HomeMy WebLinkAbout028-742-17-3303-SAN-2022-155 Ty �
_ ��''"'"'��;;. Department of Safety c°"" �
� = & Professional Services, s``�"�' c� �
j � Sanitary Permit Number(to be filled in by Co.)
� ra , Industry Services Division
', _ (9 �� I 5 �� �
Sanitary Permit Application State Transaction Number 1
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fortn to the appropriaLe governmental unit �
is required prior to obtaining a sanitary permit.Note:Appiication forms for state-owned POWTS aze submitted to Project Address(if different than mailing addre
the Department of Safety and Professional Services.Personal information you provide may be used for secondary /' l'�
purposes in accordance with thz Privacy Law,s. 15.04(1 xm).Stats. � �3�k�� ���E I"1�n/'� ('��
I.Applicallon Information-Please Print All Information
Property Owner's Name Parcel#
���� -� ,�"1��+:.�5 �y) o2g-�u2_ l �_3 3 p
Property Owner's Mailing Address Property Location
2� � Z 5�.;h�- A �-l��� I� � a��.���-
CiTy,State Zip Code Phone Number �^/ f
� Y� 5�'/s, J' ' �/s, Section t �
!�l�����, �1��S /y�,!V S � y��
II.Type of Building(check all that apply) �t# T �' N R U ` E or
�or 2 Family Dwelling-Number ofBedrooms � Subdivision Name _-
Block#
❑Public/Commercial-Describe Use �_
❑City of
❑State Owned-Describe Use CSM Number ❑Village of t
as/s3 �Ob7 y Town of� r,^ �q,�o�
III.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.
`�' ew S stem ❑ Re lacement S stzm
y p y ❑ Other Modification to Existing System(explain) ❑ Additional Pretreahnant Unit(zxplain)
B' �iolding Tank ❑ In-Ground ❑ At-Grade � YP � P )
❑ Mound ❑ Individual Site Desi ❑Oiher T e ex lain
•�� (conventional)
C. ❑ Renewal Before ❑ Revision ❑ Change of Plwnber ❑ Transfer to New Owner
ist Previous Pertnit Number and Date Issued
Expiration �'
IV.DispersaUTreatment Area and Tsnk Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal rlrea Required(s� Dispersal Area Proposed(sf) System Elevation
1t'j('l �-- � � —
ri .�.�
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � V U '`� 4 N �
New Tanks Existing Tanks � ❑ � � � � � c�'c
a U �n ti v� 'w C7 P.
Septic or Holding Tank r�f` 2(�(j � W �s e�
U��
Dosing Chamber
V.Responsibility Statement- I,the under�gned,assmne responsiMlity for installation of t)te POWTS shown on the attached plans.
Plumber's Name(Print) - Plumber's Signature MP/h1PRS Number Business Phone Number
1� I�n 5��,�(4-2_ 151� IZ �l ��s� �s''s ���G
Plumber's A dress(Street,City,State,Zip Code) ,
�� 7� ��✓ S � � 1 ti � 5��� l �,� � : S y� -
VI.Coun /Department Use Only
D�A�rii✓ ❑Disapproved $ermit Fee Date Issued ^ Iss�g Agent.Signature , v �
Yoo��� �i�� I a�-- ��;�,�.,,�-� �--�---;�--
❑Owner Given Reason for Denial �'?� �
Conditions of Approval/Reasons for Disapproval �"� �� .. > � �`I��,_�i _-- � ;
.�... _ . . � I I� �� �. J�, a ���2 �--1
�?ate - ��� � � �
�! IN� �hk# � � � �o _ _:
� — ��
t�y ,,.� N� __�or�a �`�SSo ;:;��A,� Y�v�N�TR�T�oN
__._.�._- .�i�+ ,���•!E��s�;.�,
�s 1 /va�- (�e ,
