HomeMy WebLinkAbout010-941-26-2414-SAN-2022-160 C�
`��" ���' Industry Services Division County �
�`. � _ 4822 Madison Yards Way sa k, � r �
' ,S P Madison,WI 53705 Sanitary Permit Number(to be fiiled in by C �
i.._ $ P.O.BOx 7162
-- Madison, WI 53707-7162 ��3��l � S � �
t
Sanitary Permit Application State Transaction Number --
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate govcrnmental unit �
is required prior to obtaining a sanitary permit Note:Application forms for state-owoed POWTS arc submitted to Project Address(if different than mailing ad� C
the Departmenl of Safety and Professional Services.Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I�3�a � L _w m�� I ��
I.Application Information-Please Print All Information ��0.
Property Owner's idame Parcel it
Pa�1 � R«e� Ad�e� p i0 - 9y� -�G �ylU
Property Owner's Mailing Address Propeny Location
� v�� Hu as� S� Govt.Lot
City,State Zip Code Phone Number
�Q u► C�A',t'C � W= 5�f 70�j .5 L" /, !U G.1 �/., Section a�.
II.Type of Building(check all tttat apply) I.ot# T 4�( N R�_F+o—r
❑ 1 or 2 ramily Dwelling-Number ofBedrooms � Subdivision Name
❑Public/Commercial-Describe Use
Block#
O City of
❑State Owned-Describc Use _, CSM Number ❑Village of _
�1'own of__�qY wGif� ----
III.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on Iine A. Check one box on line B.Complete line C if
a licable.)
A.
� New System �Replacement System Other Modification to�xisting System(explain) 0 Addi6onal Pretreatment Unit(explain)
B' � Holdin Tank ,IV
g A.In-Ground (YdyqQ�- Q At-Grade � Mound
� Individua(Site Design � Other 7�ype(explain)
(conventional)
C- � Renewal Before Revision � Change of Plumber 0 Transfer to New Owner List Yrevious Pem�it Number and Date Issued
Expiration ��^ '.1� / o I l� q (
1
N.DispersaUTreatment Area and Tank Information:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersa Area Proposed(sQ System Flevation
3�v �.� I • 4� CyEs��> ►S� � 87. 5 (hc.s4�) u�•s aLa.s (bas.� 4s. 5 v �
Capncity in Total #of Manufacturer
Tank Information Gallons �
Gallons Units ` o .d
New Tanks Existlng Tanks c'�e o U �-' f„ =
C_:OMFiO ; o °: � Y s � �
a. � � y � �.. c� a
Septic or Holding Tank Y O
Sro ,�cser- Cor�,r 1�c
Dosing Chamber 5..�� � S�U
V.Responsibility Statement-I,the undersigned,assume responsibility for instellation of the POWTS shown on the attac6ed plaos.
Plumbcr's Name(Print) Plumber's S' rc MP/MPRS Number Business Vhone Number
4�a U;sac��y �3oa3G �rs-�3�r-i479
Plumber's Address(SVeet,City,State,7ip Code)
I G �� S N�y Co 3 !-�ay wa�,-d, w� S`-i a�•3
VI.Cou ty/Department Use Only
np 'Fd ❑Disapproved Pertnit Fee Date Issued Issuing Agent Sienature
yry ❑OwnerGivenReasonforDenial $ l�•� �I��I�� �L�!L-}7�'��
r'..--,
Conditions of tlpproval/Reasons for Disapproval D � � C� ��� :i . �
�`-,___
� _ ----=- � �,.
�d,� Date �- ��
'� � ,
� � 5 ��2 ,
JUL � ,
�hk#�1 ��;�F '
GS��a . � S __---- .
