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Home My WebLink About026-152-00-0100-SAN-2022-079 ��' � ' Industry Services Division County 4822 Madison Yards Way �c�v y zr- � : ,�$P � Madison,WI 53705 Sanitary Permit umber(to be tiiled in by C� � a P.O. Box 7302 _ Madison,WI 53707 �;� �j �� U � � �= Sanitary Permit Application State Transaction Number " � In accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit � is required priot lo obtaining a sanitary permit.Note:Application forms for stateowned POWTS are submitted to Project Address(if different than mailing ad� J the Department of Safety and Professional Services.Personal inrormation you provide may be used for secondary purposes in accordance with the Privac}�Law,s. IS.Od(1)(m),Stats. � �� W ;.�� I.Application Information-Please Print All Information �S Property Owner's Name Parcel# � '� � �e$ecc w �f�l�,r`h5 � Z �•l S'Z�6b•o 1 o v Property Owners Mailing Address Property�Location 2 ��3 �fc,,ri e o c.�. �rn,,;I � Uo,�.�ot 2 Ciry,State 7ip Code Phone Number --7 �Oo�hVfy/ �fi�� I Z� _ �� Section � / l q II.Type of Building(check all that apply) Lot# ]� 3 N R � ( E or r 2 Family Dwelling-Number ofBedrooms � �a- �. ��-� Subdivision Name Block# Na� �c�l `Pq�k �ublic/Commercial-Describe Use ^ �City of ❑State Owned-Describe Use CSM Number Village of � ownof �ti� � �a-�� Ill.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if a licable.) 'a Ne��S stem e lacement S stem ther Nlodification to Existin S stem ex lain Additional Pretreatment Unit cx lain � � Y p Y g Y � P ) ❑ ( P ) B' ❑Holding Tank In-Ground �At-Grade �Mound Individual Site Design Other"Type(explain) �(conventional) -`-�„��( reP��n�+e• C. �Renewal Before �Revision hange of Plumber �ransfer to New Owner List Previous Permit Number and Date Issued Expiration ��- �$I � f z I$� I IV.DispersaUTreatment Area and Tank Information: Design Flow(gpd) Design Soil Applicazion Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Pttmesec�.(s� System Elevation 300 . 7 �{Z�, �7 C-x,`sf�s vso �" 9G. y3 Capaciry in Total #of Manufacturer Tank Information Gallons Gallons Units � � o $ ; New Tanks Existing Tanks � c � L y D � � 0 n`. U 'v� �, cn i:. C7 a Septic or Holding Tank '7�� 7 s'Q ( �(1i LS Fr- Dosing Chamber � � � V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumbers Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number Dylan Schultz 1516129 Plumber's Address(Street,City,State,Zip Code) 7076N Stone Lake RD, Stone Lake, WI, 54876 VI.C un /Department Use Only �,Ap rov ❑ Disapproved Permit Fee Date[$sued , �� Issuing Agent S�gnature /.� $(� eo ; �,y:i i.. � �'V^{,(,�,�,1„�.t�^-i�L'lit��-- �7/� ❑Owner Given Reason for Denial (�• i Conditions of Approval/Reasons for Disapproval � � � �� -- t� � � D �� C�T � APR 2 6 2022 � SAWYER Ct'JUP•I'fY � Attach to complete plans for the system and submit to the County only on paper not less than 8 tn x 11 inches in size sB�-639s�R.ozizz� NO REFUNDS AF'TEfi �� ISSUE OF PERMIT PAGE 1 OF 4 In-Ground Gravity Plan � Index & Cover Sheet Component Manual Design References: � Version 2.0, SBD-10705-P (N.01/01, R. 10/12j7� � `"� � 2�A��A^��,� o„/y / Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 - __ Pg 4 of 4 Management Plan Attachments: Enciosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name/ Description Owner Name(s): 1"^ Wh�k��S Phone: - - Owner Address: ZS43 Pr..��e m..k �-.ti:1 �.✓dad�.