HomeMy WebLinkAbout014-942-34-1401-SAN-2022-150 ' industry Services Division County �/ �
� 4822 Madison Yards Way SAWYER �
' �,��� ,- Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.' �
_ . P.O.Box 7162
,�-�� Madison,WI 53707-7162 (,Q j� � � � �
Sanitary Permit Application State Transaction Number �
�
In accordance with SPS 3H3.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit NA �
is reyuired prior to obtaining a sanitary pennit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing add�
the Department of Safety and Professional Ser�ices.Personal information you pmvide may be used for secondary �2390N NORWAY POI NT f���
purposes in accordance with the Privacy Law,s. 1�.04(I)(m),Stats.
I.Appiication Intormation-Please Print All Information
Property Owner's Name Parce(# ��Y� 9t�� ^.3 _ �
WENDY P. CRONKHITE 57-014-2-42-09-34-1 04-000-000010
Property Owner's Mailing Address Property Location
8549 I RW I N ROAD NO 337 ��,�.L�� -
Ciry,State "Lip Code Phone Number
BLOOMINGTON, MN 55437 NE ,,�, NE ,,, Se��on 34
II.Type of Building(c6eck all that apply) Lot# 7 42 N R 09 E or W
�i or 2 Family Dwelling-Number ofBedrooms a Nq Subdivision Name
B,��k� NA
�ublic/Commercial-DescribeUse NA
�City of
�State Owned-Describe Use _ CSM Number illage of
NA ❑✓ Town of LENROOT
IIi.Type of POWTS Permit:(Check either"New"or"Replacement"and other appiicable on line A. Check one box on line B.Complete line C if
a licable.)
A� ❑t�few System �eplacement System ❑Other Modification to Existing System(explain) �✓ Addirional Pretreatment Unit(explain)
LJ ELJEN UNITS W/12"ASTM C-33
B' �1-Ioldin Tank ❑In-Ground �At-Grade �Mound Individual Site Desi
g gn ✓Other Type(explain)
(conventionat) ELJEN UNITS
C• ❑Renewal Befon �Revision hange of Plumber �ransfer to New Owner List Previous Permit Number and Date Issued
EXp,rat�on 1122/05-03-78
IV.DispersaUTreatment Area and Tank informafion:
Design Flow(gpd) Design Soil Applicatio Rate(gpd/s� Dispersal Area R uired(s� Dispersal Area Pro osed(sf� System Elevation f
600 1.6 a_p 375 3r,,o 410 pD J6-86-�T. ��-�
Capacity in 'Cotal #oC Manufactu er
:3
Gallons Ga(lons Units a� o b �
Tank Information � ,. v �
New Tanks Existing Tanks v c a� " y p � �
y, O �
R. U V] n V] L�. C� R.�
SepticorHoldingTank �250 1250 1 WIESER ✓
Dosing Chamber � � �
V.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumber' Signature MP/MPRS Numbcr Business Phone Number
� � - - � '� l S- 5�'s'l(o7
Plum6 s Address(Street,City,State,Zip Code}
J`Zl /� %'l�-�YI �T.'�. �C� Q1'�-�- �t� � ��� ,
VI.Cou /Department Use Only
�App �� ❑Disapproved Permit Fee Date fssued lssuing Agent Signature
❑Owner(iiven Reason for Denial $ l vv•� , � �� �`'`'` �j'�'�c,'�:��'E'�-! ���`�`�`�r
Conditions of Approval/Reasons for Disapproval r,
.f., .t. . , J ����.���=�,�
�, __',� ` �`_- ;�
i
� � , CST JUL 0 � 202�
A � �. � aa � 1 � � �
,f � �
� _ �a �•��Y V �.. r�� � �p� p /'�(� �:T�,_'
S�VY 1�rl VV�.� .�4 �
ZONING A�Ivitt�l,ST�?�.����
Attach to cumplete plans(or the system and submit to the County only on paper not less than 8 u2 x 11 inches in size
sB�-639s�R.o3i2>> NO REFUNDS AF'TER
ISSUE OF PERMI7
GSf WI IN-GROUND DESIGN PROGRAM
INDEX AND TITLE PAGE
Project Name: WENDY P. CRONKHITE
Owners Name: (SAME)
Owners Address: 8549 IRWIN ROAD NO 337
BLOOMINGTON, MN 55437
Legal Description: PRT OF THE NE1/4 OF THE NE 1/4, SEC. 34, T42N, R09W
Township: LENROOT
County: SAWYER
Subdivision Name: NA
Loi Number NA Block Number NA
Parcel I.D. Number: 57-014-2-42-0934-1 04-000-000010
Plan Transadion No.:
Page 1 Index and title
.,�....,. .., _ Page 2 Data entry
" Page 3 GSF
,.. . Page4 - ���;iw ionJ ti,.�.�.tR
� Page 5 r! i: Uiew
En:- .. � , ...�d,. �
��. , •, /'" , Page 6 System main[enance specifcations
"� - Page 7 Management and contingency plan
- D '. _
� �••.;a 1sf� = Page 9 PI�DIa�
� `'• � Page 10 Soil test
C,� " '_ Paqe 11 " .,
�_.����y_„� : � Paae 12 „ ,.