�v'- �� Y�r� � , ,
� � Oi� <����r r1' �
`��^l�;J.��U _,�^-�tfic� �, (Ut`�� 1"vC !�:L�i���
Attach to complete ns for the system and submit to the County only on paper not Iccs than R 1rz x 1 I inches in s¢e
SBD-6398(R.03/21) NO REFJNDS AFTER
ISSUE OF PEFtMIY
1 �-3�5
� 6eoMat IN GROUND AND DOSING DISTRIBUTION COMPONENT DESIGN
Residential Appiication
INDEX AND TITLE PAGE
Owner Info
Project Name: Adler - Sawmill Rd
Owner's Name: Paui & Renee Adler
Ownar's Address� 122 Hudson St
Eau Claire, WI 54703
Property Info
Property Address: 10372N SawmiA Rd
Legal Description: SE NW S 26 T 41 N R 9 W
Township Hayward County: Sawyer
Subdivision Name:
Lot Number: Block Number: CSM#:
Parcel I.D. Number: 010-941-26 2414
Plan Transaction No.:
Index Pages
Page 1 Index and title Page 9 Piot plan
Page 2 Data entry Filter specifications
Page 3 GeoMat dist. cell drawings & calculations Soil test
Page 4 Lateral and ceil cross section Soil test
Page 5 Management & contingency Soil test
Page 6 Maintenance & specifications �a��► u �.?�,n.�, C� ry c
Page 7 Tank cross sections
Page 8 Distribution media
Ray Visocky License Number: 230236
Date: 07/12/22 Phone Number: 715-634-1679
Signature:
Designer Stamp: State of Wisconsin Approval Stamp:
Designed Pursuant to the
GeoMat In Ground Component Manual Ver. June 26, 2018 Version
Page 1 of 10
In Ground and Dosing Distribution Component Design
Design Worksheet
Site information
R Residentiai or Commercial Design �N � ISD Required?
200.00 Estimated Wastewater Flow(gpd)
1.50 Peaking Factor(e.g. 1.5= 150%)
300.00 Design Flow(gpd)
0.00 Site Slope(%)
95.50 Prop. System Elevation(ft)
72.00 Depth to Limiting Factor(in)
1.60 In-situ Soil Application Rate(gpd/ftZ)
98.18 Lowest Original Grade Ele. In System Area(ft)
98.18 Highest Original Grade Ele. In System Area(ft)
92.18 Limiting Factor Elevation (ft)
1.18 Depth Below Grade
Distribution Cell Information
3.25 Cell Width{ft) �� Number of Cells
2.00 Dispersal Cell Design Loading Rate(gpd/ft2)
2 Influent Wastewater Quality(1 or 2)
Distribution Information
E Center or End Manifold, Dist. Box or Drop Box
1 Number of Laterals System dosed(�- Y -�
3.00 Lateral Spacing (ft)
522 Forcemain Drainback(gal) Does the forcemain drain back?� y �
0.50 Forcemain Filter Loss(ft)
2.00 Forcemain Diameter(in)
32.00 Forcemain Length (ft)
91.00 Inside Pump Tank Elevation (ft)
3.50 System Head(ft)x 1.3
6.60 Vertical Lift(ft)
1.39 Friction Loss(ft)
11.99 Total Dynamic Head(ft) Designer must enter friction loss and system demand (gpm)
35.22 Minimum Dose Volume(gal)
25.00 System Demand (gpm)
Manufacturer Information
Treatment Tank Information Effluent Filter Information
840.00�' Septic Tank Capaci (gal) Lifetime Filter LLC Filter Manufacturer
Wieser Concrete Products Inc. Manufacturer LT 1/8 Filter Model Number
Dose Tank Information Gallons/Inch Calculator(optional)
508.26 Dose Tank Capacity(gal) 508.26 Total Tank Capacity(ga�)
11.82 Dose Tank Volume(gallin) 43.00 Total Working Liquid Depth(in)
Wieser Concrete Products, Inc. Manufacturer 11.82 gal�n (enter result in cell DoseTankVolume)
Project: Adler-Sawmill Rd
Page 2 of 10
in Ground Plan View
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Calcutations
I 1.00 ft A 325 ft Basal Area Required 187.5 ftz
K � ft B 50 ft Basal Area Pro osed 262.5 ft2
S 0.00 ft L 52 ft
� �N 525 ft
Basal Area Calculation GeoMat Dispersai Cell Basal Area Calculation
GPD Loadin Rate GPD Loadin Rate
300 1.6 gal/sq fUday 300 2.00 gal/sq ft/day
Total 187.5 ft2 Total 150 ft2
Proposed 162.5 ftz
Number of Celis 1 GeoMat Width 325 ft
Cell Length 50.00 ft Lineal Feet of GeoMat Required 46.2
Min. Cell Len th 46.2 ft Lineal Feef of GeoMat Pro osed 50
Cell Spacin 0.00 ft NOTE:Min S dimension= 1'
S stem Elevation 95.5 ft
Limitin Factor 92.18 ft
Separation 3.32 ft 2•Min
Directions:
Play with cell length to get desired cell spacing, length and width. Remember system SHOULD be longer than it is
wide. It must also Satisf basal loadin rate and GeoMat cell loadin rate.
