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HomeMy WebLinkAbout004-838-02-3403-SAN-2022-154 ,�,'"�"`r;�, Indus[ry Services Division County � ':�" � ���,,`. 4822 Madison Yards Way �Y �✓ +C f� � {.s;� ti\�' ` J�� Madison,WI 53705 Sanitary Pertnit Number(to be filled"m by Co.) `,, � . P_O.Box 7162 �a,`=;,��". Madison,W I 53707-7162 �j 3<� � 5 1 � Sanitary Permit Application State Transaction N�mber � In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (n is requireci prior to obtaining a sanitary pertnit Note:Application forms for state-owned POWTS are submitted to Project Address(if diffetent than mailing addre< � the DeparUnent of Safety and Proftssionai Sen ices.Personai information you provide may be used for secondary —1— Purposes in accordance with the Privacy Law,s. 15.04(1 xm),Stats. /z �D / � �_//„�f-�� � • I.Application Iaformation-Please Priat All Iafor�natioA rr�- Property Owner's Name Parcel# � v- Raberrf �a v�,'e 1 S Ooyg'-,�8a�.3 �D 3 Property Owner's Mailmg Address property Locaqo� 3�f� 3 G��,� �le¢ �o � s �_�- City,State Zip Code Phone Number s E' S V✓ /1/Q e/(�G► �1 �✓� �� �J � 1�'/.,_ �� '/.,, Section � Z II.Type of Bailding(c�eck all t�st apply) Lot# T � R 4 � E o w �1 or 2 Family Dwelling-Number ofBedroans � — Subdivision Name Block# � ❑Public/Commercial—Describe Use _ �Ciry of ❑State Owned—Descn�be Use CSM Number ❑Village of — �$[Town of �o v a��P�a s/ III.Type of POWTS Permit:(C�cek eiticr"New"or"ReplacemenY'aHd other app6cable on line A C�eck one box o0 6ne B.Complete line C i a licable. A' ❑ New S stem �R lacemeai S stem ❑ Otl�er Modificarion to F�cnrtin S stem ex lam Y eP Y g y ( p ) ❑Additional Pretreatrnent Unit(explain) B' Holdmg Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Desi n g ❑Other Type(explain) (conv�tional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ���V1°�P��HOi�'��d Expiration �n�` rf i IV.Dispersal/1'reatmeat Area and Tank Iaformxtioa: Design Flow(gpd) Design Soil Application RHte(gpdts� D'upersal Area Required(s� Dispersal Area Prr�posed(s� System Elevation ��� Capacity in Total #of Manufacturcr Tank Infortnation Gallons Gallons Un»s � � o v � New Tanks F�cisting Tanks c� � U � y v� F o °= � e,�j p m cc5 o- U �n m ri� w C7 a Septic or Holding Ta� ?� m � �K / L[� C,� �C ` _ '7 �r x Dosing Ch�nba V.Respoosibility Statemcot- [,t6c aotlersigeed,ass�me respoesib�lity for iestatlatioa of tre POWTS s n oa t�e attaehtd pisns. Plumber's Name(Print) Plumber's S{�o re MP PRS Number Business Phone Number r»;�t,�. mc n� r,n�,c� ���!�,� y� v�d2 s�� 9 7�s-.�GG�3a4�o Plumber's Address(Street,City,S�te,Zip Code) �13 Yo n1 �.�-/LC- W:vt�,2v l�� �L7�✓l��✓' I�.� .S y S�lo VI.Coun /Department Use Onty /� � ❑Disapproved ��Fce Date Issued Issuing Agent Signature K��/ ❑Owner Given Reason for Denial s l�-� � I��+��' �t��l�'�/✓�,v� Conditions of ApprovallReasons for Disa�rova] o f1 ,��� ^"--,^�---��---� � . �"- _._. _. C�-� �__�" JUL � 4 �II2 � ��� _�_.