HomeMy WebLinkAbout032-540-30-3112-SAN-2022-157 �
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SAWYER COUNTY ZONING & CONSERVATION ADMINISTRATION �,�
10610 Main Street, Suite 49 4.J
Hayward, Wisconsin 54843 ^
(715) 634-8288 �
sanitarian(a�sawycrcountv�ov.org �
COUNTY SANITARY PERMIT APPLICATION
In accord with Chaptcr DSPS 383, Wis. Adm. C'odc and
Sawyer County Private Sewage System Ordinance
APPLICATtON iNFORMATION—TYPE OR PRINT
Property Owner's Name Property Legal Description
`��� ��e�1� GL '/� '/<, Sec. �,Twp.`�� N,Range .� W
Property Owner's Mailing Address Lot Number Block Number
\3��? ��.,.�S.�`�� �� c�
City.State 7.ip Code Phonc Number Subdivision Namc or CSM Number
�\� kx�Z �� �H�`�3 � � �:� SS
TYPE OF BUILDII�`G: (Chcck onc) ❑ State Owncd ❑��ty voa�csi Road y������ ��
❑ Pubiic �l or 2 Family Dwelling—No.ofbedrooms� �vi��asc
'�Town of �" �� Firc Numbcr��.��
��
PURLIC BUiLDING/LAND USE: [Explain the use/purpuse for this Parcel Tax Number: (I 2 digit legacy number)
permit,(i.e.,campground,fes[i��al,recrea[iou/en[ertainnient event e[c.)] � 3 � L� � ,� � _ _� � �
- - �- - - - — � —
TYPE OF PERMiT: Additional Information:
�f POWTS Reconnection(SAN#O�-a`�1a) 1�;�(:
❑ POWTS Connection (SAN#_- ) *Attach a Plot Plan with all required information per SPS 383.21
❑POWTS Revision(SAN# - )
❑ POWTS Rcpair(SAN#_ ) *Soil Test Information (CST#��,� )
❑ Other:
* Gallons per day �v�
RESPONSIBiL�TY STATEMENT:
I,the undersigned,assume responsibility for the installation of d�e POWTS activity for which this permit is issued.
Plw e�'s Name:(Print) P e' Si�na �4P/MPRSW No: Rusiness Phone Number:
��2r � ' Zuc��� (7i5 )(v3�/ - YoJ�v
Ph�mber's Address(Street,Ciry State,"Lip Co
14�i5c� ;�.�� 77 ��- ����d C�; Sy�r3
OFFICE USE ONLY:
❑Uisapproved Review Date: Permi[Fec: Dat Issued: Issuing AFen[Signature
�A� roved ❑Owner Given Reason for � `7i)/� '
4 P Denial 7 p�+b l�C��J 7 � �c�- �� �-
COMMENTS:
**Expires 2 years from datc of issue** Expiration date: �1 I� J �� ��`�
CONDiTiONS(3F�ArRPROVAL/REASONS FOR DiSAPPROVAL: �--.,;��.�_ „—,.�,�r,
i : � ;� ;,. ; ,:;r�. l� ;( //�'' .�
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� �n k# a� �"� � � J U L 2 0 2022
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;�Cpt � , .
Rev.04/21/15 ZONItVG A(aMINiST�iATION
NQ REFJNDS AFTER
ISSUE OF PEfiMIT
3�3��
Safery and Buildings Division Counry
` 201 W.R'ashing�on Avc.,P.O.Boz 7162 ,S({,ft i y�� �
isconsln M1fadison,Wl 53707-7162 $ItcAddress 11��, w
Department of Commerce CST Not Required p ��.�./, q�r�.
�\�c�
Sanitary Permit Application S"��ry p�^"°hw"bc�
In�ccord with Comm 8}.21,Wis.Adm.Cade,persoml infortnaoon you provide 428510
m� be uud for secoM us Privac I�w,s15. 1 fm ❑Chcct J Revision
I. ppplicatioo InformaHon-Plcase Print NI Information �
Sum Pl�n I.D.Number
Properry Owrcr's Namc ' •�� .