Project: Adler-Sawmill Rd Page 3 of 10
End Connection Lateral Layout Diagram
� �� . . . ... . . �.. . . . � �.JwaN�T_ �.. .. ..
Hole spacing is every 12",1/2"hole at 4&8 0'clock,starting 4 O'clock 6"from end and
8 O'clock Holes at 12"from end.
Lateral Spacing 3.00 ft Pipe Diameter 2.00 in
Distribution Ceil Cross Section
98.18 ft � Finished GnAc � �1"�2'Y �y.y�Y
�— . . .. : -. , ...
.: .- .•.•:, ,.�; , : . ',. •�.: ;. DistribarioC
I',;� . � .,.. , . 12"-48"`'n�.►mi� La�ael Leve!
7.18 ft— �r'O�� .
' .' \\ : �,.
2 in �—► �jjj�,'. �.. �� �` ��/uiu . �tr8tive
F • . _� r�vr ��-- • '=--•�� —��Fabric
Top of geomat to be at o I` _ _ '��'�"'�''�� ��
I. ���'' " 1^.. . .. .
below original grade � � �
�I I I I 2�ASiM 33£�� � � � � � , � � � ��
- . .. Infil�ve Sutface
� f�--=�NATIVESOIL= - -�
"' �J--- _- _ _------�L��.,�PFeaar
72ft .y � �_.�_�����_._ �..�
Observation Pipes
w.c�t�gta�w
98.18 ft Fmthe°Q� %
I .�..��
, �
12"Min. °•'�"� �
48"Max. ��
Toilclllancc . 5�' I
\ �. / I IL���r
i.':]GL`. d \ .
� i \� I
OE(..`�tAl' �-- I--ri -- L :�
' 1; , '..._ f .. _�.: . t � _
� R'A]'CRCi.OSETCJL� � 1��� 1 I � �p ��� �' �
I 1 1 1 1 i 1 1 I ' �1M�DNAc ��
'�i�� � I I I 1 I� I I I
� ��i���'� �ii�' ��; I i�l�l li� I 1 I I�I�I�� i I i I '�� I�I�II�I���l�i�l�l�l�l�l�l�lii�l�l�l�l�'� ��I�����I
��i2^AS7T.1C-33�md � ' '
`'���1 i� �i ���i� �'����i
i�i i�i�i
95.5 ft
Project: Adier-Sawmiil Rd
Page 4 of 10
Notes/Maintenance Reauirements
MANAGEMENT PLAN
This private onsite wastewater(PONlTS)has 6een designed,and is to be instalietl and maintained in accordance with SPS 383,Wis.Admin.
Code,the in-Ground Soil Absorption Component Manual for Pnvate Onsite Wastewater Treatment Systems Version 20 SPS-10705-P
(N.01/07). GeoMat in ground Component manual Version 1.
1.This POWTS has been designed to accommodate a maximum tlaily flow of 30Q�g(�ons of wastewater per day.The quality of
influent discharge into the PpWTS treatment or dispersal component shall be equal to or less than all of the following.
A monihly average of 30 mg/L fa[s,oil antl grease
A monthly average of 220 mglL BODS
A monthly average of 750 mglL TSS
Wastewater shall not tlischarge lo the POWTS in quantities or qualities that exceetl thase limits or that resWt in exceeding the enforcement
standards and preventative action limits specifed in ch.NR 140Tables 1&2 at a point of stantlartls application,ezcept as provitled in OSPS
383.03(4),Wis Admin.Code-
2.The owner ot this POWTS is responsible for system operetion and maintenance.
3.Defeds or malfunctions identified during maintenance descri6ed above shall be repaired in conformancewith SPS383 Wis.Atlmin.Cotle,
and the pertaining county Private Sewage Systems Ordinance.The user's manual,provided to the owner of the POV✓TS includes the names
and[elephone numbers of the propedy licensed individuals to contact for such repairs.
5.No product for chemical or physical restoration or chemical or physical procedures Tor POWTS may be used unless approved by the Dept.
of Commerce in accordance with SPS.384,Wis.Admia Code.
6.IF the POWTS is replacetl,or its use discontinued,it shall be abandoned in accordance with SPS 383.33,Wis.Admin.Code.
NOTES
Two Effluent Filters to be installed where possi6le 1 to 6e installed in ST,and or 1 in pump tank in
order to insure partiCle size less than or equal to 1/B". Filters should be cleaned once in spring,and once in fall.Also,sirainers in sinks in
the building shall be maintained,so that solitls and fats are minimized to Flow into syslem.