____ � , � � `�i. ��� � . �---- __. ��' •.J. 1 �� a .. ZJi�,�f'JG ADMf�'�157��A7`ION Attach ta compkte pians for t�e syst�aed sabmk to the Caunty oaly on�aper not Iets tkaa 8 t2:I1 iacLes in sae NO REFJNnS AFTEFi 13SUE OF PERM17 Sawyer County Zoning & Conservation Administration ��������� 10610 Main Street,Suite 49 � - �, � Hayward,Wisconsin 54843 � �� (715)634-8288 � i. � � FAX(715)638 3277 � � w � - � �� r� ti,��,� - o:,, � `°�'r� i E m i�l �qn 1 �c�z.c i�, ��ip m t�i���� � � Toll Free Courthouse/Gencral Informatron 1-877-699-4110 ,, :�~}�; ,,��\\����`� Aolding Tank Approval Checklist I. Sanitary Cover Sheet Date Stamp o7 /�/ 'Z2 Parcel ID# �j D�- � 3 g_- O � - 3 �{ O� II. Plot Plan �( Property Lines �Benchmark BM ♦ � Site Address �North Arrow X Structure � Scale �Well �<25' to Service Road �Legal Description �Nearest Road Intersection �Setbacks to: Property Line, Well, Structure, Water bodies, Roads III. Required Plans �Index Page with Original Signature Management Plan/Contingency Plan �Servicing Contract �Holding Tank Agreeinent fonn N. Holding Tank Specifications � Cross-section—Manufacture, Gallons: �'{.. ��c, �r��y,��, �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,l�SBD-10855-P (R.3/07),, , �,1 Owner: �qv�iQ-`� Pluinber: �o��j Application Review Date: 7�(��e�-� POWTS Reviewer: ��,1/�j��� N��n� 6�5�((0 ����ns�# Revised 4/ll/2013 PAGE 1 OF 4 Holding Tank Plan Index � Cover Sheet Component Manua!Design References: Version l�Q,SBD-108.55-P(N.03/07;R 01/12) ., . a.� Pg 1 of 4 Index&Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report 8�Site Map(if applicable) Holdin Tank Pum in Contract if a licable} Holdin Tank A reement if a licable Project Name/Description Owner Narne(s): �rvt�r q � pQ�b or t- �a+�.:el 5 Phone• OwnerAddress: 3NG 3 �'rr-a�•� Moqc%KJS '�6A�,�Zp; SyjS/o Project Address: �Z 70� �.J i4-�-l�e��o,tJ Qc�• Cv�dP•-ay �JZ Govt.Lot: �1/4 of 5�-114,Section D Z •T 3� N-R O S E Q or W Q Township: CO J ct'P✓'Q J Couniy: sa ��'�� Project ParcellD�: o o N 8 3�o Z 3'/D 3 Designer Information Designer Name: M�ICrz Mo�+'e/kaYy pho�: Z r5 _a�G _ 3 o�/d DesignerAddness: N3yv N �-�+�- wJw�'� /� W,'�'�� �p- Sf'8t'/o E-I►181I: This space reserved for appro�.�l stamp. License Number. N)j0 2.2 S��a 9 Remarks: Signature• �s��� �i%/��� Date: �-�Z-zZ ��� �M�a���. �1 c ir sc �l� s o z PInJ � ooy83goz3Yo3 Le�ql D�S�. �-38N 2a $ W Sc.al� I ��- y� ' PLOT PLAN PAGE a OF � �� owue�r s o Yo �omGr4 � Rdbo.^�{- l�arie �$ 3Y4? Grand rneq,�ow5 Ncena� ti t,vr S y gsG � — laW y a 7��0 � Q�� - - P� � � —� 3. � ��� /` 1 p��{ 5 �,o � r Ex�S.►r�� � u���� s 3 Q R- a�� r►o�s.� g ic � �;�. � �y7riJ{- ( � Q� � �z�o� � — — fE�'h�✓f'o.. R � — , / v �gM = i00 . o �t�M� r -Fo P ��F 'p«�� i IL� Mor�oA�"� A7e✓�4t1�Q5�- Qir.N2v 34nN LM[C l.riG4t" A�, � a�i PSpS Sa -1-ba�5 Mef i✓rNre� t.�� SW 6Ylo � ►a.-�. �Mpe,..�a` ✓haNv�. ✓ 2 PACE 3 OF 4 �����.7 ��� a�Q��i����i�1����.�] - ��� Sc�1e} � � � _ - --��,� . � � ���� - �� ��� '� ���� Q`�or2.