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008-938-33-5408-SAN-2022-146
^rT" Industry Services Division County �\�p :��y`VYX__r.��r'� ' '1 /' ��1 4822 Madison Yards Way SC� i,t • E' > '��` f + { `�� ` �; Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) ` \��.' � � P.O.Box 7302 / � o,� ��..¢`c Madison,WI 5302 l9 '%� �y�-� � f i ��.:� � Sanitary Permit Application State Transaction Nu� � In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit -- is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diff rent than mailing addre: ,,,c the Uepartment of Safety and Professional Services.Personal information you provide may be used for secondary �r)-b �� �c'a� r��L/ %'�u-r F � purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I.Application Information-Please Print All Information Property Owner's Name � Parcel�t n �� r �� ►� G�G , G'� ��� � � `��'3•� yob' Property Owner's Mailing Address Property Location S ,' �.,_ �: Govk Lot �f y City,State Zip Code Phone Number / < secc;on 3j Scz�r K ', ` j i' .s - s � - � -- � -s 7�� �-�(, II.Type of Building( eck all that appty) Lot# T �� N R E o W C7d�1 or2FamilyDwelling-NumberofBedrooms � f �- 3 SubdivisionName Block# '-- ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM umber ❑Village of �`f�/yo2 � -� �j �Ol �Town of__� / c.�/c� T'f'I� III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete tine C if a licable.) A� ❑ New System ❑ Replacement System �Other Modificati n to Existing System(explain)r C� Additional Pretreatme,nt rUnit(explain) /�/ v � � � Lhwn��I FrS .t�' flD ks C- i�c�d> ;+�'l? B' ❑ Holding Tank '(�In-Ground ❑ At-Grade ❑ Mound ❑ Individuai Site Design ❑ Other Type(explain) (conventional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number mid Date Issued Expiration (�y` ,j� 9 /,��0 IV.DispersaUTreatment Area and Tank Information: Uesign Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(sfl Dispersal Area Proposed(s� System Elevation y � l.." f / (O �� /� J1 r �C Capacity in Total #of Manufacturer � Tank Information Gallons Gallons Units � � o � � New Tanks Existing Tanks � � U " � � " 4" � � ` a� ,� R �a 0 __, a`. U rn y v� u. C� fi. Septic or lding Tank ��G ` —'"Z- C C t� � l f-{ �,-����- � ���c: Dosmg Chamber _ V.Responsib7ity Statement- I,the undersigned,assume respons" i[ity for installation of the POWTS shown on the attached plaus. Plum er's Name(Pyint) Plum 's Signat e MP/MPRS Number Business Phone Number �!� � � �,. 7/s-�?�E �7�'�. •�; �ls! F:S , ��^ � _rr n C--- ���'�1 P m er's Address(Stre ,City,State,Zip Code) � ! ![i �l�S 'F �x _ SCi/ �G.%c� (-�;7 C' �� �� �) VI.County/Department Use Only � fi �" e� ❑Disapproved Permit Fee Date Issued, Issumg Agent Signature � ❑Owner Given Reason for Denial $ (�•� �� ��`"� �"`" ����`�`'�'t'��•������'���� Conditions of Approval/Reasons for Disapproval `l 5 y �-,���,,�-;_'�-��-'•+---�,5 . �I�� � r} �,-�'�f,,; . . _ .,��------- __.__ ! 1! � ��'�� J��. � 7 '���a z � �S� � ��--,'�� �; � ' --------__---_. � . . . � . � � �7`:`:Y?_.