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Home My WebLink About014-942-25-3204-SAN-2022-075 � .+�``'="�:: Industry Services Division County �y 4822 Madison Yards Way S� /� ��w�+� �;�' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) `�` ` ` p� � � P.O.Box 7302 , ; Madison,WI 53707 �j �� ; � �r' �-� State Transaction Number � Sanitary Permit Application � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forn�to the appropriate governmen[al unit — O is required prior to obtaining a sani[ary permit.Note:Application forms for state-owned POWTS aze submitted to Project Address(if different than mailing address) � the Department of Safety and Professional Services.Personal information you provide may be used for secondary ��2 � �� purposes in accordance with the Privac��Law.s. 1�.04(1)(m),Stats. � � l,jl I.Application Information-Please Print Atl Information Property Owner s Name Parcel# � (`ci.� r nJ O �'�-%C'� ��{�.`� 2.zJ� � .Z Ci �-r Property Owner's Mailing Address Propert Lo tion I �'�' N f a v e. ✓�l �� City,State Zip Code Phone Number /'�� ic. C�r��_ 1'``� 'S� 3�� t�'LY<>s w �/<, Section� II.Type of Buildittg(check all t6at apply) Lot� T `�� N R E o v�� 1 or 2 Family Dwelling-Number of Bedrooms ��i'�`-�'j fJ� � Subdivision Name Block# �ublic/Commercial-Describe Use �- �City of ❑State Owned-Describe Use CSM Number illage of �"I'own of L-L'N C'L`iC�i (. III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on lin��r�. Cheek one bog on lioe B.�omPlete line C if a licable. �� New System �eplacement System �ther Modiiication to Txisting S��stem(explain) �Additional Pretreatment linit(explain) B' �I-Iolding Tank �In-Ground QAt-Grade �Mound Individual Site Design Other Type(explain) (conventional) C. �Renewal Before �Revision hange of Plumber �ransfer to New O��ner �st Previous Permit Number and Date Issued Expiration �b- �OS �j� �'� � I (� 6Y IV.Dis ersal/Treatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(s� System Ele��ation /C�U �V f-� �.� �V,�� 01��'� Capacity in Total #of Manufacturer Tank Information Gallons Gallons Uniu � ` o $ � New Tanks Existing Tanks � � � � Y D � `� v� � v� i�. t7 0. Septic or Holding Tank , � � t'�c-� � � 1 (,v � �' �-t Dosing Chamber � � V.Re5pOn5ibility Statement-I,the undersfgned,assume responsibility for instaH�iion of the POWTS shown on the attached plans. Plumber's Name(Print) Plumbe 's Signature MP/[vIPRS Number Busincss Phone Number Jerry Ruid Excavating, LLC ��_ ;_��_�� t�2�i � }, ?,�-��. ,� _L�� Plu , t , ip Code) Stone Lake, WI 54876 VI.County/Department Use Only �A o9 a Yennit Fee Date Issued Issuing Ageni.Signature � ❑Disappro�ed , , ❑Owner Given Reason for Denial $Yo(�.� � i 1�; i:�:t {,�. ��..a.�.�_i�,,,,;. � Conditiorrs of Approval/Reasons for Disapproval �,�--, -,, �c , � �� U�� ir�� cs� /vo�' � , � �� MAY 13 2�22 �� SAWYER CfJU�TY ZONING AC1!411N;S-�RATiOiV Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inches in size saD-639g�x.o?i22> NO REfUNDS AFTE14 iSSUE OF PERMIT Sawyer County Zoning & Conservation Administration �� 10610 Main Street,Suitc 49 ��;: ,�i� Hayward,Wisconsin 54843 ; � �� (715)634 8288 � m �...