�.y �N Zip: S S"� Z.S- Project Address: �� 211 w B�o-�� 1�.., � Govt. Lot: 2. 1/4 of 1/4, Section � 7 , T 3 `I N-R �9 E❑or W.� Township: S�� c� ��e County: S w�y t� Project Parcel ID #: �Z� i-f Z a oo/a� Designer Information Designer Name: Dylan Schultz Phone: 715 _ 558 _ 5904 Designer Address: �076N Stone Lake RD _ Zip: 54876 E-mail• dylanschultzl8@gmail.com , i'.2�� rt5�1'V�P�.: I(�� '�.1! '::tlll;�. License Number: �516129 Remarks: Signature• Date: �� Z"G-ZZ Original � ture required on submitted copy. CHECK BOX AS MPUG�BLE. CHECK BOX AS APPIICA&.E. (� SOiL EVALUATION � �'�� 40' � � � SYSTEM PAGE 2 OF SITE MAP PLOT PLAN PROJECT NAME: ��on� �a, DE510NFLOW: J�� cao Attach design flow calculations for comrtrorcial plans. PRO.lECT ADORESS' ��i Z��6'� �fo.i^ LY� N Pipe Material/ASTM Stande►d(Tabi6s 384.30�8 38A.30�6) BM Symbol: � BM ElevaOon: /0 0 s��Y 3ewer s`� y 6 / � Forne Main: / ��. SC CKn[r �•P �^►.�t S1••s IMPORTANT: SIope Gradbnt(%) WNI Symbol(M aPPN�r$ 0 '��"o �rtO1" Show ground elevation cantours at auitaWe intervals. af T�sted Aree: on U+s appta{xMs ke. � J i 1 � � ' �oU �\�y �b — I -- - _ I I �..�,,� � � �, �� h- i�o' �� ^ ~ � . ��ivL w� � 1 � a E�� n�, �� :I � � "�" �..�r �� _ qb,6 .� _��5r �, � o �-- - � /��'�-� NoM� SYS��.. — °�G . 4S{ �sf �� ; ry�a- ,�;1� u,�►, �( \�Yi t "V �:� �;'n � { •..�� a, r'�� • ' Dytan Schuitz ��,> � ��'.;� ��„ a�`l 7076N Stone Lake R `^�>./` j � � Stone Lake,WI 5487 �:- �� v�� / , , � � \ � MPRS 1516129 v � / �--- , � 4� — � / i r``�, � � �. .. � _ � r . 9L� � ^� � � ` ''�,— _ 9 y� _ -- — �� ` �� `_ 4 — — � l�� 11� � Q D ,(, �c,.,c� �,,k a W �.-�` (�,� � ti.�._ .�✓ PAGE40F4 In-ground Gravity Management Plan IMPORTANT: The owner of this in-ground gravity system 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 system 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. Maximum Dispersal Area Operatinq Limits: Design Flow= ,� 66 gpd; BODS <_ 220 mg�"'; TSS <_ 150 mgL-'; FOG 5 30 mgL"' 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 solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution/drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities- if applicable (i.e., pump re-cycling, float switch settings, etc.) o electrica� components- if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure fateral distal pressure-compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Stats. when the volume of solids in the tank(s)exceeds one-third (1/3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s)shall be inspected every 3 years and shafl be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: � Name of individual or company:�Yr"�'� �-�'�� Z Phone: � � SSfs�S�� Local government unit: s'^"r� �o�^�� uN�� Phone: Local government unit address: H�y"'�d - S""Y�' `��^;Y CYy��°`S�C ZIP: 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 treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils. Svstem Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code. PDF.js viewer 4/26/22,11:56 AM G��- �,`�-OU- ��UL' . ��"'m"""" APPLICATION FOR SANITARY PERMIT ^ � � DILHR SAWYER �o�,ry� N (PLB 67) � ��*� UNIFORM SANITARY PERM�T#po �"""'"�`"��"°��"° CST 8 S-0 8 4 6 S 15 8 —Attach complete pians in accord with s.M 63.05,Wis.Adm.Code for the ryriem.on paper not lest thm BYax 11 incfus in size. —See reverse side for instrvations for completing thit appliution. PLEASE PRINT PROPERTY OWNER NG'1'ClI1Q, ; I (y{ MAILING