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Home My WebLink About008-937-09-5120-SAN-2022-100 '" Department of Safety c°°°ty � � � � - & Professional Services, `��v� � = Sanitary Permit Number(to be filled in by� P= Industry Services Division � - (� '� � i c U � State Tiansaction Number � Sanitary Permit Application + � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �' is requircd prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Projcct Address(if different than mailing a� the Department of Safcty and Professional Services.Pcrsonal in�ormation you provide may be used for secondary � purposes in accordance with ihe Privacy Law,s. 15.04(1)(m),Stats. ��5�A' O' �a s .� I I.Application Information-Please Print All Information �" �1«� � Property Owner's Name Parcel# .� � � ,t c �==�s-t-oJp, �. 3?�9' S �� Property wner's Mailing Address Property Location i��`'� 5 i�r�-5.��r✓ �s'�-- �"� � Govc.Lot City,State Zip Code Phone Number C� ,�' �SN'� �.� �� 7 � D�_�Section C� � 7 II.Type of Building(check ali that apply) t Lot# ,� T � f N R � E o �or 2 Family Dwelling-Number of Bedroom Subdivision Name g�� o�.Y, B�o�k# ❑Public/Commercial-Describe Use — ❑City of ❑State Owned-Describe Use CSM Number ' ❑Village of �"r5�►� 17�b3 �i��,or � I��✓hT�'�Z _ _ IIL Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if a licable.) A. ❑ New System y�Replacement System ❑ Other Modification to Existmg System(explain) ❑ Additional Pretreatment Unit(explain) B' �Holding Tank ❑ In-Ground ❑ At-Grade gn yp ( p ) ❑ Mound ❑ Individual Site Desi ❑ Other T e ex lain (conventional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issu d Expiration 9'6_ 3� � � ��9� DyJ tV.DispersaUTreatment Area and Tank Informa6on: Design Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation I�� ._. � Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units � o 'b u New Tanks Existing Tanks � ❑ � " y A � � n U `n � v� iz. C7 a, Se tic or Holdin Tank P S � � p J Jp l {J,�:' � Dosing Chamber V.Responsibility Statement-I,the undersigned,assume respo sibili for installation of the POWTS n on the attached plans. Plumber's Name(Prin Plumber's Signa e MP PRS Number Business Phone Number � � i'�,�r�,� ; r '� �� 35'�� 5� �l� � �� Plumber's Address(Street,City,State,Zip Code) � � � �'�� .� ( � r �, � ��"'��,a ;%1 �--�y �`��%� � VI.Cou ty/Department Use Only �A� � ❑Disapproved Pe�nit Fee Date Issued Issuing Agent Signature O Owner Given Reason for Denial $ `w'� � ( � �a"�` 'l'�L4�n.tJ-x-��'��3'" Conditions of Approval/Reasons for Disapproval D � �� • �� .--- � C S� N�� e.al� J U N 0 7 2022 �' �-t:�. �� Y�� _ IN � _ � SAWY�R �C��.�6•.lTY ZONING AUh•9ihl!STr��;I IU(U Attach to complete plans for the system and submit to the County only ou prper not 1e�e q�ar 8 t/2 x 1]inches in size NO REFUNDS AFTER SBD-6398(R.03/22) ISSUE OF PEAMI�f Sawyer County Zoning & Conservation Administration ` `�"�\' I 0610 Main Street,Suite 49 , 1� Hayward, Wisconsin 54843 �;. , � �� (715)634-8288 � .�� _� � % FAX(715)63R i277 i" i� �,�}'�1 i c� ii o .