��-� �... .. . ZQNIfvG A�U�;iJI;;i ri;-tc�Of� Attach to complete plans for the system and submit to the County only on paper not less than S t2 x 11 inches in size NO REF'JNDS AFTER SBD-6398(R 02/22) tSSUE OF PERMI7 7/11/22,3:18 PM Real Propehy Listing Page R2dl EStdte Sawyer County Property Listing Property5tatus: Current Today's Date: 7/11/2022 Created On: 2/6/2007 7:55:17 AM �Description Updated: 1/23/2020 � Ownership Updated: 5/24/2016 ... . . ._ .___ .. .. . Tax ID: 9560 ANDREW P&MARGARET A OPICHKA SAUK CITY WI PIN: 57-008-2-38-09-33-5 OS-004-000080 Legacy PIN: 008938335406 Billing Address: Mailing Address: Map ID: :4.8 ANDREW P&MARGARET A ANDREW P&MARGARET A Municipality: (008)TOWN OF EDGEWATER OPICHKA OPICHKA STR: 533 T38N R09W 524 SYCAMORE ST 524 SYCAMORE ST SAUK CITY WI 53583 SAUK CITY WI 53563 Destription: PRT GOVT LOT 4 LOTS 1 &3 CSM 14/142 #3492 1� Remrded Acres: 0.740 r Site Address * indicates Private Road Calculated Acres: 0.775 2567N COUNN HWY F STONE LAKE 54876 Lottery Claims: 0 First Dollar: Ves lJ Property Assessment Updated: 6/28/2021 Waterbody: Chetac Lake ZpZZ pssessment Detail � � � � � � 2oning: (RRl) Residential/Recreational One �ode Acres Land Imp. ESN: 430 G1-RESIDENTIAL 0.740 41,200 174,700 �� Tax Districts Updated: 2/6/2007 Z-year Comparison 2021 2022 Change 1 � � State of Wismnsin Land: 41,200 41,200 0.0% 57 Sawyer County Improved: 174,700 174,700 0.0% 008 Town of Edgewater Total: 215,900 215,900 0.0% 650441 Birchwood School DistriR 001700 Technical College �Property History • Recorded Documentr Updated: 1/23/2020 N/A � WARRANTY DEED Date Recorded: 3/30/2016 400399 TERMINATION OF DECEDENTS INTEREST Date Recorded: 7/6/2016 401860 TERMINATION OF DECEDENTSINTEREST Date Recorded: 7/8/2010 367376 WARRANTY DEED Date Recorded: 3/24/1992 226042 482/227 WARRANTY DEED Date Recorded: 3/24/1992 228040 482/225 CERTIFIED SURVEY MAP Date Recorded: 2/11/1992 227455 https://tassawyercountygov.org/system/frames.asp?uname=Eric+yyellauer ��� PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manual Design References: In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersal Area Cross-Section & Plan View Pg 4 of 4 Management Plan Attachments: Enciosures: POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description �� P��� !� k�� Owner Name(s): /�,.��,� �P�.� �`/�o�Q,.� � ll�, l��iC h Iv�phone: FC� - �j - 5�.3 7 Owner Address: S, � � S . u u C';' � li.'' Zip: •�� Project Address: �-i�� 7 Yl� C �i N k ✓ ,�«c «'�� Govt. Lot: ��U� 1/4 of 1/4,�n -3 j , T�N-R�E Q or W � Township: ��✓��P r,�,�c��Pi4 County: S. c. ��,� �' Project Parcel ID #: C�C� � % i � � � S �O 8 Designer Information Designer Name: ��Yc'� 'c/� �oi% F S� _ Phone: /S - .�3 6- �19 ` Designer Address:� � 7C7 �l,Psf S ¢� su�C�-'G LC.�i � 2ip: S'��,P7lI E-mail: CYi el �Y'Iw� P� In \CQ\ �l O /' <Y� C; i� I • < <� ✓� This space reserved for approval stamp. • License Number: �� 3 .