ADDRESS L 603'0,3 P VERTV LO ATI N („L,Z �LL1c,, 1/4 S �7 T3 N R E.1or)W io�E:S LOT NUMBER BLOCK NUMBER �O(yIS N�ypl€C� NEAR 5T ROAO,IAKE OF IANDMApK STATE PLAN I.D.NUMBER �' k� b q TYPE OF BUILDING OR USE SERVED /(r�I��l7 wn5 Lv� � or 2 Family Number of Bedrooms: � U Pub�ie(Spacify�: THIS PERMIT IS FOR A: �-New Svstem ❑Tank Replscement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑Privy U Alternate System [� Reconnection ❑Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMP�ETE THIS BLOCK. �'Saepaya Bed ❑$eepage Trench U Seepaga Pit ❑ Holdiny Tank J System•In•Fill ❑ In•Ground Pressure ❑Vault Privy ❑Pit Privy ❑ Existirq,For Which A Previous Permit Is On File,Permit# iswed ❑An Existinp System That Has Been Inspected And Is Compliant As Far As Soil Conditio�s. Tool 7io1 Prdap, S�n Steel FiDerglatt P4nic Gslbm T�nks Concrere Construaed SeDtft T�nk Gpacity L0t PumO Tenk/SiOhon CMmMr Holdinp T�nk typaeltv Manufeclurar tF THIS IS AN ALTERNATIVE SYSTEtA COYIPLETE THIS BLOCK: � Mound U In•Ground Pressure Total #of vrNsb. ��0 Stea� Fibnglan Pianic Gauons Tenks Concrote Conttrucnd S�Dtit Ank CapacitY UI�Vump/$iphon Ch�mM� Menuyttunr: pERCOLATION RATE ABSORPTION AREA AB501iPT10N AREA yyqTER SUPPLY: fMinutn Wr Inehl: REOUIHED ISquan iestl: PROPOSED ISauero Feet1: � �/Q Y.f�o [�}'Private ❑Joint ❑Public I,the undenigned,hereby sstume responslbiliN for installation of the private sewage system shown on the attached plans. N�m�oi%u Mr IPrinel: Sipnazur• MP/ApRAiMFNo.: Pharo NumWr: 78.D �3��'OJS Plump�r'i Addrasf: Nema of Da�igner: STo � .� COUNTY/DEPARTMENT USE ONLY Sipmt f luuinp Apsnt: Fee: Date: ❑D�� $9 5.0 0 7-2-85 1d Apprwwd ❑ow�a r.��eia� Ad.�m D�tamMatbn R�non lo� ifpp L Atmm��coundsl ol Actlon Av�iiaph: DILMqSBDfi79!�R.8/8I) DISTii1BU710N: OrpinN�o Countv, Orn Copy To; Bun�u of flumMip,Owiror,Plumb�r http://docs.sawyercountygov.org/WebLink/PdfViewer.aspx?fi�e=htt...Fdocid%3D233969%26dbid%3D1%26repoi 3DLaserfiche%26pdfView%3Dtrue Page 1 of 6 PDF.js viewer 4/26/22, 11:56 AM �s. pyFRAi�Y �.� � , �' L S �4� s �!� �; GRoss S �Gr, o �, s"`i<� ' 6' d � 3� 6'� fj�F_ /1 `'�f�0 �� M./'• a 8',> http://docs.sawyercountygov.org/WebLink/PdfViewer.aspx?file=htt...Fdocid%30233969%26dbid%3D1%26repo%3DLaserfiche%26pdfView%3Dtrue Page 3 of 6 �•��'""'�� DIVISION OF INDUSTRY SERVICES 10541 N RANCH RD !� D �, HAYWARD WI 54843-6462 Contact Through Relay ~ ' S P s http://dsps.wi.gov/programs/i�ustry-services \� _ www.wisconsin.gov _`��.. ,��`� Tony Evero-Govemor Oawn CHm-Sacrefary May 26, 2022 CONDITIONAL APPROVAL APPROVAL NUMBER: PWTS-052200011-PV TIM HAWKINS � ��At�PRUVED, r 2543 Pf2lfle 08k Tf81� � -"` �"�''�AND PROfESSIONAI SERVICES _.. ":'�N OF INDUSTRY SERVICES Woodbury MN 55125 SITE: C�� .: TIMHAWKINS 4' - ��:Fco �s�c:�c�N;,E 16211W Browns Lane Sawyer County Town of Sand Lake S17—T39N—R9W FOR:PETITION FOR VARIANCE The submittal described above has been reviewed for equivalency to applicable Wisconsin Administrative Codes and compliance with Wisconsin Statutes.The submittal has been CONDITIONALLY APPROVED.The owner,as defined in section 101.01(10),Wisconsin Statutes,is responsible for compliance with all conditions of this petition approval and other applicable code requirements. Plan submittal to and approval by the department or its agent may be necessary prior to construction undertaken per this petition. This petition approval may be affected if applicable codes are revised prior to plan submittal for any necessary construction work.This petition for variance is being processed as permitted by Wisconsin Statute s. 101.02(6)(g),and SPS 303,Wis.Adm.Code. The code section being petitioned is SPS 383(8)4.