HomeMy WebLinkAbout014-942-29-1304-SAN-2022-072 _�.�c��'�ro� County �
' Industry Services Division Sawyer
_�` �� , ��� 1400 E WBShIflgtOn AV2 Sanitary Pennit Number(to be filled in t �
� � P S , P.O. Box 7162
`% � Madison,WI 53707-7162 � z �� � --, �
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Sanitary Permit Application State Transaction Number 1 �'
In accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis fomi to the appropriate governmental unit �
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailin� (
the Department of Safety and Professional Servies. Personal information you provide may bc used for secondary ��
ur oses in accordance with the Pri��acy I.aw,s. 15.04(1)(m),Stats �27�J6N Stat@ HWy 27 �
1. A lication Information-Yleasc Print All Information
Property Owner's Name Purcel#
PATRICK & KERRI O'BEL 014-942-29-1304
Properly Owner's Mailing Address Property Location
15964 FOURTH ST cso�c Loc ----------
Cit�,State Zi Code Phone Number
} P SW y4 NE %4, Section 29
HAYWARD, WI 54843
7� 42 N: R �9 �/�/
I1.Type of Building(chcck all that apply) I.ot# �
�I or 2 Family Dwelling-Number of[iedrooms_ 4 � Subdivision Name
Block#
❑Public/Commercial-Describe Use
— ❑City of
❑State Owned-Describe Use CSM Numbcr ❑Village of
20/334 #5915 C���a���or �ENRoor
IIL Type of Permit: (Check only�onc box on line A. Complete line B if applicable)
A
�New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Moditication to Existing System(explain)
Q• ❑Permit Renewal ❑Permit Revision I:st Previous Pemiit N�unber and Date Issued
❑Change of Plumber ❑Pennit Transfer to New
[3efore I�;apiration Owner NONE �—
IV."I'�° e of PO«"I'S S �stem/Com onent/Device: Check all that a I �
❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil
❑X Holding Tank ❑Other Dispersal Component(explain) _ ❑Prctreatment Device(explain)
�'.Dis ersal/7�rcatment Area Information:
Design Flow(gpd) Design Soil Application Rate(gpds� Dispersal Area Required(s� Dispersal Area Proposed(st) System Glevation
400 — �-- � ---100.00
VI.Tank Info Capacity in Total #of Manufacturer
Gallons Gallons Units ` o � u
L U "
New Tanks E�:isting Tanks '` o Y ` � � � �
0. U v� n v� L. C.7 0.
s��d�oT xoia�����,�,k 3000 -� 3�bD Wieser Concrete X
Dosing Chamber
VI1.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POV1'TS shown on the attAched plans.
Plumber's Name(Print) P mber's Signatu MP/MPRS Nwnber Business Phone Number
Travis ButterField � 652879 715-634-8176
Plumber's Address(Street,City,State,Z,ip Code)
14346W State Rd 77, Hayward, WI 54843
VIIL Count�/Dc artmcnt l�se Onl°
Permit Fee Date Issued Issuing Agent 5ignature
�Approved ❑ Disapproved
�� ❑ O��ner Given Reason for Denial
$ �(�'� s I 15(ZZ �,�,Q.l�-�r,�'.n�
IX.Conditions o"t�llpravai/Reasons for Disapproval (�! r—�
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Attach to complete plans for the system and submit to the County only on paper not less than R I/2 x 11 inches in size
SAW�''E� CrJUNTY
ZOf�lING ADMINISTRATIGN
NO REfUNDS AFTER
s��-639s�xo3�3> ISSUE OF PERMIT
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10855-P (N. 03/07; R 01/12) . � .
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map (if applicable)
Holdin Tank Pum ing Contract (if applicable)
Holdin Tank Agreement (if applicable)
Project Name / Description
Owner Name(s): PATRICK & KERRI O'BEL Phone: - -
Owner Address: �5964 FOURTH ST _ Zip: 54843
Project Address: �2756N STATE HWY 27
Govt. Lot: SW �1/4 of N E �1/4, Section 29 , T 42 N-R 09 E ❑or W ✓❑
Township: LENROOT County: SAWYER
Project Parcel ID #: 014-942-29-1304
Designer Information
Designer Name: Travis Butterfield Phone: 715 _634 _8176
Designer Address: 14346W St. Rd 77, Hayward, WI _ Zip: 54843
E-mai1: office@butterfielddrilling.com �cl,�;;�,�,�e ,�t�t,��t�� ,,,, �,�,,,��r„a�sta,n�,.