#3�� _ � ,� �E�aott� _ t� ' �S't,�t - 18�i�t. ` �� �- � tia ,. _ � a � �` $ ' � �=� ' _ 61Tet �� - ��� ��lpe8�a� ' iRait�'1'ar9@96d1oe�roh�e - �°8 �dt�aund a �ano�e��e�ic P � t j _ ��7 gi'S*61 _ . Y�..�= 34 d O � , . - ' d = ' v - � ' - . ' ' ' a � ��d��B�Tadc T�C�1F�GT�IRE� �t"t C',a, � `�-r�•�� _ • �'�c as�y P��S'PS�.� ��=K�v�x 62.��}_�S.�C.y�x f.5 �'�_� �-G.�_�.X�.��,- 3 so �x�.�=. a..?,s��,� � . PAGE 4�4 Holding Tank Management Plan . n�oRraNr. . rne owner or nrs nol���rrq�sl�ha r�ror as pe�ml aaer�im a�a maile�,e,o,A,�,a,d� �Ii���aonsideied�a humn t�eaMli lmad R ma4fained b ao�w�l y7��ppmr6d(�g1f�¢p1�.�S� F�t�one,at 6�tlon ard rtm6�r�e��he pedortned bya�ed PaY11�S 1laif�6► eccordenoe wilh SPS 383.J2(9J,Wis�Admir�Cbde Estlm�edDs�Y]AF�blra�rrFI01I= 30 O __� ' . - �d Chscklist � flJSPECT EVERY 3 YEA[t3 o type d u0e c a0e a?s]rs�n - ' o rn�fs[�ors(La odq�,�r�r oompl�,�� � o ma�l tal'Sue(�e..�eel�.lxeals.carosion.��•etG) o neglad ar unpoper use(le..emea�g d��.P�d�.ete). o e�rtcai canpo�(Le..�;canac�a�s.�.oortds.5me►s,�eE�) ' c• s�rface�seharga d e�ar sarege back-+p 6�o stnx�re� - - . . �ERV1�16�R�l�tiCY ' . . o Tde lank(s)stml be pmpad by a�tad sepraee��8 ope�6censad under s 28'I.48 Nre��als. ' wiw�tlrwasbwabrin9»tad�sjn�fissaisYetofai�loot6Nowfl�sLd�Ehwta#6�ebudqs} . Di�sel oFooeMsnls a1m1 De puaient b t82113.1Ms�A�.Code_ Tank pmnpiny n�wRs sh�L As su�oNEsd!0 9�s Props�focd 9waennrM tspt M aZewd�wRh SP83E�.35 Mlfic Ad�dn.Cods. RN+��Y��wd falhee oT temlFuuUon to: MameaF6�vid�orcampaiy;M�hAOflf�Dff1@Ty/ p�7�Jr-2�-3�40 - ►�ea�ert����Zonin9 �715-634-8288 ��„�„�,�,�10610 Main Strtreet Suite 49,Hayward,WI �,54gq3 a�y a��c�a��y�,�es r�.�,or�a�m sPs�s,h�,w�ar�. coae.R�ir or re�o�n!dfa�ea or���aB�r wRh sPs 3�i,WsC Ad�.� No Prod�xxior d�or PhYsk�i resfo�afion dH�e POVV18 me�r be us�imtess app�wed by�s�� aa�ndence with SPS 364.11Vfise/►drNa Qode. Con�v pl�t _ � � m�n.ev■ra u�et eryte�ea��t c��s►�m mdds)e..ne ea re�a,�atmn ee�apacea p.swnt�a pi�subnimd to ua appropieds egs��r{a rerisw ard aE,po,ral, Svstarn Ahsru�nn�nt It uss of dis tar�k(a)ie�ontl�i�sF�el he abendaned in eceortlence r�SP3 383.33,VVfsc AdrNr�C.otfe. HOLDING TANK SERVICING CONTRACT ContraclDatc: �//2 / 2Z This contract is madc bctwccn thc Holding Tank Owncr and thc Pumper. Holding Tank Owner's Name: _ p Pumper's Namc: �nM�+-0. � P.Dy4"�' �4N'�.lS NorthwestSanitary, lnc. PO BOX 155 Radisson,WI54867 Parcel Identification Number: (12 Digit Legacy ID) O O t/ _ 8 � g' _ D 2 _ 3 y O 3 I. Thc owncr agrccs to filc a copy of this contract with thc govcmmcntal unit, Sawycr County, which has acccptcd and recordcd with thc OCficc of thc Rcgistcr of Dccds,thc Maintcnancc Agreement for a Holding Tank required under the Sawyer County Private Sewage System Ordinance for the issuance of a Sanitary Permit for the installation of a holding tank(s). 