A minimum of 2 observation pipes per cell shall be installed.These pipes shall be located approximately at the end of each cell.
The plumber,or coun[y shall see to it that a copy of these plens including this page,maintenance foltler,and maintenance agraement is
given to the homeowner.
This system may contain a dose chambec If a pump,float,electrical outage causes the dose tank to fill,the homeownet should see to it that
the effiuent level in the tank is brought down gradually and not all dosed to the system at once. One large dose could cause damage.
Contact a pumper or your installer rf this problem occurs.
The homeowner is responsible for formulating a water conservation plan that will ensure the system is rarely overloaded. LE.spreatl laundry
out over time,not 6 loads in 2 hours,while everybody showers,antl uses the toilet,E7C.
CONTINGENCY PLAN FOR COMPONENT FAILURE
A.Septic Tank.Any structural failure resulting in crecks or leaks in the tank must be corrected by replacement of the septic tank component.
Leaks in iha joints behveen manhole risers or covers shall be repaired by replacing taulry seals with approved materials to make joints water-
tight.
B.Outlet Fiiter.The outiet fiHer shall be replaced or repaired when it is either no longer capable of preventing the discharge of particles larger
than 1/8 inCh or when it has become permanently degraded by clogging so as to interfere with the dasign fiow out of the septic tank.
C.Dosing chamber and pump.The dosing chamber shall be replaced if any stmcturel failure is found.Leaks in joints hetween manhole
risers or wvers shall be repaired by replacing faulry seals with approved matarials to makejoints wateo-tiyht.The pump and conUols shall be
repiaced when they are no longer capable of functioning accortling to t�e tlesign pian.
D.Pressure Distribution Piping.Partial clogging of the distribution network may resutt in untluly long dosing cycles.The ends of the
tlistribution laterals may be exposed and the threadetl end raps removetl.The piping can be tlisconnectetl on the outlet end of the pump.
7he distribution piping may then be back flushed to cleanse any accumulated matter Bom the piping.It is recommendetl that the dosing
chamber then be pumped by a licensed plumber.
E.Soil Absorption Cell.The discharge of sewage or wastewater to the ground surfece is striclly prohibited due to the human health hazard
created by the effluent AII failuras created by surface discharge shall immediately be reported to the appropriate county.The pump shall
then be immediately disconnectetl to prevent further discharge to the ground surface via the soil absorption cell.The existing septic tank antl
dosing chamber shall be used as a temporary holding tank until the necessary repairs to the soil absorption cell can be achievetl.The
replacement shall be initiated only after any necessary plan approvals have been obtained from the
appropriate plan review authority and the required sanitary permit i5 obtained from the coUnty.
Project: Adler-Sawmill Rd Page 5 of 10
In Ground System Maintenance and Operation Specifications
Service Provider's Name Ra Visocky
POWTS Regulator's Name Sa er Coun SPIA - Zonin Administration Phone 715-634-1679
Phone 715 634-8288
System Flow and Load Parameters
Design Flow - Peak 300 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow - Average 200 gpd Maximum BOD5 30 mg/L
Septic Tank Capacity 840 gal Maximum TSS 30 mg/L
Soil Absorption Component Size 162.5 fiz Maximum FOG 10 mglL
Type of Wastewater pomestic Maximum Fecal Coliform 10E4 cfu/100 mL
Service Freauencv
Septic and Pump Tank Ins ect and/or service once eve 3 ears
Effiuent Filter Ins ect and clean as necessa at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test periodicaily
Pressure System Laterals should be flushed and pressure tested eve 3 ears
In Ground Inspect for pondin and seepage once every 3 years
Miscellaneous Construction and Materials Standards
1. Observation pipes are slotted and materiais conform to Table SPS 384.30-1, have a watertight cap
and are secured in as shown in the GeoMat In Ground Component Manual Ver. March 20, 2017.
2. Dispersai cel( media conforms to GeoMat products approved for use with the GeoMat In Ground Component
Manual Ver. March 20, 2017. Media is covered with an approved geotextile fabric.