License Number: 652879
Remarks:
�
Signature: - Date: '� I �
iginal signature required on ch s itted copy.
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
� SOIL EVALUATION o Scale: 4'�=40� 60 80 � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PI PROJECT NAME; Y�
1..,/ , n1/_ / 102 DE91GN FLOW GPD
�l 1�� C{� �-�� v(re( Attach design flow calculations for commercial plans.
PROJECT ADDRESS: ��7�b� Pipe Material/ASTM CSt��dard(Tables 384.30-3&384.30-5)
/ N Sanitary Sewer:_�" r U /
BM Symbol: �- BM Elevation: ( U�'� FT Force Main: �-- /
BM Description: /r L<<� /1` p-d � {^"�-tiP� ����
Slo e Gradient % Indicate northby IMPORTANT:
P � � Well Symbol(if applicable): 0 drawing an arrow Show ground elevation contours at suitable intervals.
of Tested Area: on the approprite Iine.
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherproof 12"Min.or 2.0 ft above
Junction and Approved Established Flood Elevation
Alarm Box Vent Cap (typical)
Electrical must comply with 1 Approved Locking Manhole
SPS 316 and NEC 300 4"QJ Vent Pipe � with Warning Label Attached
--Conduit >10 ft from (typical) 4"Min.or 2.0 ft above
Building I Established Flood Elevation
t (typical)
Airtight Seal �
1 _- � a Finished Grade
18"Min.
�tyF71C2�� �� ,�e . . ° ' a
a g
ea . .. d . � . .
Inlet Inlet Invert
f-Watertight
Approved Joints with � o Plug
Approved Pipe 3 ft onto Max. 12"or 90/o of total volume
Solid Ground if more than one tank
a
A Alarm-On
e
e
HOLDING TANK
VOLUME = 3000 gal �,�
' . d . • . . . . . . , .a�� n .
e �
3"Approved Bedding Material Beneath Tank
TANK MANUFACTURER: Wieser Concrete
Anchor tank as necessary
ursuant to SPS 383.43(8)(g)
Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt]x 1.5
Ballast Weight= [( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1.5 = Ibs
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 considered 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= 400 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: BUtt@t"f12Id, InC. Phone: 715-634-8176
Local government unit: S8Wy2t' COUnty ZOCllllg Phone: 716-634-8288
�ocal government unit address: 1061 O Ma111 St. SUIt2 49, Hayward, WI Z1P: 54843
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. 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.
Svstem Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
W3000—M R
TANK SPECIFICATIONS � o
15'-6" o a
� i
i �
DIMENSIONS: � o
WALL: 2 1/2" � a
BOTTOM: 4"
---- -------------�--- COVER: 6"
, � . , �_. ..
�%'� _'�� MANHOLE: 24" I.D. PRECAST CONCRETE RISER Q
�'�'� \��`� HEIGHT: 71" �
��i� 4" CAST-A-SEAL 4" CAST-A-SEAL \��� LENGTH: 15�-6" �
�>� ���\ WIDTH: 7'-9" �
� ,--�� ,�-�� i BELOW INLET: 57"
o� � � � LIQUID LEVEL: 50" o
� � i � WEIGHT: BOTTOM 12,260 LBS. -�
'� ��\ � g2 ` ��,i COVER 8,35C LBS. u � � `E
� � '. : g'' " 'i _ 3 o i
���� �A FILTER OR BAFFLE ��� INLET AND OUTLET: � m o 0
��� �,� 4" CAST-A-SEAL BOOT OR EQUAL GASKET �;; � � 3
� �
\1�� /�// Q Q � W
`�; -" INLET AND OUTLET BAFFLE AND FILTER: � o o �
`- - -- ---------- -- -�� WISCONSIN, SEE DETAIL #10 0
(OTHER STATES SEE CHART) � �
�
LIQUID CAPACITY: 58.94 GAL/IN � �
TOP VIEW HOLDING TANK: C � �
OUTLET HOLE PLUGGED � �
� ACTUAL CAPACITY: 3,183 GALLONS � o �
v�� Q �
Q� LOADING DESIGN: 8'-0" UNSATURATED SOIL � � �
� � I
+ _ TANK CAN BE USED AS: W } o
CO SEPTIC / HOLDING / PUMP OR SIPHON v, _ �
---- . a a. . . ---- � W �
____ ° " � � • - � '• •� • � � ____ COVER: MIX DESIGN #8 (NO FIBER) � �
INLET - _ OUTLET TANK: MIX DESIGN #9 (SMALL FIBER) � �
,I - - - - - - - - I 3
CUSTOMIZED TANKS:
_ `O v � �6 rn v FOR CUSTOM TANKS CONTACT
� _ �� �I � o i � � � WIESER CONCRETE
a_
i�
�n � �n � ,� �
2�, � �� � �
l _J J �I a
. ---------- --------- -- ----r--- -- oo �
REVIEWED BY o U
� REVIEW DATE 3 a
w
SIDE VIEW DRAWINGS SUBMITTED �
FOR APPROVAL
APPROVED BY: SHEET N0.