� r � i Remarks: ' , �� SF 7��'c l f�vi� d-' �G � �G�� �! ���,���� cZ � ul� l%�u�n'_ P ,�� �l s � I i'ee�C� FF � Occc�E,� �r' 6'fc�l' lf�mh 'frt� f Oci E � � /; ,�f _ , , Signature: ��'(j�y ��"< <'c�� Date: � �7� ���rigina signature required on each submitted copy. CNECK BOX AS APPIICABLE CHECK BOX AS APPLICABLE. � SOIL EVALUATION o s�iQ: '� 40' � � [� SYSTEM �PAGE 2 OF SlTE MAP PLOT PLAN PROJECT NAME:• �02 DESIGN FLOW; '7 .TD GPD , f� E �y�, Q ' � Attach design flow ca�ulations for commercial plans. PROJECT ADDRE33: �,+5 11��rf� Pipe Material !ASTM Standard (Tables 384.34-3 8 384.30-b) aM symna: � BM Elevstbn: I�II• � � N Sanlfary Sewer. ���d � S.O j4 3S /� t Force Maln: BM Descrlptfon: �,�Q a�" ��C ��'"� � ��fi r--t��r�>l.p� Slo Gradient % �n4����' IMPORTANT: � � ) wen symba tna�ncabie�: p drewlny an arrow Shaw ground elevation contours at suitable irnetvals. of Tested A(�e: on the approprfte pne. , O �C �� - . � �_, 1/ .� �r'�j ,�':y' —�--� . "^a��1_^ a. � � t�';�'� ��/� � j -�-.,'" � r J M � �6� � � . � j � F of � ��'�''�C f,{fG�� -T / � 1 � `1'��.�r-.�.,�� %� ' f'`q� ' . , � � / f j_ � ` y...+y��rr.. ��`y /� �` �Jri�� �"� C �- ' ' '-o t` r � / `'1\`\�`� 1 7r, y� � ,� `�. ( i , � , t r � f c � �r . � S 1 � . / ""---""'a ..�� �= � L Ci �� ��• G ��?.'�O. � P��- (V� �' ` s Q� �y+n � - � �.J ; , - s,� � o �. ,' ` ��� �`'� � ..�_.. .. . _ _ . _d . _----__ _ __ . .. ._- ,..'� .._ _ _ ; V ` ,� , • _ r Septic Tank(s)ManufxWrec IN-GROUND GRAVITY DISPERSAL AREA l l���1�<<,-tf- -��,� Uniform Elevation Trenches with Quick4 Standard-W Chambers SepticTank(s)Vdume(s): 3-ft Trench (down-sizing credit) �c'L`t'9a, gal gal gal ' � E���t Fi�er MarnR�Wrer o5r - F � E� o � ���+�'.� Effluent Fllter Model#: mm.ir SOIL COVER �Np�l� �r min.trench tHd�u • TYPICAL TRENCH ".a •. CROSS SECTION VIEW ��ryP�� , (No Scale) Provide minim�m 3 ft System Elevation=�ft separalion between lrenches. (typical) Qulck4 Standard-W w/End Cap 06servatbn Plpe TypICAL TRENCH (�YP���� (Show location of inlet/outlet pipe connection on plan view.) (�vc��0 InslallpermanRxiurers PLAN VIEW instructions. (No Scale) r ------��-------�f--- — —� � , :, , . : . : I A=3.Oft (�YPwap '� �—_——_——_———��———_——_��_——— ——_——� � g= � ft - -� m (rypical) puick4 Standard-W Chamber W INSTALL PER TRENCH: «�I� O (mfd by Infiltrator Systems,Inc.) � Install pursuan!to manufxlurefs ins(n,qions. � � 7 Quick4 Std-W @ 20 f�EISA/chamber= -3 yc ft' + � Pairs of end caps @ 6 ft EISA/pair= S. � ft' =Proposed EISA per trench= 3`�'S ft' Required Infiltration Area= ��� ft' Distribution Method: x o2 trenches=Proposed Total EISA= ��'I//� tt' /��r U<�,� mh� . � 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= `�S �l gpd; BODS<_220 mgL"'; TSS <_ 150 mgL''; FOG <_ 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., Ieaks, 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 priar to dosing o dosing irregularities-if applicable(i.e., pump re-cycling,float switch settings, etc.) o electrical components -if applicable(i.e.,wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral 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 Seotic and dose tank(sl 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. Coda. o Effluent filter(s)shall be inspected every 3 years and shall 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: !