2. Thc owncr agrccs to havc thc holding tank(s)scrviccd by thc pumper and guarantecs to pennit the pumper to have acecss and to en[er upoi� the property for thc purpose of sercicing thc holding tank(s). Thc owncr a�,�ces to maintain thc all-wcathcr acccss road or drivc so that thc pumper can scrvicc thc holding tank(s) with thc pumping cquipment. Thc owncr furthcr a�Tccs lo pay thc pumper for a chargcs incurrcd in scrvicing thc holding lank(s) as mu�ually agreed upon by the owner and pumper. 3. Thc pumper abTccs to submit to thc Govcmmcntal Unit, Sawycr County, a rcport for thc scrvicing of thc holding tank(s) as rcquircd undcr SPS 353.55,W'isconsin Administrativc Code and the Sawyer County Private Sewage System Ordinance. The pumper further agrces to include the follow�ng in the report: a. The name and address of[he 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 datc thc holding tank was serviced; c. Thc volumes in gnllons of the contenls pumped from Ihe holding tank for each scrvicing; £ The disposal sitcs to which the contents from the holding tank were delivered. 4. This agrccmcnt will rcmain in cffcct until thc owncr or pumper tcrminatcs this contract. In thc cvcnt of a changc in this contract, lhc owncr agrccs to filc a copy of any changcs to this servicc contract or a copy of a new scrvicc coulract with Sawycr County within ten (10) busincss days from thc datc of changc to this scrvicc contract. Owner's Name: (Pnnt) Owt7C��5 SIf�R18lUlC: (Onh nneawnerNgna�urerequl�eJ) ��`�'��O1�a► �N ��.� Pumper's Namc: (Print) Pumper's Signaturc: � Ronald L Vieceli, owner Northwest Sanitary.inc ' % �v. �-�i� L �u-� , Pumper's Rcgistration Numbcr: #2389 Rcv.03/2G'I 3 ,- - - ______ - �S� �.� �� a��.Y — II I II I I II I II I I I I �II II I�I I�) i POWTS MAiNTENpNCE AGREEMENT —� � �� � � ' ' � For Hotding Tanks } Tx :d039�71 � � 440208 �+erst�ame�)���,�,�: - --- - PAULA CHISSER � �R M ev-a� �` ��,�Q,.-� ('q,��� � REGIS7ER O� DEEDS _ � SAWYER COUNrY, WI 07/18/2022 11:Q5 AM �����r RECORDING FEE 3Q.00 � t,2�,-�,,03 Q o �_ S3 S_ o .2 _�� � � � PAGES: 2 ��Des�iption of Ptoperty: -S�E ATi A�HEfl SHEiET- We����s�Ing rtiade fior fhe�n of a twtd�g t�dC(S)a�t�e , P�Y d�on�e ad�d�ed st�eet R�um Fo:SaMryer Ca�Y 2�p��on, PO 60X 6T6, HaYwa�d.W!54843 ' As an induc�mer�#to the County of Sawyer to issue a sartitary Perm�t�or a hddirg t�c fln the abov�d� respons�bte fior the operagon�d R��� � prop�y. the ovmer is aPP�te r�eq�vf Ch. Comm 83.V1fis. Adrt� Code � ��� �n and axess, and �qrees to co�oRn to ali ���9 �n�nent. indud'mg the foflowing: 1. The o►Mner agr�ees bo c�bact widh a person wtw is fioe��Ch. NR 113,V1fis. A�n. C:ode, except as Rrovided by Sec�On 281_48 C3) (d}, Stats.,t�irave the hoid'ai9laMc ProP�Y�viced and to fi�a c�py of the servic�contract wit#t the 9rn►e�une�i u�it The owner fiut�ag�ees to fde a c�py of anY d�es io the senrice aa�frac�, or a t�py of a new seni� �act, wiih the 9o�►emme�fa! tmit v�t� (1 Q} bt� days from tlze d�e of c�ange to the servioe cartra�cf. 2 The awner ag�ees to oonbad wifh a pe�son icens�d tmder Ch NR 113.Wis.Adm. Codc, who shaq s�mit P�P�L9 �ports to - the 9avemrr�ent�����h Ct►. Comm 83.55. Vlf�. Adm. Code. for�e serv�g of the Fro�'ing f�tk. la tFte ca� ��1�+ ur�Sec�on 281-48 (3) (�, Stats.. the owner sha� submit fhe reQort to the govemrt�ntal unit. The ��r���. ��� P�P�h�� �e the �on of the hol�g t�Ec whea purnPa�9 �E�s r�Y �9 P�p�y maintained. 