APPROVAL DATE: � /
OF
PRODUCTS NEEDED BY: / �
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
�
HOLDING TANK SERVICING CONTRACT
Contract Date: 05/ 12 / 2022
This contract is made behveen the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
PATRICK & KERRI O'BEL SCOTT POPPE
Parcel Identification Number:
(12 Digit Legacy ID) 0 1 4 - 9 4 2 - 2 9 - 1 3 0 4
1. The owner agrees to file a copy of this contract with the governmental unit, Sawyer County,
which has accepted and recorded with the Office of the Register of Deeds,the Maintenance
Agreement for a Holding Tank required under the Sawyer County Private Sewage System I
Ordinance for the issuance of a Sanitary Peiznit for the installation of a holding tank(s). i
2. The owner agrees to have the holding tank(s)serviced by the pumper and guarantees to �
pennit 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)with the pumping equipment. The owner �
further agrees to pay the pumper for charges incurred in servicing the holding tank(s)as ,
mutually agreed upon by the owner and pumper. ' �
3. The pumper agrees to submit ro the Goveinmental Unit, Sawyer County,a report for the ,
servicing of the holding tank(s)as required under SPS 383.55,Wisconsin Administrative !
Code and the Sawyer County Private Sewage System Ordinance. The pumper further
agrees to include the following in the report:
a. The name and address of the person i•esponsible for servicing the holding tank;
b. The name of the owner of the holding tanlc; '
c. The site address of the holding tanlc,
d. The date the holding tanlc was serviced; ^
e. The volumes in gallons of the contents pumped from the holding tarik for each servicing;
£ The disposal sites to which the contents fi�om the holding tank were delivered. I
4. This agreement will remain in effect until the owner or pumper teiminates this contract. In
the event of a change in this contract,the owner agrees to file a copy of any changes to this
service contract or a copy of a new seivice contract with Sawyer County within ten(10)
business days fi-om the date of change to this service contract.
Owner's Name: (Print) OWIICl°S S1gT1StUPe: (Only one owner signature required)
PATRICK& KERRI O'BEL ��� „ ,� ���
�J
Pumper's Name: (Print) Pumper's Signature:
SCOTT POPPE
Pumper's Registration Number:
81813
Rev.03/26/13
�
�
Sawyer County Zoning & Conservation Administration
������ 10610 Main Street,Suite 49
��. �1� Hayward,Wisconsin 54843
�� � ��� (715)634 82R8
� ���� � ��,� FAX(715)638 3277
� �\i'1 - '..% '.: 1 : 1 ) �:�
� i F-mul �i,; � :.i ti �.�:i ��r�•
, .., `� � u .