•:N"q;;um:r�,,:,; � " Page 13 Aenal
pesigner MARY JO HUPPERT License Number: 1859-007
Date: 7/620 Phone Number. 715�26-1775
Signature: Q�i
Desgned Pursuant to the
GSF IN-GROUND NOVEMBER 2019 EDITION Page 1 of 13
GSF WI IN-GROUND DESIGN PROGRAM
DATA ENTRY
Site Infortnation
R Residential or Commercial Design O4 Number of Bedrooms(optional)
600 Design Flow(gpd)
14.0% Site Slope(%)
100.00 Installation Contour Line Elevation(R) 50.00 Contour Le�g[h Available(ft)
81 Depth to Limi[ing Factor(in)
1.6 Io-Situ Soil Application Rate(gpolft�) EFF it2
Distribution Cell Information
643 Unit Used �#of Rows(Trench Systems)
5 Cell Width(ft)3,4,5,6,8,9 or 10 40 =Dispersal Cell Length(fl)
2.0 Dispersal Cell Design Loading Rate(gpd/fl�)
2 InFluent Wastewa�er Quality Are the laterals the highest mt
in the distribution �
Pressure Distributlon Informatbn neRvork? Enter Y or N
G Center,ErM,No Mani(old(Pump to Gravity),or Gravdy(No Pump)
�
�
J
Lateral Diame[er Selection Manitold Diameter Selection
in.diam. o Gons choice in,dia. o [ions chofce
0.75 1.25
1.00 1.50
1.25 2.00
� 1.50 �' 3.00
2.00 � �
. 3.00 A(�wu�
J"
Galbns/lnch Calculator
Septic Tank Infortnation TOWI Tank Capacity(gal)
� 1250 Septic Tank Capacity(gal) To[al Working Liquid Depth(in)
� WIESER �Manutacturer gal/in
Dose Tank Information Effluent Filter information
__OiDose Tank Capacity(gal) ORENCO Filter Manufacturer
0 Dose Tank Volume(gaVin) FT008 Filter Motlel Number
Manu(acNrer
Project: WENDY P.CRONKHITE Page 2 of 13
GSF WI IN-GROUND DESIGN PROGRAM
GSF IN-GROUND DRAWINGS
Pian View
_ -: kf�s , +�d'tlb, � r+t'".�cT. Ic�y3'�t ::q �r ��c X x:��,���y'�. . �i 4 �u�:: �•r. :.i:�:
'��ai' t: SYL..::e� y....-
A ,.
