ract with a person who is licensed under Cn. NR 1 i 3,Wis.Adm.Code, except as provided by
Section 281.48(3)(d), St2ts.,to have the holding tank properly serviced and to nle a copy of the service contract with the
goverr;rrtental unit. The o�.mer further agrees io file a copy of any changes to*he service coniract,or a copy of a new service
ccr,fract,wi.h the gavernm2niai u�it wriihin ten(10}business�ays irom tne date of change to the service contract.
2. Th�e owrer agrees ta cont•act�vith a person licensed under Ch.NR 1�3.Udis.Adm.Code,who shall submit pumping reports to
tne governmental unit+n accordance with SPS 383.55,Wis.Adm. Code,ior the servicing of the hoiding tank. in the case of
Exempiian u�der Sectio^281.48(3j(d), Stats.,the owner shal3 submit the report to the governmental unit. The govemmenYaV
;;r�i;may enter upon the properry to ir�vestigate tne condition of the holding tank when pumping reports may indicate the
r�olding iank is not being cro�eriy main�ained.
3. li the awner fails to have t�e holding tank properly serviced in respanse to orders issued by the govemmental unit to prevent
o�abaie a numan heaitn hazard as describeci in 5ectian.2�.59, Stats.,the govemmentai unit may enter upon the property
sr,d sa;vice,or caus�the tank to be se.viced_ Pursuant te Section 145.20(4)Wis.Stats.,a governmenial unit may assess the
ovmer of a private sewage sysiem rar costs related to the pumpirtg of a septic or holding tank.The charges wili be assessed
as prescribed by Secticn 66.0703,siats. The owner agrees to pay aii charges and cost incurred by the governmental unit for
;nspection,pumping,hau�lr.g,or otherwise servicing and maintaining'the holding tank in such a manner as to prevent or abaie
any human heaitn hazard caused by*he hoiding+.�nk.
4. ��is ag,eement wi!{remain in 2ffec�only uniil the governmental unit respansibie for the regulation of private sewage systems
ce:�;fies:��t either a soii abs�rptior,sysiem that compiies wi�ti S?S 383,Wis.Adm.Code,or a municipal sewer serves the
p:opery. ,n additioi:tn�s agree;nent may oe cancelied by executing and recording said certification with reference to this
�•�reemer:;;n suc��anne-which wi�:p2rmit ihe existence of the certfication to be determined by reference to the property.
5. Tnis agraement snali be binding upen the owner,the neirs of the owner,and assignees of the owner.The owner shail submit
the agreement to the register of deeds,and th2 agreement shafi be recorded by the register of cieeds in a manner which will
parmit�ha�xistence of the agr2ement to be determined by�e*erence to the propery where the hoiding tank is installed.
-;,n�y cne owner si�na±Ure requ:;�d- ACKNOWLEDGMENT
, Ow r's Signat ', " � '
ff�_� � f St2te oi:
�� Ceunty of: �
O ner'si�'���.a ;?rint): !
� , l / Subscribed and swo t befor me on this
__�j�� � �� /�1 C�.t'�/P y � 3>c#'day of , 2o ZZ
� Date: � ,� J! a� ; By(Owner's Name): v�
� I iVctary Pubiic Signature:
iDraftecj,:,}�: � ( Public Notary Name(Print): �a.�'na. �.a n d q►'e n
I �G(h ,�. �Q f�V`� ��ly commission expires on: �t`!8� •a��yd
MARNA K LUNDGREN
Personal irformaiion you provide may be used for secondary purposes[Privacy La�v,§15.04(I)(m)] Notary Public Rev.03/ /13
State of Wisconsin
�
Unit Forty-Nine (49) of Revelles Condominium, Sawyer County
3/31/22,8:44 AM Novus-Wisconsin Access rev. 13.1108
Real Estate Sawyer County Property Listing Property Status:Current
Today's Date: 3/31/2022 Created On: 2/6/2007 7:55:27 AM .
�'Description Updated: 4/16/2021 � Ownership Updated:4/16/2021
Tax ID: 16145 DANIELLE M&KEVIN G HARVEY HAYWARD WI
PIN: 57-014-2-42-09-35-5 16-665-004900
Legacy PIN: 014665004900 Billing Address: Mailing Address:
Map ID: -14.49 DANIELLE M&KEVIN G DANIELLE M&KEVIN G
Municipality: (014)TOWN OF LENROOT HARVEY HARVEY
STR: S35 T42N R09W 15249W BILLS RD 15249W BILLS RD
Description: REVELLES CONDO DECL 809/216 UNIT HAYWARD WI 54843 HAYWARD WI 54843
49&1/51 INT IN COMMON ELEMENTS
R&P REVELLE-LC L REVELLE-LC � S7te Address * indicates Private Road
Recorded Acres: 0.170 15249W BILLS RD HAYWARD 54843
Lottery Claims: 0
First Dollar: Yes
.-� Pro e Assessment Updated: 9/26/2014
Waterbody: Nelson Lake p �
Zoning: (RR2)Residential/Recreational Two 2022 Assessment Detail
ESN: 400 Code Acres Land Imp.
G2-COMMERCIAL 0.170 54,400 111,000
� Tax Districts Updated: 2/6/2007
2-Year Comparison 2021 2022 Change
1 State of Wisconsin �nd: 54,400 54,400 0.0%
57 Sawyer County Improved: 111,000 111,000 0.0%
014 Town of Lenroot Total: 165,400 165,400 0.0%
572478 Hayward Community School District
001700 Technical College
.� Recorded Documents Updated: 5/19/2011
L�f Property History
0 CORRECTION INSTRUMENT N/A
Date Recorded: 3/31/2021 430898
0 CONVEYANCE RECORDED NOT USED
Date Recorded: 1/27/2021 429613
0 TERMINATION OF DECEDENTS INTEREST
Date Recorded:4/20/2016 400694
0 CORRECTIONINSTRUMENT
Date Recorded: 7/31/2014 391501
O CONVEYANCE RECORDED NOT USED
Date Recorded: 5/5/2014 390237
O LAND CONTRACT
Date Recorded:4/22/1997 260261 464/43 WD714/219
LC601/104
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�°' "`"'` PRIVATE ONSITE WASTE TREATMENT county
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(k�rosp \`��'� SYSTEMS Sawyer
����� sj� ( POWTS)
�`"r°S'—�'�''=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2�_p'�j
Personal infonnation you provide may be used for secondary purposes[Privacy C.aw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#:
�Y1 i e.�Q �4'�`�.v�� lct f�t �Y�c1�,�
Insp BM Elev: BM Description: Parcel Tax No:
(o�.o� � ��t��-t:T �;s�- lFa o��{- 66s-�o - K9�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark (oG.o `
Dosing
Aeration Bldg.Sewer �,$�
Holding � Lv;�§eS' 3�� �,�a St/Ht Inlet `$�,'
TANK SETBACK INFORMATION St I Ht Outlet 9�.L6'
TANK TO PIL WELL BLDG AIR NTA�KE ROAD D,�4wi'��t F-{T,2 n/ 16,S��
Septic NA _D�BettQrrr—
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding � }�(,s- �^' ,�- � �� � Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Weli
DISPERSAL CELL INFORMATION
DIMENSIONS N1 L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters � G ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o 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
(�Depth Over l Depth Over Depth of Seeded/Sodded � Mulched
( Cell Center � Cell Edges Topsoil _ �Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
S��3-a��
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�9C ��"J � �� c S �1` �fl�l`21�C� �a��Ar
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Plan revision required?�Yes 0 No o� �o a3 � 6� ���
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NlJMBEA: �02 �-O.S�
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