Alisch tn comple plans for the system and submit to the County only on paper not less than 8 ll2 x 11 inches in size
NO REF'JNDS AFTER
SBD-6398(R.03/22) 13SUE OF PEAMIY
Sawyer County Zoning & Conservation Administration
������ 10610 Main Street, Suite 49
�� � 1� Hayward, Wisconsin 54843
' ��� (715)634 8288
� � �i� � _;I FAX (715)6i8 3277
/ . ��L.y � -; � u tb'\M1 t "U t i 1 U4 i 1
�i E m iil. �i�iz i� � _ _;i � u,� ,�, ;r,,
�� �� � Toll Free Courthouse/General Information 1 877-699-4110
� �� `� �: '.:
f� �\������
Holding Tank Approval Checklist
I. Sanitary Cover Sheet Date Stamp �� / �� / �2
Parcel I D# o 02 � - � `( � - l � - 3 3 0.�
II. Plot Plan
� Property Lines � Benchmark BM ♦
� Site Address �North Arrow
� Structure / Scale
� Well �� 25' to Service Road
� l Lega] 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 Agreement fonn
IV. Holding Tank Specifications
� Cross-section — Manufacture, Gallons: w''�3'e-t' a r��
�Tank Anchor Calculations [SPS 383.43 8) g)]
1CLocking device, chains/locks
�C Alarm and Electrical per NEC 300, SPS 316 & 383.43 (9) (e) and
State Statutes l Ol .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: �,L (Nlh(�1.�Sc�-, Plumber: '�. ��� ���
Application Review Date: �7�t 9'�o�-�
POWTS Reviewer: j���.,... 1�..��2%�
Namc
(�� S� t �
L���nso#
Revised 4/1 U2013
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet ��_ �i t���
�i C��, ,;�1. �r�
� ���;-_�ii!
V�;
Component Manual Design Refeiences: J�J� � 5 2OZZ i-
Holding Tank Version 2.1 (May 2022-2027) --
S i'L's1'ER�--•—�
Pg 1 of 4 Index&Cover Sheet zoNiNGa.rr�i�a�,.`-�r�:,,o�a
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&Site Map (if applicable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name/Description
OwnerName(s): �\���- �`tti���^So� Phone: - -
Owner Address: 2�/Z S,`.,F kn f4.„y �l�� Zip; ��S'/8
Project Address: J 3 3 ZG N `(�c�c,h�.� rd
Govt.Lot: 1/4 of 1l4,Section � � ,T ��Z N-R ��E Q or W�
Township: S�.`�c� (``�C� County: S a.,.y a�
Project Parcel ID#: m 2B �L/Z �� 3 3 0 3
Designer Information
Designer Name:Dylan Schultz Phone:�15 558 5904
Designer Address:�076N Stone Lake RD Z�p;54876
dylanschultzl8@gmail.com
E-mal�: This space rese�ed for appr�val 6Yam�.
License Number:1516129
Remarks:
Signature: Date: 7' + Z � 2�
On � ignatur ired on each submitted copy.
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CHECKBOXASAPRJC/�BLE. N�� TJ S�-C CHECKBOXASAPPLICABLE.
� SOIL EVALUATION � �YSTEM PAGE 2 OF �
SITE MAP o 40 � 80 LOT PLAN
PROJECT NAME: �o, oesicN F�ow�. �dU cao
Attach design flow calculations for commerdal plans.
Pa�,E�T„�a��:�� 3 3 Z 6 N fcic n r./ !� Pipe Material I ASTM Standarcl(Tables 384.303 8 384.30.5)
N Sanifary5ewer 5��� �
8M Symbd: � BM ElevaUon: ��� FT Fmce Main: �
8M Descnplan'.
51 Gradient % md�icate�ortnty IMPORTANT:
°Pa ( 1 Well Symnd(aappiifaole): � arew��q a�a�,o�. Show ground elevation contours at suifable intervals.
of T��ed A!¢a: on the aPproprife Il�re.