3. if the owner fails to have the hotdng�Ic pcoperlY setviced � � or abafie a hturian t� hazard as de� in Section. 254_59. Stats., the go�rert�n�� �mer�tai un�to prevent and service, or puse the fanlc to be servic�d. Pursuant to Se�ion 145 �������� � onnrner af a privafie saw�qe sysfem�ior c�ts r�lated to the ���' �-, a 9°�menta! unit may assess the as Prescn�ed by Sedion 66.0703, stats. 'Fhe owner �� �a �P�°r hold'ing tank. The d�arges wdl be as�essed �P�°n, p�nping, ha�mg. or ot�wise servicing a�� PaY�diar�s and cost p�cumed by the 9avemmerrtal unit for anY human health hazard c�used by the hot�ng tank R� ��taNc� � a maruzer as to prevent or abate 4. This agre�r�t w� �ernain in et�ec#asly unhi tt� 9ovemmentat �it respor�,sible for the regWatmn of private ��a¢�' �b��'or� sYs�err� thaF comp�es ra�h Ch_ Cotnm 83, V1fis_A�n. Code, or a mu s�ewe se�s �J�f�}r be c.�x�ed by ex�ir�9 � reco�ding said c�rtificatiari wifh refer+erx:e to this a9reement im such manner which va� p�the existe�ce afthe�n ta be c�terma�d by reference to the property. 5. This agte2ment shail be bind�g up� � a��r, �e �� �� ��,, � a�9nees of the ovmer. The owner�{ subtrot Permit tl�e existe�the a of deeds, and the agreem�#shaR be recoNed by the register of deeds in a ma�which will 9���t to be determined by referer�ce to the property whene fhe holdrng tantc is instalted. Owner's Signature� �� ACKNOWi.EDGEMENT State Of: ,�,� � Owne�s Na r County ofi s ,y�t,y G� � �•o�-P! -�- ��,� � e ( S Subscnbed and swom to before me on this Date: 7 r day of 2Q� z.1- % O ") ..�U�Z ,`,`��NN� u�u�,i � ��� 5Y � .•• � K1N� Publ'� Signahxe: t�- �y�p � � �� � . ' � j���4vi�•• '�y'�'• �' ' ublic Name: ,��i)i1�_e��� C�S � //V()� �� • �. ; AR 1l�� `�ission expires om. _ G � -� - �G�3 � � ' � r�o , �.� ---__ . : : ��� . ? , Pe�saFai a�fa,natio„ ; •, p :• � rwi Provide may be used fa�seoo�y P����+ ��`�5.04(n(m)l ., >`� •....•••''��, r� �;, .�,� ,, � Part of the Southeast Quarter of the Southwest Quarter (SEl/4 SW 1/4), Section Two (2), Township Thirty-eight (38) North, Range Eight (8) West, lying North of S T H. "27" (Parcel No 004-838-02-3403) }'. , '._� i�i11i� H.F' - � + -y . 'c : �.:r i ;. �ltf f�,�, `_,. ; � .� �.p.. }.�iGE E � �iNYr� �� ::: !.'� , � ��' ! � �k�. �,�t, /k; ( � , ��, ,;:� �� , ,� ���� �;: � � ,�� , ��� ,�r1�=�,��� at�;;�J���,, ; �; a �7r�� , � `I� � � 9 . %j t �}r ie � . � -.��3 . �''��yl '��{ Y�3�•' �� ���� ,��t '���j}t�' yft�'r1',S: � _,;.` i r! � �J. °�a;� � k" . 1' jI, / _r' �l [ � ��f .�,s�� ��"i 1f , ` ,�$ �, u�.� i��.. 