3. All gravity and pressure piping materials conform to fhe requirements in SPS 384, Wis. Adm. Code.
4. Scarification of basal area is accomplished with a rake or other tool.
5. All disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration.
Lateral Turn-up Detail
6-s" Diameter Finished Threaded Cleanout
Lawn Sprinkler Grade \ Plug or Ball Valve
Box �
�
Lateral Ends at Last Orifice Where
Long Sweep 90 or Two
�\45 Degree Bends Same
Diameter as Lateral
Distribution Lateral Lateral Cleanout
95.5 Feet
Project: Adler - Sawmill Rd
Page 6 of 10
GRAVITY-DOSED PAGE�'OF�
SEPTIC / PUMP TANK SPECIFICATIONS � 1O
4"OVeniPipe (No Scale)
>io n r�om
Building Elaclncal musi mmply wi�h
72"Min.or 2.0 R a0ove COMM i6 and NEC 300
EsteblisheG Flootl Elevation Weaiherproof Ea1entl manhole nser as necessary.
(bPical)
Approved Juncllon Box
IMPORTANT: Ver1�P � �A1nPwam�g ebelAtlac ed
Anchor tank(s)as necessary � �N (typicap
pursuant to SPS 383.43(8)(g) --condwt
4"Min.or 2.0 ft above
Es�a6lished Flood Elevafion
(typiral)
�AirGghlSeal' �
Finishetl Gletla
- Quick Disconnec�
�
CAPACITIES @ 11.82 gaUin 18"Min.
��� '�Y. (�YPicel)
Depth(in) Volume(gal) ,
A 24.5 289.59 —'r
Weap �--App'owa.loimswm,
�I lJl(J Hole AO��'+�PIp�3ftomo
B 2A 23.64 q sa��d����
A Depth Force Main Mo�a)
[C] 4.5 53.19 Filter'
D 12.0 141.84 g Aia� 'Install antl maintain pursuant
�--�— �o� m manufactureYs inshuctlons.
� � PUMP-OFF
'rPump Tank Liquid Level= 43 in � P�mP orr . ELEVATION= 92.00 ft
�� ���
2 � co��re�e INSIDE BOTTOM
Force Main Diameter= ��
�� B'°�` ELEVATION= 91•00 ft
��
Fo�ce Main Length= 32 ft 3"Approved 6edding Matenal Beneath Tank
���
Force Main Void Volume=�.?2 9a�
[C]Total Dose Volume(TDV)= 53.19 gai/dose
��
(<02X design Flow+force main void volume)
Vertical Lift= 5�75 ft
PUMP TANK: SEPTIC TANK(S):
Volume= 50�6 9a� Total Volume= 840 a�
��9
Manufacturer: Wieser Concrete Inc Manufacturer(s): Wieser Concrete Inc
Pump Manufacturer: Zoeller
BN 53 Install approved force main filter pursuant to
Pump ModeL �s�a��a�n�P�m N � manufa turers instructions
Controls/Alarm Manufacturer: SJE Rhombus
Filter Manufacturer: SimteCh
Controls/Alarm Model: Tank Alert AB
Filter Model: STF100
Float switches containino mercury are orohibited
GeoMat Distribution Cell Media Layout
3.25 Celi Width (ft) 2.63 Sidewall to Lateral (ft)
Distribution Cell Cross-section Arrangements
�
Component Legend
O Distribution Pipe
GeoMat is covered with approved geotextile fabric as per the their product approval.
Distribution Cell Ptan View Layout - Typical
3.25 Cell Width-A(ft) 50.00 Cell Length -B (ft)
—^ — — — ...� .�. �.� � �t:
Typical Dispersal Cell
Finished Gnde `�"�}'Y V' \y V' ��/
. . �' ' .. :.' : ' '. Gistributiotr
( .� � •� ... : .''. �•� '- " `. zz°-as" : nh►rii � � Iat�raiLcv�]
�d Cuva:eoommeaded . .
i _ _•�. —T .
��- - .�\ c��u - - . _ Fnfiluxrive
' - .+ ��o� �__�.; ,: '_. '_; . '��' / Fabria
1� ^ _,.�_GEQMAT
1 � I � i � 1 1?�ASTM 33 r�� � i � • � � � � � �
� — _ _ = =NA'I"I VE�SOI L_ — �'" — _ _ ���Sw-fsce
`� � - - - - - — -- - - . _ _ _ — — �
, _ _ �
� � � _ � � � � .� � _. � � _ _ - - rm.;�;,,vgsans
See details on page 4 for number, size, and spacing of laterals.
Project: Adler- Sawmill Rd
Page 8 of 10
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MODELS 53/55/57/59 EFFLUENTAND DEWATERING
� 6 20 MODEL 53/55157/59
w '°"�,..
_ �µ"� Feet Meters Gal. Liters
c� �,.
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¢ ��t,_
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o '``'F
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�� Variable level fioat switches available. -�- �
�� Variabie level long cycle systems available.