�i � � Toll Free Courthou�se/Genera� �� ; � � � I lnformahon 1 877-699-4110 , , `� ��1�"``�� Holding Tank Approval Checklist l. Sanitary Cover Sheet Date Stamp ��O / �7/_�'�_ Parcel ID# o O g-� ,3 7-b `1 -� � �-O II. Plot Plan �Property Lines �Benchmark BM ♦ Site Address /_ North Arrow ��Structure � Scale � C Well <25' to Service Road � `�\ egal Description earest Road Intersection � Setbacks to: Property Line, ell, Structure, Water bodies, Roads III. Required Plans lndex Page with Original Signature Management Plan/Contingency Plan Servicing Contract Holding Tank Agreement fonn 1V. Holding Tank Specifications �Cross-section-Manufacture, Gallons: w��" a,0�o p�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 �SBD-10855-P (R.3/07) � � Owner: �v��Q�� Sficx.pT i� Plumber: 9 _ Q�� Application Review Date: ��b��o1-� ��_� POWTS Reviewer: � rv��»—�" E,`t S� 1� Liccnsc# Revised 4/11/2013 CONCRETE HOLDING TANK DESIGN Single Tank Opfion INDEX AND TITLE SHEET Project Zastoupil HT Owner Daniel Zastoupil Address 1804 Statesman Dr Wausau WI 54403 Legal Description S 9 T37N R 9 W Township Edgewater County Sawyer Subdivision Name Lot No. 3 Parcel ID Number 8937095120 Plan Transaction ID Number Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Designer Dan Bur Signature Phone No. 715.416.1642 License Number 253808 Date 06/07/22 Designed pursuant to: Holding Tank Component Manual For POWTS l✓�-�'�� c�a � Version 7.0(11/12) P2ge 1 Of 4 _? ° . �..:M-��are, �all noi be��at� '� ��essorY str��s HOLDING TANK SPECIFICATIONS 1 Number of bedrooms Non-residential estimated flow(gpd) 2000 0 Minimum holding tank volume required (gal) 2000.0 Proposed holding tank capacity(gal) Wieser � ��' ��'� Tank Manufacturer W2000-MR Tank model number SJE Rhombus Alarm manufacturer Tank Alert I Alarm model number Tank Dimensions and Data Tank Anchor Calculations X tor round tank 15370 Ibs Weight of tank and cover 53.0 Liquid depth below inlet invert(in) 1.10 Safety factor 8.0 Maximum depth of soil cover(ft) 18675 Ibs Weight of anchor required 66.0 Height(in) Outside 24.8 in Soil cover req. for anchor or 151.0 Length (in) Dimensions 4.6 yd' Concrete counter weight 86.0 Width (in) Only HOLDING TANK CROSS SECTION manhole cover with locking device and finished �vent cap junction � warning label grade box � � � �4"min. 12"min. �23 in. ^"`"�— Manhole and vent locations '� conduit � vent pipe 18"min. � tetherweight -- � 12.� It1 building sewer � service " _._._._._._._._._.—.—�— inlet blind plug alarm on Note: All tank joints, and to seai joints between tank ouciet openings and piping are Electrical as per 41.0 in. sealed watertight. All NEC 300 pipe and vent materials and SPS 316 comply with SPS 384. 3 in.bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Zastoupil HT Transaction Number: Page 2 of 4 ,� �.�(��- C�.�►�c-�a t �..._�.._. ____._-�__. . r a� =-- _.. _.._ .�.�...�._...�.._..� �� ' . . ._._�_�_.,,.�_..,..�_. ; ..._..� � � i=, � (� L � I �� /'QI M `� + '� - � �..�....w..-�.,r.�.� ' ,� �U , G� � � �._ J• �' � -----�----��-�-._� � � _ -_. �� av� ��— � ��-3 k : � � � �21� _ Yp �hr►c1os� � 1N1 I�o•t�i % v� � } r , f _ � ��-- �� 1�3 � rq � � � �'_ 1,��:�s e�-�v4� ��..� m " �°01l��aI[t . ��. ��a. �� (6v�c�� n�r�� _ aT�.l _ {un�i�rounti= �`d � "�p 1 ��1� �� =�{ .a� � � ��1 ��i��` ,� 1 ��,�rrng��;� �� h�l��►��r�� . � x. ` ' r ,,C�T r �y ��Q�s�ruc#u►�es �6� , - � �,��,: o �� ri : , .