HomeMy WebLinkAbout022-738-13-5109-SAN-2020-270 (2) :� ' ' . ._ I Industry Services Dirision County
( 1�`-�`����j 1400 E Washington Ave SCjw �'�
' P.O.Box 7162
i .•s' ' Sanitary Permit Number(to e filled in I �
�, = lo� � Madisoq W[53707-7162
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Sanitary Permit Application State Transaction Number r N�
In accordance with SPS 38321(2�Wis.Adm.Cod�submission of this form to the appropriate govemmenial�mit �
is required prior to obtaming a sanitary pennit.Note:Application forms for state-0wned POW7'S are submitted to Project Address(if different than mailin; �
the Departmcnt of Safety ard Professional Services.Personal information you provide may be used for secondary
in accordance with the Priwac Law,s.15.04 I xm),Stats. ��Q'a � `C ` �i�� �
I. A lication[nformatioo-Please Print All Information � e�'� Lt�� O
Property O�mer's Name Parcel# ��2.Z '7,3�' � 3`J �v•
� ��� 1�L/�G�. �/ 1'^�h�Q '"�' � �
Praperty Oamer's Mailing Address Properly Location
N 2�3�� -�w ��`�.o� I
City,State Zip Code Phone Number , ,
_�_/.,�/., Section�
,.��Q�l �e.�[\'G (�(./-..1� 5 y �� (circ(e one
T�N; R�_Eor�
II.Type of Bailding(chcek all that apply) Lot#
(�1 or 2 Family Ihvelling-Number of Bedrooms � Subdivision Name
( - s
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use
CSM Number ❑Village of
�/��� t� 3$� �Townof���_ ��,,�
IIL Type of Permit: (Check only ooe box on line A. Complete line B if applicable)
'�� �lew S ❑R lacement S stem ❑Trca[mcnt/Holdin Tank Re lacement Onl ❑Other Modifiption to Etisti S em ex lain
Y�� eP Y g P Y �8 Y� ( P )
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B- ❑Permit Rrnewal ❑Permit Revision ❑Change of Plumber ❑Permit Trarufer to New List Previous Permit Number and Date Issued
Before F�cpiration Owner �S� p�{� �" �I O�
IV.T of POW75 S stem/Com �cnt/Device: Check all that a i )rp
�.Non-Pressuriaed In-(',round ❑Pressurizcd In-Ground ❑At-Grade ❑Moand>24 in.of suitable soil ❑Mound<2d in.of suitable soil
❑ Holding Tank ❑Olher Dispersal Component(explain) ❑Pretreatrnent Device(e�cplain)
V.Dis rsaVl'reatment Area Information:
Design Flow(gpd) D�ign Soil Application Rate(gpds� Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation �
:3� a � ��y Ysa q y,e as:6�
VL T9nk Info Capacity in Total #of Manufacturer
Gallons Crallons Units � � o'� u
New Tanks E�tisting Tanks 'v o � � � �m `_'�
a U in ti in u.C7 a-
Septic or Holding Tank
� �� i3 r w �� �
Dosing Chamber O�
VII.Respoosibi6ty Ststemeot- I,the uodersigoed,assame responsibility for iestallation of the POWTS s6own on the 9ttached plaos.
Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number
e- i � li`1 - �7�/
Plum Address(S[reet,City,State,Zip ode)
VIIL .oun /De artment Use Onl
�Appr e�d ❑Disapproved p�it Fee Date lssued Issuing t Signature .,' �
7�'�" ❑Owner Given Reason for Denial a l��,� I G 7 Z aZU ✓ C�L �
IX.Conditions of ApprovaUReasons for Disapprerat
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Attaeh to rnmple0e plam far 6e system and submit to t�e Coenty ooh on paper oot kss tlun E Lz z 1 I iaches in sitt
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SBD-6398(R.08/14) OCT 19 C���
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zoi��evU�,n+,n,�a��r�,�;r�ou
'�'�`'aT';;>�%; pRIVATE ONSITE WASTE TREATMENT county
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�� � �$ ���� SYSTEMS SaWyeT
��,,.�,� Ps .-� ( POWTS)
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``''`��"��',` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION '�� _ ���
Personal intonnation vou provide may be used for secondary purposes[Privacy Law,s. 15.04(1 (m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�� .�� bt f'��h»L:._ I V . 'C���� '_���r� .�C-C..J�
insp BM Elev: BM Description: Parcel Tax No:
v�,� .C�� ���-,.�_ �`� (�.\ca \-�� ���� / �� '��"��C�(�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,z_�, �S`1�, 5�,x; Benchmark �`; �� ,��
Dosing
Aeration Bldg. Sewer �9•�>�'
Holding St/Ht Inlet �7
TANK SETBACK INFORMATION St I Ht Outlet ��,�\�
TANK TO P/L WELL BLDG VENTTO ROAD Dt inlet
AIRINTAKE
Septic �i u? �; �,a \\k NA Dt Bottom �'3.�j
Dosing NA Installation
Contour
Aeration NA Header/Man. ` `i�..5
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION infiltrative
Surface �� �
Manufacturer ( Demand Final Grade
��_\Z�
Model Number �„j��j�� GPM
TDH Lift Friction Loss Sys Head TDH Ft �,�-.�;,� �„� �j �j`'�
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 i/�/aters o GP � Chamber Model Number:
❑ EZFIow
CELL TO �-� �- '��-��� � � `��� �-- ❑ Mound ❑ Other �:�.,, Lv-- � �_
--- -- _- —---_ __
DISTRIBUTION SYSTEM X Pressure Systems Only
- --- - — _ __ _ —
Header I Manifold Distribution Pipe(s) �� X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac ; �, Spacing ❑Yes ❑ No
— —_ _----
SOIL COVER
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges � Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No �, � G' � ��.. _. �, ��� �� l�
, �'.�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
SANITARY PEAMIT NUMBER: a�� a-7C�
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