���t c �T Srv:�,'C"E-s Phone: ��> 1 3 `( � � � � l Local government unit: �c� f w ��". Z c v� ,'v,c,_ Phone: 7(5" - C 3y - �� �' � Local government unit address: !�'�/L� i dlc�ld Sf � `�9 ��e,i��_� ��_ZIP: S%b"/3 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. Continaencv 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 reptaced by a code-complying dispersal component in a pre-determined area of suitable soils. Svstem Abandonment If use of this POWTS is discontinued, it sha�l be abandoned in accordance with SPS 383.33,Wisc. Admin. Code. `�'s�+.� "�e'�''•_t 7#xas '°. a r` '.i: f,�,C �� ,T, '.- �... ; ����-0 w- .4 v� .: �. 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I } yy� Y : � y ' � � � ... .,�'�� 'i.. `�:v��. �� � tiiw f �._ . . `"^-, t" . �` y�'��p � '� ` r . .. �y�.y; .-_ • �+± 8.r �i 1, � ,s����� �,";�,y`1 ��., �y�+�� ~• `� '� [ 4 i . � �.� ', '�-� �R'� � ��Sc+:\.� * �Y + �:� _ r. �� �.,ti 'V,;�,y A•� T1, ��r ti� � F Y �� �.��'�y[ , �r'' � �r'�^4'R,y;,K \y � . , �}y� i�'� �+-t.' =.�.. f, '`_'..,;� .� 'v� �,4 ,� . � �`�C.� �.Ar a.,f_e�'ei-c. A. �' �aS�� ��� ���,� f't4 � ���4�I�Y� '.p. ���w �� 'LL - � J ~ r � �� � ` � ,� . ; ;. . . \ __,v �}� �°,.,j.�'F ��"'�, s +,T`+r}� �:.. t ,�� � � � ` _ � ... ` �* . . ��Pr�^ � z T � �,,�' .. •i' , � �� 'a"��."�. � '�••_' •••'4 �.�:. A+ r ' !�, �4 ! y.� ♦ �� .. ti•ti �\ �',i H . � � , \' � ' '� _ , � .�� 4 ��� � �il���F� _ � � �f. � � ���` �4 `� ,itr .:� .� � ' ��a'�$��.� �..* �.� � �.\_``�.�; y �,, r } .� ";!+�t '° ' � "� 4 t��. �� �e�`'` � 4�. '�.. l t\ ti '���'�)� �,. . .� . t ' x ,,,\. ` =.�;��, ; . � ��,�'T — ��C� �!. �:�Af�R�R� �`�� � �scansin Departmentaf Comrr7erce SO{L E�/.wl_�.1�1'("ION REPORT page ' of =,,.3' Diviston Qf Safety and Bulldings in accardance with Comm $5, iNis. Adrn. Cocie � County (� Attach cqmplete site plan on paper not less than S 112 x 11 inct�es in size. Pian must ' indude, but not Gmited to: vertical and hotizontal reference point (DM), direction and F�arcei 1.0. parcent slope, scale tx dimensions, nartta arrow, and iocatian and distance to nearest road. �„� ,_ c '� . -- t= x ^ Please prtnt al!infarmation. steviewed ey oate Perso�al infortnatian yau pravido may ba u.ed tor sccondary purposes{Privacy law, s. 15.04 (t}(m)}. � � C� _ C��,� Property Owner r p((Jpf,'(� �.00w'3ttOf1 '[y� F. ��1j ``� � �- �;� � �tr���� � � �o�t. �ot v� �ra s�- T�. �� �r e� � e (o�w./ Property Owner's Mailing{�dd ess �°��N� Bfock# 5ubd. Name or CSh9# �;'n t . i� L���,� L�� t� ,�'` l ;� .�,`�.'r�-'�`�''� "' _ e• Clty State Zip Cade Phone IYum�e� ��;ty [� VilEage �`7rnvn Neares#Raad i ' /�%��� ��j 1 t f..5 s y�-. ,'<��.� f �'�°�' �-��7f�,�' �� ' , ❑ Nt�snr Cor�sWcf4�on Use:�C] ResidendaE !Numt�er of bcdsooms ti�' Gode derived design flow rate _T;f_''S'�G' GPD (�Replacement .�1 P�blia o�comn�ercisl - C7escribe: j' . 