�� " Q � �'" _�' . . . . . " . . - fi1 -.,.�..---... �.��5.3 ,' ,� � : �� --��_� �j �� _ . `� --w_�, . : _� --� � . ... "�"` �-_.: : � �� _ --�-�.;�..�„� ",� HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P N. 03l07, R. 01/12), and the Sawyer County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow o� 20.0 to 400.0 gpd. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s)capacity or a level of 12" below the inlet (at which time the alarm will activate), the pumper listed in the current Service Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s)and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons may be contacted: a. Installer......................... Dan Burch Phone: 715.416.1642 b. Service Provider............... Lake Area Sanitation Phone: c. Co. Zoning or Health Dept. Sawyer Counry Zoning Phone: 715.634.8288 11. _ _ __ __ . __ _ ___ _ __ _ _ _. _____ ._ __ ._ _ __ Project: Zastoupil HT Transaction Number: Page 4 014 W2000—MR TANK SPECIFICATIONS � o a a i � 12'-7" DIMENSIONS: � o WALL: 2 1�2" a a BOTTOM: 4" COVER: 6" w •=-------------_, MANHOLE: 24" I.D. PRECAST CONCRETE RISER Q �;=--------- .�� :�. HEIGHT: 66" � .� �� LENGTH: 12'-7" ii� 4" CAST-A-SEAL 4" CAST-A-SEAL �� yy�pT}{: ��_2^ � ii � , �� BELOW INLET: 53" � ' `� '� � � LIQUID LEVEL: 46" o `i' i \� i \ WEIGHT: 15,370 LBS. � o ! � � d � E � � �� ' �2 � � ' INLET AND OUTLET: •�� 3 0 � \�� rriO� I %� 4" CAST-A-SEAL BOOT OR EQUAL GASKET � m o 0 �� • FILTER OR BAFF�E ii o N \\ // LLj Z 3 �� ii' INLET AND OUTLET BAFFLE AND FILTER: Q Q � w �� ____________,;%' WISCONSiN, SEE DETAIL #10 � o o � ��---- . ------.- ----------- (OTHER STATES SEE CHART) W o � � LIQUID CAPACITY: 42.92 GAL/IN W � � � TOP VIEW HOLD�NG TANK: Y � OUTLET HOLE PLUGGED � � �n ACTUAL CAPACITY: 1,085 GALLONS � � � o � W I � LOADING DESIGN: 8'-0" UNSATURATED SOIL � �n cn� � � �v ao �,, TANK CAN BE USED AS: o I +� SEPTIC / HOLDING / PUMP OR SIPHON eW 3 0 � = o� COVER: MIX DESIGN #8 (NO FIBER) � ---- : ---- _� TANK: MIX DESIGN #10 (STRUCTURAL FIBER) � � ---- ' ---- INLET - OUTLET CUSTOMIZED TANKS: � � . N i � � FOR CUSTOM TANKS CONTACT WIESER CONCRETE �+a i ' v� c0 � U � ' � � U �p . a- I � . I � �� i �� O J I I � � 2�„ �-- I_ 1 � a `-------- ----_1. ---------- o � 0 REVIEWED BY o c� � REVIEW DATE 3 � w SIDE VIEW DRAWINGS SUBMITTED N 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: ,�l�l 2OzZ This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Owner's Name: Pumper's Name: �- �4� �1��l��r l �(.�I e ,��Q ��G�� Parcel IdenNfication Number: (12 Digit Legacy ID) D D �- 9 3 �-o_�- ,�L� O 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 Ordinance for the issuance of a Sanitary Pernut for the installation of a holding tank(s). 2. The owner agrees to have the holding tank(s)serviced by the pumper and guarantees to permit 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 to the Governmental Unit, Sawyer County,a report for tbe servicing of the holding tank(s)as required under SPS 383.55,Wiscansin 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 gallons 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 Si ri3h1Te: (Only one owner signature required) i �if�t �!