�� FAX(715)638 3277 7 ` ' 'r�-�'.I �� ,,,:,, ,zti,��:ci uii O�_�i� / � i E mail ui= � � �:i� in , . �—`' � � �� __ _. � � ., Toll Free Courthousc/General Informahon 1 877-699-4110 I � �, tt��\�� Holding Tank Approval Checklist I. Sanitary Cover Sheet Date Stamp DS /�/ �� Parcel ID# o � y - `� �( � -.Z S-3 a O � II. Plot Plan 1�Property Lines �ry Benchmark BM ♦ X 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 �j Holding Tank Agreement form IV. Holding Tank Specifications � Cross-section—Manufacture, Gallons: �v�CS�' '�'�� X Tank Anchor Calculations [SPS 383.43 8) g)] X 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-]0855-P (R.3/07),,, Owner: ��_ Plumber: �� 1 Application Review Date: S�tq I�a�-,� POWTS Reviewer: ^ w��—�. Namc �q �� Liccnsc# Revised 4/11/2013 PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual Design Refer�nces: Version 2.0, SBD-10855-P (N. 03/07; R 01/12) ,„ Pg 1 of 4 Index 8� 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 in Contract if a licable) Holdin Tank A reement if a licable Project Name / Description � l.�,.��n}� i--4,1< ;;��.,,.,GL Owner Name(s): C�r�� !-�N c� +�a� Phone� �,/.� _3vC-�_ ��`.H�� Owner Address: f 7�t5u �.2 Nd ./�� >l1 IYI��C��:.:e.�. Zip: s�3 i/ Project Address: �� 73✓J %�N,�;.�� l� Rd �(4 Y�.�,�c-c� Govt. Lot: 1/4 of 1/4, Section 2S , T `l� N-R �1 EDor W Q Township: �. z�v�cjc;� County: S�L cy..��i.e�` Project Parcel ID#: b f��c.{" z,2,.5 3 zc��/ Designer Information Designer Name: �e�Ruid Excavating, LLC phone: �� - `�R�- 2`'�� Designer Address: Stone CakA,� �aa�a Zip: �`{g �6 E-mail: J � v i.cS (� G�e•�.,v��-Y i�I • �G� TiYis space resz:•ved fi�r app:•��ual staixtp. License Number: �--`� �."t,�� Remarks: Signature: �� Date: � _ �� 2 rig ignature required on each submitted copy. . . �U�.ls��.� L a l�e. __ _ _____ __ � ------ -- --- - _.� __- - -___---- --------- -- ______---____. _. -- ___ N l�a,re�c��., �� _ /Z G 73 iJ i�tir✓�-�G � S 13 i� U ��-S«� '2 o v Ia£�s.s� - t�- (i� . �/� �� , "2 avo �� i/v� 4J�-esGc- ,�, -- 1��, t� o� �� -l�ld,;,�` � �.� k ��,a,,�e. i zd . _ iov �2 �� `Z'v Mr�.i `_-�e�'47o�G� 5 bJ�:C"�� - ��..US i�,U k ��T-� � 7e�s.� �-� k'e. ��ti�.S O Z'`'' 4d S�.sTY2N 2��W (�A<�f' Nws�✓ C��c� �.--«.�� t� e b' Jerry Ruid Excavating, LLC � 7�S� ��d A�� 1 W208 County HWY A �'1`�r-��(f_C; �,� � M�,,, Stone Lake, WI 54876 � c s�; S S—,� / ( ��/1 S � L� �-'�1 � � � � • PAGE30F4 HOLDING TANK Sf�ECIFIC�4TIONS (No Scale} weea,e�proor 1 r Min.or 2o tt aboMe Juncdon and ��^ Alarm Box �� (tYP��) Elec�fca!must c�mply wlth Approved 1.oddrtg Maz�Nole SPS 316 and NEC 300 4�� "�� 4"Min.or 20 ft abova �� B�� (tYP��) Esisb6�hed��Eleva�on A1rtlqM Ssal � Fmfshed Grade 18"Mn. (��) • , ' . :, • � ' • � y . • .• ' ' d• • • , • Inlet lrtlet Invsrt W�� Approved,binls wlth � Approved Pipe s ft or�to nAax.�r or so96 or to�at voturne 3did Grotmd ' ff more than one tartk a s aER�O� f . f • HOLDING TANK VOLUME_ ��--�� gal ; d , , . . . . . , . • � 3"Apprnvad Beddinp Ma�rW Beneath Tank TANK MANUFACTURER: � �e S� �" Anchor tank as necessary pursuant to SPS 383.43(8)(g) Batlast Weight=[(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-Ibs.