(i),Wis.Adm. Code and Table 383.43-1 which require POWTS dispersal components to be at least 50 horizontal feet from an OHWM of a navigable water. The variance requested is to allow a dispersal component to be 48 feet from an OHWM. The intent of the code section petitioned is to provide the minimum horizontal setback distances as outlined in Table 383.43-1 as extra safety factors for public health and waters of the state. The petitioner submitted the SB-9890 application form including 2 additional pages of supporting documents and/or plans. Reviewer's Comments: • Sawyer County has no objection to this variance request with conditions. • The system elevation is 5.85'above the OHWM elevation. ��` � �� ' ��' .�`i� D ��,;��.��;�,_�:�__-.r.:=�E U h1AY 2 5 2(�22 � � SAWYFR CC:�►.'�'�"'�N ZONING ADMINi�T►-:.-., . Reviewer's Conditions of Approval/Recommendations: • When the drainfield requires replacement, it shall be moved to a compliant location. • All of the petitioner's statements of fact or intent included on the variance application form,any other documents submitted to the Department,as well as any other conditions of approval listed below,shall be carried out. This variance is specific to the subject code section(s) petitioned;and the building or object as it will exist following completion of the current construction project and shall not be used for any additional or future modifications,additions, or alterations to the subject building or object. • This decision will become final unless the department,within 30 days from the date of this letter, receives a written request for a hearing. A request for hearing should be sent to the address shown on this letterhead. A copy of this letter must be included with the request for a hearing. The request for hearing should state the reasons for objecting to the department's decision, because a request for hearing may be denied if it does not present a significant question in fact, law or policy. • Inqui�ies concerning this correspondence may be made to me at the telephone number listed below,or at the address on this letterhead. Sincerely, L'P.L'Pi /i , , CeCe(Elizabeth) Rudnicki Wastewater Specialist/POWTS Plan Reviewer, Division of Industry Services (608)400-3186 elizabeth.rudnicki@wisconsin.gev Wisconsin Department of Safety and Professional Services � ��.t+."T�e �'�% �s Application for Review-Petition for Variance-SBO-9890X ��;0 `:; Personal information you provide may be used iw seoondary purposes $ ' -Complete all pages- P S [Privacy Law s.15.04(1xm),s�ats.� '�% `�K � _ y iknc��y t. FaGl�ry�nformatlon Complete for submitted apalicationa: ! Facility(Buitding)Name: 16 3.11 w dre w�s I r► Cu,�'�::�::,;�,,,L.:i� j Number and Streei; APPROVED � JEPT OF SAFE7Y AND PROFESSTONA L SERVICES , SPS Site Number(if know�): SIT- DIVISION OF INDUSTAY SER11CcS �' Legal Description: S I� T31 A/ R O q W County of: Sw✓'�t/ o ��ri ❑ v�►�9g ,�To�, �'� ��.