��k�� Pumper's Name: (Print) Pumper's Signature: � � � �� - Pumper's Registration Number: ` �� ! Rev.03/26/13 i �i�i�iiii�i ii�i��ii��i -USE BLACK INK ONLY- � ij ,5 g g �; 4 Tx:4U38550 POWTS MAINTENANCE AGREEMENT 439557 For Hoiding Tanks PAULA CHISSER Owner's Name(s)as shown on deed: REGISTER OF DEEDS SAWYER COUNTY, WI SCtK � ��S�OGi � r 06/08/2022 02:47 PM d121� � • !G �6Gt ! a.� � RECOl2DING FEE 3Q.00 Parcel Identification Number. ' (12 Digit Legacy ID) C��-� 3 �-�g-,�� PAGES: 2 �' Legal Description of Property: -SEE ATTACHED SHEET- We acknowledge that appiication is being made for the installation of a holding tank(s)on the property described on the attached sheet. Retum 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 propert�,the�ner 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, inr,luding the foliowing: 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 governmentai 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 govemmental 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 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. -Onl one owner si nature re uired- ,'4CKNOWLEDGMENT Owner's S" natu�: r. � State of: w � _�LU�� i !�/ �`` Count of: n, Owner' ame (Print): y J -1�~y'��l^ , 1 Subscribed and sworn to before me on this + oJ ��u . GS'''r`' day of r��a , 20 Z�- Date: s.../�S.- By(Owner's Name): �. .;��. L. �ti-;-f-�w 1 ' ZZ Notary Public Signature:��w.. �z, ,�,��.� Drafted by: Public Notary Name(Print):+—�c�c-'�j�;-z�- :1•'�,1�j��,�y w- �«�1'L � Zci S�Uu�' � My commission expires on: �- Z ( --- Z..t�L 11 BARBARA h�.c,,c ,., Personal information you provide may be used for secondary purposes[Privacy Law,§15.04(I)(m)j Notar§t�Y�Q��26/13 State of Wisconsin T�t '� �� rec�rrler� yn Vnlyrme �7 nf Certi�� yTrve� Ma�,c; �AaP �� C�rvpv N�= 521$ as �ocument No. 24'�649a �ocated �n t�te T4wn of Edgewater, Sawy�r County, �4'iscor�sin,, being part of Gave�rn.ment Lo� I, Secf[on 9, Township 37 North} Range 9 West, __ - � .. . � ��'�'-s..._�'�Y�'�x"`�r� ` �'.��J. •r '�.°!��;��'�,��`� - � �.� ..� �,,I« � � ' '� �_.,s�yk•.,�"f,,�. � i�,,,,� ... �!r^a�1�!""�IE.-.i.iiJO,,..-!r J; ry�"��"�4r .'��`;� M '°� T �t'�s � -+,� ��,� ..,,,, � � r. .. < " ��4,...r � 'r .` . i -� _ �'�j' Y+ �<'� - . __�,�'�'��,. . �.�Y t u } � '-� i1�``_ '°'. ..�,... _a•�� g t�� r� d� ��a q�"��.�..��`�C..�`: e � , F �:J. . , . n. ..�..-.., < �s"* ,.-r; , . . � � � ' �x� •� �...,� �''�n��_� � � �. . ..._ � ,�. � �., .. ��'�,w� '�,,,� � T�u 'l..g �� k- ��._ �'�. � � .b; _ ! - ^t�� '� ,n �� e - .� .fi t.t "�,.'�+� �'�Yili,�t;'�-'{�",��. , '� jj�t M q �v . ..,�, / y,_ .nrr, ..-. -_ �� ' _vM Y� � � � � � *•'��+�n�"w �� r—�r�t _ "`T 1� ,'�' '�1. ..;ywrni. � �� ,�',#��a�:'. _, 7� _�+� �-# � �� ' ''}!�'a� . `"�d . a... �:,ww O 5 ��.- � ,�'� '� 'r�'A...�� 'y r'�'�'. ._ . � � -„�- 7� + . � �� ` 7� ' � . ,* f�y'' • .� -�-'�" .� � a � "r . ,� -�� ,. �` ,�•y`�e�� 5`�M �.r . +",:a r - +ri.�� G i � �d c �{ ��r }�" 1,.�e, a rt^^� �t„�� y�"�C�,�'RS ,�,,ygy�� '�t _ ` r t� ,� +� � e r'�a�-�-'Y�'"" �� . 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I t,,�'.", t 1__ "�' k . 