1 _ o ra. �,d 1 E�;. , e; ,.x � s �ir. •�r
i.. .,. *� �:4" j�'�sM_�rR4+ yw _.M� ;}"�D•2.tYr �,y;�
B
Com onent Dimensions
A 5.00 ft B 40.00 in D 1.00 ft F 7.00 in
H 1.00 ft
200.00 (ft) Dispersai Ceii Area 200.00 (ft2) Basal Area Available
15.00 (gpd/ft) Linear Loading Rate 4.00 (ft) 1/10 B Obs. Pipe Placement
�r�. . � ,�,-� �ft, _ � ��,� '
� � '�� Finished Crade
MN120F 19999 (ft) /
����M � Late�ve�Elevation _ G� rS3
l
T'(F� � Dispersal CeII Elevation _ ��.�r �
39e96� (h) �
(D) ���`D Contour Elevation
��j. K� I
1Z' S I
Shading Key � _ Typical Dispersal Cell
1 se Topsoil Cap � a See Page 5
2 Subsoil Cap o � 2 ft Geotextile
3 � ASTM C33 Sand �' o Fabric --> -
4 Tilied Layer �`0— � i I F � I 5
5 GSF Media � n � ---- --
� 0 0.5 ft 1 1
A
Project: WENDY P. CRONKHITE Page 3 of 13
•�yt',_ ,:.�'�,�i,+� i�����z���°'"'�:,�.�i';. �.;,E'}�;'��.'`
-����'�„f?�.�a�::. �...�� :,
DESIC�d -
.L ' � ��K'K'.'.�.�r ��L.p-k�..
.G�.�j� lr -w�! 1.� }
�7' „t 11eg� =�r �«r�ry~,i'r�'X.'P.�,.�E'+7��[l.t��%�.
SFL�iFl�SN�D ��4< yTx-'��rY*..�k�`;rn. ��;�t�=���^..rm,:��a��3��?�`-�-
PH2 �� �r��Y...�, � �� �i �� s..
� �� ,�F:�a 3,�y,�, .�.ay.J��[� A��J I�`����'�'' �}`••a�'
'r.�.'»rF'%• �.y.c.'�la.'�':�'z-�ir�'.?1;Y�y�''Ap.^
13 � 1 _ ,p�, _�.: .���.,,�.
�":iy`� ��x.� 'R+a.'�5't'lr'-�..i1�:�,.,�.� '
_ ' ri�4:;-�,ta,.`.,.'f'G��=-?r,`�r' y..i'r
>'x:�::z:� _
� 5'MN. —
Pfft DESIGN
P��SGN
CONSTRUCTION DETAILS
FOR
12390N NORWAY POINT ROAD, HAYWARD
THE EXISTING DRAINFIELD Wlll BE CAREFULLY REMOVED AND THE NEW EUEN UNITS AIvU ASTM
C-33$AND WILL BE PLq�ED IN THE IN-SITU SOILS. THE FIRST 6 INCHES OF SAND WILL BE PLACED AND
STABILIZED AND THEN THE NEXT 6 INCHES OF SAND IS TO BE PLACED AND STABILIZED. THE UNIT WILL
BE PLACED ON TOP OF THAT 12 INCHES OF ASTM C-33 SAND. THEN COVERED WITH APPROVED
FABRIC AND FILL MATERIAL AFTER A COUNTY INSPECTION.
��: y �i3
GSF WI IN-GROUND DESIGN PROGRAM
DISTRIBUTION MEDIA
GSf Distribution Cell Media Layout
�Celi Width(ftE 2.5 Sidewall to Lateral(ft)
Distribution Cell Cross-section Arrangements
Drag appropriate drawing to space belo�v.
5 ft Wide B43
Component Legend ,
� ASTM C33 Sand/Mound Sand
�� �l
A42 or B43 Module -
�
� Lateral
� Turn-up(contained in Tum-up Enclosure)
Distribution Cell Plan View Layout-Typicai
5 Cell Width-A(ft) 40.00 Cell length-B(ft)
9.75 843 Modules Requfred per Ro�v C���
19.5 843 Total Modules Required (2��
J.
