HomeMy WebLinkAbout032-540-35-5207-SAN-2022-118 � -
/,,,°����"� Department of Safety c°°" �
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.;, ,Sawy�-
_ � o = & Professional Services,
a P = Sanitary Permit Number([o be lilled in by Co.) � `
�, � E : Industry Services Division �.�
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Sanitary Permit Application �
State Trunsaction Number
In accordance with SPS 3R3.21(2),Wis.Adm.Code,submission of diis fo�m to the appropriate gnvernmental unit ����������� �
is required prior to obtaining a sani[ary perniit Notc:Application fonns for state-owncd POWTS are submitted to Projcct Address(if di�terent than mailing addre
the Department of Safety and Professional Sen•ices.Personal information you provide may be used ti�r secondaiy
pwposes in accordance�vi[h the Privacy law,s. I 5.04(1)(m),Stats. � �O I � 1A,�4`�� �
l.Application Information—Please Print All information ��� '��� ,
Property Owncr's Namc Parccl#
�r�vc�f 4- r��-rr� -�-� s �P�-� �n.vST o3a - SYo -3�-s�b�
PropeiTy Owner's Mailing Address Pr�op,,,e_rty l.ocation
7� �� ���J� Gorvt��[ �
Ciry,State Z.ip Code Phone Number ?
C �-(� � C J t� � �`�C --�'—� Section JS
IL Type of Building(check all that apply) Lo�# T -(� N R S F,or�
�I or2 Family f)�vellinc-NumberotBedrooms � � Subdivision Name
Block# ^
❑PuUlic/Commercial-Describe Use _
❑Ciry of
❑State Owned-Describe Use CSM Number ❑Village of
3 I��y �6og grT�,,,m�,r W��.�2r-
TII.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.
❑ Ve«�Sys[em �.Replacement System ❑ Other Moditication to lixisting System(explain) ❑ Additional Pretreatment Unit(explain)
B.
❑ Holding Tank ❑ In-Ground ❑ A[-Cnade �Mound ❑ Indi�idual Site Design ❑ Other Type(explain)
(conventional)
C• �Renewal Befbre ❑ Revision ❑ C'hange of Plumber Li�[Previotu Pennit Number and Date Issued
❑ Transfer to nea�nwner
Espiration ��...� ��� /' �r� ���
b
IV.Dispersal/'I'reatment Area and Tank Information:
Design Flow(gpd) Design Soil Applica[iun Ratelgpdis� , �)i.persal.Area Required fs� Dispersal Area Proposed(sf) System Eleva[ion
ySD ). o YSa YS`� 1���73
Capuciq�in Total Jt of Manufacturcr
Tank Information Gallons Gallons Units � v o '? u
Ncw Tanks 8xisting Tanks � � y F y �`u � b
0
a U rn � rn u. C7 a,
Scptic m�FloldinE Tank '�� ��,� i �� �
DosingChambcr 6Q� 60D
V.Responsibility Statement- I,the undersigned,assumc responsibility for installatlon of the POWTS shown on the attached plans.
Plumber's Name(Print) Flumbei's � a t e MP/�1l3.12�'t Number iittsiness Phone Number'��a�
� C'� c�c—Y �—�� /�rz z 3 - �� '?7 J
Plumber's Addres�(Street,City,State.Zip Cbde)
/�-:%'�-'-�:1�-� 7trrLft r,� � .., � `�— �� ,�
VI.C un y/Department Use Only
1� Pennit Fee Da[e lssued Tssuing,4�en[Sign�uu�c
�AE�ro ❑Dia:�pproved $ _
00 r.
�� ❑Owncr Givcn Rcason for Dcnial I��< (9 �.C; I3� j . '1,�t` ,�t� t�,r�;, _.
Conditions of Approval/Reasons for Disapproval
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S.l�I'J � �l `_ I � -� � SA ADM N STRA ION
Attach to complete plans for[he s}�strm and submit to the County onl}'on paper not less than R I/2 x t I inches in size
SBD-6398(R.03/22) ,
NO REFUWDS AFTER
ISSUE OF PEqMIT
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/°='�'`"E�;:�>;>_ PRIVATE ONSITE WASTE TREATMENT county
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� ��oSP �� SYSTEMS Sawyer
\����� ( POWTSj
`F"'��"=� INSPECTION REPORT sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� _ � 1 g
Personal infonnation you provide may be used i'or secondary purposes[Privacy Law,s. I5.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village �,Town of: State Plan Transaction ID#:
,�-��e�e. +- �e. �a � ��r�,1 W ��n�-'� ��-06�00�t ti - �
Insp BM Elev: BM Description: Parcel Tax No:
' �32-5z1�-3S-S`��
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ,,�„�1-�- dJo Benchmark OD.o�
Dosing r-c.o,M�j� bo�o
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St l Ht Outlet
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �. S� -�-�.5-� y � �j � NA Dt Bottom
Dosing µ K * � NA Installation ,
Contour �`�.�
Aeration NA Header I Man.
Holding Dist. Pipe 1o,�,O�
PUMP/SIPHON INFORMATION Infiltrative �
Surface l o o.y`
Manufacturer �,��- Demand Final Grade
Model Number q$ GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L � � Dia �� Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W 6 � 7$'� #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
INFORMATION P 1 L Bldg Well Waters °� GP ❑ Chamber Motlel Number:
,� EZFIow
CELL TO `t'S �(�� '�6D' _R� Mou nd o Other
DISTRIBUTION SYSTEM x Pressure Systems only
�Header/ManifQld „ Distribution Pipe(s) , , X Hole Size ,� X Hole,�,53 ` Observation Pipes�
Len th 3•� Dia l,S Len th �`'�,l9 Dia �•� Spac�,_o _ p,1� Spacing Yes ❑ No
--. _ �- g — -- � �-
SOIL COVER _
Depth Over l , Depth Over „ Depth of / y Seeded I Sodded � Mulched
Cell Center �C" Cell Ed es �e2 Topsoil U _ � [�Yes ❑ No — —f dB�Yes 0 No
COMMENTS: (Include code discrepancies,persons present,etc.)
���rl�� 11 �2 ��.o�� = ►'ti�
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Plan revision required?❑Yes❑ No � �` � 6`�(�1� �
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Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3I01)
A�DITIDNAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: �� - I I S
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