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Desaipdor� Updabed: 6J1/2017 O�P Upd�ed: 2/25/2014 Tax ID: 4488 TAMERA 8� ROBERT DANIELS NEENAH WI PIN; 57-004-2-38-08-02-3 04-000-000030 Legacy PIN: U04838023403 1� lir�g Add�ess: M�lina Address: Map ID; .12.3 TAMERA 8� ROBERT DANIEIS TAMERA 8E ROBERT DANIELS Mu�idp�tY: (004) TOWN OF COUDERAY 3463 GRAND MEADOWS 3453 GRAMD MEADOWS STR: S02 T38N ROSW NEENAN 1NI 54956 NffNAH WI 54956 Desaiption: PRT 5ESlA/ , Reo�rded Acres: 3.$5Q ,�',�be A�ddr� * irldicates Private Road Lottery Claims: 0 12701W ATH�TON RD COUDERAY 54828 Ftrst Doilar: Yes zoniny: (a-1) A�tua! or�e �: 4� pro�xiy As�ne� Updafied: 8/14/2013 2022�rt De� ; Tax Distrids t)pd�: Zj6J20Q7 Code /lcres i�d Imp. 61-RESIDENTIAL 1.00U 5,000 27,2� 1 _ �� �w�� G6-PROOl1CiIYE FOREST 2.850 3,4� 0 57 SawY���Y �4 Town of Couderay 2-Year Canparison 2021 2022 C.hange 576615 Winter Sd�ool District �; g�4pp g,400 0.0% OQ170Q Techrrical Coliege ���; 27,200 27,200 0.0°rb . Total: 35,b00 35,600 0.096 Reaotded Doclanents Updatied: 2/6/2014 � WARRANTY DEED Qate Recarded: 5/2/2005 �_�.t � �,�-� NJA https:JJiassawyercountygov.org/Access/REAL%20ESTATEpisting.asp?tid=875626&pid=4488&tyr=2021 Page 1 of 1 �-� � ""'��� PRIVATE ONSITE WASTE TREATMENT county `�'�o ��'� SYSTEMS $P ( POWTS) Sawyer ,;;,� s ,.�.� ��k F,`—:�.�'%. �'"���v��„ INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION '�� _ (SY Personal infonnation you provide may be used for sccondary purposes[Privacy Law,s. I S_04(1)(in)] Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#: �ct�a 2� � K.�>2Qs�' �cw C�ls � �.� , ._- 0 Insp BM Elev: BM Description: Parcel Tax No: loa.a' �p b� � n�- 1t A oo�( - B 3$ -o� - 3 Yo3 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic 3 pu�p Benchmark p�� � Dosing Aeration Bldg. Sewer qS.6S� Holding St/Ht Inlet qs:y � TANK SETBACK INFORMATION St I Ht Outlet q�. l6 ' TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet AIR WTAKE Septic �{�� �-�� ' -t'$ NA Dt Bottom Dosing NA Installation 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 � #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters a GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other DISTRIBUTION SYSTEM X Pressure Systems Only Hea�der/Manifold Distgbution Pipe(s) -- p — ! X Hol le Size _ XP oleg Observation Pipes i Len th Dia Len th Dia S ac S acin ❑ Yes ❑ No _� SOIL COVER _ - - -- — - Depth Over Depth Over � Depth of f Seeded I Sodded � Mulched Cell Center Cell Edges Topsoil � ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Inciude code discrepancies, persons present, etc.) � ����oQ �1 �23� 2� � �� r--�—T—, ;___ --� Plan revision required?�Yes ❑ No � �' —y�^- � n z ___� 6��1 � 3 � I_— -- Use other sitle for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITI�NAL C�MMENTS AN� SKETCH SANITARY PEAMIT NUMBER___ ��-�IS'� _ �\ \ �o� � S�P� �ck \ � ,��r �o--{ "l� ��� � 36�r, �g� 'R" .g�,,. a' �� N���� Qo«�/1 3�000 � � y7 3 � �� � �1�a'"'' � o �" �� � � �— ��fa�-