1 Parent material �,l`.c�+?'��� ��� �toai Plai elevation if appiicabte tt. Generai comments ���v �.'-=/�-�G� C�'�> � �".f� -�t't<'� �.�,I��/j'�7'�<S<tt'..' ._ �ifc"� /.��3-cr�- and recommendations: / /�J � /'/ �" �:� ,��4//,, (��f �+ • 1 i�.,.�'�''.� f�'f"'.r�(�!�„" G,r���,^i�C.� �� 1 ,iG...".L,.G.».r'.L'�.'✓ f.." C.l.,'t'�-G`o�("'f�'�-„��'C..•'� C`�. //, /f., /'`� � _!/� r�.{,£+� nC" :%'Lr' ...-l+�,�"t'�''G.+k". f c:3���,L �X'.'7 (��..�.�'.. � ;�,I.'°t3`,.C?t""!•..��+�' �" � �I � Borin � ❑, Boring � � 9 � � p�� Ground 5u�face etev. �� ._�it. pepth to limfting factor �z� In. 5011 Appiication RatQ Horfzan Depth Dorriinant Cplor Redox Ooscriptian T�xture Structura Consistence Boundary Roots GPOlttr f�. Munsei! Qu. SL Cut�t. Calpr Gr. Sz. Sh. 'Eff#1 'Effll� �' •-- ` � �. � ��%� -�--- ,s-� .1. - .�i j'` ,s!�;�Y'f,�' _� ��% l - �' � � j L JI ` _ .� . ;rt `/✓, La '1 � ./'S+� � �G� "'fi'; � fr / � '�L- 7 �/ c� ____ . �{" , _ _.s`I' ,✓'� � � ld-% � c. ' ..- C� �i ,_ ._ �t/j,.s . �'r- _-'. . � Boring # � E3orinf7 —,!-.-- p�t Graund suriace e1ev. Gr.- S !t. Oe{�th to lirnitinc� factor in. Soil Application f2ate Horizan Depth aominani Coiar i2edox Desc�i�Eion 'TexEure Structure Consistence Saundary Roafs GPDtftz in. MunseEt t�u. Sz. Cont. Cnlor Gr. 5z. 5h. `Eff#1 `Ef€#2 ' — � �? :5�' �G1 � ' � �' � l�r r` 1�rr'l d�f� � C�--' -,�,� � ,� .� - � '� :S' � ^ �ti; !�:' �` � G'�� 1 �Y- 9 � :�7 �� �f _� ��.s"` � - ..s � �.� �� � � /—�',�� 7 / , 2 � . _ ��, ,��� ...�. ,t,� S' c,•� _ �4 �. ,�11 � "`"' ` !�� 'g ' Effluent #4 = BOD,> 30 < 220 mcyL and TSS >30 < t 50 m�.+t • Effiueni #2 = ROD, < 30 mg/L and TSS < 30 m{}It. C N e (Piease Print) Sir�` at CST Number �3 • � T ' �' l� f� �� ,.��_/',s�''��-�r'�'� _ G' - fJ �,>'�'`ff' q,dd��yg t3ate Ev;�luatipn Gonducted 'fetephone Nurnt�er t�� � � — �. �� �~�` �,-,� (,7, L ��t ,-.�,t�,.j , , ; ' t" :'� _±''� :5 �.S *-. .:ri` !_:. , �rzn-R�zn��n�mn� PropeAy Owner Parcet ID# Papa�a�,,,� �B�g# ❑Borio9 Wl Cuottn0 surfaca day.�R Deptl�b MtiUng fador in. � Shc p6on Ra6e .Flwlmn DepU� DondnanlColor RedozDesatptlon TexWre SWdwe Conslatenee Boandary Rooq OPD/11= In. MwiseA � Qu.SL Cont Colw � Gr.Sz.Sh. •ER#1 •Effll2 � p- ��� — .fil -Ag� K2 C -� v� !� � ,S'L _�1 / uJ ��l� � 3 -r _r �-� e�v -` , t a-s ! — ,� ��* ❑s«� ❑Pit Grou�surfate dev. R Depth b Mdtlnp(ador In. Shc otlon Rffia Hmlun DaD� DOMnantCda RedoxDesalptlon Terzh�re SWdure Cauistence BoundaiY Raols GPDIR� In. Munsall �u.Sz.Cont Cala Gr.Sz.Sh. 'ERfk! 'Eff02 . ��np« ❑�� �. ❑PII GrounC swface elev. k Deptl�lo tlmltlng fada In. Soil AppOcat[on Rate Halmn DepU� Dominanl Cola Redox Desaiptlon TexWre Strudure Consisfenoe Boundary Rooh GPDlR' in. Mumep Qu.Sz ConL Calw Gr.Sz.Sh. •ER#1 'ERq2 (' -_t l.i `:��� 'em���1=BOB,����TSS>30<150 mplL •Eflluenl#2=BOOa�30 rnpfl entl TSS<30 mglL . `��y.�''!,.06 SR�� �-�YL.:. : . o t�� � . TLe Depe�ment o[Commerce is an equal oppariuniry serviw provider and emptoyer. If you need assistance to access services or need material in an altemate focma4 p��e aoNact the department at 608-2663151 or T1'Y 608-264-8777. SPW]]U(M1�1.O01 � .. . r �. .: . �. . 