�� � Partei Number
�t` F'^'��- S� �'" r ehc�' c��li 032-540-30-3107
Propeny� wrcr's MaAing Addrtss Pwperry Loadon
w -,�<<0 30-40-5
a s�u ^1 8 SS �'./2o n�l � u, c�-.:s }n T�p _ u,
ry• 2ip Code Phonc Numbcr Lot Number N.R� C
Hlak Yumy�r
Lot 15
r pn Subdivision[:�mc CSM Number
SUSSC'y� ,E��/ �jC�p / CSM Volll Pg 127
ll.Type of Building(cAcck all that apply)
�1 or 2 Famil Dwell. � �Ciry
Y ing'h'umber of Bcdrooms
�Villoge
�Public/Commcrcial-Dettribe Use
❑Snk Owocd °w�ti0 / �A �y
M1c rtst Ro/�d (
�."A�ILO '(� � i�v/�
lII.Type of Permir. (Check only one bos on 1{ne p(numbering scheme for internai usc). Compiete line B if applinble)
�� 1 O New 2�Replocement System 3�Rcplaumcnt of 6�Addiuon Io For Counly use
5 slem TaWc ON Existin S s�em
�• ❑Chcck i(Saninry Pcrtnit previously Issucd Penui�Number D�¢Issucd
IV.Type of Permit (Check a0 that npply)(numbering scheme Ls for intcrnal use)
44 O Non-Pmssurized ImGmuod 2iOttt���...Mo�m s�0 s,m r•�i�« So 0 co��N<«a w�a,,,c
22�PressurizeE In-Ground 6I�y Holcfing TaNc 48�Singie Pus 51 L7 Drip Line
t
45�Ao-Grade 66�Aerobic Treavnent Unit 49�Rctirculatlng 30�Oiher
V.Dis ersaVT'rntmmt Area Informatlon:
Design Flow(gpd) Dispersal Area Dispersal An� SoJ Applinuon Pcrcolation Ram Sysmm Ekvauon Final Gnde
� Required Proposcd Rate(Galf./Days/Sq.F�.) nfin.nn�n) Eievanon
v�
- ; ti, n �1R �-- � _ —
V.Ta nfo Gpaciry in Tonl Numbcr Manuhctumr Prct�b Sim Sled Fiber PI15tit
Gillom Gillons otTanks Corcrae Comwcmd Ghss
NcW Esistir.�
T�nk.� Ta��
Seqie or Holdin�Tank ,
r7t` / �l
Oosin�Cnunp�r
VII.RGS oRsibilit Statement-I,ILe undeni�ed,usume roponsibflity for Inslallation af the POWTS showo 0o t6e almch<d plans.
Plumber's Name(P' ) Plu r'f Signature MPlMPRS Number Business P6onc Number
Q d �,Cn� Se�l� � � / /�, °� �:YL(L/���u'�(
Piumber's Address(Svicec,C ry,Snm,Zip Code) m
(.S!' ` �0�,'1'�S nJ \�� ����Z�TCY ��.� .�� � �
VIII.Count/Dc artment Use nl
yg�pproved ❑Disapprovcd Saninry Pertnii F<e(includes Groundwater Da¢Issued Issuin geoi S mtu�1 Su pA
Sureharge F<e) I
�j ❑oW��c����wd.ine�«x $190.00 8/8/0
Dc¢rmi�uon
IX.Conditions of ApprovaUReuons for Disapproval "
Auach tomplvle plw�to 16e Couory ool))/ar Iht n�l�m oo papir mt Iw Ihanll/:a 11 I�uhn In slxe
SBD-6398(R.05101)
PRIVATE ONSITE WASTE TREATMENT SYSTEMS counry
`�sconsin ( POWTS)
oepertment ot commerce INSPECTION REPORT �C e�- �
5atery ano Buiwines Dmnsron (ATTACH TO PERMI'n SaniWry Pe It No:
GENERAL INFORMATION V 3 _2� 2
Personal infmmaGon ou iovide mo be used for seconda u es privac Ww,s.I S.Oi Ij(m
Permit Holdefs Name: p City ❑Yllage �QTown of: State Plan Transactlon IDp:
�`�1 Wl5'�'Cr L.Uiti Tt� Sa f SH D
CST BM Etev: Insp BM Elev. BM Desaiplton: Parcel Tax No:
100 ba� .l�t�J S,c�,i1 032-S�f0-3b-31o7
TANK INFORMATION ELEVATION DATA
NPE MANUFACTURER CAPACIN STATION BS HI FS ELEV
Septic Benchmark I O O
Dosing
Aeration Bldg.Sewer
Holding � t� pp O St t In t q'j'
TANKSETBACK INFORMATION StIHtOuuet --
TANK TO P!L WELL BLDG ��°,� ROAD Dt Inlet
SePi� NA Dt Botlom
Dosing Np InsWllation
Contour
Aeration NA HeaderlMan.
Holding �.5p }2S �F2.p {.7-O �-O ' Dist Pipe
PUMP!SIPHON INFORMATION Infiltrative
Surface
Manut�lurer Demand Rnal Grade
Model Number GPM
Lift Fricfion Lass System Head TDH
Forcemtin Len Dia Disl.Ta Well
DISPERSAL CELL INFORMATION
DIMENS{ONS W L NootCe� TypeofSystem Manufadurer.
SETBACK oHwM o�Nav �CHING
INFORNWTION P�� Bldg Weo Wa� CHAMBER
�-[, Model Number.
CELL TO
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Dislribu6on Pipe(s) X Hole Size X Hole Observa6on Pipes
Length_ Dia_ Lengih_ Dia_ Spac_ Spadng 0 Yes ❑No
SOIL COVER
�P�� DepM�Over Depth of Seeded f Sodded Mulched
Cell Center Cell Ed es To sail O Yes ❑No O Yes ❑No
wnnMENTS: (Indude code discrepancies,persons present,etc.)
Plan revfsion requiredlO Yes y,No �'j (Z��� Y�� �__ (� . 2 Z 4 � � S
� � � �,���y`
Use other side iw ad�tional in(ormadon Date POWfS Inspector's Signafure Cert No
Bureau of Field Operallons,PO Box 7302,Madlson,WI 53701-7302
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER; �.3 -' Z9 Z _
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