�nk.wt]x 1.5 . Baltast Weight=(( i_cu.R x 62.41bs/cu.ft)- =tbsJ x 1.5= �z=_!bs PAGE40F4 Holding Tank Management Pian IMPORTANT: The owner of this holding tank(s)shall be responsible for its perpetual operation and mairrtenance pursuant to requiremerrts of SPS 382-384,Wisc.Admin. Code. Pursuant to SPS 383.52(2),Wisc.Admin. Code,this holding tank(s) shali 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= r��' gpd Ins�ection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance fadors(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 c�mponents(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)shalf 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,wsc.Admin. Code. Tank pumpfng reports shall be submitted to the proper local govemment unit in accordance with SPS 383.55 Wis. Admin. Code. Report any component failure or maffunction to: Name of individual or c�mpany: SGoiT''S SG-A�� G- Phone: ��s��`�1" 72�� Local govemment unit s�w y er �o� 2-G^' �"'� Phone: �7/S' 6 ��{' $�$�i Local govemment unit address: 1(3C��O lMal.t h� S i 5 v cTP� �� (�b�('aZlp: s� $�-f 3 Any defec�tive 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. Continaencv 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,�sc.Admin. Code. HOLDING TANK SERVICING CONTRACT Contract Date: � l l ?JJ L"Z_ This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Owr►er's Name: Pumper's Name: �-�<<" U��--- J ca� � �O l�Li-� Parcel Identification Number: (12 Digit Legacy ID) ��-��-��- � Z � � 1. The owner agrees to file a copy of this contract with the governmental unit, Sawyer County, which has accepted and recarded with the Office of the Register of Deeds,the Maintenance Agreement for a Holding Tank required under the Sawyer County Private Sewage System Ordinance for the issuance of a Sanitary Permit for the installation af a holding tank(s). 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to pernut the pumper to have access and to enter upon the properiy 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 to the Governmental 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 responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The site address of the holding tank; d. The date the holding tank was serviced; e. The volumes in gatlons of the contents pumped from the holding tank for each servicing; f. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the 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 service contract or a copy of a new service contract with Sawyer County within ten(10) business days from the date of change to this service contract. Owner's Name: (Print) Owner's Signature: y e owner signatum required) L C��, l�1 �� . _� Pumper's Name: (Print) Pumper's Signature`�� \ J� � / r�0 �� J�� Pumper's Registration Number: g �� Rev.03/26/13 �`----__ __T��_ - ._ Q°� . zb G� E - --- . _ � .. o�� - - _.- _ �..,,, ,� } �- �- �.. � � .`�s, 0 2 y �,L if. 0. 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F � ,�qr Kss n� , �+;, �—.T�� }�� .' r'Y"v �+',�rT �..v �X. .;' A"R"� �+� -..} 1- l �. -" �� ti °f jA ° { r - V� "�. r :� � 1 --f 4; a5� �� j��. i, �, r ,� , _ �'��.,y'`:*� . �'� +- ,'J. � �r�: -.s, - � ^+:�-�j.'i � � u� . '��+-. � � ��+�r�. L�+.;r-M .�!�'�, � ' '�� . .a�- .,�r.= � a�' '� r. •��T„�a_� c� �: .7� ,� 3 �-. '��'�r � �.�*�;.�' .+3. �.� t .., #a. -�+.e• ��r x .. . � 4. .�. *'�S,,4S.�F -'� .3.. g1 ' ��" � .'k-. �_�i� -.�1. _�' ,�� .r��.�.1�y.,•m� � � '�I► y _�"v; t a�,�j � ��►°'`. +r`_, -� ��.r�e� �e� ,.