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C�.P7: .�J,r'�'cY. /Y/Ar' '.�.i:: 2 SHCG7 'g � . . .� . . � . .• .. . . ... .. iiy�'�i . . �-. \ � . , ...�;i;'. . OwnCi�.� w • �J�. ',;��'1r' 9,�, d .. ._,;, , ; :''�i..� , Sys� Elcv Syst. Rangc_—��:�,�.to ';, �rf`; -'A�',4';r�.i ! �. W. Ratc • � ' � � _96, � ,: �. a �� qs 9 a �t. 9 � B ��. :t:::,;�s,. -- --- , -- ;,,��:�::'� • .�,,,� --- ::,� .�:;�:�.. -- --- ---- •---- --- ,��� '�� -- -- ---- •---- -- � {_ � `•� . -- ---- --- ' ;� --- �b � . --- ---- ---- -- �'. ' , y� �'��`�+ �.�a "— , _�� ���� � '��� ��� '":}:y^� �"{� s,��. -- . --- ---- � ---- --- �9 k ' _-� �� u��. ��M ��' li -- � 93 �y ---- y, �� . --- '.�::,�° -- --- ---- 9 . _---- _- ��� .:,�,��;�,, ._;::� -- . --- ---- ----- --- :�w,} .�;. �. . ::� ��� ��� �w� ����� ��� ':t �l• ��� ��� ���� � ���� ��. � � I • �i �� � ���. . �"q /' � r �. ' / ��� ���� ' I � ����� �=' • � . -- 3 --- =--- 3 _---- _-- --. -- ---- � ----- --- . -- --- ---- ----- --- 3 -- --- ---- ,� ----- --- � 7, � - --.�� _,-�-� "'"`` ; PRIVATE ONSITE WASTE TREATMENT count �-�,i Y �� � ,=, �$P ,���, sYSTEMs Sawyer ,�,, s � ( POWTS) �::��.,`—,;�>i "'"°v��' INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� �t K�p 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#: ��-cw �-�'l �.�" o I?'cJ-►� crr'� �„ — Insp BM Elev: BM Description: Parcel Tax No: �oa.a ' b � q ; p o�-q 3$ — �3-�`'(6�' TANK INFOR ATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic pp Q Benchmark �.o ' Dosing Aeration Bitlg. Sewer ' �'S-0 Holding St I Ht Inlet `1 K�3 � r TANK SETBACK INFORMATION St/Ht Outlet q Y.Y3 TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIRINTAKE Septic ��` �r s� -t�� f�s� NA Dt Bottom Dosing NA Installation Contour Aeration NA Heatler/Man. Holding Dist.Pipe PUMP 151PHON INFORMATION Infiltrative , Surface a3.,K3 Manufacturer Demand Final Grade Model Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist.To Well DISPERSAL CELL INFO ATION DIMENSIONS W � � � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate ��I, INFORMATION P I L Bldg Well Waters o G � Chamber Model Number: ❑ EZFIow CELL TO -}��S �O�_____�'b,� __ IV__ ❑ Mound o Other ---- _ -- --- - �� ----- -___—_- - DISTRIBUTION SYSTEM X Pressure Systems Only -- ----- — — � Header/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 1 Sodded Mulched Cell Center ( Cell Edges Topsoil _ _ � ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) � �,5���� $�1�"��� � a�� � Qr� p�-��� a-�� ��, �r �.�I�,� ��,��a-, �-J--�---, � Plan revision required?�Yes❑ No �I �,3 p� �-3' ��___��� ������— � ���' � � � Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) � �� .1�^`(\� Q 1� ,, � �, L� � ���� . �"d —�.�,� T ,o�- ���� � � �� W9 ���' � - �, _ �-_�] `�� —� �.��:� —L , � �st�f �r � i �s'{ � ; ���p 11a`� \\l� �,�-I 1_ ` v ��� ��� �� `90��� � �S�� I�,� � �ld -��� 'kl o'9e o`K� �� ��—�� _ _ d�ewnN�iw�3d AdvliNus H�13�5 ONV S1N3WW0� 1t1N�IlI��V