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Dylan Schultz
7076N Stone Lake Rd
� Stone Lake, WI 54876
MPRS 1516129
J
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PAGE30F4
HOLDING TANK SPECIFICATIONS
(No Scale)
yy��y��F 12"Min.or 2.0 ft above
Jundion and qPPro,� Established Flood Elevation
Alartn Box Vent Cap �TyP���)
Eledrical must comply with ( Appmved Lodcing Manhole
SPS 316 and NEC300 4'H Vent Pipe � with Waming Label Attached
Conduit >10 ft from (typical) 4"Min.or 2A ft above
Building Established Flood Elevation
(�YPicaq
Airtight Seal
� Finished Grade
18"Min.
(�YP��9 , '��: ' .. � ' .
y .
� � e. ' .
Inlet Inlet Invert Watertight
Appmved.binfs with Plug
Appmved Pipe 3 ft onfn � Maz. 12'or 90Yo of total volume
Solid Giourd ' if rtrore than one tank
d
• Alartn-0n
:
i
HOLDING TANK
VOLUME _ �ao gal ,
� . a . . � . � . . . .
3'Apprwed Bedding Matenal Beneath Tank
TANK MANUFACTURER: �"�` �S G�
Anchor tank as necessary
pursuant to SPS 383.43(6)(g)
Ballast Weight= ((cu.ft_tank.vol x 62.4 Ibs/cu.ft) - Ibs.tank.wt]x 1.5
Ballast Weight= [( cu.ft. x 62.4 Ibs/cu.ft)- Ibs] x 1.5 = Ibs
Rese�.
PAGE40F4
Holding Tank Management Plan
IMPORTANT:
The owner of this holding tank(s) shall be responsible for its perpetual operation and mairnenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this holding tank(s)
shall be considered a human health hazard 'rf not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shali be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
� �
Estimated Daily Wastewater Flow = 2 gpd
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., leaks, breaks, corrosion, etc.)
o neglect or improper use (i.e., exceeding design capacities, prohibited adivities, etc_)
o electrical components (r.e., wiring, connections, switches, controls, timers, alarms, etc.)
o surface discharge ot effluent or sewage back-up into structure served
SERVICING FREQUENCY
o The tank(s)shall be pumped by a cert'rfied septage servicing operator licensed under s. 281.48 Wisc. Stats.
when the wastewffier in the tank(s) reaches a level of one foot below the inlet invert of the tank(s).
Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
Tank pumping reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to:
Dylan Schultz 715-558-5904
Name of individual or company: Phone:
Sawyer county zoning 715-634-8288
Local government unit: Phone:
10610 Main Street Hayward wi 54843
Local government unit address: Z�P=
Any detective part of this system shail be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement oT failed or maifu�ctioning components shali comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used uniess approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Continaencv Plan
In the event that any failed component of this holding tank(s)cannot be repaired, it shall be replaced pursuant to a
plan submitted to the appropriate agecy for review and approval.
Svstem Abandonment
If use of this tank(s) is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
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HOLDING TANK SERViCING CONTRACf
;
Contract Date: / / lo1Z
. ThL� coatract ta made between the Holdin�Tank Owoer and the Pamper.
Holding Taok Owna's Name: Pumper's Name:
� ��'� rlhl'�►„S�n � �c�n 6qr �� S �ol"� ��P�'
�� Parcel Identification Number:
, c�2 ��t ��y ID� o�.g_�..��-�� 3 3 0 3
. l. The owner agi�ees to file a copy of this coatract with the govemmeatal unit, Saw}�er CountY,
� . which has accepted and record�with the Of�ce of the Register of Dads, the Mainteoana
�' Agreement for a Holdiag Tank required under the Sawyer County Private SewaB�SYstem
, #
Ordinsace for the issuance of a Sanitary Permit for the installation of a holding tank(s).