�.: «: �,d �� SEE CO ;ccSPCNDENCE 2. Owner Intormation Customer#� 3. Designer Informatton Customer# Name: T!M1 H•��S Designer: Company Name� Design F�rm: Dy�B� SChUftZ Number and SVeet: �3 �A'�� ''�` �"'� Number and 5treet: T076N StOne Lek9 Rd ciri,scace,zp code: �d� , M�, SS i LS cny,scace,z�P code: �M RS 15`161 987� ContaG Person: Contact Person: Telephone Number. Telephone Num�r: 7/�-SS8-�y Email Address: Email Address: I 4. Plan Review Status Plan previously review by(piease enclose a copy of roview lettsr) ❑Plan submitted with petition ❑State ❑Municipality ❑Appraved ❑Heid ❑Denied ❑Ptan revfew not required Coda Being Petitionsd: ❑Commercial Bldg ❑HVAC ❑Plumbing , ❑Plan wilt be submitted after petition detertnination ❑Private Sewage System ❑Swimming Pool ❑Electrical ❑Boilers ❑Reduesting revision ❑Other ❑Amusement Rides ❑Uniform Dwelling Code ❑Camping Unit SPS Application Number ❑Elevators ❑Gas Systems ❑Refigeration ❑Other 5. State the code sectien being petitioned AND the specific condition w issue you are requesting be covered under this pebtion for variance. S�S 3S3 �vUrs � 353, 2s cz� ��) S��-b��Cs Sn` �►�.:,.��.ld F�,�, oN�rM 6. Reasor�why compliance with the code cannW be attained without the variance(Attach additionai sheets,N necessary) ��.:��:cid ;s ys -��... s�.� Ia�s oHwr� 7. Slate your propoaed means and retionale of providing equivalont degree of hroalth,safety,or weNare as addressed by the code sertion petitionecl. I�►�ia� $�+� (w�Cf �I'a�c� RW+►y z`OM u,L �vil QAc� �C� 13ia`� �r��G ��✓*j� 5�..,� F�•,.1 t�.kc dap��. S�,I�..i a�",�j s��l�c 8. Ust attaChments to be considered as part of the petitioners statemertts{i.e.,model code sections,test repoRs,research articles,ezpert opinion, previousiy approved va�iances,pictures,p�ans,sketches,etc.). B�+'1 � lc�o' a,,t es+�„,,,�� S.QS` � k�t�,..�.`w, d;�� (�,a„d �.�,► a� �-- loo.rr S 5.�,�ivi FJ �o �hk� wa� Itvcl. Wh�c� � bo�lw in•�`(' sys+�M �i�•s,�.�.� ��'qc.4s Y � 1�,�.� �w� ��,�W.,+g0,6 9��e. �Ft�. �.Z�;+��,� �I�,w., �-o �,a� �� So' S�.�p� � �/0 o f�,er S(�- e�} r�P�'�j/ -�w� (`�p l-c�..n�' Ar+;��ld SBD-9890X{R 1U/21) Page 1 of 3 9. Veriflcation by Owner Note: Petitioner must be the owner of the building or system w creden6al applicant for a SPS 305 petition. Tenants,agents,designers,contractors, attomeys,etc.,shail not sign petftion unless Power of Attomey is submitted with the Petltion for Vatlance Application. I scat�,as petitioner.that I have read the foregoi petition and I believe it is true and that I have significant ownership rights to the subject building or project. � Petltion ' Signat /_ � � - ,O -� ------. Make Checks Payable :State of YV�—DSPS Total Amount Due 5 Complete remainder of form for varianee from SPS 320-325,SPS 327,SPS 381-366,SPS 382,SPS3a4,and SPS 390. Attach check here. Owner's Name Project Location Plan Number _Ti� � `�Cbc�Gr� 1-�'-•'�`�S �6L1/� �$�.w S ��► Fire Department Posk3on Statement: To be completed for fire or life-safety related vanances requested from SPS 361-366,SPS 316,SPS 327,and other fire-related requirements. I have read the application for varfance and recommend:(check appropnate box) ❑Approvel ❑Conditional Approval ❑Denial ❑No Comment Explanation for recommendalion induding eny co�flicts with toral rules and regulations and suggested conditions: Fire Oepartment Neme and Address Name of Fire Chlef or Designee(type or print) Telephone Number Signature of Fire Chief or Designee Date Signed Local C3ovemment Inapection RecommendaUon To be completed for variances requested from SPS 316,SPS 320-323,SPS 327 and SPS 383. For SPS 361-366,complete rf plan review is by municipality w orders are written on the building under construdion;optional in other cases. Please submit a copy of[he oMers. I have read the applicaqon for variance and recommend:(check appropriate box) �Approval ❑Conditional Approval ❑Oenial ❑No Comment Explanation tor recommendation including any conflicts with local rules and regulations and suggested conditions: Local Govemment Exercising Jurisdidion �wY�- �.