HomeMy WebLinkAbout010-941-33-1328-SAN-2020-204 <<��°"-"%�;;;�. [ndustry Services Division County (` „
_'` � � ��,��o�}��` 1400 E Washington Ave SGwy e r ��
,,� ��� ��,� P.O.Box 7762 Sanitary Permit Namber(to be fillec�in 1 '��
Madison,WI 53707-7162 �7 r�
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State Transaction Number �
Sanitary Permit Application � G�
In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit r
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailin �
the Department of Safery and Professional Services.Personal information you provide may be used for secondary �Y
u oses in accordance with the Privac Law,s. 15.04(1 m,Stats. ``����\ ��Z`,�nvk � �
I. A lication Information—Please Print All Information
Property Owner's Name Pazcel#
1.�ca� t�oole O�O - 941 - 33 ►3�
Property Owner's Maiting Address Property Location
� Q �n Govt.Lot
City,Sta1e Zip Code Phone Number Su � � 33
�i� /4,��/<, Section
H� W q�� w,I S�$y (circle one)
IL Type of Building(check all that apply) Lot# T 4 �N; R 9 —E or�
'�1 or 2 Family Dwelling—Number of Bedrooms 3 a Subdivision Name
Block#
❑Public/Commercial—Describe Use
❑ City of
❑State Owned—Describe Use CSM Number ❑ Village of
�3M � $�bg �Townof_�wO.r-G�►
vo�.3 . �80
lll.Type of Permit: (Check only one box on line A. Complete line B if applicable)
A New S stem
� y ❑ Replacement Sys[em ❑Treatment/Holding Tank Replacement Only ❑ Other ModificaTion[o Existing System(explain)
B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner •
IV.T e of POWTS S stem/Com onentlDevice: Check all that a I
�Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑A[-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil .
❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dis ersal/Treatment Area Information: 3$ u�cK ti I� G w�.. r o c �d
Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
'�5'O o. 4 7S0 '7 7 D 9 3.S O
VI.Tank Info Capacity in To[al #of Manufacturer
Gallons Gallons Units � o '� u
New Tanks Existing Tanks � o � � Y p � �
a. U 'v� ti v� i.�. c7 a.
Septic or Holding Tank �
�b0b ��Oo � l,Ui GgQr cr-t.-L�c X.
Dosing Chamber
VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS showo on the attached planx
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
I��.a.�d A S �c�41s S� , �C✓�" >l,l0 8 8 �is-55 8- Co4'7
Plumber s Address(Stree[,City,State,Zip Code)
g o1d5 N S�� �a24` a7 ��0. weLrc�� W Z' S�/ By3
VIII. oun /De artment Use Onl
�A �dve ❑ Disapproved Permit Fee Date Issued um A ent Signature
❑Owner Given Reason for Denial $ ���'Oo �� 4 Z 1�ZC7 Vl. �
IX. onditions of ApprovaUReasons for Disapproval
'��� NO AEFUNDS AFTER
� (� l�S�J�OF PERMIT
�
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Attach to complete plans for t6e system and submit to the County only on paper not less t6an 8 t
�.CPT � 34�21� , q � �- 2�z v au� z s zo�o �
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SBD-6398(R.08/14) gAWYER COUN1`Y
ZONING ADMiNIS7RATION
=���`'"'"'�� PRIVATE ONSITE WASTE TREATMENT co�nry
,,,-
='� oa = SYSTEMS Sawyer
�J�:� �$ ( POWTS)
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''���'�_�-' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)] �U�' ���
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
����c�.1—�Cx-;�C� ���.kY�C�
Insp BM Elev: BM Description: Parcel Tax No:
1��. .�_,�� ��=�.����.,..� �\�� �i`�1- r3._3-- �3a�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �.,J ,��.� 1.��;� Benchmark .- ,-�,b �; �
Dosing
Aeration Bldg. Sewer �j�.^��
Holding St/Ht Inlet �S.a-7
TANK SETBACK INFORMATION St I Ht Outlet �S.�`1
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic \\ ti i� �p� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. �j�-j �j j,
Holding Dist.Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface �i 3�1�
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 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate
INFORMATION P I L Bldg Well Waters o GP �( Chamber Model Number:
❑ EZFIow
CELLTO ��" '— � a ❑ Mound o Other � �, � '
— -- - �`-' __ �'I'� -ti��— — - ��'' --��
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size I X Hole Observation Pipes
Length Dia_�Length Dia Spac ' Spacing 0 Yes ❑ No�
SOIL COVER
Depth Over Depth Over ! Depth of Seeded/Sodded Mulched
Cell Center �Cell Edges �', Topsoii � ❑Yes ❑ No � ❑Yes ❑ No I
COMMENTS: (Include code discrepancies, persons present,etc.)
S��s�� ;������ i�. � ���a��-�;
�
Plan revision required?❑Yes 0 No ! � �, � ��-� � �
_ _-� �' �%'�z�� �— _ ��� 1� �"�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS ANO SKETCH
/ SANiTAPv PERMIT NUMBER _�_��� _ __
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