� � �. � � -y� - �" � �- �"�..,',�� }�;� �.. � J� r�4\s �- -�*�� r �� , �; «�� -- ' �� y. "�� 7i ,..}� -: };� r�<" ,�,�,►t�l.�.' - ��...."�..A. � .: ��`- t '`�p a�x., �i°'�� '_� `1/_,��,',�w ��w f` :;?. �� +�� x� i,�ri:�. -.. £ �� `ql,�.�,r ' � L.' ;.;,. �_�� -F� � '- •�;�� S �, �^;� �'t �, .� .;} ;� � ��? � �;,�,?�. ��'4� � a .�. � '� �``''a -�.�v�.. .,"-'�.` � � � q:"�'. t. .�1 �� .,�c. _ � � i � - USE BLACK INK NLY � I IIII O I IIII I III�iII il�l�il IIII g n n g 1 6 '� POWTS MAINTENANCE AGREEMENT TY:4038142 For Holding Tanks 439242 PAULA CHISSER Owner's Name(s)as shown on deed: itEGiSTER OF DEEDS U` ,�� c ,`b� � �� SAWYER COUIVTY, WI j�V � (35/19/2022 12:59 PM Parcel Identification Number: RECORDING FEE 30.00 (12 Digit Legacy ID) �1�-��- "��- ��O � PAGES: 2 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 senriced 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. Code,who shall submit pumping reports to the govemmental 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 holding 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. Code,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 properry. 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. -O o owner si nature r uired- ACKNOWLEDGMENT O S ure State of: ��1✓1c�; '� County of: (�✓l�,�i� Owner's Name�('P�riN� Su�cribed and sworn to before me on this day of f"Ltc , 20� Date: �� Z,�_ By(Owner's Name): c.��c � c�� Notary Public Signature: �� c Drafted by: . Public Notary Name (Print): � �SS C-(kc��j (� c�c- �.,... � My commission expires on: u I -�I-2�7-`_� •°"""° HOSS C UDELL � �-�a Personal information you provide may be used for secondary purposes[Pnvacy Law,§15.04(I)(m)] ;`;. � NOTARV PUBLIC•MINf�QT�j3 6/13 �*.,..••° I�h'CO�A�ISSION E)�IRES 01;31.2025 i,egal Description p�rf nf*�a �7�rt��i�ao4 (�l>»r*nr �f*�u Cn�itl+��.nc+* (l�.n+-4n,- /T�TtITI/, C\ITl/.1 C�nnt:...,. T.<.e..4.. �...� MG\ 1 W1. Vl {.11� 1�V1�1lVY�J� �IAGi1�Vl Vl �llV UVUl11VYVJl �UC11LV1 `L`I Y♦ /4 U Y� /4l� UV4Llll11 L VVVll�,'�IlVV `G✓J� Township Forty-two (42) North, Range Nine (9) West, described as follows: l;ommencing at an iron pipe on the 5outh line ot the said 1V W'%4 5 W'/4 anci the Westerly right ot� u�av nf a t�rPeant anrl Pvictina rnarl• thanra 1�Tnrth anrl alnnrr thr� r;nht nf�a�av nf ca;ri Tn.z,,, T?r,�.a •�w' V� K t+�vvvaar H�au v��ay�+aab aVKM� �LaV1lVV 1\Vllll l�l�V \A1V11G �11V L1Gl�l V1 Y�{A1 V1 J�Al�.{ 1 V YY111\V{ili� v v r 834 feet to an iron pipe for a point of beginning; thence S38°00'W, 92 feet to an iron pipe at the WdL��S CC�I�Z (71 l�Cl$UIl Ld�C�� thence i�'o�-tneriy and alang the wat�r's edge of said Neison i,ake, � �uu reei to an iron pipe; ihence i�is i°uu'E, 1 bb ieet to an iron pipe on the W esterly right ot way line of the present and existing aforementioned road; thence South along said right of way line of said road 220 feet to the point of beginning, all in the Town of Lenroot, Sawyer County, WI. Real Estate Sawyer County Property Property Status: Current Listing Today's Date: 5/9/2022 Created On: 2/6/2007 7:55:31 AM � Description Updated: 4/15/2014 '� Ownership Updated: 7/10/2017 �.�,.. _ ..., .... .��e,��.��.�_o� � ,.�.�_.m�.,�..,� .....�,.s _..�....�.�,.w.�.,a.