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HomeMy WebLinkAbout032-539-02-5515-SAN-2020-307 (2) :�''�S}�r�� ��• >C� 1v �� � -• =�'y, V� $BfBfy 3�BlJl�dlflg8�IVIStD(1 S C(, �� 8 B (J ;,�_� Q =`• j 201 W.Washington Ave..P.O.Box 7162 saniracr p�amic 2vi,mt��filled m � �Sps " ��"�3/�� Mad�son.WI 53707-7182 " �'`'�,�--:.�� cs� Zo - z�3 �2`�U�� Z ��n��:L:' � (, Sanitary Permit Appiica.tion �°'`T'�``°"�'"°'�' , �� In accordanx�oith SPS 38321(=),�'�s.Adm.C«le,snbmission af tltis faam to ihe appaopriate ga•anmenlal utnt �� � is coquirod pri�m abtaining a maitan pamic Nota Appliaatim►fams£or statr�ownad PO�VTS me a�mdted co Project�as(if�ffamt than ma7ia c� the A-peRmmt of Safety aad Pcofassional Seniea. Pasonal amfamati�pan pia��mag be a�od for seeaadas� }J� os�in ac�dmce�ith thc Pm-�•Le�r,s.15. m�Stats- � L � iimaon Informatlon-Please Print Ai!lnformalion U O - C/� e/' PlopcftgO��t�cr`s Atamc Pat+xl+ �D, Cs re O o rropac}•o��a s� �d�as �•L� PRT l��' � W Cm4t Loc .S CIL};$CQ1C Zt�f L'OJG �IOOC t�Om�[' !i� Li $CChOR � n1dWl.'� //( . S.S �o ' SO - �o Z� (cu�ck�e . T�u R S Eo ��4' rt.Ty��of B�ta��a�en�r$r�) �«� 1 or 2 Famiiy Iht�elling-h'omber ofBedrooros�. Sbbdirision Name Block�F PublialComme►�ial-I?escnbe Use CitT af 5tatc Otirncd-i�e Use CS4f Number Villa�e of Ta�}n of_�d,�j,/L'f 2.d' IIb Typ�of Pern►it (Check onty�ee bae on line�. Completr li�B if appUcabk) '�' \e«•S}atan hccma►t S}stan RQ � � Rep �'l3i� a�RePfacemeat Onlr Otlaer\io�ficatiw�to E�tmS S3'�(�P�) .. B. PemR R�et�al Permit Ra�isioa Change of Plambc Pamii Traosfc to AEe�t List Pretiious Pieeem;t Nnmbc and Dme Issved s�E,��� o�a �o - �1�63 I� 16 I7o IE:T of POt�'TS St�emlCmn a�rlDevioe: Ched:sii that � �I�an-P4asuriud in-Graund Presmrized in-Ground at-Giade \fomd>2�{ia.of snitabk so$ I�ionnd<2d in.of saita6k srn'1 HoldinQ Tad: Other Dispeasal Campa�ent(c�plairt) Prdrmtment ik�tice(eeplam) �'.Dis ersaUTreatinent�lrea Information: ,5 n Design Flrnr(gpd) Iksipa Sal:lpplicuion Rat�� Di:pr�sat�ea Reqaitimd{s fl Di�asal�ea Stzt�Eleration C�t:S'LS i'� 3 c�o .7 ya � so 9��G ZrI.Tank Iat'o C�City m Taal #�of �tanuf:enua Cmlla�s C�allms Unita � a� '� Ae�r Tac1R Eristi�iao•L 2 '� a � � .$3 a c.Ci 'm m :n i£O ... s���w�r� x 1 L Skav Prc St� x �c��� �TL Respoilsf 6Wtr SffiOeateIIN I.t4e mdasEgoed.assmne raportsihfDts for in�f6uton of tLe PaRTS shmsn oa tlu atmehed pim�s Plum6er's�ame(Pnnt? Plom Si�smre �f11P'RS Nomba Businas Ph�a?�inmb� Cr�.� �� -sd� � � o�ar�slo ��s-��� a�ya . m����s csu�u,c�; �vr c�) So - � - S�n I2� in�e� �� 5 g � VIIL Co /U arhnent Use Oni�- t� ��,� P�mit Fee Date t 3' � S y��'°° ���ZS ZVZv � �v'� o..��.��r�n� LC.CondiNaa�s of�pprocaUReasons for Disapproe�i � ` :,� �` _ NO FiEFUNDS AFTER �,�( r _ ,��� , := ISSUE OF PERMIT _ldath tu�omplcte pleus fortht s}stcm aad submk to tLe Co¢ots m�T oa popee eoT leas thau E 1/t x 11 foe6�s ta�aa _ .-.�.,.....�',y.f_.., (� �, � �` � � ' } �C�i- #" 4�u 2� z�2� ��;,; ��-.�_��._�.__ ___-_�J� SBD-6398(R 11lI1) 1 I s:i � �-A �il� ��e�-� � ���� `�, _ , r. .S ,..„- �F�o�'v`:'`;.��:,� t;_1t�:Y f.�1l�:t::::+��Jtu��;:,_�s�,i-iTi:�N V � "0.1`'f� PRIVATE ONSITE WASTE TREATMENT county „ ��;� �X � �$ _ SYSTEMS Sawyer ��,�-.� PS �� ( POWTS) �� �_._� \�`�""`'"��';`?� 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(1)(m)J Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: -� �� �.� \ .�.�c� ��`�\�23� Insp BM ev: BM Description: Parcel Tax No: �— ��w. � � � �� �. ���� o�a- =�"'_�5�- c�a- ��\S TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic 5�� � �,� Benchmark �vc.�� ��o ;� Dosing Aeration Bldg. Sewer �j(� 3� Holding St/Ht Inlet �(S.7 TANK SETBACK INFORMATION St I Ht Outlet �j�_yH TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet AIR INTAKE Septic ,� 4/�,�- ��,��` NA Dt Bottom Dosing NA Instaliation . Contour . Aeration NA Header/Man. - �f�.�� Holding Dist. Pipe ' PUMP I SIPHON INFORMATION Surface e �� �� 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 a GP ❑ 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 I ', Spacing ❑Yes ❑ No ' --__ _ .....'.___. _ L _- _--�_ ___ _. SOIL COVER _— -- — Depth Over Depth Over Depth of Seeded I Sodded Mulched Cell Center �ell Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��� �,����� _,���a`����.� � �a� � I �o�� � __ Plan revision required?❑Yes� No �i � 7 � �<%���' �-t�-/ l�-�= �� �� ' �__� '_� ---- Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A��ITIONAL COMMENTS ANO SKETCH SANITARY PERMIT NlJMBER:�t� -���_ ��� ��. �_r� �__—__ ---- _�- . , . ',� � �\o.�-`� I � � _ ,�a — � _ �; �� ! . . , _ .�`� � yn�\���v �� � � �� - a� I . � r �1 tY�`�7� �� Sy�w f � 1� � i ��`� _ � �;�� � j I �:I✓ � ��./ ��'f')�J �' ���- / L-�� � i ��� � �� ' i I�j � � � .�" � ; _ ; _ � � i���,