- �` �I�/ �fM sc�•No
t
�;
<Fr�•,��,E
JMP i�j
RqVli v
'rojecC WENDY P.CRONKHITE Page 5 of 13
Table 2
SIZE AND ORIENTATION
<_ 6 feet = Number of product rows x product
width. Product width is shown in Table 2b; two
rows of A42s can achieve a 6 foot width. Units
Distribution cell width (A)a may also use up 18 inches of sand on each side of
the product to achieve a 6 foot width. For
instance, B43 units used with 18 inches of
specified sand can achieve a 6 foot width; refer
to Table 2c for configurations
>_ Design wastewater flow rate : design loading
rate of the fill material = square footage of
Required # of Products product (shown in Table 2b), round up to nearest
whole number; Min 5 B43 units per bedroom or
6 A42 units per bedroom in residential
applications
Distribution cell length (B)a Multiple # of GSF units x 4 ft + 1 ft
Orientation
Longest dimension parallel to surface grade
contours on sloping sites.
Deflection of distribution cell on concave < 10%
slopes
Design wastewater flow = soil application rate for
the in situ soil at the infiltrative surface or a
Basal area lower horizon if the lower horizon adversely
affects the dispersal of wastewater in accordance
with s. SPS 383.44 (4) (a) and (c) , Wis. Adm. Code
The designer may use Effluent #2 in accordance
Soil Application Rate with s. SPS Table 383.44-1 and 383.44-2, Wis.
Adm. Code
Table 2b
APPROVED PRODUCT MODEL NUMBERS AND DIMENSIONS
Product Square Footage Product Width Product Length Product Height
A42 12 square feet per unit 36" 48" 7"
B43 16 square feet per unit 48" 48" 7"
Table 2c
APPROVED PRODUCT INSTALLATIONS AND SQUARE FOOTAGE
Product Square Footage Installation Width Installation Length Install Height
12 square feet per unit 36" 48" 19"
A42 16 square feet per unit 48" 48" 19"
20 square feet per unit 60" 48" 19"
16 square feet per unit 48" 48" 19"
643 20 square feet per unit 60" 48" 19"
24 square feet per unit 72" 48" 19"
Eljen Corporation
��GSF WI IN-GROUND DESIGN PROGRAM
^� SVSTEM MAINTENANCE SPEGFICATIONS
K
Mama sysoem rAaneenar�and operaoai spec�fi�ams
Service Prmider's Name � RED'S SEP71C SERViCE&REPAIR LlC � Phone �� 715-%49412 �
POV✓rSRegulator'sName SAWYERCOUN7VZONING �Phone 715-634-8288—��
� .. _.__— —� `— .�
System Flow and Load Parameters
Design Flow-Geak 600 gptl Marimum Intiuent Partide Size 1/8 in
Es[imated Flow-Ave2ge 400 gpd Mazimum BODS 30 mg/L
Septic Tank Capaciry 3250 gal Maximum T55 30 mg/L
Soil Absorption Component Size 400 k' MaKimum FOG 10 mg/L
Maximum fecal Coliform SOE4 cFu/100 mL
Servire Frequency
Septicand7ump7ank InspectantlJorserviceonceevery3years
EHiuent Fiker Should inspect and dean a[leart once every 3 years
Pump and Controls Tes[once every 3 yean
Alartn Should test monthly
Preuure Sys[em Lateals should be flushed and pressure terted every 1.5 years
Mound Inspect/or ponding antl seepage once every 3 years
MiscelWneous ConsVucUon an0 Mlaterials StarMarAs
1.Observation pipes are sbtted and materials contorm to the rtandards,have a watertight ca0,and are secured in a as
shown in Me Eljen mounG component manual.
2.Dispersal cell media mnforms to Efjen praducts approvetl for use wi[h Me Eljen Mound Component Manual approved
August 2016.El�n metlia ls covere0 wi[h ihe manuhRurers geoteztile fabric.
3.NI�avfty and pressure piping ma[eria�s contortn the reQuirements in the state code.
4.Tllage of the basal area is acmmplished with a mold hoard or chisel plow.