� 2. Ttu owner agrces to have d�e holding tank(s) serviced by the pumper and guarantecs to �
_ � petmit the ptanper to hav�access and m eaoer upon the property for the purpose of servicing y
the holding tank(s). The own<x agroes co maintain the all-weather access road or drive so �
_ _ that the pumper can service the hoiding tantds) with the pumpin8 oquiPment The owner
` fiuther agi+as to pay the pumper for charges incwnd in servicing the holding tenk(s) as �
mutuallY agrxd upon bY the owner and pumper. �
3. The pumper agreos w submit to the Governmental Unit, Sawyer County, a teport for t�e �
servicing of the holding tank(s) as required nnder SPS 383.55,Wisc�sin Administrarive �
Code and the Sawy�er Couaty Private Sewage Sysc�m Ordinance. The pu�nper fiuther
agras oo include the following in the report:
�
a. The name and sddress of the person responsible for servicing the holding tanl�
� b. The neme of the oaner of the holding tank;
a c. The site addrass of the holding tank;
' d. The date the hoiding tank wes servic,ed:
e, The vuiumes in gallona of the coments pumped from the holding tank for eac6 servicin�
� The disposal sites to which the conunts from the holding tank were delivered.
i 4. This egreement wi�� �main �n effect until the ownsr or pumpet terminates this contract In
the eveat of a change in this contract, the owner agrees w file a copy of any changes to this
• service contract or a copy of a new service contract with Sawyer Counry within ten (10)
business days from the date of change w this service contract.
� Owner's Name: (Print) Owner's Signatore: loah�o.e m►ner enre na� ,
I � ;
� vt (� l �`'�`��� � S�� �G%�--(/ .�/ �`�� f
, � _ .
i Pumper's Name: (Print) 's Si re: �
� �� � � ,�, �
Pumper's Registration Ntanber:
� 1 g � �7
Rev.03l2NI3
� � _ . �..: =. � .
.
I '��I:I'���IIII�:II�IIIIII�IiI�III
_. oc � , � a .
r�:ao��aio
440237 ,
PAULA CHISSER ,
-USE BLACK INK ONLY- REGISTER OF DEEDS �
SAWYER COUNTY, WI .
POWTS MAINTENANCE AGREEMENT 07/19/2022 10:44 AM �
For Holding Tanks RECORDING FEE 30.00 �
Owners Nama�s)as sM�m on oaee: PAG ES: 2
K �n RT R , MU✓�Fi hsov� un� �e/�nn �,, (3a�L vw '
Pa�l IEanYficatlqi Number n i
(12D�ptLepacy101 �Z D']��• � 7 . � � � � �
�epal Descnqbn a Pippa�ty:
•SEE ATTACNED SHEET- -
We�^o.�eEpe Mat applita�pn is pelnp mype fa Ihe installalion of a holOinp lank(s)on tlw
prapahy CasCliGBC on Ihe attacnM s�eaL .
<
Retum To:S�wyv Couny 2onlag enE ConwrvNlon AOminlatrsllon _
10610 Maln SL Sul10�9,Mayward,WI 5rl�7 y�
As an inducement ro the Counry ot Sawyer to iuue a sanitary permit lor a trolding tank on tM a�ove-tlescnbe0 properry,Ne owrrer is
rosponsible for Ne operation and maintenance of the holdi�lank,locking device,alarm antl access,and agrees W conform to all '
appticaDle tequiremanls of SPS 383,Wis.Adm.CaOe relaGng to twltling tank manapament,including Ne folbwing: �
i. The owner •
agrees ro contract witA a person who is licensed unOer Ch.NR 7 73,Wis.Adm.Code,except as provided by .
Sect:on 281.48(3)(d),SWts.,to have the hWelrg hnk propedy servlced and to fib a coDY of the service contract with the .�
govemmenWl und. TAe owner fuMer agraes to file a oopy of arry cheiges to ihe serrice conVacL or a copy of a naw service '
� . conUad,vnU Ma govemmeMal unft vrithin len(10)business days from the tlate of cAarge lo the service contrect.