� � Toll Free Courthouse/General Information 1 877-699-4110
� �
/,���\�����
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp DS / ��o / �oZ
Parcel [D# d i �r -� �t a -_�q-�3 ��
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
III. Required Plans
}� Index Page with Original Signature
�Management Plan/Contingency Plan
�Servicing Contract
Holding Tank Agreement form
IV. Holding Tank Specifications
�Cross-section- Manufacture, Gallons: lu1P�eS .3�
X Tank Anchor Calculations [SPS 383.43 8) g)]
� Locking device, chains/locks
�Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) and
State Statutes 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)
Owner: �� �2,� Plumber: � Q���-�
Application Review Date: S l �-ba-
POWTS Reviewer: �
N��„�
69 S� c�
�;���,��#
Revised 4/11/2013
I �I�I Ilil'IIII�iIII�II� III
8 u � � � a 9
- USE BLACK INK ONLY- T.x,:4U3$041
POWTS MAINTENANCE AGREEMENT 439�59
For Holdin Tanks PAULA CHISSER
g REGISTER OF DEEDS
SAWYER COUNTY, WI
Owner's Name(s)as shown on deed: 05 J 17 J 2022 0$'17 AM
PATRICK & KERRI O'BEL RECORDING FEE 30.00
A�k 1':c. � c►�J I�CGrr; A D'�!
Parcel Identification Number: O 1 4 9 4 2 2 9 1 3 0 4 PAGE�: 2
(12 Digit Legacy ID) - - -
Legal Description of Property:
-SEE ATTACHED SHEET -
We acknowledge that application is being made for the installation of a holding tank(s)on the
property described on the attached sheet.
Return To:Sawyer County Zoning and Conservation Administration
10610 Main St.Suite 49,Hayward,WI 54843
As an inducement to the County of 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 all
applicable requirements of SPS 383,Wis.Adm. Code relating to holding tank management, including the following:
1. The owner agrees to contract 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 to file a copy of any changes to the service contract, or a copy of a new service
contract,with the governmental unit within ten (10)business days from the date of change to the service contract.
2. The owner agrees to contract with a person licensed under Ch. NR 113,Wis.Adm. Cocle,who shall submit pumping reports to
the governmental unit in accordance with SPS 383.55,Wis.Adm. Code, for the servicing of the holding tank. In the case of
exemption under Section 281.48(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 tank is not being properly maintained.
3. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit to prevent
or abate a human health hazard as described in Section.254.59, Stats.,the governmental unit may enter upon the property
and 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 holdiny tank.The charges will be assessed
as prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the governmental unit for
inspection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate
any human health hazard caused by the holding tank.
4. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems
certifies that either a soil absorption system that complies with SPS 383,Wis.Adm. Cocie,or a municipal sewer serves the
property. In addition,this agreement may be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
5. This agreement shall be binding upon the owner,the heirs of the owner, and assignees of the owner.The owner shall submit
the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will
permit the existence of the agreement to be determined by reference to the property where the holding tank is installed.
-Only one owner signature required- ACKNOWLEDGMENT
Owner' Signature: State of: `^ws�o�5��
CoUflty Of: Sawyer
Owner's Name (Print): Subscribed and sworn to before me on this
PATRICK &/OR KERRI O'BEL � n day of �11'1 G.i�, , 20 22
Date: ,��.'� �C h By(Owner's Name): ��r� � �Z-
5/12/2022 ��P � otary Public Signature: "
Drafted by: Z ����� blic Notary Name (Print): Keuy B�
Kelly Butterfield ;� �F�� z commission expires on: osioaizozs
--. � � _
I��� ST \���
Personal information you provide may be used for second� ���[_f��p�y Law,§15.04(I)(m)] Rev.03/26/13
�M1��►�Z�;i
Lo#s One ('I}, Two �2}, Three (3) and Four (4) as recorded in Volume 20 of Cert'rfied
Sunrey Maps, pages 334-335, Survey No. 59�5 as Document No. 2�5216, Town of
Lenroot, Sawyer Coun#y, VlTsconsin, being part of the Southwest Quarter o#the
Northeas# Quarter (SW 't/4 NE '114}, Section 29, Township 42 North, Range 9 West.