5.The mound struaure and oMer disturbed areas will be seeded and mulched to prevent soil erovon arW help reduce frost
penetration.
lateral 7um-up DeGil
6-e"pAA�ETER
UKN SRLNQER
FlMSHEDGRhDE — — — _ _
TTKiEAOED
LA7ERAL QJ0.S AT IAST 4'PERFORATED PIPE CLEANOIfr PLUCa
OPoFlCE VNfRE VAPoABLE 4'END
LENGh1CLEnNOIlT�GINS GP LONGSV`EEP90OR
TNO a5 DEGREE BENOS
&1ME DW�ETER
.. . � AS WTERAI.
-�— qSfRl&fT10NlATERAL - LATERALCLEANOUT
Projtrt: WENDV P.CRONKHRE Page 6 of 73
GSF WI IN-GROUND DESIGN PROGRAM
MANAGEMENT AND CONTINGENCY PLAN
System Management Plan
General
This system shall be operated in accordance with SPS 82-84 Wis. Adm. Code, and shall maintained in accorda
with its'component manuals Eljen Mound Component manual August 2016 and SSWMP Publication 9.6(01/81
local or state rules pertaining to system maintenance and maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases may be present that couW cause death
Septic and pump tank abandonment sha�i be in accordance with SPS 83.33, Wis. Adm. Code when the tanks a
longer used as POWTS components.
Septic or pump tank manhoie risers, access risers and covers should be inspected for water tightness and sou
Access openings used for service and assessment shail be sealed watertight upon the completion of service. A
opening deemed unsound, defective, or subject to failure must be replaced. 6cposed access openings greater
inches in diameter shall be secured by an effective locking device to prevent accidentai or unauthorized entry in
tank or component.
Seobc Tank
The septic tank shall be maintained by an individual certifred to service septic tanks under s. 281.48, Sta[s. The
contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating co
of the septic tank and outlet fitter shall be assessed at least once every 3 years by inspection.
The outlet fiRer shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be rem
unless provisions are made to retain solids in the tank that may slough off the fiker when removed from its encl
If the fiker is equipped with an alarm, the filter shall be serviced rf the alarm is activated continuousty. Intertnitte
alarms may indicate surge flows or an impending continuous alarm.
The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1!3 t
liquid votume of the tank. If the contents of the tank are not removed at the time of a fiennial assessment,
maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less
maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank perfortnance is generaliy not required.
However, 'rf such products are used they shall be approved for septic tank use by the Department of Commerce
Contingencv Plan
If the septic tank or a�y of its components become defective the tank or componerat shall be repaired or replaced to
keep the system in proper operating condition.
If the dosing tank. pump. pump controls. alarm or related wiring becomes defective the defective component(s) shall
be immediately repaired or replaced with a component of the same or equal performance.
if the mound Component fails to accept wastewater or begi�s to discharge wastewater to the ground surface. it will
be repaired or replaced in its' present location by increasing basai area if toe leakage occurs or by removing
biologically clogged absorption and dispersal media. and related piping. and replacing said components as deemed
necessary to bring the system into proper operating condition_
See Page 6 of this plan for the name and telephone number of your bcal POWTS regulator and sernce provlder.
°�,�: 7 at'�3
WLP1250-MR
TANK SPECIFICATIONS
�
�
o a
DIMENSIONS: a �
120�" WALL: 2 tIZ� p o
. BOTTOM: SEPTIC 3� a a
COVER: 5" o
MANHOLE: 24' I.D. PRECAST CONCRETE RISER �
HEIGHT: 52 1/2" O.D. e
LENGTH: 120 1/4" O.D. +
N1DTH: 84' O.D.