2. The pwner aprees to contract with a person licensed under Ch.NR 113,Wis.Adn.Cafe,wha shall su0mit pumpirg reports W ���
tha govemmentel unil in eccoNance wilh SPS 383.55,W is.Adm.Code,Por the servicing of l�e Miding Unk. In the case of
examplion uMer Sectlon 281.d8(3)(C),Stats.,t�e owner sAall submit Ihe�eport to the gwemmental uniL The govemmental
unit may eMer upo�the property to investigate the contlition o1 the Miding tank when pumpirg reports may inOicate ihe
hoiding tank is ro�Deing pmpedy malntainea. '��
�
3. It the owner fails to have the holding Wnk Droperty serviced in respor�se to orders issued by ihe govemmenWl unit to prevenl �
or abate a human health Mzard as descnbed in Sectbn.254.59,SWIs.,the govemmental unit may enter upon tM property .
anE service,or ouse the tank lo Ce serviad. Pursuant to Sectbn 745.20(4)Wis.Stats.,a govemmentd unit may assess Iha
ovmar of a private uwage system for costs related to t�e pumping o1 a sepUc or hdding Unk.The dwrggs will De a5sessgd "v
as prescnbed by Seclion 66.0703,sWts. The owner agrees b pay ell cherges antl cost incurted by the govemmenql und for
inspecUon,pumping,haulirq,a otherwix servidng aM maintaiMng the holdirg tank in sucl�a manner as fn prevent or abata �
any human healU hazard caused Dy the hWCinp tank. �
4. This agreement xnll remam in eNecl o�y until Ue govammental unit responsibie tor the tegulatbn ol pnvale sflwage systems �
certifies that etthar a sdl absorplion system Ihal complies wllh SPS 383,W is.AOm.Cotle,or a municipa�Sewer 5ervc5�he
prt�perty.in addRion,Ihk agreement may ba ca�celled Oy eaecWng and recoNing said ceAificatbn wilh reference to�his
egreement m such manner which vnll pemwt tha ezistence ol the ceniflcetion to Ge deleiminetl by reterenca to the propery. a
5. Tnis aqreement snali be buWing upon the ovmer,lhe�eirs d tha owner,aM assignoes of U�e owner.The owner sAall suDmit . i
Ihe agreement lo the regisler ol deeds,and tM agreemenl shall be recorded by the register of deeCs m a manner whlU�wi11 �
. permit Ihe existence oi the egreemerrt lo be detertnined by re(erence Io tha property whare Ihe IwWing tank is insleAed.
i
' �On� oneoxrrnrd i •n m�M- ACKNOWIEDGMENT !
� � Owne ' ' �nature� Slateoi: �'y�/� AD{-n
� County ot !!w�q,-,�o n;,,� �
e�na7 e(Pr ntj:� � � Sub*bed and swom lo befora me on Mi�s �'
� . H/ �H $o nG ^_day ol .20�
I Date: �]_ (�_ � . By(Owner's Name): � nf
� � � Nolary Pubiic SignaWre: �
i Drafled by � r �G�✓�(� Public Nolary Name(Print): h '� �
��"�'1 � L My commisslon expires on:
j
� Persmal iMo�alan yw poNae may De useC Ior aecp�y7 Wryoses lPrv+�Y uw.4 15 0a(Il(mll Rav O7R6It 3
I
i �n.� n.
� NOTIIRY rU&BLIC-NIMIESOTA . 1
My CmNWon E�pM Jen.31.202� �'
Lot Three (3) of Certified Survey Map No. 6674 as recorded in Volume 25 of Surveys on Page 53, as
Document No. 316270, located in and being part of the Southwest Quarter of the Southwest Quarter (SW1/4-
SW1/4), Section Seventeen (17), Township Forty-two (42) North, Range Seven (7) West, Town of Spider
Lake, Sawyer County, Wisconsin.