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Real Estate Sawyer County Property Listing Property Status: Current
Today's Date: 5/12/2022 Created On: 2/6/2007 7:55:31 AM
-i
�Description Updated: 3/4/2019 � Ownership Updated: 8/17/2020
___-- _ __ __ � --- _�- --�_ _�_ — _.� _ � - ----— --
Tax ID: 18502 PATRIC&KERRI O'BEL HAYWARD WI
PIN: 57-014-2-42-09-29-1 03-000-000040
Legacy PIN: 014942291304 Billing Address: Mailing Address:
Map ID: .3.4 PATRIC&KERRI O'BEL PATRIC&KERRI O'BEL
Municipality: (014)TOWN OF LENROOT 15964 FOURTH ST 15964 FOURTH ST
STR: S29 T42N R09W HAYWARD WI 54843 HAYWARD WI 54843
Description: PRT SWNE LOT 1 CSM 20/334#5915 �p
Recorded Acres: 1.503 r Site Address * indicates Private Road
Lottery Claims: 0 ----- -._.,.�______ �_._ ___-._a__ __
12756N STATE HWY 27 HAYWARD 54843
First Dollar: No
Zoning: (RRl) Residential/Recreational One
(RR2) Residential/Recreational Two � Property Assessment Updated: 9/26/2014
_ ___.___..._. _ _. . _.. _..___.. _ .
ESN: 400 2022 Assessment Detail
Code Acres Land Imp.
� Tax Districts Updated: 2/6/2007 G1-RESIDENTIAL 1.503 10,300 0
---- _ _ _____ _. ____._ _. ____---------
1 State of Wisconsin 2_Year Comparison 2021 2022 Change
57 Sawyer County Land: 10,300 10,300 0.0%
014 Town of Lenroot Improved: 0 0 0.0%
572478 Hayward Communiry School District Total: 10,300 10,300 0.0%
001700 Technical College
a� Recorded Documents Updated 3/21/2011 ,
�_�___ _ __ __ �Property History
--__— . �_ __.—___�
� QUIT CLAIM DEED __.__._ _ ._.__._._ ____. ___ _,___ _ . _
Date Recorded: 7/24/2020 425256 N/A
O COVENANTS
Date Recorded: 8/4/2020 425478
� QUIT CLAIM DEED
Date Recorded: 3/1/2019 4167�4
� TRANSFER BY AFFIDAVIT
Date Recorded: 3/1/2019 416723
� CONVEYANCE RECORDED NOT USED
Date Recorded: 9/12/2018 414334
O QUIT CLAIM DEED
Date Recorded: 4/26/1999 275984 670/202
O CERTIFIED SURVEY MAP
Date Recorded: 3/22/1999 275216
� WARRANTY DEED
Date Recorded: 9/30/1993 237961 518/256
Y "( I
� �
Oftice of
Sawyer County Zoning and
Conservation Administration
- 10610 Main Street, Suite 49
� Hayward, WI 54843
. TeL(715)634-8288
Fax:(715)638-3277
URL:http://sawyercounty�ov.or�
EmaiL•zoninysec�saw�ercountytov.or�
Toll Free:Courthouse/General Information
1-877-699-4110
Sawyer County Zoning and Sanitation "As - Built" Form
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Property Owner's Name
Fire Number and Road Name l o� 7 s � 1V S�1-c �� � �
Plumber's Name ���'> �"�" ' " + 'e�
Date of Installation �0 � A� �-a `�
County Sanitary Permit Number � � — G ��
12 Digit Parcel Number 0/y � �y'� - �� � �3��
Description and Elevation of Benchmark �3���"' S � v�� ��'- �ud' �
Tank Manufacturer and Capacity �;•es-t/' " ��� //vJ
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Setback-Tank to Nearest Lot Line Sb
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Setback- Tank to Nearest Well y0
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Setback-Tank to Building �S _
Cell Width "-'
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Cell Length
Number of Cells �-
Setback-Cell to Nearest Lot Line --
Setback-Cell to Nearest Well
Setback-Cell to Building _
Setback- Cell to Navigable Water '� _ � ,;� I� �,�/'�
�- -�,i :i � . rl
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Make and Model of Dispersal Unit AUG � O �Q23 /
a�s� � �-�- ,
Make and Model of Filter --.-..__
��.'.P,L�tI'•;,.. ., . . .
Make and Model of Pump �' ��N►N�`{J;, _ ,�
- Please complete other side -
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"As-Built Plot Plan"
Elevation Data
Benchmark /���v Please include the followin�: •
Building Sewer �,,,?S
Tank In 5 �,S � Location of observation and vent pipes '
Tank Out ��� � Feet of risers used on tank(s)
Dose Tank In — � Location of benchmark and North arrow
Dose Tank Bottom � � Location of all components
Header or Manifold 'r � Length of pipe between components
Distribution Pipe � � Number of chamber units in each cell
System Elevation � � Location of well, lot lines and road
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