BELOW INLET: 41' O.D. � > �
4" CAST-A-SEAL 4" CAST-A-SEAL LIpU10 IEVEL• 36� � a o
WEIGHT: 8,810 LBS.
mz4" � MLET AND OU7LET:
< � 4" CAST-A-SEAL 8007 OR EQUAL a
°D 1� GASKET, CAST-A-SEAL B00T OR EWAL �' g �
FILTER OR INIET AND OUTLET BAFFLE AND FILTER: m g �
BAFFLE MASCONSIN, SEE DETAIL N10
(OTHER STATES SEE CHART) � a �
0 0 �
LIOUID CAPACITY: 34.81 GAL/IN �
HOLDING TANK: � N
OU7l.ET HOLE PLUGGED
ACNAL CAPACITY: 1,323 GALLONS � �
TOP VIEW �OADING DESIGN: 8' 0" UNSATURATED SOIL � � �
� �
0 z CO
� o I
a �
� � N
TANK CAN BE USED AS: �+ o �
cn o SEP71C/ HOLDING/ PUMP OR SIPHON � � o0
a � � COVER: MIX DESIGN �8 (NO FIBER) W �
TANK: MIX DESIGN /10 (S7RUC7URAL FlBER) � '
CUSTOMIZED TANKS: � 3
INLET OUTLET FOR CUSTOM TANKS CONTACT NAESER CONCRETE
N � a � N J
� ` 7 aU � M n U O� a' �
� 22 �a �� M Z Z
< o a
� �
N
U
F
d
"' DRAWINGS SUBMITTED N
FOR APPROVAL
SIDE VIEW APPROVED BY: SHEET NO.
APPROVAL �ATE: I OF/
PRODU(TS NEEDED BY:
TANKS ARE MANUFACNRED TO MEET OR EXCEED ASTM C-1227 REWIREMENTS �
Piot Pian � ��►�
�-----�
PROPERTY OWNER: W�Nf1� � e��`�� 1" = 40 FT.
rjE�`� BF�t,i6 1��� �- {e�aoept where noted)
legal Desaiption: YCI. C�FCEn IN 'fCtE NE�4 DF Ri6 I��3N � �j—badd�cepit
Ty1J�) �R041n1 ?oWnl OF L�1Ro�T. SA�1�FR (�W�CC�. WtsCCt�NSU�.
s7- o�v- z-4z�o�-3�-i o�-oao-ooao�o� iz34anl �1c��w Pau.sr RoAD �,�so �REs
tYorth
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Site focation: r`�`���
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't`'"'-"f�:� PRIVATE ONSITE WASTE TREATMENT county
,�.��= .,.
, ,
�"� o � SYSTEMS Sawyer
;�.��Sps ' ( POWTS)
��f`_;s;.;-=�;�
��s-,�'��=' INSPECTION REPORT sa�itary Perrnit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� ^��j
Personal infonnation you provide may be used for secondacy purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village I�Town of: State Plan Transaction ID#:
�N`2h� Cw.� 4���+2 ��f'Do �
Insp BM Elev: BM Description: Parcel Tax No:
�0°•� � o�-��� tiEc�tw- . �► s� bIY� -�'i�f2- 3`�—(�(� l
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�,��- � 2� Benchmark (OO.o'
Dosing
Aeration Bldg. Sewer 9,st�
Holding St/Ht Inlet q 9,yY �
TANK SETBACK INFORMATION St/Ht Outlet g y oq �
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �-Z ` �� � ���� -1-tS� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q�,2
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �
Surface �•(�'
Manufacturer Demand Final Grade
Modei Number GPM C,3 Q'7.( r
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORM TION
DIMENSIONS W � ,Z�(` �2Y` 3�� #of Cells Type of System Distribution Media Manufacturer:
� Conv ❑ Aggregate ��
SETBACK OHWM of Nav e-►i►
INFORMATION P I L Bldg Well Waters � G ❑ Chamber Model Number:
❑ EZFIow
CELL TO �i- �lo � �-�' �S� _ _ ❑ Mound � Other Q�j 3 -- _---
DISTRIBUTION SYSTEM X Pressure Systems Only
Hea�der I Manifold Distgbution Pipe(s) — — - -P � X Hole Size Xp ole9 Observation Pipes J
Len th Dia Len th Dia S ac �_ S acin ❑Yes ❑ No
SOIL COVER
----- — _-- -- --
Depth Over Depth Over � Depth of Seeded I Sodded Mulched
Cell Center 1 Cell Edges Topsoil _____ _� 0 Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No �3 !� �jq��G _�
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Use other side for additional information Date POWTS inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AN� SKETCH
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