7119122, 10:27 AM Real Property Listing Page
Real Estate Sawyer County Property Listing Property5tatus: Current
Today's Date: 7/19/2022 Created On: 2/6/2007 7:55:52 AM
� Description Updated: 5/15/2019 � Ownership Updated: 1/11/2022
Tax ID; 30643 KURT R MARTINSON MINNEAPOLIS MN
PIN: 57-028-2-42-07-17-3 03-000-000030 DEANN L BARLOW MINNEAPOLIS MN
Legacy PIN: 028742173303
Map ID: .113 Billing Address: Mailing Address:
Municipality: (028)TOWN OF SPIDER LAKE KURT R MARTINSON KURT R MARTINSON
STR: 517 T42N R07W 2812 SAINT ANTHONY BLVD 2812 SAINT ANTHONY BLVD
Description: PRT SWSW LOT 3 CSM 25/53 #6674 MINNEAPOLIS MN 55418 MINNEAPOLIS MN 55418
Recorded Atres: 10.435 m
Calalated Acres: 10.697 r Site Address * indicates Private Road
Lottery Claims: 0 13326N TELEMARK RD HAYWARD 54843
First Dollar: No
2oning: (F-1) Forestry One J property/lssessment Updated: 9/10/2013
ESN: . . __.. . ...__. _ . ..
2022 Assessment Detail
Code Acres Land Imp.
��� Tax Districts Updated: 2/6/2007 G1-RESIDENTIAL 4.000 30,000 0
1 � � � State of Wismnsin G6-PRODUCTNE FOREST 6.435 14,800 0
57 Sawyer County
028 Town of Splder Lake 2-Year Comparison 2021 2022 Change
572478 Hayward Community School District Land: 44,800 44,800 0.0%
001700 Technical College Improved: 0 0 0.0%
Total: 44,800 44,800 0.0°/a
• Recorded Documents Updated: 1/11/2022
WARRANTY DEED
Date Recorded: 12/17/2021 436583 �Property History
WARRANTY DEED N/A
Date Recorded: 6/6/2005 330870
CERTIFIED SURVEY MAP
Date Recorded: 10/14/2003 316270
https:/itas.sawyerwuntygov.orglsystem/frames.asp?uname=Eric+Wellauer 1l1
���"-''"r"�'�� PRIVATE ONSITE WASTE TREATMENT county
��� � �,�
;-�'
� �o$ , `�; SYSTEMS SaWyer
�����,� PS ;� ( POWTS)
\i�FF�-'�P`��i
� ��-�����'��' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �„� _ � S'�
Personal infonnation you provide may be used for secondary purposes[Privacy[aw,s. 15.04(1)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
��� ���sa� S �d� ��
insp BM Elev: BM Description: Parcel Tax No:
(�oo.� � � � �i.`� r,�� I,� o��-7Y2—�7- 336�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark /oo,o�
Dosing
Aeration Bldg. Sewer —
Holding �v�q�- pep St/Ht Inlet �i�07�
TANK SETBACK INFORMATION St/Ht Outlet �'b,j'
TANK TO P/L WELL BLDG vENrro ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dnsing NA installation
Contour
Aeration NA Header I Man.
Holding �� N�� N �✓ G-r,2.S 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/L Bldg Well Waters o GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ❑ Mound o Other
-- — ---- -- -- ---
DISTRIBUTION SYSTEM X Pressure Systems Only
-- --- - I
Header I Manifoltl Distribution Pipe(sj I X H lo e Size X Hole Observation Pipes
Len th Dia Len th Dia S ac � � Spacmg ❑Yes ❑ No �
9 -- -- - g -- — P— ' — --
SOIL COVER
- --- ---- — -- --
Depth Over Depth Over ' Depth of � Seeded/Sodded � Mulched
Cell Center Cell Edges I Topsoil_ ______ �Yes � No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?❑Yes❑ No �' '� '
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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 ANO SKETCH
SANITARY PEflMIT NIJM6ER�._��.- I$�__
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