° Avaitable with special cord lengths of 15', 25', 35' and 50'. i
� Alarm systems available. i i
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� Duplex systems available. i
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� � SK858
Sin le Seal Control Selection Listin s S_:_"C i j��°�! :;_.i;�;}�
_ Model Volts Phase Mode Amps Simplex Du lex CSA UL 1. Integral float operated mechanical switch, no extemal control required.
M53r55&M5�/59 115 1 Auto 9.� 1 Y Y 2. Single pggyback vanable level float switch or double piggyback variable level
N53/55 b N57/59 715 1 Non 9.7 2 3 or 4&5 Y Y float switch. Refer to FM0477.
' BN53 115 1 Auto 9.7 ' — Y Y
* BN57 115 1 Auto 9.7 * _ N Y 3. Mechanicai aitemator"M-Pak" 10-0072 or 10-0075.
' BE53157 230 1 Auto __4.8 • y y 4. See FM0712 for correct model of Electrical Altemator.
D53155&D57/59 230 1 Auto 4,8 1 y y 5. Variable level control switch 10-0225 used as a wntrol activator,with Electrical
E53/55 8 E57159 230 1 Non 4.8 2 3 or 4&5 Y Y Altemator(3)or(4)float system.
'Singla piggyback switch included.
in oaurroN�
ForinformationonadditionalZoellerproductsreiertocatalogonPiggybackVariableLevelFloatSwitches,FM047T, ,;ll;nstrdlationofcontrois,;�rotectiondevicesande�irtngshoul�Ledon�b��aqualii5ed
EleclricalAllernator,FM0486;MechanicalAitemator,PM0495;Sump/Sewage Basins,FM0487;and Single Phase licensed electnciatt. All electrica! and safeh� codzs sti�idd be foflo4��ed inc!u�flnr the
Simplex Pump ControVAlarm Systems,FM0732. most recent NaUonal Flectric Code (NEC) and the Occupattuija! Safety and I-lealtii�cF
{OS41A).
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For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
— -------- MAILTO: P.O. BOX16347 — �--�--JJ
Louisville,KY 40256-0347 Manuladurers of..
� ��� SHIP TQ; 3699 Cane Run Road
� p Louisville,iCY 40211-1961 a „
PVMP !O, (502J 178-2731 •i(8Q0J 928-PUMP Qvei✓rr/�UMPS,J/NCE ����
_ www.zoel/er.com _— _ FAX(502) 774-3624
� Copyright 2006 Zoeller Co. All rights reserved. V �� �-`------�—�^
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'�;t'='"`"""'�; PRIVATE ONSITE WASTE TREATMENT County
v;,:
- a$ SYSTEMS Sawyer
P ( POWTS)
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�:�\�,� S;<.`'
���`�-���� INSPECTION REPORT
�T„�<,>;r�„
Safety and Buildings Division Sanitary Permit No:
(ATTACH TO PERMIT)
GENERAL INFORMATION �� . ��0
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)]
Permit Hoider's Name: ❑City ❑ Village Town of: State Pian Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
(c70.� �'�rr,�,�,5;�� s��a►,-Q. �'g�� �-t ^Y'+�-�S�c�--- 610 -`�'`f�—2�0 -�-�{(`�
TANK INFORMATION /.� s�� ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,�„� - ��(�p Benchmark (od.o �
Dosing —���a O
Aeration Bldg. Sewer �. �
Holding St I Ht Inlet �.�-'
TANK SETBACK INFORMATION St/Ht Outlet y�,.�.f, '
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic �}(o� � 30` fi p ' NA Dt Bottom �a.63�
Dosing �� « <� v NA Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe `t�.?Y �
PUMP 151PHON INFORMATION Infiltrative
Surface `fiS� �
Manufacturer �- Demand Final Grade
Model Number (j(�1S''�L GPM ''� C-33 ���Sr
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L � Dia d2 " Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W �,�,5' L ,t,� #of Cells � Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �wt�
INFORMATION P I L Bldg Well Waters °� G ❑ Chamber Model Number:
a EZFIow
CELL TO -+� -r�(p 5� f(po �
❑ Mound j� 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/Sodded � Mulchetl �
Celi Center Cell Edges Topsoil ❑Yes ❑ No 0 Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��.��(� � l�-�(2�
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Plan revision required?�Yes ❑ No �3 �� a� � ., - I � 6cl�7l / �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITI�NAL COMMENTS ANO SKETCH
54NITAPY PERMIT NiJMBER- ,___ _���_�j�__ .
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