�-�►��.��ti,yv„�1.'� '�eP'��- _ Name and Address of Jurisdiction Official(type or pri�t) Telephone Number of Enforcement OfFicial i E��we1l�,�r, to6to rv1�`�.5� Fl4v�+�++1 w�.s`t8�r3 C?�s 638-3��1 Signature of Local Govemment Enforcement Official/ �� i Date Signed �� L ��• S Publlc MeattlULffe Safety Position Statement To ba completed fw puhGc health and 1'rfe-safety reletod variences raquested from SPS 352,SPS 384 and SP5 390,and other public swimming pool related requirements. I have read the applicatlon for variance a�d recommend:(check appropriate box) ❑Approval ❑Conditionai Approva� ❑Denial ❑No Comme�t Explanation for recommendation Including any conflicts with local rvles and regulatlons and suggested conditions: (-p Department of Agriculture,Trade�Consumer Protedion(DATCP) i ❑Department of HeaRh Services(DHS) 1 p Department of Naturdl ResourCes(DNR) her /V1 PrS Name of Designee(type or print} '� Telephone Number �, (�,,, 5��+� 2 ��r-sr�-S9oy � Signature of Designee Date Signed S�_ �� L __ —_ _—._— SBO-9890X(R 10/21) Page 2 of 3 '/�'--``r,,, PRIVATE ONSITE WASTE TREATMENT county t` µ \\ � SYSTEMS ;� � °S 'K' S awyer ��`� Ps�� ( POWTS) \:�N\�-/.-v� F-'s'—�~"-''' INSPECTION REPORT sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION ��_ �"Z 9 Personal infonnation 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#: `�,.� '��eCc� �a�„�..s Sah C.�►� � —o S��OI l�`P'� Insp BM Elev: BM Description: Parcel Tax No: �a.� ' � co-�r -�o � a oa..to-- ( S� — bb-o foo TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic � Benchmark �pp,� � Dosing Aeration Bldg. Sewer qq,�� ' Holding St/Ht Inlet �j$,�� TANK SETBACK INFORMATION St/Ht Outlet R�?(p TANK TO PIL WELL BLDG VENTTO ROAD Dt Inlet AIRINTAKE Septic �p� �� 9 ` �� NA Dt Bottom Dosing NA Instaliation Contour Aeration NA Header/Man. Holding 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 W L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv �Aggregate INFORMATION P I L Bldg Well Waters o IGP ❑ Chamber Model Number: ❑ AG ❑ EZFIow CELL TO ❑ Mound o 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 0 Yes ❑ No SOIL COVER - ---- -- Depth Over Depth 9ver l Depth of Seeded I Sodded Mulched � Cell Center Cell Ed es � To soil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��• �' ��5��I,e�J� 6�3 � �-? ��1 �S' -� 5=17 �e��--b�,� Ce�.,�,� 5� Plan revision required?❑Yes❑ No a a � � /�� V Use other sitle for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS ANO SKETCH SANITAAY PEAMIT NUMBEA: �� 07� _ (`' ��7'A� �-R I�G"-� ��i�u►'�t Sa�- . . .05�5 ' �� VanqKc¢.. . � `Q� : � �` -_ _ _; _ ._ : _ ,__._. � �b w��.. � � , �P ,_ . _. , ------ - I _I � . . , . , _ _ �Y ewcz _( `, y' _ C,�.. � . . _ . \� c� p2�`u' ' clr �` ; ��f�c � � ��. ; � . _ _ ,_ .. , � , _ . _ . , ;- ' � ...- �_ - - - --- t - - �.. . , :......._. _.e. ... .. . .. . . . . . ��: . ... . . . .. ....:. . . . _.. ... . �._.. . -.. .j. _ r . , I .. t ._..s... � _., _.i. ._ ._.. .. _..__....� � . . 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