� Tax ID: 18301 LINDNER LIVING TRUST MAPLE GROVE MN 57-014-2-42-09-25-3 (32-040- PIN' 000040 Billing Address: Mailing Address: Legacy PIN: 014942253204 LiNDNER LIVING TRUST LINDNER LIVING TRUST Map ID: .10.4 17950 82ND AVE N 17950 82ND AVE N Municipality: (014) TOWN OF LENROOT MAPLE GROVE MN 55311 MAPLE GROVE MN 55311 STR: S25 T42N R09W Description: PRT NWSW Site Address " indicates Private Road Recorded Acres: 0.770 12673N TANNING POINT RD ��HAYWARD 54843 Lottery Claims: 0 First Dollar: Yes � Property Assessment Updated 5/30/2018 Waterbody: Nelson Lake �.-�_�-_ ,v.-,.��m�� -.�.�,.s,��-��,.��-�M.�-�A,�-..,�m,.�.A�m--� Zoning: (RR1) Residential/Recreational One 2022 Assessment Detail ESN: 400 Code Acres Land Imp. G1-RESIDENTIAL 0.770 150,000 224,200 '� Tax Districts �� Updated: 2/6/2007 2_Year Comparison 2021 2022 Change 1 State of Wisconsin Land: 150,000 150,000 0.0% 57 Sawyer County Improved: 224,200 224,200 0.0% 014 Town of Lenroot Total: 374,200 374,200 0.0% 572478 Hayward Community School District 001700 Technical College �+p Recorded Documents Updated: 10/1/2008 Property History �� „m 0 WARRANTY DEED """""`"""" N/A Date Recorded: 7/7/2017 407525 � WARRANTY DEED Date Recorded: 5/13/2016 401030 � WARRANTY DEED Date Recorded: 11/12/2013 388238 � WARRANTY DEED Date Recorded: 9/8/2008 355724 , : Fi 43'"1�taf'i �'�`` PRIVATE ONSITE WASTE TREATMENT county ;�;; ��{�0�\P, . �r�'� SYSTEMS � g ,` S awyer ;-,,� s ~) ( POWTSj � : /% �`s'—�'�'''' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION a� _ (j�� Personal inYonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#: �i) Liv��y�2� IR.Y�roa� �— Insp BM Elev: BM Description: Parcel Tax No: � (vo .o ��. r'�� o��-�l Y� �-�S= �2e TANK INFOR ATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark a,�.` _� ao•O� Dosing Aeration Bldg. Sewer � ��$' Holding t..v �C'�� Q�D St I Ht Inlet (,. � q(,, (' TANK SETBACK INFORMATION St/Ht Outiet TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Hoiding �-aI..S� -� S� lo ` +(O` �� 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 Well DISPERSAL CELL INFORMATION DIMENSIONS �N L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P/L Bldg Well i/�/aters o GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound � Other - ---- - __— -----__- - - --- - -- 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 I Cell Edges Topsoil _ ❑Yes ❑ No � ❑Yes ❑ Na� COMMENTS: (Include code discrepancies, persons present,etc.) ��,s�l(� 6�l Y �� , �T � ��Q. Plan revision required?❑ Yes ❑ No a� �� a3 �---JG� / � �c�Z�l� �'li J � Use other side for additional information Date POWTS Inspe or's Signature Certification Number SBD-6710(R.3/01) A�OITI�NAt COMMENTS ANO SKETCH SANITAAY PEAMIT Nl1M8EA: �'o� ` ��S "_ fV��1.�� L�, ,,._- ; , , . :_ . _ ; : . _ � _ .._�_.._._-'_.____L._._. :._. �.._ _..�.. .._. � . . . . ' _' .___ _ �.... ..__ ".._ _. ' _... __..__ _... _.___ ___ .._ .�,_..__.� ...._.. '__.___._._..___.; ,_._ . . . .�. i . _�-. �.r» .:. -i- r... _�._ .. ..� . ......... �....... . ..i. i..... .. :. . i . . ..{. .. .y. _. .♦.. � .. . .. .. .�. � .. �... . i. ... . . . . .. .. .. �� . , i ' i � � � ` . . I . � : � . . �, . . . � , � , . .�. .. . , .. . .._-,_ . �..__..:. _. .. . ._. _ '_ "._"'_1.___'.__ .. ._. l � -.. .�."""__._._.'."' __ _�'"{. '-a.__ _ '"_ _ _^ '_"_' }. � "_ . . ' � ', � . � . 1 . � . 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