6/8/22,2:08 PM Real Property Listing Page Real Estate Sawyer County Property �isting PropertyStatus: Current Today's Date: 6/8/2022 Created On: 2/6/2007 7:55:15 AM �'Description Updated: 6/17/2021 � Ownership Updated: 6/30/2021 _ . _ Tax ID: 8270 DANIEL L&SUSAN E ZAST'OUPIL WAUSAU WI PIN: 57-008-2-37-09-09-5 05-001-000200 Legacy PIN: 008937095120 Billing Address: Mailing Address: Map ID: :1.20 DANIEL L&SUSAN E DANIEL L&SUSAN E Municipality: (008)TOWN OF EDGEWATER ZASTOUPIL 2ASTOUPIL STR: 509 T37N R09W 1804 STATESMAN DR 1804 STATESMAN DR WAUSAU WI 54403 WAUSAU WI 54403 Description: PRT GOVT LOT 1 LOT 3 CSM 17/63 #5218 Recorded Acres: 0.890 � Site Address * indicates Private Road Calculated Acres: 0.806 2053N OL HAYS RD BIRCHWOOD 54817 Lottery Claims: 0 First Dol�ar: Yes � Property Assessment Updated: 6/28/2021 Waterbody: Chetac Lake 2022 Assessment Detail Zoning: (RRl) Residentia�/Recreational One Code Acres Land Imp. ESN: 430 G1-RESIDENTIAL 0.890 129,500 229,500 � Tax Districts Updated: 2/6/2007 Z-Year Comparison 2021 2022 Change 1 State of Wisconsin Land: 129,500 129,500 0.0% 57 Sawyer County Improved: 229,500 229,500 0.0% 008 Town of Edgewater Total: 359,000 359,000 0.0% 650441 Birchwood School District 001700 Technical College �Property History •� Recorded Documents Updated: 6/30/2021 N/A WARRANTY DEED Date Recorded: 6/29/2021 432938 WARRANTY DEED Date Recorded: 7/26/1996 255650 CERTIFIED SURVEY MAP Date Recorded: 5/2/1995 247609 https://tas.sawyercountygov.org/system/frames.asp?uname=Eric+Wellauer �� ""^�:;� PRIVATE ONSITE WASTE TREATMENT county ��o$ SYSTEMS Sawyer :�� Ps ( POWTS) �"�Fr:---��', '�-"'"��'" INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �2_ (�� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village $,I Town of: State Plan Transaction ID#: �+►n i e� �S�'o u 61 ew r-- Insp BM Elev: BM Description: Parcel Tax No: �cX�,p� � a� �;T. C'id-'�' 'C� OU�- '�i37-- ac('-� �� TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark �po.o � Dosing Aeration Bltlg. Sewer q'�6 � Holding p� L� St/Ht Inlet �'�.2 � TANK SETBACK INFORMATION St/Nt Outlet q 7.� ' TANK TO P/L WELL BLDG vE"T To ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding ��.5� ` fi� � �l S� ��S� Dist. Pipe PUMP 1 SIPHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade ��, Y' 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 o GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound � Other --- -- ------- _ - ------- --- DISTRIBUTION SYSTEM X Pressure Systems Only Header/Manifold Distribution Pipe(s) II X Hole Size , X Hole Observation Pipes Length Dia __ Length Dia _ _ _ Spac _ L __ � Spacing ❑Yes ❑ No _ SOIL COVER Depth Over Depth Over Depth of Seeded/Sodded Mulched Cell Center 1 Cell Edges � Topsoil � ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) �'�s}�� .6/a� �� -�� , _ _- �� T--; � Plan revision required?�Yes❑ No ,p�I133 i�3 II �� — _ _� � Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AO�ITIONAL COMMENTS ANO SKETCH 54NITAPY PFRMIT NIJMAEA- _�a_�.IO�__ _ �0 1.�V`�'�� "� ;��`e�� M�" � �o� � � � `� � c� � P,�s, � , ► � �a""� � �,�e � � � �� O� ��s3� r To a �GY�S .�--- 5��_